Early posthospitalization recovery after extracorporeal membrane oxygenation in survivors of COVID-19.

OBJECTIVE: We sought to determine the influence of venovenous extracorporeal membrane oxygenation (ECMO) on outcomes of mechanically ventilated patients with COVID-19 during the first 120 days after hospital discharge. METHODS: Five academic centers conducted a retrospective analysis of mechanically ventilated patients with COVID-19 admitted during March through May 2020. Survivors had access to a multidisciplinary postintensive care recovery clinic. Physical, psychological, and cognitive deficits were measured using validated instruments and compared based on ECMO status. RESULTS: Two hundred sixty two mechanically ventilated patients were compared with 46 patients cannulated for venovenous ECMO. Patients receiving ECMO were younger and traveled farther but there was no significant difference in gender, race, or body mass index. ECMO patients were mechanically ventilated for longer durations (median, 26 days [interquartile range, 19.5-41 days] vs 13 days [interquartile range, 7-20 days]) and were more likely to receive inhaled pulmonary vasodilators, neuromuscular blockade, investigational COVID-19 therapies, blood transfusions, and inotropes. Patients receiving ECMO experienced greater bleeding and clotting events (P < .01). However, survival at discharge was similar (69.6% vs 70.6%). Of the 217 survivors, 65.0% had documented follow-up within 120 days. Overall, 95.5% were residing at home, 25.7% had returned to work or usual activity, and 23.1% were still using supplemental oxygen; these rates did not differ significantly based on ECMO status. Rates of physical, psychological, and cognitive deficits were similar. CONCLUSIONS: Our data suggest that COVID-19 survivors experience significant physical, psychological, and cognitive deficits following intensive care unit admission. Despite a more complex critical illness course, longer average duration of mechanical ventilation, and longer average length of stay, patients treated with venovenous ECMO had similar survival at discharge and outcomes within 120 days of discharge.

Differences in lung function between major race/ethnicity groups following hospitalization with COVID-19.

BACKGROUND: Ethnic minorities have higher rates of infection, hospitalization, and death from COVID-19 compared to White Americans. RESEARCH QUESTION: Is race/ethnicity an independent predictor of lung dysfunction following hospitalization with COVID-19? STUDY DESIGN: and Methods: Patients hospitalized at the University of Virginia Medical Center with COVID-19 underwent a questionnaire within 30 days following discharge. Those who had persistent respiratory symptoms were invited to complete spirometry, lung volumes, and diffusion capacity of carbon monoxide. 128 completed pulmonary function testing at 6 months. RESULTS: Impairments in lung function were present in spirometry, lung volumes, and diffusion capacity of carbon monoxide at 6 months. The most prevalent impairments were noted in FVC (24.4%), FEV1 (20.5%), TLC (23.3%), and DLCO (20.8%). When compared between race/ethnicity groups three lung function parameters demonstrated statistically significant difference, including FEV1/FVC (p = 0.021), RV/TLC (p = 0.006) and DLCO % predicted (p = 0.002). The average difference between Hispanic and non-Hispanic Black patients with respect to DLCO % predicted was 13.09 (p = 0.01) and the average difference between non-Hispanic White and non-Hispanic Black patients was 9.46 (p = 0.04). Differences persisted when controlling for age, BMI, smoking status, history of chronic lung disease, ICU admission, treatment with corticosteroids, and socioeconomic status. INTERPRETATION: Long-term impairments in lung function following COVID-19 are common, occurring in roughly 22% of patients and across all three major domains of lung function. Non-Hispanic Black race/ethnicity was associated with a statistically significant lower DLCO % predicted when compared to non-Hispanic White and Hispanic patients.

Quantitative Measurement of IgG to Severe Acute Respiratory Syndrome Coronavirus-2 Proteins Using ImmunoCAP.

BACKGROUND: Detailed understanding of the immune response to severe acute respiratory syndrome coronavirus (SARS-CoV)-2, the cause of coronavirus disease 2019 (CO-VID-19) has been hampered by a lack of quantitative antibody assays. OBJECTIVE: The objective was to develop a quantitative assay for IgG to SARS-CoV-2 proteins that could be implemented in clinical and research laboratories. METHODS: The biotin-streptavidin technique was used to conjugate SARS-CoV-2 spike receptor-binding domain (RBD) or nucleocapsid protein to the solid phase of the ImmunoCAP. Plasma and serum samples from patients hospitalized with COVID-19 (n = 60) and samples from donors banked before the emergence of COVID-19 (n = 109) were used in the assay. SARS-CoV-2 IgG levels were followed longitudinally in a subset of samples and were related to total IgG and IgG to reference antigens using an ImmunoCAP 250 platform. RESULTS: At a cutoff of 2.5 µg/mL, the assay demonstrated sensitivity and specificity exceeding 95% for IgG to both SARS-CoV-2 proteins. Among 36 patients evaluated in a post-hospital follow-up clinic, median levels of IgG to spike-RBD and nucleocapsid were 34.7 µg/mL (IQR 18-52) and 24.5 µg/mL (IQR 9-59), respectively. Among 17 patients with longitudinal samples, there was a wide variation in the magnitude of IgG responses, but generally the response to spike-RBD and to nucleocapsid occurred in parallel, with peak levels approaching 100 µg/mL, or 1% of total IgG. CONCLUSIONS: We have described a quantitative assay to measure IgG to SARS-CoV-2 that could be used in clinical and research laboratories and implemented at scale. The assay can easily be adapted to measure IgG to mutated COVID-19 proteins, has good performance characteristics, and has a readout in standardized units.

Quantitative measurement of IgG to SARS-CoV-2 proteins using ImmunoCAP.

