Moderate Pneumonia Research Articles

Covid-19 Interstitial Pneumonia: Histological and Immunohistochemical Features on Cryobiopsies

Background: The pathogenetic steps leading to Covid-19 interstitial pneumonia remain to be clarified. Most postmortem studies to date reveal diffuse alveolar damage as the most relevant histologic pattern. Antemortem lung biopsy may however provide more precise data regarding the earlier stages of the disease, providing a basis for novel treatment approaches. Objectives: To ascertain the morphological and immunohistochemical features of lung samples obtained in patients with moderate Covid-19 pneumonia. Methods: Transbronchial lung cryobiopsy was carried out in 12 Covid-19 patients within 20 days of symptom onset. Results: Histopathologic changes included spots of patchy acute lung injury with alveolar type II cell hyperplasia, with no evidence of hyaline membranes. Strong nuclear expression of phosphorylated STAT3 was observed in >50% of AECII. Interalveolar capillaries showed enlarged lumen and were in part arranged in superposed rows. Pulmonary venules were characterized by luminal enlargement, thickened walls, and perivascular CD4+ T-cell infiltration. A strong nuclear expression of phosphorylated STAT3, associated with PD-L1 and IDO expression, was observed in endothelial cells of venules and interstitial capillaries. Alveolar spaces macrophages exhibited a peculiar phenotype (CD68, CD11c, CD14, CD205, CD206, CD123/IL3AR, and PD-L1). Conclusions: Morphologically distinct features were identified in early stages of Covid-19 pneumonia, with epithelial and endothelial cell abnormalities different from either classical interstitial lung diseases or diffuse alveolar damage. Alveolar type II cell hyperplasia was a prominent event in the majority of cases. Inflammatory cells expressed peculiar phenotypes. No evidence of hyaline membranes and endothelial changes characterized by IDO expression might in part explain the compliance and the characteristic pulmonary vasoplegia observed in less-advanced Covid-19 pneumonia.

The value of repeated CT in monitoring the disease progression in moderate COVID-19 pneumonia: A single-center, retrospective study.

The role of thoracic CT (computerized tomography) in monitoring disease course of COVID-19 is controversial. The purpose of this study is to investigate the risk factors and predictive value of deterioration on repeatedly performed CT scan during hospitalization.All COVID-19 patients treated in our isolation ward, from January 22, 2020 to February 7, 2020, were reviewed. Patients included were categorized into RD (Radiological Deterioration) group or NRD (No Radiological Deterioration) group according to the manifestation on the CT routinely performed during the hospitalization. All clinical data and CT images were analyzed.Forty three patients were included in our study. All are moderate cases with at least 4 CT scans each. Eighteen (42.9%) patients had radiological deteriorations which were all identified in CT2 (the first CT after admission). Patients in RD group had lower leukocyte count (P = .003), lymphocyte count (P = .030), and higher prevalence (P = .012) of elevated C-reactive protein (CRP) at admission. NRD patients had a lower prevalence of reticulations (P = .034) on baseline CT (CT1, performed within 2 days before admission) and a longer duration between symptom onset and the time of CT2 (P < .01). There was no significant difference in hospital stay or fibrotic change on CT4 (follow-up CT scan performed 4 weeks after discharge) between 2 groups. Shorter duration between symptom onset and CT2 time (odds ratio [OR], 0.436; 95% confidence interval: 0.233–0.816; P < .01) and lower leukocyte count in baseline evaluation (OR, 0.316; 95% CI: 0.116–0.859; P < .05) were associated with increased odds of radiological deterioration on CT image during hospitalization.For moderate COVID-19 patients, the value of routinely performed CT during the treatment is limited. We recommend avoiding using CT as a routine monitor in moderate COVID-19 patients.

Evaluation of the safety and efficacy of XAV-19 in patients with COVID-19-induced moderate pneumonia: study protocol for a randomized, double-blinded, placebo-controlled phase 2 (2a and 2b) trial

