Bioactive compounds of Jingfang Granules against SARS-CoV-2 virus proteases 3CLpro and PLpro.

OBJECTIVE: Jingfang Granules have been recommended for the prevention and treatment of corona virus disease 2019 (COVID-19). Through chemical analysis and bioactivity evaluation, this study aims to elucidate the potential effective components of Jingfang Granules. METHOD(S): The inhibitory acti-vities of Jingfang Granules extract against 3-chymotrypsin-like protease (3CLpro), papain like protease (PLpro), spike protein receptor-binding domain (S-RBD) and human cyclooxygenase-2 (COX-2) were evaluated using enzyme assay. The antitussive effects were evaluated using the classical ammonia-induced cough model. The chemical constituents of Jingfang Granules were qualitatively and quantitatively analyzed by liquid chromatography-mass spectrometry (LC/MS). The 3CLpro and PLpro inhibitory activities of the major compounds were determined by enzyme assay, molecular docking, and site-directed mutagenesis. RESULT(S): Jingfang Granules exhibited 3CLpro and PLpro inhibitory activities, as well as COX-2 inhibitory and antitussive activities. By investigating the MS/MS behaviors of reference standards, a total of fifty-six compounds were characterized in Jingfang Granules. Sixteen of them were unambiguously identified by comparing with reference standards. The contents of the 16 major compounds were also determined, and their total contents were 2 498.8 mug/g. Naringin, nodakenin and neohesperidin were three dominating compounds in Jingfang Granules, and their contents were 688.8, 596.4 and 578.7 mug/g, respectively. In addition, neohesperidin and naringin exhibited PLpro inhibitory activities, and the inhibition rates at 8 mumol/L were 53.5% and 46.1%, respectively. Prim-O-glucosylcimifugin showed significant inhibitory activities against 3CLpro and PLpro, and the inhibitory rates at 8 mumol/L were 76.8% and 78.2%, respectively. Molecular docking indicated that hydrogen bonds could be formed between prim-O-glucosylcimifugin and amino acid residues H163, E166, Q192, T190 of 3CLpro (binding energy, -7.7 kcal/mol) and K157, D164, R166, E167, T301 of PLpro(-7.3 kcal/mol), respectively. Site-directed mutagenesis indicated amino acid residue K157 was a key active site for the interaction between prim-O-glucosylcimifugin and PLpro. CONCLUSION(S): Prim-O-glucosylcimifugin, neohesperidin, and naringin as the major compounds from Jingfang Granules could inhibit severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) virus proteases 3CLpro and PLpro. The results are valuable for rational clinical use of Jingfang Granules.

Engineering Design of a Health Service Station Sewage Treatment Station under COVID-19 Epidemic

Health service station is a place in which close contacts with the COVID-19 and other key populations are centralized quarantined for medical observation.A newly built health service station is equipped with 4 700 beds and a supporting sewage treatment station with a designed treatment scale of2 200 m~3/d.The treatment process consists of enhanced biological treatment system,sewage virus disinfection and sterilization system,aerosol disinfection and sterilization system and sludge disinfection and sterilization system.After treatment,the effluent and waste gas can meet the limit specified in Discharge Standard of Water Pollutants for Medical Organization （GB 18466-2005）.The average COD,NH3-N and SS in effluent are 14.53 mg/L,1.26 mg/L and 9.11 mg/L,respectively,and the average concentrations of H2S,NH3 and odor at the outlet are 0.01 mg/L,0.8 mg/L and 6.3,respectively.The sludge is disinfected regularly and then transported outside for disposal.This project can provide reference for sewage treatment design of emergency medical temporary isolation and observation facility and cabin hospital.

Lactulose Works in the Large Bowel: But How Does It Improve Hepatic Encephalopathy in a Patient Without a Large Bowel?

