Overview & Summary: COVID-19: Addressing Ongoing Pandemic Mental HealthConcerns for Providers

The COVID-19 pandemic has had a profound impact on the mental and emotional wellbeing of healthcare providers. Post-Traumatic Stress Disorder (PTSD) is commonly associated with experiencing a significant threat to the self, or witnessingone, bringing forth feelings of sadness, fear, flashbacks, or memory repression of the event(s) (Sadock & Sadock, 2015). As anexpert in the field of Psychiatric-Mental Nursing for almost two decades, I have frequently found depression and anxietyprevalent across various populations exposed to traumatic events, including persons with chronic and persistent mentalhealth conditions;children, and adolescents with similar manifestations;those with military backgrounds;and mostespecially nurses who have cared for patients throughout the COVID-19 Pandemic © 2023,Online Journal of Issues in Nursing. All Rights Reserved.

Ensovibep antiviral activity in ambulatory patients with COVID-19 is independent of baseline anti-SARS-CoV-2 antibodies and exhibits minimal selective pressure - Results from the placebo-controlled EMPATHY trial

Background. Ensovibep is a multi-specific DARPin (designed ankyrin repeat protein) antiviral in clinical development for treatment of COVID-19. In the Phase 2 EMPATHY study, ensovibep demonstrated greater viral load decline versus placebo. Here we report (1) the efficacy of ensovibep in patients with and without anti-SARS-CoV-2 antibodies at baseline and (2) SARS-CoV-2 mutation emergence data with treatment. Methods. Eligible ambulatory patients with >=2 COVID-19 symptoms (onset within 7 days) and positive SARS-CoV-2 rapid antigen test on day of dosing, were randomized (1:1:1:1) to ensovibep (600, 225 or 75 mg) or placebo as single, IV infusion. Chemiluminescent immunoassays were used for antibody detection (SARS-CoV-2 S1/S2 IgG and SARS-CoV-2 IgM). A pre-specified subgroup analysis was performed based on baseline anti-SARS-CoV-2 antibody status. Analysis of changes in viral genome from baseline to post baseline was performed to evaluate treatment-emergent mutations. Results. Of the patients analyzed, 48.5% had anti-SARS-CoV-2 antibodies at baseline. Baseline log10 SARS-CoV-2 viral load (mean +/-SD) was similar across groups [ensovibep (all doses) 6.5 +/-1.5, placebo 6.2 +/-1.5];> 90% were infected with the Delta (B.1.617.2) variant. SARS-CoV-2 viral load reduction up to Day 8 showed similar effects in favor of ensovibep compared with placebo regardless of the presence of anti-SARS-CoV-2 antibodies (Figure 1). Patients in ensovibep 75 mg, 600 mg, and placebo groups had comparable incidences of emergent mutations, with a higher incidence in the 225 mg group. Based on analysis of 70% of the expected viral sequencing data, two mutations in the key binding residues of ensovibep were observed (Y489H and F486L) in a total of three patients treated with ensovibep. These patients either cleared virus by Day 8 or mutations were transient (occurred at a single time point but not later in the course of infection). (Figure Presented) Conclusion. Ensovibep effectively reduces SARS-CoV-2 viral load regardless of the presence of anti-SARS-CoV-2 antibodies at baseline. Furthermore, there were no emerging mutations of concern, indicating that a single dose administration of ensovibep is associated with minimal selective pressure.

Duration of Seroprevalence among Individuals Previously Infected with SARS-CoV-2 and their Household Contacts

