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Health care-associated infections/ Hospital-acquired infections (HAIs) have a significant impact on patients' morbidity and mortality. The risk of HAIs in resource-limited settings (RLS) has been reported 2-20 times higher than that in developed countries. Moreover, multi-drug- resistant organisms (MDROs) have emerged and spread throughout the world. In addition, increases in HAIs were observed during the COVID-19 pandemic throughout the world.Thus, screening strategies/surveillance of MDROs were recommended as a core component of infection prevention and control (IPC) measures for the effective HAIs prevention. We review and summarize current critical knowledge on screening strategies in different resource settings, especially on guidelines for the prevention and control of carbapenem- resistant Enterobacteriaceae (CRE), Acinetobacter baumannii (CRAB), and Pseudomonas aeruginosa (CRPsA) in health care facilities. The guidelines (especially WHO) were strongly recommended for surveillance of CRE-CRAB-CRPsA infections and surveillance cultures of asymptomatic CRE colonization. There were conditional recommended on surveillance cultures of the environment for CRE-CRAB-CRPsA colonization/contamination. The surveillance cultures (stool samples or rectal swabs) allowed the early introduction of IPC measures to prevent transmission to other patients and the hospital environment. Given the clinical importance of CRE-CRAB-CRPsA infections, regular ongoing active surveillance of infections were required in all microbiology laboratory settings. In addition, surveillance cultures for asymptomatic CRE colonization should also be performed, guided by local epidemiology and risk assessment. The surveillance cultures of asymptomatic CRE colonization should be considered for patients with previous CRE colonization and patients with a history of recent hospitalization in endemic CRE settings or contacted CRE colonized/ infected patients. In contrast, the evidence available on surveillance cultures for CRAB and CRPsA colonization in asymptomatic patients was not sufficiently relevant for the recommendation. Nowadays, the CRE surveillance strategies have been implemented in various methods from traditional culture- based methods to molecular assays. The limitation of microbiology laboratory capacity for MDROs in RLS was concerning. However, the surveillance data would help with appropriate IPC measure implementation and outbreak investigations. Thus, the proper screening strategies and strengthening microbiology laboratory capacity, especially in RLS are challenge for improving IPC measures and patient outcomes.Copyright © 2023
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This study aims to examine the international publication patterns of coronavirus protein database (PDB) structures, beginning when the first coronavirus virion PDB structures were published in 2002 to the present (2022). Sources of these depositions were extracted from their publications and used as indicators of how countries reacted to the pandemic through research output and were then compared to demographic and economic metrics. Of the approximately 40 countries examined, the United States, United Kingdom, and China had the highest number of proteins, demonstrating research productivity centeredness in highly developed countries. These countries all displayed a peak in protein depositions in 2020 or 2021, and slowed down in 2022 likely due to the peaking of the pandemic and a slowing necessity of response. Population size was found to contribute little to no factor in determining the number of coronavirus protein depositions while higher economic status measured by the GDP per capita did correlate with higher numbers of protein depositions (Jaffe et al, 2020). The number of confirmed Covid-19 cases showed a positive association with the number of PDB depositions per country, specifically in the United States. Furthermore, South Africa and Brazil, despite not being in the top 10 research-producing countries, had a high number of cases and PDB depositions, suggesting the strong impact of confirmed cases on coronavirus research output (Normile, 2022). This study's measure of how countries' economic status, population, and confirmed coronavirus cases affects their responses in terms of coronavirus protein research output suggests an unequal distribution in publication origins, which poses a challenge to global pandemic response coordination. This study continues an earlier study presented at the PDB50 - ASBMB on-line meeting, on May 4- 5, 2021 by Janet Gonzalez, Matthew K. McDevitt, David Roman, & Manfred Philipp. NA.Copyright © 2023 The American Society for Biochemistry and Molecular Biology, Inc.
