Management Of COVID-19 Pneumonia Research Articles

The safety and efficacy of imatinib a tyrosine kinase inhibitor for the treatment of SARS-COV-2 induced pneumonia: a pilot study

Introduction Infection with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) results in a wide spectrum of disease, approximately 15–20% of affected patients present with severe phenotype that require supplemental oxygen, including up to 5% who may develop critical illness. The main therapeutic strategies proposed for the management of COVID-19 pneumonia are direct antiviral and immunomodulatory treatments aiming to prevent disease progression. In this pilot study we are testing the hypothesis of using imatinib a tyrosine kinase inhibitor (TKI) as an immunomodulatory treatment to prevent disease progression, based on encouraging data from cellular, animal models and clinical trials, showing a beneficial role of TKI in the regulation of inflammation and endothelial barrier integrity, as well as their antiviral properties. Aim The primary end point is to assess the effect of the imatinib treatment, in terms of safety and efficacy, to prevent the progression of patients with moderate to severe COVID-19 pneumonia into critical illness and need for invasive mechanical ventilation. The secondary end point is a composite of change in clinical, laboratory and radiological parameters, including: clinical parameters − the percentage of patients reaching normal hypoxic index (HI) at time of hospital discharge, hospital length of stay and days on mechanical ventilation (MV) in patient intubated and mechanically ventilated, the changes in the levels of laboratory inflammatory markers: serum ferritin, serum C reactive protein (CRP), serum interleukin 6 (IL6), viral clearance presented by the delta time till negative SARS-CoV-2 PCR results, as well as the change in the chest radiological parameters (Computed tomography chest or radiography). Methods Thirty SARS-COV-2 positive patients with moderate to severe respiratory symptoms, were enrolled and randomized into three groups: group 1 Control, group 2 Low dose Imatinib (receiving 200 mg Imatinib/day) and group 3 Standard dose Imatinib (receiving 400 mg Imatinib/day). Results There was no significant difference between the three groups regarding the severity of the disease at baseline, as assessed by clinical, laboratory and radiological parameters. There was a nonstatistically significant difference in the primary end point of the study, regarding the number of patients in need for invasive mechanical ventilation, between the control group and the intervention groups receiving imatinib. Conclusion Despite the negative results regarding the efficacy of imatinib to flatten the curve of the illness and the prevention of more severe phenotype of the disease, our study showed positive findings regarding the medication’s safety and patients’ tolerability. These finding would pave the way for further studies to assess the concept of immunomodulation in the treatment of immunity derived disease, like sepsis and acute respiratory distress syndrome (ARDS).

Home management of Covid-19 pneumonia in the early phases of the pandemic: analysis of real-life data of General Practitioners in the Province of Modena from the MAGMA study.

Primary care management of Covid-19 pneumonia in the Province of Modena in the early phases of the pandemic: data integration from MAGMA study. Retrospective study on patients affected of Covid-19 and followed by General Practitioner from March 2020 to April 2021. 5340 patients were studied, 27% of them developed pneumoniae. Among these, most of them were managed entirely at home with an elevated intensity of care. Daily remote monitoring and home visits, together with a personalized pharmacological treatment, especially for the most severe forms, appeared to be the most effective interventions in reducing hospitalizations.

Management of COVID-19 Pneumonia: Experience in a Peripheral Tertiary Level Hospital in Bangladesh

