AUTOANTIBODIES RELATED TO RHEUMATIC DISEASES AFTER COVID-19 INFECTION

BackgroundSARS-CoV-2(Severe acute respiratory syndrome coronavirus 2) has been circulating worldwide for three years. It mainly causes upper respiratory tract infection, which can manifest as pulmonary infection and even respiratory distress syndrome in severe cases. Different autoantibodies can be detected in patients infected with COVID-19.ObjectivesTo explore autoantibodies related to rheumatic diseases after COVID-19 infection.MethodsNinety-eight inpatients were tested for antinuclear antibodies (ANA), antibodies to extractable nuclear antigens(ENA), anti-neutrophil cytoplasmic antibodies（ANCA), anticardiolipin antibodies,a-β2GPI (IgG/IgM). They were from a tertiary hospital in Guangzhou during the COVID-19 epidemic. Data were described statistically.ResultsNinety-eight hospitalized patients were tested for relevant antibodies. The average age was 50.64±19.54;67 (68.4%) were male, 64 (65.3%) were COVID-19 positive, 90 (90.9%) had rheumatic diseases, and 56 of them were COVID-19 positive patients with rheumatic diseases.There were 76 patients tested for antinuclear antibodies;29 （38.16%）were negative, 18 （23.68%）had a 1/80 titre, and 29（28.16%） had a titre greater than 1:80. The 31 covid patients were positive for ANA. In the high-titer group, 19 patients with rheumatic diseases were positive for COVID-19, and 12 patients had an exacerbation of the rheumatic diseases (6 of whom had previously had pulmonary fibrosis). Of 31 covid patients, only two were non-rheumatic patients, and both were elderly, aged 85 and 100, respectively.Fifty-six patients had ENA results, and 29 for positive antibodies, 8 for ds-DNA antibodies, 2 for anti-Sm antibodies, 6 for anti-nucleosome antibodies, 12 for anti-U1RNP antibodies, 2 for anti-Scl-70 antibodies, 12 for anti-SS-A antibodies, 3 for anti-mitochondrial M2 antibodies, 2 for anti-centromere antibodies, 1 for anti-Po antibodies, and one for anti-Jo-1 antibody. All 56 patients had rheumatic diseases, and no new patients were found.There were 62 patients with ANCA data. P-ANCA was positive in 12 cases(19.35%), and MPO-ANCA was positive in 2 cases. An 85-year-old non-rheumatic COVID-19 patient was P-ANCA positive. She had a history of hypertension, colon cancer, CKD3, coronary heart disease, and atrial flutter.In the anticardiolipin antibodies group, there were 62 patients;only 6 were positive, and 2 were rheumatic patients infected with COVID-19. Antiphospholipid antibodies were detected in 33 patients, and a-β2GPI was tested in one patient, an 82-year-old COVID-19 patient with gout, diabetes, and cerebral infarction in the past. We did not find a statistical difference in the above results.ConclusionWe have not found a correlation between SARS-CoV-2 and serum autoantibodies of rheumatic immune diseases. It needs large samples and an extended follow-up to research.AcknowledgementsThis work was supported by Scientific and Technological Planning Project of Guangzhou City [202102020150], Guangdong Provincial Basic and Applied Basic Research Fund Project [2021A1515111172], National Natural Science Foundation of China Youth Fund [82201998] and Third Affiliated Hospital of Sun Yat-Sen University Cultivating Special Fund Project for National Natural Science Foundation of China [2022GZRPYQN01].Disclosure of Interestsone declared.

Hemophagocytosis in the Red Bone Marrow of Patients with Covid-19 with Sars-Cov-2 Infection

Red bone marrow samples investigation in deceased COVID-19 patients enabled to identify the phenomena of secondary hemophagocytosis. Analysis of the data showed that phagocytic reactions during infection of patients with SARS-CoV-2 are manifested both in relation to erythrocytes and leukocytes. The data obtained make it possible to expand the strategy of therapeutic measures, taking into account the new data on the mechanisms of the pathogenesis of COVID-19 in severe viral infection based on morphological findings and additional information on the involvement of young erythrocytes and lymphocytes in the structure of the red bone marrow in the cascade of pathological reactions. The results obtained confirm a wide range of aggressive damaging effects of SARS-CoV-2 in the development of multiple organ failure against the background of COVID-19 and the involvement of the red bone marrow in the pathological process. The authors supplemented information about the mechanisms of hypoxia in COVID-19, which is not only a consequence of damage to the respiratory epithelium, but also the result of damage to erythrocyte differons both at the level of red bone marrow and in peripheral blood. This fact must be taken into account in the development of a treatment strategy and in the creation of new drugs for the treatment of infected patients with various strains of SARS-CoV-2.

Factors for prolonged hospital length of stay in discharged patients with COVID-19

