Mild COVID-19: a silent threat

Case Report: Pulmonary embolism (PE) is a form of venous thromboembolism (VTE) which causes an obstruction of the pulmonary vasculature. Massive PE can be a fatal, accounting for over 100,000 death/year in the US. Incidence of PEs is increased in COVID-19 infections, due to a hypercoagulable state resulting from endothelial injury, stasis and increase in prothrombic factors. We report a case of a 48-year-old male with past medical history of mild form of COVID-19 infection approx. 6 months back. He was brought to the ED after cardiac arrest resuscitated in the ambulance. 3 days prior to the cardiac arrest he presented in the ED for nonspecific upper respiratory tract symptoms, for which he received symptomatic treatment. During that visit all the workup was negative except for sinus tachycardia. The cause of patient's cardiac arrest was found to be massive bilateral PE leading to right ventricular strain, shock, and HFrEF (20%). Our patient received thrombolytic, ECMO, thrombectomy, anticoagulation, and required complex treatment for several complication during hospitalization. Was eventually discharged home recovered. COVID-19 pandemic has been one of the worst in human history, causing millions of deaths. Symptoms of COVID-19 infection vary from mild upper respiratory disease to respiratory failure or severe VTEs. Multiple studies including a large national study in Sweden reported COVID-19 being an independent risk factor for VTEs, risk extending up to 180 days after COVID-19 infection, especially in unvaccinated population as seen in our patient. New variants of SARS-Cov 2 pose a challenge to control the spread of COVID-19 infection. As more studies support COVID-19 infection association with hypercoagulability status, varied nonspecific symptomology of PE remains a diagnostic and treatment dilemma. Physicians should have low threshold for investigating PEs in patients with unexplained sinus tachycardia or non-specific respiratory distress, especially in an unvaccinated post-COVID-19 patient, including historical mild forms of infection. Many studies have arguably advocated "treatment to prevent thrombotic events” in post COVID- 19 infection, however, vaccination remains the corner stone to reduce morbidity and mortality associated with serious thrombotic events like massive PEs in patients exposed to COVID1-19.

Therapeutic Properties of Vanadium Complexes

Vanadium is a hard, silver-grey transition metal found in at least 60 minerals and fossil fuel deposits. Its oxide and other vanadium salts are toxic to humans, but the toxic effects depend on the vanadium form, dose, exposure duration, and route of intoxication. Vanadium is used by some life forms as an active center in enzymes, such as the vanadium bromoperoxidase of ocean algae and nitrogenases of bacteria. The structure and biochemistry of vanadate resemble those of phosphate, hence vanadate can be regarded as a phosphate competitor in a variety of biochemical enzymes such as kinases and phosphatases. In this review, we describe the biochemical pathways regulated by vanadium compounds and their potential therapeutic benefits for a range of disorders including type 2 diabetes, cancer, cardiovascular disease, and microbial pathology.

Acute respiratory distress syndrome after exposure to carfilzomib (KYPROLIS)

