Hepatotoxicity From Marijuana Gummies

Introduction: We report a case of drug-induced liver injury (DILI) induced by cannabis gummies containing Corydalis Rhizome. Case Description/Methods: A 37-year-old female presented to her primary care clinic with recurrent fevers, night sweats, and myalgias for 7 weeks accompanied by eye redness, brain fog, headache, nausea, and abdominal pain. She denied rashes, tick-bites, cough, dyspnea, chest pain, joint swelling, or genitourinary symptoms. Past medical history was notable for IBS, migraines, and anxiety. She reported edible marijuana use four times a week, rare alcohol use, and denied tobacco use. She denied a family history of liver disease. Physical exam was notable for tachycardia to 110 and scleral injection with the remainder of vitals and exam unremarkable. Initial labs were notable for AST 61, ALT 44 and CRP of 12. CBC, BMP, urinalysis, ESR, blood cultures, blood smear for parasite screen, tests for Lyme disease, Babesia, Tularemia, Anaplasma, Ehrlichia, Rickettsia, EBV, HIV, RPR, ANA, CMV, parvovirus B19, and chest x-ray were all negative. The patient was referred to infectious disease with further testing for West Nile, Leptospira, lymphocytic choriomeningitis virus, and COVID-19 returning negative. Repeat LFTs showed worsening transaminitis with ALT 979 and AST 712, alkaline phosphatase 88, total bilirubin 0.7, and albumin 4.9. Hepatitis workup including hepatitis A, B, and C, HSV, EBV, VZV serologies, AMA, ASMA, antiLKM Ab, acetaminophen level, INR, iron panel, CPK, TSH, and abdominal ultrasound were all normal. It was later discovered that her marijuana gummies contained Corydalis rhizome extract known to be hepatotoxic. Cessation of this drug was strongly advised. She was discharged with hepatology follow-up and underwent a liver biopsy showing patchy periportal and lobular inflammation with extension across the limiting plate, hepatocyte injury and apoptosis, and increased lipofuscin for age compatible with mild to moderate hepatitis. She had complete recovery after cessation of Corydalis-containing gummies. (Figure) Discussion: Our patient consumed '1906 Midnight', an American cannabis brand containing Corydalis rhizopus 100 mg, advertised to improve sleep, pain, and have a liver protective effect. A Korean systematic review on herbal-induced liver injury reported that Corydalis was the 3rd most frequent causative herb, with 36 cases. Although there are several personal accounts on social networking sites and other websites, there are no American-based publications reported on DILI from Corydalis. (Table Presented).

Successful Lung Clearing Even after Spontaneous Pneumomediastinum and COVID-19 ARDS

In severe COVID pneumonia, we have seen reports of patients suffering from spontaneous pneumomediastinum, as well as pneumothorax as a unique complication. Diffuse alveolar damage can be the etiology behind this. We report a case of a 51-year-old mountaineer female who had severe COVID pneumonia, developed air leaks, but her lung injury and scarring completely improved in 5 months.

Health Insurance Cost Prediction using Machine Learning

This paper represents a machine learning-based health insurance prediction system. Recently, many attempts have been made to solve this problem, as after Covid-19 pandemic, health insurance has become one of the most prominent areas of research. We have used the USA's medical cost personal dataset from kaggle, having 1338 entries. Features in the dataset that are used for the prediction of insurance cost include: Age, Gender, BMI, Smoking Habit, number of children etc. We used linear regression and also determined the relation between price and these features. We trained the system using a 70-30 split and achieved an accuracy of 81.3%. © 2022 IEEE.

Obstetric analgesia and anaesthesia in SARS-CoV-2-positive parturients across 10 maternity units in the north-west of England: a retrospective cohort study.

