Samuel Windham, Kellen Hirsch, Ryan Peterson, David Douin, Lakshmi Chauhan, Lauren Heery, Connor Fling, Nemanja Vukovic, Fernando Holguin, Shanta Zimmer, Kristine Erlandson
University of Colorado Anschutz Medical Campus, Denver, CO, USA
Introduction: The predictive potential of demographics, clinical characteristics, and inflammatory markers at admission to determine future intubation needs of hospitalised CoVID-19 patients is unknown. The study aimed to determine the predictive potential of elevated serum inflammatory markers in determining the need for intubation in CoVID-19 Patients. Methods: In a retrospective cohort study of hospitalised SARS-CoV2 positive patients, single and multivariable regression analyses were used to determine covariate effects on intubation odds, and a minimax concave penalty regularised logistic regression was used to build a predictive model. A second prospective independent cohort tested the model. Results: Systemic inflammatory markers obtained at admission were higher in patients that required subsequent intubation, and adjusted odds of intubation increased for every standard deviation above the mean for c-reactive protein (CRP) OR:2.8 (95% CI 1.8-4.5, p<0.001) and lactate dehydrogenase OR:2.1 (95% CI 1.3-3.3, p=0.002). A predictive model incorporating C-reactive protein, lactate dehydrogenase, and diabetes status at the time of admission predicted intubation status with an area under the curve (AUC) of 0.78 with corresponding sensitivity of 86%, specificity of 63%. This predictive model achieved an AUC of 0.83, 91% sensitivity, and 41% specificity on the validation cohort. Conclusion: In patients hospitalised with CoVID-19, elevated serum inflammatory markers measured within the first twenty-four hours of admission are associated with an increased need for intubation. Additionally, a model of C-reactive protein, lactate dehydrogenase, and the presence of diabetes may play a predictive role in determining the future need for intubation.
Helen E. Baxendale1, David Wells2, Jessica Gronlund1, Angalee Nadesalingham2, Mina Paloniemi2, George Carnell2, Paul Tonks2, Lourdes Ceron-Gutierrez3, Soraya Ebrahimi3, Ashleigh Sayer3, John A.G. Briggs4, Xiaoli Ziong4, James A Nathan2, Guinevere Grice2, Leo C James4, Jakub Luptak4, Sumita Pai1, Jonathan L Heeney2, Sara Lear3, Rainer Doffinger3
1 Royal Papworth Hospital NHS Foundation Trust Cambridge, UK 2 University of Cambridge, UK 3 Cambridge University Hospitals NHS Foundation Trust, UK 4 MRC Laboratory of Molecular Biology, UK
Introduction: In early 2020, at first surge of the coronavirus disease 2019 (COVID-19) pandemic, many health care workers (HCW) were re-deployed to critical care environments to support intensive care teams looking after patients with severe COVID-19. There was considerable anxiety of increased risk of COVID-19 for these staff. To determine whether critical care HCW were at increased risk of hospital acquired infection, we explored the relationship between workplace, patient facing role and evidence of immune exposure to the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) within a quaternary hospital providing a regional critical care response. Routine viral surveillance was not available at this time. Methods: We screened over 500 HCW (25% of the total workforce) for history of clinical symptoms of possible COVID19, assigning a symptom severity score, and quantified SARS-CoV-2 serum antibodies as evidence of immune exposure to the virus. Results: Whilst 45% of the cohort reported symptoms that they consider may have represented COVID-19, 14% had evidence of immune exposure. Staffs in patient facing critical care roles were least likely to be seropositive (9%) and staff working in non-patient facing roles most likely to be seropositive (22%). Anosmia and fever were the most discriminating symptoms for seropositive status. Older males presented with more severe symptoms. Of the 12 staff screened positive by nasal swab (10 symptomatic), 3 showed no evidence of seroconversion in convalescence. Conclusions: Patient facing staff working in critical care do not appear to be at increased risk of hospital acquired infection however the risk of nosocomial infection from non-patient facing staff may be more significant than previous recognised. Most symptoms ascribed to possible COVID-19 were found to have no evidence of immune exposure however seroprevalence may underrepresent infection frequency. Older male staff were at the greatest risk of more severe symptoms.
