Diaphragm dysfunctions among patients recovered from COVID

Introduction: Due to the presence of ACE 2 receptors in the diaphragm, its involvement is likely among patients with Covid 19. This study aimed to describe the presence of diaphragm dysfunction among patients who have recovered from Covid 19. Method(s): The thickness fraction (TF) of the diaphragm was assessed via ultrasonography in supine or semirecumbent posture in the right hemidiaphragm in the zone of apposition. A TF of less than 20% was classified as diaphragm dysfunction. Result(s): A total of 50 (males 34) with a mean age of 49.36 years and recovered from acute Covid were enrolled in the study. Among these 50 participants, 11, 12, and 27 had recovered from mild, moderate, severe Covid, respectively. Overall, 37(74%) subjects were hospitalized, 13 (26%) cases were home quarantined;30 (60%) subjects required oxygen during the course of illness. The average weeks from the onset of symptoms to enrolment was 7.1 weeks. Among the study participants, 9 (18%) subjects (8 males and 1 female) had diaphragm dysfunction (thickness fraction less than 20%). Among subjects who were managed at the hospital (n=37), diaphragm dysfunction was observed in 8 (21.6%). Of patients who had diaphragm dysfunction, 3 out of 9 had mild disease, whereas 6 of 9 (66.6%) subjects had severe illness. sub7 out of 9 (77.7%) subjects were hospitalized and 6 required oxygen during the illness. Conclusion. A significant percentage of COVID-19 survivors had diaphragm dysfunction which may also attribute to the persistent shortness of breath. There is an urgent need for large-scale (nationwide) assessment of diaphragm function among the survivors.

Persistent symptoms and spirometric abnormalities after COVID-19: A prospective cohort study

Introduction: The persistence of symptoms beyond 4 weeks of SARS-CoV-2 infection is referred to as long COVID. There is lack of data about the clinical determinants and natural history of this condition. Aims & objectives: We aimed to determine the risk factors, symptomatology, spirometric abnormalities and evolution of long COVID over a 1-year period. Method(s): We enrolled adult patients at 1-4 months after diagnosis of COVID-19. The demographics, COVID-19 history, clinical symptoms and spirometric results were recorded. Follow-up assessments were done in-person or telephonically at 4-8 months and 8-12 months, respectively. Result(s): We enrolled 128 patients (69% male) with median (IQR) age of 49 (37-56) years. Among these, 99 (77%) needed hospitalization, and 47 (37%) received oxygen for COVID-19. At the 1st assessment at median (IQR) of 64.5 (39.5-90) days after COVID-19 onset, 86 (67%) patients had symptoms, most commonly dyspnea (34%), fatigue (19%) and cough (19%). Reduced FVC (<80% of predicted) was found in 61% subjects. On multivariate analysis, the predictors of symptomatic long COVID were female gender (OR, 4.1;95% CI: 1.5-11;p=0.006) and dyspnea during acute COVID-19 (OR, 3.6;95% CI:1.1-11.3;p=0.03). The predictors of reduced FVC were dyspnea (OR, 4.4;95% CI: 1.6-12;p=0.004) and oxygen therapy (OR, 5.6;95% CI: 1.5-21;p=0.01) during acute COVID-19. The proportion of symptomatic patients reduced between 1st and 2nd assessment (67% vs 37%, p<0.001) and then plateaued at 3rd assessment (42%). Conclusion(s): Persistent symptoms are common over a 1-year follow-up among survivors of COVID-19. Female gender and dyspnea during acute COVID-19 may predict development of long COVID.

