Early Combination Therapy with Immunoglobulin and Steroids Is Associated with Shorter Icu Length of Stay in Multisystem Inflammatory Syndrome in Children Associated with Covid19

BACKGROUND AND AIM: Suggested therapeutic options for Multisystem Inflammatory Syndrome in Children (MIS-C) include intravenous immunoglobulins (IVIG) and steroids. Prior studies have shown the benefit of combination therapy with both agents on fever control or the resolution of organ dysfunction. The objective of this study was to analyze the impact of IVIG and steroids on hospital and ICU length of stay (LOS). METHOD(S): This was a retrospective study on 356 hospitalized MIS-C patients from 03/20-9/21 (28 U.S. sites) in the SCCM Discovery Viral Infection and Respiratory Illness Universal Study (VIRUS) COVID-19 Registry. The effect of IVIG and steroids initiated in the first two days of admission, alone or in combination, on LOS was analyzed using intention to treat analysis. Adjustment for confounders was made by multivariable mixed regression with a random intercept for the site. RESULT(S): Median age of the study population was 8.8 (IQR 4.0, 13) years. 247/356 (70%) patients required ICU admission during hospitalization. Of the total patients, 153 (43%) received IVIG and steroids, 33 (9%) received IVIG only, 43 (12%) received steroids only, and 127 (36%) received neither within first two days. After adjustment of confounders, only combination therapy showed a significant decrease of ICU LOS by 1.6 days compared to no therapy (exponentiated coefficient 0.71 [95% CI 0.51, 0.97, p=0.03]). No significant difference was observed in hospital LOS or the secondary outcome variables. CONCLUSION(S): Combination therapy with IVIG and steroids initiated in the first 2 days of admission favorably impacts ICU LOS in children with MIS-C.

The Impact of Steroids on Outcomes of Children Admitted to the Hospital with Non Misc Covid19: An Analysis from the Sccm Discovery Network Virus Registry

BACKGROUND AND AIM: Evidence for therapies for pediatric COVID-19 is limited. Primary aim was to study the effect of steroid administration within 2 days of admission for pediatric non-MIS-C-COVID-19 on hospital and ICU length of stay (LOS). The secondary aim was to study its effect on inflammation and fever defervescence. METHOD(S): A retrospective study of 1163 children hospitalized with non-MISC-COVID-19, from 03/20 to 09/21, from 58 hospitals (7 countries, 92% US), in the Viral Infection and Respiratory Illness Universal Study (VIRUS) registry. Effect of steroid administration <= 2 days of admission on hospital and ICU LOS was studied using intention to treat analysis, adjusted for confounders by multivariable mixed linear regression. RESULT(S): Median age was 7(IQR 0.9,14.3) years. 184(15.8%) children who received steroids within <= 2 days were compared to 979 (84.1%) children who did not. 56.5% (n=658) required respiratory support. Patients in the steroid group were older, with higher severity of illness. A greater proportion required respiratory and vasoactive support. On multivariable linear regression with random intercept for site (Table), there was no significant difference in hospital LOS (exponentiated [exp] co-efficient 0.92, 95%CI = 0.77, 1.10, p=0.374) or ICU LOS (exp co-efficient 1.02, 95%CI = 0.78, 1.34, p=0.864) between the groups. There was no significant difference in time to fever defervescence and normalization of inflammatory mediators by Day 3. CONCLUSION(S): In pediatric non-MIS-C COVID-19, steroid treatment <= 2 days of hospital admission did not show a statistically significant effect on hospital or ICU LOS. (Table Presented).

Leveraging the Sccm Discovery Virus Covid-19 Registry to Evaluate Drug Repurposing Research Dataset

INTRODUCTION: The CURE Drug Repurposing Collaboratory (CDRC) partnered with the SCCM Discovery VIRUS COVID-19 Registry (VIRUS) to develop and build a minimal dataset for drug repurposing research for COVID-19. This use case required a cross-sectional dataset to avoid the perceived risk of identifiability through serial laboratory results or vital sign patterns. The work took place as part of the early stages of a project funded by HHS Assistant Secretary for Planning and Evaluation to automate data extraction from the electronic health record. METHOD(S): As part of an ongoing evaluation of the dataset's utility, CDRC performed factor selection analysis to explore relationships between baseline, median, and peak laboratory values and the patient outcomes. The primary outcomes of interest in this analysis were 28-day all-cause mortality and hospital length of stay (LOS). Serum creatinine, leukocyte count, lactate dehydrogenase (LDH), international normalized ratio (INR), and PaO2:FiO2 (P:F) ratio were examined as predictors of key outcomes. Data for 17,144 patients were obtained from VIRUS: COVID-19 Registry. Data were cleaned and an analysis dataset was constructed. Records with excessive missingness were excluded and liberal clinical plausibility rules were applied. Analysis used logistic regression with least absolute shrinkage and selection operator (LASSO) along with 10-fold cross validation. The cohort was randomly divided into training and testing sets at a 9:1 ratio. The study was IRB exempted. RESULT(S): Following a year-long Delphi process, the investigators identified 35 key data elements including primary outcomes. Modeling for 28-day mortality: median creatinine (n=4,304), baseline leukocytes (n=3,731), median LDH (n=1,854), maximum INR (n=1,972), and median PF ratio (n=1,000) were most predictive. Modeling for LOS: median creatinine, maximum leukocytes, baseline LDH, baseline INR, and median PF ratio were most predictive. CONCLUSION(S): This analysis provides guidance for the evaluation of the CURE ID dataset. The data will ultimately be displayed in a publicly explorable interface through the CURE ID application and website hosted by the National Center for Advancing Translational Science at NIH in partnership with the FDA.