Rajai F. Bulbul, Jassim Al Suwaidi, Mohammed Al-Hijji, Hassan Al Tamimi, Ibrahim Fawzi
Hamad Medical Corporation, Doha, Qatar
A 49-year-old female Qatari woman, with no past medical history, presented at a hospital complaining of a history of cough and shortness of breath. The patient tested positive for severe acute respiratory syndrome (ARDS) and COVID-19. Subsequently, her course of treatment was complicated by severe acute respiratory distress syndrome, pulmonary embolism and severe myocarditis requiring treatment with venous-arterial extracorporeal membrane oxygenation as a bridge to complete recovery.
Johns Hopkins University School of Medicine, Baltimore, MD, USA
As we are writing this editorial 12 months following the publication of “The 2019 Novel Coronavirus: A Crown Jewel of Pandemics?”, there are 96 million cases with over 2 million total deaths, a public health tragedy of staggering proportions . The early stages of the pandemic were characterized by scientific uncertainty, with many authors postulating hypotheses about the transmission of SARS-CoV-2, the appropriate medical treatment, and the most effective public health measures. In retrospect, many of the early takes on coronavirus ended up being incorrect. Since January 2020, science has advanced at a breathtaking pace and the disease caused by SARS-CoV-2 has taken on dimensions few of us anticipated. In this piece, we aim to reflect on the last year, discussing aspects of the pandemic that the scientific community correctly anticipated, and highlighting where we went wrong. [More]
Khang Ning Loo1, You Jiang Tan2, Kaavya Narasimhalu2, Krishan Kumar Sharma3, Dorinda Chee Yee Chew4, Hei Man Wong5, Yvonne Fu Zi Chan5, Ken Cheah Hooi Lee6
1 Department of Internal Medicine, Singapore General Hospital, Singapore, Singapore 2 Department of Neurology, National Neuroscience Institute, Singapore General Hospital, Singapore, Singapore 3 Department of Neurosurgery, National Neuroscience Institute, Singapore General Hospital, Singapore, Singapore 4 Department of Diagnostic Radiology, Singapore General Hospital, Singapore, Singapore 5 Department of Infectious Disease, Singapore General Hospital, Singapore, Singapore 6 Department of Respiratory and Critical Care Medicine, Singapore General Hospital, Singapore, Singapore
Background: Recent studies have reported that COVID-19 infected patients with stroke, who were often in the older age group, had a higher incidence of vascular risk factors, and more severe infection related respiratory symptoms. These observations provided little evidence to suggest that COVID-19 infection is a potential causative factor for stroke. This report describes a young patient with a cerebellar stroke secondary to COVID-19 infection. Case presentation: A 45-year old male presented at a hospital, reporting a two-day history of headache, vertigo, persistent vomiting, and unsteady gait. Physical examination revealed gaze-evoked nystagmus on extraocular movement testing, left-sided dysmetria and dysdiadochokinesia. He was diagnosed with a left cerebellar stroke. An external ventricular drain was inserted, and sub-occipital craniectomy was performed to manage the effects of elevated intracranial pressure due to the extent of oedema secondary to the infarct. He also underwent screening for the COVID-19 infection, which was positive on SARS-COV-2 polymerase chain reaction testing of his endotracheal aspirate. Blood and cerebrospinal fluid samples were negative. After the surgery, the patient developed atrial fibrillation and had prolonged vomiting symptoms, but these resolved eventually with symptomatic treatment. He was started on aspirin and statin therapy, but anticoagulation was withheld due to bleeding concerns. The external ventricular drain was removed nine days after the surgery. He continued with active rehabilitation. Conclusions: Young patients with COVID-19 infection may be more susceptible to stroke, even in the absence of risk factors. Standard treatment with aspirin and statins remains essential in the management of COVID-19 related stroke. Anticoagulation for secondary prevention in those with atrial fibrillation should not be routine and has to be carefully evaluated for its benefits compared to the potential harms of increased bleeding associated with COVID-19 infection.