Hospitals were overburdened during peak periods of Coronavirus disease 2019 (COVID-19) pandemic, and bed occupancy was full. The ability to predict and plan patients' hospital length of stay allows predictability in terms of the free capacity of hospital facilities. The purpose of this article is to evaluate the factors that influence the hospital length of stay among discharged (recovered) from COVID-19 patients. This will allow the prediction of the likely number of bed days in the conditions of intensive workload of medical facilities for hospital care. A total of 441 discharged after hospital treatment for COVID-19 patients are followed up. Factors for prolonged hospital length of stay are searched among the indicators recorded at admission. Median hospital length of stay of the patients discharged from COVID-19 ward is 9 days (IQR 6-12) and in the COVID-19 intensive care unit 12 days (IQR 9.75-18.75). The median length of stay assessed by a survival analysis is 35 days in the COVID-19 unit and only 8 days in intensive care, due to the high mortality in the intensive care unit. The longer hospital length of stay of patients discharged from the COVID-19 wards is associated with the presence of hypertension (median 10 vs. 8 days for patients without the disease, p=0.006), ischemic heart disease (10 vs. 8 days, p<0.001), cerebrovascular disease (10 vs. 8 days, p=0.061 - did not reach significance), peripheral arterial disease (12 vs. 8 days, p=0.024), chronic renal failure or chroniodialysis (14 vs. 8 days, p<0.001), oncological illness (11 vs. 8 days, p=0.024), presence of at least one comorbidity (9 vs. 8 days, p=0.006), arrival at the hospital by ambulance vs. the patient's own transport (11 vs. 8 days, p=0.003), severe lung involvement shown on X-ray (10 vs. 8 days, p=0.030) or CT (18 vs. 10 days, p=0.045). Prolonged hospital length of stay is associated with older age (Spearman's rho=0.185, p<0.001), greater number of comorbidities (Spearman's rho=0.200, p<0.001), lower oxygen saturation on admission (Spearman's rho=- 0.294, p<0.001) and lower lymphocytes count (Spearman's rho=-0.209, p<0.001), as well as higher CRP (Spearman's rho=0.168, p<0.001), LDH (Spearman's rho=0.140, p=0.004), ferritin (Spearman's rho=0.143, p=0.004) and d-dimer (Spearman's rho=0.207, p<0.001). The multiple linear regression model found that the increase in the number of bed days of discharged from COVID-19 unit patients depends on the way the patient arrived at the Emergency Department (by ambulance instead of on their own transportation) and the presence of an accompanying oncological disease (R2=0.628, p<0.001). The hospital length of stay of patients discharged from COVID-19 intensive care unit is associated with the presence of hypertension (median 14 vs. 9 days for patients without the disease, p=0.067 - significance not reached) and at least one comorbidity (14 vs. 9 days, p=0.067 - significance not reached). The number of bed days is higher when recorded more comorbidities (Spearman's rho=0.818, p=0.004), lower oxygen saturation (Spearman's rho=-0.605, p=0.067 - significance not reached) and higher leukocytes count (Spearman's rho=0.546, p=0.102 - significance not reached). A multiple linear regression model demonstrated the hospital length of stay of patients in the COVID-19 intensive care unit as an outcome of the number of comorbidities only (R2=0.826, p=0.003). The ability to estimate and forecast quickly the number of bed-days based on a small number of variables would help reduce the burden on the healthcare system during a pandemic.

IMPROVING PATIENT SAFETY THROUGH THE ESTABLISHMENT OF A PHARMACIST-LED BLOOD MONITORING CLINIC FOR JAK INHIBITORS IN RHEUMATOLOGY

BackgroundJanus kinase inhibitors drugs (JAKi) are novel small molecule medications known to cause abnormalities such as elevations in hepatic transaminases, decreases in neutrophil and lymphocyte counts and elevations in cholesterol and creatinine kinase. Blood monitoring is recommended and dose adjustments are advised if abnormalities arise. Recent warnings by the EMA and MHRA have highlighted the importance of monitoring these medications.Timely review and management of patients on JAKi drugs is difficult to maintain with increasing workload amongst the rheumatology team. A baseline audit (2020) demonstrated that hospital blood monitoring guidelines for JAKi drugs were not being followed. The rheumatology multidisciplinary team met and utilised Quality Improvement methodology including fish and driver diagrams to address this. This led to the creation of a pharmacist-led JAKi blood monitoring clinic.ObjectivesTo establish a pharmacist-led rheumatology blood monitoring clinic for the JAKi drug class in order to: increase patient safety with increased compliance to blood monitoring, save consultant/nurse time, improve communication with primary care on the frequency of blood testing required, increase patient understanding of the importance of blood monitoring with JAKi drugs, reinforce counselling advice such as risk of infections, shingles and thrombosis and promote medication adherence.MethodsThe clinic was established in March 2021. Patients commencing JAKi drugs are referred to the pharmacist-led clinic by the medical team. The pharmacist contacts the patient by phone following delivery of their medication. The patient is counselled on their new medication and dates for blood checks are agreed. A letter is sent to the patient and their GP providing this information. The patient is booked into virtual telephone appointments and bloods are monitored every month for the first 3 months and every 3 months thereafter. Any change or abnormality in blood results are flagged early in the patient's treatment and if necessary, discussed with the consultant. Adjustments are made to the patient's dose if appropriate.ResultsIn order to evaluate the benefit of the pharmacist clinic a re-audit of compliance with blood monitoring (March 2021- September 2022) was carried out alongside a patient satisfaction postal survey (August 2022).A total of 58 patients were sampled in the re-audit. The re-audit found an increase in compliance in blood monitoring since the introduction of the pharmacist clinic. 98% of patients had their full blood count performed at 3 months compared to 56% in audit 1 and 95% of patients had their lipid profile completed at 3 months compared to 15% in audit 1 (Table 1).A patient satisfaction survey (N=62, response rate 48%) found that 28 (93%) patients either agreed or strongly agreed that they were more aware of the importance of attending for regular blood monitoring when prescribed JAKi therapy as a result of the clinic.The pharmacy team made several significant interventions (self-graded Eadon grade 4 and 5). For example by improving medication adherence, detecting haematological abnormalities that required JAKi dose reduction, identifying patients suffering from infection requiring intervention including shingles and Covid-19.Table 1.Comparison of audit results pre (Audit 1) and post (Audit 2) clinic establishmentAudit 1 (N=48)Audit 2 (N=58)Number of patients with full blood count completed at weeks 4, 8 & 1227 (56%)57 (98%)Number of patients with lipid profile completed at week 127 (15%)55 (95%)Number of patients LFTs completed at weeks 4, 8 & 1226 (54%)54 (93%)ConclusionIntroduction of the pharmacist-led clinic has increased patient safety by ensuring compliance with blood monitoring as per hospital guidelines. The clinic has paved the way for improved communication with primary care teams and has provided patients with extra support during their first months on treatment with their JAKi. It has also expanded the role of the rheumatology pharmacy team and saved nursing and medical time.Acknowled ementsI wish to thank the SHSCT Rheumatology team for all their help, support and guidance with this project.Disclosure of InterestsNone Declared.