Assessment of Potential Risk Factors, Characteristics, and Outcome of Pneumothorax and Pneumomediastinum in Patients with COVID-19: A Retrospective Case-control Study

Introduction: Pneumothorax (PTX) and/or pneumomediastinum (PMD) are rare complications of Coronavirus Disease-2019 (COVID-19) and are linked to high mortality. Incidence rates vary between 0.56-2.01% in the reported literature. With clinical examination being hampered in the current pandemic setting, there is a delay in the diagnosis. There is a need to identify and establish potential predictive factors, that may aid in identifying patients with a high-risk of developing PTX and/or PMD. Aim: To identify potential risk factors and thus, explore their association with PTX and/or PMD among patients with COVID-19. Materials and Methods: A retrospective case-control study was conducted at MS Ramaiah Medical College and Hospital, Bangalore, South India over a six-month period. A total of 130 patients diagnosed with COVID-19 were recruited in a 1:3 ratio as cases and controls respectively. Cases were patients, diagnosed radiologically with PTX and/or PMD, and controls were, matched individuals without PTX and/or PMD. Patient's clinical and laboratory parameters (complete blood count, renal and liver function tests, serum levels of inflammatory markers such as C-reactive protein (CRP), lactate dehydrogenase (LDH), and D-Dimer were tested for potential association with PTX and/or PMD. Student's t-test, Chi-square test, multivariate and univariate logistic regression analysis were performed. Results: During the study period, there was a total of 3,251 COVID-19 admissions at the centre with 976 patients requiring Intensive Care Unit (ICU) admission. The overall incidence of PTX and/or PMD during the study period was (31/3251) 0.95%. The previous history of COVID-19, non vaccination with COVID-19 vaccine, cough as a predominant symptom, high values of baseline CRP, total bilirubin, Aspartate Transaminase (AST), and total leukocyte counts had a positive association. In-hospital mortality (54.8% vs 33.30%) and mortality 28 days (35.7% vs 7.6%) following discharge, were higher among those with PTX and/or PMD. Conclusion: Patients with a history of previous infection with COVID-19, non vaccination/incomplete-vaccination with COVID-19 vaccines, and patients with increasing total leukocyte counts and AST levels, high baseline total serum bilirubin were at increased risk of a detrimental clinical course and may indicate, the possibility of development of PTX and/or PMD in COVID-19 disease.

Clues from the Pandora's Box: Frequency of Acute Abdominal Symptoms in COVID-19 and Its Association with Inflammatory Markers-a Cross-Sectional Study.

Coronavirus disease 2019 (COVID-19) is primarily considered to be a respiratory ailment. Hitherto, abdominal symptoms have been reported with variable frequency in acute COVID-19. The purpose of this study was to estimate the frequency of abdominal symptoms at presentation among patients hospitalised with COVID-19 infection, and to determine their association with disease severity. This was a single-centre cross-sectional observational study conducted at a COVID-19 tertiary care hospital (CTRI/2021/10/037195, registered on 08/10/2021). Consecutive patients hospitalised with acute COVID-19 illness during the study period were included in the study. Their demographic information, abdominal symptoms, comorbidities and category of COVID-19 illness were elicited. All patients had serum inflammatory markers tested on the day of hospitalisation. Among the 685 participants, 214 patients had mild-to-moderate category illness whereas the rest 471 had severe COVID-19 illness. Abdominal complaints were present among 132/685 (18.3%) patients with distension of abdomen (8.03%) being the most common symptom, followed by vomiting (6.72%) and abdominal pain (3.94%). At admission to the hospital, abdominal complaints were commoner among patients with severe disease than in those with mild-to-moderate disease (101/471 vs. 31/214; p=0.029). Abdominal symptoms were associated with a higher neutrophil to lymphocyte ratio (p=0.029). The mortality among COVID-19 patients with abdominal symptoms was higher (9.09 vs. 3.25%; p = 0.007). This study demonstrates the spectrum of abdominal symptoms that can be a part of acute COVID-19 at hospitalisation and also highlights their prognostic potential in acute COVID-19 infection.

