Recurrent Liver Abscess in a Non-Toxic Patient

Introduction: Liver abscesses are caused by direct spread from peritonitis, biliary tract infection or via hematogenous seeding from a distant source. Most are polymicrobial, however Escherichia coli and Klebsiella pneumoniae are the most common offending pathogens. Patients usually present with pain, fever, and clinical signs of infection. We describe a case of spontaneous liver abscess in a non-toxic patient that recurred 10 years after a previous abscess. Case Description/Methods: A 73-year-old-man with a history of type 2 diabetes mellitus, hypertension, CAD status post CABG and PCI 3 years ago, and abdominal aortic aneurysm status post endovascular aneurysm repair presented with 2 weeks of dark urine. After receiving his COVID-19 booster and influenza vaccinations, he developed flu-like symptoms with a self-resolving fever of 101.8degreeF. He had dark amber urine without dysuria or hematuria. Later, he experienced generalized weakness and decreased oral intake. Outpatient labs showed elevated liver function tests, and he was told to present to the ED. On arrival, he was afebrile with stable vitals. Physical exam was unremarkable. Laboratory evaluation showed a hemoglobin of 11.7 g/dL, sodium of 133 mEq/L, creatinine of 1.4 mg/dL, aspartate aminotransferase of 117 U/L, alanine aminotransferase of 212 U/L, alkaline phosphatase of 825 U/L, total bilirubin of 4.1 mg/dL, and direct bilirubin of 2.1 mg/dL. Triple-phase CT showed a 2.8 cm mass in the right liver lobe with linear enhancement. Ultrasound showed mixed echogenicity measuring 3.6 x 2.9 x 3.3 cm in segment 8 of the liver. On further evaluation, patient had an E. coli abscess diagnosed 10 years prior, managed with antibiotics and drainage. At that time, the abscess was within the right inferior liver lobe, similar to his current abscess. LFTs downtrended. Abscess was aspirated, with culture growing oxidase negative, gramnegative rods, likely E. coli. Patient started on ceftriaxone and metronidazole, to undergo colonoscopy as an outpatient and rule out colonic bacterial translocation. Discussion(s): Pyogenic liver abscess can result in significant morbidity and mortality because of worsening infection and sepsis. Abscesses occur because of spread from adjacent infection or after recent surgeries. Recurrence is very rare. Here, we describe a very unusual case of a pyogenic liver abscess growing E. coli in a non-toxic patient, with the same location and causative organism as an abscess managed 10 years prior. (Figure Presented).

Anxiety and Depression Symptoms Among Young U.S. Essential Workers During the COVID-19 Pandemic.

OBJECTIVE: Emerging cross-sectional data indicate that essential workers in the COVID-19 era face increased mental health risks. This study longitudinally examined clinical symptoms of generalized anxiety disorder, depression, and posttraumatic stress disorder (PTSD) among U.S. essential workers, including health care workers and workers in indispensable occupations such as manufacturing, food industry, construction, transportation, hospitality, and emergency services, during the COVID-19 pandemic. The authors anticipated high symptom levels and greater symptom severity among women versus men and among younger adults compared with older adults. Analyses also explored the association between COVID-19 vaccination status and clinical symptoms. METHODS: This four-wave online survey study assessed clinical symptoms in a convenience sample of 4,136 essential workers at baseline and 14, 30, and 90 days between August and December 2021. Symptoms of anxiety, depression, and PTSD were measured with the Generalized Anxiety Disorder-7, Patient Health Questionnaire-9, and Primary Care PTSD Screen instruments, respectively. RESULTS: At every time point, 74%-78% of respondents reported symptoms of anxiety and depression, which were highest among younger adults (ages 18-22 years), females, and transgender respondents. Vaccinated participants had slightly higher symptom levels than unvaccinated respondents. Rates of clinical symptoms did not change significantly over time. CONCLUSIONS: Essential workers consistently reported symptoms of generalized anxiety, depression, or PTSD, especially younger adult, female, and transgender participants. The overwhelming and unprecedented nature of the COVID-19 pandemic underscores the need to offer mental health care to essential workers, especially those in these subgroups. Employers and administrators should support and proactively encourage employees to access care when needed.

