Bilateral Acute Posterior Multifocal Placoid Pigment Epitheliopathy With Bacillary Layer Detachment Following Sinopharm COVID-19 Vaccination: A Case Report

Various ocular manifestations associated with COVID-19 and vaccines, affecting both the anterior and posterior segments of the eye have been documented in the literature. In this report, we present the case of a 25-year-old male who complained of sudden-onset blurred vision and metamorphopsia in both eyes one day after receiving the second dose of the Sinopharm COVID-19 vaccine. The visual loss was painless, with no reported flashes or floaters. The patient had no significant medical or surgical history, no history of trauma, and no drug intake. Upon ocular examination, the best-corrected visual acuity was 6/60 (Snellen chart) in both eyes. The anterior segments appeared unremarkable, while fundoscopy revealed multiple yellowish-white subretinal lesions at the posterior pole of both eyes. Spectral domain optical coherence tomography (SD-OCT) confirmed the presence of subretinal fluid (SRF) with neurosensory detachment in each eye, along with bacillary layer detachment (BALAD). There were no signs of inflammation in the vitreous cavity. A diagnosis of acute posterior multifocal plaque pigment epitheliopathy (APMPPE) was established. The patient was prescribed nepafenac 0.1% drops to be instilled three times a day in both eyes and was advised to return for a follow-up examination in two weeks. At the follow-up visit, the patient's vision had improved to 6/9 in the right eye and 6/6 in the left eye, with most of the SRF absorbed. Unilateral APMPPE with BALAD has been mentioned in the literature following various COVID-19 vaccinations, but, to the best of our knowledge, this is the first case report where bilateral APMPPE with BALAD is reported. This case emphasizes the importance of a thorough eye examination for individuals experiencing ocular symptoms after receiving the COVID-19 vaccine.

Development of Predictive Models Based on Biochemical Parameters to Triage COVID-19 Patients: A Study Conducted in a Tertiary Care Hospital

Background The COVID-19 disease continues to cause severe mortality and morbidity. Biochemical parameters are being used to predict the severity of the infection. This study aims to predict disease severity and mortality to help reduce mortality through timely intervention in a cost-effective way. Methods A total of 324 COVID-19 cases admitted at our hospital (All India Institute of Medical Sciences, Patna, BR, India) between June 2020 to December 2020 (phase 1: 190 patients) and April 2021 to May 2021 (phase 2: 134 patients) were recruited for this study. Statistical analysis was done using SPSS Statistics version 23 (IBM Corp., Armonk, NY, USA) and model prediction using Python (The Python Software Foundation, Wilmington, DE, USA). Results There were significant differences in biochemical parameters at the time of admission among COVID-19 patients between phases 1 and 2, ICU and non-ICU admissions, and expired and discharged patients. The receiver operating characteristic (ROC) curves predicted mortality solely based on biochemical parameters. Using multiple logistic regression in Python, a total of four models (two each) were developed to predict ICU admission and mortality. A total of 92 out of 96 patients were placed into the correct management category by our model. This model would have allowed us to preserve 17 of the 21 patients we lost. Conclusions We developed predictive models for admission (ICU or non-ICU) and mortality based on biochemical parameters at the time of admission. A predictive model with a significant predictive capability for IL-6 and procalcitonin values using normal biochemical parameters was proposed. Both can be used as machine learning tools to prognosticate the severity of COVID-19 infections. This study is probably the first of its kind to propose triage for admission in the ICU or non-ICU at the medical emergency department during the first presentation for the necessary optimal treatment of COVID-19 based on a predictive model.

A Retrospective Analysis of the Disruptions in the HIV Continuum of Care During the COVID-19 Pandemic: Lessons From a Clinic-Based Study

BACKGROUND

The COVID-19 pandemic profoundly affected healthcare services, including HIV patient care. This study assessed the impact of the pandemic on diverse aspects of care for individuals living with HIV (PLWH).

METHODS

Patient data from 2019 to 2021 were collected using the Cascades template, provided by the New York State Department of Health, focusing on viral testing and suppression outcomes. Age, ethnicity, sex, and race were considered variables and analyzed via chi-square analysis, logistic regression model, and F test.

RESULTS

The pandemic significantly reduced viral testing in 2020 due to restrictions and closures, but telemedicine and tele-pharmacy helped maintain care. Age was a crucial factor, predicting higher viral testing and suppression odds for older individuals, but no significant differences were observed between patient gender, race, or ethnicity in obtaining viral testing or achieving suppression.

CONCLUSIONS

While limitations existed, this study provides insights into sustaining care during crises, highlighting the importance of innovative healthcare delivery methods and age-sensitive approaches for PLWH.

Upstaging of Tuberculosis in the Post-COVID-19 Era: A Case Series

The COVID-19 pandemic has significantly impacted the global health system as well as the social and economic impact on tuberculosis (TB) treatment and diagnostic services. A high volume of patients diagnosed and treated for TB were impacted by the pandemic restrictions, particularly reduced access to TB services provided by the National Tuberculosis Elimination Programme in India; this in turn increased the number of deaths due to TB. The Indian healthcare system has been struggling with the eradication of TB, and this additional worldwide health crisis caused by SARS-CoV-2 has put the Indian healthcare system under severe stress. Both COVID-19 and TB are infectious diseases that primarily affect the lungs and have similar symptoms such as cough, fever, and difficulty breathing. The need of the hour is to take proper actions to mitigate and reverse these impacts urgently. The immediate priority is to aggressively step up the provision of essential TB services so that the levels of TB case detection and treatment return to at least pre-COVID-19 levels. The diagnosis of genital TB especially needs a high index of suspicion, as most of the cases are asymptomatic and diagnosed by chance in young women being evaluated for fertility. Here, we present a series of advanced genital TB cases that required intensive care and could have been detected and treated at an early stage.

Unveiling Gram-Ghost Cells: A Crucial Aspect of Gram Staining in the COVID-19 Era

The term "Gram-ghost appearance" refers to mycobacteria's unique Gram staining characteristics. Recognizing Mycobacterium tuberculosis as a potential pathogen in respiratory infections, especially in the elderly during the COVID-19 pandemic, is critical. This case highlights the pivotal role of Gram staining in diagnosis, particularly when COVID-19 tests consistently show negative results. Recognition of Gram-ghost bacilli facilitated prompt tuberculosis diagnosis, emphasizing the enduring diagnostic value of Gram staining, especially in the COVID-19 era.

Capgras Syndrome, Multiple Sclerosis, and COVID-19 Infection: A Case Report

Capgras syndrome is a psychotic illness characterized by an unshaken false belief in having a close family member replaced by an imposter when there is no evidence of such. The patient described in this case report is a 68-year-old Caucasian female who presented with Capgras syndrome in the context of chronic progressive multiple sclerosis (MS) following an acute COVID-19 illness. She was treated with quetiapine with full resolution of symptoms.

Right-to-Left Intra-cardiac Shunt in a COVID-19 Patient Leading to Stroke and Poor Prognosis: A Case Report and Review of the Literature

Coronavirus disease 2019 (COVID-19) often presents with a wide range of complications, including respiratory distress, acute respiratory distress syndrome (ARDS), and hypercoagulable states with resultant cerebrovascular incidents. Intra- and extra-pulmonological shunts can further complicate patient courses, leading to persistent hypoxemia and paradoxical emboli, resulting in potentially life-threatening consequences, necessitating a comprehensive, multidisciplinary approach to patient care. Here we present the case of a 73-year-old male who experienced severe persistent hypoxemic respiratory failure, superimposed methicillin-resistant Staphylococcus aureus (MRSA) pneumonia, and stroke with a previously undiagnosed patent foramen ovale (PFO) contributing to his clinical presentation.

Acro-Ischemia Associated With SARS-CoV-2: A Case Report

COVID-19 is known to cause various cutaneous lesions, including acro-ischemic lesions (AIL), which are associated with poor prognosis. Anticoagulant therapy has shown positive responses in AIL patients. However, in this case study, we present a fatal AIL case despite anticoagulant therapy. We propose different treatment approaches based on the limited current data on acro-ischemia pathogenesis related to SARS-CoV-2. The clinical case involved a 59-year-old male with severe COVID-19 symptoms, including acrocyanosis and right hemiparesis. Despite receiving anticoagulant therapy, the patient's condition worsened, leading to necrosis in the left foot. The discussion focuses on the high-risk nature of AIL, the potential link between angiotensin-converting enzyme 2 (ACE2) receptors and vasculitis or thromboembolic manifestations, and the role of immune clots in AIL pathogenesis. Behçet syndrome is referenced as a model of inflammation-induced thrombosis, guiding the suggestion for immunosuppressant-based treatment in addition to anticoagulants. Additionally, three substances, N-acetyl cysteine, sulodexide, and hydroxychloroquine, are proposed.