Background. Serological tests directed against SARS-CoV-2 can provide information about the timing of infection and immunity against the virus. However, the kinetics of the host immune response to SARS-CoV-2 remain poorly understood. We established a household transmission study to analyze the serological responses within households, to determine longitudinal immune responses to infection. Methods. From April 2020 to April 2022, we prospectively enrolled 76 households with at least one RT-PCR confirmed case of COVID-19. Participants were asked to provide blood samples at three time points: at baseline within 2 weeks of the index's diagnosis of COVID-19, and at one- and three-months post-enrollment. Samples were tested for the presence of IgG antibodies against SARS-CoV-2 spike protein via an FDA EUA approved ELISA. Demographics, medical history, and symptomatology were also collected. Results. To date, we have analyzed 238 serologic samples from 135 participants, including 82 baseline samples, 89 one-month samples, and 67 three-month samples. At baseline, 67.8% (n=40/59) of all confirmed cases tested positive for SARS-CoV-2 antibodies, which increased to 86.4% (n=57/66) at the one month, and 85.1% at three months (n=40/47). Of those confirmed infected participants that failed to seroconvert at baseline, almost all reported symptoms (n=14/19, 73.7%) and did not have chronic medical conditions (n=17/19, 89.5%). Of the 19, 3 failed to seroconvert by their third visit. All individuals who were fully vaccinated at the time of each visit tested positive for antibodies at baseline (n=26), one-month (n=27), and three-months (n=20). Of those who were not fully vaccinated, 56 (41.1%) were positive for antibodies at baseline, 62 (59.7%) were positive at one -month, and 47 (63.8%) at three-months. Differences in seropositivity rates between pediatric and adult participants, as well as between index cases and household contacts, at each visit were also identified (Table 1). Conclusion. Identifying differences in seroprevalence in various demographic groups can provide insight into longitudinal immune responses post-infection. Future analyses on seropositivity among previously infected individuals who received therapeutics may be of interest.

ADAMTS13 activity and non-parallel vWF Ristocetin CoFactor activity are associated with severity of COVID-19 infection

Background: Increased von Willebrand factor (VWF) is common in COVID-19 infection. vWF levels are reported at levels where pre-dilution of samples is required. The assumption is that such dilutions respond linearly across the measurement range, and that this response is consistent across patient subgroups. ADAMTS13 levels have also been reported as reduced in those most severely affected. The interaction of these biomarkers has potential consequences to understanding pathophysiology of COVID-19. Aim(s): To investigate the linearity of dilution of high VWF levels in patients with COVID-19 To compare the response in those mildly affected to those requiring more intensive therapy Methods: This is a laboratory bases study investigating a convenience sample of fifty age and gender matched patients hospitalised during the first wave of the COVID-19 pandemic (March to June 2020). Patients had been hospitalised for >24 hours before enrolment. Platelet RiCof activity was using the VW Select assay (BioData Corps, Horsham, USA). Dilutions were made using assay buffer provided in the kit. Data was collected in Microsoft Excel, before being analysed in both Microsoft Excel and the statistical programming environment R (R Core Team (2021)). Result(s): The findings of Mancini et al were replicated here in that locale of patient admission was associated with a statistically significant reduction of ADAMTS13 activity (ITU mean 60.21 v non-ITU mean 92.23). The activity of ADAMTS13 remained within what would be a reference range for diagnosis of TTP. VWF activity by Platelet RiCof was markedly raised. Serial dilution of samples demonstrated non-parallelism, the response being most marked in severely affected patients. Conclusion(s): Very high VWF levels disrupt the balance with mildly reduced ADAMTS13. In severe COVID-19 infection, the effect manifests as non-parallelism in platelet RiCof parameters. This calculated parameter classifies patients both by presence and severity of disease across all parameters in the platelet Ristocetin CoFactor assay. (Figure Presented).

Assessing endothelial activation and risk of bleeding in patients receiving VV-ECMO supportive therapy for COVID-19 using non-standard laboratory assays

Background: Critically ill patients infected with the SARS-CoV- 2 virus are known to have a coagulopathy with a risk of thrombosis due to endothelial activation and systemic inflammation. Veno-venous extracorporeal membrane oxygenation (VV ECMO) is recommended by the World Health Organisation (WHO) as a supportive therapy for patients with severe COVID-19 infection when conventional ICU methods have proven ineffective. VV ECMO comes with haematological complications, including loss of high molecular weight von Willebrand factor multimers, consumption of clotting factors and premature activation of platelets. Laboratory methods to characterise haemostasis in these patients are required and may be clinically useful in predicting clinical outcome. Aim(s): Can non-standard methods provide clinically meaningful results in COVID-19 positive patients supported by VV ECMO? Methods: Tissue plasminogen activator and von Willebrand factor were quantified via Abcam SimpleStep ELISA in VV ECMO supported Covid-19 patients and normal controls. Fibrinogen antigen concentration was quantified via Liaphen Fibrinogen Antigen assay in VV ECMO supported Covid-19 patients and normal controls. VW Select ristocetin cofactor assay was used to assess von Willebrand Factor activity in VV ECMO supported COVID-19 patients. Result(s): Tissue plasminogen activator and von Willebrand factor concentrations are significantly increased in COVID-19 patients supported by VV ECMO compared to healthy controls, which reflects endothelial damage displayed in critically unwell COVID patients. Fibrinogen levels were not significantly different between the two patient groups. The VW Select ristocetin cofactor assay detected patients with low vWF activity that would have otherwise been overlooked by standard methods. Conclusion(s): Non-conventional laboratory methods can be used to represent the extent of endothelial damage and risk of bleeding in patients who are COVID-19 positive and anticoagulated on VV ECMO support. The assays help to characterise pathology of COVID-19 used in conjunction with standard tests by providing clinically relevant results. (Figure Presented).