The Distribution of Work-Life Integration against COVID-19 and its Implications: Focusing on Remote Work in Switzerland

Purpose: This study aims to explore the distribution of work-life integration against COVID-19 and its Implications by analyzing remote work in Switzerland. Research design, data and methodology: The study performed literature review and descriptive analyses using various data such as perception surveys, statistics, and related documents. Results: The infectious disease was a turning point for many people in Switzerland by changing where and how people want to live. Since the COVID-19 crisis demonstrated that disease could be spread by proximity, negative perception about urban areas expanded, and rural areas are increasingly preferred due to fresh and clean air and a more ecological lifestyle. In addition, increased remote work, a change brought about by COVID-19, has subsequently led to changes in household habits and needs. Distance from work is no longer an important factor when someone chooses where to live. A trend is now emerging where households wanting to improve the quality of life leave the city center and move to the suburbs. Conclusions: Paradoxically, such trend accelerated by the COVID-19 crisis has an unintendedly positive impact on the distribution of work-life integration across society while providing more flexibility in terms of place and time management and lowering the burden on roads and infrastructure © Copyright: The Author(s)

Association between Receipt of COVID-19, Influenza, and Pneumococcal Vaccination

Background. Whether receipt of COVID-19 vaccine associates with receipt of other routinely-recommended adult vaccines such as, influenza and pneumococcal vaccines is not well described. We evaluated this relationship in a population of adults who were hospitalized for acute respiratory infection (ARI). *Odds ratio describing odds of receiving at least one COVID-19 vaccine (vs not) by influenza vaccination status adjusted for race, employment status, chronic cardiac diseases, cancer, solid organ transplant, and chronic kidney disease. **Odds ratio describing odds of receiving at least one COVID-19 vaccine (vs not) by pneumococcal vaccination status adjusted for race and chronic kidney disease. Methods. We enrolled adults (>= 18 years of age) who were hospitalized at Emory University Hospital and Emory University Hospital Midtown with symptoms consistent with ARI. Participants were interviewed and medical records ed to gather demographic information, including social behaviors during the pandemic, medical history, and prior vaccination history (i.e., COVID-19, influenza, and pneumococcal). Using two separate logistic regression analyses, we determined the association between i) receipt of influenza vaccine in the prior year among adults >= 18 years and ii) receipt of any pneumococcal vaccine in the prior 5 years among adults >= 65 years on the receipt of at least one COVID-19 vaccine>= 14 days prior to admission. Adjusted models included demographic information (e.g., age, sex, race/ethnicity, employment status), social behaviors, and history of chronic medical conditions. Results. Overall, 1056 participants were enrolled and had vaccination records available. Of whom, 509/1056 (48.2%) had received at least one dose of COVID-19 vaccine. Adults >= 18 years who received influenza vaccine were more likely to have received >=1 dose of COVID-19 vaccine compared to those who did not (267/373 [71.6%] vs 242/683 [35.4%] P=< .0001;adjusted odds ratio [OR]: 3.3 [95%CI: 2.4, 4.4]). Similarly, adults >=65 years who received pneumococcal vaccine were more likely to have received >= 1 dose of COVID-19 vaccine compared to those who did not (195/257 [75.9%] vs 41/84 [48.8%] P=< .0001;adjusted odds ratio [OR]: 3.0 [95% CI: 1.8, 5.1]). Conclusion. In this study of adults hospitalized for ARI, receipt of influenza and pneumococcal vaccination strongly correlated with receipt of COVID-19 vaccination. Continued efforts are needed to reach adults who remain hesitant to not only receive COVID-19 vaccines, but also other vaccines that lessen the burden of respiratory illness.