Since the start of the COVID-19 pandemic, few studies have reported anaesthetic outcomes in parturients with SARS-CoV-2 infection. We reviewed the labour analgesic and anaesthetic interventions utilised in symptomatic and asymptomatic parturients who had a confirmed positive test for SARS-CoV-2 across 10 hospitals in the north-west of England between 1 April 2020 and 31 May 2021. Primary outcomes analysed included the analgesic/anaesthetic technique utilised for labour and caesarean birth. Secondary outcomes included a comparison of maternal characteristics, caesarean birth rate, maternal critical care admission rate along with adverse composite neonatal outcomes. A positive SARS-CoV-2 test was recorded in 836 parturients with 263 (31.4%) reported to have symptoms of COVID-19. Neuraxial labour analgesia was utilised in 104 (20.4%) of the 509 parturients who went on to have a vaginal birth. No differences in epidural analgesia rates were observed between symptomatic and asymptomatic parturients (OR 1.03, 95%CI 0.64-1.67; p = 0.90). The neuraxial anaesthesia rate in 310 parturients who underwent caesarean delivery was 94.2% (95%CI 90.6-96.0%). The rates of general anaesthesia were similar in symptomatic and asymptomatic parturients (6% vs. 5.7%; p = 0.52). Symptomatic parturients were more likely to be multiparous (OR 1.64, 95%CI 1.19-2.22; p = 0.002); of Asian ethnicity (OR 1.54, 1.04-2.28; p = 0.03); to deliver prematurely (OR 2.16, 95%CI 1.47-3.19; p = 0.001); have a higher caesarean birth rate (44.5% vs. 33.7%; OR 1.57, 95%CI 1.16-2.12; p = 0.008); and a higher critical care utilisation rate both pre- (8% vs. 0%, p = 0.001) and post-delivery (11% vs. 3.5%; OR 3.43, 95%CI 1.83-6.52; p = 0.001). Eight neonates tested positive for SARS-CoV-2 while no differences in adverse composite neonatal outcomes were observed between those born to symptomatic and asymptomatic mothers (25.8% vs. 23.8%; OR 1.11, 95%CI 0.78-1.57; p = 0.55). In women with COVID-19, non-neuraxial analgesic regimens were commonly utilised for labour while neuraxial anaesthesia was employed for the majority of caesarean births. Symptomatic women with COVID-19 are at increased risk of significant maternal morbidity including preterm birth, caesarean birth and peripartum critical care admission.

Incidence of cardiac complications during index hospitalisation with covid-19 in Australia: Aus-covid study

Introduction: Cardiac complications of COVID-19 include acute cardiac injury, myopericarditis, cardiomyopathy and arrhythmias. This study aimed to describe the incidence of cardiac complications in patients admitted to hospital with COVID-19 in Australia. Methods: AUS-COVID is a multicentre observational cohort study across 21 Australian hospitals including all index hospitalisations with laboratory-proven COVID-19 in patients aged 18 years or older. All consecutive patients entered in the AUS-COVID Registry by 28 January 2021 were included in the present study. Results: Six hundred and forty-four hospitalised patients (62.5 ± 20.1 years old, 51.1% male) with COVID-19 were enrolled in the study. Overall in-hospital mortality was 14.3%. Twenty (3.6%) patients developed new atrial fibrillation or flutter during admission and 9 (1.6%) patients were diagnosed with new heart failure or cardiomyopathy. Three (0.5%) patients developed high grade atrioventricular (AV) block. Two (0.3%) patients were clinically diagnosed with pericarditis or myopericarditis. Among the 295 (45.8%) patients with at least one troponin measurement, 99 (33.6%) had a peak troponin above the upper limit of normal (ULN). In-hospital mortality was higher in patients with raised troponin (32.3% vs 6.1%, p<.001). New onset atrial fibrillation or flutter (6.4% vs 1.0%, p=.001) and troponin elevation above the ULN (50.3% vs 16.4%, p<.001) were more common in patients 65 years and older. There was no significant difference in the rate of cardiac complications between males and females. Conclusions: Among patients with COVID-19 requiring hospitalisation in Australia, troponin elevation was common but clinical cardiac sequelae were uncommon. The incidence of atrial arrhythmias and troponin elevation was greatest in patients 65 years and older.