Pre-analytical screening and removal of Argatroban interference for haemostasis assays

Background: Argatroban is a direct thrombin inhibitor licenced in the UK and USA for treatment of Heparin Induced Thrombocytopenia and has been utilised as alternative anticoagulation for critically ill COVID-19 patients. Interferences in specialised haemostasis assays may be clinically important when bridging anticoagulant regimens or investigating thrombotic and bleeding complications common in critically ill patients. Aim(s): * Assess effect of Argatroban on specialised haemostasis assays * Assess effectiveness of DOAC-Remove (DR) in removing Argatroban interference Methods: Argatroban calibration plasma, spanning concentrations of 0 mug/ml-2.08 mug/ml, was tested for Antithrombin (IIa activator), Factors IX, and XI, and dilute Russel's viper venom time (dRVVT) to assess Argatroban interference. Samples were treated with DOAC-Remove and re-run for these assays. A p value of <0.05 was used to assess significance using paired t-tests Results: * Antithrombin results were significantly and linearly increased by increasing Argatroban concentrations (R -0.99). * Factor IX and XI concentrations were significantly decreased by increasing Argatroban concentrations from 83.4 IU/dl at 0 mug/ml to 3.79 IU/ dL at 2.07 mug/ml Argatroban * dRVVT screen results were significantly increased by increasing Argatroban concentrations (DRVVT ratio 1.07 (no Argatroban) to 3.79 at 2.07 ng/ml Argatroban) * Pre-treatment of samples with DOAC-Remove completely removes Argatroban interference to baseline. Conclusion(s): Argatroban has significant effects on specialist haemostasis assays. Antithrombin overestimation was observed when IIa activator is used, a Xa activator should be considered in such patients. dRVVT screen ratios were significantly increased, which could lead to false positive Lupus anticoagulant results. Factors IX and XI results were significantly decreased. Similar results have been published for direct oral anticoagulants with the need for pre-analytical screening, where anticoagulant status is unknown, becoming more important. For Argatroban, dilute thrombin time can be used as a pre-analytical screening tool. (Table Presented).

Dilute thrombin time versus activated partial thromboplastin time to monitor Argatroban in critically ill patients

Background: Argatroban is a direct thrombin inhibitor currently licenced in the UK and USA for treatment of Heparin Induced Thrombocytopenia (HIT) and has been utilised as an alternative anticoagulant for critically ill COVID-19 patients. UK and US guidelines recommend Argatroban monitoring via activated partial thromboplastin time (aPTT), in critically ill patients, recommending ratios of between 1.5-3 times patient's baseline, without exceeding 100 s. This guidance is based on spiked pooled platelet poor plasma with increasing concentrations of Argatroban. Aim(s): * Does the aPTT demonstrate suitable linearity for Argatroban monitoring? * Are readily available alternatives more useful to indicate extent of Argatroban anticoagulation? Methods: From May to July 2021, 97 residual blood samples from 12 patients receiving Argatroban were processed for HemosIL APTT-SS, Thrombin time, Argatroban, and dilute thrombin time using ACL-TOP750 (Werfen, Bedford, USA). Performance was compared to commercial calibrators, across a therapeutic range from 0-2.08 mug/ml mimicking spiked plasma. Result(s): * No linearity was observed between Argatroban concentration and aPTT ratio (R2 value of 0.0778) in critically ill patient plasma compared to linearity for APTT ratios (R2 value of 0.9346) in commercial calibrators * Thrombin time produced good linearity with Argatroban (R2 value of 0.8473). Non-specific clot curve kinetic issues and exceeding acquisition times were noted. * Dilute thrombin time produced very good linearity with Argatroban (R2 value of 0.9443) Conclusion(s): In critically ill patients, aPTT ratio lacks a demonstrable linear response, unlike spiked and commercial plasmas. Non linearity is most likely due to other effects on the aPTT than Argatroban alone. 10.3% of patients exceeded an Argatroban concentration of 2.08 mug/ml with an aPTT ratio within guideline quoted ranges. Thrombin time and dTT demonstrated linearity. However, the thrombin time had non-specific clot curve kinetic abnormalities and some results exceeded acquisition time. No issues were seen with dilute thrombin time.

