A Covid -19 Virtual Ward Model: A Preliminary Retrospective Clinical Evaluation From a UK District General Hospital.

OBJECTIVE: This study aims to evaluate the safety, utilization, ability to reduce length of hospitalization and overall outcomes of a COVID-19 virtual ward providing ongoing treatment at home. METHOD: A retrospective single-center study of patients discharged to the COVID-19 virtual "step down" ward between January 27th 2021 and March 2nd 2021. The referral process, length of hospitalization, length of stay on the virtual ward, readmissions, and ongoing treatment requirements including supplemental oxygen, antibiotics, and/or steroids were all noted. RESULTS: A total of 50 patients were referred to the virtual ward. 43 referrals were accepted, 39 of which were from the respiratory ward. Four patients were readmitted, all due to hypoxia. All readmissions occurred within 5 days of discharge. 72% (n = 31) were discharged home with an ongoing oxygen requirement. 14.3% of patients were discharged with antibiotics only, 9.5% with steroids only and 23.8% with both antibiotics and steroids. The mean length of hospital stay for patients discharged to the virtual ward was 10.3 ± 9.7 days and 11.9 ± 11.6 days for all covid positive patients during this time. On average, patients spent 13.7 ± 7.3 days on the virtual ward. The average number of days spent on oxygen on the virtual ward was 11.6 ± 6.0 days. CONCLUSION: The virtual ward model exemplifies the potential benefits of collaborative working between primary and secondary care services, relieving pressure on hospitals whilst providing ongoing treatments at home such as supplemental oxygen. It also facilitates an early supported discharge of clinically stable patients with an improving clinical trajectory by managing them in the community.

Role of advanced respiratory support in acute respiratory failure in clinically frail patients with COVID-19.

Background: The main aim of this study was to assess the efficacy of advanced respiratory support (ARS) for acute respiratory failure in do-not-attempt cardiopulmonary resuscitation order (DNACPR) COVID-19 patients. Methods: In this single-center study, the impact of different types of ARS modality, PaO2/FiO2 (PF) ratio, clinical frailty score (CFS) and 4C score on mortality was evaluated. Results: There was no significant difference in age, type of ARS modality, PF ratio and 4C scores between those who died and those who survived. Overall survival rates/hospital discharge of patients still requiring ARS at 5 and 7 days post admission were 20 and 17%, respectively. Conclusion: Our study showed that ARS can be a useful tool in frail, elderly and high-risk COVID-19 patients irrespective of high 4C mortality score.

Images of the month 1: 'Soy sauce' pleural effusion: what causes black pleural fluid?

We present a case of black pleural fluid following thoracic trauma. The unusual dark colour most strikingly resembled soy sauce as independently commented upon by multiple treating physicians. The black colouration could not be fully accounted for by haemothorax or cholethorax, so other differential diagnoses were investigated, including Aspergillus niger infection and malignant melanoma. The cause, however, was thought to be due to staining of the fluid with carbon deposited in the pleural space from the non-volatilised impurities from smoking crack cocaine. A novel use of a point-of-care urine toxicology assay confirmed the presence of cocaine in the pleural fluid. Considering a broad range of differential diagnoses is needed to avoid missing important causes of unusual pleural effusions.

Relationship of D-dimer and prediction of pulmonary embolism in hospitalized COVID-19 patients: a multicenter study.

Aim: COVID-19 is a known risk factor for pulmonary embolism (PE). In this retrospective, multicenter study, we aimed to determine an optimal D-dimer cutoff to predict PE in hospitalized patients with COVID-19. Materials & methods: A total of 193 patients underwent computerized tomographic pulmonary angiography imaging and were classified into PE positive and negative groups. Physiological, radiological and biochemical parameters were compared and receiver operator curve analysis was conducted to determine a predictive D-dimer threshold. Results: An optimal D-dimer cutoff of 2494 ng/ml was selected (Youden index: 0.906), giving a sensitivity of 100% (95% CI: 100-100) and specificity of 90.62% (95% CI: 90.5-90.8) for predicting PE. Conclusion: We propose that in the absence of other clinical signs, a D-dimer threshold of 2495 ng/ml could be used with high sensitivity and specificity to predict PE in hospitalized patients with COVID-19.

Spontaneous haemopneumothorax.

An 18-year-old man presented with a 2 day history of breathlessness and left-sided chest pain, with no preceding trauma. He had no medical history of note, and had never smoked. He was in hypovolaemic shock, with Hb of 8.1 g/dl, and received fluid resuscitation. Chest x-ray (CXR) revealed left-sided hydropneumothorax, with the effusion of blood-consistency on CT thorax. Tube thoracostomy drained 1.7 litres of blood immediately. He remained haemodynamically stable after 4 units of blood transfusion on the first day with post-transfusion Hb 11 g/dl. Following cardiothoracic surgeon advice, tube was removed on day 5 draining total of 3.5 litres, with good response clinically and radiologically. Patient was well when followed up at 1 week after hospital discharge, with no recurrence and complete re-expansion of left lung on CXR.

A rearranged form of Epstein-Barr virus DNA is associated with idiopathic pulmonary fibrosis.

An association between idiopathic pulmonary fibrosis (IPF) and productive Epstein-Barr virus (EBV) infection has been found previously. Productive EBV replication can be associated with a rearrangement in EBV genomes termed WZhet. We hypothesized that WZhet genomes might be present in patients with IPF. Thirty-nine patients with IPF, 26 lung transplant recipients, and 24 normal subjects were studied. When EBV DNA-positive lung tissue biopsies from IPF patients were analyzed, 11 of 18 (61%) were positive for WZhet. Buffy coat DNA analysis showed that 75-85% were EBV DNA-positive in both IPF and control groups. Buffy coat analysis for WZhet was positive in 16 of 27 (59%) IPF patients, compared with none of 32 lung transplant recipients and 1 of 24 (4%) normal blood donors (p < or = 0.001). There was thus a good correlation between the presence of WZhet in lung tissue and peripheral blood. However, there was no significant association between the presence of WZhet and immunosuppressive therapy. These data further confirm the association between active EBV infection and IPF and provide a potential marker in the peripheral blood for the tracking of EBV in this disease.