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The uncontrollable spread of contagious disease COVID-19 is a perennial threat to mankind and has resulted in an unprecedented lockdowns in several countries including Pakistan which in turn has caused an adverse socio-economic impact to all industries. The strategic leadership and concerned state authorities are trying hard to combat and control the spread of COVID-19 pandemic. The effective use of Information Management & Decision Support (IMDS) System can play significant role in combating pandemic and its spread, managing relief actions effectively, accessing vulnerable communities to roll out targeted subsidies by ensuring the coordinated effort and subsequent implementation. Reliable information is significantly critical to assist government and public health agencies in determining the best way forward to control this global health emergency. Therefore, this paper aims to strengthen capacity of IMDS System used by government institutions and authorities for decision making and information dissemination. In this research work, we addressed the integrity-based issues that include completeness, correctness, and freshness of data by proposing a block chain-based integrity protection mechanism. The proposed novel framework is a cascaded formulation of Integrity Assurance (IA) Protocol, Cryptographic Merkle Hash Tree, Digital Signature, and Blockchain. Beside cascaded formulation, two (2) schemes for MHT Generation are also presented in the framework. The proposed framework ensures fairness, completeness, and correctness of data that will be very helpful for secure data management, integration, and utilization in analysis for decision-making. The proposed framework achieved an accuracy of more than 98.09% with better quantitative performance in standard evaluation parameters. © 2023 John Wiley & Sons, Ltd.
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Background: COVID-19 infection is associated with worse outcomes in kidney transplant recipients (KTRs). Despite wide availability of safe and effective vaccines, transplant recipients are disproportionately affected. We aim to investigate our center's experience with COVID-19 hospitalization in KTRs and measure their clinical outcomes. Method(s): In this retrospective observational cohort study, we identified KTRs who developed COVID-19 infection between March 2020 and January 2022 within our integrated health network. Through chart review, patient characteristics and outcomes were collected. Result(s): Among 186 patients who tested positive for COVID-19, 114 (61%) required hospitalization out of which 53 received at least one dose of vaccine and 61 were unvaccinated. Among the unvaccinated, 26 (43%) patients were admitted prior to January 2021 when vaccines were not yet widely available. Vaccination rate among patients admitted after January 2021 was 53/88 (60%). Baseline characterisitcs between vaccinated and unvaccinated patients were similar. There were 24 deaths during admission and another 7 deaths within 90 days, for a total of 31/114 (27%). There was a trend towards lower mortality in vaccinated patients (10/53 (19%) vs. 21/61 (34%), p=0.06). The need for dialysis was significantly lower in vaccinated patients (9/53 (17%) vs. 21/61 (34%), p=0.03) (Table). Conclusion(s): COVID-19 infection is associated with higher mortality in KTRs with a mitigating effect from vaccination. Decreased dialysis requirement in vaccinated but hospitalized KTRs with COVID-19 infection likely reflects less severe infection, indicating that vaccination confers allograft protection. Every effort should be made to encourage and educate KTRs regarding COVID-19 vaccination including booster doses in order to reduce morbidity and mortality. (Figure Presented).
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Background: Mortality rates for COVID-19 infection vary widely. Immunocompromised patients in general have worse outcomes. We aimed to evaluate kidney transplant recipients (KTRs) who were admitted for COVID-19 infection and investigate patient specific factors or comorbidities that may have influenced mortality rates. Method(s): In this retrospective study, we identified KTRs who developed COVID-19 infection between March 2020 and January 2022 within our integrated health network. Through chart review, patient characteristics were collected and stratified by 90-day mortality. Result(s): Out of 114 KTRs hospitalized with COVID-19 infection, 24 (21.0%) died during admission, and another 7 died within 90 days of admission bringing total 90-day mortality to 31/114 (27.2%). Among the114 hospitalized patients, 53 (46.5%) had received at least one prior COVID-19 vaccine dose including 35 who received two doses and 9 who received >=3 doses. KTRs who survived following COVID-19 hospitalizations were significantly younger and were more likely to be vaccinated (Table). Conclusion(s): Approximately 1 out of 4 KTRs admitted for COVID-19 infection died within 90-days. Older age was a mortality risk factor and vaccination conferred protection against mortality in these immunocompromised patients. Our study highlights the importance of vaccination in these patients. Relatively small sample size likely limited identification of other potential risk factors for mortality in our analysis.