Association of hypertension with mortality in patients hospitalised with covid-19

Introduction: To assess whether hypertension is an independent risk factor for mortality amongst patients hospitalised with COVID-19 and to evaluate the impact of angiotensin converting enzyme (ACE) inhibitors and angiotensin receptor blockers (ARBs) on mortality in patients with a background of hypertension. Methods: This observational cohort study included all consecutive index hospitalisations with laboratory proven COVID-19 aged 18 years or older across 21 Australian hospitals entered in the AUS-COVID Registry by 22nd January 2021. Patients were excluded if their past medical or medication history was not available or if they were transferred to another hospital in which case mortality outcomes were not available. Registry data were analysed for in-hospital mortality in patients with comorbidities including hypertension, and baseline treatment with ACE inhibitors or ARBs.Results: 546 consecutive patients (62.9±19.8 years old, 51.8% male) hospitalised with COVID-19 were enrolled. In the multivariable model, significant predictors of mortality were age (aOR 1.09, 95% CI 1.07-1.12, p<.001), heart failure or cardiomyopathy (aOR 2.71, 95% CI 1.13-6.53, p=.026), chronic kidney disease (aOR 2.33, 95% CI 1.02-5.32, p=.044) and chronic obstructive pulmonary disease (aOR 2.27, 95% CI 1.06-4.85, p=.035) (Figure 1). Hypertension was the most prevalent comorbidity (49.5%) but was not independently associated with increased mortality (aOR 0.92, 95% CI 0.48-1.77, p=.81). Amongst patients with hypertension, ACE inhibitors (aOR 1.37, 95% CI 0.61-3.08, p=.61) and ARBs (aOR 0.64, 95% CI 0.27-1.49, p=.30) did not affect mortality. Conclusions: In patients hospitalised with COVID-19, pre-existing hypertension was the most prevalent comorbidity but was not independently associated with mortality. Similarly, the baseline use of ACE inhibitors or ARBs had no independent association with in-hospital mortality.

IOT Based Health Monitoring System

In this research paper, an IOT based health monitoring is discussed, which will help us in keeping a check on the temperature, humidity and pulse rate of a patient's body through a mobile phone. Such a system has been proposed sut to its importance in performing a regular check on the patient's health in the situation of casualties, which are very prevalent in this pandemic situation of COVID. In such a situation, when the patient cannot be monitored closely by face-to-face monitoring, the proposed system helps in the monitoring of health parameters. Here, a fingertip heartbeat sensor to calculate the pulse rate along with DHT11 sensor to calculate the temperature and humidity of the patient's body is used. Also, Node MCU as a microcontroller is employed, a Wi-Fi module is already in it and an I2C module is used to convert serial data to parallel data for LCD screen. © 2021 IEEE.

Decision-to-delivery interval and neonatal outcomes for category-1 caesarean sections during the COVID-19 pandemic.

General anaesthesia is known to achieve the shortest decision-to-delivery interval for category-1 caesarean section. We investigated whether the COVID-19 pandemic affected the decision-to delivery interval and influenced neonatal outcomes in patients who underwent category-1 caesarean section. Records of 562 patients who underwent emergency caesarean section between 1 April 2019 and 1 July 2019 in seven UK hospitals (pre-COVID-19 group) were compared with 577 emergency caesarean sections performed during the same period during the COVID-19 pandemic (1 April 2020-1 July 2020) (post-COVID-19 group). Primary outcome measures were: decision-to-delivery interval; number of caesarean sections achieving decision-to-delivery interval < 30 min; and a composite of adverse neonatal outcomes (Apgar 5-min score < 7, umbilical arterial pH < 7.10, neonatal intensive care unit admission and stillbirth). The use of general anaesthesia decreased significantly between the pre- and post-COVID-19 groups (risk ratio 0.48 (95%CI 0.37-0.62); p < 0.0001). Compared with the pre-COVID-19 group, the post-COVID-19 group had an increase in median (IQR [range]) decision-to-delivery interval (26 (18-32 [4-124]) min vs. 27 (20-33 [3-102]) min; p = 0.043) and a decrease in the number of caesarean sections meeting the decision-to-delivery interval target of < 30 min (374/562 (66.5%) vs. 349/577 (60.5%); p = 0.02). The incidence of adverse neonatal outcomes was similar in the pre- and post-COVID-19 groups (140/568 (24.6%) vs. 140/583 (24.0%), respectively; p = 0.85). The small increase in decision-to-delivery interval observed during the COVID-19 pandemic did not adversely affect neonatal outcomes.

