Liver Injury in COVID-19 Patients

Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) preferentially infects cells in the respiratory tract, but several studies have also demonstrated low levels of SARS-CoV-2 copies in the liver. The hypothesis that patients with COVID-19 may develop liver dysfunction is supported by findings showing abnormal liver test results in such patients, but the exact mechanisms by which SARS-CoV-2 induces liver damage remain unclear. Liver injury in COVID-19 patients has probably a multifactorial etiology including the rapid onset of a systemic pro-inflammatory state due to viral infection, the use of potentially hepatotoxic drugs, pneumonia-associated hypoxia, and the eventual direct injury of the liver by SARS-CoV-2. This chapter will discuss the potential pathophysiological mechanisms for SARS-CoV-2 hepatic tropism and an overview about the main biochemical and histopathological findings observed in liver from COVID-19 patients. Finally, the effects that this infection can produce in patients with chronic liver disease will be also discussed.

Idiopathic intracranial hypertension leading to bilateral optic atrophy in a patient with recent COVID-19 infection: a case report

Neurologic complications are common in patients hospitalised with COVID-19 infection. Most common complications are myalgias, headaches, encephalopathy and dizziness. Uncommon complications are stroke, motor and sensory deficits, seizures, ataxia and movement disorders. Multiple neuro-ophthalmological manifestations have also been reported in association with COVID-19. These complications may be the result of a range of pathophysiological mechanisms like hypoxic neuronal injury during active COVID-19 infection, RAS dysfunction, immune dysfunction and direct injury by the virus etc throughout the course of the disease. Here we reported a case of neuro-ophthalmic complication of Idiopathic intracranial hypertension (IIH) followed by bilateral optic atrophy in a middle-aged man with recent COVID-19 infection. He presented to the emergency with complaints of headache, dizziness and sudden painless bilateral diminution of vision for 3 days. His fundus examination was suggestive of bilateral papilledema, his MRI brain was normal and opening pressure of CSF was raised on lumbar puncture. His MRV was normal, there was no evidence of CSVT. He was started on steroids and acetazolamide. His headache improved but there was no improvement in visual acuity. Repeat fundus showed pale disc and MRI orbit was suggestive of bilateral optic atrophy.

Fragility Index and Fragility Quotient in Randomized Controlled Trials on Corticosteroids in ARDS Due to COVID-19 and Non-COVID-19 Etiology

Background: The effectiveness of corticosteroids in acute respiratory distress syndrome (ARDS) and COVID-19 still remains uncertain. Since ARDS is due to a hyperinflammatory response to a direct injury, we decided to perform a meta-analysis and an evaluation of robustness of randomised clinical trials (RCTs) investigating the impact of corticosteroids on mortality in ARDS in both COVID-19 and non-COVID-19 patients. We conducted a systematic search of the literature from inception up to 30 October 2020, using the MEDLINE database and the PubMed interface. We evaluated the fragility index (FI) of the included RCTs using a two-by-two contingency table and the p-value produced by the Fisher exact test; the fragility quotient (FQ) was calculated by dividing the FI score by the total sample size of the trial. Results: Thirteen RCTs were included in the analysis; five of them were conducted in COVID-19 ARDS, including 7692 patients, while 8 RCTS were performed in non-COVID ARDS with 1091 patients evaluated. Three out of eight RCTs in ARDS had a FI > 0 while 2 RCTs out of five in COVID-19 had FI > 0. The median of FI for ARDS was 0.625 (0.47) while the median of FQ was 0.03 (0.014). The median of FI for COVID-19 was 6 (2) while the median of FQ was 0.059 (0.055). In this systematic review, we found that FI and FQ of RCTs evaluating the use of corticosteroids in ARDS and COVID-19 were low.

