Overview of the Healthcare Systems of the Maghreb Countries: Issues and Progress

Objectives: To provide an update overview on the current status of healthcare systems in the Maghreb region (Algeria, Morocco, and Tunisia) and to emphasize the progress made in the midst of the challenges facing these countries. Method(s): A descriptive comparative approach of healthcare systems in the three countries, based on data from sources with an established methodology, including descriptive healthcare data from the WHO database. Result(s): The population of the Maghreb will increase from 102 million to 132 million by 2050. The current population is mostly centered in Algeria and Morocco, accounting for 77%. Annual healthcare expenditure per capita is 447.9$, 776.8$ and 854.6$ in Morocco, Tunisia and Algeria, respectively. The average infant mortality rate per 1000 live improved to 10.9 in Tunisia, 16.8 in Morocco and 18.9 in Algeria. Maternal mortality rates have dropped to 43 and 48.5/100 000 births in Tunisia and Algeria, respectively while remaining relatively high in Morocco: 72.6. Number of hospital beds/1000 inhabitants is only 1.1 in Morocco, 1.9 and 2.9 in Algeria and Tunisia, respectively. The number of physicians/1000 people was 0.73 in Morocco, 1.3 in Tunisia and 1.72 in Algeria. This remains considerably low compared to the 3.9/1000 in Europe. The Maghreb countries are currently facing an exodus of physicians, mainly to France, which represents 7.1% and 10.7% of Tunisians and Moroccans, respectively, and more than 24% for Algerians. The Maghreb countries were very early mobilized (governments, ministries of health, civil society) to fight against COVID-19 and have successfully controlled the pandemic, according to pre-established control strategies and the strongly commitment of health professional. Conclusion(s): Despite the considerable progress made, the Maghreb countries still face major challenges. Physicians migration, rising cost of care and endemic infectious disease outbreaks constitute a huge hurdle on the already overburdened and resilient healthcare systems.Copyright © 2023

Detection of Mutations in SARS-CoV-2 Genomic Clades using COVIDSeq-NGS among International Travelers

Introduction/Objective Numerous SARS-CoV-2 variants/lineages have been identified based on genome sequencing. As of June 15, 2022 almost 11,399,573 whole genome sequences have been deposited in the GISAID-database. Severity and spread of COVID19 is based on their efficiency of infection and to multiply in host. That largely depend upon the structural mutation in spike, ORF and N proteins etc. That happens due to translation of genomic mutations during polypeptide synthesis. Also, the mutations are region/country specific. Specific mutation and combination of mutation causes the emergence of new strains. However, the strains can migrate from one region to other through travelers. The main objective of the current study is profiling of mutations in the genome of SARSCoV2 using Next- Generation-Sequencing (NGS) in international travelers and phylogenetic analysis of the sequences to find out different clades of SARSCoV2. Methods/Case Report A total of 557 SARSCoV2 genomes were sequenced on S4-sequencing flow-cell on NovaSeq 6000. For NGS of SARS-CoV-2 genome, Illumina, COVIDSeq kits and the protocols will be used strictly as recommended by the manufacturer. After NGS the analysis was done followed by FASTA sequences retrieval, mutations recording and phylogeny. Results (if a Case Study enter NA) This study reports 11 clades (19A, B, 20A, B, C, D, 20E;EU1, 20G, 20H;Beta V2, 20I: Alpha V1, 21D;and Eta) for the first time in international travelers. To best of our knowledge, this is the first report of the COVIDSeq approach for detection of mutation in SARSCoV2 genomic clades. The study revealed some dominants mutations was (Orf1a: P2018Q, K1053R, E176V, Orf1b: A520V, T2165A, S: D1127G, D614G, L18F etc. in other genes). Conclusion Profiling of common mutations among travelers could fill some gaps about the existence of SARS-CoV-2 variants information. However, further studies are needed to consolidate these findings before to be utilized for development of a potential therapeutic strategy.

