Mediastinal Emphysema as a Specific Complication of COVID-19 (Case Report)

During the care of patients with novel coronavirus infection at the Lomonosov MSU Medical Research and Education Center from April 21 to June 13, 2020, we observed cases of spontaneous mediastinal emphysema (spontaneous pneumomediastinum) as a manifestation or a probable complication of COVID-19.The aim of the paper. To provide clinical case descriptions and approaches to the management of patients with spontaneous pneumomediastinum in COVID-19 associated pneumonia, as they are not addressed in the current clinical guidelines, and therefore are worthy of special attention.Among 224 patients with laboratory-confirmed diagnosis of the novel coronavirus infection COVID-19, five cases of pneumomediastinum without pneumothorax were identified. Of these, in two cases the pneumomediastinum developed during noninvasive lung ventilation (NLV) (one case) and invasive lung ventilation (one case). In three cases, spontaneous mediastinal emphysema was not associated with lung ventilation. By the time of publication, one case of pneumomediastinum was completed, and four patients remained hospitalized. All five patients were males aged from 52 to 84 years.This paper presents in depth the description of two cases of mediastinal and subcutaneous emphysema in patients with COVID-19

Steroid pulse -therapy in patients With coronAvirus Pneumonia (COVID-19), sYstemic inFlammation And Risk of vEnous thRombosis and thromboembolism (WAYFARER Study)

Introduction: Coronavirus pneumonia not only severely affects the lung tissue but is also associated with systemic autoimmune inflammation, rapid overactivation of cytokines and chemokines known as “cytokine storm”, and a high risk of thrombosis and thromboembolism. Since there is no specific therapy for this new coronavirus infection (COVID-19), searching for an effective and safe anti-inflammatory therapy is critical.Materials and Methods: This study evaluated efficacy and safety of pulse therapy with high doses of glucocorticosteroids (GCS), methylprednisolone 1,000 mg for 3 days plus dexamethasone 8 mg for another 3-5 days, in 17 patients with severe coronavirus pneumonia as a part of retrospective comparative analysis (17 patients in control group). The study primary endpoint was the aggregate dynamics of patients’ condition as evaluated by an original CCS-COVID scale, which included, in addition to the clinical status, assessments of changes in the inflammation marker, C-reactive protein (CRP); the thrombus formation marker, D-dimer; and the extent of lung injury evaluated by computed tomography (CT). Patients had signs of lung injury (53.2 % and 25.6 %), increases in CRP 27 and 19 times, and a more than doubled level of D-dimer (to 1.41 µg/ml and 1.15 µg/ml) in the active therapy and the control groups, respectively. The GCS treatment group had a more severe condition at baseline.Results: The GCS pulse therapy proved effective and significantly decreased the CCS-COVID scores. Median score difference was 5.00 compared to the control group (р=0.011). Shortness of breath considerably decreased; oxygen saturation increased, and the NEWS-2 clinical status scale scores decreased. In the GCS group, concentration of CRP significantly decreased from 134 mg/dl to 41.8 mg/dl (р=0.009) but at the same time, D-dimer level significantly increased from 1.41 µg/ml to 1.98 µg/ml (р=0.044). In the control group, the changes were nonsignificant. The dynamics of lung injury by CT was better in the treatment group but the difference did not reach a statistical significance (р=0.062). Following the GCS treatment, neutrophilia increased (р=0.0001) with persisting lymphopenia, and the neutrophil/lymphocyte (N/L) ratio, a marker of chronic inflammation, increased 2.5 times (р=0.006). The changes in the N/L ratio and D-dimer were found to correlate in the GCS pulse therapy group (r =0.49, p=0.04), which underlined the relationship of chronic autoimmune inflammation with thrombus formation in COVID-19. No significant changes were observed in the control group. In result, four patients developed venous thromboembolic complications (two of them had pulmonary artery thromboembolism) after the GCS pulse therapy despite the concomitant antiplatelet treatment at therapeutic doses. Recovery was slower in the hormone treatment group (median stay in the hospital was 26 days vs 18 days in the control group, р=0.001).Conclusion: Pulse therapy with high doses of GCS exerted a rapid anti-inflammatory effect but at the same time, increased the N/L ratio and the D-dimer level, which increased the risk of thromboembolism

