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Herrera PM, Blair PW, Siddharthan T, Fong T, Pollett S, Clark DV. Implementation of an International Severe Infection Point-of-Care Ultrasound Research Network. Mil Med 2023:usad393. [PMID: 37837196 DOI: 10.1093/milmed/usad393] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2023] [Revised: 07/26/2023] [Accepted: 09/21/2023] [Indexed: 10/15/2023] Open
Abstract
INTRODUCTION Point-of-care ultrasound (POCUS) is a rapid, readily available, and cost-effective diagnostic and prognostic modality in a range of clinical settings. However, data to support its clinical application are limited. This project's main goal was to assess the effectiveness of standardizing lung ultrasound (LUS) training for sonographers to determine if universal LUS adoption is justified. MATERIALS AND METHODS We describe the effectiveness of an implementation of a LUS research training program across eight international study sites in Asia, Africa, and North America as part of prospective Coronavirus Disease of 2019 (COVID-19) and sepsis study cohorts (Rapid Assessment of Infection with SONography research network). Within our network, point-of-care LUS was used to longitudinally evaluate radiographic markers of lung injury. POCUS operators were personnel from a variety of backgrounds ranging from research coordinators with no medical background to experienced clinicians. RESULTS Following a standardized protocol, 49 study sonographers were trained and LUS images from 486 study participants were collected. After training was completed, we compared before and after image qualities for interpretation. The proportion of acceptable images improved at each site between the first 25 scans and the second 25 scans, resulting in 80% or greater acceptance at each study site. CONCLUSIONS POCUS training and implementation proved feasible in diverse research settings among a range of providers. Standardization across ongoing cohort protocols affords opportunities for increased statistical power and generalizability of results. These results potentially support care delivery by enabling military medics to provide care at the point of injury, as well as aiding frontline clinicians in both austere and highly resourced critical care settings.
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Affiliation(s)
- Phabiola M Herrera
- Division of Pulmonary, Critical Care and Sleep Medicine, University of Miami, Miami, FL 33136, USA
| | - Paul W Blair
- The Henry M. Jackson Foundation for the Advancement of Military Medicine, Inc., Bethesda, MD 20817, USA
- Division of Infectious Diseases, Johns Hopkins University School of Medicine, Baltimore, MD 21205, USA
| | - Trishul Siddharthan
- Division of Pulmonary, Critical Care and Sleep Medicine, University of Miami, Miami, FL 33136, USA
- Division of Pulmonary and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD 21205, USA
| | - Tiffany Fong
- Department of Emergency Medicine, Johns Hopkins University School of Medicine, Baltimore, MD 21205, USA
| | - Simon Pollett
- The Henry M. Jackson Foundation for the Advancement of Military Medicine, Inc., Bethesda, MD 20817, USA
- Infectious Disease Clinical Research Program, Department of Preventive Medicine and Biostatistics, Uniformed Services University of the Health Sciences, Bethesda, MD 20814, USA
| | - Danielle V Clark
- The Henry M. Jackson Foundation for the Advancement of Military Medicine, Inc., Bethesda, MD 20817, USA
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Falster C, Juul A, Jacobsen N, Raadal Skov I, Dahlerup Rasmussen L, Wulff Madsen L, Somuncu Johansen I, Markus Walbom Harders Harders S, Rømhild Davidsen J, Laursen CB. Thoracic ultrasonographic and clinical findings at 12-month follow-up of patients admitted with COVID-19. Eur Clin Respir J 2023; 10:2257992. [PMID: 37753252 PMCID: PMC10519251 DOI: 10.1080/20018525.2023.2257992] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2023] [Accepted: 09/07/2023] [Indexed: 09/28/2023] Open
Abstract