Introduction: Lactulose is a non-absorbable disaccharide which acts in the large bowel, and is commonly used in the treatment of hepatic encephalopathy. We present an interesting case of altered mental status due to hepatic encephalopathy successfully managed with lactulose in a patient with history of total colectomy. Case Description/Methods: A 67-year-old male with non-alcoholic cirrhosis and inflammatory bowel disease (IBD) post total proctocolectomy with a continent ileostomy known as a Kock-pouch (K-pouch) presented to the hospital with flu like symptoms and altered mental status. He was subsequently found to be positive for COVID-19. At the time of initial evaluation, the patient was obtunded with an elevated ammonia level of 91 umol/L. Colorectal surgery was consulted as the patient was not able to empty his K-pouch. Recently, he complained of inability to catheterize and with bleeding from the stoma. Initial catheterization with a Water's tube yielded 400 cc of effluent. Nasogastric tube was placed through which he was receiving lactulose 30 mg q8 hours. The patient's mental status improved within 24 hours. The patient ultimately underwent flexible pouchoscopy with endoscopic dilation and placement of a 22 French mushroom catheter for decompression of the K-pouch. Discussion(s): Lactulose is a non-absorbable disaccharide composed of galactose and fructose. The small intestine does not have the enzymes required to breakdown lactulose so it reaches the large bowel in its original form. In the large bowel, it is metabolized by colonic bacteria into monosaccharides and then to volatile fatty acids, hydrogen and methane. Lactulose decreases both the production and absorption of ammonia mainly through the presence of gut bacteria. The question arises as to how lactulose decreased ammonia levels in this patient without a large bowel. One proposed mechanism is the translocation of bacteria normally found in the large bowel to the small intestine. Small Intestinal Bacterial Overgrowth (SIBO), is a condition causing an increased number of bacteria in the small intestine. Patients with IBD and structural abnormalities are at increased risk of developing SIBO. Lactulose is commonly used in the diagnosis through the administration of lactulose and subsequent measurements of hydrogen and methane gas in expired air. This condition, in our patient with history of ulcerative colitis and colectomy, is a proposed mechanism of the efficacy of lactulose in the treatment of hepatic encephalopathy.

The Great Indian Water Crisis: Sarnath Banerjee's Graphic Narrative All Quiet in Vikaspuri as an Acerbic Attestation of the Urban Water Crisis in India

Through a detailed analysis of the visual imagery as well as the verbal mode of narration, in Sarnath Banerjee's Graphic narrative All Quiet in Vikaspuri, the study suggests that the water-deprived, post-apocalyptic world that Banerjee reflects, is a spitting image of the Anthropogenic water crisis in India. Drawing theoretical insights from Madhav Gadgil, Ramachandra Guha and Dipesh Chakrabarty, the paper attempts to suggest the "Great Indian Water Crisis" is fueled by "short-termism," increased corporate privatization of water, myopic government development policies and erection of dams and other capitalist structures. The paper also aims to uncover how sociopolitical "slow-violence" is rendered to the natural resources under the garb of "Vikas" (development) and privatization. By contriving the narrative around the quest for the river Saraswati, Banerjee draws attention to the ever-so-real issue of groundwater overextraction in India, leading to its dipping levels and in turn, depletion. Further, the paper argues that "intermediality" of graphic narration abets Banerjee to cater to "the representational challenges" of the Anthropocene.

Growing usage of future fuels to transform the marine lubricants industry

The shipping industry has faced two major challenges during 2019-2022: the implementation of International Maritime Organization (IMO) norms on the maximum allowed sulfur concentration to be 0.5% in marine fuel, which also are known as IMO 2020 norms, from Jan 1, 2020, and the COVID-19 pandemic, which disrupted normal operations. The next challenges that the shipping industry is expected to face are the decarbonization 2030 and 2050 norms. This article will focus on the aftermaths of the IMO 2020 norms and the COVID-19 pandemic on the marine lubricants industry and how it is likely to evolve in the future as the shipping industry tries to meet the decarbonization targets.

