Is Anxiety a Rising Concern during COVID-19 Pandemic among Healthcare Workers?

How to cite this article: Murthy PR, Venkatesha Gupta KV, Ajith Kumar AK. Is Anxiety a Rising Concern during COVID-19 Pandemic among Healthcare Workers? Indian J Crit Care Med 2020;24(5):369-370.

Clinical predictors of long-term survival in HER2-positive metastatic breast cancer.

Prior to availability of anti-HER2 therapies, HER2-positive metastatic breast cancer (MBC) was associated with a poor prognosis. Prospective randomized trials have demonstrated survival benefit from anti-HER2 treatments. Anecdotal observations have suggested that a small but meaningful fraction of patients with HER2-positive MBC may be "exceptional responders" with long survival. We hypothesized that demographic and/or clinicopathologic characteristics can be identified to distinguish short-term from long-term survivors. A retrospective, single-institution review of 168 patients with HER2-positive MBC who received treatment with anti-HER2 therapy in the metastatic setting was performed. Cox proportional hazards analysis was used to assess factors associated with long-term survival. Median overall survival from the time of breast cancer recurrence was 3.9 years (95 % CI 3.4-5.2). From the time of diagnosis of MBC, 56 (33 %) survived for 5 or more years and 12 (7 %) survived more than 10 years. Of the 66 patients diagnosed with central nervous system metastases, 9 (14 %) survived more than 5 years following that diagnosis. Younger age at diagnosis, lower stage, hormone receptor positive status, and only having one organ involved at diagnosis were associated with longer survival. Four patients discontinued anti-HER2 therapy and are without evidence of progression of disease after a median 7.4 years (0.2-12.0) since stopping therapy. In a cohort of patients with HER2-positive MBC treated primarily with trastuzumab and lapatinib, 7 % of patients were "exceptional responders." Combining these clinical factors with molecular determinants of prolonged survival may provide insights for individualizing treatment selection.

Hantavirus pulmonary syndrome in a postpartum woman.

Hantavirus infection, a rare disease diagnosed in India and carries a very high mortality. There are no reports of this infection in association with pregnancy or postpartum period in our country. We present a case of a 30-year-old female diagnosed to have hantavirus pulmonary syndrome in the postpartum period. We intend to create awareness about this infection and consider it in the differential diagnosis of patients presenting with acute respiratory distress syndrome and multiorgan dysfunction in association with pregnancy and postpartum period.

Detection of comorbid illnesses during pre-anaesthesia evaluation in a university teaching hospital: A prospective observational study.

BACKGROUND: Consultation for surgery and anaesthesia is often the first point of contact with a healthcare provider for a majority of patients in developing countries. In India, where patients have poor access to healthcare, they are likely to present with uncontrolled/untreated/undetected coexisting diseases. However, there is little published literature on this aspect. We hypothesized that many of our patients will present to our pre-anaesthesia evaluation clinic (PAC) with undetected comorbid illnesses and will require proper assessment, treatment and optimization before surgery. Thus, we aimed to assess the frequency and type of comorbid illnesses in patients attending the pre-anaesthesia clinic for elective surgery. METHODS: We did a prospective observational study on all patients evaluated in the PAC of our university teaching hospital over a 3-month period to assess the frequency and type of comorbid illnesses. The data recorded included demographic profile and presence of coexisting illness and was classified as preexisting or newly diagnosed at the time of the visit to the PAC. The data were then tabulated and analysed statistically using SPSS software version 14.0. The frequency and percentage of occurrence for each comorbid illness was determined. RESULTS: Of 3973 patients, 242 (6%) had 304 comorbid illnesses (135 cardiac, 54 endocrine, 15 respiratory, 12 others). Of these 88 (29%) were newly detected comorbid conditions (69 cardiac, 9 endocrine, 9 respiratory, 1 others). The most frequent comorbid illness both pre-existing and newly diagnosed were cardiac. Hypertension was the commonest problem in our study population (168 patients). CONCLUSION: We confirmed that a PAC can detect hitherto undetected comorbid illnesses which are likely to impact the perioperative process.