Therapeutic Use of Inhaled Corticosteroids in Covid-19: A Systematic Review and Meta-Analysis

INTRODUCTION: Previous randomized trials suggest the benefit of inhaled budesonide for COVID-19 patients in outpatient settings. We evaluated available studies on the effect of the therapeutic use of inhaled corticosteroids (ICS) on mortality and pertinent clinical outcomes. METHOD(S): A comprehensive literature search was conducted across the WHO, LitCOVID, and EMBASE databases from inception until June 30th, 2022. The primary outcome was overall mortality and secondary outcomes included symptom-based clinical improvement rates at day 14, ER visits or hospitalization, and adverse events. Data analysis was performed using Review Manager Software, version 5.2, to evaluate the combined odds ratio (OR) with 95% confidence intervals (CI) using a random-effects model. RESULT(S): Nine studies (7 RCTs (3 budesonide, 3 ciclesonide, 1 fluticasone RCTs), & 2 observational studies) were included in the mortality meta-analysis. Of the 3,934 patients included, 103 patients died (44 out of 1925 in the ICS group and 59 out of 2009 in the non-ICS group). The odds of mortality in the therapeutic ICS use group were lower compared to the non-ICS therapy group (OR 0.78, 95% CI 0.48-1.28, p-value=0.33, I2=0%). The result was statistically insignificant, possibly due to the low mortality rate. But therapeutic ICS showed statistically significant clinical improvement rates at day 14 (5 RCTs;3 Ciclesonide, 2 Budesonide) (OR 1.56, 95% CI 1.31-1.86, p < 0.0001, I2=0%). The number of ED visits/Hospitalization rate, and adverse events were not statistically significant between the groups (OR 0.73, 95% CI 0.32-1.70, p= 0.47 I2=75% and OR 1.10 95% CI 0.67-1.82, p=0.70, I2=28%). CONCLUSION(S): This meta-analysis shows that the therapeutic use of ICS in COVID-19 is associated with higher symptom-based clinical improvement rates. Although the reduction in mortality odds remained insignificant, as the overall mortality rates were low which increased the confidence interval overall. Early administration of ICS showed a trend towards the reduced likelihood of urgent care needs. Well-designed trials are needed to explore ICS efficacy in patients with a high risk of disease progression and in reducing the incidence of long-term COVID-19 symptoms or post-acute sequelae of SARS-CoV-2.

Prehospital Use of Inhaled Corticosteroids in Covid-19: A Systematic Review and Meta-Analysis

INTRODUCTION: Studies of hospitalized patients with COVID-19 have found varying clinical outcomes associated with underlying respiratory conditions and inhaled corticosteroid use. We performed a systematic review to summarize the effect of the pre-hospital use of inhaled corticosteroids on the clinical outcomes in patients with COVID-19. METHOD(S): A comprehensive literature accrual was conducted across the WHO, CDC, and LitCovid PubMed COVID-19 databases from inception until June 30th, 2022. The Overall mortality was the primary outcome, and the secondary outcomes were the need for intensive care unit (ICU) admission and the need for invasive mechanical ventilation (IMV). All included studies were observational and reported the desired outcomes with pre-hospital use of ICS in COVID-19 patients. Data analysis was performed using Review Manager Software, version 5.2 to evaluate the combined odds ratio (OR) with respective 95% confidence intervals (CI) using a random-effects model. RESULT(S): Nineteen studies assessed mortality and were included in the meta-analysis. A total of 1,122,329 patients were included, of which 10,466 patients died (2,289 out of 824,005 in ICS arm patients and 8,177 out of 298,324 in the non-ICS arm), resulting in the unadjusted odds of death (OR 1.36, 95% CI 1.09-1.70, I2=82%). However, In the subgroups analyses of COPD patients (8 studies;598 out of 106,659 in the ICS arm and 353 out of 44,496 in the non-ICS arm) and Asthma patients (7 studies;705 out of 714,126 in the ICS arm and 179 out of 222,577 in the non-ICS arm), significantly increased risk of death was not shown (OR 1.20, 95% CI 0.93-1.57, I2=32%, OR 1.61, 95% CI 0.97-2.66, I2=82% respectively). There were no significantly increased odds in the assessed secondary outcomes;ICU admission (13 studies, OR 1.11, 95% CI 0.82-1.51, I2=84%), need for mechanical ventilation (7 studies, OR 1.21, 95% CI 1.00-1.45, I2=0%). CONCLUSION(S): Prehospital use of ICS in COVID-19 patients is associated with higher odds of overall mortality in unadjusted analysis. However, this was not shown in the subgroup of patients with a history of COPD or Asthma. Other clinical outcomes such as the need for ICU admission and mechanical ventilation show similar trends. Future research with well-designed clinical trials is needed to validate our findings.