Screening of Phytoconstituents from Traditional Plants against SARS-CoV-2 using Molecular Docking Approach

Background: The emergence of COVID-19 as a fatal viral disease encourages researchers to develop effective and efficient therapeutic agents. The intervention of in silico studies has led to revolu-tionary changes in the conventional method of testing the bioactivity of plant constituents. Objective: The current study deals with the investigation of some traditional immunomodulators of plant origin to combat this ailment. Materials and Methods: A total of 151 phytomolecules of 12 immunomodulatory plants were evaluated for their inhibitory action against the main protease (PDB ID: 7D1M) and NSP15 endoribonuclease (PDB ID: 6WLC) by structure-based virtual screening. In addition, the promising molecules with ligand effi-ciency of more than-0.3(kcal/mol)/heavy atoms were further predicted for pharmacokinetic properties and druggability using the SwissADME web server, and their toxicity was also evaluated using Protox-II. Results: Myricetin-3-O-arabinofuranoside of cranberry plant was found to be the most potential candidate against both enzymes: main protease (–14.2 kcal/mol) and NSP15 endoribonuclease (–12.2 kcal/mol). Conclusion: The promising outcomes of the current study may be implemented in future drug development against coronavirus. The findings also help in the development of lead candidates of plant origin with a better ADMET profile in the future.

Liver Injury at Presentation in COVID-19 is Associated with Immuno-Inflammatory Response

Background: SARS-CoV-2 has been shown to affect liver and GI tract in addition to primary involvement of lungs. Liver injury in COVID-19 is hypothesized to be multifactorial with 14- 73% of patients showing evidence of deranged liver functional. Data regarding the liver injury due to SARS CoV-2 infection in a large cohort of unselected patients, is limited, especially from India. So, we conducted a retrospective study among consecutive patients admitted with COVID-19 disease to a tertiary care hospital during the first wave of pandemic. Methods: It was a retrospective observational study. Consecutive patients infected with SARS- CoV-2 and admitted to the COVID-19 ward or ICU of our hospital between 1/4/2020 to 30/6/2020 were included. Patients, < 18 years of age, pregnant ladies and those with underlying liver disease were excluded. Detail history along with data on laboratory parameters, treatment given and outcomes (need for oxygen therapy, ICU admission, need for ventilatory support and in-hospital mortality) was collected and analysed. Results: Data on 303 patients was analysed after exclusions. The mean age was 47.9(15.9) years and 214(69.5%) were males. Out of 303 patients 149 (49.2%) had liver injury. Mild liver injury was present in 95(31.3%), moderate to severe liver injury in 54 (17.8%) patients and only 5 (1.6%) had severe liver injury. Pure cholestatic liver injury was present 19 (6.2%) cases. Male sex (82.1% vs 58.5%;P<0.001) and presence of symptoms (97.3% vs 90.8%;P= 0.01) were associated with presence of liver injury. Patients who had liver injury had significantly longer duration of symptoms before presentation [6 (3-8) days vs 4 (3-7) days);P=0.02] and higher serum ferritin levels [322(156-552) vs 151(44.9-299.5) ng/ml;P=0.02]. On multivariate analysis, serum ferritin was the only factor, independently associated with liver injury (OR- 1.002;95% CI- 1.001-1.004;P=0.006). Serum ferritin had a positive correlation with AST [r=0.416;P=0.0001] and ALT [R=0.458;P =0.0001] in the entire cohort. Liver injury was not significantly associated with need of oxygen therapy, ICU stay, mechanical ventilation or mortality but patients with moderate-severe liver injury had a longer hospital stay than those without [12.2 (5.07) vs 10.3 (4.84) days;P=0.01]. Conclusion: In COVID-19 patients, liver injury at presentation is common in symptomatic male patients and occurs around the end of first week and correlates strongly with serum ferritin levels, suggesting that it might be driven by immuno-inflammation.

