COVID-19 and severity of liver diseases: Possible crosstalk and clinical implications.

COVID-19-infected individuals and those who recovered from the infection have been demonstrated to have elevated liver enzymes or abnormal liver biochemistries, particularly with preexisting liver diseases, liver metabolic disorders, viral hepatitis, and other hepatic comorbidities. However, possible crosstalk and intricate interplay between COVID-19 and liver disease severity are still elusive, and the available data are murky and confined. Similarly, the syndemic of other blood-borne infectious diseases, chemical-induced liver injuries, and chronic hepatic diseases continued to take lives while showing signs of worsening due to the COVID-19 crisis. Moreover, the pandemic is not over yet and is transitioning to becoming an epidemic in recent years; hence, monitoring liver function tests (LFTs) and assessing hepatic consequences of COVID-19 in patients with or without liver illnesses would be of paramount interest. This pragmatic review explores the correlations between COVID-19 and liver disease severity based on abnormal liver biochemistries and other possible mechanisms in individuals of all ages from the emergence of the COVID-19 pandemic to the post-pandemic period. The review also alludes to clinical perspectives of such interactions to curb overlapping hepatic diseases in people who recovered from the infection or living with long COVID-19.

Emergence of SARS-CoV-2: Insight in genomics to possible therapeutics

Rising of a new virus from city of Cathay, responsible for 2019 global pandemic is caused by SARS-CoV-2marked as a great threat for populations. The member (CoV-2) from vast family of Covid virus with single-stranded RNA spread to over 216 countries and billions of individuals died all around the globe. Regardless of all strict standard operating procedures, special care and therapies, SARS-CoV-2 mutating its genomic structure and leads to shutting the world. While different therapeutic approaches face problems due to the complexity in pathogenicity mechanism of CoV-2 and its variants. Mechanism of action, genome analysis, transmission, development of broad-spectrum antiviral medications and SARS-CoV-2 vaccines have been reported which are essential for future directions to control this pandemic. Here, in this review, these domains were discussed to highlight the genome structure pathophysiology, immune response, multiple diagnostic methods, and possible treatment strategies. This review deliberates the methodologies for creating practical vaccinations and treatment cocktail to manage this eruption. © 2023, The Running Line. All rights reserved.

Long-term study on wastewater SARS-CoV-2 surveillance across United Arab Emirates.

Wastewater-based epidemiology (WBE) demonstrates an efficient tool to monitor and predict SARS-CoV-2 community distribution. Many countries across the world have adopted the technique, however, most of these studies were conducted for a short duration with a limited sampling size. In this study, long-term reliability and quantification of wastewater SARS-CoV-2 surveillance is reported via analyzing 16,858 samples collected from 453 different locations across the United Arab Emirates (UAE) from May 2020 to June 2022. The collected composite samples were first incubated at 60 °C followed by filtration, concentration, and then RNA extraction using commercially available kits. The extracted RNA was then analyzed by one-step RT-qPCR and RT-ddPCR, and the data was compared to the reported clinical cases. The average positivity rate in the wastewater samples was found to be 60.61 % (8.41-96.77 %), however, the positivity rate obtained from the RT-ddPCR was significantly higher than the RT-qPCR suggesting higher sensitivity of RT-ddPCR. Time-lagged correlation analysis indicated an increase in positive cases in the wastewater samples when the clinical positive cases declined suggesting that wastewater data are highly affected by the unreported asymptomatic, pre-symptomatic and recovering individuals. The weekly SARS-CoV-2 viral count in the wastewater samples are positively correlated with the diagnosed new clinical cases throughout the studied period and the studied locations. Viral count in wastewater peaked approximately one to two weeks prior to the peaks appearing in active clinical cases indicating that wastewater viral concentrations are effective in predicting clinical cases. Overall, this study further confirms the long-term sensitivity and robust approach of WBE to detect trends in SARS-CoV-2 spread and helps contribute to pandemic management.

Surveillance of device associated infections in intensive care units at a Saudi Arabian Hospital, 2017-2020.