Heterogeneity in the onwards transmission risk between local and imported cases affects practical estimates of the time-dependent reproduction number.

During infectious disease outbreaks, inference of summary statistics characterizing transmission is essential for planning interventions. An important metric is the time-dependent reproduction number (Rt), which represents the expected number of secondary cases generated by each infected individual over the course of their infectious period. The value of Rt varies during an outbreak due to factors such as varying population immunity and changes to interventions, including those that affect individuals' contact networks. While it is possible to estimate a single population-wide Rt, this may belie differences in transmission between subgroups within the population. Here, we explore the effects of this heterogeneity on Rt estimates. Specifically, we consider two groups of infected hosts: those infected outside the local population (imported cases), and those infected locally (local cases). We use a Bayesian approach to estimate Rt, made available for others to use via an online tool, that accounts for differences in the onwards transmission risk from individuals in these groups. Using COVID-19 data from different regions worldwide, we show that different assumptions about the relative transmission risk between imported and local cases affect Rt estimates significantly, with implications for interventions. This highlights the need to collect data during outbreaks describing heterogeneities in transmission between different infected hosts, and to account for these heterogeneities in methods used to estimate Rt. This article is part of the theme issue 'Technical challenges of modelling real-life epidemics and examples of overcoming these'.

Point-of-Care Ultrasound Education During a Pandemic: From Webinar to Progressive Dinner-Style Bedside Learning

Objective: Point-of-care ultrasound (POCUS), traditionally, requires the proximity of learners and educators, making POCUS education challenging during the COVID-19 pandemic. We set out to evaluate three alternate approaches to teaching POCUS in UME. Sessions progressed from an online seminar to a remote, interactive simulation to a “progressive dinner” style session, as precautions evolved throughout the pandemic. Methods: This prospective study details a series of three POCUS workshops that were designed to align with prevailing social distancing precautions during the COVID-19 pandemic. Overall, 656 medical students were included. The first and second workshops used web-based conferencing technology with real-time ultrasound imaging, with the second workshop focusing on clinical integration through simulation. As distancing precautions were updated, a novel “progressive dinner” technique was used for the third workshop. Surveys were conducted after each session to obtain feedback on students’ attitudes toward alternative teaching techniques and quantitative and qualitative analyses were used. Results: The initial, remote POCUS workshop was performed for 180 medical students. Ninety-nine (177) percent of students felt the session was “intellectually challenging” and “stimulating.” Ninety-nine percent of students (340/344), after the second workshop, indicated the session was intellectually challenging, stimulating, and a positive learning experience. Students' ability to correctly identify pathologic images increased post-session evaluation from in-session polling. For workshop three, 99% (107/108) of students indicated that the session was “informative.” There was a significant improvement in pre- to post-workshop knowledge regarding image acquisition, interpretation, and clinical integration. Conclusion: While image acquisition skills are best conveyed at the bedside, these modified POCUS teaching techniques developed and delivered in alignment with COVID-19 pandemic restrictions during a series of three workshops were shown to be effective surrogates for traditional teaching approaches when social distancing requirements, a large learner pool, or lack of local expertise exist.

Translating Science into Improved Health for All.

