Complicated Course Research Articles

Gut Microbial Disruption in Critically Ill Patients with COVID-19-Associated Pulmonary Aspergillosis.

COVID-19 disease can be exacerbated by Aspergillus superinfection (CAPA). However, the causes of CAPA are not yet fully understood. Recently, alterations in the gut microbiome have been associated with a more complicated and severe disease course in COVID-19 patients, most likely due to immunological mechanisms. The aim of this study was to investigate a potential association between severe CAPA and alterations in the gut and bronchial microbial composition. We performed 16S rRNA gene amplicon sequencing of stool and bronchial samples from a total of 16 COVID-19 patients with CAPA and 26 patients without CAPA. All patients were admitted to the intensive care unit. Results were carefully tested for potentially confounding influences on the microbiome during hospitalization. We found that late in COVID-19 disease, CAPA patients exhibited a trend towards reduced gut microbial diversity. Furthermore, late-stage patients with CAPA superinfection exhibited an increased abundance of Staphylococcus epidermidis in the gut which was not found in late non-CAPA cases or early in the disease. The analysis of bronchial samples did not yield significant results. This is the first study showing that alterations in the gut microbiome accompany severe CAPA and possibly influence the host's immunological response. In particular, an increase in Staphylococcus epidermidis in the intestine could be of importance.

A study to evaluate post operative drop in serum albumin level as marker for surgical stress and predictor for clinical outcome in laparotomy patients

Background: Surgical involvements trigger metabolic stress responses of different magnitude, contributing to delayed recovery, complication rate and length of hospital stay. Insulin resistance, serum albumin levels, cytokines such as interleukin-6, interleukin-10, and other cytokines are used in clinical studies as measure for surgical stress. Clinical practitioners routinely measure C-reactive protein (CRP) levels in the blood after surgery to assess postoperative inflammation and predict the likelihood of postsurgical side effects. The slow kinetics of CRP, which makes it a poor predictor of stress-related complications, is a significant drawback. Albumin is widely used as nutritional marker and predictor. It shows an immediate response to surgical stress and could therefore qualify to measure surgical stress and to predict a complicated postoperative course. The aim of the present study was therefore to evaluate post-operative drop in serum albumin as a marker for surgical stress and predictor for clinical outcome in laparotomy patients.Methods: Patients admitted under surgical units from December 2020 to June 2022, at Mamata Medical College and Hospital, Khammam. A study was carried out on 50 patients admitted, undergoing Laparotomy electively and Emergency. All these patients have been assessed both preoperatively and postoperatively and their complications have been documented.Results: Serum albumin levels were compared pre-operatively and postoperatively using analysis of variance (ANOVA) test. There is statistical significance between pre-operative serum albumin levels and postoperative serum albumin levels from post-operative day (POD) 1 to POD 5.Conclusions: The serum albumin measurement is simple, cost effective and easy to perform. Using the serum albumin as a marker, reliable predictions can be made regarding the surgical complications, duration of stay in the hospital and the severity of surgical stress.

The complexities of transfusion reactions: Coexistence of a delayed haemolytic transfusion reaction and post-transfusion purpura.

Immune-mediated acute or delayed transfusion reactions occur when there is immunological incompatibility between transfused blood products and recipient's antibodies. Acute haemolytic transfusion reactions occur within 24 h and are delayed after 24 h up to 10 days following transfusion, whereas post-transfusion purpura (PTP) typically occurs 7-10 days post-transfusion. We present a case of a previously transfused and recently post-partum female who developed both delayed haemolytic transfusion reaction (DHTR) and PTP. A 42-year-old woman, G2P1, with non-alcoholic liver disease, portal hypertension and previous transfusion history with allogeneic anti-E, developed a severe DHTR and PTP following a complicated post-partum course and multiple transfusions. The antenatal and initial post-partum pre-transfusion antibody screens were negative. Subsequently five red cell antibodies, including anti-c, anti-Fya, anti-Jkb and anti-S and the reappearance of anti-E were, however, identified during follow-up investigations along with the anti-platelet antibody HPA-3a and human leukocyte antigen class I antibodies. Anti-E, anti-Jkb and anti-S were eluted from the circulating red blood cells. To our knowledge, there have been only two other case reports of DHTR and PTP occurring in the same patient.