The Language of Smell: Code Failure

In today's world filled with complex signs and symbols, visual and auditory channels are the most intensive in semiotic terms. The language of smell, associated with the most ancient reactions, is usually considered as secondary and supplementary, and its possibilities for conveying meanings are limited to simple recognition. However, experts have been using the alphabet of smells to convey emotional messages from ancient times to date. The assessment of the role of odors in the modern world became possible due to the Covid-19 pandemic which often involved the loss, change or intensification of the sense of smell. In the course of the study 250 cases were considered, representing the stories associated with the disease and deviations in the perception of odors. The loss of the perception of unpleasant odors makes it impossible to learn about the dangers which cannot be perceived visually like in ancient times (spoiled food, poisoned air, etc.). Phantom interpretation of odors is often unpleasant: people can identify the smells of burning, ammonia, acetone, decomposition, feces, and others, and sometimes the excessiveness of an ordinary smell is unpleasant as well. The change of sign recognition can cause serious consequences for people. Phantom unpleasant odors can result in changes in eating habits and cause problems in communication. © 2023, The Author(s), under exclusive license to Springer Nature Switzerland AG.

Coarse particulate matter air quality in East Asia: implications for fine particulate nitrate

Air quality network data in China and South Korea show very high year-round mass concentrations of coarse particulate matter (PM), as inferred by the difference between PM10 and PM2.5. Coarse PM concentrations in 2015 averaged 52 µg m-3 in the North China Plain (NCP) and 23 µg m-3 in the Seoul Metropolitan Area (SMA), contributing nearly half of PM10. Strong daily correlations between coarse PM and carbon monoxide imply a dominant source from anthropogenic fugitive dust. Coarse PM concentrations in the NCP and the SMA decreased by 21 % from 2015 to 2019 and further dropped abruptly in 2020 due to COVID-19 reductions in construction and vehicle traffic. Anthropogenic coarse PM is generally not included in air quality models but scavenges nitric acid to suppress the formation of fine particulate nitrate, a major contributor to PM2.5 pollution. GEOS-Chem model simulation of surface and aircraft observations from the Korea–United States Air Quality (KORUS-AQ) campaign over the SMA in May–June 2016 shows that consideration of anthropogenic coarse PM largely resolves the previous model overestimate of fine particulate nitrate. The effect is smaller in the NCP which has a larger excess of ammonia. Model sensitivity simulations for 2015–2019 show that decreasing anthropogenic coarse PM directly increases PM2.5 nitrate in summer, offsetting 80 % the effect of nitrogen oxide and ammonia emission controls, while in winter the presence of coarse PM increases the sensitivity of PM2.5 nitrate to ammonia and sulfur dioxide emissions. Decreasing coarse PM helps to explain the lack of decrease in wintertime PM2.5 nitrate observed in the NCP and the SMA over the 2015–2021 period despite decreases in nitrogen oxide and ammonia emissions. Continuing decrease of fugitive dust pollution means that more stringent nitrogen oxide and ammonia emission controls will be required to successfully decrease PM2.5 nitrate.

Impact of COVID-19 Lockdown on Ambient Air Quality in the Southwest Coastal Urban Regions of India

The rapid growth of urban areas and population as well as associated development over recent decades have been a major factor controlling ambient air quality of the urban environment in Kerala (India). Being located at the southwestern fringe of the Indian peninsula, Kerala is one of the regions that has been significantly influenced by the activities in the Indian Ocean. The present study focuses on the effect of the COVID-19 lockdown (in 2021) on ambient air quality in the selected coastal metropolitan areas of Kerala. Although previous research studies reported improvement in ambient air quality in Kerala during the lockdown period, this study demonstrates the potential of onshore transport of air pollutants in controlling the air quality of coastal urban regions during the lockdown period. Data from the ambient air quality monitoring stations of the Kerala State Pollution Control Board in the urban areas of Thiruvananthapuram (TM), Kollam (KL), Kozhikode (KZ), and Kannur (KN) are used for the analysis. Temporal variation in the concentration of air pollutants during the pre-lockdown (PRLD), lockdown (LD), and post-lockdown (PTLD) periods (i.e., 1 March to 31 July) of 2021 is examined to assess the effect of lockdown measures on the National Air Quality Index (AQI). Results indicate a significant decline in the levels of air pollutants and subsequent improvement in air quality in the coastal urban areas. All the effect of lockdown measures has been evident in the AQI, an increase in the concentration of different pollutants including CO, SO2, and NH3 during the LD period suggests contributions from multiple sources including onshore transport due to marine traffic and transboundary transport. © 2023, The Author(s) under exclusive licence to Institute of Earth Environment, Chinese Academy Sciences.

Hyperammonemia is a risk factor for poor outcomes in patients with COVID-19.