Background: Since the detection of the first case of the novel SARS-CoV-2 virus in Wuhan, China, on December 31, 2019, the world stepped into an era of the pandemic as declared by WHO on March 11, 2020. With no prior knowledge regarding this new pandemic, the evidence-based practice of medical management was at stake. Experience sharing from different corners of the world played an essential role in building knowledge to save the world. Methods: The researchers collected data for this retrospective study, from hospital records of the COVID-19 dedicated unit of Sylhet Women’s Medical College, Sylhet, Bangladesh, that was formed temporarily in July 2020, in response to the pandemic situation in the country. This article includes data on 3408 admitted COVID-19 patients with moderate to severe symptoms, managed in the isolation unit including its intensive care unit (ICU) up to November 2021. Results: The mean age of the patients was 57.21±12.58 years and male to female ratio was 1:1.8. Fever (44.4%), cough (38.9), and fatigability (33.3%) were the common symptoms. Diabetes mellitus (67.7%), systemic hypertension (63.7%), asthma (8.65%), chronic obstructive pulmonary disease (21.94%), and, ischemic heart disease (31.2%) were the top co-morbid conditions. Of the study subjects, 68.2% were RT-PCR positive for COVID-19, 67.3% had an abnormal baseline chest X-ray, and 91.1% had a ground glass shadow on a high-resolution CT scan of chest. Average C-reactive protein, D-dimer, and serum ferritin values were 71.68±60.38, 1.16±2.11, and 839±748.57 respectively. Hypoxemia, which was a common problem among them, was managed with oxygen therapy with an appropriate delivery device, with or without supplementation by dexamethasone (78.3%), or methylprednisolone (18.8%). Eighteen (18) patients refused to receive any antiviral therapy, 61 received oral Favipiravir and the rest of them received injectable Remdesevir. Standard care was augmented with Baricitinib in 60 patients. Thirty-six (36) patients in the ICU, with poor response to standard care, were treated with Tocilizumab. Death rates were 9.46% in the non-ICU block, but they were 6-10 times higher in the ICU. Conclusion: Every medical professional learned from the initial two years of the COVID-19 pandemic. Lessons learnt from experience helped building up the knowledge pool necessary for generating effective protocols for COVID-19 pneumonia management.

The effectiveness of Tocilizumab in severe covid 19 pneumonia among critically ill patients

Background: Tocilizumab, an interleukin-6 (IL-6) antagonist, is being evaluated for the management of covid-19 pneumonia. The objective of this study was to assess the effectiveness of Tocilizumab in severe covid-19 pneumonia. Methods: This was a retrospective, observational, single centre study performed in 121 patients diagnosed with severe covid-19 pneumonia. 83 patients received standard of care treatment whereas 38 patients received tocilizumab along with standard of care. Tocilizumab was administered intravenously at 8mg/kg (upto a maximum of 800mg). The second dose of Tocilizumab was given 12 to 24 hours apart. The primary outcome measure was ICU related and hospital related mortality. The secondary outcome measures were change in clinical status of patients measured by WHO (World Health Organisation) 7 category ordinary scale, changes in interleukin-6 (IL-6) levels, secondary infections and duration of ICU stay. Results: Tocilizumab was administered between 3-27 days after the patient reported symptoms ( a median of 10.9 days ) and between the 1st to 3rd day of ICU admission (median of 2.1 days) . In Tocilizumab group, 16(42.1%) of 38 patients died in ICU whereas in standard of care group, 27(32.53%) of 83 patients died. The difference in clinical status assessed using WHO (World Health Organisation) 7 category ordinary scale at 28 days between Tocilizumab group and standard of care group was not statistically significant (odds ratio 1.35, 95% confidence interval 0.61 to 2.97, p = 0.44). Conclusion: Tocilizumab plus standard care was not superior to standard care alone in reducing mortality and improving clinical outcomes at day 28.

Exploring Radiologists’ Burnout in the COVID-19 Era: A Narrative Review

Since its beginning in March 2020, the COVID-19 pandemic has claimed an exceptionally high number of victims and brought significant disruption to the personal and professional lives of millions of people worldwide. Among medical specialists, radiologists have found themselves at the forefront of the crisis due to the pivotal role of imaging in the diagnostic and interventional management of COVID-19 pneumonia and its complications. Because of the disruptive changes related to the COVID-19 outbreak, a proportion of radiologists have faced burnout to several degrees, resulting in detrimental effects on their working activities and overall wellbeing. This paper aims to provide an overview of the literature exploring the issue of radiologists' burnout in the COVID-19 era.

