Incidence and Persistence of Post-COVID-19 Conditions in the Year Following Initial Diagnosis

Objectives: Long-COVID, the persistence of various symptoms after COVID-19 infection, is still not fully understood. This study evaluated the incidence and chronicity of post-COVID-19 conditions using administrative claims, which provide a large, generalizable sample, to provide insight into the scope of long-COVID in the United States. Method(s): Patients newly diagnosed with COVID-19 from 4/1/2020-3/31/2021 were identified in the MerativeTM MarketScan Commercial and Medicare databases. The first COVID-19 diagnosis served as the index date and patients were continuously eligible for 12-months pre- and post-index. Incident conditions were defined as a new diagnosis (no pre-period diagnoses) for one of 17 conditions of interest in the first 60-days of the post-period. Among patients with an incident condition, chronicity of the condition was assessed over the remaining post-period (long-term conditions). Result(s): The sample included 503,742 patients;mean+/-SD age was 39.5+/-16.5 and 46% were male. The most common incident conditions were respiratory symptoms (24.1%), fatigue (7.3%), muscle pain (6.0%), and headache (5.9%). Among patients with each of these conditions, long-term persistence was observed in 21.9% for respiratory symptoms, 36.8% for muscle pain, 18.3% for fatigue, and 16.0% for headache. Fewer than 5% patients evidenced incident anxiety, mood disorders, myocarditis, sleep disorders, or pulmonary embolism;however, among these patients, over 40% had long-term persistence of the condition. Among patients with long-term conditions, sleep disorders (248+/-98 days), mood disorders (239+/-96 days), anxiety (236+/-95 days), respiratory symptoms (233+/-92 days), and asthma (230+/-93 days) had the longest average durations of persistence, evidenced by continued claims over the post-period. Conclusion(s): With the continued presence of COVID-19 an understanding of the risk of long-term symptoms is needed to help manage patients both during and following infection. These findings provide some initial insight into the incidence and tenure of various conditions that are affecting patients diagnosed with COVID-19.Copyright © 2023

Posterior Mediastinal Mass: Unraveling a Non-Traumatic Herniation of the Caudate Lobe of the Liver

Introduction: Posterior mediastinal mass is most likely due to neurogenic tumor, meningocele or thoracic spine lesions. Caudate lobe of the liver herniation presenting as posterior mediastinal mass is a rare occurrence. Diaphragmatic herniation (DH) of the caudate lobe presents in various way including dyspnea, dyspepsia or incidental finding on imaging. We present a case of diaphragmatic hernia of the caudate lobe of the liver presenting as a posterior mediastinal mass found during evaluation of dyspnea. Case Description/Methods: A 75-year-old female presented to her physician with worsening shortness of breath from her baseline of 3 days duration. She had a history of sarcoidosis, COVID pneumonia over 1 year ago, COPD, diastolic heart failure, and hypertension. She was initially evaluated for COVID re-infection, which was negative and a CT of the chest with contrast to check for sarcoidosis flare revealed posterior mediastinal mass measuring 4.5 x 6.5 x 6.4 cm. Further work up with CT chest and abdomen with contrast revealed that the posterior mediastinal mass had similar attenuation as the liver and appears continuous with the caudate lobe of the liver. This was confirmed by NM scan of liver. Review of her records from an outside organization revealed similar finding on imaging a few years ago. Patient denied any history of trauma and laboratory work up revealed normal liver functions. After pulmonologist evaluation she was started on 2 L home oxygen following six-minute walk test, and also CPAP following a positive sleep study. Pulmonary function tests were performed and inhalers were continued. Given the chronicity of her symptoms and co-morbidities with stable caudate lobe herniation, conservative management was advised with surgery warranted if symptoms persist despite treatment (Figure 1). Discussion(s): DH is typically found on the left side with stomach or intestine while the right side is usually guarded by the liver. Isolated herniation of part of the liver into the thoracic cavity is rarely reported and is mostly acute from traumatic or spontaneous rupture requiring immediate repair. Our patient was initially evaluated for the posterior mediastinal mass for concerns of tumor, followed by the finding of what was thought to be acute herniation of the caudate lobe of liver into the thoracic cavity. Review of records showed this to be a stable lesion, we suspect that the patient had congenital diaphragmatic defect. Chronic and stable liver herniation into thoracic cavity can be managed conservatively if uncomplicated.