Effectiveness of wearing masks during the COVID-19 outbreak in cohort and case-control studies: a systematic review and meta-analysis

OBJECTIVE

To evaluate the efficacy of wearing a mask to prevent COVID-19 infection.

METHODS

This was a systematic review and meta-analysis of cohort and case-control studies, considering the best level of evidence available. Electronic databases (MEDLINE, EMBASE, Cochrane Central Register of Controlled Trials, and Clinical Trials.gov) were searched to identify studies that evaluated the effectiveness of wearing masks compared with that of not wearing them during the COVID-19 pandemic. Risk of bias and quality of evidence were assessed using the Cochrane risk of bias tool and the Grading of Recommendations Assessment, Development, and Evaluation.

RESULTS

Of the 1,028 studies identified, 9 met the inclusion criteria (2 cohort studies and 7 case-control studies) and were included in the analysis. The meta-analysis using cohort studies alone showed statistically significant differences, wearing a cloth mask decreased by 21% [RD = -0.21 (95% CI, -0.34 to -0.07); I2 = 0%; p = 0,002] the risk of COVID-19 infection, but the quality of evidence was low. Regarding case-control studies, wearing a surgical mask reduced the chance of COVID-19 infection [OR = 0.51 (95% CI, 0.37-0.70); I2 = 47%; p = 0.0001], as did wearing an N95 respirator mask [OR = 0.31 (95% CI, 0.20-0.49); I2 = 0%; p = 0.00001], both with low quality of evidence.

CONCLUSIONS

In this systematic review with meta-analysis, we showed the effectiveness of wearing masks in the prevention of SARS-CoV-2 infection regardless of the type of mask (disposable surgical mask, common masks, including cloth masks, or N95 respirators), although the studies evaluated presented with low quality of evidence and important biases.

Preferential Impairment of Auditory Working Memory in Long COVID: An Observational Study of Undergraduate Medical Students

Background Long COVID is a multisystem condition with prolonged symptoms that develop after recovery from the COVID-19 infection, often following a mild infection. Few studies have been conducted on cognitive function among medical students after recovery from mild COVID-19. This study aimed to assess the attention span and working memory (WM) capacity of medical students after six months of recovery. Methods A cross-sectional study was performed on 17 young adult medical students who had suffered a mild COVID-19 infection at least six months prior. Eighteen age-matched healthy medical students served as the controls. Audio-visual WM tasks and attention spans were assessed using computerized software for both the cases and controls. Results The mean ages of the case and control were 19.67±1.6 and 20.0±1.2 years, respectively. The most common symptoms among cases were fatigue (33%), weight loss (26%), and nasal stuffiness (13%). The overall proportion of correct responses across all visual and auditory WM tasks (p=0.085) and reaction times (p=0.609) did not differ between the cases and controls. However, the overall target hit rate of the auditory WM task was significantly lower in cases than in controls (p=0.002). This difference was not observed in the visual WM task (p=0.374). Conclusion In the current study, the overall WM functions (visual and auditory combined) and attention span did not differ between cases and controls. However, auditory WM performance was significantly impaired in patients compared with controls, indicating selective impairment of auditory WM in patients with long COVID.

Pulmonary Mucormycosis: Beyond Classic COVID-19-Associated Fungal Infections

Coronavirus disease 2019 (COVID-19) is often linked to a broad range of opportunistic bacterial and fungal infections. The second wave of the COVID-19 pandemic has witnessed an unprecedented surge in mucormycosis cases, predominantly in India, while the disease remained relatively rare in Europe. The authors describe the case of a 62-year-old female patient admitted to the hospital for consolidation therapy with chemotherapy as a part of the treatment protocol for acute myeloid leukemia. During hospitalization, she was diagnosed with nosocomial COVID-19, which later progressed to respiratory deterioration. COVID-19 with bacterial superinfection was presumed, leading to the initiation of empirical antibiotic therapy. A bronchoscopy was performed several days later due to a lack of improvement, revealing an infection by the Rhizopus microsporus complex. Despite antifungal treatment, the patient experienced an unfavorable clinical course and ultimately died. Given the high index of suspicion required to diagnose pulmonary mucormycosis, which can lead to delays in appropriate treatment and increase the burden of disease, the authors are aiming to enhance its awareness.

Ethical and Legal Debates on Vaccine Infodemics

Over the course of three and a half years, the global toll of coronavirus disease 2019 (COVID-19) has claimed the lives of millions of individuals. Scientific breakthroughs, exemplified by mRNA vaccines, have emerged as crucial tools in saving numerous lives and fortifying our defenses against future pandemics. However, the battle against the virus has been complicated by the dissemination of misleading political and ethical information, resulting in avoidable fatalities. Recognizing this phenomenon, the term 'infodemics' has been coined to denote the proliferation of false or misleading information that hinders effective social responses. Given the historical prevalence of infodemics surrounding vaccinations, this discussion delves into the ongoing ethical and legal deliberations concerning vaccination mandates, an indispensable health intervention in the face of pandemics. Governments bear the responsibility of safeguarding their citizens, acknowledging the social requirements imposed by the collective well-being. The protection of both citizens and healthcare workers becomes paramount, considering the potential risks of infection and mortality associated with individuals refusing vaccination. Historically, governments have played a pivotal role in eradicating pandemics through the implementation of vaccine mandates. However, the contemporary landscape is marked by the infusion of political and misleading misinformation, presenting new challenges. Governments are now confronted with an ethical duty to ensure that citizens possess the necessary information to make informed decisions and safeguard their well-being. While grappling with the realization that extraordinary circumstances demand extraordinary responses, the lessons from past pandemics underscore the imperative of prioritizing public health, especially in the context of the high numbers of casualties worldwide. This discourse explores the ethical and legal dimensions surrounding vaccine mandates, with particular emphasis on their relevance to healthcare workers.

Viral Respiratory Epidemic Modeling of Societal Segregation Based on Vaccination Status

BACKGROUND

Societal segregation of unvaccinated people from public spaces has been a novel and controversial coronavirus disease 2019 (COVID-19)-era public health practice in many countries. Models exploring potential consequences of vaccination-status-based segregation have not considered how segregation influences the contact frequencies in the segregated groups. We systematically investigate implementing effects of segregation on population-specific contact frequencies and show this critically determines the predicted epidemiological outcomes, focusing on the attack rates in the vaccinated and unvaccinated populations and the share of infections among vaccinated people that were due to contacts with infectious unvaccinated people.

METHODS

We describe a susceptible-infectious-recovered (SIR) two-population model for vaccinated and unvaccinated groups of individuals that transmit an infectious disease by person-to-person contact. The degree of segregation of the two groups, ranging from zero to complete segregation, is implemented using the like-to-like mixing approach developed for sexually transmitted diseases, adapted for presumed severe acute respiratory syndrome coronavirus 2 (SARS‑CoV‑2) transmission. We allow the contact frequencies for individuals in the two groups to be different and depend, with variable strength, on the degree of segregation.

RESULTS

Segregation can either increase or decrease the attack rate among the vaccinated, depending on the type of segregation (isolating or compounding), and the contagiousness of the disease. For diseases with low contagiousness, segregation can cause an attack rate in the vaccinated, which does not occur without segregation.

INTERPRETATION

There is no predicted blanket epidemiological advantage to segregation, either for the vaccinated or the unvaccinated. Negative epidemiological consequences can occur for both groups.