Low Dose Radiotherapy in the Management of COVID-19 Pneumonia (LOWRAD-Cov19): Final Results

Purpose/Objective(s)To evaluate the results of LD-RT to lungs in the management of patients with COVID-19 pneumonia.Materials/MethodsWe conducted a prospective phase I-II trial enrolling COVID-19 patients ≥50 years-old, with bilateral lung involvement at imaging study and oxygen requirement. Patients received 1 Gy to whole lungs in a single fraction. Primary outcome was radiological response assessed as severity and extension scores at days +3 and +7. Secondary outcomes were toxicity (CTCAE v5.0), days of hospitalization, changes in inflammatory blood parameters (ferritin, lymphocytes, C-reactive protein, d-dimer and LDH) and SatO2/ FiO2 index (SAFI), at day +3 and +7. Descriptive analyses were summarized as means with standard deviation (SD) and/or medians with interquartile ranges (IQR). A Wilcoxon sign rank test for paired data was used to assess the CT scores and Chi Square was used to assess for comparison of categorical variables.ResultsForty-one patients were included. Median age was 71 (IQR 60-84). Eighteen patients (47%) previously received any antiCOVID treatment (tocilizumab, lopinavir/ritonavir, remdesivir) and thirty-two patients (84%) received steroids during LD-RT. Extension score improved significantly (p=0.02) on day +7 and SAFI on day +3 and + 7 (p<0.01). Median SAFI on day 0 was 147 (IQR 118-264), 230 (IQR 120-343) on day +3 and 293 (IQR 121-353) on day +7. Significant decrease was found in C-reactive protein on day +7 (p=0.02) and in lymphocytes counts on day +3 and +7 (p=0.02). Median number of days in hospital after RT was 11 (range 4-78). With a median follow-up of 60 days after LD-RT, 26 (63%) patients were discharged, 11 (27%) died because of COVID respiratory failure and 4 (10%) died of other causes.ConclusionLD-RT is a feasible and well-tolerated treatment that may lead to rapid clinical improvement. Large randomized trials should be done to establish the efficacy of LD-RT to treat COVID-19 pneumonia.

Effects of a Chair Positioning Session on Awake Non-Intubated COVID-19 Pneumonia Patients: A Multicenter, Observational, and Pilot Study Using Lung Ultrasound.

Background: LUS is a validated tool for the management of COVID-19 pneumonia. Chair positioning (CP) may have beneficial effects on oxygenation and lung aeration, and may be an easier alternative to PP. This study assessed the effects of a CP session on oxygenation and lung aeration (LA) changes in non-intubated COVID-19 patients. Methods: A retrospective multicenter study was conducted in an ICU. We analyzed data from LUS exams and SpO2:FiO2 performed before/after a CP session in non-intubated COVID-19 patients. Patients were divided into groups of responders or non-responders in terms of oxygenation or LA. Results: Thirty-three patients were included in the study; fourteen (44%) were oxygenation non-responders and eighteen (56%) were oxygenation responders, while thirteen (40.6%) and nineteen (59.4%) patients were classified as LA non-responders and responders, respectively. Changes in oxygenation and LA before/after a CP session were not correlated (r = −0.19, p = 0.3, 95% CI: −0.5–0.17). The reaeration scores did not differ between oxygenation responders and non-responders (1 (−0.75–3.75) vs. 4 (−1–6), p = 0.41). The LUS score was significantly correlated with SpO2:FiO2 before a CP session (r = 0.37, p = 0.04, 95% CI: 0.03–0.64) but not after (r = 0.17, p = 0.35, 95% CI: −0.19–0.50). Conclusion: A CP session was associated with improved oxygenation and LA in more than half of the non-intubated COVID-19 patients.