COVID-19 complicating pregnancy: A retrospective study of nine intensive care unit patients.

Background: With the emergence of the coronavirus 2019 (COVID-19) pandemic, it was essential to determine the impact of this disease on pregnant women and neonatal outcomes. In this study, we present a series of nine cases of pregnant women with COVID-19 disease requiring intensive care unit (ICU) admission. Methods: We retrospectively collected clinical data of pregnant women with COVID-19 disease admitted to ICU between September 2020 and September 2021. Results: Most common presenting symptom was cough. Two patients had no respiratory symptoms at presentation. Five of the nine patients required invasive mechanical ventilation. Seven patients required caesarean section, four of whom delivered preterm. There were no maternal or neonatal deaths. Conclusions: Although maternal and neonatal outcomes reported in our study are encouraging, it is imperative to emphasize the importance of an individualized, multidisciplinary approach, and good healthcare infrastructure for optimal management of this group of patients.

An Interesting Case of Dengue Encephalitis With Parkinsonism Sequela.

Expanded dengue syndrome has been associated with various neurological manifestations. In this report, we present a rare and interesting case of parkinsonism secondary to dengue encephalitis in a young female. A 25-year-old female was admitted to the ICU with high-grade fever, generalized weakness, and altered sensorium for two days. Meningoencephalitis workup was negative but she tested positive for dengue non-structural 1 (NS1) antigen. MRI brain showed a "double doughnut sign" consistent with viral encephalitis. She was managed with neuroprotective measures, a short course of steroids, and invasive mechanical ventilation via tracheostomy. During the course of her treatment, she developed left upper limb rigidity, involuntary movements, and gait abnormalities with generalized bradykinesia suggestive of dengue-associated parkinsonism. She responded well to trihexyphenidyl and levodopa with significant neurological recovery and was discharged from the hospital in a condition where she could independently walk with significant improvement in dystonia. Central nervous system involvement has been well documented in arboviral illnesses caused by neurotropic viruses. Dengue encephalitis with sequelae like parkinsonism is potentially treatable when identified appropriately and in a timely manner.

Adolescent tuberculosis in the ICU.

TB is a major concern in the paediatric age group, especially in India. More than 3.33 lakh children between 0 and 14 years of age are affected by TB. Adolescent tuberculosis has been a neglected area and this age group accounts for about 800,000 cases of tuberculosis (TB) cases every year. Information regarding adolescent tuberculosis patient requiring ICU admission/care is very scanty (unlike adult tuberculosis), and the authors believe that the mode of ICU presentation and challenges in adolescents would almost be the same as in adults, although the outcome is generally expected to be better in the adolescent population in view of lesser comorbidities when compared to adults. ARDS, multiorgan dysfunction and meningitis are the most common reasons for admission to ICU. Critically ill patients with TB carry a high mortality and the increased mortality is likely due to multiorgan dysfunction, nosocomial infections and sepsis. Advanced disease with chronic undernourishment influences not just morbidity but mortality as well. Further, the heavy financial burden incurred for ICU care in TB patients with poor expected outcome is a major concern since TB occurs predominantly in low socio-economic populations.

Connecting the Dots: The Interplay Between Stroke and the Gut-Brain Axis.

This article discusses the interplay between the gut-brain axis and stroke, a multifaceted neurological disorder that affects millions of people worldwide. The gut-brain axis is a bidirectional communication network linking the central nervous system (CNS) to the gastrointestinal tract (GIT), including the enteric nervous system (ENS), vagus nerve, and gut microbiota. Dysbiosis in the gut microbiota, alterations in the ENS and vagus nerve, and gut motility changes have been linked to increased inflammation and oxidative stress, which are contributing factors in the development and progression of stroke. Research on animals has shown that modifying the gut microbiota can impact the results of a stroke. Germ-free mice displayed improved neurological function and decreased infarct volumes, indicating a positive effect. Furthermore, studies in stroke patients have shown alterations in the gut microbiota composition, indicating that targeting dysbiosis could be a potential therapeutic strategy for stroke. The review suggests that targeting the gut-brain axis may represent a potential therapeutic approach to reduce the morbidity and mortality associated with stroke.