Awake prone positioning in non-intubated patients for the management of hypoxemia in COVID-19: A systematic review and meta-analysis

Coronavirus disease-2019 (COVID-19) may lead to hypoxemia, requiring intensive care in many patients. Awake prone positioning (PP) is reported to improve oxygenation and is a relatively safe modality. We performed a systematic review of the literature to evaluate the available evidence and performed meta-analysis of the effect of awake PP in non-intubated patients on improvement in oxygenation and reducing the need for intubation. We searched the PubMed and EMBASE databases to identify studies using awake PP as a therapeutic strategy in the management of COVID-19. Studies were included if they reported respiratory outcomes and included five or more subjects. The quality of individual studies was assessed by the Qualsyst tool. A meta-analysis was performed to estimate the proportion of patients requiring intubation. The degree of improvement in oxygenation parameters (PaO2: FiO2 or PaO2 or SpO2) was also calculated. Sixteen studies (seven prospective trials, three before-after studies, six retrospective series) were selected for review. The pooled proportion of patients who required mechanical ventilation was 0.25 (95% confidence interval (CI) 0.16-0.34). There was a significant improvement in PaO2: FiO2 ratio, PaO2, and SpO2 during awake PP. To conclude, there is limited evidence to support the efficacy of awake PP for the management of hypoxemia in COVID-19. Further RCTs are required to study the impact of awake PP on key parameters like avoidance of mechanical ventilation, length of stay, and mortality.

Anaesthetic considerations for whole lung lavage for pulmonary alveolar proteinosis

Pulmonary alveolar proteinosis (PAP) is an uncommon lung disease characterized by excessive accumulation of pulmonary surfactant that usually requires treatment with whole-lung lavage. A 47-year-old female presented with history of dry cough and breathlessness for past 6months. Chest radiograph demonstrated bilateral alveolar shadows and high resolution computerized tomography thorax showed crazy paving pattern. Broncho-alveolar lavage (BAL) and transbronchial lung biopsy confirmed a diagnosis of PAP. Due to worsening hypoxemia and respiratory failure, wholelung lavage was planned and performed. Anaesthetic management involved integrated use of pre-oxygenation, complete lung isolation, one-lung ventilation with optimal positive end-expiratory pressure, vigilant use of positional manoeuvres, and use of recruitment manoeuvres for the lavaged lung. We have discussed valuable strategies for the anaesthetic management of patients undergoing this multifaceted procedure in a case of severe PAP. Funding: None declared.

Erratum to: Joint Guidance from the Society of Gastrointestinal Endoscopy of India (SGEI), Indian Society of Gastroenterology (ISG), and Indian National Association for Study of the Liver (INASL) for Gastroenterologists and Gastrointestinal Endoscopists on the Prevention, Care, and Management of Patients with COVID-19 (Journal of Digestive Endoscopy (2020) DOI: 10.1055/s-0040-1709837)

The Editor-in-Chief has informed the Publisher that the corresponding author for the article would be Dr Mathew Philip and not Dr Mahesh Goenka. The article was published on efirst on April 6, 2020. Original article's doi is: 10.1055/s-0040-1709837.

TB infection and BCG vaccination: are we protected from COVID-19?

OBJECTIVES: The incidence of emerging coronavirus disease 2019 (COVID-19) disease is variable across the different parts of the world. Apart from travel patterns, other factors determining this difference may include host immune response. The aim of this study was to assess the effect of tuberculosis (TB) endemicity and Bacille Calmette-Guerin (BCG) coverage on COVID-19. STUDY DESIGN: This was a cross-sectional study. METHODS: We reviewed available data regarding TB incidence, BCG coverage (as per the World Health Organization), and COVID-19 incidence of 174 countries. We divided the countries into four cohorts depending on annual TB incidence and BCG coverage. RESULTS: Countries with high TB incidence had lower COVID-19 than countries with low TB incidence. Similarly, countries with high BCG coverage had lower incidence of COVID-19, suggesting some protective mechanisms in TB-endemic areas. However, the ecological differences and different testing strategies between countries could not be accounted for in this analysis. CONCLUSION: Higher TB incidence and BCG coverage were found to be associated with lesser incidence of COVID-19. This outcome paves the way for further research into pathogenesis and immune response in COVID-19.