Hospital-Acquired Achromobacter Denitrificans Bacteremia: Case Report and Review of Literature

INTRODUCTION: Achromobacter denitrificans bacteremia is a rare condition and generally affects adults with multiple comorbidities and is usually a hospital acquired infection. We report a case of hospital acquired Achromobacter denitrificans bacteremia in a young female without any comorbidities, who presented to the hospital with severe viral pneumonia. DESCRIPTION: A 33-year-old female was presented to the ER with increasing difficulty in breathing. On examination, she had labored breathing. Her oxygen saturation was 80% at room air. With oxygen support via face mask, her saturation increased to 83% with 15 L/min. Then non-invasive ventilation via BiPAP it improved to 90% and she was admitted to the medical ICU. Meanwhile, as per history from the husband, she had a cough and coryza for the past one week and was taking over the counter medications. Lab investigations at the time of admission reported WBC count as 7500/ cumm. She was tested negative for COVID-19. HR CT-scan showed bilateral ground glass opacities with bilateral patchy consolidations. For worsening hypoxia, she was intubated and placed on ventilator support (FiO2:60%). Her blood and urine culture reports were negative. The Liver function tests showed elevated SGOT/SGPT, suggesting acute hypoxic liver injury. Supportive care with IV steroids, and broad-spectrum antibiotics Pipercillin and Tazobactam was provided. In the second week, the patient's WBC started rising and peaked at 40,000/cumm on Day-10. Her condition worsened further despite being on 100% FiO2. The tracheal sample grew a colony of Acinetobacter Baumannii, while her blood cultures reported positive for A. Denitrificans sensitive to Pipercillin and Tazobactum. Chest X-Ray suggested features of acute respiratory distress syndrome with no signs of a cavitary lesion or abscess. Ultrasound abdomen and Echocardiography ruled out other sources of infection. Despite ventilatory support and medications, the patient deteriorated, and passed away after cardiorespiratory arrest. DISCUSSION: Achromobacter denitrificans cause opportunistic nosocomial infections, which has been recovered from ventilators, humidifiers, "sterile" saline, and IV fluids. A. denitrificans is associated with pneumonia, peritonitis, bacteremia, endocarditis, empyema, renal abscess, and pancreatic pseudocysts.

Therapeutic Use of Baricitinib in Covid-19: A Systematic Review and Meta-Analysis

INTRODUCTION: The reduction of mortality in COVID-19 has been clinically established only for Dexamethasone and Tocilizumab to date, but the overall mortality in COVID-19 remains high. Baricitinib is a Janus Kinase 1/2 Inhibitor with known anti-inflammatory and anti-viral properties. The US FDA recently approved Baricitinib for the treatment of hospitalized adults with COVID-19 requiring either supplemental oxygen, non-invasive or invasive mechanical ventilation, or extracorporeal membrane oxygenation (ECMO). We performed a meta-analysis of Randomized Controlled Trials (RCT) and observational studies assessing the effect of Baricitinib on mortality outcomes in hospitalized patients with COVID-19. METHOD(S): A systematic literature search was conducted on electronic databases including NIH LitCovid, WHO COVID-19 database, EMBASE, and Cochrane Central from inception until June 30th, 2022. Randomized Controlled Trials and observational studies evaluating the efficacy of Baricitinib in hospitalized patients with COVID-19 were screened for the assessment of all-cause mortality as the outcome. RESULT(S): Twenty-three studies (18 observational and 5 RCTs) were included in the mortality meta-analysis. Of the 16,390 patients (4,565 observational, 11,825 RCTs), 2,139 patients died (903 out of 7,610 in the Baricitinib arm and 1,236 out of 8,780 in the non-Baricitinib arm). Using the random-effects model, the odds of mortality in the therapeutic Baricitinib use showed a statistically significant reduction in all-cause mortality in hospitalized COVID-19 patients (OR 0.67, 95% CI 0.50-0.90;p=0.008, I2=79%). A similar trend of decreased mortality was observed in the subgroup analysis by study design (Observational OR 0.59, 95% CI 0.35-0.97, p=0.04, I2=83%;RCTs OR 0.72, 95% CI 0.56-0.93, p=0.01, I2=53%). CONCLUSION(S): Baricitinib used along with the standard of care treatments is associated with a reduction in mortality in hospitalized patients with COVID-19 disease.

