From Pro, Anti to Informative and Hesitant: An Infoveillance study of COVID-19 vaccines and vaccination discourse on Twitter (preprint)

COVID-19 pandemic has brought unprecedented challenges to the world, and vaccination has been a key strategy to combat the disease. Since Twitter is one of the most widely used public microblogging platforms, researchers have analysed COVID-19 vaccines and vaccination Twitter discourse to explore the conversational dynamics around the topic. While contributing to the crisis informatics literature, we curate a large-scale geotagged Twitter dataset, GeoCovaxTweets Extended, and explore the discourse through multiple spatiotemporal analyses. This dataset covers a longer time span of 38 months, from the announcement of the first vaccine to the availability of booster doses. Results show that 43.4% of the collected tweets, although containing phrases and keywords related to vaccines and vaccinations, were unrelated to the COVID-19 context. In total, 23.1% of the discussions on vaccines and vaccinations were classified as Pro, 16% as Hesitant, 11.4% as Anti, and 6.1% as Informative. The trend shifted towards Pro and Informative tweets globally as vaccination programs progressed, indicating a change in the public's perception of COVID-19 vaccines and vaccination. Furthermore, we explored the discourse based on account attributes, i.e., followers counts and tweet counts. Results show a significant pattern of discourse differences. Our findings highlight the potential of harnessing a large-scale geotagged Twitter dataset to understand global public health communication and to inform targeted interventions aimed at addressing vaccine hesitancy.

Clinical virology and effect of Covid-19 vaccination and monoclonal antibodies against highly infectious SARS- CoV-2 omicron sub variant BF.7 (BA.5.2.1.7): A systematic review.

Over time, the SARS-CoV-2 virus has acquired several genetic mutations, particularly on the receptor-binding domain (RBD) spike glycoprotein. The Omicron variant is highly infectious, with enhanced immune escape activity, and has given rise to various sub-lineages due to mutations. However, there has been a sudden increase in COVID-19 reports of the Omicron subvariant BF.7 (BA.2.75.2), which has the highest number of reported cases, accounting for 76.2% of all cases worldwide. Hence, the present systematic review aimed to understand the viral mutations and factors associated with the increase in the reports of COVID-19 cases and to assess the effectiveness of vaccines and mAbs against the novel Omicron variant BF.7. The R346T mutation on the spike glycoprotein RBD might be associated with increased infection rates, severity, and resistance to vaccines and mAbs. Booster doses of COVID-19 vaccination with bivalent mRNA booster vaccine shots are effective in curtailing infections and decreasing the severity and mortality by enhancing the neutralizing antibodies (Abs) against the emerging Omicron subvariants of SARS-CoV-2, including BF.7 and future VOCs.

Introducing virtual classrooms for undergraduate physiology teaching during the COVID-19 pandemic: acceptance by students and subjective impact on learning.

The COVID-19 pandemic and worldwide lockdowns brought major changes in education systems. There was a sudden obligatory shift toward utilization of digital resources for teaching and learning purposes. Medical education, specifically physiology teaching, comprises hands-on training in the laboratory. It is challenging to offer a course like physiology in a virtual format. The objective of this study was to assess the effectiveness and influence of virtual classroom technology on online physiology education in a sample size of 83 first-year MBBS undergraduates. A questionnaire comprising questions related to technology accessibility and utilization, comprehensibility and effectiveness of instructions, faculty proficiency, and learning outcomes was administered to the group. The responses were collected and analyzed. Validation through principal components and factor analysis showed that online teaching is not very effective and has a limited application in the physiology education of undergraduate MBBS students. Our study also revealed that virtual physiology teaching of undergraduate medical students during the COVID-19 pandemic had a moderate level of effectiveness.NEW & NOTEWORTHY In the present qualitative study, we have conducted and validated an online physiology teaching platform at a medical college to continue medical education during the peak times of the COVID-19 pandemic and prolonged lockdowns. Furthermore, we have evaluated the effectiveness of online physiology teaching through multidimensional feedback from undergraduate MBBS students. It is experimental evidence of inadequate sustainability, moderate efficacy, limited application, and poor first-hand experience gained by the students in virtual physiology teaching in a preclinical and clinical setting.

Emerging Bacterial Pathogens in the COVID-19 Era: Chryseobacterium gleum -A Case in Point.