Clinical Outcomes of Angiotensin Converting Enzyme Inhibitors and Angiotensin II Receptor Blockers in COVID-19 Patients With Pre-existing Cardiac Comorbidities: A Literature Review

The growing research regarding the implementation of angiotensin-converting enzyme-2 inhibitors (ACEi) and angiotensin receptor blockers (ARBs) in the treatment of COVID-19 in patients with pre-existing cardiac comorbidities has become a large topic of discussion since the onset of the pandemic. Previous research primarily associates positive outcomes to the use of these drug classes due to their mechanism of action, which involves the downregulation of angiotensin I-converting enzyme 2 (ACE2) in the renin-angiotensin-aldosterone-system (RAAS) pathway, inflammatory mediators, and cytokines. Thus, these medications can convey preventative and protective effects in patients suffering from a SARS-CoV-2 infection. While we explored the studies that supported the positive outcomes of the use of these drugs in the first half of this review, we also expanded on the limitations of these studies in the latter portion. We also further explored the contradictory studies that indicated that using these antihypertensives can paradoxically increase the severity of COVID-19 infection as well. The studies in support of the use of these medications should consider epigenetic variations, ACE2 variants and acknowledge inherent genetic variations in certain ethnic groups as some have a predisposition for a severe COVID-19 infection. Additionally, mortality rates need to be taken into consideration in these studies as they naturally differ throughout the trajectory of the COVID-19 pandemic. While some studies are in support of the use of these antihypertensives despite other studies suggesting otherwise, further research is needed to explore the long-term effects of these antihypertensives and observe whether they are truly beneficial or not in reducing the severity of COVID-19 infections.

Drug-Drug Interactions Between COVID-19 Treatments and Psychotropic Medications: An Updated Study

The recent evolution of coronavirus disease 2019 (COVID-19) treatments has created challenges for healthcare providers in terms of new potential interactions between these COVID-19 treatments and psychotropic drugs in patients with psychiatric disorders. Current clinical practice guidelines on managing interactions between psychotropic medications and COVID-19 treatments do not account for the newer COVID-19 medications. There is a need for updated patient management recommendations that take into account drug interactions between psychotropic drugs and the latest pharmacological approaches to COVID-19 treatment. A search of literature pertaining to drug interactions and outcomes in patients concurrently prescribed COVID-19 treatments and psychotropic medications was conducted. Drug databases were also analyzed to screen for interactions. Our review focuses on the most recent and effective COVID-19 treatments, including PaxlovidTM (nirmatrelvir/ritonavir), remdesivir, dexamethasone, tocilizumab, and baricitinib. The study provides condensed and easily interpretable tables for healthcare providers to screen for potentially harmful drug interactions. We discuss the implications of our findings on appropriate treatment plan selection by healthcare providers for patients taking select antipsychotics, antidepressants, mood stabilizers, and benzodiazepines while receiving COVID-19 treatments. Notably, PaxlovidTM may interact with several medications, particularly antipsychotics and anxiolytics, necessitating close monitoring and, in some cases, reconsideration of use. We find that dexamethasone, remdesivir, tocilizumab, and baricitinib have fewer reported interactions with psychotropics, and while some monitoring is necessary, no major adjustments are recommended for their administration in conjunction with psychotropic medications. These findings underscore the importance of careful consideration and monitoring when combining COVID-19 treatments with other medications to mitigate the risk of adverse interactions and ensure patient safety.

Organizing Pneumonia as a Pulmonary Sequela of Post-COVID-19 Syndrome in a Patient in Trinidad: A Case Report

Cryptogenic organizing pneumonia (COP) is a form of idiopathic interstitial pneumonia that commonly presents with exertional dyspnea. The mainstay diagnostic criterion is with histopathological confirmation alongside excluding secondary causes of interstitial lung disease. The COVID-19 pandemic left many mysteries regarding the long-term sequelae of this disease. We explore a case of post-COVID-19 syndrome organizing pneumonia (PCOP) in a patient presenting with new-onset respiratory symptoms seven weeks after recovery from COVID-19 infection. Upon further review of the literature, there were no published case reports on PCOP in Trinidad and Tobago. We describe a case of PCOP presented at Apley Medical Clinic, Trinidad, and Tobago, West Indies, with the aim of increasing awareness of this condition to allow for early identification and effective management.

A Successfully Treated COVID-19 Vaccine Induced Immune Thrombocytopenic Purpura

Immune Thrombocytopenic Purpura (ITP) is a life-threatening condition where an accurate initial assessment is essential to be able to offer the proper therapy in a timely matter to improve the outcome of the patient. Here, we present a case of ITP secondary to the coronavirus disease 2019 (COVID-19) vaccine (BioNTech, Pfizer vaccine). A 61-year-old obese African American female presented to the emergency room (ER) from a clinic with a platelet count of 11k/ul 21 days after she received the second dose of the BioNTech, Pfizer vaccine. The patient was immediately started on intravenous immunoglobulin (IVIG) 1g/kg twice daily (bid) and dexamethasone 20 mg IV every 12 hrs (q12h). The next day, the platelet count increased to 63 k/ul, and after the second dose of IVIG, the platelet count improved to 122 k/ul and trended up. The early detection of ITP induced by the mRNA COVID-19 vaccine is determinant to guide the early and proper therapy with immunoglobulins and steroids to improve the outcome of our patients.

Vasculitis-Like Hemorrhagic Herpes Zoster and HIV Infections: An Intricate Association

Herein, we report the case of a 69-year-old patient who presented to our dermatology clinic for a skin eruption characterized by grouped hemorrhagic vesicles and erosions covered by hemorrhagic crusts on an erythematous background located on the lower right limb. The lesions were small, clustered, and variable in size (diameters between one and 10 mm) and located at the level of the L4-L5 dermatomes. The rash had started three to five days after the complete COVID-19 vaccination scheme with the BNT162b2 Pfizer BioNTech vaccine and had been accompanied by a flu-like syndrome. The histopathological examination established the diagnosis of leukocytoclastic vasculitis potentially in the context of a cytopathic zoster phenomenon. The atypical aspect of the zosterian eruption required additional laboratory work-up to identify possible causes of immunosuppression, i.e., screening for the presence of the human immunodeficiency virus (HIV) infection, solid cancers, as well as measurement of serum immunoglobulin concentrations, which revealed that the subject was HIV-positive. Antiviral treatment was started, with a favorable evolution of the lesions, and the patient was referred to an infectious diseases clinic for initiation of antiretroviral therapy (ART).

Implementation of Health Policies in the COVID-19 Pandemic Phases of Myanmar and How the Population Approach Influenced Their Success Rate

The impact of the COVID-19 pandemic is continuing in developing countries, and post-pandemic individuals are still suffering mentally and physically. Many researchers have tried to find the causes and risks that can impact the spread of disease. Among the causes and risks identified, socioeconomic factors and health policies played an important role in determining the transmission of the disease. However, the significance of these factors for the spread of infection is different depending on the country. In this editorial, we discuss the implementation of health policies in Myanmar and their effect on infection transmission.

Burnout symptoms among physicians and nurses before, during and after COVID-19 care

OBJECTIVE

this study evaluated burnout symptoms among physicians and nurses before, during and after COVID-19 care.

METHOD

a cross-sectional comparative study in the Pulmonary Care unit of a tertiary-level public hospital. The Maslach Burnout Inventory was used.

RESULTS

280 surveys were distributed across three periods: before (n=80), during (n=105) and after (n=95) COVID-19 care; 172 surveys were returned. The response rates were 57.5%, 64.8% and 61.1%, respectively. The prevalence of severe burnout was 30.4%, 63.2% and 34.5% before, during and after COVID-19 care (p<0.001). Emotional exhaustion (p<0.001) and depersonalization (p=0.002) symptoms were more prevalent among nurses than among physicians. Severe burnout was more prevalent in women, nurses and night shift staff.

CONCLUSION

the high prevalence of burnout doubled in the first peak of hospital admissions and returned to pre-pandemic levels one month after COVID-19 care ended. Burnout varied by gender, shift and occupation, with nurses among the most vulnerable groups. Focus on early assessment and mitigation strategies are required to support nurses not only during crisis but permanently.