Unique Differentiation and Homing Features of T Cells in Individuals with Long Covid

Background: A significant portion of individuals experience persistent symptoms months after SARS-CoV-2 infection, broadly referred to as Long COVID (LC). Although the frequencies of subsets of SARS-CoV-2-specific T cells have been shown to differ in individuals with LC relative to those with complete recovery, a deep dive into phenotypic and functional features of total and SARSCoV- 2-specific T cells from individuals with LC has yet to be performed. Method(s): Here, we used CyTOF to characterize the phenotypes and effector functions of T cells from LIINC cohort. The median age was 46, the cohort was 55.8% female, and 9/43 had been hospitalized. Participants were reported a median of 7 LC symptoms at 8 months. SARS-CoV-2-specific total antibody levels were also measured in concurrent sera. Manual gating was used to define T cell subsets, SPICE analyses for polyfunctionality, T cell clustering for phenotypic features, and linear regression for correlation. Permutation tests, Student's t tests, and Welch's t test were used for statistical analysis. Result(s): SARS-CoV-2 total antibody responses were elevated in the LC group (p=0.043), and correlated with frequencies of SARS-CoV-2-specific T cells in those without LC (r=0.776, p< 0.001) but not those with LC. While the frequencies of total SARS-CoV-2-specific CD4+ and CD8+ T cells were similar between individuals with and without LC, those from individuals without LC tended to be more polyfunctional (co-expressing IFNgamma, TNFalpha, IL2, and/or MIP1beta). CD4+ T cells from individuals with LC harbored higher frequencies of Tcm (p=0.003), Tfh (p=0.037), and Treg subsets (p=0.0412), and preferentially expressed a variety of tissue homing receptors including CXCR4 and CXCR5 (p=0.037). SARS-CoV-2-specific CD4+ T cells producing IL6, albeit rare, were observed exclusively among those with LC (p=0.016). In addition, participants with LC harbored significantly higher frequencies of SARS-CoV-2-specific CD8+ T cells co-expressing exhaustion markers PD1 and CTLA4 (p=0.018). Conclusion(s): Long COVID is characterized by global phenotypic differences in the CD4+ T cell compartment in ways suggesting preferential migration of these cells to inflamed mucosal tissues. Individuals with LC also harbor higher numbers of exhausted SARS-CoV-2-specific CD8+ T cells, potentially implicating viral persistence. Finally, our data additionally suggest that individuals with LC may uniquely exhibit an uncoordinated T cell and antibody response during COVID-19 convalescence.

A New CURE in Molecular Biology: Testing a Novel Pyrrolidine Compound to Determine Mechanism of Action in an Upper-Division Molecular Biology Course

The COVID-19 pandemic shut down forced introductory biology and chemistry laboratory courses online at DePauw University from March 2020-June 2021, leaving multiple classes of students without the opportunity to learn basic laboratory skills that are essential for the molecular biology laboratory. In an effort to provide students with both basic laboratory skills and advanced molecular biology skills, a new course-based undergraduate research experience (CURE) was developed for the 2022-23 academic year. In collaboration with Dr. Jeff Hansen in the Chemistry and Biochemistry department, novel compounds with potential anti-tumor properties were identified. The CURE in Molecular Biology was designed to have students use Saccharomyces cerevisiae as a model system to evaluate possible cellular pathways affected by the compound, including: cytoskeleton and cell migration, nucleotide biosynthesis, glucose metabolism, apoptosis, and cell cycle regulation. Students learned techniques DNA isolation and PCR, transformation, RNA isolation, cDNA synthesis, qPCR, and Western Blotting, while contributing to an active research project. At the conclusion of the project, students were surveyed about their comfort with molecular techniques and data analysis.Copyright © 2023 The American Society for Biochemistry and Molecular Biology, Inc.