Case Report Introduction Plasma cell leukemia is very rare and an aggressive form of leukemia with a poor prognosis. Interim analysis of a phase II trial (EMN12/HOVON 129) using carfilzomib, lenalidomide, and dexamethasone (KRd) in patients with PCL ≤65 years showed a very good partial response or greater response in 80% with 33% achieving at least a complete response. Carfilzomib (Kyprolis TM) is a proteosome inhibitor and is associated with ARDS and acute respiratory failure in 2% of the cases per FDA package insert. We present a case report of acute respiratory distress syndrome presumed to be potentiated 2/2 to carfilzomib infusion. Case A 58-year-old male with a history of hypertension, recent COVID-19 infection and new diagnosis of untreated Plasma Cell Leukemia presented to our hospital with worsening chest pain, fatigue and dyspnea. Vitals on admission were notable for BP 158/88, HR 101, Tmax 99F and sating 100% on room air. Peripheral blood exam showed WBC: 27.7 x109/L, Hb: 8 gm/dl, platelet: 121000, corrected calcium: 13.3 mg/dl, creatinine: 1.16 mg/dl, total protein:11 g/ dl, uric acid: 8.2 mg/dl, B-2 micro globulin: 5.8 mg/L, Mspike: 5.6 g/dl;IgA lambda type. CT Chest abdomen pelvis revealed diffuse lytic bone lesions. Due to inability to obtain bone marrow biopsy from limited resources after Hurricane Ida and aggressive nature of the cancer, treatment was initiated based off a previous flow cytometry from the peripheral blood which showed 55% plasma cells. Patient started on chemotherapy with Cyclophosphamide, Carfilzomib, and dexamethasone with plans to change to Revlimid from cycle 2. He was also started on fluid hydration and Zometa for hypercalcemia. Patient also received aggressive blood pressure control with metoprolol, amlodipine and IV labetalol as needed. After 2nd dose of Kyprolis, he developed acute hypoxic respiratory distress and was initiated on Bipap. Chest Xray was concerning for fluid overload and/or evolving pneumonia. He was supported with diuretics and broad-spectrum antibiotics;however, he eventually was intubated. He was also started on high dose steroids. Repeat CT chest was negative for thrombosis, but showed extensive bilateral pleural -parenchymal opacities. He had a bronchoalveolar lavage with no obvious infection. Over the next 2 days, patient showed improvement and eventually self-extubated. After his recovery, we continued chemotherapy with Kyprolis and he has tolerated it without issues. Discussion The etiology of ARDS is likely multifactorial, however Kyprolis may have played a major role in his decompensation mainly due to the timing and known side effects of the medication. Based on a study from 2018, only 5 case reports of Kyprolis-associated non-infectious progressive lung injury were found at that time. Clinicians should be mindful of Kyprolis induced lung injury and emphasize the need for tight blood pressure control and careful administration of intravenous fluids to decrease the possibility of lung injury.

An unusual suspect for cholestatic liver injury

Introduction: Vanishing Bile Duct Syndrome (VBDS) and idiopathic cholestasis (IC) have been associated with lymphoma in rare cases. In VBDS, the defining feature on liver biopsy is ductopenia, while in IC there is canalicular cholestasis and mixed inflammatory changes. Existing literature reports a few cases of paraneoplastic cholestasis with pathological features of either VBDS or IC. We describe an unique case of severe cholestasis as the presenting sign of Hodgkin's lymphoma in the absence of bile duct loss or inflammatory changes. Case Description/Methods: 60-year-old man with no past medical history presented to the ED with increasing fatigue and jaundice that started five months earlier. He underwent cholecystectomy and intraoperative liver biopsy four months earlier which showed bland lobular cholestasis and mild lobular injury with no fibrosis, inflammatory changes, abnormal lymphocytic infiltration, or evidence of bile duct loss. An MRI/MRCP 6 weeks before presentation showed multiple small hepatic cysts and no biliary obstruction or ductal dilatation. Ursodiol 14 mg/kg/d was started 2 weeks later but he developed hypotension and presented to the ED. In the ED, vital signs were normal. Physical exam showed jaundice and hepatomegaly. Labs revealed ALP 1002 U/L, AST 81 U/L, ALT 90 U/L, total bilirubin 10.8 mg/dL, and direct bilirubin 8.1 mg/dL. Further work up showed negative AMA, ANA, ASMA and vasculitis serologies, normal ceruloplasmin, and negative viral studies including hepatitis A, B, C, HSV, CMV, HIV and COVID-19. EBV PCR was 69,697 copies/mL with positive IgG suggestive of reactivation of previous infection. Lyme and Ehrlichia serologies were negative. Repeat MRI/MRCP showed normal bile ducts but extensive retroperitoneal lymphadenopathy. Lymph node core needle biopsy revealed classic Hodgkin's lymphoma. He was started on chemotherapy and liver enzymes improved. Discussion: Hodgkin's lymphoma can present with cholestatic liver injury as shown in our patient who was on no medications and had no other identifiable causes of cholestasis. In the existing literature, VBDS and IC have been described as the pathological features for these patients where either ductopenia or canalicular cholestasis and mixed inflammatory changes are seen. Our case is unique because our patient had neither of these features. Bland cholestasis associated with lymphoma should be kept in the differential in someone with otherwise unexplained cholestatic liver injury. (Figure Presented).