Introduction Thoracic ultrasound (TUS) has proven useful in the diagnosis, risk stratification and monitoring of disease progression in patients with coronavirus disease 2019 (COVID-19). However, utility in follow-up is poorly described. To elucidate this area, we performed TUS as part of a 12-month clinical follow-up in patients previously admitted with COVID-19 and correlated findings with clinical assessment and pulmonary function tests. Methods Adult patients discharged from our hospital following admission with COVID-19 during March to May 2020 were invited to a 12-month follow-up. Enrolled patients were interviewed regarding persisting or newly developed symptoms in addition to TUS, spirometry and a 6-min walk test. Patients were referred to high-resolution computed tomography (HRCT) of the lungs if suspicion of pulmonary fibrosis was raised. Results Forty patients were enrolled in the study of whom had 13 developed acute respiratory distress syndrome (ARDS) during admission. Patients with ARDS were more prone to experience neurological symptoms at follow-up (p = 0.03) and showed more B-lines on TUS (p = 0.008) but did not otherwise differ significantly in terms of pulmonary function tests. Four patients had pathological findings on TUS where subsequent diagnostics revealed that two had interstitial lung abnormalities and two had heart failure. These four patients presented with a significantly lower diffusing capacity of lung for carbon monoxide (p=0.03) and 6-min walking distance (p=0.006) compared to the remaining 36 patients without ultrasound pathology. No significant difference was observed in spirometry values of % of predicted FEV1 (p=0.49) or FVC (p=0.07). No persisting cardiovascular pathology was observed in patients without ultrasonographic pathology. Conclusion At 12-month after admission with COVID-19, a follow-up combining TUS, clinical assessment, and pulmonary function tests may improve the selection of patients requiring further diagnostic investigations such as HRCT or echocardiography.
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Affiliation(s)
- Casper Falster
- Odense Respiratory Research Unit (ODIN), Institute of Clinical Research, University of Southern Denmark, Odense, Denmark
- Department of Respiratory Medicine, Odense University Hospital, Odense, Denmark
| | - Amanda Juul
- Odense Respiratory Research Unit (ODIN), Institute of Clinical Research, University of Southern Denmark, Odense, Denmark
- Department of Respiratory Medicine, Odense University Hospital, Odense, Denmark
| | - Niels Jacobsen
- Odense Respiratory Research Unit (ODIN), Institute of Clinical Research, University of Southern Denmark, Odense, Denmark
- Department of Respiratory Medicine, Odense University Hospital, Odense, Denmark
| | - Inge Raadal Skov
- Odense Respiratory Research Unit (ODIN), Institute of Clinical Research, University of Southern Denmark, Odense, Denmark
- Department of Respiratory Medicine, Odense University Hospital, Odense, Denmark
| | - Line Dahlerup Rasmussen
- Open Patient Data Explorative Network (OPEN), Odense University Hospital, Odense, Denmark
- Department of Infectious Diseases, Odense University Hospital, Odense, Denmark
- Research Unit for Infectious Diseases, Odense University Hospital, University of Southern Denmark, Odense, Denmark
| | - Lone Wulff Madsen
- Department of Infectious Diseases, Odense University Hospital, Odense, Denmark
- Research Unit for Infectious Diseases, Odense University Hospital, University of Southern Denmark, Odense, Denmark
| | - Isik Somuncu Johansen
- Department of Infectious Diseases, Odense University Hospital, Odense, Denmark
- Research Unit for Infectious Diseases, Odense University Hospital, University of Southern Denmark, Odense, Denmark
| | | | - Jesper Rømhild Davidsen
- Odense Respiratory Research Unit (ODIN), Institute of Clinical Research, University of Southern Denmark, Odense, Denmark
- Department of Respiratory Medicine, Odense University Hospital, Odense, Denmark
- South Danish Center for Interstitial Lung Diseases (SCILS), Odense University Hospital, Odense, Denmark
- Pulmo-Rheuma Frontline Center (PURE), Odense University Hospital, Odense, Denmark
| | - Christian B. Laursen
- Odense Respiratory Research Unit (ODIN), Institute of Clinical Research, University of Southern Denmark, Odense, Denmark
- Department of Respiratory Medicine, Odense University Hospital, Odense, Denmark
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Dearing E, Rempfer E, Frasure SE, Akselrod H, Dobbs JE, Poon AN, Salazar JE, Prajapati D, Boniface KS. Point-of-Care Ultrasound of Post-acute COVID-19 Syndrome: A Prospective Cohort Study. Cureus 2023; 15:e42569. [PMID: 37637589 PMCID: PMC10460260 DOI: 10.7759/cureus.42569] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/26/2023] [Indexed: 08/29/2023] Open
Abstract