Chronic Chilblain Like Lesions Associated with the Covid-19 Pandemic

Background/Aims We report the features of chronic chilblain-like digital lesions newly presenting since the start of the covid-19 pandemic. Comparison with primary perniosis and acrocyanosis, reveals a unique phenotype which appears to be a long-covid phenomenon. Methods The case records of 26 patients with new onset persistent chilblain-like lesions presenting to the Rheumatology service of St George's University Hospital, London between Autumn 2020 and Spring 2022 were reviewed. Demographic and clinical features, serology, imaging, treatment response and outcome up to Summer 2022 were collated retrospectively. Results Chilblain-like lesions first occurred between September and March;2019/ 2020 6 cases, 2020/2021 18 cases and 2021/2022 2 cases. Mean age 35.4 (17-60) years, 88% female, 85% white, all non-smokers. Median body mass index (BMI) 20.2, range 17.0 - 33.2. BMI underweight (<18.5) in 27%. All cases reported new red-purple-blue colour changes of the fingers, some with pain, swelling and pruritis, affecting both hands in 12, one hand in 6, and both hands and feet in 8 cases. There was a past history of cold sensitivity or primary Raynaud's in 54%. Covid was confirmed in 3 cases, 2 - 8 months prior to onset of chilblain-like symptoms. Possible covid, unconfirmed, was suspected in 5 cases, 1 - 11 months earlier. Affected digits appeared diffusely erythro-cyanotic in 81%, with blotchy discrete maculo-papular erythematous lesions in 42%, some with both features. Involvement was asymmetric in 54%, thumbs spared in 69%. Complement was low in 50% (8/16), ANA positive in 26% (6/23). MRI of hands showed phalangeal bone marrow oedema in keeping with osteitis in 4 of 7 cases. More severe signs and symptoms were associated with low BMI, low C3/4 and a past history of cold sensitivity or Raynauds. Cold avoidance strategies were sufficient for 58%. Pain prompted a trial of NSAIDs, aspirin, nitrates, calcium channel blockers, hydroxychloroquine, oral or topical corticosteroid or topical tacrolimus in 42%. In general, these were minimally effective or not tolerated. 4 severe cases received sildenafil or tadalafil, effective in 2. In 27% complete remission occurred during the first summer season after symptoms commenced, median duration 6 (range 2 - 10) months. In the remaining 19 cases, chilblain-like symptoms returned or worsened in the subsequent second winter period, with 6 of 19 entering remission the following summer. For the remaining 13 persistent cases the total duration of symptoms spans more than a year, and in four cases more than 2 years. Conclusion This series illustrates a distinct chronic chilblain-like condition. Features similar to primary perniosis include female predominance, middle age, pruritic painful blotchy lesions, asymmetry and low BMI. Features in keeping with acrocyanosis include chronicity, extensive diffuse erythro-cyanotic discoloration, relative improvement in warm weather and lack of association with smoking.

Unmasking of Immunoglobulin A Deposits Posttransplant due to COVID-19 AKI-Incidental or Causal - A Nephrologists' Dilemma A Case Report

COVID-19 is a global pandemic with the chronically immunosuppressed transplant recipients being the most vulnerable both to infection as well as complications of COVID-19. Here, we report a case of live-related renal allograft recipient who presented with complaints of loose stools and new-onset graft dysfunction 2 years posttransplant. He tested positive for COVID-19 infection. On allograft biopsy, there were significant immunoglobulin A (IgA) deposits with no evidence of rejection or ATN or crescents or significant chronicity. The initial pretransplant biopsy of the recipient had revealed chronic glomerulonephritis with nil deposits. The donor had no evidence of hematuria or hypertension and had a preserved GFR. We, therefore, considered the possibility of the unmasking of IgA deposits posttransplantation diagnosed in a recipient with COVID-19 infection. Copyright © 2022 Indian Journal of Transplantation.

