COVID19 Acute respiratory distress syndrome and extra-corporeal membrane oxygenation; A mere option or ultimate necessity.

Extracorporeal membrane oxygenation (ECMO) is considered a salvage therapy in patients with acute respiratory distress syndrome (ARDS) and refractory hypoxemia (hypoxemia persisting despite lung-protective ventilation). One aspect of ECMO is whether there would be an application of the technology related to the Coronavirus pandemic. The number of people diagnosed with Coronavirus disease (COVID19) has crossed the five million mark on 9 August 2020, with a case fatality rate of 5.2%. Due to this exponential increase in the number of coronavirus disease (COVID19) cases particularly the ones associated with ARDS, experts are evaluating the need for ECMO in intensive care units. Herein, we chronicle a review encompassing the available evidence on ECMO and its potential role in COVID19 ARDS, as we aim for optimal patient care with appropriate resource utilization and conservation.

IDENTIFYING PARATHYROID HORMONE DISORDERS AND THEIR PHENOTYPES THROUGH A BONE HEALTH SCREENING PANEL: IT'S NOT SIMPLE VITAMIN D DEFICIENCY!

OBJECTIVES: To determine the utility of bone health screening panels in identifying disorders of parathyroid gland secretions. METHODS: A retrospective analysis of biochemical parameters in a bone health screening panel (BHSP) was conducted. Low and high cutoffs were applied to determine hypofunctioning and hyperfunctioning conditions related to parathyroid hormone. Clinical phenotypes of parathyroid gland abnormalities were determined using a combination of levels of calcium, 25-hydroxyvitamin D, and intact parathyroid hormone (iPTH). A PTH nomogram was applied to calculate the maximum expected PTH for existing levels of 25-hydroxyvitamin D. Medical records of patients were reviewed for clinical validation of biochemical findings. RESULTS: Sixty-eight percent of subjects showed abnormal PTH secretion. Primary hyper- and hypoparathyroidism were detected in 1% (n = 5) and 0.4% (n = 2) of subjects, respectively. Normocalcemic hyperparathyroidism and hypercalcemia with inappropriately high-normal PTH were identified in 8.5% (n = 37) and 2% (n = 10) of subjects, respectively. All subjects with primary and normocalcemic hyperparathyroidism had higher measured PTH than calculated maximum PTH using the PTH nomogram. Secondary hyperparathyroidism and functional hypoparathyroidism were present in 18% (n = 88) and 39% (n = 194) of subjects, respectively. High prevalence of bone pains, renal stones, and low bone mineral density were identified in patients with abnormal PTH secretion. CONCLUSION: Panel testing is useful in early diagnosis of metabolic bone disorders related to PTH. A BHSP helps identify normocalcemic hyperparathyroidism and hypercalcemia with inappropriately high PTH. ABBREVIATIONS: 25OHD = 25-hydroxyvitamin D AKUH = Aga Khan University Hospital BHSP = bone health screening panel iPTH = intact parathyroid hormone maxPTH = maximum parathyroid hormone MBD = metabolic bone disease NCHPT = normocalcemic hyperparathyroidism PHPT = primary hyperparathyroidism PTH = parathyroid hormone SHPT = secondary hyperparathyroidism VDD = vitamin D deficiency.

Cardiac Thromboembolism in COVID-19: A Case Series.

Venous thromboembolism (VTE) is a very common complication of coronavirus disease-2019 (COVID-19) because of the acquired hypercoagulability in these patients. Cardiovascular thromboembolism (CTE) is another complication that is relatively rare yet catastrophic. We present two cases of COVID-19 which were complicated by CTE. Case one describes a 55-year-old male with COVID-19 who had an ST-segment elevation myocardial infarction (STEMI) secondary to coronary artery embolism and was also found to have biventricular thrombi (BVT). Case two describes a 65-year-old female presenting with STEMI secondary to coronary artery embolism. This document highlights how CTE can be present in COVID-19 patients and describes the available evidence for its management. Given the paucity of data on these complications, we illustrate the offered treatment which was based on the data extrapolated from the treatment of VTE in COVID-19 and the treatment of CTE in non-COVID-19 patients.

Euglycemic Diabetic Ketoacidosis Due to SGLT2 Inhibitor in a Patient With Gitelman Syndrome: A Therapeutic Dilemma.

Euglycemic diabetic ketoacidosis (DKA) is a rarely reported side effect of sodium-glucose cotransporter-2 inhibitor (SGLT2i) empagliflozin. A 51-year-old female with Gitelman syndrome and type 2 diabetes mellitus (DM) presented with abdominal pain after a recent hospitalization for acute pancreatitis. Her diabetes medications included metformin, pioglitazone, and empagliflozin. Diabetic ketoacidosis was suspected; however, glucose levels were below the cutoff for DKA; therefore, she was diagnosed with euglycemic DKA. Her pancreatitis workup was insignificant. Severe symptomatic hypokalemia despite aggressive repletion limited the management of DKA with insulin infusion therapy. As her ketonemia resolved, she was initiated on subcutaneous insulin with a small but acceptable decrease in potassium. The therapeutic dilemma of managing euglycemic DKA due to SGLT2i in a patient with Gitelman syndrome has not been previously described.

Newborn screening for congenital hypothyroidism: improvement in short-term follow-up by audit and monitoring.

OBJECTIVE: Newborn screening for congenital hypothyroidism (CH) at our hospital during this study was by measurement of thyroid stimulating hormone (TSH) in serum samples. This audit was conducted over a 2 year period, to determine the compliance of reporting of results greater than the screening cutoffs for serum TSH. Gaps of non-compliance were identified, and re-audit was undertaken after the corrective actions were taken. RESULTS: The critical limit was defined as serum TSH (≥ 20 µIU/ml) following consultation with a pediatric endocrinologist. All results above this limit were reported urgently to physicians. During the audit period, 27,407 tests were performed, 0.7% had a value of ≥ 20 µIU/ml, of those only 62% were reported to the general paediatrician or neonatologist. Reasons for not reporting results included non-availability of contact information, lack of policy awareness by technologists, critical results not highlighted on the computer display, and absence of regular monitoring. Corrective measures were taken, and re-audit was done. During the re-audit period, a total of 22,985 tests was performed, 0.6% had a value of ≥ 20 µIU/ml. Of these, 77% were reported to the general paediatrician or neonatologist. Critical result reporting was improved after the audit, and further enhanced the laboratory service of CH screening.