Objective. We analyzed clinical features and laboratory markers of COVID-19 patients according to favorable outcomes versus fatal outcomes. Material and methods. The medical history of 80 patients was analyzed: 51 patients with favorable outcomes were included in group 1, 29 patients with a fatal outcome were included in group 2. Demographic data, duration of the disease, comorbid-ities, laboratory markers, and results of the instrumental studies were included. The ammonia level in the peripheral blood was de-termined by the express method using a PocketChem BA 4140 photometric portable analyzer. Results. Patients in group 2 were older (68+/-11 years) had hypertension stage 3 with high cardiovascular risk;every third had a history of myocardial infarction. At admission, patients from group 2 were most likely with febrile fever and high levels of inflammatory markers - predictors of a cytokine release syndrome. In addition, 71% of patients at admission had elevated ammonia levels. Hyperammonemia correlated with high ferritin levels, leukopenia, non-alcoholic fatty liver disease in patients, and lethal outcomes. Conclusions. The risks of poor COVID-19 outcomes are higher in comorbid patients of the older age group. Hyperammonemia may be one of the predictors of poor COVID-19 outcomes.Copyright © 2022, Media Sphera Publishing Group. All rights reserved.

Global Atmospheric Composition Needs from Future Ultraviolet–Visible–Near-Infrared (UV–Vis–NIR) NOAA Satellite Instruments

Presentations spanned a range of applications: the public health impacts of poor air quality and environmental justice;greenhouse gas measuring, monitoring, reporting, and verification (GHG MMRV);stratospheric ozone monitoring;and various applications of satellite observations to improve models, including data assimilation in global Earth system models. The combination of methane (CH4), carbon dioxide (CO2), carbon monoxide (CO), and NO2 retrievals can improve confidence in emissions inventories and model performance, and together these data products would be of use in future air quality management tools. The ability to retrieve additional trace gases (e.g., ethane, isoprene, and ammonia) in the thermal IR along with those measured in the UV–Vis–NIR region would be extremely useful for air quality applications, including source apportionment analysis (e.g., for oil/natural gas extraction, biogenic, and agricultural sources). Ground-level ozone is one of six criteria pollutants for which the EPA sets National Ambient Air Quality Standards (NAAQS) to protect against human health and welfare effects.

Glutamine Deficiency Promotes Immune and Endothelial Cell Dysfunction in COVID-19.

The coronavirus disease 2019 (COVID-19) pandemic has caused the death of almost 7 million people worldwide. While vaccinations and new antiviral drugs have greatly reduced the number of COVID-19 cases, there remains a need for additional therapeutic strategies to combat this deadly disease. Accumulating clinical data have discovered a deficiency of circulating glutamine in patients with COVID-19 that associates with disease severity. Glutamine is a semi-essential amino acid that is metabolized to a plethora of metabolites that serve as central modulators of immune and endothelial cell function. A majority of glutamine is metabolized to glutamate and ammonia by the mitochondrial enzyme glutaminase (GLS). Notably, GLS activity is upregulated in COVID-19, favoring the catabolism of glutamine. This disturbance in glutamine metabolism may provoke immune and endothelial cell dysfunction that contributes to the development of severe infection, inflammation, oxidative stress, vasospasm, and coagulopathy, which leads to vascular occlusion, multi-organ failure, and death. Strategies that restore the plasma concentration of glutamine, its metabolites, and/or its downstream effectors, in conjunction with antiviral drugs, represent a promising therapeutic approach that may restore immune and endothelial cell function and prevent the development of occlusive vascular disease in patients stricken with COVID-19.