Introduction In the ongoing severe acute respiratory syndrome coronavirus 2 pandemic, a long hospital stay and empirical broad-spectrum antibiotics make the patients prone to acquire nosocomial infections especially with unconventional organisms, and Chryseobacterium gleum is one such rare nosocomial pathogen. Methods The given study is a case-series-based study conducted from September 2020 to April 2021 in which clinically suspected pneumonia patients who recovered from coronavirus disease 2019 (COVID-19) were included. Results Seventeen C. gleum isolates were obtained in pure culture from the tracheal aspirates of nine COVID-19 patients (including repeat samples to rule out colonization) within a period of eight months (September 2020-April 2021). Our records showed that there has been an increase in the number of isolates of C. gleum obtained in respiratory samples in 2020. We also did a review of literature of all the cases of C. gleum pneumonia reported till now. Conclusion To the best of our knowledge, this is the first study reporting the isolation of this rare pathogen from COVID-19 patients with clinical significance in a large cohort of patients. Therefore, it becomes important to consider this pathogen as a significant cause of respiratory infections, especially in patients recovered post COVID-19.

Evaluation of risk factors, clinico-radiographic presentations of COVID-associated mucormycosis in the maxillofacial region reporting to a tertiary care dental facility.

Purpose: To evaluate the prevalence of risk factors associated with COVID-associated mucormycosis (CAM) in the maxillofacial region with emphasis on clinical and radiological characteristics of the disease reporting to the dentists. Methods: Archival records of the patients diagnosed with rhino-cerebral mucormycosis through histopathology or culture, were screened and 266 records were included. These records were divided into three groups-previously diabetic (PD, n = 122), recently diagnosed diabetic (RD, n = 105) and non-diabetic (ND, n = 39). All the records were evaluated and compared among the three groups for the duration of presentation, history of co-existing medical conditions, the association of treatment given during COVID-19, and the clinical and radiographic presentations of the disease. Results: The results confirmed uncontrolled diabetes mellitus as the major risk factor for the disease. The prevalence of steroid administration was lower in our study in contrast to previous literature. The risk factors and treatment rendered during COVID-19 did not differ significantly among the three groups (p > 0.05). The findings indicate that the disease was milder and progressed more slowly in the ND group, both clinically and radiographically, and it had close resemblance to odontogenic infection. Conclusion: Patients with early CAM mimicked the odontogenic infection and were more likely to report in a dental setup. Hence, a multidisciplinary and holistic management approach is necessary.

Progress in vaccine development for infectious diseases-a Keystone Symposia report.

The COVID-19 pandemic has taught us many things, among the most important of which is that vaccines are one of the cornerstones of public health that help make modern longevity possible. While several different vaccines have been successful at stemming the morbidity and mortality associated with various infectious diseases, many pathogens/diseases remain recalcitrant to the development of effective vaccination. Recent advances in vaccine technology, immunology, structural biology, and other fields may yet yield insight that will address these diseases; they may also help improve societies' preparedness for future pandemics. On June 1-4, 2022, experts in vaccinology from academia, industry, and government convened for the Keystone symposium "Progress in Vaccine Development for Infectious Diseases" to discuss state-of-the-art technologies, recent advancements in understanding vaccine-mediated immunity, and new aspects of antigen design to aid vaccine effectiveness.

HyFlex environment: addressing students' basic psychological needs.

Active learning strategies engage students and promote student-centered learning environments. Implementing active learning in a HyFlex environment during the Fall of 2020 global pandemic was challenging. We describe the Interactive Synchronous HyFlex approach to teaching design thinking at the introductory college level and explore impacts on students' basic psychological needs, including autonomy, competence, and relatedness. Aligned with Self-Determination Theory, active learning has been shown to motivate students and increase performance and retention in science, engineering, and mathematics disciplines, among others (Freeman et al., 2014; Lo & Hew, 2019). In active environments, the predominant mode of instruction is not lecture based and it engages students through student-to-student interactions and student-to-instructor interactions. The flipped classroom is a pedagogical model in which the typical lecture and homework elements of a course are reversed. This model of instruction is ideal for our design thinking course used as a context for this study because students are challenged to learn by doing. In active learning courses, students engage in video-recorded lectures or talks, text-based materials and online quizzes, or other preparation activities before and in preparation for class (Bishop & Verleger, 2013; Lo et al., 2017; O'Flaherty & Phillips, 2015). Scheduled class meeting time is used for engagement and interaction between students informed by a social constructivist learning theory. Students challenge each other to apply what they have learned with guidance and support from the instructor.

Hesperidin: A Potential Therapeutic agent against COVID-19.