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The SARS-CoV-2 coronavirus (COVID-19) pandemic is a major public health issue;it is the greatest challenge facing humanity in the 21st century, and a sharp increase in the prevalence of the disease has resulted in an increase in morbidity and mortality in many countries. The global health community, in an effort to reduce the spread of the virus, has been taking precautionary measures to address the crisis and alleviate the economic impact of the pandemic on healthcare services. Global information exchange is vital for health systems to meet these challenges. Health systems, even those in developed countries, appear to have been unprepared to meet this challenge, partly because of pre-existing problems. This study identifies some important features of health systems around the world, and the policies implemented by those responsible for addressing this global health crisis caused by SARSCoV-2. In addition, it highlights the government decisions and mechanisms that were implemented to strengthen and finance health systems, and to mitigate the cost of the pandemic. The response of health systems to the requirements created by the coronavirus pandemic shows adaptation to successive changes, allowing recovery and satisfaction of their needs for the protection of public health.Copyright © Athens Medical Society.
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The article demonstrates estimated data of influenza and COVID-19 morbidity and infection fatality rate (IFR) mortality in the context of restrictions and vaccination (years 2020-2021 mostly developed countries). A division into two age groups was included: Up to 65 years of age and over 65 years of age. Influenza mortality (IFR) did not change between 2020 and 2021 and was about 0.05% among all, and 0.005 among those under 65 years of age. IFR COVID-19 was on average approx. 0.5% overall, and in groups under 65 years of age a minimum of 0.07%. COVID-19 morbidity varied greatly from about 50/100,000 in Japan to 600/100,000 in Peru during 2020 plus 2021. In the United States and Poland, about 250 per 100 thousand in 2 years. The morbidity rate of COVID-19 in lower risk groups was 70/100 thousand in the United States. The pre-2020 flu morbidity rate in the United States ranged from 1-10 per 100,000 per season. In the 2020/21 season, it decreased to 1/100 thousand. In groups 65 age old and younger, influenza morbidity in the United States was about 0.3 per 100,000 in the 2020/2021 season, and in typical seasons 0.3 to 3/100,000. Examples of absolute numbers. In the United States, in 2021, COVID-19 471,000 victims (a year of available vaccinations). Influenza season 2021 max. 4,500 victims. The average flu season in unrestricted seasons, was about 25,000 victims. Predictions of the consequenc-es of the lack of restrictions and vaccinations are theoretical, because the preliminary ones talk about 2-3 million COVID-19 victims and even more than ten million additional hospitalizations in the United States, which may mean the collapse of the health system, and thus in practice a greater number of victims. The data presented did not result from diagnostic errors. A proper epidemic assessment confirms the effectiveness of vaccination and targeted therapy. COVID-19 vaccination reduced IFR mortality by about 10-fold.Copyright © 2023, Termedia Publishing House Ltd.. All rights reserved.
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COVID-19 has created much concern among general public, policy makers and especially heath care workers. The reason is not one but varied such as anxiety, fear, compromised health, isolation, economic crisis and social stigma all of which leads to psychological stress. The disease became a global concern due to unmanageable death even in much developed countries. Coronavirus disease 19 (COVID-19) is a newly discovered disease caused by coronavirus which reside both in humans and animals. The article is a detailed review from the origin of the disease, its progression in India and its various other aspects.Copyright © 2023, Informatics Publishing Limited and Society for Biocontrol Advancement. All rights reserved.