Introduction Acute COVID-19 patients can suffer from chronic symptoms known as post-acute sequelae of SARS-CoV-2 infection (PASC). Point-of-care ultrasound (POCUS) is established in acute COVID, but its utility in PASC is unclear. We sought to determine the incidence of cardiac and pulmonary abnormalities with POCUS in patients with PASC in a COVID-19 recovery clinic. Methods This prospective cohort study included adults (>18 years old) presenting with cardiopulmonary symptoms to the COVID-19 recovery clinic. A lung ultrasound and standard bedside echocardiogram were performed by ultrasound-trained physicians. Images were interpreted in real time by the performing sonographer and independently by a blinded ultrasound faculty member. Discrepancies in interpretation were addressed by consensus review. A modified Soldati score was calculated by the sum of the scores in each of the 12 lung zones, with each zone score ranging from 0 to 3 (maximum score of 36). The score was then compared to clinical outcomes and outpatient testing. Results Between April and July 2021, 41 patients received POCUS examinations, with 24 of those included in the study. In all, 15 out of 24 (62.5%) had a normal lung ultrasound. Of the nine subjects with lung abnormalities, the median modified Soldati score was 2. Three patients had trivial pericardial effusions, and all had normal left and right ventricular size and function. Conclusion The majority (62.5%) of patients presenting to the PASC clinic had a normal pulmonary ultrasound, and the vast majority (87.5%) had normal cardiac ultrasounds. These findings suggest that cardiopulmonary symptoms in PASC may be from etiologies not well evaluated by POCUS.
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Affiliation(s)
- Elizabeth Dearing
- Department of Emergency Medicine, George Washington University School of Medicine and Health Sciences, Washington, USA
| | - Elizabeth Rempfer
- Department of Emergency Medicine, George Washington University School of Medicine and Health Sciences, Washington, USA
| | - Sarah E Frasure
- Department of Emergency Medicine, George Washington University School of Medicine and Health Sciences, Washington, USA
| | - Hana Akselrod
- Department of Internal Medicine, George Washington University School of Medicine and Health Sciences, Washington, USA
| | - John E Dobbs
- Department of Internal Medicine, George Washington University School of Medicine and Health Sciences, Washington, USA
| | - Adrienne N Poon
- Department of Internal Medicine, George Washington University School of Medicine and Health Sciences, Washington, USA
| | - Juan E Salazar
- Department of Environmental and Occupational Health, George Washington University School of Medicine and Health Sciences, Washington, USA
| | - Dhruvil Prajapati
- Department of Internal Medicine, George Washington University School of Medicine and Health Sciences, Washington, USA
| | - Keith S Boniface
- Department of Emergency Medicine, George Washington University School of Medicine and Health Sciences, Washington, USA
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Altersberger M, Grafeneder A, Cho Y, Winkler R, Zwick RH, Mathis G, Genger M. One-Year Follow-Up Lung Ultrasound of Post-COVID Syndrome-A Pilot Study. Diagnostics (Basel) 2022; 13. [PMID: 36611362 DOI: 10.3390/diagnostics13010070] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2022] [Revised: 12/19/2022] [Accepted: 12/20/2022] [Indexed: 12/28/2022] Open
Abstract
(1) Background: Millions of people worldwide were infected with COVID-19. After the acute phase of the disease, many suffer from prolonged symptoms, the post-COVID syndrome, especially the phenotype with lung residuals. Many open questions regarding lung ultrasound (LUS) have to be answered. One essential question is the means for optimal following-up of patients with post-COVID-19 residuals with LUS; (2) Methods: A retrospective data analysis of patients after acute COVID-19 infection diagnosed with post-COVID syndrome in the state hospital of Steyr and the rehabilitation center of Hochegg was performed. LUS examinations following a 12-zone scanning protocol were performed, and the LUS score quantified comet tail artifacts. A total of 16 patients were evaluated twice with LUS from May 2020 until June 2021. (3) Results: All patients’ reverberation artifacts were reduced over time. The initial LUS score of 17.75 (SD 4.84) points was decreased over the duration of the second rehabilitation to 8,2 (SD 5.94). The difference in the Wilcoxon test was significant (p < 0.001); (4) Conclusions: Lung ultrasound was a valuable tool in the follow-up of post-COVID-syndrome with lung residuals in the first wave of COVID-19. A reduction in reverberation artifacts was demonstrated. Further studies about the clinical significance have to follow.