Parental Hesitancy and Attitude Concerning COVID-19 Vaccine and Its Side Effects in Saudi Arabia, Eastern Region

Background Vaccine hesitancy poses a substantial challenge to the field of public health. There are various factors that influence the willingness of parents to vaccinate their children. Addressing the factors contributing to vaccine hesitancy within the community has the potential to facilitate the development of more effective approaches for global vaccination initiatives. This study aims to assess parents' perspectives regarding the immunization of children aged five to 12 against COVID-19, including their experiences with adverse effects, as well as the factors that influence their hesitancy or acceptance of the vaccine in the Eastern Province of Saudi Arabia. Methods A web-based, cross-sectional study utilized an independently administered online questionnaire. The validated questionnaire was distributed to study participants through social networking platforms in order to recruit individuals from various locations in the eastern region of Saudi Arabia, such as Dammam, Al-Hassa, Al-Jubail, Ras Tanura, Dhahran, Al-Khobar, and Al-Qatif. Results The study encompassed a total of 399 participants. The most commonly reported adverse effects among the first and second children were pain at the injection site (1st child: 267 (66.70%), second child: 263 (66.20%)) and fever (1st child: 171 (43.10%), second child: 187 (47.50%)). A significant proportion of the participants, specifically 139 individuals (35%), expressed apprehension regarding immunization. This concern stemmed from various factors, including the fear of experiencing adverse effects, skepticism regarding the vaccine's efficacy, and exposure to potentially harmful information about the vaccine. Ninety-nine participants, accounting for 25% of the sample, indicated their agreement with the safety of COVID-19. Additionally, 104 participants, constituting 26% of the sample, held the belief that receiving vaccination aids in the prevention of severe illnesses caused by COVID-19. Notably, the most prevalent reason for vaccine hesitancy among participants was the fear of experiencing adverse effects. A total of 132 individuals, accounting for 33% of the participants, identified healthcare providers, including physicians and scientists, as reliable and trustworthy sources of vaccine information. A statistically significant correlation was observed between the demographic variables of the participants and their acceptance of the vaccine. Conclusion The study observed an acceptable vaccination rate among children aged five to 12 for the COVID-19 vaccine. Based on the investigation results, the primary apprehension expressed by parents regarding the immunization of their offspring pertained to the potential negative consequences associated with the vaccine. Nonetheless, it was observed that adverse effects were reported in less than fifty percent of vaccinated children. Addressing the concerns pertaining to the COVID-19 vaccination can enhance global participation in the immunization program aimed at mitigating future pandemics.

Tendon Transfer to Treat Radial Nerve Palsy Following COVID-19 Infection

Multiple manifestations have been associated with the novel severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) virus. Among them are mononeuritis multiplex (MNM) and other neurological complications, whose connection to coronavirus disease 2019 (COVID-19) is still unclear. One of the most common sites of nerve injury is the radial nerve, which can be treated with both nerve or tendon transfer. In this case report, a patient who was afflicted with severe COVID-19 infection and developed mono neuritis multiplex after prolonged mechanical ventilation with radial nerve palsy was treated with multiple tendon transfers. This is a way to use an established mechanism of resolving the manifestations of radial nerve palsy to aid in the recovery of COVID-19-related mononeuritis multiplex.

The Risk of Suicide in the Post-COVID-19 Emergency Era: Psychological and Forensic Implications

The emergence of the coronavirus disease 2019 (COVID-19) pandemic brought numerous challenges, including the management of psychological and psychiatric disorders, leading to an increased risk of suicide. At the end of the COVID-19 emergency, we wonder what the impact of the pandemic has been, and still is, on the state of public mental health with respect to the phenomenon of suicide. Therefore, this review aims to explore the psychological and forensic aspects of suicide in the post-COVID-19 emergency era. The paper will delve into the various psychiatric disorders associated in the literature with COVID-19, the risk factors for suicide during the pandemic, and measures that can be taken to prevent suicide in the post-COVID-19 era. Additionally, the paper will look at how forensic experts investigate suicide cases due to COVID-19 and the legal implications of suicide due to the pandemic. The findings of this study will provide insights into the psychological and forensic aspects of suicide in the post-COVID era, and emphasize interventions and policy development to address this growing public health concern.

The Impact of the COVID-19 Pandemic and Lockdown on Adult Foot and Ankle Fractures Presenting to the Largest Trust in the United Kingdom

Background The COVID-19 pandemic induced unprecedented changes in medical practices, prompting a reassessment of their impact on adult foot and ankle fractures within the National Health Service (NHS). This study employs a retrospective observational approach, leveraging the Pathpoint™ eTrauma platform for a comprehensive analysis of prospectively collected data. Methods Data encompassing weekly fracture incidence, weekly surgical procedures, patient demographics, and mean wait time from injury presentation to surgery were systematically evaluated. The study population included all adults (18+) admitted during five distinct periods: pre-pandemic, national lockdown 1, post-lockdown, national lockdown 2, and national lockdown 3. Results An analysis of 434 foot and ankle fractures revealed that national lockdown 1 exhibited the lowest fracture incidence (4.97 per week) and surgeries performed (4.77 per week), reflecting a notable reduction in trauma cases and elective procedures. Conversely, post-lockdown displayed the highest fracture incidence (7.46 per week) and surgeries performed (6.31 per week), suggesting a resurgence in both trauma and elective surgical activities. The pre-pandemic cohort, characterized by the highest mean age (51.98 years) and mean wait time (8.74 days), served as a temporal baseline. Conclusion While the incidence of fractures decreased during all three national lockdowns compared to pre-pandemic or post-lockdown periods, a gradual increase was observed in subsequent lockdowns. Notably, mean wait times showed a significant reduction, reaching the lowest point (5.79 days) during national lockdown 3. These findings underscore the complex interplay between pandemic-related disruptions, evolving guidelines, and adaptive measures within the healthcare system, influencing the dynamics of foot and ankle fracture management.

Large Cutaneous Squamous Cell Carcinoma: A Consequence of Elective Surgery Deferment During the COVID-19 Pandemic

Cutaneous squamous cell carcinoma (cSCC) is a common skin cancer that can be treated effectively with limited morbidity if caught and treated early with elective surgical procedures. The COVID-19 pandemic caused most healthcare facilities to delay or defer elective surgeries as they allocated workforce and resources to treating significant increases of critically ill patients. This care delay has increased morbidity and mortality of many conditions treated with surgery. A few case reports exist on delayed elective surgeries' effects on patients and healthcare facilities. We report a case of cSCC enlarging and locally spreading due to elective surgery delay during the COVID-19 pandemic.

Unpacking COVID-19 Vaccine Attitudes: Exploring Hesitancy and Acceptance Among Undergraduate Students in Bangladesh

BACKGROUND

Vaccine hesitancy is a significant global health concern, and mass vaccination is essential in preventing the spread of COVID-19. Undergraduate students need to be prioritized for vaccination as they continue their academic curriculum physically. However, limited research explores vaccine hesitancy and acceptance among undergraduate students in Bangladesh. Therefore, this study evaluated vaccine hesitancy and acceptance among this population.

METHOD

A web-based cross-sectional study was conducted between May and June 2021 using a structured questionnaire to assess COVID-19 vaccine hesitancy and acceptance among undergraduate students in Bangladesh. The Oxford Covid-19 Vaccine Hesitancy Scale was used to measure vaccine hesitancy. The study used convenient sampling.

RESULT

Across the country, 334 undergraduate students participated in this study on COVID-19 vaccine acceptance, with a mean age of 22.4 years. Most participants were male and unmarried, most having spent four years at university. 89.52% of participants would accept a COVID-19 vaccine if it were suggested by educational institutions or available, while 4.49% refused to receive the COVID-19 vaccine. Participants showed low levels of vaccine hesitancy, with a mean score of 10.77 on the Oxford COVID-19 Vaccine Hesitancy Scale. Most participants had a positive attitude towards receiving the vaccine, with the majority wanting to get it as soon as it becomes available. No association was found between vaccine acceptance and participants' background characteristics.

CONCLUSION

Our study found a high level of vaccine acceptance among undergraduate students in Bangladesh, indicating that this group can be vaccinated quickly, significantly accelerating vaccination goals. However, further large-scale studies are recommended among vulnerable groups, including school and college students, to ensure vaccine preparedness.

COVID-19 Vaccines and Axillary Nerve Dysfunction: A Case Report

COVID-19 resulted in a worldwide pandemic and the rapid introduction of vaccines in an attempt to mitigate it. Neuritis and neuropathy after intramuscular injection had been previously seen with influenza vaccines and appear to be a side effect of the COVID-19 vaccine as well. In the following report, we present the case of a 43-year-old female who developed axillary nerve symptoms after administration of the COVID-19 vaccine and her subsequent recovery.