Stage and Grade Migration of Prostate Cancer during the Covid-19 Pandemic

INTRODUCTION AND OBJECTIVE: The COVID-19 pandemic likely affected the healthcare system's ability to deliver prostate cancer care services. Herein, we sought to evaluate prostate cancer's stage and grade migration resulting from the COVID-19 pandemic. METHOD(S): We retrospectively analyzed the National Cancer Database (NCDB) for men with prostate cancer between 2018-2020. We divided our cohort into the "Pre-Pandemic" (2018/2019) and "Pandemic" (2020) periods. Stage and grade of prostate cancer were stratified according to the severity of disease: PSA value (<=20 vs. >20), clinical T stage (cT1-T2 vs. cT3-T4), clinical M stage (cM0 vs. cM1), International Society of Uropathology (ISUP) grade group (ISUP 1-2-3 vs. ISUP 4-5), and D'Amico risk classification (low risk vs. intermediate & high risk). Pearson's chi-square test was used to assess differences in the distribution of stage and grade across the two periods. We performed multivariable logistic regressions to estimate the effect of the "Pandemic" period on stage and grade distribution adjusting for clinical and socioeconomic covariates. RESULT(S): A total of 398,719 men were diagnosed with prostate cancer during the "Pre-pandemic" (70.6%) and "Pandemic" (29.4%) periods (Table 1). On univariable comparisons, an increase in stage/ grade across the two periods was demonstrated (all p<0.001). After adjusting for covariates, compared to the "Pre-pandemic", the "Pandemic" period was associated with increased odds of PSA >20 levels (aOR 1.06;95% CI 1.03 - 1.08;p-value <0.001), cT3-4 stages (aOR 1.12;95% CI 1.08 - 1.16;p<0.001), cM1 stage (aOR 1.15;95% CI 1.12 - 1.18;p<0.001), ISUP grade group 4 or 5 (aOR 1.03;95% CI 1.01 - 1.05;p=0.003) and D'Amico Intermediate & High risk groups (aOR 1.15;95% CI 1.13 - 1.18;p<0.001). CONCLUSION(S): The COVID-19 pandemic was associated with significant changes in the distribution of both stage and grade of prostate cancer. Possible explanations for this migration include a better selection of patients for prostate biopsy during the pandemic or changes in prostate cancer screening patterns.

A Case Report Of The Effects Of Chemotherapy On Post-heart-transplant Gene Expression Profiling

Introduction: Malignancies are a major complication of heart transplant (HT). Noninvasive surveillance after HT using gene expression (GEP) profiling and donor derived cell free DNA (dd-cfDNA) are noninferior to biopsy and are widely utilized. The interpretation of % dd-cfDNA, is not well understood in malignancies with a conceptual increase in the recipient fraction. The effect of chemotherapy on GEP in the setting of post-HT surveillance has not been described to the best of our knowledge. Hypothesis: Induction of chemotherapy will cause global transcriptional reduction in GEP. Method(s): GEP was performed with AlloMap (AM, CareDx), which evaluates expression levels of 11 mononuclear cell genes, involved in lymphocyte activation, T-cell priming, cell migration, hematopoietic proliferation, steroid sensitivity, and platelet activation. Scores range from 0-40, higher scores have a stronger correlation with rejection. At our center a total of 995 draws were analyzed from 2019-2022. In parallel dd-cfDNA, which informs about graft injury was analyzed using AlloSure (AS, CareDx). Case Events: A 71-year-old male HT recipient for nonischemic cardiomyopathy and no rejection history was diagnosed with metastatic gastric adenocarcinoma at 16 months post-HT. Following diagnosis, mycophenolic acid was stopped, prednisone 5 mg was started, and tacrolimus trough goal was gradually lowered to 4-6 given infectious complications. Palliative chemotherapy with folinic acid, fluorouracil (5-FU), oxaliplatin (FOLFOX) was initiated at 18 months post-HT with planned dose reduction of oxaliplatin and holding of 5-FU bolus to reduce risk of myelosuppression given comorbidities. Oxaliplatin was stopped at 18 months post HT. Due to COVID he last received 5-FU at 33 months post-HT. Graft function remained stable and DSA negative. At 36 months post-HT, he developed a bowel obstruction without surgical options for interventions and expired shortly thereafter. Result(s): With initiation of prednisone and following chemotherapy there was a drastic decrease in AM scores (Fig. A). Steroid therapy led to an 18% decline in AM scores, the greatest decrease occurred with chemotherapy, with 67% decline from the mean when compared to all center patients (Fig B). Dd-cfDNA levels remained stable during the course aside from one early elevation. Conclusion(s): To the best of our knowledge this is the first published case on the effect of chemotherapy on GEP profiling in the setting of post-HT surveillance. This case advises caution when interpreting GEP in the setting of chemotherapy showing great reduction in GEP scores. While dd-cfDNA levels remained relatively stable after malignancy diagnosis and treatment initiation further studies will need to inform on the use of both GEP and dd-cfDNA in these patients.Copyright © 2022

Investigating neutrophil function during SARS-CoV2 infection in human airway epithelial cells from elderly and young individuals