Carbapenem-Resistant Gram-Negative Fermenting and Non-Fermenting Rods Isolated from Hospital Patients in Poland-What Are They Susceptible to?

Gram-negative fermenting and non-fermenting bacteria are important etiological factors of nosocomial and community infections, especially those that produce carbapenemases. Klebsiella pneumoniae, Acinetobacter baumannii, and Pseudomonas aeruginosa are the most frequently-detected carbapenemase-producing microorganisms. The predominant type of resistance is metallo-β-lactamase (MBL). These bacteria are predominantly isolated from bronchial alveolar lavage, urine, and blood. Carbapenemase-producing Enterobacterales (CPE) strains are always multi-drug-resistant. This significantly limits the treatment options for this type of infection, extends the time of patient hospitalization, and increases the risk of a more severe and complicated disease course. Preventing the transmission of these microorganisms should be a major public health initiative. New antibiotics and treatment regimens offer hope against these infections.

Management of diabetic dyslipidemia in Indians: Expert consensus statement from the Lipid Association of India

In 2021 an estimated 74 million individuals had diabetes in India, almost all type 2 diabetes. More than half of patients with diabetes are estimated to be undiagnosed and more 90% have dyslipidemia that is associated with accelerated development of atherosclerotic cardiovascular disease (ASCVD). Patients of Indian descent with diabetes have multiple features that distinguish them from patients with diabetes in Western populations. These include characteristics such as earlier age of onset, higher frequency of features of the metabolic syndrome, more prevalent risk factors for ASCVD, and more aggressive course of ASCVD complications. In light of the unique features of diabetes and diabetic dyslipidemia in individuals of Indian descent, the Lipid Association of India developed this expert consensus statement to provide guidance for management of diabetic dyslipidemia in this very high risk population. The recommendations contained herein are the outgrowth of a series of 165 webinars conducted by the Lipid Association of India across the country from May 2020 to July 2021, involving 155 experts in endocrinology and cardiology and an additional 2880 physicians.

Newly Diagnosed Crohn's Disease Patients in India and Israel Display Distinct Presentations and Serological Markers: Insights from Prospective Cohorts.

Background: Crohn’s disease (CD) incidence is rising in India. However, features of newly diagnosed patients with CD in this population are largely unknown. The Indo-Israeli IBD GastroEnterology paRtnership (TiiiGER) aimed to investigate differences in presentation among patients with newly diagnosed CD in India and Israel, and to explore phenotype−serotype correlations. Methods: A prospective observational cohort study of consecutive adults (>18 years) conducted in two large referral centers in India and Israel (2014−2018). Clinical data, an antiglycan serological panel, and 20 CD-associated genetic variants were analyzed. Outcomes: complicated phenotype at diagnosis and early complicated course (hospitalizations/surgeries) within 2 years of diagnosis. Results: We included 260 patients (104, Indian (65.4%, male; age, 37.8); 156 Israeli (49.4%, male; 31.8, age)). Median lag time from symptoms onset to diagnosis was 10.5 (IQR 3−38) vs. 3 (IQR 1−8) months in Indian vs. Israeli patients (p < 0.001). Complicated phenotype at diagnosis was observed in 48% of Indian and 30% of Israeli patients (p = 0.003). Complicated phenotype was associated with higher anti-Saccharomyces cerevisiae antibody (ASCA) seropositivity rate among Israeli patients (p < 0.001), but not among Indian patients. Antiglycan serology did not correlate with the tested genetic variants. Early complicated course occurred in 28 (18%) Israeli and 13 (12.5%) Indian patients. The time from diagnosis to complication was comparable (log rank p = 0.152). Antiglycan serology did not correlate with a complicated early course in either cohort. Conclusions: There are significant differences in patients presenting with newly diagnosed CD in India and Israel, including phenotype and distinct biomarkers at diagnosis. These differences suggest different genetic and environmental disease modifiers.