Gabriela Droc, Lavinia Brezeanu, Cristina Martac, Alexandra Solomon, Stefan Andrei
Clinical Institute Fundeni, Bucharest, Romania
The new severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection is an ongoing global challenge with unpredictable future evolution. Different epidemiological and clinical strategies currently are being evaluated, and the optimal treatment modalities are still to be determined. Developed healthcare systems have been struggling to cope with the additional medical requirements and the lockdown measures, adopted by many countries, are presenting a substantial economic burden. Countries with more fragile economies and medical systems are facing difficult choices. Romania possesses a progressive yet fragile healthcare system. The national lockdown was declared on 25th March 2020, in order to gain time for better logistic healthcare preparations. This brief report aims to describe the challenges of managing an in-hospital SARS-CoV-2 outbreak in an academic hospital of national importance. Our institution is the primary national centre for liver transplantation and liver surgery, a major centre for bone marrow transplantation and one of the two national centres for renal transplantation. It shares common buildings with the major national cardiovascular and emergency cardiac surgery centre. [More]
Christophe de Terwangne1, Antonio Sorgente2, Redente Tortora3, Diana Cheung3, Frederic Duprez3, Sammy Place1, Jerome R. Lechien4, Lucio Capulzini2, Michael De Cubber2, Sven Saussez4, Fabio Silvio Taccone5, Shahram Mashayekhi3
1 Department of Internal Medicine, Centre Hospitalier EpiCURA Hornu, Hornu, Belgium 2 Department of Cardiology, Centre Hospitalier EpiCURA, Hornu, Belgium 3 Department of Intensive Care, Centre Hospitalier EpiCURA, Hornu, Belgium 4 Department of Human Anatomy and Experimental Oncology, University of Mons, Mons, Belgium 5 Department of Intensive Care, Hopital Erasme, Université Libre de Bruxelles, Brussels, Belgium
Aim: The objective of the study was to assess mortality rates in COVID-19 patients suffering from acute respiratory distress syndrome (ARDS) who also requiring mechanical ventilation. The predictors of mortality in this cohort were analysed, and the clinical characteristics recorded. Material and method: A single centre retrospective study was conducted on all COVID-19 patients admitted to the intensive care unit of the Epicura Hospital Center, Province of Hainaut, Belgium, between March 1st and April 30th 2020. Results: Forty-nine patients were included in the study of which thirty-four were male, and fifteen were female. The mean (SD) age was 68.8 (10.6) and 69.5 (12.6) for males and females, respectively. The median time to death after the onset of symptoms was eighteen days. The median time to death, after hospital admission was nine days. By the end of the thirty days follow-up, twenty-seven patients (55%) had died, and twenty–two (45%) had survived. Non-survivors, as compared to those who survived, were similar in gender, prescribed medications, COVID-19 symptoms, with similar laboratory test results. They were significantly older (p = 0.007), with a higher co-morbidity burden (p = 0.026) and underwent significantly less tracheostomy (p < 0.001). In multivariable logistic regression analysis, no parameter significantly predicted mortality. Conclusions: This study reported a mortality rate of 55% in critically ill COVID-19 patients with ARDS who also required mechanical ventilation. The results corroborate previous findings that older and more comorbid patients represent the population at most risk of a poor outcome in this setting.
Ioannis Ilias1, Vassiliki Mantziou2, Efstratios Vamvakas2, Efstathia Kampisiouli2, Maria Theodorakopoulou2, Chariklia Vrettou2, Evangelia Douka2, Alice G. Vassiliou2, Stylianos Orfanos2, Anastasia Kotanidou2, Ioanna Dimopoulou2
1 Elena Venizelou Hospital, Athens, Greece 2 National and Kapodistrian University of Athens
Introduction: Healthcare professionals who are directly involved in the diagnosis, treatment, and general care of patients with SARS-CoV-2 are at risk of developing adverse psychological reactions. A cross-sectional study of healthcare professionals aimed to determine the impact of the SARS-CoV-2 pandemic on the mental health of healthcare professionals in two of the largest referral hospitals in Athens, Greece. Methods: The study was conducted in the two largest SARS-CoV-2 referral hospitals in Athens, Greece. An assessment and the interrelationship of post-traumatic stress disorder, using the Impact of Event Scale-Revised [IES-R]) and burnout, using the Maslach Burnout Inventory [MBI]) was carried out. Results: A total of 162 subjects were enrolled in the study. Fifty-six (35%) had an IES-R score > 33, suggesting post-traumatic stress disorder. Forty-nine (30%) had an MBI score > 27. Seventy-five (46%) had a personal accomplishment score of < 33 and 46 (28%) had a depersonalization score >10. Stepwise backward logistic regression revealed that the only independent variable that was retained regarding the presence of post-traumatic stress disorder was the emotional exhaustion score of the MBI (at a cut-off of 24 in this scale, the 95% CI of the odds ratio for the presence of post-traumatic stress disorder was 1.077-1.173). Conclusions: In this sample of first-line Greek healthcare professionals against SARS-CoV-2, most of them were proven to be quite resilient to this challenge. One-third of them had post-traumatic stress disorder, which depended on their degree of emotional exhaustion. Healthcare professionals, as represented by this study, performed their duties without feeling helpless and developing adverse psychological reactions.
