Inflammatory Bowel Disease Management During the COVID-19 Outbreak: The Ten Do's and Don'ts from the ECCO-COVID Taskforce.

Our knowledge of COVID-19 is changing and evolving rapidly, with novel insights and recommendations, almost on a daily basis. It behooves the medical community to provide updated information on a regular basis, on best practice to facilitate optimal care of infected patients and on appropriate advice for the general population. This is particularly important in the case of patients with chronic conditions, such as inflammatory bowel disease [IBD]. In this review, we have compiled existing evidence on the impact of COVID-19 in IBD patients and provide guidance on the most appropriate care to adopt during the pandemic. Our review highlights that IBD, per se, is not a risk factor for COVID-19. However, all IBD patients with symptoms should be tested for SARS-CoV-2 and the procedures for disease management should be carefully adapted: [i] in SARS-CoV-2-positive IBD patients, medical treatments should be re-evaluated [with a particular focus on corticosteroids] always with the purpose of treating active disease and maintaining remission; [ii] non-urgent surgeries and endoscopic procedures should be postponed for all patients; [iii] online consultancy should be implemented; and [iv] hospitalization and surgery should be limited to life-threatening situations.

Genital ulcers: it is not always simplex .

Patients with vulval aphthae, also termed Lipschütz ulcers, often present to genitourinary medicine clinics. Typically, these ulcers present as acute, painful, vulval ulcers in young women and adolescents. The aetiology is unknown, and often these ulcers are accompanied by flu-like symptoms. Previous case reports have linked such lesions to acute viral infections such as Epstein-Barr virus, cytomegalovirus and influenza A. We report the first case of influenza B virus and adenovirus infections associated with this presentation.

Successful treatment of parvovirus B19 infection and red cell aplasia occurring after an allogeneic bone marrow transplant.

Chronic parvovirus B19 infection in the immunocompromised host may cause severe anaemia secondary to failure of erythropoiesis. This has been previously documented in patients with the Acquired Immune Deficiency Syndrome (AIDS), congenital immunodeficiencies and in children with acute lymphoblastic leukaemia during maintenance chemotherapy. We describe persistent parvovirus infection in a 14-year-old boy after HLA-matched sibling allogeneic bone marrow transplantation for acute lymphoblastic leukaemia in second remission.

Forces and moments on the human leg in the frontal plane during static bipedal stance.

An experimental apparatus was assembled that permitted measurement of the vertical and lateral ground reaction forces as the hip is abducted, resulting in foot separations ranging from 0.25 to 71 cm, with the knee in 0 degree flexion. Twelve healthy volunteers (8 men and 4 women) were tested. The hip joint was located by means of center of rotation measurements on each subject's legs, and the location of the knee joint was determined using anatomical measurements. It was observed that the mediolateral force was nonzero and directed toward the body midline, even when the subject's feet were placed together. With the feet placed at shoulder width, the population mean mediolateral force was 3% of body weight. It was determined that simplifying assumptions based upon either "zero lateral force," or "zero hip moment," produced errors, when compared with our measured values, over various ranges of foot separation, with the zero hip moment assumption providing accuracy over a broader range. The inclination of the tibial plateau, with respect to the long axis of the tibia, that would produce minimal mediolateral shear at the knee is presented. Research and clinical applications of our results and techniques are discussed.

Symptomatic cytomegalovirus infection complicating treatment of acute systemic vasculitis.

Cytomegalovirus (CMV) is usually a complication of renal/solid organ or bone marrow transplantation. We describe three cases of severe CMV in the context of vasculitis immunosuppression.

Knee surgery assistance: patient model construction, motion simulation, and biomechanical visualization.

We present a new system that integrates computer graphics, physics-based modeling, and interactive visualization to assist knee study and surgical operation. First, we discuss generating patient-specific three-dimensional (3-D) knee models from patient's magnetic resonant images (MRIs). The 3-D model is obtained by deforming a reference model to match the MRI dataset. Second, we present simulating knee motion that visualizes patient-specific motion data on the patient-specific knee model. Third, we introduce visualizing biomechanical information on a patient-specific model. The focus is on visualizing contact area, contact forces, and menisci deformation. Traditional methods have difficulty in visualizing knee contact area without using invasive methods. The approach presented here provides an alternative of visualizing the knee contact area and forces without any risk to the patient. Finally, a virtual surgery can be performed. The constructed 3-D knee model is the basis of motion simulation, biomechanical visualization, and virtual surgery. Knee motion simulation determines the knee rotation angles as well as knee contact points. These parameters are used to solve the biomechanical model. Our results integrate 3-D construction, motion simulation, and biomechanical visualization into one system. Overall, the methodologies here are useful elements for future virtual medical systems where all the components of visualization, automated model generation, and surgery simulation come together.

Physiologic bowing in children: an analysis of the pendulum mechanism.

Prompted by common observations, we investigated why physiologic bowing occurs in infants and what purpose is served by its characteristic varus to valgus to neutral movement of the mechanical axis of the knee which we term "pendulum-like swing" in the frontal plane. Anthropomorphic data were readily available on age-related increase in weight, femoral and tibial lengths, and changes in lower extremity to allow construction of an "average" leg representing "normal" limb alignment of a growing infant male aged 1-8 years. This enabled us to calculate the bending moments on five anatomic levels of the limb about the knee; more important, during some growth periods the bending moments are minimal and may be used to diagnose pathologies of the lower limb. This form of analysis may prove useful in pathologies in which mechanisms serve to "mask" problems diagnosed on the basis of knee angle alone. When the child begins to stand, the pendulum mechanism is needed to equalize physeal growth about the knee.