Social Risk Factors for COVID-19-Related Hospitalizations in Adults

Background. During the COVID-19 pandemic, social interventions such as social distancing and mask wearing have been encouraged. Social risk factors for SARS-CoV-2 infection and subsequent hospitalization remain uncertain. Methods. Adult patients were eligible if admitted to Emory University Hospital or Emory University Hospital Midtown with acute respiratory infection (ARI) symptoms (<= 14 days) or an admitting ARI diagnosis from May 2021 - Feb 2022. After enrollment, an in-depth interview identified demographic and social factors (e.g., employment status, smoking history, alcohol use), household characteristics, and pandemic social behaviors. All patients were tested for SARS-CoV-2 using PCR. We evaluated whether these demographic and social factors were related to a positive SARS-CoV-2 test upon admission to hospital with ARI using a logistic regression model. Results. 1141 subjects were enrolled and had SARS-CoV-2 PCR results available (700 positive and 441 negative). The median age was greater in the SARS-CoV-2 negative cohort than in the positive cohort (60 and 53 years, respectively;P< .0001). Those who tested positive were more likely to have had at least some college education compared to those who tested negative (64.3% vs 52.3%, P< .0001;adjusted odds ratio [aOR]: 1.4 [95%CI: 1.1, 2.0]). Compared to those who tested negative, those who were SARS-CoV-2 positive were also more likely to be employed (48.9% vs 26.5%, P< .0001;aOR: 1.7 [95%CI: 1.1, 2.3]), have children 5-17 yo at home (27.6% vs 17.9%, P=.0002;aOR: 1.5 [95%CI: 1.1, 2.1]). Those with COVID-19 were less likely to receive home healthcare (6.2% vs 13.3%, P< .0001;aOR: 0.5 [95%CI: 0.4, 0.9]) and to be a current or previous smoker (7.6% vs 17.7%, P< .0001;aOR: 0.3 [95%CI: 0.2, 0.5]). Conclusion. Among adults admitted to the hospital for ARI, those who tested positive for SARS-CoV-2 were typically younger, more likely to care for school-aged children, more likely to work outside the home, but were less likely to receive home healthcare or smoke. Personal and public health strategies to mitigate COVID-19 should take into consideration modifiable social risk factors.

Prior SARS-CoV-2 infection and risk of subsequent COVID-19-related hospitalization: a test negative design

Background. Studies show that past SARS-CoV-2 infection provides a protective immune response against subsequent COVID-19, but the degree of protection from prior infection has not been determined. History of previous SARS-COV-2 Infection and Current SARS-COV-2 Infection Status at Admission. *Adjusted for chronic respiratory disease and prior COVID-19 vaccination Methods. From May 2021 through Feb 2022, adults (>= 18 years of age) hospitalized at Emory University Hospital and Emory University Hospital Midtown with acute respiratory infection (ARI) symptoms, who were PCR tested for SARS-CoV-2 were enrolled. A prior history of SARS-CoV-2 infection was obtained from patient interview and medical record review. Previous infection was defined as a self-reported prior SARS-CoV-2 infection or previous evidence of a positive SARS-CoV-2 PCR test >= 90 days before ARI hospital admission. We performed a test negative design to evaluate the protection provided by prior SARS-CoV-2 infection against subsequent COVID-19-related hospitalization. Effectiveness was determined using logistic regression analysis adjusted for patient sociodemographic and clinical characteristics and COVID-19 vaccination status. Results. Of 1152 adults hospitalized for ARI, 704/1152 (61%) were SARS-CoV-2 positive. 96/1152 (8%) had a prior SARS-CoV-2 infection before hospital admission. Patients with a previous history of SARS-CoV-2 infection were less likely to test positive for SARS-CoV-2 upon admission for ARI compared to those who did not have evidence of prior infection (31/96 [32%] vs 673/1056 [64%];adjustedOR: 0.25 [0.15, 0.41] (Table). Conclusion. Reinfections represented a small proportion (< 10%) of COVID-19-related hospitalizations. Prior SARS-CoV-2 infection provided meaningful protection against subsequent COVID-19-related hospitalization. The durability of this infection-induced immunity, variant-specific estimates, and the additive impact of vaccination are needed to further elucidate these findings.