Effect of synbiotics on inflammatory markers and white blood cell count in COVID-19 patients: a randomized, double-blind, placebo-controlled clinical trial. (Special Issue: The relationship between nutrition and COVID-19.)

Purpose: Today, coronavirus disease-19 (COVID-19) treatment is an evolving process, and synbiotic administration has been suggested as a new therapeutic strategy. This study aims to investigate the effect of synbiotic supplementation in COVID-19 patients. Design/methodology/approach: In this placebo-controlled trial, 80 patients were randomized to receive oral synbiotic capsule (containing fructooligosaccharide and seven bacterial strains;Lactobacillus (L) casei, L. rhamnosus, Streptococcus thermophilus, Bifidobacterium breve, L. acidophilus, Bifidobacterium longum, L. bulgaricus, each one 109 colony-forming units) or placebo for two months. Inflammatory markers (Interleukin-6 [IL-6], C-reactive protein [CRP], erythrocyte sedimentation rate [ESR]) and white blood cell (WBC) count were evaluated at two timepoints (baseline, two months later). The measured variables were adjusted for confounders and analyzed by SPSS v21.0. Findings: All 80 enrolled patients completed the study. The study adherence was good (approximately 70%). The mean changes for IL-6 were not significant ( = -0.6 +or- 10.4 pg/mL vs = +11.2 +or- 50.3 pg/mL, p > 0.05). There were no significant improvements for CRP, ESR and WBC. Originality/value: Administration of synbiotics for two months did not improve inflammatory markers in COVID-19 patients.

LABORATORY PARAMETERS ASSOCIATED WITH CODIV-19 CYTOKINE STORM DEVELOPMENT

BackgroundSince the end of 2019, physicians became more and more familiar with SARS-CoV-2 infection and the variety of forms in which it may present and evolve. There have been a lot of studies trying to understand and predict why some patients develop a dysregulation of the immune response, with an exaggerated release of pro-inflammatory cytokines, called cytokine storm (1–4). There is scarce evidence in Romania regarding this aspect.ObjectivesThis study aims to verify the correlation between some laboratory parameters and the development of cytokine storm in SARS-CoV-2 infection in a cohort of over 200 patients admitted in a tertiary hospital from Romania, hoping that early identification of these risk factors of progression to a severe form of the disease can bring considerable benefit to patient care.MethodsThis is an analytical, observational, case-control study which includes 219 patients (all COVID-19 hospitalized patients on the Internal Medicine 3 department of Colentina Clinical Hospital, Bucharest, from 01 March 2020 to 1 April 2021). A series of data were collected, the laboratory parameters being the most important, including: albumin, lymphocyte (percentage), neutrophil (absolute value), aspartate aminotransferase, alanine aminotransferase, D-dimers, lactate dehydrogenase (LDH), anionic gap, chloremia, potassium and the BUN:creatinine ratio (BUN - blood urea nitrogen). The laboratory parameters used for the statistical analysis represent the average values of the first 7 days of hospitalization for those who did not develop cytokine storm, respectively until the day of its development, for the others. Patients were classified into these groups, those who developed cytokine storm, respectively those who did not have this complication taking into account the clinical and paraclinical criteria (impairment of respiratory function, elevations of certain markers 2-3 times above the upper limit of normal, those who died as a result of SARS-CoV-2 infection). Then Binary Univariate Logistic Regression was applied in order to verify the individual impact of every laboratory parameter on cytokine storm development. Furthermore, all laboratory parameters were subsequently included in the multivariate analysis, using the backward selection technique to achieve a model as predictive as possible.ResultsWe mention that the analysis of demographic data was previously performed, showing no statistically significant relationship between patient gender, age or comorbidities (history of neoplasm, lung diseases, cardiac pathology, obesity, type II diabetes and hypertension) and their evolution to cytokine storm. After performing binary univariate logistic regression we concluded that 8 of the 13 laboratory analyzes have had a significant change between groups (ferritin, PCR, albumin, Lymphocyte, Neutrophils, TGO, LDH, BUN:creatinine ratio). Only 150 patients were then included in the multivariate analysis. After the analysis, some of the variables lost their statistical significance, the final model including C-reactive protein, neutrophilia, LDH, ferritin and the BUN:creatinine ratio. This model correctly predicts the development of cytokine storm in 88% of cases.ConclusionHigh C-reactive protein, neutrophilia, LDH, ferritin and the BUN:creatinine ratio are risk factors for cytokine storm development and should be monitored in all COVID-19 patients in order to predict their evolution.References[1]Pedersen SF et all. SARS-CoV-2: A storm is raging[2]Mehta P et al. COVID-19: consider cytokine storm syndromes and immunosuppression[3]Hu B et al. The cytokine storm and COVID-19.[4]Caricchio R et al. Preliminary predictive criteria for COVID-19 cytokine stormAcknowledgements:NIL.Disclosure of InterestsNone Declared.

Pharmacological Properties and Safe Use of 12 Medicinal Plant Species and Their Bioactive Compounds Affecting the Immune System

This paper presents raw plant materials and their characteristic compounds which may affect the immune system. Plant-derived agents in specific doses affect the body's non-specific, antigen-independent defense system. They have immunostimulatory effects on the entire immune regulatory system. They can enhance the immune response through various factors such as macrophages, leukocytes, and granulocytes, as well as through mediators released by the cellular immune system. This paper was inspired by the threats caused by the COVID-19 pandemic. The proper functioning of the immune system is important in limiting the effects of viral infection and restoring the normal functioning of the body. This paper also emphasizes the importance of the skillful use of plant immunostimulants by potential patients, but also by those who prescribe drugs. It is important not only to choose the right plant drug but above all to choose the correct dose and duration of treatment.