Impact of COVID-19 on Hawai'i Community Agencies, Service Organizations, and the Individuals They Serve: A Snapshot from a Spring 2020 HI-EMA Survey

Health and social service organizations across Hawai'i were surveyed between April 29 and May 11, 2020 by the Community Care Outreach Unit of the Hawai'i Emergency Management Agency. This article contextualizes and describes some of the major findings of that survey that reveal the impact of coronavirus disease 2019 (COVID-19) on Hawai'i community agencies, service organizations, and the individuals they serve. Major issues for individuals served by the responding organizations included securing basic needs such as food and housing as well as access to health services, mental health needs, and COVID-19 concerns (such as inadequate personal protective equipment, cleaning supplies, quarantine, and testing issues). Respondents reported that job loss and the resulting financial problems were a root cause of personal strain among clients served. Community-level stress was related to the distressed economy and store closures. Fulfilling immediate and future needs of health and social service agencies and the individuals they serve, as articulated in this report, could dampen the effect of COVID-19, promote population wellbeing, and support community resilience. ©Copyright 2021 by University Health Partners of Hawai‘i (UHP Hawai‘i).

A Report on the Impact of the COVID-19 Pandemic on the Health and Social Welfare of the Native Hawaiian Population in Hawai'i

Native Hawaiians (NHs) are among the most vulnerable groups at greater risk for coronavirus disease 2019 (COVID-19). To understand the impact of COVID-19 on the state's population, a 35-question cross-sectional survey was administered across the state of Hawai'i. NH data from the larger report are provided here. The findings indicate that the impact of COVID-19 is disproportionately affecting NH households in areas of income and housing stability, chronic disease prevalence, emotional wellness, and COVID-19 prevention. Short-, medium-, and long-term recommendations are presented as next steps to addressing the health inequities among NHs. ©Copyright 2021 by University Health Partners of Hawai‘i (UHP Hawai‘i).

A Report on the Impact of the COVID-19 Pandemic on the Health and Social Welfare in the State of Hawai'i

The coronavirus disease 2019 (COVID-19) pandemic has had a profound impact on the world. To address the impact of COVID-19 in the state of Hawai'i, the Hawai'i Emergency Management Agency (HI-EMA) Community Care Outreach Unit conducted an assessment survey to determine the impact of COVID-19 on the health and social welfare of individuals and their families across the state. This article presents key statewide findings from this assessment, including areas of need and community-based recommendations to help mitigate the impact of the pandemic, particularly for vulnerable groups. A total of 7927 participants responded to the assessment survey from across the state's counties. In all questions related to paying for essentials, the percentage of participants that expect to have problems in the future, as compared to now, almost doubled. Slightly higher than one-third reported that they would know how to care for a family member in the home with COVID-19, and half of the respondents reported a lack of space for isolation in their home. About half reported that if they got COVID-19, they would have someone available to care for them. Overall, Native Hawaiian, Pacific Islander, and Filipino groups reported greater burden in almost all areas surveyed. The results presented provide a baseline in understanding the impact, needs, and threats to the health and social welfare of individuals and their families across the state of Hawai'i. Local stakeholders can utilize this information when developing priorities, strategies, and programs to address current and future pandemics in the state. ©Copyright 2021 by University Health Partners of Hawai‘i (UHP Hawai‘i).