A QUALITY INITIATIVE TO INCREASE HOSPICE REFERRALS FOR STARS PATIENTS DURING THE SECOND COVID SURGE

Background: CMS uses the Overall Hospital Quality Star Rating program to stratify hospitals based on specific quality criteria (e.g., 30-day readmissions of older adults with pneumonia). "STARS patients” experience more readmissions, longer LOS and often have more complex discharge plans. During the second surge of COVID we implemented a program to increase hospice referrals through early identification and implementation of goals of care (GOC) conversations. Methods: Electronic Medical Records reviewed for STARS patients from pre- (1/2019-7/2020) and post (3/2021–2/2022) program implementation. Location: 2 community-based hospitals. Data collected: demographics, hospital outcomes, discharge disposition. Data compared with Student's t tests and Chi square. Results: 459 patients, 177 pre-program and 282 post-program were included. Groups were similar in age (83.0 vs 83.6), LACE score (13.0 vs 12.8), principal diagnoses (PNA: 41.5% vs 46.0%, HF/COPD/AMI: 58.5% vs 54.0%), and mortality (3.5 vs. 4.0%). LOS increased 4.9 days vs. 6.1 days (p < 0.01), readmission rates unchanged: 12.6% vs 13.0% (p=0.90). GOC conversations increased, 48.6% to 75.0% (p < 0.01), DNR from 24% to 44% (p < 0.01), and comfort measures from 0.5% to 5% (p < 0.01). Hospice referrals increased from 0.5% to 11.2% (p < 0.01). Discussion: Early identification of STARS patients increased GOC conversations, DNR, comfort measures and hospice referral. Patients across time periods were similar in age, LACE and admitting diagnoses. LOS increased by a day, likely reflecting time needed to arrange discharge disposition. Increased hospice at end-of-life is associated with better quality care and patient/family satisfaction. This program may be adapted to larger, academic medical centers within the health system.

The Distribution of Technological Innovation & Environmental Policy against COVID-19: Perspectives and Challenges

Purpose: This article aims to explore the distribution of technological innovation and environmental policy challenges to respond to COVID-19. The study also attempts to tackle a paradigm shift in science and technology policies against the pandemic and a desirable direction for environmental policies. The COVID-19 pandemic has been the one that rapidly changed global people’s lifestyle. For the spread of a terrible infectious disease could not be avoided, regardless of a highly industrialized society. Research design, data and methodology: This study basically employs a qualitative approach as a methodology. This study is based on the fact that environmental pollution, various natural disasters continuously occur, and there are many unforeseeable parts, despite remarkable development of scientific technology, and that the circumstances are becoming more complex. Results: This study noted that scientific technology civilization formed due to industrial revolutions can deteriorate environment and increase environmental threat factors. As an alternative to this, this study investigates alternative discussions on how the 4th Industrial Revolution can help scientific technology and human environment to harmoniously coexist and develop. Conclusions: It implies that this study focuses on the possibility of overcoming this crisis through science and technology innovation, although mankind is in crisis of COVID-19 due to excessive human development. © This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://Creativecommons.org/licenses/by-nc/4.0/) which permits unrestricted noncommercial use, distribution, and reproduction in any medium, provided the original work is properly cited

Evaluating the Endothelial Impairments in COVID-19 Patients Using Near-Infrared Spectroscopy: the HEMOCOVID-19 trial

HEMOCOVID-19 is a multi-center trial aiming to assess the microvascular and endothelial health of severe COVID-19 patients in the intensive care using near-infrared spectroscopy. Here, we present the preliminary results, showing that peripheral microcirculatory alterations are associated with the severity of acute respiratory distress syndrome. © 2022 The Author(s).