Nonalcoholic Fatty Liver Disease Association with Intubation and Severity of Covid-19

INTRODUCTION: Non-alcoholic fatty liver disease (NAFLD) and its hepatic manifestation, metabolic-associated fatty liver disease (MAFLD) have a rising prevalence worldwide in the background of the ongoing global pandemic. It is imperative to explore the relationship with COVID-19 to improve patient care and treatment protocols for better outcomes. This metaanalysis aims to investigate the association between NAFLD and MAFLD with the severity of COVID-19 infection and the need for mechanical ventilation. METHOD(S): A systematic review of literature across 5 databases was conducted from January 2019 to June 2022. Observational studies or clinical trials were included. Studies that evaluated NAFLD/ MAFLD using laboratory methods, non-invasive imaging, or liver biopsy were included. The study protocol was registered in Prospero and Prisma guidelines were followed (Figure 1). Meta-analysis was performed on studies with mechanical ventilation and severity of COVID-19 infection outcomes using Revman software. The Mantel- Haenszel odds ratio was generated to describe the overall effect size using random effect models. RESULT(S): Mechanical Ventilation A total of 36,817 patients from twelve studies were included in the qualitative analysis. There were 5615 patients in the NAFLD group and 31,202 patients in the Non-NAFLD group. A total of 3148 patients with COVID-19 required mechanical ventilation;778 (13.8%) in the NAFLD group and 782 (2.5%) in the Non-NAFLD group with high odds of need for mechanical ventilation (OR 2.03, 95%CI 1.06-3.88, p-value=0.03, I2=95%) (Figure 2). COVID-19 Severity A total of 5286 patients from fourteen studies were included in the qualitative analysis. 2716 patients were in the NAFLD group, while 2570 patients were in the Non-NAFLD group. A total of 1,623 patients had increased severity of COVID-19;901 (33.1%) in the NAFLD group and 722 (28.9%) in the Non-NAFLD group. COVID-19 patients with NAFLD had worse COVID-19 infection outcomes compared to those without NAFLD (OR 1.59, 95%CI 1.12-2.26, p-value=0.01, I2=81%) (Figure 4). CONCLUSION(S): Our meta-analysis suggests that NAFLD patients had higher odds of needing mechanical ventilation or ICU admission and developing more severe forms of COVID-19 than Non-NAFLD patients.

Nonalcoholic Fatty Liver Disease Association with Hospital and Icu Admission in Covid-19

INTRODUCTION: Association between non-alcoholic fatty liver disease (NAFLD) and metabolic-associated fatty liver disease (MAFLD) with COVID-19 is still an ongoing debate. We aimed to conduct a systematic review and meta-analysis investigating the impact of NAFLD/ MAFLD on the duration of ICU and hospital stay in COVID-19 patients. METHOD(S): A systematic review of literature from January 2019- to June 2022 on databases PubMed, Cochrane, Embase, Science Direct, and Web of science was conducted. Observational studies or clinical trials were included. Studies that assessed NAFLD/ MAFLD using lab assessment, non-invasive imaging, or liver biopsy were included. The protocol of the study was registered in Prospero and Prisma guidelines were followed (Figure 1). The meta-analysis was performed using Revman software. Mantel- Haenszel odds ratio was generated to describe the overall effect size using random effect models. RESULT(S): ICU Admission A total of 37,109 patients from fifteen studies were included in the qualitative analysis. A total of 5624 patients were in the NAFLD group and 31,485 patients were in the Non-NAFLD group, where 3148 patients with COVID-19 required ICU admission. Out of these, 1098 (19.5%) were in the NAFLD group and 2050 (6.5%) in the Non-NAFLD group. We observed a significantly increased ICU admission among COVID-19 patients with NAFLD compared to those without NAFLD (OR 1.67, 95%CI 1.02- 2.72, p-value= 0.04). (Figure 2). Hospital Admission A total of 27,683 patients from three studies were included in the qualitative analysis. A total of 1128 patients in the NAFLD group and 26,555 patients in the Non-NAFLD group, where 4019 patients with COVID-19 required hospital admission. Out of these, 518 (45.9%) were in the NAFLD group and 3501(13.1%) in the Non-NAFLD group. We observed a significant increase in hospital admissions among COVID-19 patients with NAFLD compared to those without NAFLD (OR 2.71, 95%CI 1.10-6.70, p-Value=0.03). CONCLUSION(S): The NAFLD patients may have increased ICU and hospital admission compared to Non-NAFLD Patients. Fatty liver disease has an association with increased healthcare admission and critical care service utilization among COVID-19 patients.