Severe pneumococcal infection: a one year survey.

Invasive pneumococcal infection is a major health problem with considerable mortality. In most patients the diagnosis is relatively straightforward but this study points out that in many, especially children, it is difficult because of a lack of clinical signs of septicaemia. While chronic respiratory disease is a major predisposing factor, malignancy and immune disorders are also common underlying features. Certain risk groups may benefit considerably from vaccination. The treatment of established infection is now complicated by the emergence of resistant strains, but penicillin remains the mainstay of therapy.

A parainfluenza-3 outbreak in a SCT unit: sepsis with multi-organ failure and multiple co-pathogens are associated with increased mortality.

The estimated frequency of parainfluenza virus 3 (PIV-3) infections following haematopoietic SCT (HSCT) is 2-7%, whereas reported mortality ranges from 18 to 33%. We report a retrospective outcome analysis following an outbreak of PIV-3 infection in our transplant unit. A total of 16 HSCT patients developed PIV-3 infection. All patients had upper respiratory tract infection, whereas lower respiratory tract infection occurred in 8 patients. Overall, 13 patients were treated with aerosolised Ribavirin (2 g t.d.s. for 5 days) and i.v. Ig (0.5 g/kg) as per standard protocol. One patient refused treatment, whereas two patients with full immune reconstitution were not treated. Overall mortality was 62.5%. Sepsis with multi-organ failure and the presence of pulmonary co-pathogens were both significantly associated with PIV-3-related mortality. Our series confirms that high mortality is associated with PIV-3 infection in HSCT recipients. In patients who develop PIV-3 infection, despite strict enforcement of infection control policies, the best strategy might be careful risk assessment, with effective broad-spectrum anti-microbials in those who are at risk of secondary infection.

Identification and control of nosocomial adenovirus keratoconjunctivitis in an ophthalmic department.

AIMS: To identify the extent of nosocomial adenovirus keratoconjunctivitis (AKC) and assess the effect of a new infection-control policy. METHODS: Nosocomial AKC was defined as AKC in patients attending the hospital within 3 weeks of a previous visit for an unrelated non-infective condition. An audit of culture-proven nosocomial AKC was carried out from October 1998 to September 1999 to establish its extent in our outpatient department. A new infection-control policy for AKC was introduced in June 2001 that differed from the previous policy by segregating suspected AKC cases in a separate waiting area and examination room, and by expediting their examination, to reduce their exposure to both staff and patients in the common waiting areas. In October 2002, AKC was made an index infection and subjected to continual quarterly audit; the figures for this until December 2005 are reported. RESULTS: In the 1998-9 audit, before the introduction of the new infection-control measures, 48.4% (75/155) AKC infections were nosocomial. In the 12 months following the introduction of the quarterly audit in October 2002, 22.7% (5/22) were nosocomial, but thereafter the numbers of nosocomial cases dropped to 3.4% (8/235). CONCLUSION: Introduction of audit of nosocomial AKC infection identified that there was chronic cross-infection in the Moorfields Eye Hospital Accident and Emergency Department. This was controlled by the introduction of patient segregation, as an additional infection-control measure, which has almost eliminated nosocomial AKC transmission in the hospital.

Measles-associated encephalopathy in children with renal transplants.

Two children, boys of 8 and 13 years, presented with measles-associated encephalopathy several years after kidney transplantation for congenital nephrotic syndrome. In the absence of prior clinical measles, the neurological symptoms initially eluded diagnosis, but retrospective analysis of stored samples facilitated the diagnosis of measles-associated encephalopathy without recourse to biopsy of deep cerebral lesions. Each had received a single dose of measles mumps and rubella vaccine before 12 months of age. Prior vaccination, reduction of immunosuppression and treatment with intravenous immunoglobulin and ribavirin may have contributed to their survival. Persistent measles virus RNA shedding, present in one child, was not controlled by treatment with i.v. ribavirin. Two years later, both patients continue to have functioning allografts with only minimal immunosuppression. These cases illustrate the difficulty in diagnosing measles-associated encephalopathy in the immunocompromised host, even in the era of molecular diagnostics, and highlight the renewed threat of neurological disease in communities with incomplete herd immunity.

Transmission of syphilis by solid organ transplantation.

Two organ recipients developed serologic evidence of syphilis infection after renal transplantation from a common deceased donor with a history of treated syphilis. Testing of donor serum for syphilis, which occurred after transplantation, gave results interpreted as consistent with past infection. However, subsequent serologic results in the recipients suggested transmission of infection at transplantation due to active infection of the donor. This may be explained by recent donor re-infection in view of the current syphilis epidemic in the United Kingdom. An initial error in the treatment of recipients further served to highlight unfamiliarity in managing this resurgent infection in the context of organ transplantation.

In situ localization of Epstein-Barr virus in thymic carcinoma.

Epstein-Barr virus (EBV) genome is associated with a variety of lymphoid and epithelial malignancies. EBV DNA has been detected in some cases of thymic carcinoma, but the cellular locus of the virus has never been defined. Detection of EBV has also been reported in normal thymus, thymic lymphoid hyperplasia, and thymoma by some investigators but not by others. In order to better define the association of the virus with benign and malignant thymic tissues and to characterize its cellular locus, we applied a recently developed in situ hybridization technique using a very abundant EBV transcript (EBER1) as target to a variety of thymic tissues. We detected expression of this transcript only in the malignant epithelial cells in one case of thymic lymphoepithelioma-like carcinoma. EBV expression was not detected in six other cases of thymic carcinoma, nor in tissue from 16 normal thymuses, 14 thymomas, and 10 thymic lymphoid hyperplasias.