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Blair PW, Hwang J, Pearce J, Fong TC, Cui E, Herrera P, Liu G, Crainiceanu C, Siddharthan T, Clark DV. Do worsening lung ultrasound scans identify severe COVID-19 trajectories? Front Med (Lausanne) 2022; 9:1021929. [PMID: 36479093 PMCID: PMC9720255 DOI: 10.3389/fmed.2022.1021929] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2022] [Accepted: 10/17/2022] [Indexed: 11/22/2022] Open
Abstract
BackgroundWhile point-of-care ultrasound (POCUS) has been used to track worsening COVID-19 disease it is unclear if there are dynamic differences between severity trajectories.MethodsWe studied 12-lung zone protocol scans from 244 participants [with repeat scans obtained in 3 days (N = 114), 7 days (N = 53), and weekly (N = 9)] ≥ 18 years of age hospitalized for COVID-19 pneumonia. Differences in mean lung ultrasound (LUS) scores and percent of lung fields with A-lines over time were compared between peak severity levels (as defined by the WHO clinical progression scale) using linear mixed-effects models.ResultsMean LUS scores were elevated by 0.19 (p = 0.035) and A-lines were present in 14.7% fewer lung fields (p = 0.02) among those with ICU-level or fatal peak illness compared to less severe hospitalized illness, regardless of duration of illness. There were no differences between severity groups in the trajectories of mean LUS score 0.19 (p = 0.66) or percent A-lines (p = 0.40).DiscussionOur results do not support the use of serial LUS scans to monitor COVID-19 disease progression among hospitalized adults.
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Affiliation(s)
- Paul W. Blair
- Henry M. Jackson Foundation for the Advancement of Military Medicine, Inc., Bethesda, MD, United States
- Division of Infectious Diseases, The Johns Hopkins University School of Medicine, Baltimore, MD, United States
- *Correspondence: Paul W. Blair,
| | - Jimin Hwang
- Department of Medicine, University of Texas Southwestern Medical Center, Dallas, TX, United States
| | - Jackson Pearce
- College of Medicine, Medical University of South Carolina, Charleston, SC, United States
| | - Tiffany C. Fong
- Department of Emergency Medicine, Johns Hopkins University, Baltimore, MD, United States
| | - Erjia Cui
- Department of Biostatistics, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, United States
| | - Phabiola Herrera
- Division of Pulmonary and Critical Care Medicine, University of Miami, Miami, FL, United States
| | - Gigi Liu
- Division of General Internal Medicine, The Johns Hopkins University School of Medicine, Baltimore, MD, United States
| | - Ciprian Crainiceanu
- Department of Biostatistics, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, United States
| | - Trishul Siddharthan
- Division of Pulmonary and Critical Care Medicine, University of Miami, Miami, FL, United States
- Division of Pulmonary and Critical Care Medicine, The Johns Hopkins University School of Medicine, Baltimore, MD, United States
| | - Danielle V. Clark
- Henry M. Jackson Foundation for the Advancement of Military Medicine, Inc., Bethesda, MD, United States
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Rola P, Doroszko A, Trocha M, Giniewicz K, Kujawa K, Gawryś J, Matys T, Gajecki D, Madziarski M, Zieliński S, Skalec T, Drobnik J, Sebastian A, Zubkiewicz-Zarębska A, Adamik B, Kaliszewski K, Kiliś-Pstrusinska K, Matera-Witkiewicz A, Pomorski M, Protasiewicz M, Sokołowski J, Włodarczak S, Jankowska EA, Madziarska K. Usefulness of C 2HEST Score in Predicting Clinical Outcomes of COVID-19 in Heart Failure and Non-Heart-Failure Cohorts. J Clin Med 2022; 11:jcm11123495. [PMID: 35743564 PMCID: PMC9225357 DOI: 10.3390/jcm11123495] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2022] [Revised: 06/02/2022] [Accepted: 06/15/2022] [Indexed: 01/27/2023] Open