Spatial Variation of Air Quality in Delhi During Diwali: A Case Study of Covid-19 Period

The current study compared air pollution levels during the Covid-19 pandemic years (14 Nov. 2020, 04 Nov. 2021) and the previous year's Diwali celebrations (19 October 2017, 07 November 2018, 27 October 2019) in Delhi. PM2.5, NH3, SO2, PM10, NO2, CO, and O3 concentrations were substantially higher in 2020 Diwali than in 2017, 2018, 2019, and 2021 Diwali. PM2.5, PM10, and CO concentrations were always above the permissible limits (Very poor and Sever AQI Category);however, except on Diwali days, NO2 concentrations were within allowable limit (Good and Satisfactory AQI Category), and other pollutants such as SO2, NH3, and O3 concentrations were determined to be within permissible limits (Good AQI Category) throughout the year in Delhi. This data suggests that during the pandemic, people were following the guideline given by honorable Supreme Court of India and use less amount of firecrackers than in previous years. But the stubble burning contribution in 2020 was higher than last year and the meteorological condition was also unfavorable in that year. © 2022, The Author(s), under exclusive license to Springer Nature Switzerland AG.

The Language of Smell: Code Failure

In today's world filled with complex signs and symbols, visual and auditory channels are the most intensive in semiotic terms. The language of smell, associated with the most ancient reactions, is usually considered as secondary and supplementary, and its possibilities for conveying meanings are limited to simple recognition. However, experts have been using the alphabet of smells to convey emotional messages from ancient times to date. The assessment of the role of odors in the modern world became possible due to the Covid-19 pandemic which often involved the loss, change or intensification of the sense of smell. In the course of the study 250 cases were considered, representing the stories associated with the disease and deviations in the perception of odors. The loss of the perception of unpleasant odors makes it impossible to learn about the dangers which cannot be perceived visually like in ancient times (spoiled food, poisoned air, etc.). Phantom interpretation of odors is often unpleasant: people can identify the smells of burning, ammonia, acetone, decomposition, feces, and others, and sometimes the excessiveness of an ordinary smell is unpleasant as well. The change of sign recognition can cause serious consequences for people. Phantom unpleasant odors can result in changes in eating habits and cause problems in communication. © 2023, The Author(s), under exclusive license to Springer Nature Switzerland AG.

Maternal COVID-19 Infection: A Cause of Neonatal Stroke?

Perinatal arterial ischemic stroke (PAIS) is a rare cause of neonatal seizures, with an incidence of 1 in 2500 to 4000 live births, globally. This is a case of a neonate with PAIS due to transpla-cental passage of COVID-19 IgG antibodies from the mother. A term, male neonate, born to a primigravida with an unevent-ful antenatal history was presented on the second day of life with multiple episodes of focal clonic seizures involving the right upper and lower limbs. Magnetic resonance imaging revealed an acute infarct in the left frontal lobe, extending into the parietal region, anterior limb, and genu of internal capsule suggestive of arterial ischemic stroke. The known causes of PAIS were evaluated and ruled out. The result of reverse transcription polymerase chain reaction analysis for SARS-CoV-2 antigen was negative for both the mother and the neonate. COVID-19 IgG antibodies in the mother and neonate were elevated. Seizures were controlled with antiepileptics. The neonate had no further seizure episodes and was discharged on oral levetiracetam. The infant was developmentally and neurologically normal at 3 months of age. PAIS is a rare cause of neonatal seizures, and maternal COVID-19 infection may be associated with neonatal stroke.Copyright © 2022, Himalaya Wellness Company. All rights reserved.

The dental office: A safe place against COVID19 and other future pandemics

Background: The pandemic caused by the spread of COVID19 generated throughout the world great changes in all areas of life. Social distancing was carried out very drastically in some countries, and even in the field of dental care, some countries prohibited the practice of dentistry. Objective(s): To demonstrate that the dental office is safe regarding the possibility of contagion of Sars-Cov-2 as long as good biosecurity protocols are used. Method(s): A structured survey of 19 questions was applied to 103 patients who subsequently attended a periodontics and oral and maxillofacial surgery office in Mexico, to receive care from these specialties between April 2020 and July 2021. The questions posed in this survey were aimed at knowing the opinion of the patients regarding the measures that this establishment has for the prevention of the transmission of COVID19, as well as questions regarding the possible effects of attending this office in contagion of the disease from patients and their families. Result(s): A total of 18 (17.5%) patients reported having suffered COVID19, and none reported that they fell ill after the consultation. None of the clinic's specialists and assistants have fallen ill with COVID-19 during the pandemic. Conclusion(s): It is not necessary to suspend or condition dental care during times of pandemics such as what happened with COVID19, as long as strict safety protocols are observed within clinical facilities.Copyright © 2022 The Authors