The coronavirus disease pandemic among adult congenital heart disease patients and the lessons learnt – results of a prospective multicenter european registry

BackgroundAt the beginning of the COVID-19 pandemic, professionals in charge of particularly vulnerable populations, such as adult congenital heart disease (ACHD) patients, were confronted with difficult decision-making. We aimed to assess changes in risk stratification and outcomes of ACHD patients suffering from COVID-19 between March 2020 and April 2021. Methods and resultsRisk stratification among ACHD experts (before and after the first outcome data were available) was assessed by means of questionnaires. In addition, COVID-19 cases and the corresponding patient characteristics were recorded among participating centres. Predictors for the outcome of interest (complicated disease course) were assessed by means of multivariable logistic regression models calculated with cluster-robust standard errors. When assessing the importance of general and ACHD specific risk factors for a complicated disease course, their overall importance and the corresponding risk perception among ACHD experts decreased over time. Overall, 638 patients (n = 168 during the first wave and n = 470 during the subsequent waves) were included (median age 34 years, 52% women). Main independent predictors for a complicated disease course were male sex, increasing age, a BMI >25 kg/m2, having ≥2 comorbidities, suffering from a cyanotic heart disease or having suffered COVID-19 in the first wave vs. subsequent waves. ConclusionsApart from cyanotic heart disease, general risk factors for poor outcome in case of COVID-19 reported in the general population are equally important among ACHD patients. Risk perception among ACHD experts decreased during the course of the pandemic.

Immunohistochemical features lymphoid tissue colonic mucosa of children with different phenotypic variants of Crohn’s disease

The aim of the study was to determine the immunohistochemical features of the lymphoid tissue of the mucous membrane (MM) of the colon in children with different course of Crohn’s disease. Methods: the results of IHC and morphometric analyzes of colonic colony of children with Crohn’s disease of uncomplicated and complicated course are presented. Results: An important role of the ratio and distribution of subpopulations of T-lymphocytes of CO and lymphoid clusters in children with Crohn’s disease is shown, depending on the phenotypic variant of the course of the disease. In children with a favorable prognosis of Crohn’s disease, the immunoregulatory index (IRI) was close to normal with a predominance of the CD4 + T-lymphocyte population against the background of a moderately increased number of CD8 + cells and B-lymphocytes. IRI of children of the II group was significantly increased due to a sharp increase in CD4 +, CD8 + T-lymphocytes and CD19 + B-lymphocyte link. Conclusion: A high level of IRI with a pronounced disproportion of intrapopulation T-lymphocytes is combined with an unfavorable course of the disease. For children with uncomplicated course of the disease, a minimal mismatch in the intrapopulation T-lymphocyte system is characteristic against the background of increased IRI.

Endothelial biomarkers and platelet reactivity on ticagrelor versus clopidogrel in patients after acute coronary syndrome with and without concomitant type 2 diabetes: a preliminary observational study