Mycology lab of the future-slants to sequencing

As the world enters the third decade of the 21st century, infectious diseases continue to pose major challenges to the survival and well-being of human kind.The COVID-19 pandemic demonstrated how indispensable technological advances and innovations are in our fight against the vast legion of bugs;also, it a fascinating living pro of of the adage 'Necessity is the mother of invention' to witness at what stupendous pace not only diagnostics but therapies and even vaccines were developed, approved, validated, distributed and utilized. All fueled by the overwhelming and unprecedented health emergency that was the severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) pandemic.Many more infectious pathogens, presumably viral, are believed to be waiting in the wings;Monkeypox did not waste much time in proving us right! In our country, India, the foresight of our best scientific brains and scientific policymakers led to the establishment of a network of Viral Research and Diagnostic Laboratories (VRDL) at the medical college, state, and regional levels with the premier institutes like National Institute of Virology (NIV), Pune, acting as an able mentor, under the aegis of the Indian Council of Medical Research (ICMR). The VRDL Network proved its worth and played an extremely important role in monitoring and managing the pandemic as, wave after wave, swept across our nation. Moreover, our indigenous drug makers jumped into the fray and excelled on par with our western counterparts in the timely development of effective vaccines. In a country like India, we are faced with additional challenges in the form of certain infectious diseases whose burden is borne mainly by the socio-economically disadvantaged, mainly in the tropics. These diseases and strategies for their mitigation have been taken up by the World Health Organization (WHO) in a big way by means of the Initiative for Control of Neglected Tropical Diseases (NTDs). Besides bacterial and viral diseases, Eukaryotic organisms are also important entities as etiological agents of NTDs. Eukaryotic medical microbiology (EMM) comprising medical mycology, medical protistology, medical helminthology, and medical entomology needs greater attention in India. Except malaria which has been at the forefront owing to the huge disease burden and associated mortality, several other parasitic infestations have indeed been neglected-an issue which the WHO rightly highlighted as part of its NTD elimination initiative. Though Mycetoma, chromoblastomycosis, and other deep mycoses are the only fungal diseases to find a place on the list of NTDs, many other fungal diseases continue to plague our communities. Mucocutaneous candidiasis and dermatophytosis may neither be commoner in the tropics nor are they neglected (rather, dermatophytosis tends to be overtreated in many cases!) but they merit attention simply because of the discomfort and disruption to daily life that they cause. We propose that a network of Medical eukaryotic microbiology (MEM) Laboratories be set up with special emphasis on the NTDs on a regional and national scale in our country to effectively deal with these infectious diseases prevalent in our communities. The diagnostic services offered by these 'MEM-NTDLs' can comprise of: Microscopy, including fluorescent microscopy and special stains Microarrays MALDI-T OF Multiplex PCR NGS, including handy DNA sequencing technologies exemplified by the Nanopore MinION For dealing with these eukaryotic diseases, we believe that we need to adopt advanced techniques like MALDI and NGS in a big way. Culture, which continues to be the gold standard for bacteriological diagnoses, may now be termed to have historical significance at best in the case of fungal diseases because of the slow turnaround time and by the ubiquitous presence of fungal spores behaving as lab contaminants.Similarly, serological techniques may have a very limited role in the workup of eukaryotic infections owing to the complex antigenic profile of these organisms and the chronicity of the disease condition . Microscopy can be retained for the relative procedural simplicity and rapidity of results. The 'advanced' diagnostic techniques mentioned above have been around for quite some time now and have been widely applied in the microbiology diagnostic laboratory as well.With requisite training and provision of equipment and appropriately trained technical staff, a MEM-NTDL can be operated successfully at the district level in a planned manner.This would greatly enhance the quality of health services available to our population and enable our country to reach the goal of Health for All in the near future. Following identification, comes the very important aspect of antimicrobial chemotherapy susceptibility testing.Even here, alternatives to the growth-based, culture-dependent systems should be sought-the role of Biomarkers related to the growth and metabolism of eukaryotic organisms should be explored and incorporated in practical diagnostics as an aid to infectious diseases therapy and patient management. This can be part of the scope of the MEM-NTDL of the future.

The Mental Health of Emerging Adults: Hostile Home Environments and COVID-19.

Purpose: Due to shifts in societal and educational expectations alongside the COVID-19 pandemic, many emerging adults live with their family of origin for extended periods of time. Little is known about patterns of parent-perpetrated maltreatment in emerging adulthood. Therefore, this study evaluates the relation between forms of parent-perpetrated maltreatment, including economic abuse, and COVID stress, on symptoms of depression, anxiety, and traumatic stress. Method: 423 emerging adults who were enrolled in college in the United States in March of 2020 were recruited via MTurk to complete an online survey. An age-related COVID questionnaire and six empirically validated measures assess levels of COVID-19 exposure, lifetime maltreatment, economic abuse, and mental health status. Results: 13.0% of participants reported maltreatment that most recently occurred over the age of 18 in their household of origin. Mean COVID stress level was found to be significantly higher in the Maltreated Over 18 group compared to the Never Maltreated group (t(345) = -3.03, p = 0.003), and in the Maltreated Under 18 group compared to the Never Maltreated group (t(346) = -3.20, p = 0.002). In accounting for the contribution of demographic variables, maltreatment chronicity, economic abuse, and COVID stress, our model predicted 38.6% of variance in depression symptoms, 37.2% of variance in anxiety symptoms, and 42.9% of variance in traumatic stress. Conclusions: Findings indicate need for increased maltreatment screenings within the emerging adult population and calls for age-specific interventions to address the mental health disparities experienced by emerging adults with maltreatment histories.

Differences in Outcomes Between High Dose and Low Dose Belatacept Conversion on Allograft Function in Kidney Transplant Patients

Background: Belatacept, a selective costimulation T cell blocker is used to avoid unwanted side effects from calcineurin inhibitors. Improved allograft function despite increased risk of early rejection and viral infection have been reported. Method(s): This is a single center retrospective study conducted at Mayo Clinic Arizona. We converted patients to the high dose belatacept (10mg/kg) if transplanted within 1 month and to the low dose (5mg/kg) after 1 month if they had significant side effects with calcineurin inhibitors or suboptimal allograft function with chronicity changes on biopsy findings. Tacrolimus dose was discontinued immediately in high dose conversion group but was overlapped and tapered down within 4 weeks in low dose conversion group. We included both deceased donor and living donor transplant recipients from 2013 to 2021. We compared the effect of high dose and low dose on the occurrence of rejection and infection at 1 year. Result(s): Total of 75 patients were switched to belatacept and 56 (74%) was converted to low dose and 17 (26%) were converted to high dose. No statistical difference found in recipient and donor characteristics between 2 groups (Fig 1). There was no statistical significance in allograft function, rejection rate and infection rate at 1 year (Fig 2). However, the ocurrence of COVID 19 infection was statistically significant in high dose conversion group. Conclusion(s): Allograft function was comparable at 12 months between 2 groups for those transplaned within 1 year. It is important to recognize the potential for overimmunosuppression when transitioning to belatacept.

