Seizures, Vitamin D Deficiency, and Severe Hypophosphatemia: The Unique Presentation of a SARS-CoV-2 Case

Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) is a virus that belongs to the species severe acute respiratory syndrome-related coronavirus (SARSr-CoV), which is related to the SARS-CoV-1 virus that caused the 2002-2004 SARS outbreak. SARS-CoV-2 causes coronavirus disease 2019 (COVID-19). It has been associated with electrolyte abnormalities. In this report, we discuss the case of a SARS-CoV-2-infected person presenting with recurrent seizure episodes resulting from hypophosphatemia. A 52-year-old male patient with questionable prior seizure history presented to the emergency department (ED) twice within eight days with recurring seizure episodes. While the physical examination at the first presentation was significant for a head laceration with post-ictal confusion, that at the second presentation was only significant for post-ictal confusion. Laboratory examination at the first visit revealed SARS-CoV-2 positivity, hypokalemia, hypophosphatemia, and low vitamin D levels. On the second visit, the patient was again found to have hypophosphatemia. CT of the head and the cervical spine, as well as radiographs of the chest done on the first visit, were all normal. On his first visit, the patient's electrolyte abnormalities were corrected, and he was discharged with antiepileptic medications after 24 hours of observation and consultation with neurology. However, his vitamin D levels, the results of which came back only after his first discharge, were corrected only during his second visit. This time, he was discharged from the ED and had an effective resolution of symptoms. SARS-CoV-2 infections can result in vitamin D deficiency and hypophosphatemia, resulting in seizures, and hence should be treated with both replacement therapies and antiepileptic medications. This case also highlights the importance of obtaining phosphorus and vitamin D levels in SARS-CoV-2-infected patients with seizures.

Mortality and Severity in COVID-19 Patients on ACEIs and ARBs-A Systematic Review, Meta-Analysis, and Meta-Regression Analysis

Purpose: The primary objective of this systematic review is to assess association of mortality in COVID-19 patients on Angiotensin-converting-enzyme inhibitors (ACEIs) and Angiotensin-II receptor blockers (ARBs). A secondary objective is to assess associations with higher severity of the disease in COVID-19 patients. Materials and Methods: We searched multiple COVID-19 databases (WHO, CDC, LIT-COVID) for longitudinal studies globally reporting mortality and severity published before January 18th, 2021. Meta-analyses were performed using 53 studies for mortality outcome and 43 for the severity outcome. Mantel-Haenszel odds ratios were generated to describe overall effect size using random effect models. To account for between study results variations, multivariate meta-regression was performed with preselected covariates using maximum likelihood method for both the mortality and severity models. Result: Our findings showed that the use of ACEIs/ARBs did not significantly influence either mortality (OR = 1.16 95% CI 0.94-1.44, p = 0.15, I 2 = 93.2%) or severity (OR = 1.18, 95% CI 0.94-1.48, p = 0.15, I 2 = 91.1%) in comparison to not being on ACEIs/ARBs in COVID-19 positive patients. Multivariate meta-regression for the mortality model demonstrated that 36% of between study variations could be explained by differences in age, gender, and proportion of heart diseases in the study samples. Multivariate meta-regression for the severity model demonstrated that 8% of between study variations could be explained by differences in age, proportion of diabetes, heart disease and study country in the study samples. Conclusion: We found no association of mortality or severity in COVID-19 patients taking ACEIs/ARBs.

An Adrenocortical Carcinoma Evolving After Nine Years of Latency From a Small Adrenal Incidentaloma

Adrenal incidentalomas (AIs) are common incidental findings in medical practice with clinical significance. Although most AIs are nonsecretory and nonmalignant, they require a short course of follow-up over one to two years to rule out malignancy or hormonal secretion according to clinical practice guidelines. However, this can result in some adrenocortical carcinomas (ACCs) being missed if they transform at a later stage or evolve slowly. Here, we report one such case of an AI, which although remained indolent, eventually transformed into an ACC many years after the initial detection.

Point-of-Care Ultrasonography Saves the Day in Dilated Cardiomyopathy: A Rare Presentation of Hyperhomocysteinemia