Association of Early Heparin Use among Patients with Covid-19 and Sepsis and Hospital Outcomes

INTRODUCTION: There is published literature about COVID-19 disease associated coagulopathy in hospitalized patients. We aim to study association of early heparin use among adult patients with COVID-19 and sepsis and hospital outcomes. METHOD(S): Retrospective study utilizing the EMR (electronic medical record) data at a large tertiary care academic center with ICU patients admitted for COVID-19 and sepsis and received therapeutic heparin for anticoagulation. We reported nominal variables in (gender, exposure - yes/no, etc) as number and percentage. And reported continuous (age, length of stay, etc) as median (IQR). We used Chi Square test and t-test as appropriate for nominal and continuous data analysis. This study was IRB approved. RESULT(S): A total of 230 patients with age >=18 years were included in final analysis. Out of these, 183 (79.6%) patients received heparin within 48 hours of ICU admission and 47 (20.4%) after 48 hours. The median (IQR) age was 67.5 years (58-77) with majority being caucasian (73.9%) male (68%) patients. Overall, 59 (26%) patients had died, 86 (37%) had been discharged home without assistance, 12 (5%) discharged home, with home health from the hospitals. In univariable analysis, early (< 48 hours) administration of heparin was associated reduced utilization of invasive mechanical ventilation (IMV) (OR 0.23, p=< 0.01) and non-IMV (NIMV) (OR 0.49, p=0.03) and reduced ICU (MD -1.64, SE 0.58, p=< 0.01 and hospital length of stay (LOS) (MD-4.15, SE 0.93, p=< 0.01. This association remained significant when model was adjusted for age, gender, BMI, race, ethnicity, SOFA score on day 1, APACHE-III score on ICU admission: IMV utilization (aOR 0.12, p=< 0.01), NIMV utilization (aOR 0.47, p=0.35), ICU LOS (MD -1.65, SE 0.57, p=< 0.01) and hospital length of stay (MD -4.43, SE 0.95, p=< 0.01). The hospital mortality was observed to be not statistically significant (unadjusted OR 0.68, p=0.28 and adjusted OR 0.67, p=0.32) due to small sample size. CONCLUSION(S): Early administration of heparin in patients with moderate to severe COVID-19 sepsis was associated with reduced utilization of IMV and NIMV and reduced hospital LOS. Association with reduced hospital mortality did not reach the statistical significance.

Chronic Anticoagulant Use Prior to Covid-19 Diagnosis: A Systematic Review and Meta-Analysis

INTRODUCTION: Coagulopathy and thromboembolic events are poor prognostic indicators of COVID-19 disease. There is a discrepancy in the results of different studies regarding the effects of chronic anticoagulation on clinical outcomes. This systematic review aims to summarize the evidence on the impact of chronic anticoagulation on clinical outcomes in COVID-19. METHOD(S): A Literature search was performed on LitCovid PubMed, WHO, and Embase databases from inception (December 2019) till May 2022. Our eligibility criteria included original studies that reported the association between prior use of anticoagulants for unrelated indications at the time of COVID-19 diagnosis and the patient outcomes in adults suffering from COVID-19. The risk of thromboembolic events in COVID-19 infected patients on chronic anticoagulation is the primary outcome and severity of COVID-19 disease in terms of ICU admission or invasive mechanical ventilation/intubation requirements, and all-cause mortality were the secondary outcomes. Random effects models were used to compute crude ODDs ratios (OR) and adjusted odds ratios (aOR) with 95% confidence intervals (CIs). RESULT(S): A total of 44 observational studies met our inclusion criteria. In unadjusted analysis, prior anticoagulation was not associated with reduced risk of thromboembolic events in COVID-19 patients (N=43851, 9 studies, OR 0.67 [0.22, 2.07];p= 0.49;I2= 95%). However, pre-hospital use of anticoagulants significantly increase the risk of allcause mortality in COVID-19 patients (N= 580601;37 studies, OR 1.56 [1.22, 2.01];p=0.0005;I2= 97%). There was no statistically significant association between prehospital anticoagulants usage and COVID-19 disease severity (N=186239;20 studies, OR 0.96 [0.70, 1.33];p= 0.82;I2= 88%). Pooling adjusted estimates revealed no statistically significant association between pre-hospital use of anticoagulants and risk of Thromboembolic events in COVID-19 patients (aOR= 0.85 [0.34, 2.12];p= 0.72), COVID-19 related mortality (aOR= 0.93 [0.82, 1.07];p= 0.32), and the severity of COVID-19 infection (aOR= 0.96 [0.72, 1.30];p= 0.81). CONCLUSION(S): Prehospital use of anticoagulation was not significantly associated with reduced risk of thromboembolic events, improved survival, and lower severity of disease in COVID-19 patients.