Our world is at a turning point with biological and social pathogens wreaking havoc at the same time that science and technology are exploding with new discoveries. It is a pivotal time for the new report Oral Health in America: Advances and Challenges to be released and a pivotal time for our profession to take action and lead. The art, science, and practice of dentistry is very different from 20 y ago when the original Surgeon General's report was released. We are on the precipice of individualized health care where providers will collaborate to deliver diagnostics and therapeutics that are data driven and inclusive of the social determinants of health. To move forward with alacrity requires a strong scientific foundation, effective educational approaches, an understanding of the upstream determinants of health, and partnerships across the health professions and beyond. Oral health has never been more important, and now is the time for our profession to further develop, elevate, and translate the science into practice and policy to improve the nation's health.

eP236: TeleKidSeq: Incorporating telehealth into clinical care of children from diverse backgrounds undergoing clinical genome sequencing

Introduction: The global pandemic required healthcare institutions and clinical research programs to adapt quickly to non-traditional care models. TeleKidSeq is a pilot study that emerged from the NYCKidSeq program, an NIH-funded Clinical Sequencing Evidence-Generating (CSER) Consortium site focused on incorporating genomic medicine into the care of diverse New York City children with suspected genetic disorders. Embracing the opportunity to study the use of telehealth in delivering genomic results, TeleKidSeq will examine the impact of innovative remote genetic counseling modalities in medically underserved populations. Studies focusing on the use of telehealth performed before the COVID-19 pandemic have shown that patients prefer in-person visits to virtual visits;however, with the increased familiarity and widespread use of virtual platforms, we anticipate an increase in the preference for telehealth visits. TeleKidSeq aims to fill the gaps in current knowledge on the impact of visual aids in telehealth in diverse urban patient populations. Methods: TeleKidSeq will recruit 496 pediatric participants (aged 0-21 years) with neurologic, immunologic, or cardiac conditions suspected to have an underlying genetic cause who receive care predominantly within two large health systems in the New York metropolitan area. The Mount Sinai Genomics Stakeholder Board, consisting of diverse stakeholders and key community advisors, provided guidance about our study design and materials. Participants will be English- or Spanish-speaking, and based on prior enrollment data from NYCKidSeq study, we expect more than 65% will be from populations underrepresented in medical research. Prior to enrollment, participants will be randomized to receive their genomic results from a genetic counselor via telehealth either with screen sharing (ScrS) or without screen sharing (NScrS). All participants will receive genome sequencing (GS) from a clinically validated laboratory. Additionally, we will use GUÍA, a web-based application designed to enhance the delivery of genomic test results, in both the ScrC and NScrS arms to facilitate delivery of individualized genomic results and clinical information in a personalized, highly visual, and narrative manner. Surveys administered at baseline, after results disclosure, and 6-months post-results disclosure will be used to evaluate study outcomes. The primary outcome of the TeleKidSeq study will be participants’ perceived understanding of their GS results with a comparison between the results disclosed via videoconferencing with ScrS and NScrS arms. Secondary outcomes will include: objective understanding of GS results;understanding of medical follow-up recommendations and the actionability of genome sequencing results;adherence to medical follow-up recommendations made based on genomic results;and satisfaction with and ease of use of the telehealth experience, compared across the two arms. Diagnostic yield, clinical utility and cost of GS will also be assessed. Results: Not applicable. Conclusion: Overall, the TeleKidSeq pilot study will contribute to innovations in communicating genomic test results to diverse populations through telehealth technology. In conjunction with NYCKidSeq, this work will inform best practices for the implementation of genomic medicine in diverse, English- and Spanish-speaking populations.

Prescribing intranasal steroids in HIV-positive patients: systematic review of the literature.

BACKGROUND: There are significant drug-drug interactions between human immunodeficiency virus antiretroviral therapy and intranasal steroids, leading to high serum concentrations of iatrogenic steroids and subsequently Cushing's syndrome. METHOD: All articles in the literature on cases of intranasal steroid and antiretroviral therapy interactions were reviewed. Full-length manuscripts were analysed and the relevant data were extracted. RESULTS: A literature search and further cross-referencing yielded a total of seven reports on drug-drug interactions of intranasal corticosteroids and human immunodeficiency virus protease inhibitors, published between 1999 and 2019. CONCLUSION: The use of potent steroids metabolised via CYP3A4, such as fluticasone and budesonide, are not recommended for patients taking ritonavir or cobicistat. Mometasone should be used cautiously with ritonavir because of pharmacokinetic similarities to fluticasone. There was a delayed onset of symptoms in many cases, most likely due to the relatively lower systemic bioavailability of intranasal fluticasone.