Point-of-care lung ultrasound: A useful diagnostic tool in the management of COVID-19

Patients with COVID-19 disease frequently present with severe respiratory distress and hypoxia in emergency department. Point-of-care lung ultrasound has proven its efficacy in the diagnosis and management of various clinical conditions including pneumonia, acute respiratory distress syndrome and pulmonary oedema. Incorporating bedside lung ultrasound as an imaging tool for the diagnosis and management of COVID-19 pneumonia can help in quick assessment of the severity of lung damage and to track the evolution of disease during follow-up. Serial lung ultrasounds may be particularly useful in assessing the clinical response to the respiratory interventions and guiding the appropriate medical therapy.

Mucormycosis and Its Co-Relation with Raised Ferritin Levels

Background: Mucormycosis has emerged as an epidemic within the COVID-19 pandemic due to widespread use of corticosteroids and immune-modulators like Tocilizumab, in the management of COVID-19 pneumonia,. It is an invasive fungal disease which spreads by angioinvasion and rapidly spreads to adjacent tissues. If untreated its outcomes are dangerous and often fatal. Uncontrolled diabetes, malignancies and dialysis are predisposing factors. Raised blood iron is an important factor in pathogenesis and rapid progression of fungal invasion that needs to be investigated. Aim: To establish a correlation between raised serum ferritin level and aggressiveness of Mucormycosis. Methodology: A retrospective study was done from February 2021 to February 2022 of patients diagnosed with mucormycosis by middle meatal biopsy and microscopy along with CT &amp; MRI scan of PNS with brain. They were treated either surgically or conservatively. All the blood parameters including serum ferritin level, were carried out. A comparison was done on extent of disease in patients in-relation to their serum ferritin level. Results: Our study suggested that higher levels of ferritin are often associated with aggressive form the disease. Zygomycetes are dependent on environmental iron for their growth. Higher the serum ferritin level, more aggressive &amp; widespread is mucormycosis. Conclusion: Serum free iron aggravates mucormycosis. Measures should take to control the serum ferritin in patients under risk for mucormycosis. Iron chelating agents or novel methods like anti-ftr1 immune serum should be developed for controlling the disease at its earlier stages.

Management of COVID ARDS: Highlighting the knowledge Gap among Pediatricians

To find out the gaps in the knowledge among pediatricians regarding the management of COVID ARDS. Cross-sectional descriptive study. Online survey was done through social media apps over the period of 2 months. Data was collected through a predesigned questionnaire that was circulated to Pediatrician electronically through social media. 147 doctors submitted their response; the Majority were females (65.3%); respondents include different cadres of doctors including consultants (32.7%), postgraduate trainees (40.7%) and medical officers (26.5%). COVID knowledge score was obtained by the number of correct answers to 18 selected questions and it was 11.18 ± 2.35. Postgraduate trainees and those who are working in government hospitals have better knowledge scores as compared to others (p-value &lt;0.05). Several areas of concern were revealed particularly only 34.7 % have the knowledge about in-line suction, 22.4 % have the expertise in video laryngoscopy, 42.9 % know that lower tidal volume ventilation should be done in COVID ARDS patients and only 12.2 % know that lower pH values are acceptable in such patients. 51 % of the respondents have been trained or attended courses on the management of COVID-19 patients and only 53 % feel comfortable managing pediatric COVID-19 patients. This study demonstrates an urgent need for awareness and training activities regarding the management of COVID-19 pneumonia and ARDS patients and about the protective measures in performing the procedures on such patients.

Low-dose Radiation Therapy in the Management of COVID-19 Pneumonia (LOWRAD-Cov19). Final results of a prospective phase I–II trial