A Global Survey of Impact of Violence against Healthcare Workers in Critical Care Settings: Vishwas

INTRODUCTION: A rise in the incidents of violence against Health Care Workers (HCWs) in recent years calls for improvement in modes of spreading awareness and educating the public. We aimed to conduct a large global cross-sectional survey called ViSHWaS- Violence Study of Healthcare Workers and Systems in the departments of Anesthesiology, Critical Care Medicine, and Emergency medicine. METHOD(S): A global survey after tool validation, was created using REDCap forms and distributed from June 5th to July 24th, 2022. Communication tools including emails, phone calls, SMS, and social media applications like WhatsApp, Twitter, and LinkedIn were used in securing responses. This study was deemed eligible for category-2 Institutional Review Board exempt status. RESULT(S): Total of 598 responses from 69 countries, out of these 445 (74%) were complete. The maximum responses were from India (N=49), followed by the USA (N=44) and while those from the other 67 countries ranged from N=1-30. Out of these, 221 (50%) were female, the majority (56%) were in the 26-35 years category, followed by (19%) in 36-45 years. The participants encompassed 156 (35%) consultants, 97 (22%) nurses and the rest were residents/fellows in training, auxiliary/ staff, advanced registered nurse practitioners (ARNP), physician assistants (PA), researcher and others. The vast majority (73%) reported facing violence within the past year;Verbal (63%) and physical (39%) were the most commonly reported. Total 126 (28.3%) reported that patient and/or family member as the type of aggressor they/ their colleague encountered most frequently. A majority (75%) reported that the incidence of violence has either stayed the same (39%) or increased (36%) during COVID-19 pandemic. Because of violent episodes, 48% felt less motivated/ had decreased job satisfaction;an additional 25% were willing to quit. While half of respondents were familiar with Occupational Safety and Health standards, only 20% felt prepared to handle aggressive situation. CONCLUSION(S): In this global cross-sectional survey, a majority of HCWs reported to have faced violence. They felt that it either increased or stayed the same during the COVID-19 pandemic. It has led to decreased job satisfaction. Majority of those, who responded, felt unprepared to handle the violence.

Assessment of Readmission Risk Factors after Index Hospital Discharge for Covid-19 Patients

INTRODUCTION: During the COVID-19 pandemic, the burden on the healthcare system makes it critical to examine readmission patterns. In this study, we evaluated the readmission rates and risk factors associated with COVID-19 from the large SCCM Discovery VIRUS: COVID-19 Registry. METHOD(S): This was a retrospective, cohort study including hospitalized adult patients from 181 hospitals in 24 countries within the VIRUS: COVID-19 Registry. Demographic, clinical, and outcome data were extracted and divided into two groups: Patients with readmission with COVID-19 in 30 days from discharge and those who were not. A univariate analysis is done using chi-square and t-test as appropriate. Multivariable logistic regression was used to measure risk factor associations with 30-day readmission. RESULT(S): Among 20,283 patients, 1,195 (5.9%) were readmitted within 30 days from discharge. The median (IQR) age of readmitted patients was 66 (55-78) years and 45.2% were female, 60.2% were white, and 78.9% non-Hispanic. Higher odds of readmission were observed in patients aged >60 vs 18-40 years (OR 2.76;95% CI, 2.23-3.41), moderate COVID-19 disease (WHO Ordinal scale 4-5) vs Severe COVID-19 (WHO Ordinal scale 6-9) (OR 1.23;95% CI, 1.10-1.39), no ICU admission at index hospitalization (OR 1.70;95% CI, 1.32-1.80), and Hospital length of stay <=14 vs >14 days (OR 1.53;95% CI, 1.32-1.80) vs those not readmitted (p= < 0.001). Comorbidities including coronary artery disease (OR 2.14;95% CI 1.84-2.48), hypertension (OR 1.58;95% CI 1.40-1.78), congestive Heart Failure (OR 2.54;95% CI 2.16-2.98), chronic pulmonary disease (OR 2.26;95% CI 1.94-2.63), diabetes (OR 1.32;95% CI 1.17-1.49) or chronic kidney disease (CKD) (OR 2.41;95% CI 1.2.09-2.78) were associated with higher odds of readmission. In multivariate logistic regression adjusted for age group, hospital length of stay <=14 days and, highest WHO COVID-19 ordinal scale and index ICU admission coronary artery disease, congestive heart failure, chronic pulmonary disease, chronic kidney disease, hospital length of stay <=14 days and age >60 years remained independent risk factors for readmission within 30 days. CONCLUSION(S): Among hospitalized patients with COVID-19, those readmitted had a higher burden of comorbidities compared to those non-readmitted.