Impact of COVID-19 on the cerebrovascular system and the prevention of RBC lysis.

Severe acute respiratory syndrome coronavirus 2 (SARS-CoV2) uses Angiotensin- converting enzyme 2 (ACE2) receptors to infect host cells which may lead to coronavirus disease (COVID-19). Given the presence of ACE2 receptors in the brain and the critical role of the renin-angiotensin system (RAS) in brain functions, special attention to brain microcirculation and neuronal inflammation is warranted during COVID-19 treatment. Neurological complications reported among COVID-19 patients range from mild dizziness, headache, hypogeusia, hyposmia to severe like encephalopathy, stroke, Guillain-Barre Syndrome (GBS), CNS demyelination, infarcts, microhemorrhages and nerve root enhancement. The pathophysiology of these complications is likely via direct viral infection of the CNS and PNS tissue or through indirect effects including post- viral autoimmune response, neurological consequences of sepsis, hyperpyrexia, hypoxia and hypercoagulability among critically ill COVID-19 patients. Further, decreased deformability of red blood cells (RBC) may be contributing to inflammatory conditions and hypoxia in COVID-19 patients. Haptoglobin, hemopexin, heme oxygenase-1 and acetaminophen may be used to maintain the integrity of the RBC membrane.

The effect of COVID-19 on general anaesthesia rates for caesarean section. A cross-sectional analysis of six hospitals in the north-west of England.

At the onset of the global pandemic of COVID-19 (SARS-CoV-2), guidelines recommended using regional anaesthesia for caesarean section in preference to general anaesthesia. National figures from the UK suggest that 8.75% of over 170,000 caesarean sections are performed under general anaesthetic. We explored whether general anaesthesia rates for caesarean section changed during the peak of the pandemic across six maternity units in the north-west of England. We analysed anaesthetic information for 2480 caesarean sections across six maternity units from 1 April to 1 July 2020 (during the pandemic) and compared this information with data from 2555 caesarean sections performed at the same hospitals over a similar period in 2019. Primary outcome was change in general anaesthesia rate for caesarean section. Secondary outcomes included overall caesarean section rates, obstetric indications for caesarean section and regional to general anaesthesia conversion rates. A significant reduction (7.7 to 3.7%, p < 0.0001) in general anaesthetic rates, risk ratio (95%CI) 0.50 (0.39-0.93), was noted across hospitals during the pandemic. Regional to general anaesthesia conversion rates reduced (1.7 to 0.8%, p = 0.012), risk ratio (95%CI) 0.50 (0.29-0.86). Obstetric indications for caesarean sections did not change (p = 0.17) while the overall caesarean section rate increased (28.3 to 29.7%), risk ratio (95%CI) 1.02 (1.00-1.04), p = 0.052. Our analysis shows that general anaesthesia rates for caesarean section declined during the peak of the pandemic. Anaesthetic decision-making, recommendations from anaesthetic guidelines and presence of an on-site anaesthetic consultant in the delivery suite seem to be the key factors that influenced this decline.