Background and purposeTo evaluate the results of low-dose radiation therapy (LD-RT) to lungs in the management of patients with COVID-19 pneumonia. Material and methodsWe conducted a prospective phase I–II trial enrolling COVID-19 patients ≥50 years-old, with bilateral lung involvement at imaging study and oxygen requirement (oxygen saturation ≤93% on room air). Patients received 1 Gy to whole lungs in a single fraction. Primary outcome was a radiological response assessed as severity and extension scores at days +3 and +7. Secondary outcomes were toxicity (CTCAE v5.0), days of hospitalization, changes in inflammatory blood parameters (ferritin, lymphocytes, C-reactive protein, d-dimer and LDH) and SatO2/FiO2 index (SAFI), at day +3 and +7. Descriptive analyses were summarized as means with standard deviation (SD) and/or medians with interquartile ranges (IQR). A Wilcoxon sign rank test for paired data was used to assess the CT scores and Chi Square was used to assess for comparison of categorical variables. ResultsForty-one patients were included. Median age was 71 (IQR 60–84). Eighteen patients (44%) previously received an anti-COVID treatment (tocilizumab, lopinavir/ritonavir, remdesivir) and thirty-two patients (84%) received steroids during LD-RT. The extension score improved significantly (p = 0.02) on day +7. Mean baseline extension score was 13.7 (SD ± 4.9) with a score of 12.2 (±5.2) at day 3, and 12.4 ± 4.7 at day 7. No differences were found in the severity score. SAFI improved significantly on day +3 and +7 (p < 0.01). Median SAFI on day 0 was 147 (IQR 118–264), 230 (IQR 120–343) on day +3 and 293 (IQR 121–353) on day +7. Significant decrease was found in C-reactive protein on day +7 (p = 0.02) and in lymphocytes counts on day +3 and +7 (p = 0.02). The median number of days in hospital after RT was 11 (range 4–78). With a median follow-up of 60 days after LD-RT, 26 (63%) patients were discharged, 11 (27%) died because of COVID respiratory failure and 4 (10%) died of other causes. ConclusionsLD-RT is a feasible and well-tolerated treatment that could lead to rapid clinical improvement. Large randomized trials would be required to establish the efficacy of LD-RT to treat COVID-19 pneumonia.

Contribution of Computed Tomography in the Diagnosis of Pulmonary Lesions Due to Coronavirus Disease (SRAS-CoV-2), COVID-19

Our study was carried out at Robert BALLANGER Hospital, its aim was to determine the contribution of the scanner in the diagnosis of COVID-19. It was a prospective descriptive study during the first wave of the COVID-19 epidemic in France. Patients were referred to the medical imaging department for a thoracic CT scan without contrast injection or an angioscanner in the context of a suspected COVID-19 pneumopathy or pulmonary embolism. The study involved both sexes, the male sex was with 55.20% and sex ratio of 1.24. In our study 50% of our patients had a comorbid factor, of which diabetes and hypertension were the most represented with 33% and 17%. The RT PRC test is considered the gold standard in the diagnosis of COVID-19 disease. This test was positive in 63.62% of our patients. CT imaging played a key role in the management of COVID-19 pneumonia because chest CT scans found lesions consistent with COVID-19 pneumonia in 71% of patients. The depoliated lung lesion was present in 87% of our patients, with sub pleural topography and minimal parenchymal involvement predominating. In our study, the chest CT scan had a higher sensitivity and a lower specificity than the PCR test.

Complementary and alternate therapies (CAM) in the management of novel Corona virus (COVID-19): protocol for systematic review and meta-analysis

Abstract Background: In December 2019, a new corona-virus (COVID-19) infection broke out in the Chinese province of Wuhan. With the rampant spread of virus around the world, COVID-19 was declared as a global pandemic in the following year. Many complementary and alternate therapies (CAM) were used experimentally alongside conventional treatments for effective management of COVID-19. Aim: This paper presents a protocol for the systematic review and meta-analysis of the studies with various CAM therapies for the management of COVID-19 pneumonia. Methods: Electronic databases such as PubMed, Embase, Scopus, and the Cochrane Central Register of Controlled Trials (CENTRAL) could be used for searching the relevant trials and studies with keywords related to COVID-19 and CAM therapies. Two independent reviewers would screen a list of all the trials and extract the relevant variables. Additionally, we would also evaluate the risk of bias of the selected studies. Review Manager software (RevMan; version 5.3.5) and R statistical software (version 3.6.1) would be used for the data analysis. Results: Risk ratio (RR) would be estimated for dichotomous outcomes, and the mean differences (MD) would be measured for continuous outcomes. Heterogeneity with the help of I2 statistic would be used for the assessment of inconsistency across studies with the level of significance at P&lt; 0.10. We would also assess publication bias using funnel plots and Egger’s test for the selected studies. Conclusion: The protocol for systematic review and meta-analysis would investigate the beneficial and possible adverse effects of various CAM therapies in the prevention and management of COVID-19 associated pneumonia.