Public Interest in Vitamin C Therapy and Associated Risk of Nephrolithiasis during the COVID-19 Pandemic

Introduction &Objective: High-dose vitamin C therapy is commonly believed to treat or protect against viral illnesses, such as seasonal influenza. However, not only is there a lack of supporting evidence for this practice, but high-dose vitamin C can also carry clinical risks. This includes its metabolic conversion to oxalate and resultant hyperoxaluria, which increases the risk of oxalate-based kidney stones. During the COVID-19 pandemic, there has been new interest in vitamin C therapy. This study aims to characterize public interest in vitamin C therapy and its association with nephrolithiasis. Method(s): The Google Trends platform was queried to assess worldwide searches for vitamin C, influenza, and COVID-19 using multiple related keywords. We analyzed search traffic from 2011 to 2021 for influenza and from 12/2019 to 9/2021 for COVID-19. To assess sources and accuracy of information about vitamin C therapy, we performed Google searches of "vitamin C COVID" and analyzed top results by support for the therapy and discussion of potential risks. Result(s): Online searches for vitamin C and influenza show a yearly chronicity with seasonal fluctuations (Fig. 1A). Online search traffic for vitamin C therapy paralleled interest in COVID (Fig. 1B). Subsequent peaks in COVID searches during the summer 2020, winter 2021, and summer 2021 surges were all associated with increased interest in vitamin C therapy. Among the top results for COVID-related vitamin C queries, most (90%) were medical websites or scientific publications. About a third of results stated without support that vitamin C may have potential benefit in treating COVID. No sources discussed the increased risk of kidney stones due to vitamin C therapy;only 1 source noted "potential adverse effects" but did not specify risks. Consistent with the lack of public information about stone risk, there were no apparent associations in search patterns between vitamin C or COVID and kidney stones (Fig. 1C). Conclusion(s): Online interest in vitamin C therapy reflects surges in COVID-19 incidence. Despite the known association between high-dose vitamin C and oxalate stones, no online sources discussing this therapy for COVID cited this risk. Continued public interest in COVID therapies may have unexpected epidemiological consequences including increased risk of kidney stones.

A CASE OF MICROSCOPIC POLYANGIITIS (MPA) FOLLOWING SARS-COV-2 INFECTION

SESSION TITLE: Unique Inflammatory and Autoimmune Complications of COVID-19 Infections SESSION TYPE: Rapid Fire Case Reports PRESENTED ON: 10/19/2022 12:45 pm - 1:45 pm INTRODUCTION: ANCA-associated vasculitis (AAV) is a systemic disease that causes inflammation of small vessels in various organs, such as the lungs, kidneys, and nervous system. We report a case of AAV following SARS-CoV-2 infection. CASE PRESENTATION: A 64-year-old female from Albania with no known medical history, presented with intermittent low-grade hemoptysis and fever for 1 week prior to admission. She had chills, myalgias, fatigue, and poor appetite 6 weeks prior. On arrival, she was febrile (101F), and hypoxic (Spo2 92% on 3L O2). Labs were significant for anemia [Hb 6.8 g/dl], acute kidney injury (AKI) [Cr 2.5 mg/dl]. She was found to be Positive for Sars-CoV-2 by PCR. Chest X-Ray showed patchy bilateral airspace opacities with peripheral and lower lobe predominance, concerning for atypical pneumonia (Fig 1). Urinalysis was significant for proteinuria (2+) and hematuria (2+). CT (Computed Tomography) thorax showed extensive bilateral airspace disease (dense consolidations and ground-glass opacities) favoring multifocal infection and mediastinal lymphadenopathy(Fig 2). Due to the chronicity of her symptoms and atypical imaging for viral pneumonia, other diagnoses were explored including bacterial superinfection, Tuberculosis, and autoimmune disease. Sputum studies were negative for infections including Acid Fast Bacilli. Workup revealed elevated Antimyeloperoxidase antibodies (MPO) and positive COVID-19 Ig G. She was started on methylprednisolone 1g for AAV. Renal biopsy revealed pauci-immune glomerulonephritis with features of cellular crescent consistent with microscopic polyangiitis (Fig 3). Follow-up CT chest showed improved airspace abnormalities and mediastinal lymphadenopathy. After induction therapy with Rituximab was initiated, she continued to recover and was discharged home. DISCUSSION: The pathogenesis of AAV is believed to be an aberrant pathogenic autoimmune response that follows an initial insult which can include infections. SARS-CoV-2 has been associated with the emergence of autoimmune diseases in susceptible patients(1). The proposed mechanism is linked to elevated levels of circulating neutrophil extracellular traps (NETs) observed in covid infection. These NETS are covered with proteins including neutrophilic enzymes which can activate complement pathways causing tissue destruction and vasculitis. The diagnosis of new-onset AAV can be challenging in COVID-19 patients as symptoms and clinical manifestations of both diseases can overlap. AAV should be considered strongly in patients who are currently infected or have been infected with SARS-CoV-2 and present with atypical or non-resolving pneumonia and other organ involvement such as AKI to avoid permanent organ damage. CONCLUSIONS: The presence of non-resolving or atypical pneumonia and AKI in a patient with SARS-CoV-2 should prompt evaluation of immunological markers to assess or rule out AAV for early diagnosis and treatment. Reference #1: Caso F, Costa L, Ruscitti P, Navarini L, Del Puente A, Giacomelli R, Scarpa R. Could Sars-coronavirus-2 trigger autoimmune and/or autoinflammatory mechanisms in genetically predisposed subjects? Autoimmun Rev. 2020;19(5):102524. doi: 10.1016/j.autrev.2020.102524 DISCLOSURES: No relevant relationships by Tarik Al-Bermani No relevant relationships by Anant Jain No relevant relationships by Ian Kaplan No relevant relationships by Alina Kifayat No relevant relationships by Lisa Paul