The COVID-19 pandemic caused by the SARS-CoV2 virus poses a global health threat with over 5 million deaths recorded. There is little understanding regarding SARS-CoV2 pathogenesis in the human airways and disease severity increases with age. Neutrophils are white blood cells found in large numbers in the airways of the lungs in severe COVID-19 patients. It is not known whether this influx of neutrophils into the airway has a protective or detrimental effect. We aim to understand the role of neutrophils during COVID-19 pathology, using an experimental infection model of the airway epithelium from the eldelry and children. To do this, we collect nasal airway cells from healthy elderly and children and grow them at air-liquid interface. Once differentiation and ciliation of these cells is reached, we infect the cells with SARS-CoV2 virus and allow neutrophils to migrate from the basolateral (blood) to the apical (air) side of the epithelium, similar to a physiological airway. Using flow cytometric analyses, we measure the expression of activation markers and the number of neutrophils that migrate across the epithelium of different ages in response to SARS-CoV2 infection. Preliminary work shows less viable neutrophils recovered from the elderly epithelium, more activated neutrophils when migrating through the elderly epithelium, as well as increased numbers of neutrophils remaining on the basolateral (blood) side of the elderly epithelium. These findings point to an inflammatory neutrophil phenotype influenced by the damaged elderly epithelium and supports the hypothesis that neutrophils are responsible for the severity of disease.

Developing advanced cell culture models to study COVID19-associated pulmonary fibrosis

Patients with severe COVID-19-associated pneumonia are at risk to develop pulmonary fibrosis. To study the underlying mechanisms, we aim to develop advanced cell culture models that reliably reflect COVID-19-related profibrotic microenvironment. To identify key cellular players, we performed pilot immunohistochemistry analysis on lung tissue from COVID-19 patients with fibrosis collected during autopsy. Results revealed diffuse alveolar damage with macrophage infiltration, and myofibroblast accumulation with enriched collagen deposition surrounding the damaged alveoli. To mimic SARS-CoV-2 infection in alveoli, we infected human primary type II alveolar epithelial cells (AEC2) and found enhanced signaling of profibrotic cytokine transforming growth factor beta (TGFbeta) in some donors. To recreate the early fibrotic niche, an alveolar-macrophage-fibroblast (AMF) tri-culture model was established. After infecting AEC2 with SARS-CoV-2 in this AMF model, gene expression analysis provided evidence for fibroblast-to-myofibroblast transition. Furthermore, we found that overexpression of SARS-CoV-2 papain-like protease (PLpro) can promote TGFbeta signaling in HEK293T and A549 cells. After infecting AEC2 with SARS-CoV-2 PLpro lentivirus in the AMF model, we found signs of epithelial-to-mesenchymal transition and fibroblast-to myofibroblast transition. In future studies, we will use a detailed analysis of COVID-19-associated lung fibrosis with other types of lung fibrosis, to further refine COVID-19-related fibrosis models, including lung-on-chip models.

The COVID19 pandemic may lead to the activation of the forgotten tuberculosis

Introduction: The Covid-19 pandemic has cast a shadow over many other diseases, including tuberculosis (TB). Once again, an infectious disease that was once quite active will most likely knock on our door. The purpose of this study was to determine if there were any differences in TB clinical characteristics in patients treated before and after the pandemic. Method(s): In this retrospective observational study, we looked at patients treated for TB at the Institute for Pulmonary Diseases in Vojvodina, Serbia, two years before the pandemic (2018/2019) and two pandemic years (2020/2021). Result(s): We examined 280 patients (159 in pre-pandemic years and 121 in pandemic years). The percentage of patients who had symptoms for more than 3 months before TB diagnosis in prepandemic years was 37.11%, while in pandemic years that percentage rose up to 48.76% (p=0.034). Direct microscopy was the most common method of diagnosis before and throughout the pandemic (p=0.638). Before the pandemic, it took 28.03 days to convert sputum;during the pandemic, it took 34.39 days (p=0.043). In these two groups, there was no deterioration in radiological presentation (p=0.676). Conclusion(s): The pandemic resulted in a fall in the number of diagnosed TB patients, and patients went to the doctor later despite TB symptomatology, potentially increasing the risk of TB transmission in the general population. Our experience shows that after periods of war, migrations, and epidemics of other infectious diseases, the incidence of TB increases. Taking all of this into account, we must intensify and systemise the approach to these patients in terms of early screening, particularly in vulnerable groups.