BACKGROUND: Device-associated infections (DAIs) are important components of healthcare associated infection and are associated with increased morbidity and mortality. This study describes DAIs across different intensive care units (ICUs) in a hospital in Saudi Arabia. METHODS: The study was conducted between 2017 and 2020 and followed the definitions of National Healthcare Safety Network (NHSN) for DAIs. The calculated the rates of ventilator-associated events (VAE), catheter-associated urinary tract infections (CAUTI) and central line-associated blood stream infections (CLABSI) followed NHSN definitions. RESULTS: During the study period, there were 82 DAIs in adult ICUs and of these 16 (19.5%) were CLABSI, 26 (31.7%) were CAUTI and 40 (48.7%) were VAE. The overall rates for adult ICUs were 1.6, 1.9, 3.8 per 1000 device-days for CAUTI, CLABSI and VAE, respectively. The device-utilization ratio was 0.5, 0.6, and 0.48 for urinary catheters, central lines, and ventilators, respectively. VAE rates for medical and surgical ICU were about 2.8 times the rate in the coronary care unit and the rates were high in 2020 corresponding with the COVID-19 pandemic. Of the adult ICUS, medical ICU had a CLABSI rate of 2.13/1000 device-days and was about double the rate in surgical and cardiac ICU. For CAUTI, the rates per 1000 device-days were 2.19, 1.73, and 1.65 for medical, surgical, and coronary ICUs, respectively. The rate of CLABSI per 1000 device-days for pediatric and neonatal ICUs were 3.38 and 2.28, respectively. CONCLUSIONS: CAUTI was the most common infections among adult ICUs and medical ICU had higher rates than other adult ICUs. VAE rate was higher in the first year of the COVID-19 pandemic, indicating increased device-use, change in patients characteristics as well as possible change in practices across the ICUs.

A Cross-Sectional Study to Assess mRNA-COVID-19 Vaccine Safety among Indian Children (5–17 Years) Living in Saudi Arabia

The objective of this study is to assess the frequency and severity of adverse events following immunization (AEFI) in Indian children aged 5–17 years who received the Pfizer-BioNTech mRNA COVID-19 vaccine, as well as to investigate for predictors of AEFI. To examine AEFI following the first and second doses of Pfizer's vaccine, semi-structured questionnaires were distributed as Google forms at Indian schools in Saudi Arabia. The 385 responses included 48.1% male and 51.9% female children, with 136 responses of children aged 5–11 years (group A) and 249 responses from children aged 12–17 years (group B). Overall, 84.4% of children had two shots. The frequency of AEFI was reported to be higher after the first dose than after the second (OR = 2.12, 95% CI = 1.57–2.86). The reported AEFIs included myalgia, rhinitis, local reaction with fever, a temperature of 102 °F or higher, and mild to moderate injection site reactions. While group B frequently reported multiple AEFIs, group A typically reported just one. Local reaction with low grade fever was more frequently reported in group B after the first dose (24.1%) and second dose (15.4%), while local reaction without low grade fever was most frequently observed in group A after the first (36.8%) and second dose (30%). Only prior COVID-19 infection (OR = 2.98, 95% CI = 1.44–6.2) was associated with AEFI after the second dose in the study sample, whereas male gender (OR = 1.71, 95% CI = 1.13–2.6) and prior COVID-19 infection (OR = 2.95, 95% CI = 1.38–6.3) were predictors of AEFI after the first dose. Non-serious myocarditis was reported by only one child. According to the analysis conducted, the Pfizer's mRNA COVID-19 vaccination was found to be safe in Indian children.

Combatting with challenges in medical education during COVID-19 pandemic: A mixed-methods study on the effectiveness of e-learning in pediatric clinical clerkship of a university hospital, Pakistan

The purpose of this research is to ascertain the effectiveness of using the e-learning method for a module in pediatric clerkship at the [redacted name] University Hospital, Karachi. The fourth-year undergraduate medical students, who rotates for eight weeks in Pediatric clerkship, participated in this study. It was a sequential (Quantitative-Qualitative) mixed-method study, which was conducted from May-August 2020. Students were divided according to their status of in-person rotation (Novice, Semi-expert, Expert). The quantitative component of the study consisted of pre and post-tests and pre-validated post-session feedback., while focused-group discussions were done to explore students' experiences. SPSS version 20.0 was used for quantitative data while qualitative data underwent content analysis. Fifty-nine participants (68.8%) were female. The intervention batch comprised of 102 students (41 Novice (40.2%), 21 Semi-expert (19.6%), and 40 Expert (39.2%)). Using paired t-test analysis between pre and post-test scores of each session, it was discerned that there was indeed a positive effect on knowledge acquisition during each session, depicted by the improvement in test scores. The Semi-expert and Expert groups were merged for analysis. The Novice group was found to be statistically significant for only the common newborn problem session. The qualitative component explored students' views, and three main themes emerged, i.e., the effectiveness of online learning, barriers and challenges to online learning, and future goals to enhance online learning. In conclusion, E-learning is an effective way of continuing the process of delivering medical education, especially in unprecedented times. Technological enhancements will help carry the impact forward as a blended-learning pedagogical approach in undergraduate medical education. © The Author(s) 2023.