Exploring the Correlation Between Influenza A Virus (H3N2) Infections and Neurological Manifestations: A Scoping Review.

Influenza A virus (IAV), particularly the H3N2 variant, is known to cause respiratory manifestations, but it can also lead to neurological complications ranging from mild symptoms like headache and dizziness to severe conditions such as encephalitis and acute necrotizing encephalopathy (ANE). In this article, the correlation between the H3N2 variant of the IAV and neurological manifestations is discussed. Additionally, prompt recognition and treatment of influenza-associated neurological manifestations are highlighted to prevent infection-related long-term complications. This review briefly discusses various neurological complications linked to IAV infections, such as encephalitis, febrile convulsions, and acute disseminated encephalomyelitis, and the potential mechanisms involved in the development of neurological complications.

Extracorporeal membrane oxygenation in COVID-19- Associated acute respiratory distress syndrome - Outcome and experience in a tertiary care intensive care unit - A retrospective study.

Background: Extracorporeal membrane oxygenation (ECMO) has been used in patients with severe acute respiratory distress syndrome (ARDS) due to coronavirus disease 2019 (COVID-19) who fail conventional treatment. Methods: A retrospective observational study was designed in patients who underwent ECMO for severe COVID-19 ARDS in a tertiary care centre from September 2020 to July 2021. The primary outcome was to assess factors influencing clinical outcomes and survival to hospital discharge. Secondary outcomes were to assess the clinical profile and pre-ECMO features, ECMO characteristics and complications. Collected data were entered in Excel software and analysed using R software version 4.0.2 (R foundation for statistical computing, Vienna, Austria). Results: A total of 19 patients underwent ECMO. Ten patients survived and discharge. Survivors had a longer median (interquartile range [IQR]) duration (days) on ECMO, that is, 25 (7-50), compared to non-survivors, that is, 12 (1-34) (P = 0.133). We also noted that patients who survived had a longer median (IQR) duration (days) of intensive care unit (ICU) stay, that is, 41.5 (30-70), compared to non-survivors, that is, 9 (2-40) (P = 0.001). Conclusion: In our study, 52.3% of patients survived and discharge, and with ECMO outcomes for COVID-19 ARDS were at par with ECMO outcomes for non-COVID-19 ARDS despite requiring ECMO for longer duration and increased ICU length of stay.

The prevalence of asymptomatic COVID-19 infection in cancer patients. A cross-sectional study at a tertiary cancer center in New York City.

OBJECTIVE: Several factors raise concern for increased risk of COVID-19 in cancer patients. While there is strong support for testing symptomatic patients. The benefit of routine testing of asymptomatic patients remains contentious. We aim to evaluate the prevalence of asymptomatic COVID-19 infection in cancer patients. METHODS: Between June 1 and September 3, 2020, we obtained nasopharyngeal swab from asymptomatic cancer patients who were visiting a single tertiary-care cancer center, and tested the specimen for the presence or absence of SARS-CoV-2 RNA. We performed a descriptive statistic of data RESULTS: We tested a total of 80 patients, of which 3 (3.75%) were found positive for COVID-19. A significant proportion of the tested patients were on active immunosuppressive or immunomodulatory treatment, cytotoxic chemotherapy (n = 34), and immunotherapy (n = 16). However, all three COVID-19 positive patients were only actively on hormonal therapy. All three patients observed a minimum of 2 weeks home quarantine. None of the patients developed symptoms upon follow up and no changes were required to their treatment plan. CONCLUSIONS: Despite published evidence that cancer patients may be at increased risk of severe COVID -19 infection, our data suggest that some infected cancer patients are asymptomatic. The overall prevalence of asymptomatic COVID-19 infection in this population of cancer patients was similar to that in the general population. Therefore, since asymptomatic infections are not uncommon in patients with cancer, we recommend universal COVID-19 testing to help guide treatment decisions and prevent the spread of the disease.

Clinical Determinants Differentiating the Severity of SARS-CoV-2 Infection in Cancer Patients: Hospital Care or Home Recovery.