Disc Degeneration in Direct Injury or Instability Models Share Common Metabolic Pathways

Introduction: Disc degeneration is the central component involved in numerous common spinal pathologies. Degenerative disc disease affects millions of people every year, yet the mechanisms driving degeneration remain poorly understood. Previous work to date has shown that high levels of intracellular lactate seem to be involved in driving this pathology once thought to be purely mechanical. Here, we present a series of studies utilizing mouse models of mechanical injuring or loading of the intervertebral disc (IVD), with a goal of better defining the role of lactate and lactate transport in degenerative disc disease. Methodology: Four models of disc degeneration were studied: (i) lumbar disc poke, (ii) tail disc poke, (iii) spinal instability, and (iv) sham. Female mice (C57BL/6J, n = 30) were randomly assigned to one group. In group 1, a retroperitoneal approach exposed the IVD of the lumbar spine, and a 27G needle was used to injure the disc. In group 2, the needle was inserted in the tail IVD. In group 3, lumbar instability was induced by resection of bilateral facet joints and supraspinous/interspinous ligaments. In group 4, a sham was used for each. The mice were euthanized at two, four, and eight weeks. IVD was evaluated by histological and immunofluorescence analysis. RNA extraction from disc tissue was analyzed with QPCR. Result: Sham mice did not have significant disc degeneration. In groups 1 and 2, the degenerative process at two, four, and eight weeks was characterized by loss of nucleus pulposus (NP) cells and the gradual increase in matrix components in NP. The distinction between NP and annulus fibroids (AF) or endplate cartilage is lost. There was increased expression of collagen X and MMP13 in the NP, and MCT4 was decreased, while MCT3 was increased. In group 3, disorder of the AF was evident in the first two weeks post surgery, the collapsed disc space and the NP area gradually lessened. The proteoglycan detected in the inner layer of AF and the periphery of NP decreased after eight weeks. There was increase in type X collagen and MMP13 in the inner AF and NP. Conclusion: Our results demonstrate a common molecular pathway whereby discs degenerate after direct injury or becoming unstable. In our model, there was a rapid degeneration of the IVD in mice who exhibit up- and downregulation of several important markers. Importantly, MCT4 was downregulated, while MCT3 was upregulated. While MCT4 was associated with lactate exportation, and its loss resulted in elevated intracellular lactate and disc degradation, MCT3 is rarely expressed and may be acting as a rescue lactate transporter.

Management of post burn groin contracture: a case account

Similar to burns of the face, hands, and feet, groin and perineal burn injuries result in physical as well as psychosocial scarring for the patient. It often results in loss of functionality which is usually out of proportion to the percentage of burns. Hence, these burns are classified as major burns. Direct injury to the genitalia can lead to sexual dysfunction. In such circumstances, the treatment plan should comprehensively look into even psychosocial aspects of the patient. Both functional and cosmetic appearance should be the primary concern. With scarcely available burns unit and dedicated hospitals in India to treat burns, patients often develop severe contractures without proper post burns care. Most of the burn patients end up being treated by staff without special training in burn care. A variety of surgical procedures in post burn contractures of groin and perineum have been described all aimed to achieve satisfactory functional and cosmetic outcome. However, advantages of long-term care with regular physiotherapy, use of pressure garments, and massaging with emollient creams should not be overlooked and cannot be overemphasized. We present such a case of a young female with poor post burns care which resulted in post burn contracture of the groin and perineal area and had to endure with inconveniences. Patient was treated in our department adequately.

Iatrogenic peripheral nerve injury: a guide to management for the orthopaedic limb surgeon

Nerves may be inadvertently injured during trauma surgery due to distorted anatomy, traction applied to a limb, soft tissue retraction, by power tools, instrumentation and from compartment syndrome. Elective orthopaedic surgery has additional risks of joint dislocation for arthroplasty surgery, limb lengthening, thermal injury from cement and direct injury from peripheral nerve blocks. The true incidence is unknown, and many cases are diagnosed as neurapraxia with the expectation of a full and timely recovery without the need for intervention. The incorrect assignation of a neurapraxia diagnosis may delay treatment for a higher grade of injury and in addition fails to recognize that a diagnosis of neurapraxia should be made with caution and a commitment to regular clinical review. Untreated, a neurapraxia can deteriorate and result in axonopathy. The failure to promptly diagnose such a nerve injury and instigate treatment may result in further deterioration and expose the clinician to medicolegal challenge. The focus of this review is to raise awareness of iatrogenic peripheral nerve injuries in orthopaedic limb surgery, the importance of regular clinical examination, the role of investigations, timing and nature of interventions and also to provide a guide to when onward referral to a specialist peripheral nerve injury unit is recommended. Cite this article: EFORT Open Rev 2021;6:607-617. DOI: 10.1302/2058-5241.6.200123

Acquired tracheoesophageal fistula in a pregnant patient with COVID-19 pneumonia on prolonged invasive ventilation