HEMOLYTIC ANEMIA AND METHEMOGLOBINEMIA DUE TO HYDROXYCHLOROQUINE USE FOR COVID-19 TREATMENT IN A GLUCOSE-6-PHOSPHATE DEHYDROGENASE-DEFICIENT PATIENT

SESSION TITLE: Medical Student/Resident Chest Infections Posters SESSION TYPE: Med Student/Res Case Rep Postr PRESENTED ON: October 18-21, 2020 INTRODUCTION: Glucose-6-phosphate dehydrogenase (G6PD) deficiency is a genetic disorder caused by red blood cell (RBC) enzymatic defects that leads to hemolytic anemia with sufficient oxidative stress.G6PD deficiency affects approximately 400 million people, mainly African populations.Methemoglobinemia is a condition in which oxidative stress converts the ferrous ion in hemoglobin into a ferric ion with higher binding affinity to oxygen leading to the inability to release O2 to tissue.Both conditions can be precipitated by medications such as hydroxychloroquine (HCQ), which has seen widespread use to treat the novel coronavirus (COVID-19). CASE PRESENTATION: A 39 year old African American male presenting with weakness was found to have acute kidney failure and liver injury.He was recently diagnosed with COVID-19 pneumonia and received HCQ as outpatient.HCQ was stopped upon admission but the patient's mental status worsened and his hemoglobin fell from 12.2 g/dL to 6.3 g/dL with evidence of hemolylsis- LDH 1758 U/L.Total bilirubin peaked at 25.4 mg/dL without evidence of biliary obstruction and an undetectable haptoglobin.The patient required multiple RBC transfusions. He also had significantly elevated methemoglobin levels, which peaked at 14.8%.These findings along with his ethnic background prompted a G6PD assay to be sent which showed decreased enzyme activity. Due to his G6PD deficiency, the patient received ascorbic acid to treat the methemoglobin. His methemoglobin level remained elevated for 7 days and severe hemolysis persisted for 10 days before resolving. He also experienced severe delirium, renal failure requiring hemodialysis and hypoxic respiratory failure requiring 100% O2 high flow nasal cannula. He was eventually discharged home on room air. DISCUSSION: In this case, HCQ along with COVID-19 infection caused enough oxidative stress to cause methemoglobinemia and also trigger a separate hemolytic anemia due to G6PD deficiency. A 2018 study of Duke rheumatology patients prescribed HCQ found that in 275 patients, 4% had G6PD deficiency. Of those, only 2 patients experienced hemolytic anemia but during severe lupus flares while they were not taking HCQ. The authors recommended to not screen for G6PD deficiency, as HCQ use alone was not enough to trigger hemolytic anemia. CONCLUSIONS: With the widespread use of HCQ as an off-label treatment for COVID-19, it is important to monitor for potential complications.G6PD deficiency hemolytic anemia should be monitored for especially in patient populations at risk for the condition. Methemoglobinemia happening simultaneously is exceedingly rare but should be watched for as well in patients with COVID-19 due to the severe systemic inflammation. There is currently only one case report in the literature of both conditions occurring with the use of HCQ, however, these disorders can potentially worsen oxygenation in already critically ill COVID-19 patients. Reference #1: Kuipers MT, van Zwieten R, Heijmans J, et al. G6PD deficiency-associated hemolysis and methemoglobinemia in a COVID-19 patient treated with chloroquine [published online ahead of print, 2020 May 10]. Am J Hematol. 2020;10.1002/ajh.25862. doi:10.1002/ajh.25862 Reference #2: Mohammad S, Clowse MEB, Eudy AM, Criscione-Schreiber LG. Examination of Hydroxychloroquine Use and Hemolytic Anemia in G6PDH-Deficient Patients. Arthritis Care Res (Hoboken). 2018;70(3):481-485. doi:10.1002/acr.23296 Reference #3: Beauverd, Y, Adam, Y, Assouline, B, Samii, K. COVID-19 infection and treatment with hydroxychloroquine cause severe haemolysis crisis in a patient with glucose-6-phosphate dehydrogenase deficiency. Eur J Haematol. 2020;00: 1– 3. https://doi.org/10.1111/ejh.13432 DISCLOSURES: No relevant relationships by Karishma Bhatia, source=Web Response No relevant relationships by Young Lee, source=Web Response No relevant relationships by Steven Lim, source=Web Response