Changing features of liver injury in COVID-19 patients: Impacts of Infection with the SARS-CoV-2 Delta (B.1.617.2) variants

Objectives: In many studies, abnormal liver function test has been reported in more than half of the COVID-19 patients. However, it is not known for the liver involvement of the virus according to the strain. We investigated the features of liver injury in the COVID-19 patients with the SARS-CoV-2 Delta (B.1.617.2) variants. Materials and Methods: We performed a retrospective study that included 375 patients between 1 February 2020 and 31 November 2020 (pre-Delta period (PDP) group) and 125 patients between 1 August 2021 and 31 August 2021 (Delta period (DP) group) hospitalized for COVID-19 at National Medical Center in Korea. Initial liver injury was defined as ALT or AST levels ≥ 3 9 upper limit of normal (ULN), or ALP or total bilirubin ≥ 2 9 ULN within 3 days from admission. Severe COVID-19 was defined as respiration rate ≥ 30, oxygen saturation ≤ 93%, or oxygen requirement with pneumonia. Results: Of 500 patients with COVID-19, 301 (60.2%) had abnormal liver test and 43 (8.6%) had liver injury within 3 days. The patients with abnormal liver test were similar in both groups. (58.4%vs60.8% P = 0.635). On the other hand, the DP group had a significantly higher proportion of liver injury than the PDP group (15.2% [n = 19]vs.6.4%[n = 24], P = 0.002). The DP group (Odds ratio (OR), 2.539;95% confidence interval (CI), 1.211-5.325;P = 0.014), patients with pneumonia involvement over 50% of lung field at admission (OR, 4.982;95% CI, 1.966-12.625;P = 0.001), younger patients (OR,0.963;95%CI,0.940-0.988;P = 0.003), lower creatinine at admission (OR,0.132;95%CI,0.028-0.631;P = 0.011), higher CRP at admission (OR,1.009;95%CI,1.003-1.015;P = 0.002) were independently associated with liver injury. During hospitalization, 164 patients had severe COVID-19. The DP group and initial liver injury were high odds of progressing to severe COVID-19 (OR 2.867;95%CI 1.244-6.608, and OR 3.229;95% CI 1.131-9.219, respectively). Conclusion: Initial liver injury is more common in COVID-19 patients with Delta variants. Also, Delta variants is associated with poor clinical outcomes. Therefore, careful monitoring in COVID-19 patients with Delta variants is needed.

Evaluation and Comparative Analysis of Semantic Web-Based Strategies for Enhancing Educational System Development

Educators have been calling for reform for a decade. Recent technical breakthroughs have led to various improvements in the semantic web-based education system. After last year's COVID-19 outbreak, development quickened. Many countries and educational systems now concentrate on providing students with online education, which differs greatly from traditional classroom education. Online education allows students to learn at their own pace. As a consequence, education has become more dynamic. In the educational system, this changing nature makes user demands difficult to identify. Many instructors suggest using machine learning, artificial intelligence, or ontology to improve traditional teaching methods. Due to the lack of survey studies examining and comparing all of the researcher's semantic web-based teaching methodologies, the authors decided to conduct this survey. This paper's goal is to analyse all available possibilities for semantic web-based education systems that enable new researchers to develop their knowledge.

ACUTE MYOCARDIAL INFARCTION WITH VESSEL OCCLUSION IN A YOUNG ADULT WITH A MECHANICAL AORTIC VALVE

Background: The occurrence of myocardial infarction (MI) with coronary vessel occlusion in an otherwise young, healthy adult with a mechanical aortic valve is rare. Case: A 25-year-old male with a history of congenital AS status-post mechanical aortic valve replacement presented to the hospital with an acute MI due to thromboembolism due to subtherapeutic INR. The patient developed ventricular fibrillation en route to the emergency department. Return of spontaneous circulation was achieved after one round of CPR with synchronized cardioversion. On admission, labs were significant for high sensitivity troponin >27,000 x 3, BNP 23, INR 1.8. The patient was positive for COVID-19 but was asymptomatic. EKG showed ST elevations in leads I, AVL with reciprocal depressions in leads II, III and AVF. The patient underwent an emergent left heart catheterization which showed a normally functioning mechanical aortic valve and 100% occlusion of the mid LAD. After several rounds of balloon angioplasty, a thrombus was aspirated, mechanical thrombectomy was performed and a drug-eluding stent was deployed under IVUS guidance with restoration of TIMI 3 flow. A transthoracic echocardiogram following PCI showed an ejection fraction of 40% with anterior wall hypokinesis and mean aortic valve gradient of 10mmHg. The patient followed up in clinic two months later and was doing well. Decision-making: The effect of valvular heart disease on heart failure and cardiogenic shock is well studied. However, the occurrence of myocardial infarction due to thromboembolism in young patients with a subtherapeutic INR in the setting of mechanical aortic valve is not well described in literature. Conclusion: This case highlights both the importance of compliance with anticoagulation in patients with mechanical valves and a rare cause of myocardial infarction;i.e., non-compliance with anticoagulation in the setting of mechanical aortic valve. In addition, COVID-19 has been well established as a prothrombotic disease process, adding to the plot of this unusual case.