Mechanisms of Post-critical Illness Cardiovascular Disease.

Prolonged critical care stays commonly follow trauma, severe burn injury, sepsis, ARDS, and complications of major surgery. Although patients leave critical care following homeostatic recovery, significant additional diseases affect these patients during and beyond the convalescent phase. New cardiovascular and renal disease is commonly seen and roughly one third of all deaths in the year following discharge from critical care may come from this cluster of diseases. During prolonged critical care stays, the immunometabolic, inflammatory and neurohumoral response to severe illness in conjunction with resuscitative treatments primes the immune system and parenchymal tissues to develop a long-lived pro-inflammatory and immunosenescent state. This state is perpetuated by persistent Toll-like receptor signaling, free radical mediated isolevuglandin protein adduct formation and presentation by antigen presenting cells, abnormal circulating HDL and LDL isoforms, redox and metabolite mediated epigenetic reprogramming of the innate immune arm (trained immunity), and the development of immunosenescence through T-cell exhaustion/anergy through epigenetic modification of the T-cell genome. Under this state, tissue remodeling in the vascular, cardiac, and renal parenchymal beds occurs through the activation of pro-fibrotic cellular signaling pathways, causing vascular dysfunction and atherosclerosis, adverse cardiac remodeling and dysfunction, and proteinuria and accelerated chronic kidney disease.

Arterial Thrombosis as a Presentation of Systemic Lupus Erythematosusin a Young Child

Introduction: Systemic lupus erythematosus (SLE) is a rare diagnosis in children and can present with nonspecific symptoms. Similarly, arterial thromboses in children without risk factors is also rare. Together, they present a diagnostic challenge which may lead to a delay in proper management. Our objective is to emphasize the importance of having high suspicion for SLE in children, especially when presenting with arterial thrombosis. Case Description: Our patient is a 6-year-old female who presented with a 3-week history of severe right foot pain with a 1-week history of discoloration in the same foot. She sought care multiple times prior to presentation. She initially received the diagnosis of “COVID toes” despite a negative COVID PCR. Prior to presentation, she developed fevers, worsening foot pain, increasing discoloration, decreased oral intake, weight loss, and fatigue. Further lab work showed acute kidney injury, elevated inflammatory markers, and coagulopathy. She was also found to have elevated troponins and QTc prolongation. Additionally, a lower extremity Doppler demonstrated an acute partially occluding thrombus in her right popliteal artery. She was transferred to the pediatric intensive care unit (PICU) and started on a heparin infusion. An Echocardiogram with bubble study showed no interatrial shunting. Thrombolysis was considered but held due to concerns regarding thrombus chronicity. COVID-19 PCR and antibodies were negative, so Infectious Disease team determined this was unlikely related to an acute or remote COVID-19 infection or multisystem inflammatory syndrome in children (MIS-C). Her hemoglobin and platelets began to downtrend and Coombs was positive, raising concern for autoimmune hemolytic anemia. Autoimmune and coagulopathy work-up was significant for positive ANA titer, low complement levels and elevated anticardiolipin, anti-dsDNA, anti-Smith, anti-chromatin, and anti-RNP antibodies. She also had a chest X-ray that showed small non-infectious pleural and pericardial effusions suggestive of serositis. The constellation of these findings eventually led to the diagnosis of SLE. Discussion: There have been several cases of thrombotic or thromboembolic events reported in pediatric patients with SLE, with a majority being venous related events. Only two reports involving cerebral arteries have been published. For several of these patients, thrombosis was the presenting symptoms of their disease. In our literature review, we did not find any cases of arterial thrombosis outside the central nervous system related to SLE. Conclusion: Arterial thrombosis can be a presenting symptom for SLE in children. Despite being a rare presentation, rheumatologic diseases such as SLE should always be considered to prevent a delay in diagnosis and management. In our case, our patient experienced a notable delay in care due to a misdiagnosis related to the COVID-19 pandemic. While it is extremely important to consider sequelae of COVID-19, we would like to emphasize the importance of ensuring consideration of other diagnoses as well.