Complex Network and Source Inspired COVID-19 Fake News Classification on Twitter

In COVID-19 related infodemic, social media becomes a medium for wrongdoers to spread rumors, fake news, hoaxes, conspiracies, astroturf memes, clickbait, satire, smear campaigns, and other forms of deception. It puts a tremendous strain on society by damaging reputation, public trust, freedom of expression, journalism, justice, truth, and democracy. Therefore, it is of paramount importance to detect and contain unreliable information. Multiple techniques have been proposed to detect fake news propagation in tweets based on tweets content, propagation on the network of users, and the profile of the news generators. Generating human-like content allows deceiving content-based methods. Network-based methods rely on the complete graph to detect fake news, resulting in late detection. User profile-based techniques are effective for bots or fake accounts detection. However, they are not suited to detect fake news from original accounts. To deal with the shortcomings in existing methods, we introduce a source-based method focusing on the news propagators’community, including posters and re-tweeters to detect such contents. Propagators are connected using follower-following relations. A feature set combining the connectivity patterns of news propagators with their profile features is used in a machine learning framework to perform binary classification of tweets. Complex network measures and user profile features are also examined separately. We perform an extensive comparative analysis of the proposed methodology on a real-world COVID-19 dataset, exploiting various machine learning and deep learning models at the community and node levels. Results show that hybrid features perform better than network features and user features alone. Further optimization demonstrates that Ensemble’s boosting model CATBoost and deep learning model RNN are the most effective, with an AUC score of 98%. Furthermore, preliminary results show that the proposed solution can also handle fake news in the political and entertainment domain using a small training set. Author

A Report on the Impact of the COVID-19 Pandemic on the Health and Social Welfare in the City and County of Honolulu, Hawai'i

To address the impact of COVID-19 in the state of Hawai'i, the Hawai'i Emergency Management Agency Medical Public Health Branch activated its' Community Care Outreach Unit (CCO Unit). A team from this unit developed a survey to assess the impact, needs, and threats to the health and social welfare of individuals and their families as they pertain to COVID-19. This article presents key findings for the City and County of Honolulu (CCH). A total of 5598 CCH residents responded. Approximately half of these respondents reported they or their household members experienced reduced work hours or lost their job as a result of COVID-19. In all questions related to paying for essential living costs, at the time of the survey, the percentage of participants who expected to have future problems nearly doubled. Those preparing for school in the fall school semester expected challenges centered on insufficient funds to purchase school supplies, lack of available face-coverings, and language barriers. Financial assistance, rental assistance, and food assistance seemed to be more difficult to apply for compared to health care services. The most common reasons for difficulty with applications noted by residents included that they could not figure out how to complete the form, did not have all the documents, or could not get through on the telephone. About one-half of CCH participants reported feeling nervous more than half of the days or nearly every day in the past 2 weeks. Most perceived the severity of COVID-19 to be moderate to very high. Less than half reported knowing how to provide care for someone in their family with COVID-19. Half of the CCH participants reported that they practice social distancing usually or all of the time, and the majority reported wearing a face-covering usually or always when outside of the home. A significant portion of respondents reported barriers for providing care for a household member exposed or infected with COVID-19. Such barriers included a lack of space in their home for isolation;not having enough cleaning supplies;no working thermometer in the home, or no family member available to care for them. The results presented may provide a baseline for understanding the impact, needs, and threats to the health and social welfare of individuals and their families in CCH and across the state of Hawai'i. Local stakeholders can utilize this information in developing priorities, strategies, and programs to address the pandemic as it continues to unfold and learn lessons for future pandemics.