BackgroundPleiotropic effects have been implicated in clinical benefits of ticagrelor compared to thienopyridine P2Y12 antagonists. There are conflicting data regarding effects of ticagrelor vs. thienopyridine P2Y12 blockers on endothelial function. Our aim was to compare endothelial biomarkers and their relations with platelet reactivity in real-world patients after acute coronary syndrome (ACS) on maintenance dual antiplatelet therapy (DAPT) with ticagrelor or clopidogrel stratified by diabetes status.MethodsBiochemical indices of endothelial dysfunction/activation and platelet reactivity by multiple electrode aggregometry were compared in 126 stable post-ACS subjects (mean age: 65 ± 10 years, 92 men and 34 women), including patients with (n = 61) or without (n = 65) coexistent type 2 diabetes (T2DM) on uneventful maintenance DAPT with either ticagrelor (90 mg b.d.) or clopidogrel (75 mg o.d.) in addition to low-dose aspirin. Exclusion criteria included a complicated in-hospital course, symptomatic heart failure, left ventricular ejection fraction < 40% and relevant coexistent diseases except for well-controlled diabetes, mild renal insufficiency or hypertension.ResultsClinical characteristics were similar in patients on ticagrelor (n = 62) and clopidogrel (n = 64). The adenosine diphosphate-induced platelet aggregation and circulating soluble P-selectin (sP-selectin) were decreased in ticagrelor users irrespective of T2DM status (p < 0.001 and p < 0.01 for platelet reactivity and sP-selectin, respectively). Plasma levels of soluble vascular cell adhesion molecule-1 (sVCAM-1) were lower in T2DM subjects on ticagrelor vs. clopidogrel (758 ± 162 vs. 913 ± 217 µg/L, p < 0.01). In contrast, plasma sVCAM-1 was similar in non-diabetic patients on ticagrelor and clopidogrel (872 ± 203 vs. 821 ± 210 µg/L, p > 0.7). The concentrations of sE-selectin, monocyte chemoattractant protein-1 and asymmetric dimethylarginine did not differ according to the type of P2Y12 antagonist regardless of T2DM status. Platelet reactivity was unrelated to any endothelial biomarker in subjects with or without T2DM.ConclusionsOur preliminary findings may suggest an association of ticagrelor-based maintenance DAPT with favorable endothelial effects compared to clopidogrel users in stable post-ACS patients with T2DM. If proven, this could contribute to more pronounced clinical benefits of ticagrelor in diabetic subjects.

Possibilities of phytopreparations in treatment of patients with pharyngeal pathology

Patients with infectious- inflammatory diseases of the pharynx make up a significant percentage on the intake of otorhinolaryngologists and therapists. Most pharyngeal diseases have pronounced clinical signs, have a significant impact on the performance and quality of life of patients, and have a fairly high risk of a complicated course. It is important for such patients to therapeutically provide relief of pain syndrome and stop inflammatory changes. Pharyngeal diseases and their consequences place a pronounced economic burden on the health system and society as a whole. Timely and correctly selected treatment contributes to a favorable resolution of the pathological process, against the background of preserving the protective functions of the pharyngeal mucosa and is economically feasible. Herbal preparations are effective drugs for this purpose. Phytopreparations have long been actively used in clinical practice due to their effectiveness, safety and accessibility. According to the literature, the administration of herbal preparations as monotherapy in patients with acute infectious and inflammatory pharyngeal diseases was found to be a highly effective way of treatment. The active ingredients, chamomile, marshmallow and horsetail contribute to the improvement of the body’s nonspecific defences due to enhancement of phagocytic activity of macrophages and granulocytes. Polysaccharides, essential oils and bioflavonoids of chamomile, marshmallow and yarrow have an anti-inflammatory effect and reduce oedema of the respiratory tract mucous membrane. In addition to antimicrobial and anti-inflammatory effects, herbal preparations have an immunomodulatory effect, which is particularly important because infectious inflammation, trauma, chronic stress entail a secondary immunodeficiency condition. Unnecessary prescriptions of antibacterial drugs, deterioration of the ecological situation contribute to the development of this condition. The immunomodulating effect of phytopreparations is promising not only in the treatment of upper respiratory tract pathology, but also in the secondary prophylaxis and the prevention of chronization of inflammation processes.