COVID-19, aka Coronavirus Disease 2019, triggered by new severe acute respiratory syndrome coronavirus-2 or SARS-CoV-2, is now a public health emergency due to its rapid spread, high transmission efficiency, and severe viral pandemic that is significantly increasing the number of patients and associated deaths. At present, no specific treatment is available that can this highly contagious virus. The unavailability of effective and specific treatments and the severity of this epidemic situation potentiate medicinal chemists' in supporting new prophylactic or therapeutic interventions against COVID-19. This study discusses the therapeutic potential of hesperidin, a traditionally used herbal medicine with an exceptional safety profile. Recent studies on hesperidin advocate its promising potential in the prevention and management of COVID 19. This paper also discussess the recent clinical studies based on the previously documented antiviral activity of hesperidin. Herein, we propose the detailed preclinical and clinical manifestations of hesperidin based on its multifaceted bioactivities to develop a novel anti-COVID-19 lead.

Extensive multifocal emphysematous osteomyelitis of spine: A rare case and a review of literature.

BACKGROUND: Emphysematous osteomyelitis (EO) is an extremely rare form of osteomyelitis which is complicated mainly by infection with gas-forming organisms. The common causative agents of this disease are mainly members of Enterobacteriaceae family, the most common are Escherichia coli and Klebsiella pneu¬moniae along with anaerobes. A total of 48 cases of EO have been reported in the literature till now globally and none have documented the isolation of Corynebacterium amycolatum. CASE PRESENTATION: We report a rare case of emphysematous osteomyelitis of the spine and pelvis due to Escherichia coli along with the isolation of Corynebacterium amycolatum from the same pus samples in two consecutive occasions in a 50-year-old female with uncontrolled diabetes mellitus, who was successively treated with antibiotics and drainage of pus. We also did a brief review of the literature of all cases reported till now. CONCLUSION: The role of Corynebacterium amycolatum in the etiology of emphysematous osteomyelitis needs to be evaluated further in future studies as we cannot completely ignore its isolation in two consecutive samples as a mere contaminant.

Value of new advanced hematological parameters in early prediction of severity of COVID-19.

INTRODUCTION: COVID-19 usually presents with upper respiratory tract infection in varying severity which can lead to sepsis. Early prediction of sepsis may reduce mortality by timely interventions. The intended purpose of this study was to determine whether the advanced parameters like the extended inflammation parameters (EIPs) can predict prognosis and early progression to sepsis as a sequel of COVID-19 infection and can be used as a screening profile. Also, to evaluate the Intensive Care Infection Score (ICIS) and the COVID-19 prognostic score and validate the scores for our population. METHODS: Prospective observational study of 50 reverse transcription- polymerase chain reaction (RT-PCR) proven admitted COVID-19 patients. The data assessed included complete blood counts (CBC) with EIP measurements, from Day 1 of admission to Day 10. The following groups were studied: noncritical (NC) and critical illness (CI) in COVID-19 positive cases, COVID negative sepsis and nonsepsis cases, and healthy volunteers for reference range. RESULTS: The parameters that showed statistically significant higher mean in CI group compared to the NC group are reactive lymphocyte number and percentage (RE-LYMPH#, RE-LYMPH%), antibody synthesizing lymphocyte number and percentage (AS-LYMPH#, AS-LYMPH%), Reactive monocyte count and percentage (RE-MONO#, RE-MONO%/M), ICIS, COVID-19 prognostic score (p-value <0.05). The AUC confirmed the diagnostic accuracy of all these parameters. From the multivariate logistic regression, the significant risk factor was RE-LYMPH# with cut-off >0.10 (p value: 0.011). CONCLUSION: The new EIP parameters, RE-MONO#, RE-MONO%/M, ICIS score and COVID-19 prognostic score are useful for early prediction of critical illness. AS-LYMPH is the most useful predictor of critical illness on multivariate analysis. RE-MONO# and RE-MONO%/M parameter are useful in distinguishing critical and noncritical non-COVID and COVID-19 patients.

Plasmon-Exciton Coupling Effect in Nanostructured Arrays for Optical Signal Amplification and SARS-CoV-2 DNA Sensing.