Here, we report a case of hereditary hyperhomocysteinemia presenting as dilated cardiomyopathy which was successfully diagnosed using a combination of point-of-care ultrasonography (POCUS) and echocardiogram (ECHO). A 39-year-old Caucasian male with a family history of homocystinuria and early deaths in adult male members from cardiovascular disease presented with complaints of purplish discoloration and 4/10 pain in bilateral feet along with severe nausea/vomiting for the last two days. Physical examination was significant for tachycardia, low normal mean arterial pressures, dry mucous membranes, right basilar crepitations, S3 gallop with holosystolic murmur along with peripheral cyanosis, and pitting edema. Laboratory examination revealed leucocytosis, elevated d-dimers, high anion gap metabolic acidosis secondary to worsening renal function, elevated liver enzymes, hyperhomocysteinemia, elevated B-type natriuretic peptide, and troponins along with low protein C and S. Electrocardiogram demonstrated left axis deviation with abnormal QRS-T angle and intraventricular conduction delay with a QRS duration of 133 ms. Bedside POCUS and ECHO revealed marked left ventricular dilatation with an ejection fraction of 10% and mitral regurgitation. Computed tomography angiography of the chest and abdomen was positive for partial left subclavian vein thrombus with extensive collateral formation and right-sided pleural effusion. The patient was started on anticoagulants and promptly transferred to a tertiary care center for left ventricular assist device placement. Hyperhomocysteinemia can present with atypical heart failure symptoms, and early usage of bedside POCUS and interpretation of findings in the context of family history are imperative for a successful diagnosis.

Effectiveness of Mechanical Chest Compression Devices over Manual Cardiopulmonary Resuscitation: A Systematic Review with Meta-analysis and Trial Sequential Analysis

Introduction

Our goal was to systematically review contemporary literature comparing the relative effectiveness of two mechanical compression devices (LUCAS and AutoPulse) to manual compression for achieving return of spontaneous circulation (ROSC) in patients undergoing cardiopulmonary resuscitation (CPR) after an out-of-hospital cardiac arrest (OHCA).

Methods

We searched medical databases systematically for randomized controlled trials (RCT) and observational studies published between January 1, 2000–October 1, 2020 that compared mechanical chest compression (using any device) with manual chest compression following OHCA. We only included studies in the English language that reported ROSC outcomes in adult patients in non-trauma settings to conduct random-effects metanalysis and trial sequence analysis (TSA). Multivariate meta-regression was performed using preselected covariates to account for heterogeneity. We assessed for risk of biases in randomization, allocation sequence concealment, blinding, incomplete outcome data, and selective outcome reporting.

Results

A total of 15 studies (n = 18474), including six RCTs, two cluster RCTs, five retrospective case-control, and two phased prospective cohort studies, were pooled for analysis. The pooled estimates’ summary effect did not indicate a significant difference (Mantel-Haenszel odds ratio = 1.16, 95% confidence interval, 0.97 to 1.39, P = 0.11, I2 = 0.83) between mechanical and manual compressions during CPR for ROSC. The TSA showed firm evidence supporting the lack of improvement in ROSC using mechanical compression devices. The Z-curves successfully crossed the TSA futility boundary for ROSC, indicating sufficient evidence to draw firm conclusions regarding these outcomes. Multivariate meta-regression demonstrated that 100% of the between-study variation could be explained by differences in average age, the proportion of females, cardiac arrests with shockable rhythms, witnessed cardiac arrest, bystander CPR, and the average time for emergency medical services (EMS) arrival in the study samples, with the latter three attaining statistical significance.

Conclusion

Mechanical compression devices for resuscitation in cardiac arrests are not associated with improved rates of ROSC. Their use may be more beneficial in non-ideal situations such as lack of bystander CPR, unwitnessed arrest, and delayed EMS response times. Studies done to date have enough power to render further studies on this comparison futile.

Mortality Benefit of Convalescent Plasma in COVID-19: A Systematic Review and Meta-Analysis

Importance/Background: With a scarcity of high-grade evidence for COVID-19 treatment, researchers and health care providers across the world have resorted to classical and historical interventions. Immunotherapy with convalescent plasma (CPT) is one such therapeutic option. Methods: A systematized search was conducted for articles published between December 2019 and 18th January 2021 focusing on convalescent plasma efficacy and safety in COVID-19. The primary outcomes were defined as mortality benefit in patients treated with convalescent plasma compared to standard therapy/placebo. The secondary outcome was pooled mortality rate and the adverse event rate in convalescent plasma-treated patients. Results: A total of 27,706 patients were included in the qualitative analysis, and a total of 3,262 (2,127 in convalescent plasma-treated patients and 1,135 in the non-convalescent plasma/control group) patients died. The quantitative synthesis in 23 studies showed that the odds of mortality in patients who received plasma therapy were significantly lower than those in patients who did not receive plasma therapy [odds ratio (OR) 0.65, 95% confidence interval (CI) 0.53-0.80, p < 0.0001, I 2 = 15%). The mortality benefit remains the same even for 14 trials/prospective studies (OR 0.59, 95% CI 0.43-0.81, p = 0.001, I 2 = 22%) as well as for nine case series/retrospective observational studies (OR 0.78, 95% CI 0.65-0.94, p = 0.01, I 2 = 0%). However, in a subgroup analysis for 10 randomized controlled trials (RCTs), there was no statistically significant reduction in mortality between the CPT group compared to the non-CPT group (OR 0.76, 95% CI 0.53-1.08, p = 0.13, I 2 = 7%). Furthermore, the sensitivity analysis of 10 RCTs, excluding the study with the highest statistical weight, displayed a lower mortality rate compared to that of non-CPT COVID-19 patients (OR 0.64, 95% CI 0.42-0.97, p = 0.04, I 2 = 0%). The observed pooled mortality rate was 12.9% (95% CI 9.7-16.9%), and the pooled adverse event rate was 6.1% (95% CI 3.2-11.6), with significant heterogeneity. Conclusions and Relevance: Our systemic review and meta-analysis suggests that CPT could be an effective therapeutic option with promising evidence on the safety and reduced mortality in concomitant treatment for COVID-19 along with antiviral/antimicrobial drugs, steroids, and other supportive care. Future exploratory studies could benefit from more standardized reporting, especially in terms of the timing of interventions and clinically relevant outcomes, like days until discharge from the hospital and improvement of clinical symptoms.