Feasibility of Specimen Self-collection in Young Children Undergoing SARSCoV-2 Surveillance for In-person Learning

Background. While pediatric cases of COVID-19 are at low risk for adverse events, schoolchildren should be considered for surveillance as they can become infected at school and serve as sources of household or community transmission. Our team assessed the feasibility of young children self-collecting SARS-CoV-2 samples for surveillance testing in an educational setting. Methods. Students at a K-8 school were tested weekly for SARS-CoV-2 from September 2020 - June 2021. Error rates were collected from September 2020 -January 2021. Clinical staff provided all students with instructions for anterior nares specimen self-collection and then observed them to ensure proper technique. Instructions included holding the sterile swab while making sure not to touch the tip, inserting the swab into their nostril until they start to feel resistance, and rubbing the swab in four circles before repeating the process in their other nostril. An independent observer timed random sample self-collections from April - June 2021. Results. 2,590 samples were collected from 209 students during the study period when data on error rates were collected. Errors occurred in 3.3% of all student encounters (n=87). Error rates over time are shown in Figure 1, with the highest rate occurring on the first day of testing (n=20/197, 10.2%) and the lowest in January 2021 (n=1/202, 0.5%). 2,574 visits for sample self-collection occurred during the study period when independent timing data was collected (April - June 2021). Of those visits, 7.5% (n=193) were timed. The average duration of each visit was 70 seconds. Conclusion. Pediatric self-collected lower nasal swabs are a viable and easily tolerated specimen collection method for SARS-CoV-2 surveillance in school settings, as evidenced by the low error rate and short time window of sample self-collection during testing. School administrators should expect errors to drop quickly after implementing testing.

Natural History of Shedding and Household Transmission of Severe Acute Respiratory Syndrome Coronavirus 2 Using Intensive High-Resolution Sampling

Background. In order to mitigate the spread of SARS-CoV-2 and the COVID-19 pandemic, public health officials have recommended self-isolation, self-quarantine of exposed household contacts (HHC), and mask use to limit viral spread within households and communities. While household transmission of SARS-CoV-2 is common, risk factors for HHC transmission are poorly understood. Methods. In this prospective cohort study, we enrolled 37 households with at least one reverse transcription polymerase chain reaction-confirmed (RT-PCR) COVID-19 index case from March 2020 - March 2021, in order to calculate secondary attack rates (SAR) and define risk factors for secondary infections. Participants were tested daily for SARS-CoV-2 via RT-PCR, using self-collected lower nasal samples. Households were followed until all members tested negative for seven consecutive days. We collected demographics, medical conditions, relationship to index case, and socioeconomic indicators. Subgroup data analysis was conducted and stratified by positivity status. Results. Of 99 enrolled participants, 37 were index cases and 62 were household contacts (HHC), of whom 25 HHC were infected (40.3%). Secondary attack rate (SAR) was highest among adults caring for a parent (n=4/4, 100%) and parents of index cases (5/10, 50%). Households whose income came from service work had greater risk of transmission compared to households whose primary income was technology (n=5/7;71.4% vs 3/8;37.5% respectively). Pediatric contacts were at lower risk of infection when compared to adult contacts (n=5/18, 27.8% vs n=20/44, 45.5% respectively). Conclusion. This study suggests that household transmission represents a key source of community-based infection of SARS-CoV-2. Allocating resources for education/ training regarding prevention among infected individuals and their close contacts will be critical for control of future outbreaks of SARS-CoV-2.

The Use of Tocilizumab and Remdesivir in SARS- CoV-2 Patients in El Paso Texas: A Longitudinal Comparative Observational Study