BackgroundEarly inhibition of entry and replication of the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) is a very promising therapeutic approach. Polyclonal neutralizing antibodies offers many advantages such as providing immediate immunity, consequently blunting an early pro-inflammatory pathogenic endogenous antibody response and lack of drug-drug interactions.By providing immediate immunity and inhibiting entry into cells, neutralizing antibody treatment is of interest for patient with COVID-19-induced moderate pneumonia. Convalescent plasma to treat infected patients is therefore a relevant therapeutic option currently under assessment (CORIMUNO-PLASM NCT04324047). However, the difficulties of collecting plasma on the long term are not adapted to a broad use across all populations.New polyclonal humanized anti-SARS-CoV2 antibodies (XAV-19) developed by Xenothera and administered intravenous. XAV-19 is a heterologous swine glyco-humanized polyclonal antibody (GH-pAb) raised against the spike protein of SARS-CoV-2, blocking infection of ACE-2-positive human cells with SARS-CoV-2.MethodsPharmacokinetic and pharmacodynamic studies have been performed in preclinical models including primates. A first human study with another fully representative GH-pAb from Xenothera is ongoing in recipients of a kidney graft. These studies indicated that 5 consecutive administrations of GH-pAbs can be safely performed in humans.The objectives of this 2-step phase 2 randomized double-blinded, placebo-controlled study are to define the safety and the optimal XAV-19 dose to administrate to patients with SARS-CoV-2 induced moderate pneumonia, and to assess the clinical benefits of a selected dose of XAV-19 in this population.DiscussionThis study will determine the clinical benefits of XAV-19 when administered to patients with SARS-CoV-2-induced moderate pneumonia. As a prerequisite, a first step of the study will define the safety and the dose of XAV-19 to be used.Such treatment might become a new therapeutic option to provide an effective treatment for COVID-19 patients (possibly in combination with anti-viral and immunotherapies). Further studies could later evaluate such passive immunotherapy as a potential post-exposure prophylaxis.Trial registrationClinicalTrials.gov NCT04453384, registered on 1 July 2020, and EUDRACT 2020-002574-27, registered 6 June 2020.

Novel outpatient management of mild to moderate COVID-19 spares hospital capacity and safeguards patient outcome: The Geneva PneumoCoV-Ambu study.

BackgroundSevere Acute Respiratory Coronavirus 2 (SARS-CoV-2), the novel coronavirus that causes coronavirus disease (COVID-19), is creating an unprecedented burden on health care systems across the world due to its high rate of pneumonia-related hospitalizations. This study presents recommendations for the outpatient management of moderate SARS-CoV-2 pneumonia implemented at the Geneva University Hospital, Switzerland, from April 4 to June 30, 2020 and evaluated the impact of these recommendations on patient safety, patient satisfaction, and overall hospital capacity.MethodsRecommendations for the outpatient management of moderate pneumonia implemented in the Geneva University Hospital (PneumoCoV-Ambu) between April 4 and June 30, 2020, were evaluated prospectively. The primary endpoint was hospitalization. Secondary endpoints were: severity of COVID-19 disease based on a 7-points ordinal scale assessed at 1 and 2 months following SARS-CoV-2 infection; patient satisfaction using a satisfaction survey and the analysis of number of beds and costs potentially averted.ResultsA total of 36 patients with COVID-19-related pneumonia were followed between April 4 and May 5, 2020. Five patients (14%) were hospitalized and none died over a median of 30 days follow-up. The majority of patients (n = 31; 86%) were satisfied with the ambulatory care they received. These novel recommendations for outpatient management resulted in sparing an estimated potential 124 hospital bed-nights and CHF 6’826 per capita averted hospitalization costs over the three months period.ConclusionsRecommendations developed for the outpatient management of COVID-19-related pneumonia were able to spare hospital capacity without increasing adverse patient outcomes. Widely implementing such recommendations is crucial in preserving hospital capacity during this pandemic.

Características epidemiológicas y clínicas de pacientes internados con COVID-19 en la Ciudad de Buenos Aires