Background: Cancer patients may carry a worse prognosis with SARS-CoV-2 infection. Most of the previous studies described the outcomes of hospitalized cancer patients. We aimed to study the clinical factors differentiating patients requiring hospital care vs. home recovery, and the trajectory of their anti-cancer treatment. Methods: This study was conducted in a community cancer center in New York City. Eligible patients were those who had cancer history and were diagnosed of SARS-CoV-2 infection between March 1 and May 30, 2020, with confirmatory SARs-CoV-2 virus test or antibody test. Four groups were constructed: (A) hospitalized and survived, (B) hospitalized requiring intubation and/or deceased, (C) non-hospitalized, asymptomatic, with suspicious CT image findings, close exposure, or positive antibody test, and (D) non-hospitalized and symptomatic. Results: One hundred and six patients were included in the analysis. Thirty-five patients (33.0%) required hospitalization and 13 (12.3%) died. Thirty (28.3%) patients were asymptomatic and 41 (38.7%) were symptomatic and recovered at home. Comparing to patients who recovered at home, hospitalized patients were composed of older patients (median age 71 vs. 63 years old, p = 0.000299), more who received negative impact treatment (62.9 vs. 32.4%, p = 0.0036) that mostly represented myelosuppressive chemotherapy (45.7 vs. 23.9%, p = 0.0275), and more patients with poorer baseline performance status (PS ≥ 2 25.7 vs. 2.8%, p = 0.0007). Hypoxemia (35% in group A vs. 73.3% in group B, p = 0.0271) at presentation was significant to predict mortality in hospitalized patients. The median cumulative hospital stay for discharged patients was 16 days (range 5-60). The median duration of persistent positivity of SARS-CoV-2 RNA was 28 days (range 10-86). About 52.9% of patients who survived hospitalization and required anti-cancer treatment reinitiated therapy. Ninety-two percent of the asymptomatic patients and 51.7% of the symptomatic patients who recovered at home continued treatment on schedule and almost all reinitiated treatment after recovery. Conclusions: Cancer patients may have a more severe status of SARS-CoV-2 infection after receiving myelosuppressive chemotherapy. Avoidance should be considered in older patients with poor performance status. More than two thirds of patients exhibit minimal to moderate symptoms, and many of them can continue or restart their anti-cancer treatment upon recovery.

Atypical Neurological Manifestations of COVID-19.

The novel coronavirus (SARS-CoV-2), belonging to a group of RNA-enveloped viruses and believed to be transmitted by aerosol route, is a worldwide pandemic. Many studies have described typical clinical manifestations such as fever, cough, fatigue, diarrhea, and nasal congestion. However, to our knowledge, there are minimal studies on the neurological manifestations in SARS-CoV-2 positive patients. Our review aims to identify the various neurological manifestations in SARS-CoV-2 positive patients, which could be an added advantage in the early diagnosis and prevention of further complications of the nervous system.

Caffeine as a Neoadjuvant Therapy in Parathyroid Adenomas: A Narrative Review.

Caffeine is the most used central nervous system stimulant drug to date. Many studies have shown the association of caffeine with bone remodeling, urinary calcium excretion, kidney stones, acid peptic disease, and the development of cancer. However, there has been very little research exploring the association between caffeine use and parathyroid gland disorders. We shed light on the possible connection between caffeine and parathyroid adenomas, as suggested in the literature.

Chemotherapy Treatment Modifications During the COVID-19 Outbreak at a Community Cancer Center in New York City.