Seasonal and Lockdown Effects on Air Quality in Metro Cities in India

Air pollution is one of the worst avoidable threats in developing nations across the world. India has undergone a substantial number of infrastructure changes during recent years due to the ever-increasing population. This and the consequent industrialization, the air quality of Indian cities became worsened. The changes in climatic conditions across various cities in India also contribute to air pollution. To control the air pollution within the acceptable limit several control measures have been imposed in India, despite these efforts the air pollution level has not decreased considerably. In India, the first COVID-19 case has reported on 30th January 2020 in the state of Kerala. To control the quick spread of COVID-19 in India, the central government executed a three-week nationwide lockdown from 24th March 2020, and further, it has extended into several phases. It was the first time in India a long-term shutting down of all the sectors happening and which resulted in positively on the environment. This study is dealing with the lockdown effect on air quality in metro cities in India and is compared with the pre-existing conditions. Also, the seasonal variations in air quality in the course of the past two years are compared. The data of pollutants PM10, PM2.5, SO2, NO2, O3, CO, and NH3 from metro cities were collected and by adopting the National Air Quality Index to depict the variations in overall air quality. During the lockdown period, most of the cities experience a considerable improvement in overall air quality and PM10, NO2, PM2.5, and CO concentrations. Whereas, the Ozone shows some increasing trend in a few cities might be due to the increment in the temperature caused by the exposure of sun during the summer season. © 2023, The Author(s), under exclusive license to Springer Nature Singapore Pte Ltd.

COVID-19 Severity, Cardiological Outcome, and Immunogenicity of mRNA Vaccine on Adult Patients With 22q11.2 DS

Ammonia-nitrogen, a grave environmental concern, is a typical pollutant in deliming process due to the inclusion of ammonium salts as deliming agents in leather manufacture. In order to reduce the emission of ammonianitrogen and improve the biological treatment of mixed tannery wastewater, an ammonium-free deliming method was designed and optimized based on the synergistic effects of aromatic sulfonic acids and sodium dihydrogen phosphate. The results indicated that, the penetrating and buffering performance of the mixtures of p-Hydroxybenzene sulfonic acid (pHBSA) and sodium dihydrogen phosphate (SDHP) at weight ratio of 2:1 was good enough to fulfill the requirement of deliming. The organoleptic and mechanical properties of the crust leather produced by pHBSA-SDHP mixtures deliming were similar with the conventional ammonium sulfate deliming, and the grain pattern was found to be protected against the damage caused by enzymes during bating. The concentrations of ammonia-nitrogen and total nitrogen in pHBSA-SDHP deliming effluent were dramatically cut down by 99% and 94%. It is anticipated that the mixed tannery wastewater could be disposed of more easily by means of adjusting the total organic ratios of C:N:P to their natural ratio by introducing an additional carbon and phosphorus source to the tannery wastewater. This investigation provides an improved method of leather making with significant reduction of ammonia nitrogen emission in deliming operation and fulfills the integral requirements of the modern sustainable leather industry.

Severe progression of autoimmune hepatitis in a young COVID-19 adult patient: A case report

Rationale: The impact of COVID-19 in patients with autoimmune liver disease treated with immunosuppressive therapy has not been described so far. This case report describes the clinical course of a patient with autoimmune hepatitis (AIH) who developed COVID-19 and the features of cytokine syndrome leading to its deterioration in our intensive care unit. Patient's Concern: A 28-year-old male presented with generalized anasarca for two weeks and chronic liver disease for 8 months. Diagnosis: AIH and Covid-19 with features of cytokine storm syndrome. Interventions: Intravenous furosemide, mannitol, syrup lactulose, steroids (prednisolone 40 mg), azathioprine 1 mg/kg body weight, rifaximin, vitamin K, and blood products. Outcomes: The patient had hepatic encephalopathy and AIH and died on the 10th day after admission despite ventilatory support, sustained low-efficiency hemodialysis, and resuscition. Lessons: The dramatic release of cytokines and the inflammatory-immune responses not only alter the pathophysiology but also affects the onset and severity of disease progression in patients with AIH.