A surface plasmon resonance (SPR)-enhanced optical signal using a nanoslit array and acridine orange (AO) dye system at a flexible poly(dimethylsiloxane) (PDMS) substrate was achieved in this work and demonstrated a simple sensing scheme to directly detect SARS-CoV-2 nucleic acid via DNA hybridization. A simple nanoimprinting pattern transfer technique was introduced to form uniform reproducible nanoslit arrays where the dimensions of the slit array were controlled by the thickness of the gold film. The plasmon-exciton coupling effect on the optical enhancement of different dye molecules, i.e., AO, propidium iodide (PI), or dihydroethidium (DHE) attached to the nanoslit surfaces, was examined thoroughly by measuring the surface reflection and fluorescence imaging. The results indicate that the best overlap of the plasmon resonance wavelength to the excitation spectrum of AO presented the largest optical enhancement (∼57×) compared to the signal at flat gold surfaces. Based on this finding, a sensitive assay for detecting DNA hybridization was generated using the interaction of the selected SARS-CoV-2 ssDNA and dsDNA with AO to trigger the metachromatic behavior of the dye at the nanoarray surfaces. We found strong optical signal amplification on the formation of acridine-ssDNA complexes and a quenched signal upon hybridization to the complementary target DNA (ct-DNA) along with a blue shift in the fluorescence of AO-dsDNAs. A quantitative evaluation of the ct-DNA concentration in a range of 100-0.08 nM using both the reflection and emission imaging signals demonstrated two linear regimes with a lowest detection limit of 0.21 nM. The sensing method showed high sensitivity and distinguished signals from 1-, 2-, and 3-base mismatched DNA targets, as well as high stability and reusability. This approach toward enhancing optical signal for DNA sensing offers promise in a general, rapid, and direct vision detection method for nucleic acid analytes.

Characterizing intentions to receive the COVID-19 vaccine among the general population in British Columbia based on their future intentions towards the seasonal influenza vaccine.

Introduction: This study assessed the relationship between intention to receive a COVID-19 vaccine and intention to receive a seasonal influenza vaccine, as well as how intention to receive a COVID-19 vaccine has changed during the pandemic. Methods: Residents of British Columbia aged 25-69 years were invited to complete an online cross-sectional survey from August 2020 - March 2021. Mixed-effects logistic regression models assessed the relationship between intention to receive a COVID-19 vaccine and intention to receive the seasonal influenza vaccine. A generalized additive mixed model was used to investigate changes in COVID-19 vaccine intention during the pandemic (August 2020-March 2021). The relationship between intention to receive a COVID-19 vaccine and retrospective overall perceived value of vaccines prior to and during the pandemic was also considered. Results: Of 6,333 participants, 80.2 % of participants were 'somewhat or very likely' to receive a COVID-19 vaccine and 69 % of participants reported intending to receive a seasonal influenza vaccine. In multivariable modeling, intention to receive a COVID-19 vaccine was strongly associated with intention to receive a seasonal influenza vaccine (aOR = 4.25, 95 %CI 3.33-5.43). Intention to receive a COVID-19 vaccine increased over the study period (p < 0.0001), with the largest increase coinciding with the announcement of forthcoming approvals of COVID-19 vaccines in November 2020 (aOR = 1.45, 95 %CI 1.11-1.91). Conclusion: Intention to receive the COVID-19 vaccine was associated seasonal influenza vaccine intention, which is an important relationship to measure for implementation and future planning of COVID-19 booster doses. We found an increase in the intention to receive a COVID-19 vaccine after public announcements of forthcoming vaccine approval, which highlights the importance of ongoing monitoring and reporting of vaccine uptake, and the potential impact of emerging vaccine safety and efficacy information may have on vaccine acceptance.

An evocative approach to utilize castoff PPE kits (Covid-19): Sustainable approach

Severe acute respiratory syndrome-corona virus-2 (SARS-CoV-2) responsible for causing Covid-19 has taken millions of life. Globally, combating COVID-19 pandemic is the primary aim of all the researchers working in any field of study viz. pharmaceutical, chemistry, physics, economics etc. One of the warrior against Covid-19 is Personal Protection Equipment (PPE), which is an indispensable requirement for healthcare workers and others working closely with Covid-19 patients. The kits are providing protection from direct infection. They are made of different types of plastics and their disposal is going to be a serious menace, if not taken care of properly. The disposal of PPE is being done as per the guidelines provided by World Health Organization. However, the final fate of polymer is yet to be decided. This study is critical suggestive approach to value add the disposed PPE kits by converting them to bio-oil. In addition to environmental advantages, it could also minimize the dependency on non-renewable fossil fuels.

Examination of national survey data regarding academic foundation training during the COVID-19 pandemic second wave.