A previously healthy pregnant woman was diagnosed with COVID-19 pneumonia and was subsequently intubated. Throughout the course of her illness, the patient was treated for recurrent bouts of pneumonia. A high-resolution chest and neck CT scan confirmed the presence of a tracheoesophageal fistula (TEF), which may have been caused by the presence of the overinflated endotracheal cuff, prolonged steroid use, hypoxic injury and possible direct injury of the tracheal mucosa from COVID-19 itself. A temporising procedure, involving tracheostomy with an extended-length tracheal tube, was performed. Unfortunately, the patient succumbed to infection prior to definitive repair. This case highlights the importance of keeping a high index of suspicion for tracheal injury in patients who experience prolonged periods of intubation. It also underlies the high morbidity and mortality rate associated with TEF, although being a rare disease.

The safe zones for endoscopic proximal hamstring repair: a cadaveric assessment of standard portal placement and their relationship to major neurovascular structures

Purpose: To define the anatomical relationship of the major neurovascular structures to the standard endoscopic portals used in endoscopic hamstring repair. A secondary outcome was to determine the safest angle of insertion from each standard portal. Methods: Endoscopic portals were established in the 3 standard locations (lateral, medial, and inferior) and Steinmann pins inserted at various angles. Each hip was dissected and the distance between the pins and the pertinent anatomy measured. Results: The lateral portal placed the sciatic and posterior femoral cutaneous (PFC) nerves at greatest risk: direct injury to the sciatic nerve was seen in 11/30 (37%) of the lateral portals sited. A lateral portal with an approach at 60° was the most dangerous orientation with a mean distance of 0.36 ± 0.49 mm and 4.30 ± 2.69 mm from the sciatic and PFC nerves, respectively ( p < 0.001). The 60° medial portal was the safest of all portals measured, at a mean distance of 67.37 ± 11.06mm (range, 47–78 mm) from the sciatic nerve and 58.90 ± 10.57 mm (range 40–70 mm) from the PFC nerve. Conclusions: While currently described techniques recommend establishing the standard lateral portal first, this study shows that it carries the highest risk of injury if used blind. We recommend that the standard medial endoscopic portal is established first to identify the neurovascular structures and minimise iatrogenic neurovascular injury. The inferior and lateral portals can then be established created under direct vision. The lateral portal should be inserted in a more horizontal orientation to decrease the risk of nerve injury.

A rare lesion of the wanderer’s nerve with an unusual postoperative complication: vagal nerve schwanomma

<p class="abstract">Vagal nerve schwannomas are rare parapharyngeal tumours which was first described by Figi in 1933. Hoarseness is the most common symptom. Occasionally, a paroxysmal cough may be produced on palpating the mass. This is a clinical sign, unique to vagal schwannoma. Presence of this sign, along with a mass located on the medial border of the sternocleidomastoid muscle, should make clinicians suspicious of vagal nerve sheath tumours. However, in our case, the patient presented to us with a swelling in the neck and no other symptoms. MRI in the pre-operative work-up is helpful in defining diagnosis and in evaluating the extent and the relationship. A careful intracapsular enucleation with nerve-sparing technique remains the treatment of choice in order to avoid nerve injury which can lead to vocal cord paralysis. Horner’s syndrome following cervical surgeries is a rare phenomenon. Its occurrence following excision of a vagal schwannoma can occur due to direct injury to cervical sympathetic chain during excision or indirect injury due to traction on the sympathetic chain. Here is a case report of a patient diagnosed with left vagal scwanomma who developed horner’s syndrome post operatively.</p>

Microbial Toxins in Insect and Nematode Pest Biocontrol

Invertebrate pests, such as insects and nematodes, not only cause or transmit human and livestock diseases but also impose serious crop losses by direct injury as well as vectoring pathogenic microbes. The damage is global but greater in developing countries, where human health and food security are more at risk. Although synthetic pesticides have been in use, biological control measures offer advantages via their biodegradability, environmental safety and precise targeting. This is amply demonstrated by the successful and widespread use of Bacillusthuringiensis to control mosquitos and many plant pests, the latter by the transgenic expression of insecticidal proteins from B. thuringiensis in crop plants. Here, I discuss the prospects of using bacterial and fungal toxins for pest control, including the molecular basis of their biocidal activity.