Implementing Lung Ultrasound in the Outpatient Management of COVID-19 Pneumonia: A Pilot Study to Update Local Guidelines.

Background: Lung ultrasound (LUS) has a good performance with a high sensitivity and specificity for the diagnosis of pneumonia compared with chest X-ray, and it has been extensively used to assess patients during the COVID-19 pandemic. This study aims to evaluate the potential advantages of the regular use of LUS for the assessment of the severity and prognosis of COVID-19 pneumonia and to propose an adapted protocol with its inclusion in current local validated and published guidelines.Methods: This is a single-center prospective study conducted during the first (April–May 2020) and second (October 2020–January 2021) waves of the SARS-CoV2 pandemic in Switzerland. All adult patients presenting to dedicated test centers with a suspicion of mild-to-moderate COVID-19 pneumonia and not requiring hospitalization at the time of diagnosis were included. Patients with confirmed COVID-19 pneumonia were referred to an ambulatory follow-up unit at our institution for reassessment, with the inclusion of the use of LUS in a random selection. Descriptive statistics were calculated for demographics using percentages, means, and standard deviations according to the distribution of variables.Results: Eighty-eight ambulatory patients with a confirmed COVID-19 pneumonia were included (men = 57 [59%]; mean age, 52.1 ± 13.5 years). Among these, 19 (21%) were hospitalized and none died. Twenty-five lung assessments by ultrasound were performed during the follow-up consultation. All were consistent with the clinical examination and confirmed the clinician's opinion.Conclusion: The use of a standardized pleuro-pulmonary ultrasound protocol for ambulatory patients with COVID-19 could help to reduce the use of chest X-rays and improve overall management at the time of referral and eventual follow-up. However, a specific study including LUS in a systematic approach should be performed to evaluate the outcome of patients according to findings.