Factors associated with noncompliance of COVID-19 guidelines recommended by Government of Pakistan for international travelers arriving at Islamabad International Airport, 1st June to 30th July 2021

Introduction: Since the start of pandemic new variants have been evolving and moving from one country to another either by air travel or ground crossings. Objective: To find out factors associated with noncompliance of recommended guidelines by international passengers so that we can improve the arrangements at airports where required, improve future preparedness, and give recommendations to concerned authorities for improvement in enforcing guidelines. Methodology: A cross-sectional study was carried out at Islamabad International Airport during the months of June and July 2021. The study population included international arriving passengers aged 12 years and above. Questions were asked about following guidelines before boarding, on board, and after disembarkation. Twenty questions were asked to assess compliance level. A median cut off value was set for assessment of noncompliance. Results: The male to female ratio was 1:1. The age range was 12 – 75 years. The odds of noncompliance to guidelines were higher in females compared to males. The results revealed a significant association between region of arrival of respondents and noncompliance. Passengers arriving from Afghanistan, the UK and the USA were more likely to be noncompliant to guidelines (p-value = 0.00). There was a significant association between occupation of participants and noncompliance. Housewives and retired were more likely to be noncompliant (p-value = 0.00). A significant association was observed between vaccinated people and noncompliance. Conclusion: Travelers arriving from some specific countries were noncompliant to guidelines. Vaccinated were most noncompliant which indicates still we need to work on awareness and need legislations, fines, or travel restrictions for noncompliant travellers. © 2022 The Author(s).

Patterns of acute poisoning for children during outbreak of Corona virus in Makkah region Saudi Arabia.

Background: Poisoning occurs when a person is exposed to an external substance at a too high dose for them. It is possible for young children to be exposed to chemicals. Lungs, the heart, CNS, the digestive tract, and kidneys can be poisoned. In 2004, over 45,000 children and teenagers died from acute poisoning, representing 13% of all accidental poisoning deaths worldwide. Poisoning patterns vary by exposure type, age group, poison type, and dose. Aim: This study assessed the pattern of acute poisoning with drugs, chemicals, and natural toxins among children (<12 years old). The study was done in Makkah region and registered in the poison control center in Makkah, the forensic chemistry center in Haddah during 2020-2021. Methods: A retrospective cohort study was done on 122 children exposed to toxic substances in Makkah. The children were 12 years old and had good health for a maximum of one year. Stratified random sampling was used to divide cases into groups of similar poisons (pharmaceutical products, household products, plant envenomation, and animal envenomation). Then each group got a random samples. The data were analysed with SPSS software. Results: The mean age of children was 5.2 years, with 59% being boys. The mean temperature, pulse, systolic, diastolic, and respiratory rates were 36.77, 98.29, 109.1, 69.17, and 21.49. The most documented pharmaceutical products (200 mg) were carbamazepine (5 mg), methanol, risperidone (5 mg), propranolol (5 mg), and olanzapine (5 mg). The most common poison forms were tablets (42.6%), syrups (15.6%), capsules (13.9%), and solutions (13.1%). The most common poisoning routes were ingestion (82.8%), dermal (5.7%), injection (4.9%), and inhalation (6.6%). Accidental poisoning was 83%, with a 30-minute lag for 30.3% of children, and most (69.7%) occurred at home. Benzodiazepines were the most commonly used category class drug (18%), with normal pupils and an ECG of 85.2%. Sixty-seven percent had blood tests. Sickness was 9.48, and the positive result was 213.01. The most common presenting symptoms were GIT and neurological (23.8%). 31.1% had mild, moderate, or severe toxicity. Most cases (68%) were complex. 34.4% were intubated, 9.8% had repeated-dose-activated charcoal for enhanced elimination, and 27.8% were on IV fluids. Children with GIT, CVS, respiratory, dermal, and neurological symptoms had a higher percentage of severe toxicity (p < 0.05). Slight toxicity was associated with whole bowel irrigation, intubation for oxygen therapy, N-acetylcysteine or sedation, fluids, and phenytoin (P < 0.05). Complicated cases had a higher mean AST/IUL than non-complicated cases (75.5 vs. 20.08, p < 0.05). The level of toxicity did not correlate with the mean of all lab tests (p > 0.05). The age of the children correlated positively with their systolic BP (r = 0.22, p < 0.01). Conclusion: The results show how important it is to teach the public about poisoning and make rules for tracking and dealing with poisonings in Saudi Arabia.