NEUTROPHIL TO LYMPHOCYTE RATIO (NLR) PREDICTS FRACTURE IN PATIENTS ON LONG-TERM GLUCOCORTICOID

BackgroundLong-term glucocorticoid (GC) exposure leads to systemic bone loss and fracture. In addition, GC is known to increase white blood cell (WBC) amount and change the distribution of differential count (DC). Neutrophil-to-Lymphocyte ratio (NLR) has been studied as an optimal marker of subclinical inflammation, predicting the prognosis of cardiovascular diseases, cancers and even covid-19 infection. For patients under long-term GC exposure, the hemogram change might be a potential parameter to predict prognosis.ObjectivesThis pilot study aims to investigate if GC related WBC-DC change, including NLR, is associated with future fractures during 3 years follow-up.MethodsThis retrospective study is based on a registry, conducted in Kaohsiung Chang Gung Memorial Hospital, Taiwan, from September 2014 till April 2021, aimed to monitor bone mineral density (BMD) changes and fractures in patients with autoimmune diseases. All recruited patients were followed at least 3 years and took X-ray images annually to capture new fragility fracture, including morphometric vertebral fractures. We screened participants who used GC continuously at least 3 months before the index day. We recorded the complete blood count (CBC) and WBC-DC values at least twice during the period of 3 months before and after the index day, and excluded patients who were febrile, under infection status, diagnosed as cancers or cardiovascular diseases at the index day. The NLR was calculated by the absolute neutrophil count divided by absolute lymphocyte count individually.ResultsA total of 346 participants were enrolled in current study, and 101 (29.2%) suffered from new fragility fracture in 3 years. Among patients with fracture and non-fracture, conventional fracture risk factors, such as age, BMD, and previous fracture remained significantly different, while the WBC revealed no difference (Table 1). Nevertheless, the absolute neutrophil and lymphocyte count were significantly higher and lower in the fracture group, respectively, and no difference in the monocyte, eosinophil, and basophil count. We compared different WBC ratio, and NLR is significantly higher in the fracture group, providing the odds ratio of 1.24 (95% confidence interval 1.07-1.44, p=0.005). Figure 1 showed that the observed fracture risk raised as the NLR values increased.ConclusionIn patients under long-term GC, NLR might be a helpful marker to predict fracture, and higher NLR indicates higher fracture risks.Figure 1.Observed fracture rate is associated with baseline NLR[Figure omitted. See PDF]Table 1.Demographic characteristics of enrolled patients on long-term glucocorticoid.Fracture N=101No-Fracture N=245p-valueAge63.7 ± 9.056.5 ± 9.6<0.001*Sex(women)89(88.1)210(85.7)0.55BMI24.1 ± 3.923.4 ± 3.90.14Previous Fracture64(63.4)55(22.4)<0.001*Total hip BMD0.738 ± 0.1330.790 ± 0.1220.001*Femoral neck BMD0.575 ± 0.1130.626 ± 0.109<0.001*Lumbar BMD0.841 ± 0.2000.855 ± 0.1500.49WBC7.3 ± 2.16.9 ±1.70.14Hemoglobin12.8 ± 1.512.9 ± 1.40.33Platelet239.2 ± 64.7247.9 ± 71.40.30Neutrophil67.3 ± 9.764.3 ± 9.70.009*Lymphocyte24.3 ± 8.726.6 ± 9.50.04*Monocyte6.2 ± 1.86.3 ± 1.60.52Eosinophil1.8 ± 1.81.9 ± 1.30.77Basophil0.4 ± 0.20.4 ± 0.20.18NLR (Neutrophil to lymphocyte)3.3 ± 1.72.8 ± 1.40.004*NMR (Neutrophil to monocyte)11.9 ± 4.511.0 ± 3.60.04*LMR (Lymphocyte to monocyte)4.2 ± 1.74.5 ± 1.90.20AcknowledgementsThis work was supported by funding grant CMRPG8J0331 from the Chang Gung Memorial Hospital (https://www.cgmh.org.tw).Disclosure of InterestsNone Declared.