Status and recommendations for interventional radiological procedures in COVID-19patients

Particularly at the beginning, the COVID-19 (coronavirus disease 2019) pandemic caused areduction in the number of interventions in interventional radiology. At the same time, interventional training became more challenging. Infectious patients and disease transmission within interventional radiology departments continue to pose significant challenges. This article describes the status and recommendations for interventional radiological procedures in COVID-19patients. Guidelines and recommendations from international and national societies as well as original works and reviews were evaluated. Interventional radiological care of COVID-19patients with complicated courses of infection has become established during the course of the pandemic. To protect patients and staff, interventions in COVID-19patients should be prioritized, performed in separate procedure rooms if possible, and patients should be tested before interventions. Logistics, staff planning, and hygiene measures should be continuously optimized. Structured workflows within interventional radiology in dealing with COVID-19patients appear necessary to minimize infection risks and to guarantee the staff's work capability and health. In order to develop concepts for the handling of COVID-19patients and to be prepared for potential upcoming waves of infections, recommendations of the Robert Koch Institute (RKI) and (inter-)national professional societies are helpful.

Clinical case of complicated course of infectious endocarditis in a teenager

Infective endocarditis (IE) is a heart disease of an infectious nature with a primary lesion of the endocardium, heart valves, ligaments, followed by dissemination of the process to various organs. Infective endocarditis still remains a disease that is difficult to diagnose and unpredictable in terms of outcomes; it is registered in all countries of the world. Despite all the advances in medicine, infective endocarditis remains an extremely dangerous disease, with a mortality rate of 10–30%. The most common causes of lethal outcome of IE are multiple complications: embolisms of various localization, including cerebral arteries, aneurysms, toxic lesions of the spleen, myocarditis and pericarditis, acute renal failure. Currently, in pediatric cardiology practice, the frequency of primary infective endocarditis, which occurs with a change in the clinical picture, its atypical variants, has increased. The awareness of doctors of all specialties about this problem, the correct and timely diagnosis of the disease allows prescribing adequate therapy earlier and thereby improves the prognosis. The aim of our work was to familiarize physicians with the clinical observation of a teenager with an atypical onset of primary infective endocarditis, occurring under the “mask” of acute cerebrovascular accident. Also, the peculiarity of this case was the primary diagnosis of hereditary thrombophilia in the patient and the possible debut of a demyelinating disease of the central nervous system during the examination, which certainly complicated the diagnostic search and affected the outcome of infective endocarditis. The significance of dental procedures preceding the disease in a child, unfortunately, was not properly appreciated by the parents, but it is the inflammatory process in the oral cavity that should be considered as a key etiological factor in the development of infective endocarditis in this case.

Which is the best way for patients with ureteral obstruction? Percutaneous nephrostomy versus double J stenting.

Percutaneous nephrostomy (PCN) and Double J stenting (DJS) are the 2 main treatment options of ureteral obstruction. We evaluate which of these 2 methods is superior concerning the course of procedure, postoperative complication and quality of life. A detailed review of electronic databases including PubMed, Embase, Cochrane Library, China Biology Medicine disc, China National Knowledge Infrastructure up to February 21st, 2021 was searched. Continuous data were evaluated using mean difference (MD) with 95% confidence interval (CI), while nominal data were analyzed by risk ratio (RR) with 95% CI. Meanwhile, we performed the subgroup analysis based on study design, disease type, sample size, sepsis, DJ diameter, nephrostomy diameter, anesthesia type and guidance under X-ray or ultrasound. There were 18 previous studies included in current study. As a result, we found that there were significant differences in fluoroscopy time (MD = 0.31; 95% CI, 0.14-0.48, P < .001) and hospital stay (MD = 1.23; 95% CI, 0.60-1.85, P < .001). However, no statistic difference was detected in operative time (MD = 5.40; 95% CI, -1.78 to 12.58, P = .140) between the paired groups. Although DJS showed a higher rate of postoperative complications (25.19% vs 17.61%), there was no significant difference in the incidence of complications following DJS and PCN (RR = 0.92; 95% CI, 0.60-1.43; P = .720). Based on the EuroQol analysis, the 2 main treatment options had different impacts on quality of life. The pooled results showed that PCN patients reported more difficulties in self-care compared to DJS patients (RR = 3.07; 95% CI, 1.32-7.14; P = .009). DJS is a safe and better method of temporary urinary diversion than PCN for management of ureteral obstruction with shorter fluoroscopy time and hospital stay. As for quality of life, patients receiving PCN had a distinct difficulty in self-care compared to those receiving DJS. However, these 2 treatment options often depends on the individual situation.