Creating an Effective Clinic Model for Post-COVID Mental Health Treatment

Background: The University of Colorado (UCH) Consultation-Liaison Psychiatry (CLP) service and Psychiatric Consultation for the Medically Complex clinic (PCMC) are developing a brain health outreach program for those hospitalized with COVID. Patients with COVID have increased risk of cognitive and psychiatric sequelae due to intrinsic viral properties, hyperinflammatory state, and increased disposition to ICU level care (Inoue, 2019;Cothran, 2020). Development of a post COVID brain health program has become paramount and UCH is not alone in creation of new clinic protocols to meet the needs of this population (Rovere Querini, 2020;O'Brien, 2020). Hospitals around the globe are developing new screeners to identify patients at higher risk of neuropsychiatric sequelae and refer them to appropriate resources. Methods: The program makes use of two arms: The first assesses those discharged from the hospital using a screener developed by the UCH post-COVID hospitalization program. The second screens patients currently admitted to the hospital with COVID using psychiatric and neurocognitive screeners. Both allow patients to be referred to PCMC for evaluation and treatment. Evaluation includes psychiatric interview and additional screeners including: Hospital Anxiety and Depression Scale (HADS), Montreal Cognitive Assessment (MoCA) and PTSD Checklist for DSM-5 (PCL-5). Additional neuropsychiatric evaluation via Repeatable Battery for the Assessment of Neuropsychological Status (RBANS), and cognitive rehabilitation referral, are available. Clinic treatment includes pharmaceuticals, individual therapy referral, or referral to the PCMC COVID Survivorship Support Group. Results: To date, 100 patients have been screened in arm 1 (outpatient outreach) and arm 2 (inpatient outreach). In arm 2, about 54% of the population identifies as female, 46% as male, 61% identified as white, and 86% spoke English. Of those in arm 2 that agreed to full participation, 26% agreed to future check-ins and 6% were seen in the clinic. There was a difference in those who did and didn't fully participate based on ethnicity, language, and insurance status;though not of statistical significance. HADs scores demonstrated different trends based on these same demographic factors, though also not statistically significant. Discussion: By using this two-armed approach, the service has been able to more effectively outreach patients and refer them to appropriate care. Though data is not complete, referral needs seem to differ based on demographic data. Conclusions: As data continues to be collected, the clinic model is expanding to outreach high risk patients for neuropsychiatric sequelae. This will strengthen our existing system, with risk of reoccurrence of similar events, and inform a new standard of care for COVID survivors. 1. Cothran, T. P., Tam, J. W.;et.al. (2020). A brewing storm: The neuropsychological sequelae of hyperinflammation due to COVID-19. Brain Behav Immun, 88, 957-958. 2. Inoue, S., Nishida, O, et.al. (2019). Post-intensive care syndrome: its pathophysiology, prevention, and future directions. Acute Med Surg, 6(3), 233-246. 3. O'Brien, H., Hurley, K., et.al. (2020). An integrated multidisciplinary model of COVID-19 recovery care. Ir J Med Sci, 1-8. 4. Rovere Querini, P., Ciceri, F., et.al. (2020). Post-COVID-19 follow-up clinic: depicting chronicity of a new disease. Acta Biomed, 91(9-s), 22-28.

CHRONOTYPE PREDICTS HEALTH OUTCOMES BUT NOT SLEEP DURATION IN EARLY PANDEMIC SLEEP SCHEDULES

Introduction: Lockdowns associated with the COVID-19 pan-demic allowed for individuals to change their schedules. Chronicity is a trait-like preference for individuals' times of the day for activity and feeling best. As a result of the lockdowns, some individuals were able to adjust their schedule to reflect personal chronotype needs. This study examined whether chronotype predicted sleep duration and health outcomes. Methods: A sample of 304 participants were recruited through Amazon's Mechanical Turk service to fill out surveys relating to personality and health. Individuals responded with their normal bedtime and waketime for weeknights and weekends and filled out the Morningness-Eveningness Questionnaire (MEQ;Horne & Östberg, 1976). Self-reported health outcomes were measured via 9 items on the Patient Reported Outcomes Measurement Information System (PROMIS;Cella et al., 2010). Data were cleaned and analyzed via linear regressions in SPSS with age, sex, race, ethnicity and education as covariates. Results: Participants reported an average of 8.52 hours of sleep (SD = 1.97 hours). 35.3% of the sample scored strong- or moder-ately morning-type, 54.7% were neither morning-nor evening-type and 10% scored as evening- or strong-evening types (M = 54.95;SD = 9.42). Results from the PROMIS ranged from 18 to 45 (M = 32.24, SD = 5.49). The model predicting sleep duration (R2 = .06, p = .03) produced a significant effect of ethnicity but not chronicity. Hispanic or Latino ethnicity reported shorter sleep durations relative to those who self-identified as non-Hispanic or Latino. The model predicting PROMIS (general health) scores (R2 = .14, p < .001) produced effects of education (b = .46, p = .04) and Morningness (b = .21, p < .001). People with higher educa-tional levels and those with morning preferences reported better health. Conclusion: Morningness is often associated with better self-regula- tion, lower risky behaviors, better physical and mental health and better sleep. During the early stages of the COVID-19 pandemic, lockdowns allowed many individuals more scheduling flexibility. As a result, sleep duration differences across chronotypes were ab -sent, though health differences remained. Future research should continue to explore differences in sleep schedules in predicting.