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Background: Multiple studies have shown an association between immune status and SARS CoV-2 disease severity, however data on specific immunosuppressive medications is not fully described. Immunocompromised individuals are at increased risk of mortality and morbidity therefore, vaccination against COVID-19 is essential. Research also suggests that elevated IgG levels post-vaccination correlate with host viral neutralization. We present data indicating that induction and maintenance immunosuppression therapy affects responsiveness to SARS CoV-2 vaccination among kidney transplant recipients. Method(s): 48 kidney transplant patients at our institution were retrospectively analyzed after receiving two doses of the SARS CoV-2 mRNA type vaccine between January and March 2021. Kidney transplantation occurred between 1983 and 2020. SARS-CoV-2 spike antigen-specific IgG levels were measured after 30-days to evaluate immunological responsiveness to the vaccine. Result(s): 35% of study subjects showed detectable peak COVID IgG serum levels 30 days after the second vaccine dose while 65% showed no response. Of the nonresponders, (62%) were predominantly heavily immunocompromised;on either high dose Mycophenolate (at least 720 mg twice daily) in addition to standard Calcineurin inhibitor/Sirolimus +\- Prednisone), or had received high dose Thymoglobulin (6 mg/kg or more) within a year of vaccination. This contrasts to published reports of over 95% immunological responsiveness or viral neutralization after the second vaccination dose among immunocompetent patients. Conclusion(s): Induction therapy with Anti-Thymocyte globulin and maintenance immunosuppression with Mycophenolate serve as the cornerstone of transplantation management. However, their utilization impacts B cell proliferation which is hypothesized to reduce antibody production and the effectiveness of the SARS-CoV-2 vaccine in transplant patients. This finding supports the need for a third or possibly fourth booster dose to achieve a sustained and effective response in combination with ongoing immunological surveillance post-vaccination among transplant patients.
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Background: Studies have shown suboptimal immunological response to COVID-19 vaccination in kidney transplant recipients (KTRs). We aimed to describe specific characteristics of vaccinated KTRs who required hospitalization for COVID-19 infection. Method(s): In this descriptive study utilizing chart review, we identified KTRs who were hospitalized for COVID-19 infection between March 2020 and January 2022 within our integrated health network. Demographic characteristics were identified for KTRs who received >=2 COVID-19 vaccine doses prior to hospitalization. Result(s): Among 114 KTRs admitted to the hospital with COVID-19 infection, 44 (39%) had received 2 or more vaccine doses prior to hospitalization including 35 patients who received 2 vaccines and 9 who received >2 vaccines. Vaccinated patients requiring hospitalization were generally older with male predominance. Prevalent comorbidities included overweight/obesity, hypertension, and diabetes. Among these patients, 18% required dialysis and 90-day mortality was 20% (Table). Conclusion(s): Despite receiving at least 2 doses of preventative vaccination, many KTRs developed COVID-19 infection requiring hospitalization. Our findings are consistent with studies showing reduced antibody and cell mediated response to vaccination in KTRs. Every effort should be made to educate and encourage this vulnerable population about measures to prevent infection, especially vaccination with subsequent booster doses.