RELATION BETWEEN COVID-19 AND ANCA VASCULITIS. STUDY IN A SINGLE UNIVERSITY HOSPITAL

BackgroundAnti-neutrophil cytoplasmic antibodies (ANCA) associated vasculitis (AAV) is a small vessel vasculitis. Hallmarked by the presence of antibodies against antigens in cytoplasmic granules of neutrophils. Different microbiological agents and vaccines can trigger an AAV, including severe acute respiratory syndrome coronavirus 2 (SARS-CoV2) infection and Coronavirus disease 2019 (COVID-19) vaccine.ObjectivesTo compare: a) proportion of positive ANCA (+ANCA) test in 2019 (COVID-19 pre-pandemic) vs 2021 (COVID-19 pandemic), b) clinical features and c) vasculitis activity between vasculitis related to COVID 19 vaccination vs non-related.MethodsAll ANCA tests performed in 2019 and 2021 in a referral hospital were reviewed. Additionally, we studied 18 +ANCA patients diagnosed in 2021 and accepted to participate in present study. The patients were divided in two groups: a) +ANCA after SARS-CoV-2 mRNA vaccine (COVID-related) and +ANCA before COVID-19 vaccine (COVID-nonrelated). Diagnosis of underlying AAV was based on ACR/EULAR 2022 criteria. Disease activity was assessed with Birmingham Vasculitis Activity Score (BVAS). ANCA testing was done by chemiluminescence assay using IO-FLASH (Inova, San Diego, CA) according to the instructions of the manufacturer.ResultsANCA tests were positive in 14 of 1287 cases (1.1%) and in 32 of 1434 (2.2%) cases in 2019 and 2021, respectively (figure 1, the differences were statistically significant (p=0.020). The main features of 18 ANCA+ patients diagnosed in 2021 are summarized in table 1. COVID-19 related patients showed a median of 7 points on BVAS score compared of the median of 5 points on BVAS score on not related patients.ConclusionThere seems to be an increase of +ANCA at the expense of anti-PR3 antibodies following the COVID-19 vaccine. In patients with +ANCA following vaccination there seems to be an increased disease activity according to BVAS score without reaching statistical significance.References[1]Damoiseaux, J., et al Autoimmunity Reviews.2021. PMID 34896650.[2]Irure-Ventura, et al. IScience.2022. PMID 35937087.Table 1.Main general features of 18 patients with ANCA+ test diagnosed in 2021.FEATURESAll cases n= 18Related n= 13Non-related n= 5p*Age (years), mean±SD62±1767±15.352±16.50.167Male/ Female n, (% male)10/8 (55.6)9/4 (69.2%)1/4(20)0.067ANCA-test specificity, n (%)MPO-ANCA9 (50)7 (53.8)2(40)0.609PR3-ANCA8 (44.4)5 (38.5)3(60)0.423Both1 (5.6)1 (7.7)0-CRP (mg/dL), median [IQR]2,4 [0.4-10.7]3.8 [0.4-10.1]1 [0.4-10.9]0.802ESR, mm/1st hours, median [IQR]50 [25-104]47 [25.3-71.8]50 [25-120]0.634BVAS, median [IQR]6.5 [4.2-8]7 [4-8]5 [5-8]0.842FFS, n (%)03 (16.7)2 (15.4)1 (20)0.819≥115 (83.3)11 (84.6)4 (80)0.819ENT involvement, n (%)12(66.7)10 (76.9)2 (40)0.148MSK involvement, n (%)11(61.1)7(53.8)4 (80)0.322CNS/PNS involvement, n (%)10 (55.6)7 (53.8)3 (60)0.819Lung involvement, n (%)9 (50)6 (46.2)3 (60)0.609Kidney involvement, n (%)8 (44.4)7 (53.8)1 (40)0.208Ocular involvement, n (%)2 (11.1)2 (15.4)00.366Cutaneous involvement, n (%)2 (11.1)02 (40)0.019*p values according to Man Whitney test.Abbreviations (in alphabetical order):AAV: anti-neutrophil cytoplasmic antibodies (ANCA)-associated vasculitis;ACR: American college of Rheumatology;ANCA: Antineutrophil cytoplasmic antibody;BVAS: Birmingham Vasculitis Activity Score;CNS: central nervous system;CRP: C-Reactive protein;dL: deciliter;ENT: ear, nose, throat;ESR: erythrocyte sedimentation rate;FFS: Five-Factors Score;g;IQR: Interquartile range;mg: milligram;MSK: musculoskeletal;MPO-ANCA= ANCA specific for myeloperoxidase;n=Number;PNS: peripheral nervous system;PR3-ANCA= ANCA specific for proteinase 3;SD: Standard DeviationFigure 1.Comparison of ANCA test in 2019 and 2021.[Figure omitted. See PDF]Acknowledgements:NIL.Disclosure of InterestsFabricio Benavides-Villanueva: None declared, Vanesa Calvo-Río Speakers bureau: Dra V. Calvo had participation in company-sponsored speaker´s bureau from Roche, Novartis, Galápagos, UCB Pharma, MSD, Celgene, and Grünenthal and received support for attending m etings and/or travel from Janssen, Abbvie, Roche, Novartis, MSD, UCB Pharma, Celgene, Lilly, Pfizer, Galápagos., J. Loricera Speakers bureau: Dr. J. Loricera had participation in company-sponsored speaker´s bureau from Roche, Novartis, Galápagos, UCB Pharma, MSD, Celgene, and Grünenthal., Consultant of: Dr. J. Loricera had consultation fees in company-sponsored speaker´s bureau from Roche, Novartis, Galápagos, UCB Pharma, MSD, Celgene, and Grünenthal and received support for attending meetings and/or travel from Janssen, Abbvie, Roche, Novartis, MSD, UCB Pharma, Celgene, Lilly, Pfizer, Galápagos., Juan Irure-Ventura: None declared, Marcos Lopez-Hoyos: None declared, Ricardo Blanco Speakers bureau: Dr. R. Blanco had participation in company sponsored speaker´s bureau from Abbvie, Pfizer, Roche, Bristol-Myers, Janssen, Lilly and MSD., Consultant of: Dr. R. Blanco had consultation from Abbvie, Pfizer, Roche, Bristol-Myers, Janssen, Lilly and MSD., Grant/research support from: Dr. R. Blanco received grants/research supports from Abbvie, MSD and Roche.