Liver Injury in Favipiravir-Treated COVID-19 Patients: Retrospective Single-Center Cohort Study.

(1) Background: Favipiravir (FVP) is a new antiviral drug used to treat COVID-19. It has been authorized to be used in the kingdom of Saudi Arabia in the treatment of COVID-19. The mechanism of action of FVP is working as a specific inhibitor for the RNA-dependent RNA polymerase of the RNA chain virus. FVP has the potential to be hepatotoxic because of the structure similarity with pyrazinamide. This retrospective study aimed to determine the prevalence of liver injury in FVP-treated COVID-19 patients in General East Jeddah Hospital, Saudi Arabia, during the COVID-19 pandemic. (2) Methods: A total of 6000 patients infected with COVID-19 and treated at the East Jeddah Hospital were included, with a sample size of 362 patients. The participants ranged from 18 to 70 years of age, both males and females, with normal hepatic and renal function and had a confirmed diagnosis of COVID-19 infection. Patients who had gouty arthritis, hepatic and renal dysfunction, dead patients, pregnant women, and breastfeeding mothers were all excluded from this study. A retrospective cohort study compared two groups of patients treated with and without FVP and who followed the Saudi Ministry of Health protocol to manage COVID-19 infection. (3) Results: An adverse effect of FVP on the liver was found that ranged from mild to severe. Stopping treatment with FVP was associated with an observed important increase in the levels of liver enzymes AST (p < 0.001), ALT (p < 0.001), alkaline phosphatase (p < 0.03), total bilirubin (p < 0.001), and direct bilirubin (p < 0.001) in the treated compared with the untreated group. (4) Conclusion: This study showed a significant difference between the treated and the untreated groups with FVP in liver injury. FVP influences the liver, increasing the blood levels of the liver function parameters.

E-commerce and cybersecurity challenges: Recent advances and future trends

COVID-I9 has accelerated the digital transformation in the business sector as many business organizations adopted electronic commerce to keep their operations running. Business organizations have also increased their participation on social networking applications to attract customers. Due to huge presence of users, social networking sites have also evolved into an emerging marketplace, which is referred as social commerce. There are many security issues involved in technological adoption in different business processes. On the other hand, social media is extensively used for product marketing, so fake information and fake product reviews can also influence consumers purchasing decision, so providing accurate marketing information is also a challenge for business organizations. In this chapter, the authors conduct a systematic literature review to understand the cybersecurity issues faced by business organizations and customers and how recent advances such as fintech, etc. provide additional cybersecurity challenges for business organization to protect themselves and their customers. © 2023, IGI Global.

The use of the nutritional supplements during the covid-19 outbreak in Saudi Arabia: A cross-sectional study.

BACKGROUND: COVID-19 causes moderate to severe illness and is spreading globally. During a pandemic, vitamins and minerals are vital to health. Therefore, the prevalence and epidemiology of supplement use in Saudi Arabia during the COVID-19 pandemic must be known. METHODS: This cross-sectional study was conducted in Saudi Arabia using an online survey. The study was conducted from June to March 2022 on both adults and children. The link to the survey was shared on social media platforms. The survey included questions on participants' demographics, vaccination status, supplements they used, and side effects of supplements. Participation in this study was optional, and there was no obligation to participate. There was a declaration about the aim of the study and different objectives before starting the survey. RESULTS: The present study reported that most of the participants reported that they used vitamin C (64.6 %), zinc (51.9 %), multivitamins (46.1 %), black seeds (26.7 %), garlic (Allium sativum) (15.4 %), omega-3 (22.1 %), vitamin D (22.2 %), echinacea (10.1 %), manuka honey (26.0 %), curcumin (13.6 %), ginger (22.5 %), royal jelly (12.9 %), and propolis (7.5 %) before and during the COVID-19 pandemic period. These supplements were used more frequently by subjects during the pandemic than before. DISCUSSION AND CONCLUSION: The respondents' risk of these supplements' use may partially reflect the public's behavioral response during a pandemic. Future studies can document the health beliefs and motivations of nutritional supplement users.