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Purpose: The COVID-19 pandemic portends significant morbidity and mortality in immunocompromised individuals. Vaccination against COVID-19 among immunocompromised population is an essential step to minimize deadly complications. Numerous studies have shown an association between immune status, disease severity, and suboptimal responsiveness to vaccination. Additionally, data suggests that elevated IgG levels correlated with host viral neutralization. We herein present data indicating that induction and maintenance immunosuppression therapy affects responsiveness to vaccination among kidney transplant recipients. Method(s): The study data was retrospectively analyzed for 48 kidney transplant patients who received mRNA type COVID-19 vaccine at our institution. Majority of patients received vaccination between January and March 2021;two doses in total. The 30 days post-vaccination SARS-CoV-2 spike antigen-specific IgG levels were measured to assess immunological response to vaccine. Result(s): The included patients underwent kidney transplantation between 1983 and 2020. Among these patients, 35% showed detectable peak COVID IgG serum levels 30 days after the 2nd vaccine dose. A total of 31 patients (65%) did not show any response;majority of these non-responders (62%) were heavily immunocompromised, either on high dose Mycophenolate (at least 720 mg twice daily) in addition to standard Calcineurin inhibitor/Sirolimus+/-Prednisone), or had received high dose Thymoglobulin (6 mg/kg or more) within a year of vaccination. Among immunocompetent patients, over 95% immunological responsiveness or viral neutralization after the second vaccination dose has been reported. Conclusion(s): Anti-thymocyte globulin as induction immunosuppression and antimetabolites like Mycophenolate as maintenance immunosuppression serve as the cornerstone of transplantation management. However, their utilization impacts B cell proliferation, thereby reducing antibody production and the effectiveness of the SARS-CoV-2 vaccine in transplant patients. The ability of these immunosuppressive medications to suppress responsiveness to the SARS CoV-2 vaccine supports the need for 1) regular immunological surveillance post-vaccination among transplant patients, and 2) the need for a third or possibly fourth booster dose to achieve a sustained and effective response.
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Purpose: Vaccination against SARS-CoV-2 is essential. Complicating this effort are reports of a suboptimal response to the SARS-CoV-2 spike protein in patients on immunosuppressive medications and possible thrombotic microangiopathy (TMA) in renal transplant patients who receive the mRNA type vaccines. Method(s): 48 year old male with end stage renal disease who received a living unrelated transplant in 2015. Pre-operative creatinine was 10.42 mg/dL and decreased to 2.48 mg/dL within a week. Patient received Basiliximab induction and maintained on tacrolimus and mycophenolate (MMF). One month post-transplant patient was diagnosed with TMA. Tacrolimus was stopped and patient was switched to Sirolimus and continued on MMF. Patient was followed closely by transplant nephrology for the next 5 years with a baseline creatinine of 1.9 mg/dL, protein to creatinine ratio below 0.5 mg/mg and well controlled diabetes. No DSA Class I or II detected on regular testing. Patient was compliant with all prescribed medications. On January 25 2021 patient received Pfizer Vaccine. Second Pfizer vaccine administered on February 18 2021. A week later creatinine was noted to be 3.44 mg/dL. Repeat creatinine of 4.27 mg/dL. Biopsy revealed diffuse lymphocytic interstitial inflammation, peritubular capillaritis, and C4D negative. Findings consistent with chronic TMA. DSA testing revealed Class II DSA:DQ2 (SI-5933), Allosure 1.2 %. BK < 500 and CMV undetected. Patient received therapeutic plasma exchange, IV Ig infusion and steroids while on MMF and sirolimus. His creatinine decreased to 2.9 mg/dL on discharge. Over the next 6 months graft function deteriorated. He is now CKD stage 5 and under evaluation for a second transplant. Result(s): There are case reports of COVID-19 vaccine administration and transplant graft dysfunction. A possible mechanism involves the mRNA lipid nanoparticleencapsulated platform producing such a robust CD4 and CD8 T-cell response that pro-inflammatory cytokines are activated or that immune complex associated glomerular disease occurs resulting in the development of TMA in susceptible patients. Conclusion(s): A possible link between SARS CoV-2 vaccination and kidney transplant TMA warrants the implementation of close surveillance of vaccinated transplant patients, particularly susceptible individuals. More research is needed to determine if this link exists.