Impact of the COVID-19 Public Health Crisis and a Structured COVID Unit on Physician Behaviors in Code Status Ordering

Purpose: Code status orders are standard practice impacting end-of-life care for individuals. This study reviews the impact of a COVID unit on physician behaviors towards goal-concordant end-of-life care at an urban academic tertiary-care hospital. Methods: We conducted a retrospective cohort study of code status ordering on adult inpatients comparing the pre-pandemic period to patients who tested positive, negative and were not tested during the pandemic from January 1, 2019, to December 31, 2020. Results: We analyzed 59,471 unique patient encounters (n = 35,317 pre-pandemic and n = 24,154 during). 1,631 cases of COVID-19 were seen. The rate of code status orders among all inpatients increased from 22% pre-pandemic to 29% during the pandemic (P < .001). Code status orders increased for both patients who were COVID-negative (32% P < .001) and COVID-positive (65% P < .001). Being in a cohorted COVID unit increased code status ordering by an odds of 4.79 (P < .001). Compared to the pre-pandemic cohort, the COVID-positive cohort is less female (50% to 56% P < .001), more Black (66% to 61% P < .001), more Hispanic (6.5% to 5%) and less white (26% to 30% P < .001). Compared to Black patients, white patients had lower odds (.86) of code status ordering (P < .001). Other race/ethnicity categories were not significant. Conclusions: Code status ordering remains low. Compared to pre-pandemic rates, the frequency of orders placed significantly increased for all patients during the pandemic. The largest increase occurred in patients with COVID-19. This increase likely occurred due to protocols in the COVID unit and disease uncertainty.

A Rare Case of COVID-19 Presenting as Acalculous Cholecystitis

At its onset, coronavirus disease 2019 (COVID-19) commonly presents with generalized myalgia and upper respiratory symptoms. COVID-19 presenting as acalculous cholecystitis has been rarely described in the literature. The following case presents a patient whose first presentation of COVID-19 was acalculous cholecystitis without respiratory symptoms, critical illness, or severe COVID-19 infection.

Beyond the Norm: A Case of Multiorgan Injury Triggered by Ibuprofen

We report the case of a 71-year-old African American male with a history of chronic obstructive pulmonary disease (COPD), heart failure, vitiligo, penicillin allergy, and cocaine use, who presented with respiratory symptoms and was diagnosed with sepsis, COVID-19 pneumonia, exacerbation of COPD, and acute kidney injury (AKI). Treatment included antibiotics and high-dose steroids. The patient developed thrombocytopenia, autoimmune hemolytic anemia, acute liver failure, and interstitial nephritis associated with prolonged ibuprofen use. High-dose steroids and ibuprofen discontinuation led to significant improvement. This case highlights the rare occurrence of multiorgan injury from ibuprofen use, possibly aggravated by COVID-19, emphasizing the need for cautious non-steroidal anti-inflammatory drug (NSAID) use and close patient monitoring.

An Evaluation of Gastroscopy Findings During the COVID-19 Pandemic: A Public Hospital-Based Study From Turkey

Background and objective Emotional factors can affect stomach secretions, acid expression, and stomach motor functions. The coronavirus disease 2019 (COVID-19) pandemic was an emotionally difficult time for many individuals as the whole world faced a life-threatening disease for which definitive treatment is still not fully established. In light of this, the aim of this study was to compare the results of gastroscopies performed among individuals before and after the pandemic. Methods The study included patients who underwent gastroscopy at Bursa Çekirge State Hospital in the following four different time frames: March-June 2019 (Group 1), March-June 2020 (Group 2), March-June 2021 (Group 3), and March-June 2022 (Group 4). All gastroscopy procedures were performed under anesthesia in the endoscopy unit. During the COVID-19 pandemic, all patients underwent a polymerase chain reaction (PCR) test, and gastroscopy was performed on those with negative results. Biopsies were taken from the antrum in all cases. Patient data were collected retrospectively and the groups were examined and compared in terms of age, gender, COVID-19 history, histopathology examination results, and diagnoses. Results A total of 803 patients were evaluated: 201 in Group 1, 200 in Group 2, 201 in Group 3, and 201 in Group 4. Group 1 comprised 66 (32.8%) males and 135 (67.2%) females, Group 2 consisted of 76 (38%) males and 124 (62%) females, Group 3 had 76 (37.8%) males and 125 (62.2%) females, and Group 4 comprised 86 (42.8%) males and 115 (57.2%) females. The mean age was 52.77 ±14.92 years in Group 1, 52.5 ±14.49 years in Group 2, 50.08 ±15.71 years in Group 3, and 52.83 ±13.20 years in Group 4. Helicobacter pylori (HP) positivity was found in 84 (41.8%) patients in Group 1, 146 (73%) in Group 2, 107 (53.2%) in Group 3, and 70 (34.8%) in Group 4. The HP infection was mild in 47 (23.4%) patients in Group 1, 26 (13%) in Group 2, 49 (24.4%) in Group 3, and 72 (35.8%) in Group 4. Moderate severity of HP infection was found in 16 (8%) patients in Group 1, 18 (9%) in Group 2, 25 (12.4%) in Group 3, and 25 (12.4%) in Group 4. Very severe HP infection was noted in 21 (10.4%) patients in Group 1, nine (4.5%) in Group 2, 20 (10%) in Group 3, and 34 (16.9%) in Group 4. With regard to mild HP infection, the highest rate was seen in Group 4 (35.8%). As for patients with very severe HP infection, a statistically significant difference was found between Group 2 and Group 4. In 2020 (Group 2), the rate was 4.5%, increasing to 16.9% in 2022 (Group 4). Regarding the comparison among groups based on histopathological examination findings, the frequency of chronic antral gastritis was determined to be highest in Group 4, at a statistically significant level (p<0.001). Conclusion The COVID-19 pandemic has caused physical and emotional hardships for several people worldwide. The possibility of transmission of the disease, unknown facts about the disease, and anxiety due to the condition being potentially fatal have had a drastic impact on the emotional states of many people. It is a condition that affects the lives of many people in the short term, and we believe that its effects reflected in the chronic period can be better evaluated through further studies conducted over the long term.

Evaluation and Perception of the Immediate Impact of COVID-19 on Dental Education: An Observational Study

Background The primary aim of the study is to assess how the COVID-19 pandemic has affected dental education for students and teachers, particularly concerning the efficiency of online teaching strategies for both clinical and academic outcomes. Additionally, it also emphasizes psychological behavior like stress and anxiety in the post-pandemic era due to academic pressure. Materials and methods The study included 300 undergraduate dental students from various years of studying and 31 teachers actively teaching in dental college from all nine departments. The questionnaire was created in Google Forms for both students and teachers. The questionnaire contained various aspects of an education system that was adopted post-pandemic. The questions were given to evaluate the opinions of students as well as teachers to understand which method of teaching is preferable for them. Whether it's an online method of teaching or the offline mode, out of which the majority of respondents preferred the offline method of teaching. Result Most of the respondents agreed that the pandemic had affected their academic as well as clinical performance. Online mode of learning was not as effective as face-to-face learning. It did not affect the students clinically but mentally, which made them more anxious and stressed out during their studies and preparation for exams. Teachers too had to face a lot of problems from technical aspects while teaching online which led to mental stress and anxiety. This study re-emphasizes the negative impact of COVID-19 on dental education. It also further highlights the more fundamental changes and improvements that are desperately needed in the education system to adapt and overcome the current pandemic situation and future such events. Conclusion The COVID-19 pandemic has significantly impacted educational institutions, curricula, and clinical practice. Dental students are particularly vulnerable, and online education platforms in India face challenges in regulation. The quality of materials, technical assistance, and expertise in online classes significantly impact teaching and learning experiences. The pandemic has led to concerns about students and staff contracting the disease, creating a skill gap in dental graduates, and loss of clinical exposure, causing more anxiety. To address these concerns, regular, open, and compassionate communication with students is essential. Educational institutions must undergo a transformation to adapt to the pandemic and potential future disasters.