In-hospital mortality in non-COVID patients: women die more

Premise and Study aim: In Italy at the end of 2020 more than 30.000 deaths were observed not attributable to COVID;we wanted to test this hypothesis in our non-COVID internal medicine, benchmark for an area of about 150.000 inhabitants. Materials and Methods: We compared the number of discharges and deaths hospitalized in our UOC in the year of the pandemic, 2020 and 2021, respect to 2019, and we assessed any differences in mortality between the years and gender, and if these had statistical significance. Results: Total mortality showed an increasing trend from 2019 to 2021 (statistically not significant);hospital mortality in males is reduced in 2020 and unchanged in 2021, mortality in females showed a clear increasing trend (OR:1.58, IC:0.96-2.06) in 2019, statistically significant (OR:1.9, IC:1.2-3.1) in 2021. Conclusions: Delayed hospitalization for “fear of infection” of more serious patients and with lower chances of survival, together with the drastic reduction/absence of territorial outpatient diagnosis and treatment activities starting from March 2020, with further impact on chronicity in 2021, can be considered responsible for the increase in in-hospital mortality compared to 2019, detected in our patients. Data become statistically significant in female population, and it is attributable both to a greater fragility (living alone, less economic resources, less education) and the role of main care givers in the pandemic, continuing to guarantee assistance to all family members, in particular to the partner, even if detrimental of self health.

Acute Onset Chronic Inflammatory Demyelinating Polyneuropathy Following COVID-19

The cases of Guillain Barre Syndrome (GBS) have been reported following the coronavirus disease 2019 (COVID-19). Here, we describe a case that evolved from GBS to chronic inflammatory demyelinating polyneuropathy (CIDP) after COVID-19 in terms of contributing to the literature due to its different aspects. In the cerebrospinal fluid examination of the acute onset mixed type polyneuropathy case, albuminocytological dissociation was not detected. The patient was given a loading dose and monthly maintenance intravenous immunoglobulin (IVIG) for six months. Blood ferritin levels gradually decreased in parallel with clinical improvement. Four months after the IVIG treatment was terminated, the findings recurred and the CIDP was developed and IVIG treatment was continued. Long-term follow-up of post-COVID-19 GBS patients is important in terms of recurrence and chronicity. Ferritin level may be a biochemical marker in the clinical follow-up of these cases.

GRAVE DANGER: RARE CASE OF COMPLETE HEART BLOCK SECONDARY TO GRAVES DISEASE

Background: Complete heart block (CHB) is a cardiac conduction disorder commonly due to age-related degeneration of the conduction system. Other etiologies include hypothyroidism, Lyme disease or COVID-19, infiltrative cardiomyopathy, myocarditis, and atrioventricular (AV) nodal blocking agents. Hyperthyroidism is an extremely rare cause of CHB. Case: We present the case of a 40-year-old previously healthy male who presented after two syncopal episodes. He denied any home medications, recreational drug use, or prior syncopal episodes. He did endorse worsening palpitations, heat intolerance, anxiety, insomnia and diarrhea for one month. Initial EKG was normal. Labs revealed an undetectable thyroid stimulating hormone (TSH), and high T4 of 3.26 ng/dL. Potassium was 3.1 mMol/L which was replaced to normal levels. In the emergency department, he had another syncopal episode. Telemetry showed a 20 second episode of CHB. Patient was admitted and started on methimazole. Decision-making: Labs showed positive TSH receptor antibodies and thyroid stimulating immunoglobulins, confirming a diagnosis of Graves’ disease. COVID-19 IgG antibodies were positive with negative COVID-19 PCR, indicative of remote COVID 19 infection. Cardiac MRI did not show any myocarditis or infiltrative disease, and otherwise revealed a structurally normal heart. Lyme disease antibodies were negative. Toxicology screen was negative. Thyroid ultrasound showed diffuse heterogeneity of the gland. 72 hour telemetry monitoring revealed no further conduction abnormalities. At this point, CHB wes attributed to hyperthyroidism. As this was reversible, and CHB resolved after initiation of methimazole, a permanent pacemaker was not placed. He was discharged with a 30-day event monitor which did not show any conduction abnormalities. Conclusion: This case highlights a rare sequela of hyperthyroidism induced CHB. Although the pathophysiology is not well understood, a proposed mechanism is the direct toxic effect of T3 leading to focal inflammation of the AV node. Further studies are needed to evaluate the pathophysiology and chronicity of this process, which will assist in the decision to implant a permanent pacemaker.