SINGLE CELL MULTIOMIC PROFILING OF DISRUPTED REGULATORY NETWORKS IN COVID19 ASSOCIATED MULTISYSTEM INFLAMMATORY SYNDROME IN CHILDREN

BackgroundChildren infected with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) usually present minimal symptoms or are asymptomatic. Nevertheless, a subset of children 2-6 weeks after the initial SARS-CoV-2 infection develops a postinfectious SARS-CoV-2-related multisystem inflammatory syndrome in (MIS-C). Recently, transient expansion of TRBV11-2 T cell clonotypes in MIS-C was associated with signatures of inflammation and T cell activation, however, the underlying pathophysiology of MIS-C is not fully understood [1].ObjectivesThe purpose of our project is to characterize the complexity of cell populations and capture cellular heterogeneity to uncover the regulatory networks and interactions that are disrupted during MIS-C flare with simultaneous profiling of gene expression and open chromatin regions from the same nuclei.MethodsSamples of peripheral blood mononuclear cells from patients with MIS-C diagnosed at the University Children's Hospital, University Medical Center Ljubljana, were collected during the initial presentation before any treatment and at 6-12 months in remission. The primary aim is to identify which regulatory networks are driving inflammation in MIS-C flare, for which we are performing single cell Multiome ATAC + Gene Expression Sequencing. To enable simultaneous profiling of epigenomic landscape and gene expression from the same nuclei, we are using Chromium Next GEM Single Cell Multiome ATAC + Gene Expression kit from 10X Genomics.ResultsWe included 32 patients with MIS-C from whom we collected paired blood samples during the initial presentation before treatment and at 6-12 months in remission. In single cell multiomic experiment we included 10 patients with paired samples, with the most viable cell count prior cryopreservation. All samples that are included into multiomic single cell analysis have 75% - 99% viability prior cryopreservation. In the protocol the key is to remove remaining granulocytes causing high mitochondrial RNA burden and extensively optimize the dilution factor of lysis buffer and the length of cell lysis step in order to get intact nuclei with no significant blebbing. Afterward, the single cell ATAC libraries as well as single-cell gene expression libraries are constructed and sequenced. Data are undergoing pairwise analysis to compare the cell population heterogeneity, expression profile and open chromatin landscape in the time of the initial presentation of MIS-C and in the remission, with Cell ranger software as well as with R package scREG [2], and custom scripting. In the second step we will inspect if the resulting altered transcriptomic signature from single-cell experiment is present on larger cohort. In that regard, we will perform bulk transcriptomic profiling on all paired collected samples during the initial presentation of MIS-C before treatment and at 6-12 months in remission.ConclusionThe results of this project are expected to enlighten the underlying pathophysiology of MIS-C flare and thus support clinical decision on more targeted treatment. The identified disrupted networks during MIS-C flare could lead the way to establish an early diagnosis and improve long-term outcome, including prevention of myocardial and neuropsychological impairment. Moreover, a better understanding of the disrupted regulatory networks that are driving inflammation in MIS-C, could lead to new insights into diseases with similar clinical presentations as is Kawasaki Disease.References[1]Sacco, K., Castagnoli, R., Vakkilainen, S. et al. Immunopathological signatures in multisystem inflammatory syndrome in children and pediatric COVID-19. Nat Med 28, 1050–1062 (2022).[2]Duren, Z., Chang, F., Naqing, F. et al. Regulatory analysis of single cell multiome gene expression and chromatin accessibility data with scREG. Genome Biol 23, 114 (2022).AcknowledgementsThis research was supported by Slovenian research agency grant J3-3061 and Interreg ITA-SLO project Cattedra.Disclosure of InterestsNone Declared.

Special Issue: The relationship between nutrition and COVID-19. (Special Issue: The relationship between nutrition and COVID-19.)

This special issue contains 8 articles that discuss and highlights the importance of nutrition in mitigating the mental and health-related issues associated with the pandemic, as well as its effects on diet quality and physical activity levels. Topics include: (1) a systematic literature review that emphasizes the role of nutrition in minimizing mental and health-related issues during COVID-19. The review concludes that a healthy diet rich in essential nutrients can play a crucial role in supporting mental health, immune function and overall well-being during the pandemic. In addition, it highlights the need for public health interventions that promote healthy eating habits and provide access to nutritious foods, (2) adherence to the Mediterranean diet in Greek adolescents during COVID-19, (3) a randomized, double-blind, placebo-controlled clinical trial investigated the effect of synbiotics on inflammatory markers and white blood cell count in COVID-19 patients, (4) COVID-19 pandemic anxiety was reflected in nutritional habits in adults, (5) investigation of the link between metabolic risks, dietary patterns and COVID-19 prognosis, (6) exploration of the factors related to sedentary lifestyle in a Brazilian sample during the COVID-19 initial quarantine.

A specific combination of laboratory data is associated with overweight lungs in patients with COVID-19 pneumonia at hospital admission: secondary cross-sectional analysis of a randomized clinical trial.

Background: Lung weight may be measured with quantitative chest computed tomography (CT) in patients with COVID-19 to characterize the severity of pulmonary edema and assess prognosis. However, this quantitative analysis is often not accessible, which led to the hypothesis that specific laboratory data may help identify overweight lungs. Methods: This cross-sectional study was a secondary analysis of data from SARITA2, a randomized clinical trial comparing nitazoxanide and placebo in patients with COVID-19 pneumonia. Adult patients (≥18 years) requiring supplemental oxygen due to COVID-19 pneumonia were enrolled between April 20 and October 15, 2020, in 19 hospitals in Brazil. The weight of the lungs as well as laboratory data [hemoglobin, leukocytes, neutrophils, lymphocytes, C-reactive protein, D-dimer, lactate dehydrogenase (LDH), and ferritin] and 47 additional specific blood biomarkers were assessed. Results: Ninety-three patients were included in the study: 46 patients presented with underweight lungs (defined by ≤0% of excess lung weight) and 47 patients presented with overweight lungs (>0% of excess lung weight). Leukocytes, neutrophils, D-dimer, and LDH were higher in patients with overweight lungs. Among the 47 blood biomarkers investigated, interferon alpha 2 protein was higher and leukocyte inhibitory factor was lower in patients with overweight lungs. According to CombiROC analysis, the combinations of D-dimer/LDH/leukocytes, D-dimer/LDH/neutrophils, and D-dimer/LDH/leukocytes/neutrophils achieved the highest area under the curve with the best accuracy to detect overweight lungs. Conclusion: The combinations of these specific laboratory data: D-dimer/LDH/leukocytes or D-dimer/LDH/neutrophils or D-dimer/LDH/leukocytes/neutrophils were the best predictors of overweight lungs in patients with COVID-19 pneumonia at hospital admission. Clinical trial registration: Brazilian Registry of Clinical Trials (REBEC) number RBR-88bs9x and ClinicalTrials.gov number NCT04561219.