A Report on the Impact of the COVID-19 Pandemic on the Health and Social Welfare in the County of Hawai'i, Hawai'i

The Community Care Outreach Unit (CCO) of the Hawai'i Emergency Management Medical/Public Health Services Branch conducted a survey to gauge the impact of coronavirus disease 2019 (COVID-19) on the health and social welfare of individuals and families in the state of Hawai'i. A mixed-methods framework was utilized for survey distribution;7927 respondents participated in the survey. This article presents key findings for the state's Hawai'i County (HC). It presents a descriptive analysis of the data to provide a basic overview of the impact of COVID-19 in HC, as assessed in August-September 2020. A total of 936 participants from HC responded to the survey. Approximately one-third reported that they or their family members experienced reduced work hours, and one-fifth lost their jobs because of COVID-19. Many reported difficulties paying for many types of living essentials and expected these difficulties to increase in the near future. Challenges for the fall school semester included lack of access to funds for school supplies and face-coverings. The majority perceived the severity of COVID-19 to be moderate/very high and most had at least a moderate level of knowledge about risks for developing severe COVID-19. Approximately half reported maintaining social distancing usually/all of the time, and about two-thirds reported wearing a face-covering usually/always when needed. Other barriers for COVID disease prevention and response included a lack of space for quarantine/isolation of family members, not having enough cleaning supplies, low knowledge of how to care for a household member with COVID disease and not having someone available to care for them if they contracted the virus. The results provide a baseline for understanding the impact, needs, and threats to the health and social welfare of individuals and their families as a result of COVID-19 in HC. Local stakeholders can utilize this information when developing priorities, strategies, and programs to address the pandemic where needed.

A Report on the Impact of the COVID-19 Pandemic on the Health and Social Welfare in the County of Maui, Hawai'i

The Community Care Outreach Unit of the Hawai'i Emergency Management Agency (HI-EMA) Medical/Public Heath Branch conducted a survey to gauge the impact, needs, and threats to the health and social welfare of individuals and their families pertaining to coronavirus disease 2019 (COVID-19). This article presents key findings for the County of Maui (MC) in the state. A mixed-methods framework was utilized for survey distribution and recruitment of participants from across the state. Recruitment strategies included snowball sampling via website and social media, and paper surveys. Descriptive analysis of the data is presented to give a basic overview of the impact of COVID-19 in MC. A total of 883 participants in MC responded to the survey. Approximately one-third reported that they or family members experienced reduced work hours or lost their job because of COVID-19. In all questions related to paying for essential living needs, the percentage of participants who expected to have future problems was higher than the percentage who reported having current problems. Of those preparing for the fall 2020 school semester, expected challenges included lack of funds to purchase school supplies, lack of face coverings, and language barriers. Most participants in MC perceived the severity of COVID-19 to be moderate to very high, and there was a moderate level of knowledge about which groups are more at risk for contracting severe COVID-19. Less than half would know how to provide care for someone in their family with COVID-19. Several resource barriers for caring for a family member with COVID-19 were identified. The COVID-19 pandemic has had a more severe impact on Native Hawaiian and Pacific Islander groups compared to others in the county. The results may provide a baseline for understanding the impact, needs, and threats to the health and social welfare of individuals and their families in MC. Local stakeholders can utilize this information to develop priorities, strategies, and programs to address the COVID-19 pandemic response in MC.

A Report on the Impact of the COVID-19 Pandemic on the Health and Social Welfare in the County of Kaua'i, Hawai'i

The Hawai'i Emergency Management Agency Community Care Outreach Unit (CCO) conducted a survey to gauge the impact of coronavirus disease 2019 (COVID-19) on the health and social welfare of individuals and their families across the state of Hawai'i. A mixed-methods framework was utilized for survey distribution. This article presents a descriptive analysis of the data to provide a basic overview of the impact of COVID-19 in Kaua'i County (KC), as assessed in August/September 2020. A total of 420 participants in KC responded to the statewide survey. Approximately one-third reported that they or their family members experienced reduced work hours or lost their job because of COVID-19. Many reported difficulties paying for many types of living essentials and expected these difficulties to increase in the near future. Prevalent challenges for the fall school semester included access to funds for school supplies and face-coverings. About one-third reported feeling nervous more than half the time or nearly every day in the past 2 weeks, and one-fourth reported feeling worried more than half the time or nearly every day in the past 2 weeks. The majority perceived the severity of COVID-19 to be moderate/very high and most had at least a moderate level of knowledge about risks for contracting severe COVID-19. Less than half said they would know how to provide care for someone in their family with COVID-19. Half of the respondents in KC reported maintaining social distancing usually/all of the time, the majority reported wearing a face-covering usually/always when needed. The results provide a baseline for understanding the impact, needs, and threats to the health and social welfare of households and their families in KC as a result of COVID-19. Local stakeholders can utilize this information for developing priorities, strategies, and programs to address the pandemic where needed and also to assess progress in areas of need.