Lockdown on Peace? COVID-19's Impact on Women Peacebuilders

COVID-19 threatens to slow progress on the implementation of peace agreements, and reverse hard-won gains of women peacebuilders' work towards holistic, gender-equal peace, rooted in human security. Through an analysis of in-depth interviews from a purposive sample of women peacebuilders in Colombia, South Sudan, the Philippines, and Ukraine, this article contributes to a greater understanding of the pandemic's impact on women's peace activism, as these peacebuilders adapted to emerging realities and became first responders. We argue that the pandemic has deepened the marginalization of women peacebuilders from formal peace processes, possibly to detriment of both immediate recovery and long-term peacebuilding.

The Distribution of Mismatches in Government Policy Response against COVID-19 in Terms of Risk Communication and its Implications*

Purpose: This study aims to explore the effects of government's value intervention messages on the prevention and control of infectious disease in the risk communication process in terms of goveremnt policy response to COVID-19 from the mismatch message perspective, and draws the relevant implicaitons. Due to the infeciton spread, some people point out that depression caused by COVID-19 is because of wrong signals of the government and infectious disease prevention and control authorities, namely value intervention messsages. Research design, data and methodology: This study examined the epidcmic situation through message deails regarding the effects of government's mismatch messages on prevention and control of infectious disease and the resulting phenomena. Results: People's lives are under serious threat overall, so the declaration of the end of COVID-19 is almost impossible unlike MERS. Economic downturn due to foreced prevention and control regulaitons of COVID-19, mistruct of social distancing, fatigue on mismatch messages, and moral hazard on the awareness of prevention and control of infectious disease are negative phenomena to risk communiaiton on COVID-19. Conclusions: This study investigated the government authorities' policy sending wrong signals due to mismatching of the reality at this point in time for infectious disease prevention and control from the risk communicaiton perspectrive. © 2021 The Author(s). All Rights Reserved.

Therapeutic exosomes for various human diseases: Special issue of BMB Reports in 2022

Extracellular vesicles (EVs), especially exosomes, are cell-derived nanoparticles harboring various cellular components such as RNAs, lipids, and proteins for intercellular communication. Roles of EVs as intercellular communicators have been extensively studied in the last few decades, especially under various pathological conditions. Deciphering the message in EVs isolated from biological fluids of patients can provide valuable information not only for disease diagnosis, but also for disease monitoring or treatment responses. EVs are also attractive treatment modality and drug delivery system with favorable properties of biocompatibility, selective tropism, and stability. Stem cell-derived naive EVs have been tested for their regenerative or immunomodulatory effects in numerous preclinical and clinical studies. This so-called "cell-free cell therapy" is supported by the idea that most therapeutic actions of conventional cell therapy are mediated by paracrine action of EVs released from stem cells. In that sense, immune cell-derived EVs are regarded as a reasonable option for cancer immunotherapy. Such therapeutic effect of EVs can be dramatically augmented by incorporating active pharmaceutical ingredients (APIs) to make engineered exosomes as "Trojan Horses". Biomimetic EVs or cell-derived nanovesicles can be generated through various physicochemical methos such as serial extrusion. They provide alternative options due to their high productivity and relatively easy purification. In this special issue, therapeutic applications of naive or engineered EVs are discussed in various human diseases including cardiovascular diseases, renal disorders, neurological diseases, cancers, and infectious diseases focusing on COVID-19.