Introducción: La pandemia de COVID-19 representa un desafío para la salud mundial y continúa en investigación.&#x0D; Objetivo: Describir las características epidemiológicas, demográficas, clínicas y la mortalidad por todas las causas de pacientes internados con COVID-19 en un establecimiento de salud privado de la Ciudad de Buenos Aires.&#x0D; Materiales y métodos: Se realizó un estudio retrospectivo, de corte transversal y descriptivo entre el 3 de marzo y el 8 de julio de 2020. Se incluyeron pacientes adultos con diagnóstico confirmado de COVID-19 por RT-PCR de hisopado nasofaríngeo internados en sala general y unidad de terapia intensiva (UTI) del Sanatorio San José. Se analizaron las características epidemiológicas, demográficas (edad, sexo, ocupación, procedencia, residencia), clínicas y mortalidad por todas las causas. Las variables continuas fueron descriptas con mediana y rango intercuartilo (RIC) y las variables categóricas con número y porcentaje. Se utilizó el programa STATA v 13.0.&#x0D; Resultados: Se incluyeron 118 pacientes. La mediana de edad fue de 50 años, 51% varones. Las comorbilidades más prevalentes fueron hipertensión arterial 31,4%, enfermedad neurológica crónica 27,1%, enfermedad cardiovascular 14,4% y diabetes 13,6%. Los signos y síntomas más frecuentes: fiebre 68,6% y tos 51,7%. Según la severidad inicial: 33,9% neumonía moderada y 27,1% grave. El 75% de las tomografías de tórax reveló vidrio esmerilado; linfopenia presentó el 30%. No se detectó coinfección viral. La mortalidad por todas las causas fue del 20%, y del 57% en UTI con ventilación mecánica.&#x0D; Conclusiones: Nuestro trabajo describe las características y mortalidad de pacientes internados con COVID-19. Es necesario aumentar la evidencia para desarrollar modelos de predicción clínica relacionados con COVID-19.

Signs and symptoms to determine if a patient presenting in primary care or hospital outpatient settings has COVID-19.

Signs and symptoms to determine if a patient presenting in primary care or hospital outpatient settings has COVID-19.

Imaging Findings and Changes in Discharged Moderate Novel Coronavirus Pneumonia Patients with Positive Nucleic Acid Retest

The clinical and imaging data belonging to 52 discharged novel coronavirus pneumonia (NCP) patients with positive nucleic acid retesting results during the follow-up period were collected from the First People’s Hospital, Xiaogan, Hubei Province, China, for analysis. These moderate NCP patients underwent a plain CT scan before the admission, at the time of discharge, and at re-admission due to the positive result of their COVID-19 nucleic acid retesting. The CT signs of these patients were analyzed in this study and a total of 32 (61.54%) patients presented with 123 lesions with patchy fuzzy shadows. In addition, 24 (75%) and 8 (25%) patients out of the 32 patients, had lesions distributed in both lungs and single lung, respectively. It is worth mentioning that the CT manifestations varied in discharged moderate NCP patients whose COVID-19 nucleic acid retest was positive in the follow-up period. Most patients presented with patchy fuzzy shadows and ground-glass opacity (GGO) lesions distributed in the lower lobe of both lungs. The results of the study indicated that some discharged moderate NCP patients with positive COVID-19 nucleic acid retest developed new patchy fuzzy shadows and GGO lesions. Moreover, the recurrence of NCP needs to be verified once patchy fuzzy shadows and GGO lesions appear and are not absorbed during the follow-up period. This study provided a reference for the follow-up NCP evaluation.

N-acetylcysteine as a part of complex treatment of moderate COVID-associated pneumonia

The need for safe and effective treatment is becoming increasingly urgent due to the high COVID-19 mortality rates observed worldwide. The choice of drug products for COVID-19 treatment regimens is based on the efficacy and safety data, the mechanism of action, and potential interactions. N-acetylcysteine's (NAC) pharmacological activity and its potential to suppress the progression of COVID-19 make it a promising therapeutic agent for COVID-19.Aimof the study was to evaluate the efficacy of NAC in the complex treatment of moderate COVID-associated pneumonia.Methods. The study included adult patients (n= 46) with moderate COVID-associated (the 2nddegree on CT) pneumonia (age 57 (51; 71) years, body mass index - 30 (27.1; 32.3) kg/m2, duration of the disease before hospitalization - 7 (6; 8) days, body temperature at the admission - 37.5 (37.1; 37.8)°С). The patients were randomized into two study groups. The 1stgroup (n= 22) received standard COVID-19 treatment [1]. The 2ndgroup (n= 24) additionally received NAC 1,200 - 1,500 mg/day intravenously. Treatment with NAC was started together with the standard therapy.Results. Our study showed that the inclusion of NAC in the complex treatment of moderate COVID-associated pneumonia led to a statistically significant increase in blood oxygen saturation, oxygenation index, the difference in delta increase in oxygenation index, a quicker reduction in the volume of lung damage and the difference between the groups in delta reduction of this index. Also, the rate of reduction of C-reactive protein and reduction of the duration of hospitalization in the group of patients who received NAC was statistically significantly more profound than in the standard treatment group.Conclusion. The study confirmed the effectiveness of NAC as a part of the complex treatment of moderate COVID-associated pneumonia.