Background. Currently, the management of SARS-CoV-2 varies with no definitive clinical guidelines, as scientific evidence across the globe differs in therapeutic options. This study intends to provide some clarity to the insufficient data based on the role of monotherapy with tocilizumab (TCZ) and combination therapy with remdesivir (RDV) and TCZ among patients in El Paso, Texas. Methods. 154 SARS-CoV-2-positive patients from four different hospitals in El Paso, Texas, were screened, with 113 eligible for this longitudinal comparative observational study (2/1/2020-10/31/2020). Group 1 (80 patients) were given TCZ within the first 24 hours of hospitalization, followed by methylprednisolone for 72 hours, and Group 2 (33 patients) received TCZ as detailed in the single therapy group, plus RDV within the first 24 hours. Mann Whitney U test assessed Median differences in laboratory biomarkers and Bivariate Logistic Regression assessed the odds of risk. An observation is said to be statistically significant if P-value is ≤ 0.05. Results. A statistically significant increased median IL-6 values were noted among those given only TCZ compared to those that received TCZ plus RDV (511.33 vs. 199.0) with a P-value (0.007). Patients in Group 1 had statistically significant lower odds for ventilation use than Group 2 (OR=0.34, 95%CI=0.12-0.95, p=0.034), although no statistically significant difference in mortality outcomes was observed across groups (OR=0.43, 95%CI:0.13-1.39, p=0.269). Table 1. Laboratory biomarkers and treatment groups (Mann Whitney U test) Table 2. Clinical outcomes and treatment groups using the Bivariate Logistic regression (OR) Conclusion. This study population is unique as it reflects a predominantly Hispanic demographic population in El Paso with different genetics, background characteristics, and predisposition to diabetes, and obesity than the rest of the United States (US). We concluded that the use of TCZ in SARS-CoV-2 positive patients in El Paso, with or without RDV, reported no mortality benefit. However, some minimal/non-use of ventilation benefit was observed in Group 1. Our study design is considered the first of its kind using TCZ and RDV in a longitudinal comparative observational study. Nonetheless, a randomized controlled trial study is recommended to ultimately determine the combination role of TCZ and RDV among this highly vulnerable group of patients.

Identification of a Conserved Intracellular Loop (CIL) Structure That Scaffolds PIP3 to Amplify Oncogenic Signaling during Malignant B-Cell Transformation

Background: Within seconds of antigen-encounter, B-cell receptor (BCR) signaling induces dramatic changes of cell membrane lipid composition, including >40-fold increases of local PIP3-concentrations within lipid rafts. While several structural elements, including pleckstrin homology (PH) domains have been identified as PIP3-binding proteins, the underlying mechanisms that amplify BCR-signaling to assemble large signaling complexes within lipid rafts within 15 to 30 seconds, remained elusive. To understand the mechanistic and biophysical requirements for PIP3 accumulation during normal B-cell activation and acute oncogenic transformation, we identified PIP3-interacting proteins by cell-surface proteomic analyses. Results: In addition to proteins known to bind PIP3 with their PH-domains, we identified the short 133 aa protein IFITM3 (interferon-inducible transmembrane protein 3) as a top-ranking PIP3 scaffold. This was unexpected because IFITM3 was previously identified as endosomal protein that blocks viral infection by stiffening endosomal membranes to firmly contain viral cargo. Previous studies revealed that polymorphisms that lead to the expression of truncated IFITM3 are associated with increased susceptibility to viral infections, including SARS-CoV2. Among known cell membrane lipids, PIP3 has the highest negative charge. Instead of a PH-domain, IFITM3 laterally sequestered PIP3 through electrostatic interactions with two basic lysine residues (K83 and K104) located at the membrane-solution interface. Together with three other basic lysine and arginine residues K83 and K104 form a conserved intracellular loop (CIL), which enable IFITM3 to efficiently capture two PIP3 molecules. Bivalent PIP3-binding of the IFITM3-CIL enables a crosslinking mechanism that results in dramatic amplification of B-cell activation signals and clustering of large signaling complexes within lipid rafts. In normal resting B-cells, Ifitm3 was minimally expressed and mainly localized in endosomes. However, B-cell activation and oncogenic kinases induced phosphorylation at IFITM3-Y20, resulting in translocation of IFITM3 from endosomes and massive accumulation at the cell surface. Ifitm3ˉ /ˉ naïve B-cells developed at normal numbers, however, activation by antigen encounter was compromised. In Ifitm3ˉ /ˉ B-cells, lipid rafts were depleted of PIP3, resulting in defective expression of >60 lipid raft-associated surface receptors and impaired PI3K-signaling. Ifitm3ˉ /ˉ B-cells were unable to undergo affinity maturation and di not contribute to germinal center formation upon immunization. Analyses of gene expression and clinical outcome data from patients in six clinical cohorts for pediatric and adult B-ALL, mantle cell lymphoma, CLL and DLBCL, we consistently identified IFITM3 as a top-ranking predictor of poor clinical outcome. Inducible activation of BCR-ABL1 and NRAS G12D rapidly induced development of B-ALL but failed to transform and initiate B-ALL from Ifitm3ˉ /ˉ B-cell precursors. Conversely, the phospho-mimetic IFITM3-Y20E mutation, mimicking phosphorylation of the IFITM3 N-terminus at Y20 induced constitutive membrane localization of IFITM3, spontaneous aggregation of large oncogenic signaling complexes and readily initiated transformation in a genetic model of pre-malignant B-cells. Conclusions: We conclude that phosphorylation of IFITM3 upon B-cell activation induces a dynamic switch from antiviral effector functions in endosomes to oncogenic signal-amplification at the cell-surface. IFITM3-dependent amplification of PI3K-signaling is critical to enable rapid expansion of activated B-cells. In addition, multiple oncogenes depend on IFITM3 to assemble PIP3-dependent signaling complexes and amplify PI3K-signaling for malignant transformation and initiation of B-lymphoid leukemia and lymphoma. [Formula presented] Disclosures: Weinstock: SecuraBio: Consultancy;ASELL: Consultancy;Bantam: Consultancy;Abcuro: Research Funding;Verastem: Research Funding;Daiichi Sankyo: Consultancy, Research Funding;AstraZeneca: Consultanc ;Travera: Other: Founder/Equity;Ajax: Other: Founder/Equity.