HEMOCOVID-19 Study: An International Clinical Study to Evaluate Microvascular and Endothelial Impairments in Severe COVID-19 Patients Using Near-Infrared Spectroscopy

We present the HEMOCOVID-19 study spanning four countries and eight hospitals where near-infrared spectroscopy is utilized to evaluate microvascular and endothelial health of severe COVID-19 patients at the intensive care. © 2021 SPIE. All rights reserved.

Development of educational environment to improve efficiency of online education on control systems

In recent years, lectures on control systems have focused on hands-on experience using actual control equipment than before. However, the online education triggered compulsorily by the Covid-19 pandemic poses has restricted the construction of an education environment for hands-on experience. In this study, we proposed an economical and compact experimental environment for control education that enables hands-on experience even through online education. To this end, we utilized a light weight rapid control prototyping (LW-RCP), which is a lab-built RCP environment, and the environment was constructed using 3D printing. In the proposed environment, LW-RCP enabled students to focus on the learning and application of related control concepts, without the inconvenience of manual C-coding and the possibility of debugging errors. In addition, the proposed control equipment, which was manufactured using 3D printing, is an inexpensive equipment with a sufficiently small size that can be placed on a desk. Owing to the low cost and small size of the proposed environment, each student can have his/her own experimental equipment, which will enable a hands-on experience even through online education. Online education is expected to expand more and more in the future as it exhibits various advantages and potentials from traditional face-to-face classes. The proposed educational environment is expected to play a meaningful role in satisfying the demands of hands-on experience for control-related lectures. © ICROS 2021.

A RARE AND FATAL CASE OF ACUTE FULMINANT LIVER FAILURE INDUCED BY COVID-19 INFECTION

TOPIC: Chest Infections TYPE: Medical Student/Resident Case Reports INTRODUCTION: The SARS-CoV-2 virus, in accordance with the name designated to it by viral taxonomists, primarily causes severe acute respiratory distress syndrome. A challenge of this novel coronavirus has been discovering and preventing its indiscriminate and catastrophic effect on other organs. We present a rare case of the SARS-CoV-2 virus precipitating fulminant hepatic failure in a patient without respiratory symptoms or prior evidence of liver disease. CASE PRESENTATION: A 60 year-old female with history of atrial fibrillation, emphysema, and renal cell carcinoma status post left radical nephrectomy presented with weakness and fatigue. On day 12 of admission, she became hemodynamically unstable due to atrial fibrillation with rapid ventricular response, requiring electrical cardioversion, emergent intubation and transfer to ICU. Repeat SARS-CoV-2 PCR test was positive, although negative on admission. Dexamethasone, vancomycin and piperacillin-tazobactam were initiated, and one dose of Remdesivir was given after an unremarkable liver panel. No further Remdesivir was given, as six hours later, the patient had abrupt worsening of her liver function tests, with eventual peak AST of 2610 IU/L, ALT of 14860 IU/L and INR of 9.12. Fibrinogen was 136 mg/dL, ammonia 290 mcmol/L, lactate 11.51 mmol/L and IL-6 143.9 pg/mL. Viral causes for acute hepatitis were negative and abdominal ultrasound was unremarkable. The patient was treated with N-acetylcysteine, methylprednisolone, lactulose and rifaximin. She was ineligible for transfer to a liver transplant center due to her COVID-19 positive status. Unfortunately, despite conservative management, patient expired after developing severe disseminated intravascular coagulation, renal failure, and refractory septic shock. DISCUSSION: In recent literature, SARS-CoV-2 has primarily been recognized for causing mild liver injury, while fulminant hepatic failure is a rare occurrence (1,2). Remdesivir, which this patient received only one dose of, is known to cause mild transaminitis. It has been shown to cause severe liver injury only when used in combination with amiodarone, due to the latter's role as a moderate inhibitor of CYP3A4 and p-glycoprotein (3). This patient did not have exposure to hepatotoxic agents, prolonged state of shock, evidence of metastatic liver lesions or acute viral hepatitis to explain profound liver failure. Hence, we postulate that the SARS-CoV-2 virus may have directly targeted the hepatobiliary cells. Further studies of the pathophysiology of liver injury from this virus may allow better prevention and treatment. CONCLUSIONS: Understanding SARS-CoV-2's effects on a hepatocellular level may allow for anticipatory monitoring and prevention of liver damage from this virus. For those more severely affected, better treatments would help avoid the difficult course of emergency liver transplantation and resultant need for lifelong immunosuppression. REFERENCE #1: Gupta A, Mahhavan MV, Sehgal K, et al. Extrapulmonary manifestations of COVID19. Nature Medicine 26:1017-1032, July 2020 REFERENCE #2: Melquist S, Estepp K, Aleksandrovich Y, et al. COVID-19 presenting as fulminant hepatic failure. Medicine 99:issue 43, October 23, 2020 doi 10.1097 REFERENCE #3: Remdesivir in LiverTox: Clinical and Research Information on Drug-Induced Liver Injury (Internet). National Institute of Diabetes and Digestive and Kidney Diseases, November 4, 2020;https://www.ncbi.nlm.nih.gov/books/NBK564049/?report=printable DISCLOSURES: No relevant relationships by Chester Choi, source=Web Response No relevant relationships by Madlena Nalbandian, source=Web Response No relevant relationships by Eulia Tlisov, source=Web Response

