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Wide open Ankle joint Fractures: Precisely what Forecasts Disease? Any multi-center study.
Sleep services are assigned a non-essential status during COVID-19. The American Academy of Sleep Medicine strongly urges sleep clinicians to continue postponing non-urgent care until a later date, if such a recommendation is made by state officials due to local conditions. At the same time, one cannot ignore the fact that sleep is important for people's health and wellbeing. Therefore, to protect the health of the population, it is essential to find ways and means to continue the practice of sleep medicine even during the COVID-19 pandemic.

Social environment and work ethics in sleep clinics and sleep laboratories in Asia, Africa, and Latin America are different from those in the US. Under these circumstances, the Indian Society for Sleep Research (ISSR) created a task force to develop guidelines for the practice of sleep medicine, not only for the Indian environment but also for other countries that are affected by the COVID-19 pandemic. The task force examined documents regarding practice of sleep medi and resume operations is made, the safety of the patients and office staff should become the major priority. The ISSR recommendation is to postpone and reschedule in-laboratory positive pressure therapy, but it mentions the considerations to be followed in emergency situations. At the same time, high clinical risk patients may be diagnosed on the basis of clinical findings, and without performing polysomnography or home sleep testing. However, at some point, there is a need to reinitiate the in-lab testing. In addition, daily assessment of the COVID-19 situation in the community, along with a review of the situation with local public health and the state health department is advised.With the advent of COVID-19 infection and its rapid spread, preventive strategies are being developed worldwide, besides following the universal infection control guidelines. Prevention of spread through aerosol generation is one of the essential strategies in this regard, particularly for patients with sleep-disordered breathing at home and during hospital admission. Aerosols are produced, at home and in health care facilities, by natural processes and aerosol-generating procedures. To address this impinging problem, aerosol-generating procedures, like non-invasive ventilation (NIV), are to be handled meticulously, which might warrant isolation and sometimes device/interface modifications.
Best practice for prevention, diagnosis, and management of venous thromboembolism (VTE) in patients with SARS-CoV-2 disease 2019 (COVID-19) is unknown due to limited published data in this population.

We aimed to assess current global practice and experience in management of COVID-19 associated coagulopathy to identify information to guide prospective and randomized studies.

Physicians were queried about their current approach to prophylaxis, diagnosis, and treatment of VTE in patients with COVID-19 using an online survey tool distributed through multiple international organizations between April 10 and 14, 2020.

515 physicians responded from 41 countries. The majority of respondents (78%) recommended prophylactic anticoagulation for all hospitalized patients with COVID-19 with most recommending use of low-molecular-weight heparin or unfractionated heparin. Significant practice variation was found regarding need for dose escalation of anticoagulation outside the setting of confirmed or suspected VTE. Respondents reported the use of bedside testing when unable to perform standard diagnostic imaging for diagnosis of VTE. 291 respondents reported observing thrombotic complications in their patients with 64% noting that the complication was pulmonary embolism (PE). Of the 44% of respondents that estimated incidence of thrombosis in patients with COVID-19 in their hospital, estimates ranged widely from 1 to 50%. 174 respondents noted bleeding complications (34% minor bleeding, 14% clinically relevant non-major bleeding, and 12% major bleeding).

Well-designed epidemiologic studies are urgently needed to understand the incidence and risk factors of VTE and bleeding complications in COVID-19 patients. Randomized clinical trials addressing use of anticoagulation are also needed.
Well-designed epidemiologic studies are urgently needed to understand the incidence and risk factors of VTE and bleeding complications in COVID-19 patients. Randomized clinical trials addressing use of anticoagulation are also needed.We thank May et al for their comments, expanding the number of reported cases of suspected and confirmed heparin-induced thrombocytopenia (HIT) associated with COVID-19, and reemphasizing the complexity of the prothrombotic state observed (1). We agree that false-positive enzyme immunoassay (EIA) detection of anti-platelet factor 4 (PF4)/heparin antibodies could explain the results we observed in patients #2 and #3 (2), and this has been the conventional interpretation when functional testing (such as the serotonin-release assay [SRA]) returns negative. We suggested that a false negative SRA result could have explained our findings, as opposed to the contention by May et al that we concluded they were falsely positive, to broaden our discussion about SRA-negative HIT, a relatively new and evolving clinical condition (3-6).
The COVID-19 pandemic has caused a large surge of acute respiratory distress syndrome (ARDS). Prior phase I trials (non COVID-19) demonstrated improvement in pulmonary function in ARDS patients using fibrinolytic therapy. A follow-up trial using the widely available tissue-plasminogen activator (alteplase) is now needed to assess optimal dosing and safety in this critically ill patient population.

To describe the design and rationale of a Phase IIa trial to evaluate the safety and efficacy of alteplase treatment for moderate/severe COVID-19-induced ARDS.

A rapidly adaptive, pragmatic, open label, randomized, controlled, phase IIa clinical trial will be conducted with three groups intravenous(IV) alteplase 50mg, IV alteplase 100mg, and control (standard-of-care). Inclusion criteria are known/suspected COVID-19 infection with PaO2/FiO2 ratio<150mmHg for >4 hours despite maximal mechanical ventilation management. Alteplase will be delivered through an initial bolus of 50mg or 100mg followed by heparin infusion for systemic anticoagulation, with alteplase re-dosing if there is a >20% PaO2/FiO2 improvement not sustained by 24 hours.