I Can't Leave the Icu to Go Do Yoga

BACKGROUND AND AIM: Staff in paediatric critical care (PCC) experience higher levels of burnout and moral distress than other healthcare professionals. PCC consultants face unique challenges, supporting the wider team, making critical decisions as part of that team. Previous research, largely focused on nurses and trainee medical professionals, has predominantly collected quantitative data. This study aimed to understand the wellbeing experiences of PCC consultants working in the United Kingdom. METHOD(S): An exploratory qualitative design was used to interview consultants working in PCC between April 2021 and June 2021. Interviews were conducted by a researcher independent to healthcare. RESULT(S): Eleven PCC consultants took part from 9 PCC units or critical care transport services. Years of experience as a consultant ranged from 4 to 23. Within this data eight key themes emerged across the data: 1) Positive & negative impact of working during COVID 19 2) Job satisfaction & scrutiny in the unique environment of PCC 3) Ageing workforce and shift work 4) Support and recognition from the Trust 5) Successful coping strategies are personal & adaptive 6) Importance of civility & staff retention for good teamwork 7) Recognition of the cumulative effect of stressors in and out of work 8) Recommendations for future solutions to enhance wellbeing involve being heard, seen, supported and personal growth CONCLUSION(S): The study highlights the critical areas to be addressed on a local and national level. Addressing these will allow PCC consultants to thrive at work. Further intervention based research is needed.

Don't Cop Out: Fulminant Cryptogenic Organizing Pneumonia Following Methamphetamine Inhalation

INTRODUCTION: Cryptogenic organizing pneumonia (COP) accounts for 5% of all ILD cases. Due to a low incidence rate of 1 case per 100,000 persons per annum, it is often misdiagnosed as bacterial pneumonia, but when timely managed, it has an excellent prognosis. We discuss Methamphetamine, a commonly abused stimulant that has unfortunately not yet garnered enough notoriety as a respiratory toxidrome for causing inhalation injury, potentially leading to fulminant COP. DESCRIPTION: A 44-year-old male presented to ED with fevers, cough, and dyspnea gradually worsening over the past two weeks. Of note, he smoked ten cigarettes/day and relapsed to methamphetamines inhalation, the latest use being two weeks prior. On physical exam, oxygen saturation was 70% on RA and had significant bilateral inspiratory crackles. The respiratory Viral Panel, including COVID-19, was negative. Drug screens were negative. Chest X-Ray and CTA showed bilateral ground glass opacities concerning multifocal pneumonia but no pulmonary embolism. Broadspectrum antibiotics were started. For worsening Acute Hypoxemic Respiratory failure (AHRF) on Day 3, he underwent intubation and mechanical ventilation. Further workup for infectious etiologies like S. pneumoniae and Legionella, HIV-1, and sputum and blood cultures were all negative. Initial autoimmune and connective tissue disease workup was within normal limits. Bronchoalveolar lavage (BAL) analysis did not yield an infectious, inflammatory, or neoplastic source. On day 7, he underwent an open lung biopsy which confirmed COP, with histological features of toxic injury. IV glucocorticoids were started, with gradual improvement noticed in AHRF. DISCUSSION: Respiratory failure within 30 days of hospitalization is the most common cause of mortality in fulminant COP.If a patient's history suggests exposure to inhaled amphetamine and have no response to antibiotics for supposed pneumonia, physicians should consider COP to make a timely diagnosis and initiate glucocorticoid treatment to warrant rapid clinical improvement, often seen as early as 72 hours, and prevent future relapses.With Substance use continuing to be a major healthcare problem, now more than ever, healthcare providers must be familiar with respiratory toxidrome to provide timely diagnosis and treatment.

A Cross-Sectional Study to Assess mRNA-COVID-19 Vaccine Safety among Indian Children (5-17 Years) Living in Saudi Arabia.