UNEXPECTED OPPORTUNISTIC INFECTION IN PATIENT WITH SEVERE COVID-19 PNEUMONIA

TOPIC: Chest Infections TYPE: Medical Student/Resident Case Reports INTRODUCTION: The pathogenesis of the novel coronavirus, Covid-19, was characterized by an overdrive of the immune system that lead to some patients to a life-threatening cytokine storm with severe lung inflammation and multiorgan failure. Considering this pathogenic pathway, the use of high dose systemic steroids, and other immunomodulatory therapy was part of the main therapy. As management evolves, complications have risen, including cardiac, thromboembolic, neurologic and secondary infections. Multiple clinical reports have described complications with bacteria, and fungal infections in different organ systems, most commonly the respiratory track. However, systemic and multiorgan infections have been reported due to severe immunosuppression after viral infection and the use of anti-inflammatory therapy. CASE PRESENTATION: We present the case of an 86-year-old male with a past medical history of benign prostate hypertrophy, hyperlipidemia and hypertension who developed respiratory failure due to severe COVID-19 pneumonia, managed with antiviral therapy and high dose dexamethasone. After initial improvement from the respiratory standpoint, the patient developed persistent fungemia with Candida parapsilosis. There was no evidence of endocarditis. The patient presented with persistent altered mental status after cessation of sedation. Brain imaging revealed a right posterior parietal parafalcine hematoma with surrounding vasogenic edema. Angiogram revealed a saccular aneurysm measuring approximately 5.7 mm in largest dimension located at midline posterior frontal in location in relation to pericallosal arteries. Cerebral arterial aneurysm secondary to systemic fungal infection, knowns as mycotic aneurysms, have been reported in medical literature. DISCUSSION: Aneurysms are an abnormal arterial focal dilation which can become infected, but also aneurysmal degeneration of the arterial wall can occur due to bacteremia or a septic embolus;as seen in mycotic aneurisms. Despite its name, most mycotic aneurysms are caused by bacteria from associated endocarditis. This is a serious complication associated to an elevated morbidity and mortality. Several risk factors predispose to infected aneurysm, these include arterial injury, infection, immunocompromised status, atherosclerosis and pre-existing aneurysms. Fungal infections tend to be rare but may occur in immune suppressed patients or as sequelae of treatment of disseminated fungal disease. CONCLUSIONS: This is an unexpected complication of immunosuppression with systemic steroids in management of COVID-19 pneumonia. Treatment with systemic steroid and thromboembolic complication prevention have helped improve COVID-19 pneumonia patient prognosis, however physicians should be careful as it predisposes patients, especially those with advanced age, to opportunistic infections in unexpected organ and settings. REFERENCE #1: WHO Rapid Evidence Appraisal for COVID-19 Therapies (REACT) Working Group, Sterne JAC, Murthy S, Diaz JV, Slutsky AS, Villar J, Angus DC, Annane D, Azevedo LCP, Berwanger O, Cavalcanti AB, Dequin PF, Du B, Emberson J, Fisher D, Giraudeau B, Gordon AC, Granholm A, Green C, Haynes R, Heming N, Higgins JPT, Horby P, Juni P, Landray MJ, Le Gouge A, Leclerc M, Lim WS, Machado FR, McArthur C, Meziani F, Moller MH, Perner A, Petersen MW, Savovic J, Tomazini B, Veiga VC, Webb S, Marshall JC. Association Between Administration of Systemic Corticosteroids and Mortality Among Critically Ill Patients With COVID-19: A Meta-analysis. JAMA. 2020 Oct 6;324(13):1330-1341. doi: 10.1001/jama.2020.17023. PMID: 32876694;PMCID: PMC7489434. REFERENCE #2: Wu FZ, Lai PH. Evolution and regression of intracranial infectious aneurysm diagnosed by brain computed tomographic angiography. Arch Neurol. 2010 Sep;67(9):1147. doi: 10.1001/archneurol.2010.216. PMID: 20837863. REFERENCE #3: World Health Organization. Corticosteroids for COVID-19: Living guidance. https://www.who.int/publications/i/item/WHO-2019-nCoV-Cor icosteroids-2020.1 DISCLOSURES: No relevant relationships by Onix Cantres-Fonseca, source=Web Response No relevant relationships by Porfirio Diaz-Rodriguez, source=Web Response No relevant relationships by Hector Nieves, source=Web Response No relevant relationships by Luis Vazquez, source=Web Response

Metabolic Ketoacidosis in a Gravida Diagnosed with COVID-19: A Case Report

We present a case of term pregnancy which presented with chief complaint of Breathlessness, chest pain as well as a one day history of vomiting. She tested positive for COVID19 through reverse transcriptase polymerase chain reaction of nasopharyngeal swab and the symptoms were attributed to Pneumonia caused due to COVID19.However,the arterial blood gas showed metabolic acidosis with high anion gap. This was a non lactate acidosis with no hypoxemia. Most reasonably the state of pregnancy with increased energy demands along with increased metabolic maternal demand due to infection coupled with maternal starvation had resulted in this Ketoacidosis . In view of non progression of labor caesarian section was carried out and a healthy neonate was delivered. There was an initial improvement in maternal ketoacidosis post partum however optimal management of COVID19 pneumonia required oxygen support and use of corticosteroids. Thus we highlight how an unusual metabolic demands of pregnancy might mimic COVID 19.