The primary outcome is improvement in PaO2/FiO2 at 48 hours post-randomization. Other outcomes include ventilator- and ICU-free-days, successful extubation (no reintubation ≤3 days after initial extubation), and mortality. Fifity eligible patients will be enrolled in a rapidly adaptive, modified stepped-wedge design with four looks at the data.

Findings will provide timely information on the safety, efficacy and optimal dosing of tPA to treat moderate/severe COVID-19-induced ARDS, which can be rapidly adapted to a phase III trial. (NCT04357730; FDA IND 149634).
Findings will provide timely information on the safety, efficacy and optimal dosing of tPA to treat moderate/severe COVID-19-induced ARDS, which can be rapidly adapted to a phase III trial. (NCT04357730; FDA IND 149634).
Previous studies reported that coronavirus disease 2019 (COVID-19) was likely to result in liver injury. However, few studies investigated liver injury in COVID-19 patients with chronic liver diseases. We described the clinical features in COVID-19 patients with non-alcoholic fatty liver disease (NAFLD).

Confirmed COVID-19 patients from hospitals in 10 cities of Jiangsu province, China were retrospectively included between January 18, 2020, and February 26, 2020. Hepatic Steatosis Index (HSI) was used to defined NAFLD.

A total of 280 COVID-19 patients were enrolled. Eighty-six (30.7%) of 280 COVID-19 patients were diagnosed as NAFLD by HSI. 100 (35.7%) patients presented abnormal liver function on admission. The median ALT levels (34.5 U/L vs. 23.0 U/L, P<0.001) and the proportion of elevated ALT (>40 U/L) (40.7% vs. 10.8%, P<0.001) were significantly higher in patients with NAFLD than in patients without NAFLD on admission. The proportion of elevated ALT in patients with NAFLD was also signifipitalization.As social distancing and strict stay-at-home orders have been instituted to slow the spread of coronavirus disease 2019 (COVID-19), unintentional outcomes among those with chronic diseases including screening for the lethal hepatocellular carcinoma (HCC) may be occurring. We aimed to describe the changes in liver care before and after COVID-19 restricted access to health care. We obtained data on the number of liver clinic visits, abdominal ultrasound, computed tomography, and magnetic resonance imaging using electronic query or clinic registry at three medical centers in the United States, Japan, and Singapore for the following periods February 1 to March 14, 2018, 2019, and 2020; and March 15 to May 1, 2018, 2019, and 2020. PFTμ We performed trend analysis using logistic regression. In total, 14,403 visits were made to the liver clinics at the three centers 5,900 in 2018, 5,270 in 2019, and 3,233 in 2020. Overall, there were no significant changes in the distribution of males and females between February 1 and May 1 from 2018 to 2020, but there was a lower proportion of seniors ages 65 years and older (P less then 0.001). There were significant decreasing trends in the total number of liver clinic visits overall (p-trend = 0.038) and in the subanalysis for chronic hepatitis B, C, and other liver diseases. HCC/cirrhosis visits also dropped from 883 to 538 (39.07% decrease) overall and 665 to 355 (46.62% decrease) for the US site. In addition, there was a significant decreasing trend in the number of abdominal ultrasounds (P-trend = 0.004) and computed tomography/magnetic resonance imaging (P-trend = 0.007) performed overall. Conclusion Liver clinic visits, hepatoma surveillance, and diagnostic abdominal imaging fell dramatically as social distancing measures were instituted. Care providers must find ways to recall patients for important care monitoring, including HCC surveillance.A newly identified coronavirus, severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), which causes the infectious coronavirus disease 2019 (COVID-19), emerged in December 2019 in Wuhan, Hubei Province, China, and now poses a major threat to global public health. Previous studies have observed highly variable alanine aminotransferase (ALT) and aspartate aminotransferase (AST) levels in patients with COVID-19. However, circulating levels of the cholangiocyte injury biomarker γ-glutamyltransferase (GGT) have yet to be reported in the existing COVID-19 case studies. Herein, we describe the relationship between GGT levels and clinical and biochemical characteristics of patients with COVID-19. Our study is a retrospective case series of 98 consecutive hospitalized patients with confirmed COVID-19 at Wenzhou Central Hospital in Wenzhou, China, from January 17 to February 5, 2020. Clinical data were collected using a standardized case report form. Diagnosis of COVID-19 was assessed by symptomatology, reverse Italy has been the first Western nation facing COVID-19 outbreak. Despite the emergency situation, all efforts have been done to preserve liver transplant (LT) activity and to minimize the impact of current scenario on transplant waiting list time and mortality. Little is known about COVID-19 consequences in transplant candidates, especially those with limited life expectancy due to the severity of their baseline disease. We report here the case of a young patient requiring inpatient care due to severe decompensated liver disease (MELD 24), justifying her referral from her local hospital to our high-volume LT unit, despite the unfavourable COVID-19 epidemiology in our Region. She was quickly listed for liver transplant (MELD 26), but 5 days later she was incidentally diagnosed with COVID-19 in the setting of our surveillance program for very sick patients and, despite her underlying condition, had an indolent course of the viral disease. Concerns about potential COVID-19 consequences in a LT candidate were overruled by the severity of liver disease (MELD 36), forcing our team to proceed with an urgent successful LT as soon as 9 days after the COVID-19 diagnosis, 2 days after the first negative SARS-CoV-2 RNA by a nasopharyngeal swab and 1 day after the confirmation of its negativity on bronchoalveolar lavage.
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