The objective of this study is to assess the frequency and severity of adverse events following immunization (AEFI) in Indian children aged 5-17 years who received the Pfizer-BioNTech mRNA COVID-19 vaccine, as well as to investigate for predictors of AEFI. To examine AEFI following the first and second doses of Pfizer's vaccine, semi-structured questionnaires were distributed as Google forms at Indian schools in Saudi Arabia. The 385 responses included 48.1% male and 51.9% female children, with 136 responses of children aged 5-11 years (group A) and 249 responses from children aged 12-17 years (group B). Overall, 84.4% of children had two shots. The frequency of AEFI was reported to be higher after the first dose than after the second (OR = 2.12, 95% CI = 1.57-2.86). The reported AEFIs included myalgia, rhinitis, local reaction with fever, a temperature of 102 °F or higher, and mild to moderate injection site reactions. While group B frequently reported multiple AEFIs, group A typically reported just one. Local reaction with low grade fever was more frequently reported in group B after the first dose (24.1%) and second dose (15.4%), while local reaction without low grade fever was most frequently observed in group A after the first (36.8%) and second dose (30%). Only prior COVID-19 infection (OR = 2.98, 95% CI = 1.44-6.2) was associated with AEFI after the second dose in the study sample, whereas male gender (OR = 1.71, 95% CI = 1.13-2.6) and prior COVID-19 infection (OR = 2.95, 95% CI = 1.38-6.3) were predictors of AEFI after the first dose. Non-serious myocarditis was reported by only one child. According to the analysis conducted, the Pfizer's mRNA COVID-19 vaccination was found to be safe in Indian children.

Perceptions of Nursing Students' Regarding Coronavirus Vaccination Acceptance: A Mixed Methods Study

Background: The first COVID-19 vaccine was authorized in the United States in December 2020. It is recognized that vaccination is a preventive and effective measure for limiting the coronavirus pandemic. Nursing students' perspectives on vaccine acceptance may be critical for COVID-19 pandemic prevention as future professionals. The study has focused on perceptions of nursing students regarding coronavirus vaccine acceptance.Design: This study was conducted using a sequential explanatory mixed-methods design with two phases. Methods: A convenience sample method was applied in phase one, and 255 nursing school students between February 14 and February 24, 2022, from six universities in Iraq participated. The findings were used in phase two to refine in-depth interview questions that would allow for a deeper investigation of student perceptions. Fifteen participants were questioned one-on-one using personal interviews. Using an inductive method of theme analysis, the dataset was coded, classified, and thematizedResults: Out of 255 students, the results of the quantitative phase revealed that 123 (48.2%), 120 (47.1%), and 12 (4.7%) of them had, respectively, unsound, somewhat sound, and sound perceptions of coronavirus vaccines. Based on the students' perceptions, the main themes from the qualitative phase emerged and include: (persuasion, preservation, accountability, efficacy doubts, and apprehension). Conclusions: Most student nurses have unsound perceptions about COVID-19 vaccinations. Findings showed that nursing students need to take vaccination issues into account and educate others about vaccine production. The development of suitable solutions and interdisciplinary educational programs in the post-pandemic phase may depend on understanding perceptions and encouraging health engagement and awareness. © 2022, Association Res Militaris. All rights reserved.

A Patient With Schizophrenia in Remission Relapses Following COVID-19: A Case Report.

As managing COVID-19 complications has become more prevalent in psychiatry, its effects can range from provoking new illnesses in previously healthy individuals to inducing relapses in patients in remission. However, an aspect of COVID-19's influence that is not well documented is its effect on medication responsiveness. In this case, we present a 28-year-old male diagnosed with treatment-resistant schizophrenia for eight years. While in remission on a maintenance dose of clozapine, he was admitted to the hospital with signs of severe psychosis after testing positive for COVID-19. On admission, he did not have any other major stressors and no prior comorbidities that could have induced the relapse. Despite being on a higher dose of clozapine for four weeks while hospitalized, the patient's psychosis did not improve. This raises the question if his infection had altered his response to medication that previously brought on remission.

THAT BLOODY CLOT DOES NOT ALWAYS NEED A TUNNEL TO MIGRATE: A CASE OF MULTIPLE ARTERIAL AND VENOUS THROMBOSIS IN A COVID-19 PATIENT