PURPOSE: As a result of their immunocompromised status associated with disease and treatment, patients with cancer face a profound threat for higher rates of complications and mortality if they contract the coronavirus disease 2019 infection. Medical oncology communities have developed treatment modifications to balance the risk of contracting the virus with the benefit of improving cancer-related outcomes. METHODS: We systemically examined our community cancer center database to display patterns of change and to unveil factors that have been considered with each decision. We studied a cohort of 282 patients receiving treatment and found that 159 patients (56.4%) had treatment modifications. RESULTS: The incidence of treatment modification was observed in patients undergoing adjuvant and neoadjuvant (41.4%), palliative (62.9%), or injectable endocrine or bone-modulating only (76.0%) treatments. Modifications were applied to regimens with myelosuppressive (56.5%), immunosuppressive (69.2%), and immunomodulating (61.5%) potentials. These modifications also affected intravenous (54.9%) and subcutaneous injectable treatments (62.5%) more than oral treatments (15.8%). Treatment modifications in 112 patients (70.4%) were recommended by providers, and 47 (29.6%) were initiated by patients. The most common strategy of modification was to skip or postpone a scheduled treatment (49%). Among treatment with no modifications, treatment regimens were maintained in patients who tolerated treatment well (37.0%), in treatments with curative intent (22%), and in symptomatic patients who required treatment (14%). CONCLUSION: Our observation and analysis suggested that the primary goal of treatment modification was to decrease potential exposure. The pattern also reflected the negative impact of the pandemic on health care providers who initiated these changes. Providers have to consider individualized recommendations incorporating multiple factors, such as tolerance, potential toxicity, treatment nature and route, and disease severity.

The Possibility and Cause of Relapse After Previously Recovering From COVID-19: A Systematic Review.

The severe acute respiratory distress syndrome coronavirus-2 (SARS-Cov-2) is a novel coronavirus that is believed to be mainly transmitted via droplet and contact transmission. While research is focusing on epidemiology, transmission, vaccine development, and therapeutics for coronavirus disease 2019 (COVID-19), there is a possibility of disease relapse. There are reports of patients who tested positive for SARS-Cov-2 after clinical recovery and initial clearance of the virus. Objective This systematic review aims to identify the trends of COVID-19 relapse, the effects of co-morbidities on it, and associated mortality rates. Methods We conducted a systematic search during March and April 2020 for research articles on the relapse of COVID-19 using two primary databases, PubMed and Embase. Results A total of 13 eligible studies were screened of which 11 (case reports) were eligible for data extraction. The earliest to report relapse was after two days of discharge and the latest was 22 days after discharge. The mean number of days to relapse was 12 days and the median number was seven days. There was incomplete information about comorbidities. No mortalities were reported at the time of the study.

PARP inhibitors: clinical development, emerging differences, and the current therapeutic issues.

Following years in development, poly-adenosyl-ribose polymerase (PARP) inhibitors continue to advance the treatment of ovarian and breast cancers, particularly in patients with pathogenic BRCA mutations. Differences in clinical trial design have contributed to distinct indications for each of the PARP inhibitors. Toxicity patterns are also emerging that suggest agents differ in their normal tissue tolerance - beyond what might be expected by dose variations and/or exposure to prior treatment. PARP inhibitor resistance is an increasingly relevant issue as the drugs move to the forefront of advanced ovarian/breast cancer treatment, and is an active area of ongoing research. This review examines the PARP inhibitor clinical trials that have led to approved indications in ovarian and breast cancers, PARP inhibitor targets and pharmacological differences between the PARP inhibitors, emerging mechanisms of resistance, and key clinical questions for future development.

Women's cancers: how the discovery of BRCA genes is driving current concepts of cancer biology and therapeutics.

Over the last two decades, discoveries related to the breast cancer susceptibility genes 1 and 2 (BRCA1 and BRCA2) have profoundly changed our understanding and management of hereditary breast and ovarian cancers. The concept of synthetic lethality, which arises when cells become vulnerable to a combination of deficiencies in DNA repair, has driven the expanding roles of poly (adenosine diphosphate (ADP)-ribose) polymerase inhibitors in breast and ovarian cancers, and prevention strategies are taking into account the tissue specificity, natural history (fallopian tube origin of some high-grade serous ovarian cancers) and hormone sensitivity of BRCA-associated cancers. Current research has focussed on further elucidating the roles of BRCA proteins in DNA repair, investigating other key DNA repair processes and proteins and linking aberrant DNA repair with carcinogenesis. The ultimate goal is to translate this evolving knowledge into improving the clinical care and treatment of patients with pathogenic BRCA variants or other deficiencies in homologous recombination (HR). In this review, we will discuss 1) the role of BRCA proteins in DNA repair; 2) emerging concepts in the biology of HR deficiency and 3) implications for prevention and treatment.