Дерматоскопические аспекты диагностики кожных метастазов рака молочной железы

Introduction. Skin metastases are the result of skin infiltration caused by the proliferation of cells of remotely located malignant tumors occurring with a frequency of 0.6–10.4 % in various oncological processes. They may be a sign of progressive neoplasm or a manifestation of newly diagnosed cancer. Due to a high variability of clinical manifestations leading to misdiagnoses, a limited number of articles describe clinical and dermatoscopic signs of solid tumors metastatic nodes. Aim: to analyze the clinical and dermatoscopic features of skin metastases from breast cancer.Materials and methods. A female patient has complaints of slight pain and itching in the lesions area on the scalp. According to her medical history, a right mastectomy was performed for right breast cancer in 2012, followed by hormone therapy willfully discontinued by the patient. Given the uncommon localization limited with the scalp, the differential diagnosis was made with a spectrum between a cylindroma, multiple basal cell cancer and metastatic carcinoma. A biopsy was carried out to confirm the diagnosis. Results and examination. The pathological skin process revealed itself through multiple nodes up to 2 cm in diameter, pinkish in color, dense, painless on palpation, poorly demarcated. Dermatoscopically: polymorphic vessels on an erythematous background, chrysalis-like structures. Breast cancer metastases were verified by histological and immunohistochemical examination.Conclusion. Skin metastases may be the first sign of cancer recurrence. Dermatoscopy can facilitate differenting them from other skin diseases. Density and diameter of pathological vessels are prognostically significant. Ifdetected lesions do not fit the standard pattern of skin neoplasms, histological verification of the diagnosis is recommended to be carried out.Введение. Кожные метастазы являются результатом инфильтрации кожи за счет пролиферации клеток отдаленно расположенных злокачественных опухолей, встречающихся с частотой 0,6–10,4 % при различных онкологических процессах. Они могут быть признаком прогрессирующего новообразования или являться проявлением впервые диагностированного рака. Ограниченное количество статей включают в себя описание клинических и дерматоскопических признаков метастатических узлов солидных опухолей. Это связано с большой вариабельностью клинических проявлений, приводящей к диагностическим ошибкам.Цель исследования: разобрать клинические и дерматоскопические особенности кожных метастазов рака молочной железы.Материалы и методы. Пациентка с жалобами на незначительные болевые ощущения и зуд в области образований на коже волосистой части головы. Из анамнеза: в 2012 году по поводу рака правой молочной железы была выполнена мастэктомия справа с последующей гормональной терапией, которую пациентка самовольно прекратила. Учитывая нехарактерную локализацию, ограниченную волосистой частью головы, проводился дифференциальный диагноз между цилиндромой, множественным базальноклеточным раком и метастазами карциномы. С целью уточнения диагноза была выполнена биопсия.Результаты и обследование. Патологический кожный процесс был представлен множественными узлами до 2 см в диаметре, розоватого цвета, плотными, безболезненными при пальпации, без четких границ. Дерматоскопически: полиморфные сосуды на эритематозном фоне, структуры по типу хризолит. По данным гистологического и иммуногистохимического исследований были верифицированы метастазы рака молочной железы.Заключение. Кожные метастазы могут быть первым признаком рецидива злокачественной опухоли. Дерматоскопия может облегчить их дифференциальную диагностику с другими заболеваниями кожи. Прогностически значимы плотность и диаметр патологических сосудов. При выявлении образований, не укладывающихся в стандартную клиническую картину новообразований кожи, целесообразно выполнение гистологической верификации диагноза

Prognostic value of renal function in patients with acute decompensation of chronic heart failure

Aim. To study renal function and prognostic value of creatinine and glomerular filtration rate (GFR) levels in regard to lethality among patients with acute decompensation of chronic heart failure (AD CHF).Material and methods. Fhe study included 392 patients hospitalized with AD CHF symptoms (mean age 65,2+8,4 years; 263 (68%) males; CHF duration - 3,6 years). Serum creatinine concentration was measured daily up to Day 7 of hospitalization. Persistently elevated creatinine level by at least 26,5 mkmol/1 pointed to deteriorating renal function. GFR was calculated according to Cockroft-Gault formula. Echocardiography at admission was performed in all participants.Results. Baseline renal dysfunction (GFR<90 ml/min/1,73 m2) was observed in 270 (69%) patients, hospitalized with AD CHF. Severe renal failure (RF) - GFR<30 ml/min/1,73 m2, was observed in 54 (20%) subjects, including 11 (4%) with terminal RF - GFR<15 ml/min/1,73 m2. Deterioration of renal function during hospitalization was registered in 120 (30,6%) patients, being linked mostly to CHF duration. In this group, 13 (10,8%) patients died - substantially more than in participants without progressing renal dysfunction (19 (7%) deaths).Conclusion. In patients hospitalized with AD CHF, baseline GFR decrease was observed in 69%, including 20% with severe renal dysfunction (GFR<30 ml/min/1,73 m2). Renal dysfunction progression during hospitalization, registered in 30,6% of AD CHF patients, was linked to CHF duration and higher lethality