SESSION TITLE: Rare Cases of Nervous System and Thrombotic Complication Posters SESSION TYPE: Case Report Posters PRESENTED ON: 10/17/2022 12:15 pm - 01:15 pm INTRODUCTION: Covid 19 virus has impacted nearly 450 million people across the globe;ranging from an asymptomatic carrier state to respiratory symptoms, cardiovascular symptoms, hematologic manifestations and multiorgan failure to death. Thrombotic events are one of its devastating complications. CASE PRESENTATION: A 66 year old man with a history of diabetes mellitus, hypertension and 30 pack years smoking history presented to the emergency room with hypoxia and altered mental status. On exam, his GCS was 8/15 and oxygen saturation was 85% on room air. He was subsequently intubated. CTA chest demonstrated bilateral diffuse ground glass opacities and left pulmonary embolism (PE). CT abdomen and pelvis showed multifocal infarcts in the right kidney with findings suggestive of renal artery thrombosis. Initial platelet count was 80,000/ul with creatinine of 3.9 mg/dl and creatine kinase (CK) of 3977 u/l. His INR was 1.4. Patient was not a candidate for thrombolysis given his thrombocytopenia. He was started on intravenous (IV) heparin and given IV hydration. On day 3 of his admission, he developed dry gangrene of the toes. Ankle brachial index of the right lower extremity (LE) was 1.16 and left LE was 0. Duplex ultrasonography of left LE showed mid to distal popliteal artery thrombus occluding below knee popliteal and tibial arteries. Echocardiogram showed ejection fraction of 55% and bubble study was negative for any intra atrial or pulmonary shunting. On day 4 of his admission, he developed oliguria and his gangrene got worse. His platelet counts decreased to 36,000/ul. Other pertinent labs showed INR 1.2, PT 15.3, PTT 34, D dimer 14.82, fibrinogen 498, CK 6434 mg/dl, hemoglobin 13.2 g/dl, haptoglobin 243 mg/dl and LDH 1041 U/l. Given his poor prognosis in the setting of ventilator dependent respiratory failure, multiple thrombosis and kidney failure requiring hemodialysis, the family decided to withdraw care. DISCUSSION: There are multiple hypotheses of thrombus formation in Covid 19 infection such as interleukin 6 and other cytokines induced endothelial injury, angiogenesis and elevated prothrombotic factors such as factor VIII and fibrinogen. Our patient had PE, renal artery thrombosis and popliteal artery thrombosis. Despite being on full dose anticoagulation, he developed gangrene of the toes. His lab results were not consistent with disseminated intravascular coagulation, thrombotic thrombocytopenic purpura and he was not known to have any baseline hypercoagulable disorder. He did not have any intra cardiac shunts. Hence, it is most likely Covid 19 induced multiple arterial and venous thrombosis. CONCLUSIONS: The treatment of Covid 19 related thrombosis has become very challenging especially in the setting of multiple clots. It is crucial to have large multicenter studies to investigate vascular complications of Covid-19 and to formulate management strategies to ensure good patient outcomes. Reference #1: https://www.nejm.org/doi/full/10.1056/nejmoa2015432 Reference #2: https://journal.chestnet.org/article/S0012-3692(21)01126-0/fulltext DISCLOSURES: No relevant relationships by Devashish Desai No relevant relationships by Swe Swe Hlaing no disclosure on file for Jean Marie Koka;No relevant relationships by Hui Chong Lau No relevant relationships by Subha Saeed No relevant relationships by Anupam Sharma No relevant relationships by Muhammad Moiz Tahir

DIEULAFOY LESION CAUSING LOWER GI BLEEDING: A CASE OF COVID-19 CRITICAL ILLNESS PROMPTING UNUSUAL PRESENTATION OF A MORE RARE CONDITION