Mantle Cell Lymphoma: A Single Centre Experience from a Tertiary Care Centre in North India

Introduction: Mantle cell lymphoma (MCL) is an aggressive lymphoma with an incidence of 2.4-6% among all non-Hodgkin's lymphoma. Though with the addition of rituximab to standard chemotherapy backbone with autologous stem cell transplant (ASCT) consolidation and novel small molecule inhibitors, the outcome of MCL has improved, however, not many patients undergo ASCT due to financial constraints. Aims & Objectives: To study the clinical profile of all patients of MCL over a period of 6 years and assess their outcome. Material(s) and Method(s): This study was a retrospective cohort study which included all patients diagnosed with mantle cell lymphoma, between January 2016 to January 2022, conducted in the Department of Haematology, Sanjay Gandhi Institute of Medical Sciences, Lucknow, India. A total of 53 cases were included in the study. SPSS-23 was used for the data analysis. Result(s): The median age was 59 years (ranging from 39-81 years), with a male to female ratio of 5.3:1. The ECOG performance status was of 0-2 was seen in 85.2%. The median haemoglobin, leukocyte count and platelet count at presentation was 10.6 g/dL, 7400/mm3 and 1,52,000/mm3 respectively. Of the 53 patients, 48% presenting with B symptoms. The median Lactate dehydrogenase levels were 521 (ranging from 220-1230). 72% patients presented with stage IV disease and MIPI score was high, intermediate and low risk in 43.4%, 32.1% and 24.5% low risk. 48% patients received RCHOP/RDHAP regimen, 36% received RCHOP and 16% received R-Benda. 5 patients underwent ASCT. 13 patients relapsed, 1 was refractory and 1 died post-transplant due to Covid sepsis. The third patient, who had relapsed, received R Benda, was found to have multiple myeloma 1 year after therapy, and succumbed to sepsis. 63% were put on Rituximab maintenance. Conclusion(s): MCL is a rare, aggressive B cell lymphoma with a lesser incidence in Indian population compared to the world. While aggressive chemotherapy with monoclonal antibody has improved the response rate of patients with nodal MCL, wait and watch strategy remains the backbone of management of leukaemic NNMCL.

COVID-19 HOSPITALIZATION PATTERNS THROUGHOUT THE PANDEMIC ACROSS 10 US DEPARTMENT OF HEALTH AND HUMAN SERVICES (HHS) REGIONS

SESSION TITLE: COVID-19 Infections: Issues During and After Hospitalization SESSION TYPE: Original Investigations PRESENTED ON: 10/17/2022 01:30 pm - 02:30 pm PURPOSE: COVID-19 pandemic is well studied, but it’s impact on hospitalization pattern is still unclear. We aim to study the hospitalizations pattern throughout the COVID-19 pandemic across 10 US Health and Human Services (HHS) regions. METHODS: This study was conducted using two publically and freely available databases;1. The COVID Tracking Project- manually aggregated data from available sources from official, public state government sites, and 2. The US Department of HHS – state wise patient impact and hospital capacity data. The state wise hospitalization data was extracted and collated by noting hospitalization for the complete time range (from March 1, 2020 to March 7th, 2021) for dataset-1 and data reported between the dates of March 7th, 2021, to March 12th, 2022, for dataset-2. The HHS wise regional hospitalization data was then calculated by adding the respective daily state statistics and scaled to per 100,000 population. A 7-day moving average filter was finally applied to the data before visualization and analysis, to account for repeated days of missing recordings in the data sources. No patient and hospital identifiers were utilized;thus, study was IRB exempted. RESULTS: Based on proximity of the spikes in each wave, data visualization tools grouped, HHS regions 1, 2, 3, 5 in group A;regions 4, 6, 9 in group B, and regions 7, 8. 10 in group C. The visualization of data determined total 6 spikes till date. The start and end of spikes were determined by placing a threshold (10 cases per day per 100,000 population) on the number of daily hospitalizations. The spikes were further divided when a given start/end date pair has multiple clear peaks. Maximum number of days difference observed between the occurrence of COVID-19 peaks in number of hospitalizations, were 47 days for spike-3 for HHS regions in group A (Compared to 2 and 12 days in group B and C, respectively). For Spike-5 it was highest in group C as 78 days (compared to 18 and 1 day in group A and B, respectively). CONCLUSIONS: In a latest COVID-19 hospitalization data analysis, after normalization of data, states in HHS regions, 4, 6, and 9 have the closest spikes throughout the pandemic. These regions included three most populous states of US (Florida, Texas, California) among others and consisted of 67M (region 4), 42M (region 6) and 51M (region 9) people, total of roughly 50% US population. CLINICAL IMPLICATIONS: The result of this study, first to be presented at CHEST conference will pave the way in adding to public health policy discussion in preparedness and resources allocations for hospitalized patients. A subset-analysis of ICU admission is underway, which will be included at CHEST meeting presentation. DISCLOSURES: No relevant relationships by Ramesh Adhikari no disclosure on file for Keerti Deepika;No relevant relationships by Taru Dutt No relevant relationships by Rahul Kashyap No relevant relationships by Arjun Rajasekar no disclosure on file for Shruti Srivnivasan;No relevant relationships by Salim Surani

