“Heart failure in COVID-19 patients: Critical care experience”: A letter to the editor

Coronavirus disease 2019 (COVID-19) is associated with poor cardiovascular outcomes in patients with heart failure (HF) of all categories of ejection fraction (EF), but mainly in patients with HF with reduced EF. Moreover, cardiac transplant patients exhibit worse cardiovascular prognosis, high mortality, and more admissions to the intensive care unit. In general, COVID-19 seems to de-teriorate the clinical status of HF and favors the development of acute respiratory distress syndrome and multiorgan failure, especially in the presence of cardiovascular comorbidities such as diabetes mellitus, kidney dysfunction, and older age. COVID-19 may induce new-onset HF with complex mechanisms that involve myocardial injury. Indeed, myocardial injury comprises a large category of detrimental effects for the myocardium, such as myocardial infarction type 1 or type 2, Takotsubo cardiomyopathy, microvascular dysfunction and myocarditis, which are not easily distinguished by HF. The pathophysiologic mechanisms mainly involve direct myocardial damage by severe acute respiratory syndrome coronavirus 2, cytokine storm, hypercoagulation, inflammation, and endothelial dysfunction. The proper management of patients with COVID-19 involves careful patient evaluation and ongoing monitoring for complications such as HF.     

Intrathoracic papillary thyroid carcinoma from occult primary disease

A 42-year-old woman undertook a chest radiograph for a routine evaluation prior to surgery for pelvic endometrioma, which revealed a right paratracheal mass slightly displacing the trachea to the left. CT of the thorax disclosed a well demarcated, heterogeneous, lobular, right paratracheal mass, bearing punctate, coarse, and curvilinear calcifications. MRI further revealed two components within the lesion: a larger, cystic, exhibiting thin septations, and a solid component at the lower part exhibiting strong enhancement. No continuity of the mass with the thyroid gland was demonstrated, which had normal size and no focal lesion. Histological examination of the resected mass disclosed lymph node tissue infiltrated by papillary thyroid carcinoma; subsequent total thyroidectomy revealed small foci of papillary carcinoma within both lobes of the thyroid gland. Ablative dose I-131 was administered and the patient was put on daily thyroid supplements.     

Successful Percutaneous Closure of Atrial Septal Defect via Transjugular Approach with the Cocoon Septal Occluder

The percutaneous closure of ostium secundum atrial septal defects (ASD) is a well-established procedure. Currently available devices and delivery systems are designed to be used via the femoral venous route. However, an alternative approach needs to be considered in cases of congenital or acquired caval obstruction. We describe a successful transjugular closure of a moderate sized secundum ASD with the Cocoon Septal Occluder in a 37-year-old symptomatic woman with inferior vena cava (IVC) thrombosis, using a novel deployment technique to overcome difficulties, namely maintaining stable sheath position in the left atrium. Percutaneous closure of secundum ASDs via the transjugular approach is safe, feasible and effective and can be a reasonable alternative to surgical closure in patients with failed femoral venous access and not anatomically complex atrial septal defects.     

Prevention,diagnostic evaluation,management and prognostic implications of liver disease in critically ill patients with COVID-19

Coronavirus disease 2019 (COVID-19), caused by severe acute respiratory syndrome coronavirus 2, broke out in December 2019 in Wuhan city of China and spread rapidly worldwide. Therefore, by March 2020, the World Health Organization declared the disease a global pandemic. Apart from the respiratory system, various other organs of the human body are also seriously affected by the virus. Liver injury in patients with a severe form of COVID-19 is estimated to be 14.8%-53.0%. Elevated levels of total bilirubin, aspartate aminotransferase and alanine aminotransferase and low levels of serum albumin and prealbumin are the main laboratory findings. Patients with pre-existing chronic liver disease and cirrhosis are much more prone to develop severe liver injury. This literature review presented the recent scientific findings regarding the pathophysiological mechanisms responsible for liver injury in critically ill patients with COVID-19, the various interactions between drugs used to treat the disease and the function of the liver and the specific tests providing the possibility of early diagnosis of severe liver injury in these patients. Moreover, it highlighted the burden that COVID-19 put on health systems worldwide and its effect on transplant programs and the care provided to critically ill patients in general and particularly to those with chronic liver disease.     

Incarcerated transmesosigmoid hernia presenting in a 28-year-old female

We report the case of a transmesosigmoid hernia in a 28-year-old female who presented to the emergency room complaining of abdominal pain. History, clinical and radiographic examination revealed small bowel ileus, but without being able to diagnose the cause. We decided to perform laparoscopy, which showed herniation of a small intestine loop through a small defect of the mesosigmoid. Due to the inability to reduce the internal hernia laparoscopically, we converted to mini-laparotomy; we reduced the hernia and performed segmental small bowel resection and anastomosis. It is essential to suspect the presence of an internal hernia as soon as possible, because if the operation is delayed, it will often eventually lead to bowel necrosis.     

Are the effects of tamoxifen on the serum lipid profile modified by apolipoprotein E phenotypes?