Therapeutic Management of Covid-19 Pneumonia with Ayurveda – Case Series Report

Infection of Severe Acute Respiratory Syndrome Corona virus 2 (SARS-CoV- 2) which causes novel corona virus disease (COVID-19) has put the world in a medical disaster. Scientists are taking vast efforts to contain the disease by finding a vaccine or clinically proven medicine. Despite the efforts there is no proven medication in any stream of medicine. Covid19 affects respiratory tract and causes pneumonia. Here we are presenting a case series report of patients who had developed Covid19 with subsequent pneumonia and approached for Ayurvedic treatment. All these patients were primarily diagnosed with Covid-19 by RT PCR and SAARS Covid-19 Antigen test. They had subsequently developed viral pneumonia. As per Ayurveda, patients had developed symptoms of vitiation of Vata and Kapha Doshas which affected Rasavaha Srotasa and Pranavaha Srotasa. Patients were treated uniformly with internal Ayurvedic medicines which were prescribed for median duration of 30days and had been analyzed clinically with pre and post chest X-rays. All the symptoms were relieved as well as haziness in chest was also cleared in all patients, which was confirmed with pre and post chest x-rays. This study will be an evidence-based example that Ayurveda can contribute in fight against Covid-19 successfully.

Effects of non-invasive respiratory support on gas exchange and outcomes in COVID-19 outside the ICU

Non-invasive respiratory support (NRS) outside of the ICU has played an important role in the management of COVID-19 pneumonia. There is little data to guide selection of NRS modality. We present outcomes of NRS outside the ICU and discuss the effects of NRS on gas exchange with implications for management.

Elderly COVID-19 Pneumonic Patient with both Graded and Movable-weaning off Phenomenon or Yasser's Phenomena in a Surgical Severe Aortic Stenosis; at-home Dilemma Management

Rationale: Coronavirus disease is a leading remarkable critical pandemic global infection. Graded phenomenon or Yasser's phenomenon is a novel electrocardiographic phenomenon that changes the arrhythmia didactic. It is decisive progress in understanding arrhythmia. The phenomenon is a contemporary vigorous instructor for monitoring and follows up the arrhythmic patients. Movable-weaning off phenomenon or Yasser's phenomenon is another novel electrocardiographic phenomenon characterized by serial dynamic changes in all cases of either Wavy triple or double electrocardiographic signs (Yasser signs) of hypocalcemia. Movable-weaning off phenomenon is a guide for both Wavy triple and double an electrocardiographic. Severe symptomatic aortic stenosis has a bad outcome after the evolution of symptoms, and prompt operative intervention is advisable. Patient concerns: An elderly female COVID-19 pneumonic patient presented to physician outpatient clinic with bilateral peripheral pneumonia and both Graded and Movable-weaning off phenomenon or Yasser's phenomena in severe aortic stenosis. Diagnosis: Elderly COVID-19 pneumonia with both Graded and Movable-weaning off phenomenon or Yasser's phenomena. Interventions: Oxygenation, electrocardiography, chest CT scan, and echocardiography. Outcomes: Gradual dramatic clinical, electrocardiographic, and radiological improvement had happened. Lessons: It denotes the role of the anticoagulants, the antiplatelets, steroids, and antimicrobial therapy in the management of COVID-19 pneumonia with Graded and Movable-weaning off phenomenon or Yasser's phenomena in severe aortic stenosis. The presence of Graded and Movable-weaning off phenomenon or Yasser's phenomena, elderly, and pneumonia, in the case presentation, represent new complicated risk factors especially, with an associated severe sclerotic aortic stenosis. Short title: A case report article in cardiology, critical care, emergency medicine, and infectious diseases

A Pictorial Review of the Role of Imaging in the Detection, Management, Histopathological Correlations, and Complications of COVID-19 Pneumonia.

Imaging plays an important role in the detection of coronavirus (COVID-19) pneumonia in both managing the disease and evaluating the complications. Imaging with chest computed tomography (CT) can also have a potential predictive and prognostic role in COVID-19 patient outcomes. The aim of this pictorial review is to describe the role of imaging with chest X-ray (CXR), lung ultrasound (LUS), and CT in the diagnosis and management of COVID-19 pneumonia, the current indications, the scores proposed for each modality, the advantages/limitations of each modality and their role in detecting complications, and the histopathological correlations.