SESSION TITLE: COVID-19 Case Report Posters 1 SESSION TYPE: Case Report Posters PRESENTED ON: 10/17/2022 12:15 pm - 01:15 pm INTRODUCTION: Dieulafoy lesions are abnormally dilated submucosal vessels remain uncommon cause of upper gastrointestinal bleeding, accounting for approximately 1.5% of all GI bleeds [1]. Although the exact etiology remains unknown, multiple co-morbid conditions have been attributed to this condition, including heart diseases, hypertension, chronic kidney disease, diabetes, or excessive alcohol use [2].In our case, it was identified as a cause of lower GI bleed in a critically ill Covid patient. CASE PRESENTATION: A 49-year-old male with a history of diabetes, internal hemorrhoids, and diverticulosis was admitted to the hospital due to hypoxic respiratory failure from COVID pneumonia with characteristic CT findings of bilateral ground-glass opacification. On admission, the patient was afebrile, normotensive, tachypneic with a respiratory rate of 34.The physical examination was unremarkable except for coarse crackles in upper and middle lung zones. We treated patient with Dexamethasone and Remdesivir. His hypoxia deteriorated, and he was eventually intubated. On admission patient hemoglobin was within normal range. During the patient's hospital course, he had a significant drop in hemoglobin, requiring multiple blood transfusions. Blood clots were found on perianal examination. Flexible sigmoidoscopy revealed blood in the rectosigmoid colon. A visible vessel without apparent ulcer was seen in the rectum, which was actively oozing blood. It was determined to be a Dieulafoy lesion. The affected area was injected with epinephrine for hemostasis, and subsequently, hemostatic clips were placed. After the procedure patient did not have any repeat episodes of hematochezia or drop in hemoglobin. DISCUSSION: Dieulafoy lesions are an uncommon cause of GI bleeding and are usually present in the upper gastrointestinal tract. Furthermore, they caused hemodynamically significant bleeding from the lower gastrointestinal tract in our case. Dieulafoy lesions can be asymptomatic or may bleed intermittently to cause severe hemodynamic compromise. They may be missed on endoscopy due to the small size and intermittent bleeding [2]. In up to 9-40% of the cases, these lesions tend to rebleed. Therefore the patients need close monitoring [3]. In our case, after the intervention with the clips, the patient's bleeding stopped, and he had no further blood loss from the lesion. CONCLUSIONS: Dieulafoy's lesion is an infrequent cause of gastrointestinal bleeding, and it is challenging to diagnose [3]. It is a rare cause of GI bleeding, and even in those instances, it is found chiefly in upper GI bleed cases but can also be the cause of lower GI bleeding. Knowing that GI bleeding in Covid patients leads to worse outcomes, it is prudent to account for rare causes of GI bleed during the work-up. Reference #1: Van Zanten SV, Bartelsman J, Schipper M, Tytgat G. Recurrent massive haematemesis from Dieulafoy vascular malformations–a review of 101 cases. Gut. 1986;27(2):213. Reference #2: Shin HJ, Ju JS, Kim KD, et al. Risk factors for Dieulafoy lesions in the upper gastrointestinal tract. Clinical Endoscopy. 2015;48(3):228. Reference #3: Baettig B, Haecki W, Lammer F, Jost R. Dieulafoy's disease: endoscopic treatment and follow up. Gut. 1993;34(10):1418-1421. DISCLOSURES: No relevant relationships by Swe Swe Hlaing No relevant relationships by Joyann Kroser No relevant relationships by Hui Chong Lau No relevant relationships by Sze Jia Ng No relevant relationships by Subha Saeed No relevant relationships by Muhammad Moiz Tahir

Online action research in the Maldives amidst the Covid-19 pandemic: Unexpected challenges

The Covid-19 pandemic has significantly affected the field of teaching and educational research, requiring new changes to methodological tools in my research. My doctoral study examines Maldivian primary teachers’ engagement with social studies pedagogies through reflection. The pandemic posed several complex data collection challenges which I experienced as a researcher. As a result of not being able to return to the Maldives from New Zealand to gather data, data methods were altered from Participatory action research (PAR) to form online action research (OAR). The data were gathered from four different teachers in Maldivian primary schools through an online questionnaire, online workshops, online reflective narrative texts and online interviews. Unexpected research challenges included (i) time zone differences, (ii) my own and participants’ unfamiliarity with new methods of online data collection in the research, and (iii) challenges of maintaining good researcher rapport with participants. These research challenges contribute to an emerging understanding of the unexpected issues that researchers might face using an OAR approach. © 2022, Wilf Malcolm Institute of Educational Research. All rights reserved.

Pulmonary Ultrasound Scoring System for Intubated Critically Ill Patients and Its Association with Clinical Metrics and Mortality

Background: Preliminary research has shown that pulmonary ultrasonography (PU) has become a vital tool for quickly diagnosing the cause of acute respiratory failure (ARF), as well as monitoring therapy progress in critically sick patients. The aim of the present study is to examine the relationship between the PU grading system and clinical metrics to identify the etiology of ARF with assessment of treatment response. Patients and methods: A prospective cohort study of 50 ARF patients was recruited from Benha University Hospital's respiratory, general, and coronary critical care units. PU examinations were performed at 3 time points during a patient’s ICU stay at intubation, 48 hours after intubation and after extubation. Results: The research comprised 28 men and 22 women. The average age of participants was 58 years old. COVID-19 was the most common diagnosis (46%). Average intubation was 6.42 days, with a P/F ratio of 172.14 and average length of stay in the ICU 10.06 days. The average length of stay in the hospital was 12.6 days, with death rate 68%. Mean first US score was 18.1 and second US score 17.54. The first total US score had a substantial positive association with mortality rate. The initial total US score had also a substantial positive link with the length of ICU stay and ventilation days (p<0.001), whereas the P/F ratio had a negative correlation with the total lung score (p<0.001). Conclusion: First-to-total US score had positive connection with mortality, length of hospital stay, length of ICU stays, ventilation days, and negative connection with P/F ratio. © 2022, Ain Shams University Faculty of Medicine. All rights reserved.