Endoscopic transpapillary interventions in the diagnosis and treatment of biliary complications in patients after orthotopic liver transplantation

Objective: to evaluate the efficiency of endoscopic transpapillary interventions in the diagnosis and treatment of biliary complications in patients after orthotopic liver transplantation (OLT).Materials and methods. One hundred and seventy-one OLTs were carried out at the N.V. Sklifosovsky Research Institute of Emergency Care in January to October 2010. Of them, endoscopic transpapillary interventions into the bile ducts for biliary complications were undertaken in 13 (7.6%) patients. These patients underwent a total of 33 endoscopic retrograde cholangiographies (ERCG), 13 endoscopic papillosphincterotomies, 5 bouginages, and 22 stentings.Results. There were no fatal outcomes associated with endoscopic interventions. By and large, the immediate result of endoscopic treatment was positive in 10 (77.0%) patients. Our results of endoscopic treatment were comparable with the data available in the literature.Conclusion. ERCG can reveal post-OLT bile-biliary anastomostic strictures and failure, which serve as an indication for endoscopic bilioduodenal stenting with stepwise restenting

General anaesthesia versus local anaesthesia for carotid surgery (GALA): a multicentre, randomised controlled trial

Background: The effect of carotid endarterectomy in lowering the risk of stroke ipsilateral to severe atherosclerotic carotid-artery stenosis is offset by complications during or soon after surgery. We compared surgery under general anaesthesia with that under local anaesthesia because prediction and avoidance of perioperative strokes might be easier under local anaesthesia than under general anaesthesia. Methods: We undertook a parallel group, multicentre, randomised controlled trial of 3526 patients with symptomatic or asymptomatic carotid stenosis from 95 centres in 24 countries. Participants were randomly assigned to surgery under general (n=1753) or local (n=1773) anaesthesia between June, 1999 and October, 2007. The primary outcome was the proportion of patients with stroke (including retinal infarction), myocardial infarction, or death between randomisation and 30 days after surgery. Analysis was by intention to treat. The trial is registered with Current Control Trials number ISRCTN00525237. Findings: A primary outcome occurred in 84 (4·8%) patients assigned to surgery under general anaesthesia and 80 (4·5%) of those assigned to surgery under local anaesthesia; three events per 1000 treated were prevented with local anaesthesia (95% CI -11 to 17; risk ratio [RR] 0·94 [95% CI 0·70 to 1·27]). The two groups did not significantly differ for quality of life, length of hospital stay, or the primary outcome in the prespecified subgroups of age, contralateral carotid occlusion, and baseline surgical risk. Interpretation: We have not shown a definite difference in outcomes between general and local anaesthesia for carotid surgery. The anaesthetist and surgeon, in consultation with the patient, should decide which anaesthetic technique to use on an individual basis. Funding: The Health Foundation (UK) and European Society of Vascular Surgery. © 2008 Elsevier Ltd. All rights reserved

General anaesthesia versus local anaesthesia for carotid surgery (GALA): a multicentre, randomised controlled trial

BACKGROUND: The effect of carotid endarterectomy in lowering the risk of stroke ipsilateral to severe atherosclerotic carotid-artery stenosis is offset by complications during or soon after surgery. We compared surgery under general anaesthesia with that under local anaesthesia because prediction and avoidance of perioperative strokes might be easier under local anaesthesia than under general anaesthesia. METHODS: We undertook a parallel group, multicentre, randomised controlled trial of 3526 patients with symptomatic or asymptomatic carotid stenosis from 95 centres in 24 countries. Participants were randomly assigned to surgery under general (n=1753) or local (n=1773) anaesthesia between June, 1999 and October, 2007. The primary outcome was the proportion of patients with stroke (including retinal infarction), myocardial infarction, or death between randomisation and 30 days after surgery. Analysis was by intention to treat. The trial is registered with Current Control Trials number ISRCTN00525237. FINDINGS: A primary outcome occurred in 84 (4.8%) patients assigned to surgery under general anaesthesia and 80 (4.5%) of those assigned to surgery under local anaesthesia; three events per 1000 treated were prevented with local anaesthesia (95% CI -11 to 17; risk ratio [RR] 0.94 [95% CI 0.70 to 1.27]). The two groups did not significantly differ for quality of life, length of hospital stay, or the primary outcome in the prespecified subgroups of age, contralateral carotid occlusion, and baseline surgical risk. INTERPRETATION: We have not shown a definite difference in outcomes between general and local anaesthesia for carotid surgery. The anaesthetist and surgeon, in consultation with the patient, should decide which anaesthetic technique to use on an individual basis. FUNDING: The Health Foundation (UK) and European Society of Vascular Surgery