Cholecystitis Associated with Extracorporeal Membrane Oxygenation: Temporal Trends and Outcomes from National Inpatient Sample Analysis from 2010-2017

INTRODUCTION: Extracorporeal Membrane Oxygenation (ECMO) has become essential support to patients with severe cardiac and pulmonary dysfunction refractory to conventional management. The usage of ECMO has strikingly progressed, especially during the pandemic of novel coronavirus disease 2019. Previous research has shown increased frequencies of cholecystostomy and cholecystectomy in patients receiving ECMO. The aim of this study was to determine the trends and outcomes of cholecystitis in hospitalized patients receiving ECMO. METHODS: The NIS database was used to identify adult patients receiving ECMO who had the diagnosis of cholecystitis from 2010 to 2017 using ICD codes. Primary outcomes included the trend of prevalence of ECMO, cholecystitis, and inpatient outcomes. RESULTS: Between 2010 and 2017, there was an uptrend in the number of patients receiving ECMO (weighted: 1471 in 2010 to 8525 in 2017, P < 0.0001), while the rate of cholecystitis has remained stable (1.4%). In patients receiving ECMO with cholecystitis, 73.9% had acalculous cholecystitis (ACC). Both patients with ACC and calculous cholecystitis (CC) had high mortality rates (48.8% vs. 61.5%), prolonged length of stay (LOS) (38.9 vs. 46 days) and significant hospitalization charges ($1214147.4 vs. $1346440.9), with an uptrend in hospitalization charges (P < 0.0001). More than 95% of ECMO patients with cholecystitis had at least two Elixhauser comorbidities. ECMO patients with ACC were generally Caucasian (56.5%) and male (72.8%) dominant with an average age of 51.3 years old. More than 90% were treated in medium to large urban teaching hospitals, and more than 50% had private insurance. Compared to CC patients, patients with ACC were more likely to be male (P < 0.042) and had fewer cardiogenic indications for ECMO (P < 0.011). The ACC cohort was also associated with higher rates of HCV infection (P < 0.020) and cirrhosis (P < 0.007). CONCLUSION: This study demonstrated a stable rate of cholecystitis from 2010 to 2017 in ECMO patients despite an increased number of ECMO use. ECMO patients with cholecystitis were associated with more comorbidities, high mortality rates, prolonged LOS and significant hospitalization costs. Patients with ACC were associated with fewer cardiogenic indications for ECMO, but more HCV infection and cirrhosis compared to those with CC. Further prospective studies are needed to evaluate the different characteristics and underlying pathophysiology between ACC and CC in patients receiving ECMO.