Aim: We aimed to examine the effect of the second wave of the COVID-19 pandemic on Academic Foundation Programme (AFP) trainees. Methods: A voluntary, anonymous questionnaire was circulated to all UK AFP doctors. Data were collected from February 2021 to April 2021 then analysed. Results: Of a possible 1,096 trainees, 149 responded to the survey: 48% of respondents were at least partially redeployed, 31% lost academic time and 47% had projects cancelled or postponed. In free-text responses, despite some research opportunities, frustration at lost research time and opportunities were common themes. Trainees also highlighted communication and wellbeing issues. Conclusion: These results demonstrate that the overall effect of COVID-19 on this cohort cannot be underestimated. We propose that a series of measures are implemented to protect and support academic trainees. We hope that these measures would encourage high-quality academic output and help secure the development of the academic clinical workforce.

Barriers and enablers of breastfeeding in mother-newborn dyads in institutional settings during the COVID-19 pandemic: A qualitative study across seven government hospitals of Delhi, India.

Introduction: The COVID-19 pandemic disrupted newborn care and breastfeeding practices across most healthcare facilities. We undertook this study to explore the barriers and enablers for newborn care and breastfeeding practices in hospitals in Delhi, India for recently delivered mother (RDM)-newborn dyads during the first wave of the COVID-19 pandemic (2020) and inductively design a "pathway of impaction" for informing mitigatory initiatives during the current and future pandemics, at least in the initial months. Materials and methods: We used an exploratory descriptive design (qualitative research method) and collected information from seven leading public health facilities in Delhi, India. We conducted separate interviews with the head and senior faculty from the Departments of Pediatrics/Neonatology (n = 12) and Obstetrics (n = 7), resident doctors (n = 14), nurses (labor room/maternity ward; n = 13), and RDMs (n = 45) across three profiles: (a) COVID-19-negative RDM with healthy newborn (n = 18), (b) COVID-19-positive RDM with healthy newborn (n = 19), and (c) COVID-19 positive RDM with sick newborn needing intensive care (n = 8) along with their care-giving family members (n = 39). We analyzed the data using grounded theory as the method and phenomenology as the philosophy of our research. Results: Anxiety among clients and providers, evolving evidence and advisories, separation of the COVID-positive RDM from her newborn at birth, providers' tendency to minimize contact duration and frequency with COVID-positive mothers, compromised counseling on breastfeeding, logistic difficulties in expression and transportation of COVID-positive mother's milk to her baby in the nursery, COVID restrictions, staff shortage and unavailable family support in wards and nursery, and inadequate infrastructure were identified as major barriers. Keeping the RDM-newborn together, harmonization of standard operating procedures between professional associations and within and between departments, strategic mobilization of resources, optimization of human resources, strengthening client-provider interaction, risk triaging, leveraging technology, and leadership-in-crisis-situations were notable enablers. Conclusion: The separation of the RDM and newborn led to a cascade of disruptions to newborn care and breastfeeding practices in the study institutions. Separating the newborn from the mother should be avoided during public health emergencies unless there is robust evidence favoring the same; routine institutional practices should be family centered.

GeoCovaxTweets: COVID-19 Vaccines and Vaccination-specific Global Geotagged Twitter Conversations (preprint)

Social media platforms provide actionable information during crises and pandemic outbreaks. The COVID-19 pandemic has imposed a chronic public health crisis worldwide, with experts considering vaccines as the ultimate prevention to achieve herd immunity against the virus. A proportion of people may turn to social media platforms to oppose vaccines and vaccination, hindering government efforts to eradicate the virus. This paper presents the COVID-19 vaccines and vaccination-specific global geotagged tweets dataset, GeoCovaxTweets, that contains more than 1.8 million tweets, with location information and longer temporal coverage, originating from 233 countries and territories between January 2020 and November 2022. The paper discusses the dataset's curation method and how it can be re-created locally, and later explores the dataset through multiple tweets distributions and briefly discusses its potential use cases. We anticipate that the dataset will assist the researchers in the crisis computing domain to explore the conversational dynamics of COVID-19 vaccines and vaccination Twitter discourse through numerous spatial and temporal dimensions concerning trends, shifts in opinions, misinformation, and anti-vaccination campaigns.