Association Between Candida albicans and COVID-19 in Complete Denture Wearers: An Observational Study

Introduction The phenomenon of coronavirus disease 2019 (COVID-19)-related candidiasis is gaining increased attention and acknowledgment as an integral component of the severe consequences of COVID-19. The aim of the present study was to assess the association between Candida albicans and COVID-19 in complete denture wearers. Materials and methods An observational study was conducted on 45 complete denture wearers, who were divided into three groups as follows: Group 1, 15 subjects with mild to moderate COVID-19 infection; Group 2, 15 subjects with severe COVID-19 infection; and Group 3, 15 subjects without COVID-19 infection. Mean colony forming units (CFU) were observed on agar plates containing Sabouraud dextrose in the salivary samples of the participants. Analysis of variance, followed by post-hoc analysis by Tukey's test, was used to compare CFU between the groups. Pearson's correlation coefficient was used to study the correlation between variables. Results The highest average colony-forming units of Candida albicans were observed in Group 2, followed by Group 1, compared to the control group, and a significant (p<0.001) difference was found. A weak positive correlation was found between the age of the patients and the duration of denture usage, as well as between age and the counts of Candida albicans in Groups 1 and 3. This correlation was more pronounced in Group 3. A strong positive correlation was observed in all groups between the Candida albicans count and the duration of denture usage by the patients. Conclusion The association between Candida albicans and denture wear was compounded by the presence of COVID-19. Consequently, the timely identification of Candida albicans infection in patients with COVID-19 is important to establish more efficacious approaches for antifungal treatment and prophylactic interventions.

Acute Ischemic Stroke in a Teenage Patient: Are We "MIS-C"ing Something?

The reported annual incidence of acute ischemic stroke (AIS) among pediatric and young adults is 1-13/100,000. In adults, ischemic stroke is attributed to several risk factors such as smoking, hypertension, atherosclerosis, and diabetes. Alternatively, pediatric ischemic stroke is associated with a broad spectrum of etiologies including prematurity, congenital heart disease, arteriopathies like moyamoya, chronic inflammatory disease, sickle cell, hypercoagulability, and malignancy. In rare cases, AIS has been associated with multisystem inflammatory syndrome in children (MIS-C), a Kawasaki-like inflammatory disease affecting patients younger than 21 years of age. This recently recognized and rare condition has been linked to severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection, and presentations can vary widely in terms of severity and systemic involvement. While the exact reason behind this association is unknown, there is a growing body of evidence in adult literature that links SARS-CoV-2 infection to hypercoagulability and immune-mediated thrombosis. In pediatric patients, this association is not very clear. We report a case of a 17-year-old, previously healthy male who presented with acute-onset expressive aphasia, right-sided hemiparesis, and facial droop after two weeks from experiencing coronavirus disease 2019 (COVID-19)-like symptoms. A non-contrast head CT revealed an acute left M2 territory infarct while serum workup was consistent with MIS-C. Providers must maintain a high degree of suspicion and consider AIS in pediatric patients presenting with even mild neurological changes and a recent history of SARS-CoV-2 infection.

Sensorineural Hearing Loss as a Complication of COVID-19 and the COVID-19 Vaccine

The relationship between COVID-19 and sensorineural hearing loss (SNHL) continues to solidify in light of a growing body of evidence. In addition to the well-established COVID-19 symptoms and sequelae, otolaryngologists have observed an increased incidence of SNHL in patients with COVID-19 and following COVID-19 immunizations. Although the precise mechanisms behind this association remain unclear, various hypotheses are discussed within the scientific literature. This case report expands on the relationship between COVID-19 and SNHL by discussing a unique case of bilateral tinnitus and subsequent SNHL shortly following COVID-19 immunization. It contributes to the growing body of evidence associating COVID-19 with SNHL, underlining the importance of further research to understand potential causal mechanisms. It underscores the clinical importance of monitoring hearing in COVID-19 patients and those receiving immunizations, advocating for increased awareness among clinicians to facilitate early identification and appropriate intervention in cases of COVID-19-related hearing loss.

COVID-19: Its Impact on Delayed Management of Pre-established Chronic Conditions

Chronic venous insufficiency (CVI) is a common condition affecting the venous system, typically arising in the setting of increased venous pressure and impaired blood return secondary to weakened valves or damaged veins. Diabetes mellitus causes impaired circulation, neuropathy, impaired healing, and increased susceptibility to infection. Because diabetes and CVI are interconnected, ulcerations can progress to necrotizing fasciitis if not treated promptly and appropriately. The coronavirus disease 2019 (COVID-19) pandemic has further complicated patient care and is a potential risk for complications and delays in the management of time-sensitive conditions like necrotizing fasciitis. Here, we present a case study highlighting the impact of COVID-19 on the delayed management of necrotizing fasciitis in a 51-year-old male with multiple comorbidities.

The Characteristics and Follow-Up of SARS-CoV-2 Infection in Pediatric Oncology Patients

Introduction Clinical data about the first and second most prominent waves of SARS-CoV-2 among pediatric cancer patients were inconsistent. This study aims to retrospectively report the clinical characteristics and outcomes of SARS-CoV-2 infection in pediatric oncology patients. Methods This is an observational, retrospective study conducted in a tertiary care oncology center from March 2020 to May 2022. We reviewed the prevalence, severity of symptoms, and duration of positivity in relation to blood count laboratory data and mortality with a follow-up of 30 days post-infection for SARS-CoV-2. Results A total of 396 PCR tests were performed on 342 pediatric cancer patients. The overall rate of SARS-CoV-2 positivity was 43.1% (2.7% in the first wave and 95.4% in the second wave). Among 342 screened pediatric cancer patients, 72 patients had confirmed SARS-CoV-2 positivity in 92 different episodes. Nearly 59% had a mild or moderate infection, with fever and cough as the predominant presentations. The mean duration of positivity was 18.4±7.76 days. Comparing the laboratory values before and after acquiring the COVID-19 infection, only monocytes, hemoglobin, hematocrit, and platelets were statistically significantly affected, with P-values of 0.002, 0.03, 0.02, and 0.01, respectively. More than 18% of patients had grade 3 to 4 neutropenia (absolute neutrophil count=0.39±0.35) before COVID-19 infection and remained neutropenic throughout the disease, regardless of symptom severity. The mean recovery time was 13.67±8 days, which resulted in a delay in cancer treatment delivery of up to four weeks in 42.2% of patients. Conclusion Our data demonstrated that pediatric cancer patients with SARS-CoV-2 infection have a mild to moderate course of COVID-19 disease, with the majority being symptomatic, yet a great portion of our study population experienced treatment interruptions reaching up to four weeks caused by COVID-19.

Extremely Elevated Creatine Kinase in COVID-19-Associated Rhabdomyolysis

Rhabdomyolysis is a condition characterized by the destruction of skeletal muscle cells with the release of myoglobin and creatine kinase into the blood. Viral infections such as influenza and Severe acute respiratory syndrome coronavirus 2 (SARS‑CoV‑2) have been associated with rhabdomyolysis with varying degrees of morbidity and mortality. We present the case of a male in his early thirties who was diagnosed with rhabdomyolysis associated with coronavirus disease 2019 (COVID-19) infection who developed excessively high creatine kinase levels, peaking at 1,650,000 U/L. He was treated with IV fluids and made a complete recovery.

Lung Metastasis From Uterine Leiomyosarcoma: An Asymptomatic Presentation for a Rare Tumor

Uterine leiomyosarcoma (ULC) is an uncommon neoplasm characterized by poor prognosis, it can predispose to distant metastasis, causing various symptomatic presentations. We present a unique case of a large heterogeneous mass in the lung cavity arising from a ULC, with complete absence of pulmonary symptoms and with concurrent coronavirus disease 2019 (COVID-19) infection. A high degree of clinical suspicion is required for ULC with accompanying metastasis.