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Purpose: COVID-19 infection involves entry of SARS-CoV-2 virus into cells via interaction between its spike protein and angiotensin converting enzyme resulting in an NF-kappabeta mediated inflammatory response. A cytokine storm may cause organ dysfunction. Cardiac manifestations without pulmonary symptoms is uncommon but has been described in the literature during an acute infection. We report a rare case of a potential late cardiac complication months after an acute COVID-19 infection. Method(s): A 62-year-old male with hypertension and end stage renal disease on hemodialysis three times a week presented with fever, arthralgia and myalgia. He denied chest pain or respiratory symptoms. Patient tested positive for COVID-19 and received conservative management only. Over the next nine months he reported persistent fatigue and new onset of shortness of breath. He continued to be very compliant with dialysis. On presentation to the hospital, all laboratory investigations, including BUN (27mg/dL) were within normal limits. Chest X- ray revealed cardiomegaly. Echocardiogram showed a large circumferential pericardial effusion without tamponade. Pericardiocentesis was accomplished with removal of 1700 ml of bloody fluid. Cell count, LDH, protein and glucose was normal. Fungal, aerobic, and anaerobic cultures of the pericardial fluid was negative. No malignant cells were detected. Patient had gradual resolution of his symptoms. Serial echocardiograms at 1, 3 and 5 months revealed a persistent small pericardial effusion. Result(s): Cardiac manifestations of SARS-CoV-2 includes myocarditis, pericarditis and pericardial effusions. In case reports, the presence of the cardiac inflammatory state occurred simultaneously with an acute COVID-19 infection. In our case the COVID-19 infection occurred over nine months earlier yet remains a plausible explanation for his hemorrhagic pericardial effusion due to the absence of other identified causes. Further, COVID-19 molecular PCR testing of pericardial testing remains low yield due to its specific development for nasopharyngeal swab sampling. Conclusion(s): Cardiac manifestations of SARS-CoV-2 infection typically occur at the time of diagnosis. A late cardiac complication of COVID-19 may include pericardial inflammation with effusion. Further data and testing needs to be developed to confirm the diagnosis and guide therapy.
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The coinfection with novel coronavirus disease (COVID-19) and cytomegalovirus (CMV) among disease donor kidney transplant (DDKT) recipients is rarely reported, to date. We present a case series of 3 DDKT recipients coinfected with COVID-19 and CMV. A 37 year-old male with DDKT secondary to membranous glomerulonephritis, presented with pneumonia, acute kidney injury (AKI), positive COVID-19 and CMV. Patient was admitted to ICU due to worsening respiratory status and Ganciclovir-resistant CMV pneumonitis, for which high dose Ganciclovir was given. After 10 days in ICU, respiratory status, oxygen requirement, and CMV titers improved, and patient was subsequently discharged. A 49 year-old female with DDKT secondary to diabetes, presented with pneumonia, AKI, positive COVID-19 and CMV. Despite initial standard treatment, patient remained hypoxic and subsequently intubated. After a prolonged and complicated 35 days ICU course, patient was eventually extubated and is currently stable. A 49 year-old male with DDKT secondary to diabetes, presented with fever, abdominal pain, AKI, positive COVID-19 and CMV, without any respiratory compromise. Patient was started on Ganciclovir and continued on immunosuppression. Over the course of next few days, patient's symptoms improved and was discharged. (Figure) Among DDKT recipients, the coinfection of COVID-19 and CMV is rare and very challenging in the setting of their immunosuppressed status. Interestingly, our stated 3 cases of coinfection and AKI were relatively young and presented within a year of transplant, and were successfully recovered. The COVID-19 and CMV coinfection can lead to variable disease severity among DDKT recipients and can be treated with combined antiviral and immunosuppressive regimen. A high index of suspicion for coinfection is warranted in immunocompromised patients with atypical or prolonged respiratory failure.
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Background: Unexpectedly and unfortunately the end of the year 2019 has proved to be the start of a deadliest era of Coronavirus disease 19. Spread of this lethal disease has remained uninhibited so far. How rapidly it has wrapped up the whole world is dangerously alarming. Aim: To determine frequency of Covid outcome in Covid patients with preexisting different co-morbid conditions. Methods: This descriptive study was conducted from July 2020 to January 2021 in two tertiary care hospital i.e. Services hospital, Lahore (Punjab) and hospital, Quetta (Baluchistan). After ethical approval and informed consent from the patients, data from PCR positive patients was recorded. The demographic parameters, travel or exposure history, duration of stay in the hospital and co morbidities including diabetes, hypertension, stroke and ischemic heart diseases of the patients were collected. Results: In our study, total 124 patients including 84(67.7%) male and 40(32.3%) female. The mean ages was 41.29±20.21 years, mean weight and height 83.46±15.1, 174.2±8.31. 82%patients were discharged, and 42%patients suffered death. Among the patients included in this study, 51(%) patients presented with diabetes, 55(%) patients presented with hypertension, 52% had ischemic heart diseases and 1.6% had stroke. Conclusion: The conclusion of this study, there is a significant impact of pre-existing co-morbidities on Covid outcomes. Thus, it can be inferred that by modifying the comorbidities, positive outcome can be observed.