Pharmacological drug interactions in the treatment of community-acquired pneumonia in hospital settings (based on electronic databases of reported drug interactions)

The article presents the results of a study of potential drug interactions in the treatment of moderate and severe community-acquired pneumonia (CAP) in hospital settings. The study was conducted by analysis of treatment standards and data from real clinical practice regarding antimicrobial therapy. Methods. The study used the lists of drug products for medical use for the treatment of CAP (according to the standards of specialized medical care for moderate and severe CAP with complications). Also, the medical records of patients (n = 165) with CAP, hospitalized in hospitals of medical organizations (Nizhny Novgorod) were used. The study period was 2 years (2015 - 2016). The study included all patients admitted to the hospital during the analyzed period. CAP was treated in accordance with treatment standards. Results. The analysis of potential interactions of drugs used for moderate and severe CAP according to the treatment standards, showed that 27 and 72 drugs can be used, respectively. 325 potential interactions are possible in hospital settings for moderate CAP and 2,485 for severe CAP. According to the treatment standard, the number of minimally clinically significant potential interactions during the pharmacotherapy of moderate CAP in hospital settings is 8, the number moderately clinically significant interactions - 19; undesirable interactions - 7. In case of severe CAP, the number of potential interactions increases and amounts to 27 minimally clinically significant, 105 moderately clinically significant, and 41 undesirable. The analysis of the results of antimicrobial therapy in real clinical practice showed 4 therapeutic duplications (prescribing 2 β-lactam antibacterial drugs simultaneously) and 2 moderately clinically significant interactions during antimicrobial therapy in hospital 1. Only 1 therapeutic duplication was noted during antimicrobial therapy in hospital 2. Therapeutic overlap has been found between β-lactam antibacterial drugs (ceftaroline fosamil and meropenem). It is advisable to prescribe no more than one в-lactam antibacterial drug and it is inappropriate to include &gt; 3 antimicrobial drugs in an antimicrobial regimen. Conclusion. Electronic databases simplify the selection of medicines and thus ensure the safe and effective use of registered drug interactions.

In vivo Activity of Dust Inhalation at Ratcon Quarry, Sokuro Village, Oluyole, Ibadan Oyo State

A total of twenty (20) experimental adult male rats, aged 60 days (7 to 8 weeks) with average body weight between 150-200 gm were grouped, restrained inside laboratory approved plastic holders and exposed to dust inhalation at the quarry site with exposure time of 7, 14 and 21 days to reflect short-term effects while 42days represent long-term effects of dust inhalation on human beings. Each specimen was collected and sacrificed at their grouped survival periods and subjected to laboratory analysis that include Hematology and Histopathology of the lungs. The Hematologyresults of the 7 and 14days specimens revealed no remarkable changes in the Erythrogram (PCV, HB and RBC), the Leucogram (WBC) and the Platelets but however, the results of the 21 and 42 days specimen revealed leukocytosis (increase in WBC), lymphocytosis (increase Lym) and neutrophilia (increase neutrophils) (p&lt;0.05). The Histopathology results of the first specimen (7 days exposure) showed no observable lesion, the second specimen(14 days) showed capillary congestion and mild interstitial pneumonia, while the third (21 days) and fourth (42 days) samples showed the rats graduating from mild to moderate interstitial pneumonia and oedema. The risk of these diseases depends on the amount of organic or inorganic dusts inhaled and deposited in the alveolar region, the air concentration of respirable dust as well as the exposure time and breathing pattern.

Estimating COVID-19 Pneumonia Extent and Severity From Chest Computed Tomography.