Abstract 13836: Factors Associated With a Complicated Hospital Course in Patients With Spontaneous Coronary Artery Dissection: A Report of the iSCAD Registry

Introduction: Spontaneous coronary artery dissection (SCAD) is a cause of acute coronary syndrome in younger patients. Though associated with lower short and long-term mortality, there is still a need to identify the subset of patients who are at a higher risk of adverse events or a more complex hospital course. Methods: Using data from the iSCAD Registry, a multicenter registry of patients with SCAD, univariate and multivariable logistic regression models were created to assess the association between factors related to the index admission and a complicated hospital course. A complicated hospital course was defined as the occurrence of either a recurrent myocardial infarction (MI), cerebrovascular accident (CVA), a new arrhythmia, heart failure requiring diuretics, ≥ 2 angiograms performed, or a hospital admission of more than 5 days. The multivariable logistic regression model was developed using a backward selection approach with exit criteria set at p &gt;0.2. Patients presenting with cardiac arrest were excluded. Results: Of the 414 patients included, 159 patients (38.4%) had a complicated hospital course: 76 patients had a prolonged admission, 27 had a recurrent MI, 1 had a CVA, 39 had an arrhythmia, 13 had heart failure requiring diuretics and 72 had ≥ 2 angiograms in the index admission. The final model showed that patients who had structural complications related to MI, fibromuscular dysplasia (FMD), or a history of cardiomyopathy were more likely to experience a complicated hospital course (Table). Finally, patients on anticoagulation were at a higher risk of having the composite outcome but this may be secondary to the indication for anticoagulation. Conclusions: The presence of structural complications related to MI, a diagnosis of FMD, or a history of cardiomyopathy were associated with an increased risk of a complicated hospital course related to SCAD. Identification of risk factors for a complex inpatient stay may help to tailor the acute care of SCAD patients.

Alcohol use disorder with comorbid anxiety disorder: a case report and focused literature review

BackgroundAlcohol use disorder (AUD) and anxiety disorders (AnxD) are prevalent health concerns in clinical practice which frequently co-occur (AUD-AnxD) and compound one another. Concurrent AUD-AnxD poses a challenge for clinical management as approaches to treatment of one disorder may be ineffective or potentially counterproductive for the other disorder.Case PresentationWe present the case of a middle-aged man with anxiety disorder, AUD, chronic pain, and gamma-hydroxybutyrate use in context of tapering prescribed benzodiazepines who experienced severe alcohol withdrawal episodes during a complicated course of repeated inpatient withdrawal management. After medical stabilization, the patient found significant improvement in symptoms and no return to alcohol use with a regimen of naltrexone targeting his AUD, gabapentin targeting both his AUD and AnxD, and engagement with integrated psychotherapy, Alcoholics Anonymous, and addictions medicine follow-up.ConclusionProper recognition and interventions for AUD and AnxD, ideally with overlapping efficacy, can benefit individuals with comorbid AUD-AnxD. Gabapentin, tobacco cessation, and integrated psychotherapy have preliminary evidence of synergistic effects in AUD-AnxD. Meta-analysis evidence does not support serotoninergic medications (e.g. selective serotonin reuptake inhibitors) which are commonly prescribed in AnxD and mood disorders as their use has not been associated with improved outcomes for AUD-AnxD. Additionally, several double-blind placebo-controlled randomized trials have suggested that serotonergic medications may worsen alcohol-related outcomes in some individuals with AUD. Areas for future investigation are highlighted.