Clinical Virology and Effect of Vaccination and Monoclonal Antibodies against SARS-CoV-2 Omicron Sub variant BF.7 (BA.5.2.1.7) : A systematic review (preprint)

Since its identification in late 2019 the novel coronavirus, severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) In Wuhan, China, by the World Health Organization (WHO), which cause the coronavirus disease 2019, it is rapidly spreading, resulting in the global pandemic. As of 19 December 2022, more than 64 million confirmed cases and 6,645,812 deaths have been reported across the world. Over time, the SARS-CoV-2 acquired genetic mutations resulting in multiple types of SARS-CoV-2 variants and subvariants that have been confirmed. The Omicron (B.1.1.529) variant was identified later in November 2021, with enhanced immune escape and was followed with various sublineages due to mutations in the spike protein of the SARS-CoV-2. However, rapid resurge in COVID-19 reports by Omicron subvariant BF.7(BA.2.75.2) in China and other countries, alarming global threat. The present systematic review was conducted using "Omicron" AND "BA.5.2.1.7" OR "BF.7" in Pub Med, Google Scholar and MedRXiv database and grey literature from the authentic database and websites . We have identified a total of 14 published studies. We have reviewed all the eligible available studies to understand the viral mutations, factors associated with increase in the reports of COVID-19 cases in china and across the world and to evaluate the effectiveness of vaccination and monoclonal antibodies against BF.7 variant

Title of the article: Current Review of the SARS-CoV-2 Omicron Subvariant BF.7 (BA.5.2.1.7) Virology and Preventing Strategies. (preprint)

Since its identification in late 2019 the novel coronavirus, severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) In Wuhan, China, by the World Health Organization (WHO), which cause the coronavirus disease 2019, it is rapidly spreading, resulting in the global pandemic. As of 19 December 2022, a total of 64 million (649,038,437) confirmed cases including 6,645,812 deaths have been reported across the world. Over time, the SARS-CoV-2 acquired genetic mutations resulting in multiple types of SARS-CoV-2 variants and subvariants that have been confirmed. The Omicron (B.1.1.529) variant was identified later in November 2021, with enhanced immune escape and was followed with various sublineages BA.1, BA.2, BA.3, BA.4 and BA.5 and Other sublineages BQ.1, BQ.11, BF.7, BA.2.75, and XBB due to mutations in the spike protein of the SARS-CoV-2. In response to the current surge in the COVID-19 reports by Omicron subvariant BF.7 also known as BA.2.75.2, in China and other countries, triggering global alarm. The present review was conducted to understand the virology, factors associated with increased transmissibility with BF.7 and possible urgent preventing strategies to be taken to curtail the novel omicron variants outbreak across the world.

Congenital cardiac liver cirrhosis with combined hepatocellular-cholangiocarcinoma-a case report.

Background: Cardiac liver cirrhosis secondary to Fontan procedure has been associated with hepatocellular carcinoma at a younger age. However, Fontan associated liver disease and combined hepatocellular-cholangiocarcinoma has not been previously reported. Combined hepatocellular-cholangiocarcinoma is a rare cancer that accounts for 2-5% of primary liver tumors and poses significant diagnostic and treatment challenges. This case highlights these needs and potential screening and treatment considerations. Herein we describe a case of combined hepatocellular-cholangiocarcinoma in a patient with autism, congenital heart disease, and Fontan procedure. Case Description: The patient is a 27-year-old male who presented with a liver mass detected on MRI performed in the context of a rising alpha-fetoprotein during a screening visit. Biopsy of the mass revealed a combined hepatocellular-cholangiocarcinoma which was staged as localized. Due to the COVID-19 pandemic and subsequent halt of all elective surgeries, the patient received local therapy with chemoembolization followed by pembrolizumab. The disease progressed though, and therapy was changed to gemcitabine plus cisplatin. Patient received 2 cycles of therapy, after which he and his family decided to transfer medical care to Memorial Sloan Kettering. Next generation sequencing of the tumor revealed TP53 and FGFR2 mutations. By then patient was also found to have lung metastasis. To help address the hepatocellular carcinoma, lenvatinib was added. Patient had sustainable disease control for about a year, yet eventually developed thrombocytopenia complicated by an episode of gastrointestinal bleeding. With a worsening performance status, adverse events of the treatment, and recurrent hospitalizations, a goals of care discussion with his family led to the discontinuation of active cancer therapy and patient was started on best supportive care. Patient remained in active follow-up until the time of this report and passed away less than a year from initiating best supportive care alone. Conclusions: This challenging case raises awareness towards screening and monitoring all patients with Fontan procedure for Fontan associated liver disease and liver cancers, including combined hepatocellular-cholangiocarcinoma. To the best of our knowledge, this is the first description of combined hepatocellular-cholangiocarcinoma occurring in the context of cardiac cirrhosis. The management difficulties that led to altering the goals of care, is another reminder of the dynamic nature of the care oncologists would provide.