PULMONARY BAROTRAUMA DURING NONINVASIVE VENTILATION IN PATIENTS WITH COVID-19

SESSION TITLE: Chest Infections Posters SESSION TYPE: Original Investigation Posters PRESENTED ON: October 18-21, 2020 PURPOSE: The pathophysiology of respiratory distress in hospitalized patients with COVID-19 is not yet fully understood. Spontaneous pulmonary barotrauma (PBT) is a pulmonary complication typically seen in intubated patients. However, in the related viral epidemic of SARS in 2002, 6.6% to 15% of patients on non-invasive ventilation (NIV) were described to have developed PBT, with severe alveolar destruction as the suggested mechanism. Within the COVID-19 pandemic, isolated case studies have described bulla and PBT, and a systematic review of imaging has suggested PBT to be a sign of disease progression. METHODS: In this single center retrospective case series, two patients with confirmed COVID-19 infection who developed PBT on NIV were identified in a New York City hospital from March 2020 to April 2020 and were included in this study. RESULTS: Both the patients were non-smokers with no pre-existing lung disease. The first patient was a 58-year-old woman with a history of pemphigus vulgaris, and the second patient was a 69-year-old man with a history of hypertension and type 2 diabetes mellitus. Both patients received treatment with hydroxychloroquine, azithromycin, therapeutic anticoagulation, high dose steroids, and were enrolled in the hospital’s remdesivir trial. Both patients required oxygen therapy which included escalation from nasal cannula to continuous positive airway pressure (CPAP), and both were encouraged to self-prone. The first patient was found to have a large left pneumothorax (PTX), pneumomediastinum (PM), and extensive subcutaneous emphysema (SE) on day 18 of hospitalization while on CPAP of 12 cm H2O, requiring surgical chest tube placement. The second patient developed a small left apical PTX, PM, and SE on day eight of hospitalization while on CPAP of 14 cm H2O, which was conservatively managed. Both patients eventually required intubation for worsening hypoxemia and later succumbed to their illness. CONCLUSIONS: In this study we identified two patients who developed PBT without being subjected to invasive ventilation or very high levels of PEEP. Both patients had poor outcomes, suggesting that COVID-19 may be associated with alveolar destruction, especially in the setting of steroid use. Glucocorticoid use may interfere with lung healing which could further increase the risk of alveolar rupture. CLINICAL IMPLICATIONS: This study encourages clinicians to have low threshold to suspect PBT in COVID-19 patients even while on NIV. Prospective studies are needed further to determine the utility of steroid use, given this potential risk for PBT and the clinical significance of our observations in COVID-19 patients. DISCLOSURES: No relevant relationships by Kirtipal Bhatia, source=Web Response No relevant relationships by Joseph Ghassibi, source=Web Response No relevant relationships by Julia Goldberg, source=Web Response No relevant relationships by Yasmin Herrera, source=Web Response No relevant relationships by Kam Sing Ho, source=Web Response No relevant relationships by Vivek Modi, source=Web Response No relevant relationships by Archana Pattupara, source=Web Response

Safe biochemical testing of COVID-19 samples: A clinical lab perspective

The current COVID-19 pandemic has not only greatly burdened healthcare system globally but also exposed the medical and paramedical staff to risk of infection. Although the major mode of transmission of this highly infectious disease is via close contact with an infected person, droplet infection due to coughing/sneezing and aerosol generation, few research articles have shown presence of SARS-CoV-2 in blood and serum. This poses a potential risk to health care professionals who are handling these samples. Once the suspected/confirmed case of COVID-19 is admitted in the hospital, setting it requires a battery of clinical chemistry investigations. Laboratory has a vital and indispensable role to play in the management of COVID-19 patients as several biochemical markers are used for prognostication as well as monitoring and guiding treatment in the critical patients. Hence, this evaluation was undertaken to have protocols based on robust recommendations and guidelines to be followed while handling the potentially infective samples in the clinical laboratories in order to ensure safety of the staff. However, these recommendations are based on the limited and rapidly evolving knowledge available at the moment and hence need to be reviewed periodically.