Retinopathy of prematurity, a two-year experience at the ROP screening unit from AL-Zahraa Teaching Hospital, AL-Najaf, Iraq

This study aimed to assess the incidence of retinopathy of prematurity (ROP) in Al Najaf city, define the risk factors of ROP, and assess the performance of the newly implemented ROP screening. This retrospective study was performed in the ROP screening clinic in Al Najaf city between January 2018 and December 2019. 247 neonates were examined at the ROP screening clinic, with gestational age ≤30 weeks, weight ≤1500 g, other fetal and maternal risk factors, and older or heavier newborns with a complicated course. Out of all the neonates, 90 were enrolled in this study because all others lost contact with the ROP clinic. 62 out of 90 enrolled neonates (69%) were diagnosed with ROP. Of them, 82% had stage 1-2 ROP, and 18% had stage 3-4. We found that the higher gestational age was protective for ROP (P-value=0.012, OR=0.434, CI=0.227-0.829). CPAP carried a higher risk of ROP (P-value=0.072, OR=7.276, CI=0.834-63.441). The P-value was significant for maternal age and premature rupture of membranes (PROM) (P-value=0.028 and 0.01, respectively). This study showed the incidence of ROP in the accepted range compared to other countries with similar resources. Furthermore, there was a strong association between ROP and the following factors: decreased gestational age, CPAP, maternal age, and PROM.

Risk of Severe COVID-19 in Non-Adherent OSA Patients.

Patients with obstructive sleep apnoea (OSA) are at increased risk of severe course of COVID-19. Vaccination remains to be the most effective prevention of complicated courses of infection. The best contemporary conservative treatment of OSA is continuous positive airway pressure (CPAP) therapy. To compare vaccination acceptance and outcomes of COVID-19 infection between OSA patients adhering to the CPAP therapy and those who rejected CPAP and surgical therapy. Subjects were divided into two groups: group A (N = 167) were individuals with sufficient CPAP adherence (more than 4 hours per night on average) over the last 10 years. Group B (N = 106) were individuals who did not use the CPAP therapy at all and had no indications to surgical therapy. Three patients in group B died, and one had a severe course of COVID-19. None of the patients in group A died or experienced a severe course of COVID-19. Group A had a significantly higher proportion of males (77.8% compared to 66% in group B) and all parameters of OSA severity. The vaccination status was similar among both groups, with a complete triple dose vaccination rate of 69.5% and 67.9% in groups A and B, respectively. The results show that the patients with OSA adherent to CPAP therapy were less likely to experience a severe course of COVID-19 or death than the OSA patients non-compliant with therapy, despite the former group having more severe OSA. This result underlines the importance of adherence to CPAP therapy in OSA.

THE UNIQUE ROLE IMMUNOLOGISTS PLAY IN NAVIGATING THE CARE OF CRITICALLY ILL PEDIATRIC PATIENTS

<h3>Introduction</h3> Immunologists can play a critical role in navigating prognostic determinations and thus, treatment choices in patient populations with cultural/religious beliefs that diverge from recommended aggressive medical care. <h3>Case Description</h3> An 18-month-old Amish female presented with fever, respiratory distress, hypoxemia and diffuse lymphadenopathy. Chest CT revealed diffuse lymphadenopathy with resultant occlusion of her left mainstem bronchus. Bronchoscopy was performed after which she had respiratory failure requiring extracorporeal membrane oxygenation (ECMO) support. Bronchoalveolar lavage was positive for Blastomyces antigen, respiratory culture positive for <i>Streptococcus anginosus</i> and serum positive for EBV. Flow cytometry showed normal levels of T cells, naïve T cells and B cells but absent natural killer (NK) cells. She was treated for pulmonary blastomycosis and superimposed bacterial pneumonia with excellent clinical improvement. Flow cytometry subsequently repeated with improving but low NK cells (1%). <h3>Discussion</h3> Immunology was consulted to help determine if an underlying immunodeficiency placed her at increased risk for such a severe infection and prognosis given need for ECMO. NK cells are part of the innate immune defense against infection. Reassuringly, she initially had absent NK cells while she was critically ill and being treated with systemic corticosteroids and her levels improved alongside her clinical status. The rest of her immune work-up was also reassuring including newborn screen (including wild-type RMRP/RAG1), immunoglobulin levels, complement studies and dihydrorhodamine test.This case highlights the importance of specialized immunology expertise to assist in discussions with families and providers regarding complicated disease courses in the context of cultural/religious preferences and ethical dilemmas.