COVID-19 neutrophils show elevated migration and NETosis, which is reduced by PI3K inhibition

Rational: Evidence of neutrophil dysfunction in COVID-19 is based on transcriptomics. Cell functions are interwoven pathways, so understanding the effect of COVID-19 across neutrophil function may identify therapeutic targets. We examined neutrophil phenotype and function in 41 hospitalised, non-ICU COVID-19 patients versus 23 age-matched controls (AMC) and 26 community acquired pneumonia (CAP) patients. Method(s): Isolated neutrophils underwent ex vivo analyses for migration, phagocytosis and NETosis, and the effect of PI3K inhibition. Circulating DNAse 1 activity and levels of cfDNA were measured. Result(s): Compared to AMC and CAP, COVID-19 neutrophils demonstrated elevated transmigration (p=0.0397, A) and NETosis (p=0.0366, B), but impaired phagocytosis (p=0.0236, C) associated with impaired ROS generation (p<0.0001). COVID-19 and CAP patients showed increased systemic markers of NETosis including increased cfDNA (p=0.0153) and impaired DNAse activity (p<0.0.001, D). Ex vivo inhibition of PI3K gamma and delta reduced NET release by COVID-19 neutrophils (p=0.0156). Conclusion(s): COVID-19 is associated with neutrophil dysfunction across all main effector functions, with elevated migration, impaired antimicrobial responses and elevated NETosis. These changes represent a clear mechanism for tissue damage and highlight that targeting neutrophil function via PI3k may help modulate COVID-19 severity. (Figure Presented).

74th Annual Congress of the Japan Society of Obstetrics and Gynecology

The proceedings contain 429 papers. The topics discussed include: a short peptide encoded by long non-coding RNA small nucleolar RNA host gene 6 promotes cell migration and epithelial-mesenchymal transition by activating transforming growth factor-beta/SMAD signaling pathway in human endometrial cells;a short peptide encoded by long non-coding rna small nucleolar rna host gene 6 promotes cell migration and epithelial-mesenchymal transition by activating transforming growth factor-beta/smad signaling pathway in human endometrial cells;compatible cut-off values for luteinizing hormone and the luteinizing hormone/follicle-stimulating hormone ratio in diagnostic criteria of the Japan society of obstetrics and gynecology for polycystic ovary syndrome;intracytoplasmic sperm injection cycle success in patients under 35 years old with diminished ovarian reserve plus severe male factor;assisted reproductive technology and neonatal intensive care unit: a retrospective observational study from a single center;the value of clinical symptoms, the neutrophil-to-lymphocyte ratio, and ultrasonographic features in predicting adnexal torsion: a case-control study;construction of a diagnostic classifier for cervical intraepithelial neoplasia and cervical cancer based on xgboost feature selection and random forest model;and impact of the COVID-19 pandemic on surgery for benign diseases in gynecology: a nationwide survey by the japan society of obstetrics and gynecology.

ADDRESSING GLOBAL DISPARITIES IN BLOOD PRESSURE CONTROL: PERSPECTIVES OF THE INTERNATIONAL SOCIETY OF HYPERTENSION

Raised blood pressure is the leading cause of preventable death in the world. Yet, its global prevalence is increasing, and it remains poorly detected, treated, and controlled in both high and low resource settings. From the perspective of members of the International Society of Hypertension based in all regions, we reflect on the past, present, and future of hypertension care, highlighting key challenges and opportunities, which are often region-specific. We report that most countries failed to show sufficient improvements in blood pressure control rates over the past three decades, with greater improvements mainly seen in some high-income countries, also reflected in substantial reductions in the burden of cardiovascular disease and deaths. Globally there are significant inequities and disparities based on resources, sociodemographic environment, and race with subsequent disproportionate hypertension- related outcomes. Additional unique challenges in specific regions include conflict, wars, migration, unemployment, rapid urbanisation, extremely limited funding, pollution, COVID-19-related restrictions and inequalities, obesity and excessive salt and alcohol intake. Immediate action is needed to address suboptimal hypertension care and related disparities on a global scale. We propose a Global Hypertension Care Taskforce including multiple stakeholders and societies to identify and implement actions in reducing inequities, addressing social, commercial and environmental determinants, and strengthening health systems implement a welldesigned customised quality of care improvement framework.