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Background: Timing of kidney replacement therapy (KRT) and transplant referral in chronic kidney disease (CKD) G4 and G5 is a difficult topic. The COVID-19 pandemic has disrupted nearly all aspects of healthcare, including the process of KRT plan. This study examined if the addition of a Transition Coordinator (TC) improved KRT transition plan despite the pandemic. Methods: Retrospective descriptive study examining patients at single academic practice with eGFR <20 that completed CKD educational program (CKDEP). Control Group: 5/1/19-1/31/20 with in-person CKDEP, no TC. Intervention Group (IG): 5/1/20-1/31/21 with virtual or in-person CKDEP with addition of TC. TC called patient monthly to assess barriers to KRT planning, assist with scheduling, and communicate with Nephrologist. Success was defined as having a KRT plan. Failure was defined as either urgent start dialysis via dialysis catheter (DC) or patients without KRT plan. Results: CG had n=15 while IG had n=47. Both groups were evenly distributed with age, average eGFR (15). The CG had slightly higher rates of urgent starts and patients without KRT plan compared to IG (Table 1). Patients were referred for Vascular access +/-Transplant 20% (3) in CG and 23% in IG. PD +/-Transplant was chosen in 6.7% (1) of CG and 36% (17) of IG. Success and Failure rates were similar in both groups (Table 2). Conclusions: Despite the pandemic, there was no overall change in rate of failure (urgent start or lack of KRT plan), however, individual decreases in these groups were noted. This could indicate that TC may improve outcomes when the pandemic is controlled. Increased interest in PD was noted which could indicate greater understanding via follow up provided by TC. (Table Presented) .
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INTRODUCTION: Malignancies metastasizing to the stomach are rare and occur during the late stages of malignancy. Primary malignancies associated with gastric metastases include melanoma, esophagus, lung, renal cell carcinoma and breast. Of patients with metastatic breast cancer, one review reported a 0.3% incidence rate.We report a patient with known metastatic breast cancer to the bone and healing gastric ulcers found to have biopsy-proven breast cancer metastasis to the stomach. CASE DESCRIPTION/METHODS: A 74 year-old female with a past medical history of invasive lobular carcinoma of the breast complicated by bone metastases presented to an outpatient clinic for hospital follow-up. Although originally presenting to the hospital secondary to hematemesis, esophagogastroduodenoscopy (EGD) findings reported a pyloric ulcer with a bleeding vessel requiring epinephrine injections and heater probe cauterization. The ulcer was likely due to nonsteroidal anti-inflammatory drug (NSAID) use. She was discharged with a proton pump inhibitor twice daily with no further bleeding. Follow-up EGD reported ulcer healing;however, antral thickening was noted. Antral biopsies reported poorly differentiated adenocarcinoma with negative staining for cytokeratin 20 and CDX2 whereas estrogen receptor staining reported nuclear positivity in the neoplastic cells with mammaglobin suggesting breast cancer as the primary source. She was continued on palliative chemotherapy with palbociclib, letrozole, and denosumab. Unfortunately, she suffered frequent admissions for recurrent gastrointestinal hemorrhage and eventually passed away due to complications of coronavirus disease 2019. DISCUSSION: Metastases to the stomach are a rare complication of breast cancer. Such etiologies could be considered in breast cancer patients with recurrent gastrointestinal bleeding. Given her history of a gastric ulcer secondary to NSAID use, symptoms of hematemesis was attributed to gastric ulcers. However, gastric mucosal irregularities are not always obvious with metastatic lesions. Furthermore, up to 30% of cases may be missed due to metastatic spread to deep mucosal layers. Given this, in patients with a history of malignancy, suspicion for metastatic lesions should remain high especially if they have gastric mucosal irregularities. These should always be investigated with biopsies to prevent delays in management.