Guest editorial: the relationship between nutrition and COVID-19

[...]the journal Nutrition and Food Science has published this special issue exploring the intersection of nutrition and COVID-19 [1], [2], [3], [4], [5], [6], [7], [8]. [...]a study explored the factors related to sedentary lifestyle in a Brazilian sample during the COVID-19 initial quarantine [8]. [...]the papers published in the special issue "The relationship between nutrition and COVID-19” underlined the importance of nutrition in mitigating the mental and health-related impacts of the COVID-19 pandemic.

Effect of synbiotics on inflammatory markers and white blood cell count in COVID-19 patients: a randomized, double-blind, placebo-controlled clinical trial

PurposeToday, coronavirus disease-19 (COVID-19) treatment is an evolving process, and synbiotic administration has been suggested as a new therapeutic strategy. This study aims to investigate the effect of synbiotic supplementation in COVID-19 patients.Design/methodology/approachIn this placebo-controlled trial, 80 patients were randomized to receive oral synbiotic capsule (containing fructooligosaccharide and seven bacterial strains;Lactobacillus (L) casei, L. rhamnosus, Streptococcus thermophilus, Bifidobacterium breve, L. acidophilus, Bifidobacterium longum, L. bulgaricus, each one 109 colony-forming units) or placebo for two months. Inflammatory markers (Interleukin-6 [IL-6], C-reactive protein [CRP], erythrocyte sedimentation rate [ESR]) and white blood cell (WBC) count were evaluated at two timepoints (baseline, two months later). The measured variables were adjusted for confounders and analyzed by SPSS v21.0.FindingsAll 80 enrolled patients completed the study. The study adherence was good (approximately 70%). The mean changes for IL-6 were not significant (Δ = −0.6 ± 10.4 pg/mL vs Δ = +11.2 ± 50.3 pg/mL, p > 0.05). There were no significant improvements for CRP, ESR and WBC.Originality/valueAdministration of synbiotics for two months did not improve inflammatory markers in COVID-19 patients.

Nutritional assessment of COVID-19 patients admitted in intensive care units in Pakistan

Coronavirus disease 2019 (COVID-19) can be life threating if untreated. Early diagnosis and effective nutritional management can save life. To assess the nutritional status and predict possible outcomes of critical patients Sequential Organ Failure Assessment (SOFA), nutrition risk in critically ill patients (NUTRIC), and acute physiology and chronic health evaluation (APACHE) score has been used. This retrospective observational study was conducted on confirmed COVID-19 cases in Intensive Care Unit (ICU) of Shifa hospital between November 24, 2020 to May 31, 2021. The demographic, clinical and laboratory information was obtained from hospital records. Risk factors for COVID-19 were identified and compared using multivariate logistic regression analysis. The nutritional risk for each patient was assessed. In this study 162 COVID-19 patients with median age of 64 years (IQR: 56-74) were included. Hypertension (59.2%) was found to be the most common comorbidity and the most prevalent symptoms upon admission were fever (54.9%). The patients in critical condition were supplied nutrients through nasogastric route (61.7%) while 37.7% and 0.6% were assisted through oral and total parenteral nutrition (TPN) route. The Glasgow comma score was found to be mild (72.2%) (GCS>12) with increased creatinine, white blood cell count, C-reactive protein (CRP C), and glycosylated haemoglobin HbA1c level were present. Interestingly based on SOFA, APACHE and NUTRIC score low insignificant malnutrition risk was observed. Our study found different demographic factors and comorbidities have a substantial impact on COVID-19 patients, as evidenced by demographic, laboratory, clinical, and nutritional risk factors.

Correlation between laboratory findings and clinical severity among the COVID-19 patients in the tertiary care centre

Background: Coronavirus is a highly infectious novel virus we are in urge to know more about their clinical characteristics and laboratory findings for the characterization and selection of treatment protocol. Methods: Prospective, single centre study. Two months data was collected, clinical characteristics data from patient case sheet and the laboratoryvalues from the Hospital Information System (HIS) for the month of July and August 2020. Results: Of 462 patients, 55 (11.9%) are falls under asymptomatic category, 194 (42%) are in mild category, 167 (36.1%) are in moderate category and 46 (10%) in severe category. Fever 230 (49.8%) and cough 211 (45.7%) was most common clinical symptom with p value < 0.01. Non-severe vs severe, 340 (73.6%) and 201 (43.5%) showed decreased in eosinophil count and absolute eosinophil count, 125 (27.1%) and 80 (17.3%) patient showed decrease in lymphocyte count and absolute lymphocyte count, 200 (43.3%) showed increase in neutrophil count with a significance of p value >0.05.186 (40.3%) patients had one or more co-morbidities. Laboratory findings between Asymptomatic VS symptomatic, showed significance changes in neutrophil, lymphocyte, Aspartate aminotransferase, Alkaline phosphatase, globulin values (p value <0.05). Conclusion: Clinical severity categorization at the time of admission was very helpful for the treating doctors in proper understanding of disease progression and appropriate treatment of the patient. Presence of co-morbidity, abnormal laboratory values, old age group patients, higher Computed Tomography score, higher mortality rate are seen more in patients who were in clinical severity grade severe category than in non-severe category patients.