BackgroundCOVID-19 pneumonia extension is assessed by computed tomography (CT) with the ratio between the volume of abnormal pulmonary opacities (PO) and CT-estimated lung volume (CTLV). CT-estimated lung weight (CTLW) also correlates with pneumonia severity. However, both CTLV and CTLW depend on demographic and anthropometric variables.PurposesTo estimate the extent and severity of COVID-19 pneumonia adjusting the volume and weight of abnormal PO to the predicted CTLV (pCTLV) and CTLW (pCTLW), respectively, and to evaluate their possible association with clinical and radiological outcomes.MethodsChest CT from 103 COVID-19 and 86 healthy subjects were examined retrospectively. In controls, predictive equations for estimating pCTLV and pCTLW were assessed. COVID-19 pneumonia extent and severity were then defined as the ratio between the volume and the weight of abnormal PO expressed as a percentage of the pCTLV and pCTLW, respectively. A ROC analysis was used to test differential diagnosis ability of the proposed method in COVID-19 and controls. The degree of pneumonia extent and severity was assessed with Z-scores relative to the average volume and weight of PO in controls. Accordingly, COVID-19 patients were classified as with limited, moderate and diffuse pneumonia extent and as with mild, moderate and severe pneumonia severity.ResultsIn controls, CTLV could be predicted by sex and height (adjusted R2 = 0.57; P < 0.001) while CTLW by age, sex, and height (adjusted R2 = 0.6; P < 0.001). The cutoff of 20% (AUC = 0.91, 95%CI 0.88–0.93) for pneumonia extent and of 50% (AUC = 0.91, 95%CI 0.89–0.92) for pneumonia severity were obtained. Pneumonia extent were better correlated when expressed as a percentage of the pCTLV and pCTLW (r = 0.85, P < 0.001), respectively. COVID-19 patients with diffuse and severe pneumonia at admission presented significantly higher CRP concentration, intra-hospital mortality, ICU stay and ventilatory support necessity, than those with moderate and limited/mild pneumonia. Moreover, pneumonia severity, but not extent, was positively and moderately correlated with age (r = 0.46) and CRP concentration (r = 0.44).ConclusionThe proposed estimation of COVID-19 pneumonia extent and severity might be useful for clinical and radiological patient stratification.

The effect of moderate and severe COVID-19 pneumonia on short-term right ventricular functions: a prospective observational single pandemic center analysis.

It has been reported that myocardial damage and heart failure are more common in COVID-19 patients with severe symptoms. The aim of our study was to measure the right ventricular functions of COVID-19 patients 30 days after their discharge, and compare them to the right ventricular functions of healthy volunteers. Fifty one patients with COVID-19 and 32 healthy volunteers who underwent echocardiographic examinations were enrolled in our study. 29 patients were treated for severe and 22 patients were treated for moderate COVID-19 pneumonia. The study was conducted prospectively, in a single center, between 15 May 2020 and 15 July 2020. We analyzed the right ventricular functions of the patients using conventional techniques and two-dimensional speckle-tracking. Right ventricular end-diastolic and end-systolic area were statistically higher than control group. The right ventricular fractional area change (RVFAC) was significantly lesser in the patient group compared to the control group. Tricuspid annular plane systolic motion (TAPSE) was within normal limits in both groups, it was lower in the patient group compared to the control group. Pulmonary artery pressure was found to be significantly higher in the patient group. Right ventricular global longitudinal strain (RV-GLS) was lesser than the control group (− 15.7 [(− 12.6)–(− 18.7)] vs. − 18.1 [(− 14.8)–(− 21)]; p 0.011). Right ventricular free wall strain (RV-FWS) was lesser in the patient group compared to the control group (− 16 [(− 12.7)–(− 19)] vs − 21.6 [(− 17)–(− 25.3)]; p < 0.001). We found subclinical right ventricular dysfunction in the echocardiographies of COVID-19 patients although there were no risk factors.

Clinical Characteristics and Outcome of Patients With Severe COVID-19 Pneumonia at a Public Sector Hospital in Karachi, Pakistan.