Imaging tumor-infiltrating CD8+ T-cells in non-small cell lung cancer patients upon neo-adjuvant treatment with durvalumab

Aim/Introduction: Immune checkpoint inhibitors (ICI), like targeting programmed death receptor ligand 1 (PD-L1), have revolutionized anti-cancer treatments, including non-small cell lung cancer (NSCLC) [1, 2]. Assessment of PD-L1 expression on tumor biopsies is current practice, but there is a need for additional biomarkers correlating to the complex mechanism of action of ICI. The presence of tumorinfiltrating CD8+ T-cells (TILs) is a robust biomarker associated with immune therapy success [3]. Tools to track TILs in patients during ICI treatment allow further development of immune-oncology drugs. Material(s) and Method(s): This ongoing single-center prospective study (NCT03853187) includes patients with histologically proven T1b-3N0-1M0 NSCLC eligible for resection. Exclusion criteria are previous anti-cancer therapy and known immune disorders or suppression. Patients receive two courses neo-adjuvant durvalumab (750mg Q2W), after which TIL imaging is performed. Cohort 1 underwent apheresis and magnetic-activated cells sorting to isolate 100 x10e6 autologous CD8+ T-cells for cell labeling with 111In-oxine. Re-injection was followed by 4h post-injection (p.i.) planar imaging, 70h p.i. SPECT imaging, standard-of-care surgery and 78h p.i. uSPECT of the resected lobe. Patients in cohort 2 (ongoing) receive 1.5mg 89Zr-Df-crefmirlimab followed by PET/CT 24h p.i. Result(s): In cohort 1, 8/10 patients underwent apheresis and TIL imaging;one procedure was withdrawn due to COVID-19 restrictions and one due to unsuccessful T-cell isolation. Yield ranged 240-714 x10e6 CD8+ T-cells, purity 84%-97% and cell viability 92%-100%. Labeling efficacy of 100 x10e6 cells for re-injection ranged 42%-64% and injected activity 22,4-36,7 MBq In-111.TIL imaging was completed by 4/5 patients in cohort 2, one subject discontinued neo-adjuvant treatment due to post-obstruction pneumonia.Tumor-to-bloodpool were determined to quantify specific TIL accumulation in the tumor. Our results favor quantification of T-cells on PET over SPECT given its higher sensitivity and spatial resolution. Correlation of imaging findings with density of CD8+ T-cells in the resected tumor is currently ongoing. Conclusion(s): We implemented two methods for tracking CD8+ T-cells in earlystage NSCLC patients after neo-adjuvant durvalumab treatment. Although ex vivo cell labeling perhaps more specifically targets migrating TILs into the tumor, 89Zr-Df-crefmirlimab has the potential to also target residing cells. Quantitative correlation with presence of TILs in the resected tumor will help to determine the role of these imaging tools in the development of immune-oncology drugs.

Muscle Pain in a Patient with Recent Sars-Cov-2 Infection

INTRODUCTION: Thrombosis associated with SARSCoV-2 infection has been well established. Even patients with mild disease, who are able to treat their symptoms at home without supplemental oxygen, are prone to significant sequelae of the disease process. IVC filters, while once considered a standard treatment for deep vein thrombosis (DVT), have fallen out of favor except when there are absolute contraindications for therapeutic anticoagulation due to increased risk of significant adverse events directly correlating with time in-situ including migration, thrombosis, and tears/dissection of the aorta or associated vessels. DESCRIPTION: A 45 y/o F with h/o insulin dependent DM2 and HTN presented for evaluation of bilateral leg cramps with subjective numbness and abdominal pain in the setting of recent COVID-19 infection treated at home. Her exam was notable for significant quadriceps tenderness and induration bilaterally with diminished distal pulses. Initial lab work was significant for lactic acidosis of 6.1, CK 110, and creatinine 2.2. She was admitted to ICU for oliguric AKI and vasopressor support. Broad autoimmune workup was negative. Her renal function continued to deteriorate eventually prompting kidney replacement therapy. Doppler US revealed bilateral DVT in the femoral and popliteal veins. Her CK was monitored daily given continued concern for rhabdomyolysis. CK was >20,000 by day five. Concern for congestive nephropathy prompted CT with contrast of abdomen, pelvis which showed extensive DVT throughout the visualized femoral and iliac veins, extending superiorly past an IVC filter to the inferior margin of the liver. At this time, the patient confirmed she had an IVC filter placed roughly eight years prior after an MVC. The patient underwent successful catheter-directed thrombolysis. Her symptoms slowly improved during her hospitalization which totaled 33 days. The patient was able to discontinue outpatient hemodialysis after 1.5 months. DISCUSSION: It is imperative to obtain complete history in patients with recent COVID as underlying predisposition for thrombosis can greatly increase their morbidity and mortality even with seemingly mild infection. The combination of two highly pro-thrombotic foci in this patient resulted in multisystem sequelae of large IVC and femoral vein thrombosis.