Restrospective study of hemogram profile in effusive feline infectious peritonitis

Feline Infectious Peritonitis (FIP) is highly mortality disease in cats. The reliable and fast diagnosis is crucial to the best prognosis. The aim of this study to evaluate the hemogram profile in cats infected with effusive FIP. Twenty cats had been diagnosed effusive FIP at Animal Clinic Department of Internal Medicine, Faculty Veterinary Medicine, Universitas Gadjah Mada were used in the study. The diagnosis were based on clinical examination, ultrasound, x-ray, rivalta test, and rapid test. The hemogram profile were analyzed include routine hematology and serum biochemistry. Hemogram profile in effusive FIP showed the decreased hematocrit, hyperproteinemia, and leukocytosis with an average 22.9+or-7.4%;9.0+or-2.2 g/dL;22425+or-4116 cells/mm3 respectively. Erythrocyte, hemoglobin and fibrinogen levels were still in the normal range. The results of differential leukocytes revealed that 90% cats had neutrophilia and 75% lymphopenia with an average 20066+or-3337 cells/mm3 and 1861+or-1818 cells/mm3 respectively. The blood chemistry profile showed 60% of cats experienced increase in SGPT and SGOT with an average 138.4+or-72.3 IU/L and 101+or-60.5 IU/L respectively. Hyperglobulinemia was found in 90% samples with an average 6.7+or-0.8 g/dL. All cats have a low albumin:globulin ratio with an average 0.3+or-0.1. The hemogram profile of effusive FIP were: leukocytosis, neutrophilia, lymphopenia, hyperglobulinemia, and decreased albumin-globulin ratio..

Classifying Microscopic Images of Reactive Lymphocytosis Using Two-Step Tandem AI Models

The practical applications of automatic recognition and categorization technology for next-generation systems are desired in the clinical laboratory. We approached the identification of reactive lymphocytosis using artificial intelligence (AI) technology and studied its clinical usefulness for blood smear screening. This study created one- and two-step AI models for the identification of reactive lymphocytosis. The ResNet-101 model was applied for deep learning. The original image set for supervised AI training consisted of 5765 typical nucleated blood cell images. The subjects for clinical assessment were 25 healthy cases, 25 erythroblast cases, and 25 reactive lymphocytosis cases. The total accuracy (mean ± standard deviation) of the one- and two-step models were 0.971 ± 0.047 and 0.977 ± 0.024 in healthy, 0.938 ± 0.040 and 0.978 ± 0.018 in erythroblast, and 0.856 ± 0.056 and 0.863 ± 0.069 in reactive lymphocytosis cases, respectively. The two-step AI model showed a sensitivity of 0.960 and a specificity of 1.000 between healthy and reactive lymphocytosis cases. As our two-step tandem AI model showed high performance for identifying reactive lymphocytosis in blood smear screening, we plan to apply this method to the development of AI models to differentiate reactive and neoplastic lymphocytosis.

Hematological findings in COVID-19 and their correlation with severity of Disease

Objective: To evaluate the efficacy of hematological parameters to predict severity of COVID-19 patients. Method: This was a cross-sectional comparative study conducted at Central Park Teaching Hospital, Lahore in COVID ward and COVID ICU between April 23, 2021 to June 23, 2021. Patients of all ages and both genders with positive PCR admitted in the COVID ward and ICU during this time span of two months were included in the study. Data was collected retrospectively. Results: This study included 50 patients with male to female ratio of 1.38:1. Though males are more affected by COVID-19 but the difference is not statistically significant. The mean age of the study population was 56.21 and the patients in the severe disease group have higher age. It was observed that in severe/critical group the mean values of total leukocyte count 21.76×103 µI (p-value= 0.002), absolute neutrophil count 71.37% (p-value=0.045), neutrophil lymphocyte ratio (NLR) 12.80 (p-value=0.00) and PT 11.9 seconds (p-value=0.034) and the difference was statistically significant. While in severe/critical group, the mean values of hemoglobin 12.03g/dl (p-value=0.075), lymphocyte count 28.41% (p-value=0.8), platelet count 226×103 µI (p-value=0.67) and APTT 30.7 (p-value=0.081) and the difference was not significantly different between groups. Conclusion: It can be concluded from the study that total leucocyte count, absolute neutrophil count and neutrophil lymphocyte ratio can predict in-hospital mortality and morbidity in COVID-19 patients.

The effect of functional exercise along with online nutritional education on inflammatory biomarkers in children with autism spectrum disorder during COVID-19 pandemic: a randomized clinical trial

Background and Objectives: Autism spectrum disorder (ASD) is a neuro-developmental disorder which is mostly caused by deficits in social interactions. Lack of physical activity and poor nutritional habits are common problems in these patients which may be exaggerated by the Covid-19 pandemic. The study aims to assess the effect of functional training along with online nutrition education on inflammatory biomarkers in children with ASD. Subjects and Methods: In this randomized controlled clinical trial, 80 children with ASD (age=9.73+or-1.29 years, weight=49.94+or-2.08 kg, height=146.08+or-40 cm, body mass index=24.71 +or-1.48 kg/m2) were randomly divided into four groups of training, education, training+ education, and control. The interventions lasted for 8 weeks. The inflammatory biomarkers including white blood cell (WBC) count, C-reactive protein (CRP) level, neutrophil count, eosinophil count, and basophil count were assessed (using blood samples collected from antecubital vein) before and after the interventions. Results: There was no significant difference between the groups before the interventions (P>0.05). After the intervention, the results showed a significant decrease in WBC (P<0.001), CRP (P=0.001), neutrophils (sig.=0.009), and eosinophil (P=0.003) in all groups. Basophil count decreased in all groups (P=0.01) except in the education group. Conclusion: Functional training and online nutrition education are beneficial interventions for management of inflammatory biomarkers in children with ASD which can be used during the Covid-19 pandemic.