Abstract
Background: Patients with heart failure represent a vulnerable population for COVID-19 and are prone to having worse prognoses and higher fatality rates. Still, the clinical course of the infection is dynamic, and complication occurrence in particular in patients with heart failure is fairly unpredictable. Considering that individual components of the C2HEST (C2: Coronary Artery Diseases (CAD)/Chronic obstructive pulmonary disease (COPD); H: Hypertension; E: Elderly (Age ≥ 75); S: Systolic HF; T: Thyroid disease) are parallel to COVID-19 mortality risk factors, we evaluate the predictive value of C2HEST score in patients with heart failure (HF) Material and Methods: The retrospective medical data analysis of 2184 COVID-19 patients hospitalized in the University Hospital in Wroclaw between February 2020 and June 2021 was the basis of the study. The measured outcomes included: in-hospital mortality, 3-month and 6-month all-cause-mortality, non-fatal end of hospitalization, and adverse in-hospital clinical events. Results: The heart failure cohort consists of 255 patients, while 1929 patients were assigned to the non-HF cohort. The in-hospital, 3-month, and 6-month mortality rates were highest in the HF cohort high-risk C2HEST stratum, reaching 38.61%, 53.96%, and 65.36%, respectively. In the non-HF cohort, in-hospital, 3-month, and 6-month mortalities were also highest in the high-risk C2HEST stratum and came to 26.39%, 52.78%, and 65.0%, respectively. An additional point in the C2HEST score increased the total death intensity in 10% of HF subjects (HR 1.100, 95% CI 0.968−1.250 p = 0.143) while in the non-HF cohort, the same value increased by 62.3% (HR 1.623, 95% CI 1.518−1.734 p < 0.0001). Conclusions: The C2HEST score risk in the HF cohort failed to show discriminatory performance in terms of mortality and other clinical adverse outcomes during hospitalization. C2HEST score in the non-HF cohort showed significantly better performance in terms of predicting in-hospital and 6-month mortality and other non-fatal clinical outcomes such as cardiovascular events (myocardial injury, acute heart failure, myocardial infarction, cardiogenic shock), pneumonia, sepsis, and acute renal injury.
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Affiliation(s)
- Piotr Rola
- Department of Cardiology, Provincial Specialized Hospital, Iwaszkiewicza Street 5, 59-220 Legnica, Poland
- Correspondence: ; Tel.: +48-76-7211-443
| | - Adrian Doroszko
- Clinical Department of Internal Medicine, Hypertension and Clinical Oncology, Wroclaw Medical University, Borowska 213, 50-556 Wroclaw, Poland; (A.D.); (J.G.); (T.M.); (D.G.)
| | - Małgorzata Trocha
- Department of Pharmacology, Wroclaw Medical University, Mikulicz-Radecki Street 2, 50-345 Wroclaw, Poland;
| | - Katarzyna Giniewicz
- Statistical Analysis Centre, Wroclaw Medical University, K. Marcinkowski Street 2-6, 50-368 Wroclaw, Poland; (K.G.); (K.K.)
| | - Krzysztof Kujawa
- Statistical Analysis Centre, Wroclaw Medical University, K. Marcinkowski Street 2-6, 50-368 Wroclaw, Poland; (K.G.); (K.K.)
| | - Jakub Gawryś
- Clinical Department of Internal Medicine, Hypertension and Clinical Oncology, Wroclaw Medical University, Borowska 213, 50-556 Wroclaw, Poland; (A.D.); (J.G.); (T.M.); (D.G.)