HYPERAMMONEMIA POSTLUNG TRANSPLANTATION: AN UNCOMMON BUT LIFE-THREATENING COMPLICATION

SESSION TITLE: Lung Transplantation Cases SESSION TYPE: Rapid Fire Case Reports PRESENTED ON: 10/18/2022 10:15 am - 11:10 am INTRODUCTION: Hyperammonemia is an uncommon yet serious complication that has been described in patients after solid organ transplantation, most commonly after lung transplantation. It has an incidence of about 2-4 % and a high fatality rate. Given the myriad of etiologies that can lead to encephalopathy post lung transplantation, hyperammonemia can easily be missed unless we have a high index of suspicion. Unlike in hepatic cirrhosis, non cirrhotic hyperammonemia can result in rapidly rising high levels of ammonia which can result in cerebral edema, seizures and long term neurological deficits. Hence, quick diagnosis and a multi faceted treatment approach is required for a favorable outcome CASE PRESENTATION: 37 year old man with COVID pneumonia and respiratory failure on ECMO support underwent bilateral orthotopic lung transplant. He had no significant past medical history. ECMO was decannulated on post op day 4 and by day 6 he was progressing well and working with physical therapy. On post op day 11 he had an abrupt decline in mental status and had an episode of seizure. Initial ammonia level was 181 uMol/L (Normal < 45 uMol/L) with a peak level of 248 uMol/L. Bronchial wash was positive for Ureaplasma species by PCR. CT head did not reveal any signs of cerebral edema. Management included daily hemodialysis, Sodium phenyl butyrate, Levocarnitine, Rifaximin, Lactulose and Doxycycline. Mental status started improving and ammonia levels normalized in the next 4 days. He was subsequently discharged home from the hospital without any neurological deficits. DISCUSSION: The etiology of post lung transplant hyperammonemia is not very clear. The etiology with the most evidence is an infection with urease producing bacteria as in our patient. Based on this, obtaining a PCR screening for these organisms in the Donor/recipient has been proposed. Obtaining a screening ammonia level at around day 7 post transplant has also been suggested. Given the high mortality and morbidity associated with this condition an aggressive multimodal treatment approach is required that includes renal replacement therapy, Nitrogen scavengers, bowel decontamination and empiric antibiotics. Hemodialysis has been shown to be more effective than continuous veno-venous hemodialysis for ammonia clearance. Antibiotics such as Azithromycin and Doxycycline that would be effective against urease producing organisms should be administered. In patients with signs of raised intracranial pressure, prompt neuroimaging and also measures to reduce cerebral edema must be instituted. CONCLUSIONS: Clinical signs of hyperammonemia should be promptly recognized in post lung transplant patients and managed aggressively given high mortality rates without treatment. A multi-pronged treatment approach with Intermittent high flux hemodialysis, bowel decontamination and agents targeting the urea cycle should be used to rapidly decrease the ammonia levels. Reference #1: Krutsinger D, Pezzulo A, Blevins AE, Reed RM, Voigt MD, Eberlein M. Idiopathic hyperammonemia after solid organ transplantation: Primarily a lung problem? A single-center experience and systematic review. Clin Transplant. 2017 May;31(5). doi: 10.1111/ctr.12957. Epub 2017 Apr 7. PMID: 28295601. Reference #2: Leger RF, Silverman MS, Hauck ES, Guvakova KD. Hyperammonemia Post Lung Transplantation: A Review. Clin Med Insights Circ Respir Pulm Med. 2020 Oct 26;14:1179548420966234. doi: 10.1177/1179548420966234. PMID: 33192115;PMCID: PMC7594252. Reference #3: Anwar S, Gupta D, Ashraf MA, Khalid SA, Rizvi SM, Miller BW, Brennan DC. Symptomatic hyperammonemia after lung transplantation: lessons learnt. Hemodial Int. 2014 Jan;18(1):185-91. doi: 10.1111/hdi.12088. Epub 2013 Sep 2. PMID: 23998793. DISCLOSURES: Research Grant relationship with Alung Please note: $1001 - $5000 by Bindu Akkanti, value=Grant/Research Support No relevant relationships by Soma Jyothula no disclosure on file for Manish Patel;No relevant relationships by Sandeep Patri