Stage Migration, Changed Treatment Profile and Survival Impact in Newly Diagnosed Oesophago-gastric Cancer in Scotland during the COVID-19 Pandemic - A National study

Background: COVID-19 has significantly disrupted cancer care. This may have impacted on staging, management and survival as health services worldwide had to adapt. Responding to the pandemic, the UK government declared a national lockdown on 23rd March 2020. This national study investigated the effect of the national response on oesophago-gastric (OG) cancers in Scotland, including time from referral to gastroscopy, staging at presentation, multidisciplinary team (MDT) treatment outcomes and overall survival. Method(s): This was a retrospective cohort study. Consecutive new patients presenting in NHS Scotland to five regional OG cancer MDTs covering 93.2% of the Scottish population between October 2019 and September 2020 were identified. Electronic health records were reviewed. The study period was divided into pre- and post-lockdown, based on the first UK national lockdown. Result(s): 931 patients with biopsy-proven OG cancer were identified;499 (53.6%) pre- and 432 (46.4%) post-lockdown. Median age was 71 years (range 25-95) and 66% were male. There were 252 (27.1%) gastric and 679 (72.9%) oesophageal cancers. No clinically meaningful difference in median time to gastroscopy was observed post-lockdown (19 days vs 15 days, P<0.001), however, patients were more likely to present as an emergency (11.1% vs 8.2%, p=0.014). Post-lockdown, patients tended to poorer ECOG PS (p=0.09), were more symptomatic (p=0.007), and presented with higher stage disease (stage 4;57.6% vs 49.3%). There was a significant shift to palliative intent treatment post-lockdown (76.2% vs 64.7%, p<0.001). Median overall survival post-lockdown was 7.6 months vs 10.1 months pre-lockdown (HR 1.24;95% CI 1.06-1.43, p=0.005). Conclusion(s): This national study highlights the impact of COVID-19 on OG cancer diagnosis and outcome in Scotland. Patients presented at a later stage and a shift towards palliative intent treatment was observed, with subsequent negative impact on overall survival. The reason for the observed stage migration of OG cancers is likely multifactorial, occurring prior to the diagnostic pathway and not simply due to a delay in performing gastroscopy.

Profound Dysregulation of T cell Homeostasis and Function in Patients With Severe COVID-19

PURPOSE OF THE STUDY: T cell lymphopenia is prevalent in severe coronavirus disease 2019 (COVID-19). This study evaluated associations with homeostatic and functional T cell responses in COVID-19 with the goal of identifying immunologic features of severe disease. STUDY POPULATION: Patients aged 18 years and older with symptomatic, real time-quantitative polymerase chain reaction confirmed SARS-CoV-2 (mild, n = 54;severe, n = 49) were recruited at 4 hospitals in the Canton of Zurich, Switzerland from April 2 to August 19, 2020, and a group of healthy controls recruited for comparison (n = 27). A subset (mild, n = 28;severe, n = 38, healthy, n = 22) had comprehensive T cell characterization. METHODS: In this prospective, observational, cross-sectional study, symptomatic participants with mild and severe COVID-19 and healthy controls were sampled at a single time point. Phenotypic and functional characteristics of T cells were evaluated using 40-parameter mass cytometry, flow cytometry, targeted proteomics, and functional assays. RESULTS: Compared with mild disease, severe COVID-19 was associated with T cell lymphopenia and redistribution of T cell populations, including loss of naïve and memory CD4+ and CD8+ T cells, skewing toward CD4+ T follicular helper cells and cytotoxic CD4+ T cells, and expansion of activated and exhausted T cells. Individuals with severe disease and T cell lymphopenia had signs of tissue migration, extensive T cell apoptosis, and impaired T cell responses to common viral antigens. Patients with severe disease also showed elevated interleukin-7 and increased T cell proliferation. Those sampled longest after symptom onset had higher T cell counts and improved antiviral T cell responses. CONCLUSIONS: Severe COVID-19 is characterized by extensive T cell dysfunction. Reduced naïve T cells and virus-specific memory T cell numbers are associated with severe disease and impaired T cell responses to viral antigens, particularly early in the disease. Increased T follicular helper cells may contribute to a robust antibody response often observed in COVID-19. T cell apoptosis is associated with lymphopenia and homeostatic T cell proliferation and T cell recovery in the later stages of disease.