A Comparison of the Adverse Effects and Utility of Different Monoclonal Antibodies for SARS-CoV-2: A Retrospective Cohort Study

Introduction Multiple monoclonal antibody (mAb) treatments have been developed to combat the growing number of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) strains. These treatments have been shown to be effective in reducing the risk of hospitalization and death from SARS-CoV-2 infection with a low risk of adverse effects; however, more data is required to evaluate the comparative efficacy of mAbs. The primary objective of this study is to describe the hospitalization rate, length of stay (LOS), and mortality rate in SARS-CoV-2 patients treated with four different mAb treatments, including bamlanivimab plus etesevimab, casirivimab plus imdevimab, sotrovimab, and bebtelovimab. Methods A retrospective chart review and prospective phone surveys of SARS-CoV-2 patients treated with mAbs in a 400-bed tertiary, suburban medical center were conducted between June 2020 and April 2022. Eligibility criteria for mAbs included non-hospitalized patients over the age of 18 with less than 10 days of SARS-CoV-2 symptoms and no oxygen requirement on emergency department (ED) admission. Data were collected from the retrospective chart review and subjective patient surveys. A chi-squared test was used. Significance was assessed at p < 0.05. Results The study population included 3249 patients, with 1537 males and 1712 females and an average age of 62.48 ± 17.54 years. Five hundred forty-two patients received bamlanivimab plus etesevimab; 849 received bebtelovimab; 1577 received casirivimab plus imdevimab; and 281 received sotrovimab. The overall hospitalization rate was 1.0%, and the mortality rate was 0.2% following mAb treatment. The hospitalization rate was greatest among patients administered Sotrovimab (2.1%) and least among patients administered Bebtelovimab (0.1%) (p = 0.010). 2.4% of patients who were discharged from the ED after receiving one of the four mAbs returned within 30 days with SARS-CoV-2 symptoms. The average length of stay was 4.75 ± 4.56 days, with no significant differences between the mAbs. The provider-reported adverse event rate was 2.2%, with significant differences in adverse event rates between mAbs. Bamlanivimab-etesevimab was associated with the highest adverse event rate (4.6%), and sotrovimab was associated with the lowest adverse event rate (1.4%) (p < 0.001). Conclusion This study shows a low hospitalization and mortality rate following mAb infusion in patients with mild and moderate COVID-19. However, there were significant differences in hospitalization and mortality among patients receiving each of the four mAb treatments. There was a high degree of patient-reported symptom improvement, and adverse reactions were reported in only 2.2% of patients with no severe reactions. Multiple monoclonal antibody treatments are not effective as monotherapy; however, this study shows the potential benefits of including a mAb infusion as part of a SARS-CoV-2 treatment plan.

Incidence of Air Leak Syndrome in Pediatric Patients With SARS-COV-2 Pneumonia and Respiratory Failure: A Single-Center Retrospective Study

Air leak syndrome (ALS) is defined as the extrusion of air from an aerated compartment into an unaerated compartment with associated symptoms of respiratory distress. This syndrome can occur as a consequence of trauma, iatrogenic causes, or spontaneously. Retrospective investigations conducted in the adult population have demonstrated an elevated risk of spontaneous ALS development in patients with coronavirus disease 2019 (COVID-19) pneumonia, along with its correlation with mortality. However, no studies have yet explored this phenomenon within the pediatric population. In light of this knowledge gap, we conducted a retrospective chart review comprising 128 pediatric patients ranging in age from one month to 18 years. The primary objective was to assess the incidence of ALS in two distinct groups: patients diagnosed with COVID-19 pneumonia and those with non-COVID-19 viral pneumonia. The groups were compared using Fisher's exact test for sex, the presence of ALS, the requirement of extracorporeal membrane oxygenation (ECMO), and death. The modified Wald method was used to calculate the 95% confidence interval for the mortality rate in patients with COVID-19 pneumonia in the presence of ALS. Our findings revealed a higher prevalence of ALS in patients with COVID-19 pneumonia compared to the non-COVID-19 viral pneumonia group, with a statistically significant P-value of 0.02 and an odds ratio (OR) of 6.72. In terms of mortality rates, there was a statistically significant difference between the two groups (P = 0.025, OR = 1.083). In addition, in patients with ALS in the presence of COVID-19 pneumonia, the mortality rate was 37.5%. However, the requirement of ECMO was not statistically significant (P = 0.16, OR = 1.04). These results suggest that patients with COVID-19 pneumonia have an increased mortality rate and a heightened risk of developing ALS compared to individuals with other viral pneumonias. Furthermore, the presence of ALS was associated with a high mortality rate in COVID-19 pneumonia patients. However, it is crucial to note that obtaining a larger patient sample and involving multiple institutions would be necessary to obtain more consistent and robust data.

Exacerbation of Very Late-Onset Darier Disease With COVID-19 Infection: A Case Report

Darier disease is an uncommon hereditary skin disorder characterized by the presence of hyperkeratotic papules and plaques affecting seborrheic areas. The uniqueness of this case lies in the exceptionally late-onset pattern of Darier disease, involving an 82-year-old female patient, and its correlation with COVID-19 infection. The patient had a history of a scaly and itchy rash limited to her arms, initially misdiagnosed as dermatitis, which persisted and worsened over three months. The manifestation of classical features of Darier disease coincided with her recent contraction of COVID-19. This instance emphasizes the varying manifestations of Darier disease that appear very late in life, which could result from new mutations or partial penetrance. Additionally, this case points out the potential worsening of Darier disease when combined with a COVID-19 infection. It highlights the need to be aware of atypical clinical progressions and the potential for increased severity of skin disorders during COVID-19. More studies are essential to grasp the relationship between COVID-19 and inherited skin conditions, aiming to improve patient treatment and care approaches.

COVID-19-Related Bilateral Avascular Necrosis of the Femoral Head

Osteonecrosis is a pathologic process that involves focal bone infarction and death of bone tissue caused by trauma, infections, autoimmune conditions, and chronic steroid use; however, most cases go undiagnosed. The link between bilateral osteonecrosis and coronavirus disease 2019 (COVID-19) infections has not been fully investigated. This is the case of a 42-year-old Caucasian woman who presented to the emergency department for bilateral hip pain, which started three months prior. Initially, the pain was mild; however, her symptoms worsened, causing her to have difficulty ambulating. Co-incidentally she tested positive for COVID-19 10 days after the onset of pain. She denied any lower-extremity numbness, weakness, and loss of bowel or bladder function. X-ray of the hips showed significant sclerosis of bilateral femoral heads and acetabula, indicating avascular necrosis. She was given ketorolac injection intramuscularly for analgesia and remained in stable condition. Upon discharge, she was given a referral to orthopedic surgery for bilateral total hip arthroplasty. Atraumatic osteonecrosis of the femoral head can be caused by multiple etiologies, including exposure to medications, post-transplantation procedures, trauma, and hypercoagulable states. This condition is likely due to poor angiogenesis after an infarct, causing a domino effect of bone demineralization, trabecular thinning, and cortical collapse. A literature search demonstrated prior cases of unilateral femoral head necrosis associated with COVID-19 infection and steroid use. There have been no cases of bilateral osteonecrosis of the femoral head reported without long-term steroid use. Considering the disease severity in both hips and limited steroid use (only five days of prednisone), other common etiologies were sought and were ruled out. In our patient, the only event that was related to her initial onset of hip pain was a COVID-19 infection. We suggest a relationship between COVID-19 infection and avascular necrosis given the rapid progression of the disease. We acknowledge that this presentation of bilateral osteonecrosis is rare and warrants further investigation. More research should be performed to establish a tenable relationship between COVID-19 infection and osteonecrosis, with and without the use of steroids.

The Impact of COVID-19 Infection Control Measures on End-Stage Renal Disease Patients in a Community Hemodialysis Setting

INTRODUCTION

Several non-pharmaceutical infection control measures have been implemented at community-based hemodialysis centers to reduce the risk of Coronavirus Disease of 2019 (COVID-19) transmission, caused by the SARS-CoV-2 virus. However, there have been concerns that such measures may disrupt the routine and timely care required by patients, with adverse effects on their health outcomes. This cross-sectional study aims to determine the unintended consequences of COVID-19 infection control measures on hemodialysis patients.

METHODS

 Electronic medical records were extracted from patients enrolled in community-based hemodialysis centers in Singapore. A baseline group prior of patients consisted of those enrolled in 2017, which was three years prior to the SARS-CoV-2-related pandemic (n = 548). This was compared with the study group of patients enrolled in 2019 (n = 426), just before the COVID-19 pandemic started. Medical records for these two groups were extracted from January to July 2018 for the baseline group and from January to July 2020, respectively. Three regression models were built to study dialysis adherence, kidney disease biomarkers, and hospitalization episodes.

RESULTS

 There was no statistically significant difference in hospitalization and mortality outcomes, adherence to dialysis management, laboratory results for dialysis-related clearance, and anemia outcomes. There was a higher proportion of patients hospitalized for vascular access-related reasons in the study group as compared to the baseline group (OR 1.6, 95% CI: 1.10 to 2.29, P = 0.014). Patients in the study group had albumin levels 2.13% higher (95% CI: 0.88 to 3.39, P < 0.001) and alkaline phosphatase levels 7.3% lower (95% CI: 1.17 to 13.02, P = 0.020) than those in the baseline group.