ИЗУЧЕНИЕ ВЛИЯНИЯ ДЛИНЫ ТЕЛОМЕР НА КЛИНИЧЕСКУЮ КАРТИНУ ПНЕВМОНИЙ РАЗЛИЧНОЙ ЭТИОЛОГИИ

The results of the study of the features of the clinical course of pneumonia of various etiologies, considering the epigenetic index of the human body, such as telomere length, are presented. Telomeres are specialized functional complexes that are located at the ends of chromosomes and protect them from merging with each other, which preserves the integrity of the eukaryotic cell genome. Telomere length is an important characteristic of a person's overall health. It is associated with such characteristics as longevity and susceptibility of the human body to various diseases, such as type 2 diabetes mellitus, hypertension, coronary heart disease. The study estimated the length of telomeres in patients with pneumonia of various etiologies. 121 young men who were treated at the hospital therapy clinic of the Military Medical Academy named after S. M. Kirov were examined. Patients were divided into three groups according to telomere length at admission: I group of 32 people aged 27.4±5.21 years with telomere length of more than 8000 nucleotide pairs; Group II – 52 people aged 27.9±5.83 years with a telomere length of 6000 to 8000 pairs of nucleotides; group III – 37 people aged 26.7± 5.75 years with a telomere length of less than 6000 nucleotides. Patients were examined and treated according to the standard scheme. During a clinical study in patients with pneumonia of various etiologies, the features of the initial state were studied and the indicators of the main clinical, functional and laboratory parameters were studied, as well as the length of telomeres was estimated. It was found that patients with various epigenetic parameters are characterized by the features of clinical symptoms and physical indicators of community-acquired pneumonia, characterized by more pronounced initial signs of clinical course and intoxication, a longer period of asthenization in patients with telomere length less than 6,000 nucleotide pairs. Community-acquired pneumonia in patients with telomere lengths of more than 8000 nucleotide pairs is characterized by a mild course and the absence of prolonged and complicated forms of the disease. The results of the clinical study can be used as a prediction of a severe course, as well as a complicated and prolonged course of viral lung damage caused by a new coronavirus infection. The obtained data give a promising idea to consider the telomere length of peripheral blood lymphocytes as a specific biological predictor of assessing the severity, prolonged and complicated course of pneumonia caused by the SARS-CoV-2 virus.

Chronic pancreatitis: about some complications and features of their pathogenesis and course

The review article provides up-to-date information on the complications of pancreatitis that are important for the tactics and strategy of patient management both at the inpatient and outpatient stages of observation. The purpose of the review was to emphasize the importance of complications for the course and life of patients with chronic pancreatitis. The authors draw the attention of internists to the course of such complications as pseudocysts, cysts, fistulas, thrombohemorrhagic, cholestatic syndromes, compression syndrome of adjacent organs, pancreatic encephalopathy (acute and chronic). The symptomatology of complications of chronic pancreatitis is discussed in detail, which is very important for differential diagnosis with the corresponding diseases. Such complications include the formation of erosive and ulcerative lesions, varicose veins of the esophagus and bleeding from varicose veins of the esophagus and stomach, portal hypertension syndrome with pancreatic ascites and chronic pancreatic encephalopathy, idiopathic non-cirrhotic portal hypertension, pancreatic cancer. The authors emphasize the need to analyze the corresponding symptoms, indicating the possibility of complications, negative consequences with each recurrence or exacerbation of chronic pancreatitis, since it concerns the prognosis and life of the patient.