A Report on the Impact of the COVID-19 Pandemic on the Health and Social Welfare of the Pacific Islander Population in Hawai'i

Hawai'i's Pacific Islander (PI) population has suffered a higher burden of coronavirus disease 2019 (COVID-19) infections, hospitalizations, and deaths compared to other groups in the state. The Hawai'i Emergency Management Agency Community Care Outreach Unit conducted an assessment across the state to gain an understanding of the impact of the COVID-19 pandemic on the health and social welfare of households. Survey data was collected from individuals across the state during a period of 3 weeks (August 12-September 5, 2020). The following are resulting recommendations from the Pacific Island community to mitigate the impact and disparities of the pandemic as immediate and medium-term structural requests: (1) ensure that Pacific Island communities are proactively represented in state and county committees that develop health interventions to ensure that relevant language and culturally tailored communications and strategies are included, (2) provide consistent funding and community centered support to ensure consistent COVID-19 impact services for the Pacific Island families, (3) enhance the capacity of PI health care navigators and interpreters through increased funding and program support, and (4) engage state policy makers immediately to understand and address the systemic structural barriers to health care and social services for Pacific Islanders in Hawai'i. These recommendations were developed to address the generational inequities and disparities that exist for Pacific islanders in Hawai'i which were exacerbated by the COVID-19 pandemic.

A Report on the Impact of the COVID-19 Pandemic on the Health and Social Welfare of the Filipino Population in Hawai'i

Hawai'i's Filipino community has been deeply impacted by coronavirus disease 2019 (COVID-19). This article reports the findings for the Filipino population from the Hawai'i Emergency Management Agency (HI-EMA) Community Care Outreach Unit (CCO) Unit evaluation assessment of the impact of COVID-19 on the health and social welfare of individuals across the state. The survey was conducted from August-September 2020. We propose recommendations to mitigate the impact of the pandemic on this community, including the following actions: (1) developing linguistically and culturally appropriate support for all COVID-19 related services, especially for the high number of older Filipinos with limited English proficiency, (2) providing support and resource information in locations that are accessible to Filipino communities, and (3) supporting those already doing work to address the deep and diverse needs in the Filipino community with funding. Building partnerships between existing Filipino organizations, health and social service providers, and state agencies will contribute to sustainability over time.

Rapid Implementation of a Statewide Observational Surveillance System to Monitor Wearing of Face Masks in Public Spaces

This report describes the rapid implementation of a statewide observational surveillance program to monitor the public's wearing of face masks in public spaces during community spread of Coronavirus disease 2019 (COVID-19). It describes how the Hawai'i State Department of Health partnered with University of Hawai'i faculty to develop and implement the surveillance program. The surveillance program involved organizing volunteers to conduct weekly direct observations in designated locations. A smartphone application (app) was created to record real-time observational surveillance data. From September 5, 2020, to March 13, 2021, a total of 84 577 observations were conducted across the state. Eighty-three percent of those observed were correctly wearing a face mask, 7% were wearing a face mask incorrectly, and 10% were not wearing a mask. Following the 2-week pilot phase of the project, volunteers were surveyed regarding facilitators and barriers for conducting observations and motivations for volunteering. Feedback was used to refine project procedures. With few states having implemented such a surveillance program, the information reported in this article may inform communities interested in tracking mask-wearing behaviors in the context of the COVID-19 pandemic.