COVID-19 infections post-liver and kidney transplantation in a Southern CA program

Purpose: Southern CA is at the epicenter of the Covid-19 pandemic. We reviewed outcomes of our center's liver, kidney, and pancreas transplant patients stricken with Covid-19 infection. Methods: Retrospective review of 161 post-transplant patients with Covid-19 infection. Results: From March 2020 to January 2021, 43 liver, 107 kidney, 6 liver/kidney, and 4 kidney/pancreas patients came down with Covid-19 (TABLE). Transplants were performed from August 2000 to December 2020. Mean age was 54±1 yrs. Median time of infection was 27 months post-transplant (range 15 days to 21 years). Frequency of symptoms were: shortness of breath (55%), fever (52%), muscle aches (48%), diarrhea (36%), headaches (34%), loss of taste or smell (27%). Only 10 (6%) pts were asymptomatic. Overall mortality rate was 20% (33/161) and severe Covid-19 (hospitalization and death) occurred in 90/161 (56%) patients. Mortality risk factors included older age (62±2 vs 52±1 yrs, p<0.01), hospitalization (32/33, 97% vs 59/128, 46% p<0.01), mechanical ventilation (30/33, 91% vs 4/128, 3% p<0.01);there was no difference in gender (p=0.5), race (p=0.88), presence of diabetes (p=0.26), hypertension (p=0.06), or obesity (p=0.83). Liver/kidney recipients had the highest mortality rate (Table). Risk factors for severe Covid-19 included age (56±1 vs 51±2 yrs, P=0.01) and presence of diabetes (54/90, 60% vs 29/71, 41% p=0.02);there was no difference in gender (p=0.97), race (p=0.39), presence of hypertension (p=0.09), or obesity (p=0.82). Kidney patients had more severe Covid-19 than the other organ recipients. Kidney/pancreas patients were younger and tended to have mild infection and had no mortality. 156 (97%) patients were on tacrolimus (2 were on CyA, 2 on belatacept), 113 (70%) on MMF, and 127 (79%) on prednisone. 101 (63%) of patients were on triple immunosuppression. MMF was the most common agent to be adjusted (48/113, 42%) followed by tacrolimus (9/156, 6%). Of the 90 pts hospitalized, 70 (78%) received steroids, 30 (33%) received Remdesivir, and 53 (59%) were anticoagulated. 5 patients received convalescent plasma. Peak C-reactive protein levels when measured were significantly higher in patients who died (53.7±15.8 vs 19.8±5.3 mg/L, p=0.02). Conclusions: Covid-19 infection inflicts a high mortality rate in liver, kidney, and pancreas transplant recipients. (Table Presented).