CONCLUSIONS

 From this community-based hemodialysis study in Singapore, it was shown that the COVID-19 pandemic did not disrupt regular healthcare services for these patients. With strategies instituted for a coordinated health delivery workflow, ensuring sufficient capacity in the various healthcare delivery sites and overall pandemic preparedness, the patient clinical outcomes measures continued to be met with no adverse consequences noted. Some improvements in dialysis-related laboratory values and quality of care targets may be due to more stringent measures instituted to protect these vulnerable patients in the community.

A Rare Post-infectious Rash: Pityriasis Rubra Pilaris After COVID-19 Infection

Pityriasis rubra pilaris (PRP) is a rare papulosquamous skin disorder that often presents with erythematous follicular-based hyperkeratotic papules that can become confluent and lead to erythroderma and electrolyte and thermoregulatory imbalances resulting from increased tissue perfusion and skin barrier breakdown. Due to this condition being uncommon, many specialties outside of dermatology are unfamiliar with this entity which poses unique diagnostic and management challenges. This case report involves a 55-year-old woman who presented to the emergency room with erythroderma secondary to PRP. It highlights the relevance of PRP in the context of in-hospital management by presenting the patient's clinical profile, diagnostic workup, and treatment plan. By emphasizing the distinctive clinical features and natural course of the disease, this report aims to enhance the understanding of this uncommon inflammatory skin condition.

Dermatomyositis Flare-Up Following the SARS-CoV-2 Vaccine: A Case Report and Literature Review

Dermatomyositis is a rare auto-immune inflammatory myopathy of unknown etiology. Several environmental factors, including vaccines, have been identified as potential triggers in genetically susceptible individuals. Since the beginning of the coronavirus disease 2019 (COVID-19) pandemic, the development of vaccines (mRNA and vector-based) has been the most effective tool in reducing the incidence, hospitalization rates, and mortality of COVID-19. However, among individuals with immune dysregulation and auto-immune conditions, unique challenges may arise with immune stimulation. We present a case of a dermatomyositis flare-up following severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) vaccination. A 40-year-old Hispanic female presented to the emergency department with shortness of breath, muscle pain and weakness, and skin rash for two days. She had been recently diagnosed with dermatomyositis six months prior based on clinical presentation, laboratory investigations, and characteristic muscle biopsy findings. She had been on treatment with mycophenolate mofetil, prednisone, and hydroxychloroquine since. She reported receiving the second dose of the BNT162b2 COVID-19 vaccine one day prior to the onset of symptoms. Physical examination revealed erythematous plaques over her cheeks, upper chest, and arms, in addition to Gottron papules on her hands. She had reduced proximal muscle strength and scattered dry crackles bilaterally on lung auscultation. Her laboratory investigations were remarkable for elevated erythrocyte sedimentation rate, C-reactive peptide, creatinine kinase, and troponin T. The SARS- CoV-2 PCR test was negative. CT scan of the chest showed evidence of pneumonitis. A diagnosis of the dermatomyositis flare-up potentially secondary to the SARS-CoV-2 BNT162b2 vaccine was established. The patient was admitted and treated with pulse steroids and intravenous immunoglobulin. She responded well to therapy and was discharged home four days later. There have been several reports of a new onset of dermatomyositis following the SARS-CoV-2 vaccine which highlights the need for further large-scale studies to estimate the prevalence of such adverse effects. The benefits of the SARS-CoV-2 vaccine outweigh the risks even among patients with auto-immune and rheumatologic conditions; however, it is important for clinicians to recognize the possibility of occurrence of such events in order to manage patients appropriately.

Emergence of Pulmonary Tuberculosis While Recovering From COVID-19 Pneumonia: A Case Report

COVID-19 can have different presentations; from asymptomatic to multiorgan involvement. This case report is of an elderly gentleman, with known comorbidities of chronic obstructive airway disease and alcoholic liver disease on treatment. He presented with a history of increasing dyspnea and cough for a few days which was present after cold symptoms, and was admitted for the treatment of severe COVID-19 pneumonia. Later, while he was recovering from COVID-19 pneumonia, his respiratory symptoms worsened. After a thorough evaluation, his sputum smear was positive for acid-fast bacilli and also rifampicin sensitive on GeneXpert assay. With timely diagnosis and appropriate treatment, he recovered from both acute conditions and was sent home on the twentieth day of admission.

SARS-CoV-2: Current Tools to Fight COVID-19 ST-Elevation Myocardial Infarction

The capacity of the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) to wreak havoc on the inflammatory and coagulation pathways via the cytokine storm has led to over 6.3 million fatalities globally. Based on recent data, the mechanism predominately involves the formation of microvascular thrombosis when pertaining to cardiovascular disease. However, a subset of coronavirus disease-2019 (COVID-19)-positive patients present emergently with acute ST-elevation myocardial infarction (STEMI) are found to have severe epicardial thrombosis which is refractory to traditional coronary revascularization. We have noted mortality in these patients presenting to our facility to be as high as 90% and all angiographically confirmed to have thrombus which was refractory to traditional therapy. We present a case series of COVID-19-positive patients presenting with STEMI found to have epicardial thrombus who were treated with different traditional STEMI therapies but with fatal outcomes. Other possible techniques including mechanical thrombectomy, optimizing traditional and nontraditional anticoagulation therapy with the use of early hemodynamic support may prove more efficacious to destroy thrombus and potentially improve mortality.

Impact of the COVID-19 Pandemic on the Management of Gallbladder, Biliary Tract, and Pancreatic Diseases

Introduction Biliary diseases are a major acute general surgical burden. Laparoscopic cholecystectomy is the gold standard surgical procedure, although it was discontinued during an outbreak. Effective management permits decisive therapy, symptom alleviation, and fewer hospitalizations and complications. Throughout the initial COVID-19 situation, surgical procedures for patients were delayed. Invasive services were required to employ conservative or non-operative therapy, which could lead to increased recurring presentations and biliary-pancreatic problems. Aim Examining the impact of COVID-19 on the outcomes and hospitalizations of patients suffering from gallstone, biliary tract, and pancreatic diseases.  Methods The retrospective analysis included patients with the following ICD-10 codes who presented to our unit: cholelithiasis (K80), cholecystitis (K81), and acute pancreatitis (K85). We compared the interval of the first COVID-19 pandemic wave, from March to August 2020, with the period before the pandemic, referred to as Pre-COVID-19. After applying exclusion criteria, a total of 868 patients were enrolled in the trial, having initially recruited around 1,400 individuals using these codes. Patients with inaccurate coding, cancer, or non-stone disease were excluded (e.g., alcoholic pancreatitis). The demographic information, admission details, investigations, surgical therapy, operating specifics, and postoperative complications of the patients were noted. Changes in surgical management, patient representation, and postoperative complications were the key outcomes. Results A statistically significant (p<0.05) rise was seen in repeat presentations in the COVID group, most likely due to the failure of definitive treatment. The other outcome is the distribution of presentations was comparable, patients with acute cholecystitis and gallstone pancreatitis showed statistically significant (p<0.05) lower rates of definitive therapy. Conclusion During the COVID period, all surgeries except those for cancer were halted. Unknown causes led to several consequences related to the gallbladder, biliary tract, and pancreas. Patients with cholecystitis, gallstone pancreatitis, and pancreatic inflammation experienced a lower probability of treatment. The increase in hospitalizations and self-presentations indicated that definitive therapy, designed to restrict COVID-19 exposure, actually increased patient risk. Despite this risk, we had no COVID-19 instances in our cohort. The evaluation of the long-term consequences of the pandemic on acute pancreatitis and its care will require a large-scale, multicenter investigation.

Emphysematous Gastritis in a Patient With Recent COVID-19 Infection

Emphysematous gastritis, a rare pathology, causes gastric inflammation and intramural gas accumulation due to gas-forming microorganisms. Its diagnosis is made based on high clinical suspicion and confirmed by CT imaging of the stomach, which shows circumferential gas formation along the gastric wall. Early diagnosis and treatment are critical, as emphysematous gastritis is associated with a high mortality rate. Medical treatment consists of bowel rest, hydration, and intravenous broad-spectrum antibiotics. In the event of severe clinical decline despite medical treatment, surgery may be indicated. There may be an association between emphysematous gastritis and coronavirus disease 2019 (COVID-19) infection. We present a case of emphysematous gastritis in a patient with carbapenem-resistant Acinetobacter baumannii (CRAB) and a recent COVID-19 infection.