The meaning of sleep in urban and rural areas during the COVID-19 pandemic. Preliminary report in the province of Quebec, Canada

Objectives/Introduction: The social representations of sleep (SRS) are a set of cognitive elements related to sleep which are determinant in understanding an individual's sleep patterns. This research investigates the SRS in the adult population of Quebec, Canada. We assess the impact on SRS of living in a rural or urban setting and of migrating from one to the other during the COVID-19 pandemic. Method(s): A sample of 79 participants (mean age = 33.9;SD = 13;77% women) took part in a comparative study with a convergent parallel mixed methodology. Of these, 34 participants were born and live in an urban area and three in rural areas. Forty-two migrated from one to another. Participants completed the Pittsburgh Sleep Quality Index (PSQI), Internal Acculturation Index and a sleep diary. Sixty-six participants completed a semistructured interview focusing on the meaning of sleep, sleep patterns, routines, living environment, internal migration and the impact of the COVID-19 pandemic on their sleep. Qualitative data were recorded and transcribed verbatim. Student's T tests were used for the PSQI. Result(s): Participants identify sleep as a mean of recharging energy as well as resting the brain and body. The rural environment is seen by participants as a quiet place to get better sleep. A tendency to migrate to a rural area following the COVID-19 outbreak was observed. The main motives reported for such move were to (re)connect with nature and the increasing acceptance of working remotely from home. Preliminary results do not show a significant difference in PSQI scores or any of its sub-components between the urban and rural groups. Despite both urban and rural dwellers waking up on average around the same time (7:25 a.m.), rural participants appeared to go to bed earlier (7:50 p.m.) than urban participants (9:30 p.m.), although this difference was not statistically significant. Conclusion(s): The COVID-19 pandemic leads to a redefinition of living and sleeping habits favoring rural areas to sleep and to work remotely from home. Recruitment is still in progress and further analysis are expected to show whether internal migration and acculturation are associated to the SRS in Quebec.

Glomerular Annexin A3 and Cathepsin C Staining in COVID-19-Associated and HIV-Associated Nephropathy (HIVAN)-Associated Collapsing Glomerulopathy

Background: Prior studies demonstrated glomerular tuft staining for annexin A3 (Anxa3), a marker of parietal epithelial cells (PECs), and cathepsin C (Ctsc), a master regulatory protease, distinguishing primary collapsing glomerulopathy (CG) from other glomerular diseases. We hypothesized these staining patterns would differentiate COVID-19 associated CG (COVID-19+/CG+) from COVID-19(+) without CG (COVID-19+/CG-). Method(s): Biopsy sections used were from patients with COVID-19 infections and a pathologist-based tissue diagnoses including CG (COVID-19+/CG+;n=4) or lacking CG diagnosis (COVID-19+/CG-;n=6) were stained for Anxa3 and Ctsc using published protocols. HIVAN-associated CG (n=4) biopsies were used as a secondary CG control. Historical controls data for non-CG biospies (PMID:32561683). Glomerular staining was tabulated as for PEC staining, phenotypic characteristics of normal and activated (enlarged nuclei, hypertrophic/enlarged cuboidal shape cells, vacuolization) PECs, and for glomerular tuft to Bowman's capsule adhesions or cellular PEC bridges. Globally scarred glomerulii were omitted from analysis. Serial section staining was used to demonstrate Anxa3 and Ctsc co-localization. Differences in the mean (i) number of glomeruli staining OR (ii) glomerular tuft area stained for Anxa3 and Ctsc per biopsy were compared by one-tailed t-test assuming an increase in staining in CG over non-glomerular disease. A p-value <0.05 was used for statistical significance. Result(s): All COVID-19+/CG+ and HIVAN patients with CG demonstrated extensive Anxa3 and Ctsc glomerular tuft staining. The frequency of glomerular tuft Anxa3 and Ctsc staining and percent glomerular area was significantly (p<0.05) increased in biopsies with COVID-19+/CG+, compared to COVID-19+/CG- (log2FC 2.8-2.9). No statistical difference in frequency or area stained for Anxa3 and Ctsc was observed between COVID-19+/CG+ and HIVAN-associated CG. Conclusion(s): Anxa3 and Ctsc glomerular tuft expression is increased significantly in COVID-19 and HIVAN patients with CG, mirroring our findings in primary CG. These data support the hypotheses that (a) migration of activated PECs into the glomerular tuft is a prevalent event in both primary CG and virus-associated secondary CG, and (b) glomerular Anxa3 or Ctsc may be theragnostic biomarkers of CG.