Patients leaving without being seen from the emergency department: A prediction model using machine learning on a nationwide database

OBJECTIVE

The objective of this study was to develop a US-representative prediction model identifying factors with a greater likelihood of patients leaving without being seen.

METHODS

We conducted a retrospective cohort analysis using a 2016 nationwide emergency department (ED) sample. Patient factors considered for analysis were the following: age, sex, acuity, chronic diseases, weekend visit, quarter of presentation, median household income quartile for patient's zip code, primary/secondary insurance, total charges for the visit, and urban/rural household. Hospital factors considered were urban/rural location, trauma center/teaching hospital, and annual ED volume. Multivariable logistic regression was used to find significant predictors and their interactions. A random forest algorithm was used to determine the order of importance of factors.

RESULTS

A total of 32,680,232 hospital-based ED visits with 466,047 incidences of leaving without being seen were included. The cohort comprised 55.5% females, with a median (IQR) age of 37 (21-58) years. Positively associating factors were male sex (odds ratio [OR], 1.22; 99% confidence interval [CI], 1.17-1.26), lower acuity (P < 0.001), and annual ED visits ≥60,000 (OR, 1.44; 99% CI, 1.21-1.7) versus <20,000. Negatively associating factors were primary insurance being Medicare/Tricare or private insurance (P < 0.001); weekend presentations (OR, 0.87; 99% CI, 0.85-0.89); age >64 or <18 years (P < 0.001); and higher median household income for patient's zip code second (OR, 0.86; 99% CI, 0.77-0.97), third (OR, 0.8; 99% CI, 0.7-0.91), and fourth (OR, 0.7; 99% CI, 0.6-0.8) quartiles versus the first quartile. Significant interactions existed between age, acuity, primary insurance, and chronic conditions. Primary insurance was the most predictive.

CONCLUSION

Our derivation model reiterated several modifiable and non-modifiable risk factors for leaving without being seen established previously while rejecting the importance of others.

Psychological effects of the COVID 19 pandemic on healthcare workers globally: A systematic review

In this systematic review, we compared the incidences of psychological issues during the COVID-19 pandemic, such as anxiety, depression, occupational stress, PTSD and insomnia, in healthcare workers (HCW) and non-healthcare workers (NHCW). PubMed, Ovid, Google Scholar and PsycInfo were systematically searched for related published articles. In all electronic databases, the following search strategy was implemented, and these key words were used: "COVID 19″ OR "SARS-CoV-2″ AND "psychological" OR "stress" OR "depression" AND "healthcare$". We identified 6 studies, out of the final 15 selected, which reported numerical estimates for incidences of psychological effects. Meta-analysis was conducted, comparing both combined and individual effect sizes of all psychological manifestations. Qualitative evidence was reported from the remaining 9 cross- sectional studies. The summary effects of the combined quantitative meta-analysis conducted on 6 studies did indicate near significant differences between HCW and NHCW. Summary effects of individual manifestations indicated significantly higher incidence of insomnia among HCW, when compared to NHCW. Qualitative evidence from remaining cross-sectional studies provided additional information into the nature of the psychological issues. We conclude that even though reasons for psychological distress among HCW and NHCW may be different, both suffered in equal measures excepting for insomnia.

A Review of Neurological Complications of COVID-19

The SARS-CoV-2, a novel virus has shown an association with central nervous system (CNS) symptoms. Initial retrospective studies emerging from China and France, as well as case reports from different parts of the world revealed a spectrum of neurological symptoms ranging from a simple headache to more serious encephalitis and dysexecutive syndromes. Authors have tried to explain this neurotropism of the virus by comparing invasion mechanisms with prior epidemic coronavirus like severe acute respiratory syndrome (SARS) and Middle East respiratory syndrome (MERS). Concrete evidence on those viruses has been limited. This review attempts to discuss various pathophysiological mechanisms as it relates to neurological complications of SARS-CoV-2. We will also discuss the neurological manifestations seen in various retrospective studies, systemic reviews, and case reports.