Introduction: In Pakistan, the first case of COVID-19 was reported in February of 2020, cases peaked in June, and by January 2021, approximately 500,000 confirmed cases and over 10,000 deaths have been reported. There is a lack of data in Pakistan of the demographics, clinical characteristics, and outcome of patients with COVID-19 pneumonia, particularly those with severe illness, which we aim to assess.Methods: This is a single-centered, observational study conducted at the COVID unit of the Shaheed Mohtarma Benazir Bhutto Institute of Trauma in Karachi, Pakistan. A manual medical record review of patients admitted from April 24, 2020 to August 24, 2020 was conducted, and all patients with polymerase chain reaction (PCR) positive for severe acute respiratory syndrome coronavirus 2 (SARS-CoV2) with moderate, severe, and critical COVID-19 pneumonia were included.Results: Of 299 patients, the median age was 60 years (50-65). Males accounted for 221 (73.9%). Most common symptoms were shortness of breath seen in 270 (90.3%) and fever in 225 (75.3%) patients. Diabetes mellitus (51.2%) and hypertension (50.3%) were the predominant co-morbidities. COVID disease was categorized on admission as moderate in 68 (22.7%), severe in 151 (50.5%), and critical in 80 (26.8%) patients. Survival analysis was done in 252 patients, all of whom received steroids, while tocilizumab was administered to 111 (44%) patients. Hundred (39.7%) patients received non-invasive ventilation (NIV), while 57 (22.6%) were placed on mechanical ventilation. Overall, 95 (37.7%) patients died. Factors associated with mortality included older age with those above 60 years more likely to die (odds ratio [OR]: 1.925; 95% CI: 1.148-3.228; pvalue: 0.009), presence of co-morbidities (OR 1.843; 95% CI: 0.983-3.456; p value: 0.070), development of cytokine release syndrome (CRS) (73 [56.2%] vs 57 [43.8%], p value: <0.001), acute kidney injury (31 [81.6%] vs 7 [18.4%], p value: <0.001), cardiac complications (12 [75%] vs 4 [25%], p value: 0.002), and sepsis (29 [87.9%] vs 4 [12.1%], p value: <0.001). Non-survivors were more likely to develop acute respiratory distress syndrome (ARDS), having been placed on NIV and mechanical ventilation. Laboratory parameters at final outcome found that in non-survivors, median total leukocyte count, C-reactive protein (CRP), neutrophil lymphocyte ratio (NLR), and lactate dehydrogenase (LDH) were higher, while absolute lymphocyte count and platelet counts were lower which were found to be statistically significant compared to survivors.Conclusion: In this study of patients with severe COVID-19 pneumonia at a public sector hospital in Karachi, Pakistan, most were males, and the average age was 60 years. Mortality was high, and associated factors included older age, presence of comorbid conditions, and the development of ARDS, CRS, and sepsis.

Blood ozonization in patients with mild to moderate COVID-19 pneumonia: a single centre experience: reply.

Blood ozonization in patients with mild to moderate COVID-19 pneumonia: a single centre experience: reply.

Surgical treatment of patients with neurosurgical pathology combined with COVID-19

The objective is to present first-hand experience of microsurgical operations in patients with neuro-oncological diseases, vascular pathology and COVID-19 in the absence of unified standards of work during the pandemic, as well as summarize literature data on this problem. Clinical cases. Five cases of surgical interventions in patients with moderate COVID-19 pneumonia are presented: 1) microsurgical clipping of a saccular aneurysm of the posterior communicating artery which caused massive basal subarachnoid hemorrhage with bleeding into the IV ventricle; 2) microsurgical resection of glioblastoma of the right temporal lobe; 3) resection of an intracerebral hematoma in the right temporal, occipital and parietal lobes with total volume of 100 cm3 which caused transverse brain dislocation up to 10 mm to the left; 4) micro coil embolization of a ruptured aneurysm of the posterior communicating artery; 5) microcoil embolization of a ruptured aneurysm of the right middle cerebral artery. All surgeries were performed in personal protective gear and FFP3 masks. In 3 patients, positive pneumonia dynamics were observed; in 2 patients (with glioblastoma and subarachnoid hemorrhage from an aneurysm of the right middle cerebral artery), dynamics were negative. Among 5 patients, 4 were discharged in stable condition, 1 case ended in death (despite the absence of coagulopathy, massive brain ischemia with hemorrhagic transformation developed, probably due to endothelial cell dysfunction, high vascular permeability of cerebral arteries in conjunction with coronavirus effect on angiotensin transforming enzyme receptors). Literature analysis . Summarizing experiences of other researchers, the following changes in organization of neurosurgical practice during the pandemic can be recommended: 1) all patients should be considered potentially infected; 2) emergency surgeries should be performed under local anesthesia and/or in separate operating rooms; 3) in emergency cases of vascular pathology of the brain, endovascular interventions are the preferred approach; 4) surgeries should be performed in FFP2/FFP3 masks, protective goggles, two pairs of gloves, protective suits and shoe covers; 5) the number of personnel in the operating room should be minimized; 6) manipulations that can potentially lead to increased formation of aerosol (craniotomies, coagulations) should be performed with special care, craniotome rotation speed should be decreased to minimize formation of bone particles, opening of paranasal sinuses and mastoid cells should be avoided if possible; 7) negative pressure (—5 Pa) should be maintained in the operative room, frequency of interruption of the artificial lung ventilation machine circuit should be minimized, patients’ nose and mouth should be covered with wet wipes; 8) the personnel should be divided into several teams working in turns; 9) personnel older than 65 years should be isolated; 10) planned surgeries should be postponed indefinitely and patients should be consulted by phone, hospitalized only if their condition worsens; 11) during admission, patients should be placed in observation rooms, where thermometry, computed tomography of the lungs and pharyngeal swab for SARS-CoV-2 should be performed; 12) regardless of the SARS-CoV-2 analysis result, patients after surgery should be quarantined for 14 days. Conclusion . Our experience shows that patients with concomitant COVID-19 infection can receive neurosurgical help. Compliance with the guidelines leads to low risk of infection for the personnel and sufficient quality of medical care.