Electroencephalogram-based deep learning framework for the proposed solution of e-learning challenges and limitations

There is a high surge in usage of online e-learning platforms due to the current ongoing COVID-19 scenario. There are specific problems that persist in the current e-learning online models, i.e., validations and tracking of students’ learning curves, validation of presented course material, content-based personalisation as per the requirements of the students, identification of learning disabilities among students, etc. Our paper proposes the deep learning model to solve the issues related to existing machine learning models of manual feature extraction and training on limited data. Also, real-time e-learning data will be collected from students wearing EEG-headband while taking online classes. It solves the issues associated with conventional machine learning models and historical data. The proposed CNN model will classify the students on different grades and help in the development of an automated framework for the tracking of a student learning curve, providing recommendations for the betterment of e-learning course materials. Copyright © 2022 Inderscience Enterprises Ltd.

Neurologic Manifestations of Patients Hospitalized with COVID-19 in the SCCM VIRUS Registry

Objective: To describe the prevalence, associated risk factors, and outcomes of serious neurologic manifestations (encephalopathy, stroke, seizure, and meningo-encephalitis) among patients hospitalized with coronavirus disease 2019 (COVID-19). Background: Though case series abound, limited prospective multi-center data exists describing neurologic manifestations of COVID-19 Design/Methods: Prospective observational study of hospitalized adults in 179 hospitals in 24 countries with laboratory-confirmed SARS-CoV-2 infection within the SCCM Discovery Viral Infection and Respiratory Illness University Study (VIRUS) COVID-19 Registry Results: Of 16,225 patients enrolled in the registry with discharge status available, 2,092 (12.9%) developed serious neurologic manifestations including 1,656 (10.2%) with encephalopathy at admission, 331 (2.0%) with stroke, 243 (1.5%) with seizure, and 73 (0.5%) with meningitis/encephalitis at admission or during hospitalization. Patients with serious neurologic manifestations were older with median (IQR) age 72 (61.0-81.0) vs. 61 (48.0-72.0) years and had higher prevalence of chronic medical conditions, including vascular risk factors. Systemic viral symptoms (fever, dyspnea, and cough) were less commonly reported in patients with severe neurologic manifestations as were milder neurologic symptoms including anosmia, dysgeusia, and headache. Adjusting for sex and time since the onset of the pandemic, serious neurologic manifestations were associated with more severe disease (OR 1.82, p<0.001) as defined by the WHO ordinal disease severity scale. Patients with neurologic manifestations were more likely to be admitted to the ICU (OR 1.45, p<0.001) and ICU interventions (ECMO: OR 1.78, p=0.009 and RRT: OR 1.99, p<0.001). Hospital and 28-day mortality for patients with neurologic manifestations was higher (OR 1.51 and 1.58, p<0.001), and patients had fewer ICU-free, hospital-free, and ventilator-free days (OR -0.84, -1.34, and -0.84, p<0.001). Conclusions: Encephalopathy at admission is common in COVID-19 infection and is associated with worse outcomes. While serious neurologic manifestations including stroke, seizure, and meningitis/encephalitis were less common, all were associated with increased ICU support utilization, more severe disease, and worse outcomes.

Cerebral Venous Sinus Thrombosis as a Complication of COVID-19 Vaccination

This chapter discusses the pathophysiology and adverse effects of adenoviral vector vaccinations for SARS-CoV-2 and the importance of identifying the true epidemiology of adverse outcomes regarding promoting increased acceptance of COVID-19 vaccinations. This book chapter includes all published studies relating to outcomes after adenoviral-vector vaccination. The findings described show adenoviral vector vaccines are associated with an increased risk of thrombosis, typically with thrombocytopenia. This phenomenon has been termed vaccine-induced thrombotic thrombocytopenia (VITT). The rate of thrombotic adverse effects following vaccination remains lower than the rate of thrombosis following COVID-19 infection. At the current rate of reported severe adverse outcomes, the benefits of vaccination outweigh the risks of remaining unvaccinated regardless of the vaccine vector. © 2021 by Nova Science Publishers, Inc.