BACKGROUND: Detailed understanding of the immune response to SARS-CoV-2, the cause of coronavirus disease 2019 (COVID-19), has been hampered by a lack of quantitative antibody assays. OBJECTIVE: To develop a quantitative assay for IgG to SARS-CoV-2 proteins that could readily be implemented in clinical and research laboratories. METHODS: The biotin-streptavidin technique was used to conjugate SARS-CoV-2 spike receptor-binding-domain (RBD) or nucleocapsid protein to the solid-phase of the ImmunoCAP resin. Plasma and serum samples from patients with COVID-19 (n=51) and samples from donors banked prior to the emergence of COVID-19 (n=109) were used in the assay. SARS-CoV-2 IgG levels were followed longitudinally in a subset of samples and were related to total IgG and IgG to reference antigens using an ImmunoCAP 250 platform. RESULTS: Performance characteristics demonstrated 100% sensitivity and 99% specificity at a cut-off level of 2.5 µg/mL for both SARS-CoV-2 proteins. Among 36 patients evaluated in a post-hospital follow-up clinic, median levels of IgG to spike-RBD and nucleocapsid were 34.7 µg/mL (IQR 18-52) and 24.5 µg/mL (IQR 9-59), respectively. Among 17 patients with longitudinal samples there was a wide variation in the magnitude of IgG responses, but generally the response to spike-RBD and to nucleocapsid occurred in parallel, with peak levels approaching 100 µg/mL, or 1% of total IgG. CONCLUSIONS: We have described a quantitative assay to measure IgG to SARS-CoV-2 that could be used in clinical and research laboratories and implemented at scale. The assay can easily be adapted to measure IgG to novel antigens, has good performance characteristics and a read-out in standardized units.

Proteus empyema as a rare complication from an infected renal cyst, a case report.

BACKGROUND: The most commonly isolated organisms in a parapneumonic effusion include S. pneumoniae, H. influenzae, and S. aureus. If unusual organisms are isolated from the pleural space, further investigation is warranted to locate the primary source. We present a patient with an infected chronic renal cyst found to have an empyema secondary to Proteus mirabilis to highlight the importance of further diagnostic workup when encountering unusual organisms in the pleural space. CASE PRESENTATION: A 40-year-old African-American female, with a past medical history of asthma and sickle cell trait, presented with 5 weeks of upper respiratory tract symptoms and chest pain. A computed tomography angiogram (CTA) of the chest was negative for a pulmonary embolism but revealed a loculated left sided pleural effusion with associated left-lower lobe consolidation. She was started on empiric antibiotics, and a chest tube was inserted with drainage of frank pus. Fluid gram stain was positive for gram negative rods. Intrapleural fibrinolytics were administered for 72 h given the presence of loculations. With no improvement following fibrinolytics, she was taken to the operating room for large bore chest tube placement and left visceral pleura decortication. Pleural fluid cultures speciated to Proteus mirabilis, so further cross-sectional imaging of her abdomen/pelvis was pursued to evaluate for a primary source. A complex cystic lesion in the upper pole of the left kidney that communicated with the ipsilateral diaphragm was identified. Subsequent drainage and culture of the renal cyst was positive for Proteus mirabilis. Given clinical improvement following these interventions she was discharged with an extended course of antibiotics with plans for repeat imaging following completion of treatment. CONCLUSIONS: While cases of Proteus mirabilis empyema have previously been reported as a consequence of conditions such as pyelonephritis, we present, to our knowledge, the first case of a Proteus mirabilis empyema as a consequence of an infected renal cyst communicating with the pleural space. This study highlights that further evaluation with cross-sectional imaging is warranted when unusual organisms are found in the pleural space. Anatomic abnormalities that become apparent on imaging may help elucidate the source of infection.

Neurologic Manifestations of Systemic Disease: Sleep Disorders.

PURPOSE OF REVIEW: Sleep is intimately involved in overall health and wellbeing. We provide a comprehensive report on the interplay between systemic diseases and sleep to optimize the outcomes of systemic disorders. RECENT FINDINGS: Spanning the categories of endocrinologic disorders, metabolic/toxic disturbances, renal, cardiovascular, pulmonary, gastrointestinal, infectious diseases, autoimmune disorders, malignancy, and critical illness, the review highlights the prevalent coexisting pathology of sleep across the spectrum of systemic disorders. Although it is rare that treating a sleep symptom can cure disease, attention to sleep may improve quality of life and may mitigate or improve the underlying disorder. Recent controversies in assessing the cardiovascular relationship with sleep have called into question some of the benefits of treating comorbid sleep disorders, thereby highlighting the need for an ongoing rigorous investigation into how sleep interplays with systemic diseases. SUMMARY: Systemic diseases often have sleep manifestations and this report will help the clinician identify key risk factors linking sleep disorders to systemic diseases so as to optimize the overall care of the patient.

Verrucous carcinoma of the esophagus: A case report and literature review.

Verrucous carcinoma of the esophagus is a variant of a squamous cell cancer. Our case is a 78-year-old male patient comes in with the dysphagia and weight loss, and on endoscopy (EGD) he is found to have an irregular intraluminal mass at the distal esophagus. With the deep EGD assisted biopsy, diagnosis of the verrucous carcinoma is made. Due to multiple co morbidities and possible infiltration to the pericardium, patient is taken for the esophageal stent placement and is being referred for the chemo-radiation treatment. The diagnosis can be very difficult to make with the superficial biopsies due to very non specific histological changes and requires very high clinical suspicion and deep mucosal biopsies are required for accurate diagnosis of the tumor. Chronic and local disease process is the main risk factor for the development of the verrucous carcinoma of the esophagus. Surgery is the treatment of the choice for the early stage tumor and advanced cases are treated with the palliation and possibly chemo- radiation. The prognosis is usually guarded and needs long term follow up.