Adaptive immune dysregulation in cancer patients with SARS-CoV-2 infection Santosha

Coronavirus disease 2019 (COVID-19) infection results in high rates of both acute and long-term mortality patients with hematologic malignancies, but the immunologic mechanisms underlying poor outcomes in this population remain poorly understood. In this presentation, we discuss how immune dysregulation, resulting from either underlying hematologic malignancy or immune-directed therapies, affects COVID-19 morbidity and mortality. First, we evaluated both clinical and immunological parameters of hospitalized cancer patients with COVID-19 infection. To our surprise, neither receipt of anti-CD20 therapy nor diminished B-cell counts were predictive of mortality in this population;however total CD8+ T-cell counts and lack of functional T-cell responses to COVID-19- derived antigens were strongly predictive of mortality. These results indicate that T-cell immunity is the dominant predictor of COVID-19-infected hematologic malignancy patients, and that loss of Bcell immunity is not associated with increased mortality so long as T-cell immunity is sufficient. In addition to short-term mortality, persistent and/or recurrent COVID-19 infection has been exclusively described in hematologic malignancy patients, but the primary drivers of persistent infection are not well understood. We identified patients with B-cell lymphomas as having a particularly high risk for persistent SARS-CoV-2 positivity. Subsequent analysis of patients with lymphoid malignancies and COVID-19 identified discrete risk factors for severity of primary infection as compared to disease chronicity. Active therapy and diminished T-cell counts were key drivers of acute mortality in lymphoma patients with COVID-19 infection. Conversely, B-cell depleting therapy was the primary driver of re-hospitalization for COVID-19. In patients with persistent SARS-CoV-2 positivity, we observed high levels of viral entropy consistent with intrahost viral evolution, particularly in patients with impaired CD8+ T-cell immunity. These results suggest that persistent COVID-19 infection is likely to remain a risk in patients with impaired adaptive immunity and that additional therapeutic strategies are needed to enable viral clearance in this high-risk population. Finally, we discuss disease and therapy-specific predictors of humoral responses to COVID-19 vaccination in the hematologic cancer population. As expected, patients with hematologic cancers had a blunted humoral response to vaccination when compared to healthy donors, and this defect was even more profound when considering the neutralizing capacity of these antibodies, suggesting both a qualitative and quantitative defect to the humoral immune response in patients with hematologic cancers. Second, we identified novel populations of patients with poor humoral responses to vaccination, such as patients receiving anti-CD38 antibodies and BH3 mimetics. Our current ongoing work is exploring the development of functional T-cell memory in these unique patient populations.

Mental health and perceived impact during the first Covid-19 pandemic year: A longitudinal study in Dutch case-control cohorts of persons with and without depressive, anxiety, and obsessive-compulsive disorders.

BACKGROUND: Little is known about the longer-term impact of the Covid-19 pandemic beyond the first months of 2020, particularly for people with pre-existing mental health disorders. Studies including pre-pandemic data from large psychiatric cohorts are scarce. METHODS: Between April 2020 and February 2021, twelve successive online questionnaires were distributed among participants of the Netherlands Study of Depression and Anxiety, Netherlands Study of Depression in Older Persons, and Netherlands Obsessive Compulsive Disorder Association Study (N = 1714, response rate 62%). Outcomes were depressive symptoms, anxiety, worry, loneliness, perceived mental health impact of the pandemic, fear of Covid-19, positive coping, and happiness. Using linear mixed models we compared trajectories between subgroups with different pre-pandemic chronicity of disorders and healthy controls. RESULTS: Depressive, anxiety and worry symptoms were stable since April-May 2020 whereas happiness slightly decreased. Furthermore, positive coping steadily decreased and loneliness increased - exceeding pre-Covid and April-May 2020 levels. Perceived mental health impact and fear of Covid-19 fluctuated in accordance with national Covid-19 mortality rate changes. Absolute levels of all outcomes were poorer with higher chronicity of disorders, yet trajectories did not differ among subgroups. LIMITATIONS: The most vulnerable psychiatric groups may have been underrepresented and results may not be generalizable to lower income countries. CONCLUSIONS: After a year, levels of depressive and worry symptoms remained higher than before the pandemic in healthy control groups, yet not in psychiatric groups. Nevertheless, persistent high symptoms in psychiatric groups and increasing loneliness in all groups are specific points of concern for mental health care professionals.

Chronic cerebral aspects of long COVID, post-stroke syndromes and similar states share their pathogenesis and perispinal etanercept treatment logic.

The chronic neurological aspects of traumatic brain injury, post-stroke syndromes, long COVID-19, persistent Lyme disease, and influenza encephalopathy having close pathophysiological parallels that warrant being investigated in an integrated manner. A mechanism, common to all, for this persistence of the range of symptoms common to these conditions is described. While TNF maintains cerebral homeostasis, its excessive production through either pathogen-associated molecular patterns or damage-associated molecular patterns activity associates with the persistence of the symptoms common across both infectious and non-infectious conditions. The case is made that this shared chronicity arises from a positive feedback loop causing the persistence of the activation of microglia by the TNF that these cells generate. Lowering this excess TNF is the logical way to reducing this persistent, TNF-maintained, microglial activation. While too large to negotiate the blood-brain barrier effectively, the specific anti-TNF biological, etanercept, shows promise when administered by the perispinal route, which allows it to bypass this obstruction.