| | - Tomasz Matys
- Clinical Department of Internal Medicine, Hypertension and Clinical Oncology, Wroclaw Medical University, Borowska 213, 50-556 Wroclaw, Poland; (A.D.); (J.G.); (T.M.); (D.G.)
| | - Damian Gajecki
- Clinical Department of Internal Medicine, Hypertension and Clinical Oncology, Wroclaw Medical University, Borowska 213, 50-556 Wroclaw, Poland; (A.D.); (J.G.); (T.M.); (D.G.)
| | - Marcin Madziarski
- Clinical Department of Rheumatology and Internal Medicine, Wroclaw Medical University, Borowska Street 213, 50-556 Wroclaw, Poland; (M.M.); (A.S.)
| | - Stanisław Zieliński
- Clinical Department of Anaesthesiology and Intensive Therapy, Wroclaw Medical University, Borowska Street 213, 50-556 Wroclaw, Poland; (S.Z.); (T.S.); (B.A.)
| | - Tomasz Skalec
- Clinical Department of Anaesthesiology and Intensive Therapy, Wroclaw Medical University, Borowska Street 213, 50-556 Wroclaw, Poland; (S.Z.); (T.S.); (B.A.)
| | - Jarosław Drobnik
- Department of Population Health, Division Epidemiology and Health Education, Wroclaw Medical University, Bujwida Street 44, 50-368 Wroclaw, Poland;
| | - Agata Sebastian
- Clinical Department of Rheumatology and Internal Medicine, Wroclaw Medical University, Borowska Street 213, 50-556 Wroclaw, Poland; (M.M.); (A.S.)
| | - Anna Zubkiewicz-Zarębska
- Clinical Department of Gastroenterology and Hepatology, Wroclaw Medical University, Borowska Street 213, 50-556 Wroclaw, Poland;
| | - Barbara Adamik
- Clinical Department of Anaesthesiology and Intensive Therapy, Wroclaw Medical University, Borowska Street 213, 50-556 Wroclaw, Poland; (S.Z.); (T.S.); (B.A.)
| | - Krzysztof Kaliszewski
- Clinical Department of General, Minimally Invasive and Endocrine Surgery, Wroclaw Medical University, Borowska Street 213, 50-556 Wroclaw, Poland;
| | - Katarzyna Kiliś-Pstrusinska
- Clinical Department of Paediatric Nephrology, Wroclaw Medical University, Borowska Street 213, 50-556 Wroclaw, Poland;
| | - Agnieszka Matera-Witkiewicz
- Screening of Biological Activity Assays and Collection of Biological Material Laboratory, Wroclaw Medical University Biobank, Wroclaw Medical University, Borowska Street 211A, 50-556 Wroclaw, Poland;
| | - Michał Pomorski
- Clinical Department of Gynecology and Obstetrics, Wroclaw Medical University, Borowska Street 213, 50-556 Wroclaw, Poland;
| | - Marcin Protasiewicz
- Institute of Heart Diseases, Wroclaw Medical University, Borowska Street 213, 50-556 Wroclaw, Poland; (M.P.); (E.A.J.)
- Institute of Heart Diseases, University Hospital, Borowska Street 213, 50-556 Wroclaw, Poland
| | - Janusz Sokołowski
- Clinical Department of Emergency Medicine, Wroclaw Medical University, Borowska Street 213, 50-556 Wroclaw, Poland;
| | - Szymon Włodarczak
- Department of Cardiology, The Copper Health Centre (MCZ), 59-300 Lubin, Poland;
| | - Ewa Anita Jankowska
- Institute of Heart Diseases, Wroclaw Medical University, Borowska Street 213, 50-556 Wroclaw, Poland; (M.P.); (E.A.J.)
- Institute of Heart Diseases, University Hospital, Borowska Street 213, 50-556 Wroclaw, Poland
| | - Katarzyna Madziarska
- Clinical Department of Nephrology and Transplantation Medicine, Wroclaw Medical University, Borowska Street 213, 50-556 Wroclaw, Poland;
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