Megan M. Lowery1, Muhammad Taimur Malik2, Joseph Seemiller2, Cynthia S. Tsai1
1 Pulmonary/Critical Care Medicine, Geisinger Medical Center, Danville PA, USA
2 Geisinger Neuroscience Institute, Geisinger Medical Center, Danville, PA, USA
Objective: A rare variant Miller Fisher Syndrome overlap with Guillain Barre Syndrome is described in an adult patient with SARS-COV-2 infection.
Case Presentation: The clinical course of a 45-year-old immunosuppressed man is summarized as a patient who developed ataxia, ophthalmoplegia, and areflexia after upper respiratory infection symptoms began. A nasopharyngeal swab was positive for COVID-19 polymerase chain reaction. He progressed to acute hypoxemic and hypercapnic respiratory failure requiring intubation and rapidly developed tetraparesis. Magnetic resonance imaging of the spine was consistent with Guillain Barre Syndrome. However, the clinical symptoms, along with positive anti-GQ1B antibodies, were consistent with Miller Fisher Syndrome and Guillain Barre Syndrome overlap. The patient required tracheostomy and had limited improvement in his significant neurological symptoms after several months.
Conclusions: The case demonstrates the severe neurological implications, prolonged recovery and implications in the concomitant respiratory failure of COVID-19 patients with neurological symptoms on the spectrum of disorders of Guillain Barre Syndrome.
Nishant R Tiwari1, Khalid I Khatib2, Subhal B Dixit3, Prajay K Rathore4, Sameer Melinkeri5, Abhijeet Ganapule6, Kapil S Borawake7, Ujwala Mhatre8
1 Byramjee Jeejeebhoy Medical College and Sassoon General Hospital, Pune, Maharashtra, India
2 Smt Kashibai Navale Medical College and General Hospital, Pune, India
3 Sanjeevan Hospital, Pune, India
4 Danbury Hospital, Danbury, USA
5 Deenanath Mangeshkar Hospital and Research Centre, Pune, India
6 Niche Hematology Care, Kolhapur, India
7 Prayag Hospital, Pune, India
8 Nanavati Hospital, Mumbai, India
The novel coronavirus disease, 2019 (COVID – 19) evolved as an unprecedented pandemic. The severe acute respiratory syndrome-corona virus-2 (SARS-CoV-2) infection has been associated with significantly deranged coagulation parameters and increased incidence of thrombotic events. Deranged coagulation parameters, such as D-dimers and fibrin degradation products, can indicate a poor prognosis, and their measurement will help stratify the patients according to the disease severity, need of intensive care unit admission, and prediction of the clinical course. Gaps in understanding the natural history of the disease cause difficulties in tailoring therapies and optimizing the management of patients. Lack of specific treatment further complicates this situation. While thrombotic events can cause significant morbidity and mortality in patients, a focused approach to the prevention and treatment of venous thromboembolism (VTE) can, to a great extent, decrease the disease burden caused by thrombotic diseases. Pharmacological prophylactic anticoagulants and mechanical therapies such as pneumatic compression devices can help prevent venous thromboembolism and other thrombotic events. Thrombotic events due to COVID-19, their prevention and management, are the focus of this paper, with the prospect of providing insights into this relatively unexplored area.
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