BACKGROUND: Tamoxifen has favorable effects on the serum lipid profile. It has been suggested that the apolipoprotein (Apo) E phenotype can influence serum lipid parameters; the ApoE allele 4 (ApoE4) is associated with higher total and low-density lipoprotein (LDL) cholesterol levels. The ApoE phenotype also affects lipid responses to diets or treatment with statins. However, the effect of tamoxifen on the lipid profile in different ApoE phenotypes is unknown. PATIENTS AND METHODS: In the present study, we evaluated the effects of tamoxifen on the serum lipid profile in 11 ApoE4-positive postmenopausal women with breast cancer (phenotypes 3/4 and 4/4) compared with 33 ApoE4-negative women (phenotypes 3/2 and 3/3). Serum lipid parameters [high-density (HDL), LDL and total cholesterol, triglycerides, ApoAI, ApoB and lipoprotein (a)] were measured after an overnight fast before treatment and after 3 and 12 months. ApoE isoforms were determined by isoelectric focusing of delipidated very-low-density lipoproteins (VLDL). RESULTS: During the follow-up period, serum levels of total and LDL cholesterol and ApoB decreased significantly in both groups, but no significant differences were found. Concentrations of serum HDL cholesterol were not significantly different between both groups. However, serum ApoAI levels increased significantly in ApoE4-negative subjects (p = 0.00005), but no significant changes in ApoE4-positive women were observed. Serum triglyceride levels increased by 23.2% (p < 0.05) in ApoE4-positive patients, but they did not change significantly in ApoE4-negative patients. The LDL/HDL cholesterol ratio decreased similarly in the two groups, but the ApoAI/ApoB ratio, which may be a better predictor of cardiovascular events, significantly changed in the ApoE4-negative subjects. Finally, the median level of Lp(a) decreased by 43.4% in the ApoE4-negative patients, whereas it did not change significantly in the ApoE4-positive group. CONCLUSION: In postmenopausal Greek women with breast cancer, the levels of Lp(a) and triglycerides and the ApoAI/ApoB ratio respond more favorably to tamoxifen treatment in ApoE4-negative than in ApoE4-positive patients.     

Pulmonary candidiasis after hematopoietic stem cell transplantation: thin-section CT findings

PURPOSE: To retrospectively evaluate thin-section computed tomographic (CT) findings in hematopoietic stem cell transplant (ie, bone marrow transplant) patients with histopathologically proved pulmonary candidiasis. MATERIALS AND METHODS: Ethical approval was obtained from the institutional review board of each of the three institutions; informed consent was not required. The study included 17 hematopoietic stem cell transplant recipients with proved pulmonary candidiasis. Histopathologic specimens were acquired at transbronchial biopsy (n = 8), open lung biopsy (n = 6), and autopsy (n = 3). The patients included seven men and 10 women (age range, 20-62 years; mean age, 37 years). The thin-section CT scans were retrospectively reviewed by two thoracic radiologists for the presence, appearance, and distribution of parenchymal abnormalities. RESULTS: Multiple nodules were present in 15 (88%) patients, including centrilobular nodules and tree-in-bud pattern in seven (41%) patients. Nodules were bilateral in 12 patients and unilateral in three. An associated halo of ground-glass opacity was identified in five (33%) patients. Nodules were the only CT finding in five patients (29%). Areas of air-space consolidation were identified in 11 (65%) patients. Areas of ground-glass opacity were seen in six (35%) of 17 patients and were always associated with other abnormalities. Other less common CT findings included pleural effusion (n = 3), thickening of the bronchial walls (n = 2), and cavitation (n = 1). CONCLUSION: The most common thin-section CT findings of pulmonary candidiasis in hematopoietic stem cell transplant patients are multiple bilateral nodular opacities often associated with areas of consolidation.     

“Heart failure in COVID-19 patients: Critical care experience”: A letter to the editor

Coronavirus disease 2019 (COVID-19) is associated with poor cardiovascular outcomes in patients with heart failure (HF) of all categories of ejection fraction (EF), but mainly in patients with HF with reduced EF. Moreover, cardiac transplant patients exhibit worse cardiovascular prognosis, high mortality, and more admissions to the intensive care unit. In general, COVID-19 seems to de-teriorate the clinical status of HF and favors the development of acute respiratory distress syndrome and multiorgan failure, especially in the presence of cardiovascular comorbidities such as diabetes mellitus, kidney dysfunction, and older age. COVID-19 may induce new-onset HF with complex mechanisms that involve myocardial injury. Indeed, myocardial injury comprises a large category of detrimental effects for the myocardium, such as myocardial infarction type 1 or type 2, Takotsubo cardiomyopathy, microvascular dysfunction and myocarditis, which are not easily distinguished by HF. The pathophysiologic mechanisms mainly involve direct myocardial damage by severe acute respiratory syndrome coronavirus 2, cytokine storm, hypercoagulation, inflammation, and endothelial dysfunction. The proper management of patients with COVID-19 involves careful patient evaluation and ongoing monitoring for complications such as HF.