Poor compliance with an antibiotic directive—A call for intensified monitoring

BackgroundIn April 2017, the Central Denmark Region Antibiotic Stewardship Committee issued a directive to reduce the general use of piperacillin-tazobactam and prescribe narrow-spectrum antibiotics for mild and moderate pneumonia. The directive was distributed to all regional hospital clinicians. MethodsElectronic medical records were used to obtain de-identified details of all antibiotics administered (together with diagnosis codes) to all in-hospital patients (pre-directive and post-directive) in the nine regional hospitals. Average moving range statistical process control charts were used to analyze pre-directive and post-directive variation in antibiotic usage patterns. ResultsUpon the distribution of the directive, a period of decline of the overall usage of piperacillin-tazobactam ensued. Rather than benzylpenicillin, as recommended for pneumonia, the initial decline in piperacillin/tazobactam usage was accompanied by increased use of cefuroxime. ConclusionsA steward-directed reduction in piperacillin-tazobactam usage was accompanied by less desirable usage of a broad-spectrum alternative. Future antibiotic stewardship initiatives will hopefully benefit from close monitoring and timely feedback to clinicians. A dialogue with clinicians based on near real-time data is predicted to improve antibiotic stewardship actions.

Elevated Extracellular Volume Fraction and Reduced Global Longitudinal Strains in Participants Recovered from COVID-19 without Clinical Cardiac Findings.

BackgroundIt is unknown if there are cardiac abnormalities in participants recovered from COVID-19 without cardiac symptoms and those who have normal biomarkers and normal ECGs.PurposeTo evaluate cardiac involvement in participants recovered from COVID-19 without clinical evidence of cardiac involvement using cardiac MRIMaterials and methodsIn this prospective observational cohort study, 40 participants recovered from COVID-19 with moderate(n=24) or severe(n=16) pneumonia and no cardiovascular medical history, without cardiac symptoms, with normal ECG, normal serological cardiac enzyme levels, and discharged > 90 days between May and September 2020. Demographic characteristics, serum cardiac enzymes, and cardiac MRI were obtained. Cardiac function, native T1, ECV and Two-dimensional (2D) strain were quantitatively evaluated and compared with controls (n = 25).The Comparison among the 3 groups were performed using one-way analysis of variance (ANOVA) with Bonferroni corrected post-hoc comparisons(for normal distribution) or Kruskal-Wallis tests with post-hoc pairwise comparisons(for non-normal distribution).ResultsForty participants (54±12 years; 24 men) enrolled with a mean time between admission and CMR of 158 ±18 days and discharge and CMR examination of 124 ±17 days. There was no LV and RV size or functional differences among participants recovered from COVID-19 and healthy controls. Only one (3%) participants had positive LGE located at the mid inferior wall. Global ECV values were elevated in both participants recovered from COVID-19 with moderate or severe pneumonia, compared to the healthy controls [median ECV (IQR)], [29.7% (28.0%-32.9%), versus 31.4% (29.3%-34.0%), versus 25.0% (23.7%-26.0%); both p<.001]. The 2D-global LV longitudinal stains (GLS) were reduced in both groups of participants [COVID-19 moderate group,-12.5%(-10.7%--15.5%), COVID-19 severe group, -12.5%(-8.7%--15.4%) compared to healthy control group -15.4%(-14.6%-17.6%), p=.002 and p=.001, respectively].ConclusionCMR myocardial tissue and strain imaging parameters suggest that a proportion of participants recovered from COVID-19 had subclinical myocardial abnormalities detectable months after recovery.

Evaluation of the relationship between COVID-19 pneumonia severity and pulmonary artery diameter measurement

The goal of the present work was to examine associations between COVID-19 pneumonia severity and pulmonary artery diameter. A total of 101 patients with COVID-19 were included in this retrospective observational study. The patients were divided into three groups based on the CT images: 41 patients with mild pneumonia, group 2 had 39 patients with moderate pneumonia, and group 3 had 21 patients with severe pneumonia. Furthermore, the diameter of the main pulmonary artery was calculated as well as ascending aorta, right and left pulmonary artery diameters. Laboratory analysis results were also compared. Analyses show an increased main pulmonary artery diameter is associated with poorer prognosis for patients with COVID-19 pneumonia. Further studies are needed into the mechanisms between severe hypoxemia, increased inflammation, and vascular resistance and higher numbers of thromboembolic events.

SARS-CoV-2-Induced ARDS Associates with MDSC Expansion, Lymphocyte Dysfunction, and Arginine Shortage.

PurposeThe SARS-CoV-2 infection can lead to a severe acute respiratory distress syndrome (ARDS) with prolonged mechanical ventilation and high mortality rate. Interestingly, COVID-19-associated ARDS share biological and clinical features with sepsis-associated immunosuppression since lymphopenia and acquired infections associated with late mortality are frequently encountered. Mechanisms responsible for COVID-19-associated lymphopenia need to be explored since they could be responsible for delayed virus clearance and increased mortality rate among intensive care unit (ICU) patients.MethodsA series of 26 clinically annotated COVID-19 patients were analyzed by thorough phenotypic and functional investigations at days 0, 4, and 7 after ICU admission.ResultsWe revealed that, in the absence of any difference in demographic parameters nor medical history between the two groups, ARDS patients presented with an increased number of myeloid-derived suppressor cells (MDSC) and a decreased number of CD8pos effector memory cell compared to patients hospitalized for COVID-19 moderate pneumonia. Interestingly, COVID-19-related MDSC expansion was directly correlated to lymphopenia and enhanced arginase activity. Lastly, T cell proliferative capacity in vitro was significantly reduced among COVID-19 patients and could be restored through arginine supplementation.ConclusionsThe present study reports a critical role for MDSC in COVID-19-associated ARDS. Our findings open the possibility of arginine supplementation as an adjuvant therapy for these ICU patients, aiming to reduce immunosuppression and help virus clearance, thereby decreasing the duration of mechanical ventilation, nosocomial infection acquisition, and mortality.Supplementary InformationThe online version contains supplementary material available at 10.1007/s10875-020-00920-5.

Kinetics of serum amyloid A during the treatment period of foals with pneumonia

The ultrasonographic examination of foals with pneumonia has been proven successful in monitoring the course of the disease during treatment. However, the question arises whether another parameter, such as the acute phase protein serum amyloid A (SAA), could also be suitable for evaluating the response to treatment, the course during treatment or the decision to terminate the treatment in foals with pneumonia. The course of moderate or severe pneumonia was recorded by several diagnostic tests in a prospective study performed on 52 foals. Clinical and ultrasonographical examination of the thorax and blood values (SAA, white blood cell count) of these foals were measured on the day of diagnosis and weekly during treatment. Foals with a pulmonary abscess score of 15–19.5 cm determined by sonography of the thorax (moderate pneumonia) were assigned to group 1 (n = 31) and received a treatment with rifampin and tulathromycin. If the abscess score was > 20 cm (severe pneumonia), the foals were included in group 2 (n = 21) and were treated with rifampin and azithromycin. All foals recovered during the treatment period. Sonography of the thorax of the foals with moderate pneumonia (group 1) showed no more pathologic findings after ten days, and the foals with severe pneumonia (group 2) after eleven days of treatment. At diagnosis the median SAA value at diagnosis was 367 mg/L (median; 25th/75th: 23–937) in foals with moderate pneumonia and 216 mg/L (median; 25th/75th: 16–690) in those with severe pneumonia. The SAA values of foals with initially elevated values decreased significantly until they reached normal values < 40 mg/L after five days in the foals with moderate pneumonia and four days in the those with severe pneumonia. The time between the day SAA reached normal values and ultrasonography of the lung revealed no more abnormalities was three days in foals with moderate pneumonia and seven days in those with severe pneumonia. The SAA as a diagnostic method had a sensitivity of 68 % in the case of moderate pneumonia and 71 % in the case of severe pneumonia on the day of diagnosis. If only the foals with pneumonia and fever were considered, 91 % showed an initially increased SAA. During treatment, the SAA correlated with the abscess score, the clinical score and the age at diagnosis, but not with the number of white blood cells. In conclusion, the ultrasonographic examination remains the most precise tool to diagnose pneumonia and follow its progress during treatment in foals. However, the SAA can be used as an additional parameter for evaluating the treatment success. Especially foals with fever and younger foals show high SAA values in patients with pneumonia. By observing the kinetics of SAA in a patient, this blood parameter could be a support to adjust the date of the final ultrasonographic examination. Thereby, the duration of treatment can be individually adapted.