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Male and female sterilisation are important forms of contraception worldwide despite declining popularity in developed countries and limited access during the Covid-19 global pandemic. Vasectomy is the only highly reliable form of male contraception. Appropriate counselling about permanent methods of contraception in both sexes is vital and should include information about irreversibility, failure rates and complications. The alternatives to sterilisation, particularly long-acting reversible contraception (LARC), should be discussed in detail as they are at least as effective and have the advantage of reversibility. Hysteroscopic techniques for female sterilisation are no longer available. In males the no-scalpel technique vasectomy requires minimal operating time and results in less post-operative discomfort than the incisional method. Regret after sterilisation and requests for reversal are more common in patients under 30 years and in men with no children.Copyright © 2023
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Background: The pattern of new drug approval is changing across the world as shown by the study using Center for Drug Evaluation and Research and European Medicines Agency data in US and UK with more drug approval for anti-cancer and immunomodulator drugs. There is a need to generate similar database for developed South East Asian countries too. Aims and Objectives: This study was conducted for one such country-Singapore for the new drug approval pattern of last 5 years (2017-2021). Material(s) and Method(s): This was a pharmacoepidemiological study, in which government drug regulatory website data available in public domain was searched. The new drug approval data were classified according to active ingredient, drug approval date, new drug application category, indication of drugs, and World Health Organization Anatomic Thoracic Classification. Result(s): In this study, 418 new drug approvals were found in last 5 years in Singapore. From this maximum, drug approvals were given to anti-neoplastic and immunomodulator category drugs. In anti-neoplastic category new drugs approval few examples were Trastuzumab deruxtecan and Tucatinib for breast cancer therapy and Tepotinib and Capmatinib for non-small cell lung cancer therapy. Conclusion(s): This study shows that drug development in anti-cancer drug and immunomodulator is significant in Singapore. This trend is quite matching with other country such as US and UK.Copyright © 2023 Priti Solanky, et al.
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Introduction: Coronavirus disease 2019 (COVID-19) was described for the first time in December 2019. Symptoms include cough, fever, myalgia, headache, dyspnea, sore throat, diarrhoea, nausea, vomiting, and loss of smell or taste. Viral-induced myocarditis and pericarditis have been described in developed countries, and SARS-CoV-2 is cardiotropic. Pericarditis can mimic myocardial infarction (MI) in its presentation and ECG findings. Case report: A 46-year-old smoker with no previous medical condition presented with left-sided chest pain, sweating, trouble breathing, palpitations, and left-hand numbness. He denied having reduced effort tolerance, orthopnea, or paroxysmal nocturnal dyspnea. Three weeks earlier, he was infected with Covid-19 category 2A infection. On examination, he is haemodynamically stable, and his respiratory and cardiovascular exams were unremarkable. His ECG showed anterior ST elevation, and the bedside echocardiography showed no hypokinesia or pericardial effusion. High-sensitive cardiac troponin T reached 5000. The emergency team contacted the on-call cardiologist for primary PCI. After analysing the serial ECG and bedside echocardiography, he decided against primary PCI due to acute pericarditis. He was started on intravenous diclofenac acid and colchicine. His pain subsided after 3 days with NSAIDs and colchicine. He was reviewed back in the clinic and had a normal ECG and ECHO. Discussion(s): Pericardial disease caused by COVID-19 has been more common since the pandemic outbreak. Mycobacterium tuberculosis, Borrelia burgdorferi, Parvovirus B19, and Epstein-Barr virus are the most common infecting agents. Most cases of acute pericarditis in developing nations are due to tuberculosis infection. Nearly half of all patients who had previously recovered from COVID-19 infection have now presented with new cardiac MRI findings indicating pericardial involvement. Fibrosis and/or oedema may be linked to persisting active pericarditis following infection resolution, which may lead to short and long-term clinical consequences. Conclusion(s): The ST elevation in post-covid patients does not always signify myocardial infarction. Despite complaints and ECG findings, this could not be an acute myocardial infarction, for which clinicians should have a high index of suspicion.Copyright © 2023
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The availability of sufficient, efficient nursing staff and the development of nursing services are crucial in the provision of high quality care to healthcare services users. Provision of adequate nursing staff is of vital importance as it affects patient outcomes and safety. Limited nursing staff and a low ratio of nurses per patient are associated with an increased risk of patient death. Understaffing affects the staff members themselves, the patients and the health-care organizations, and, internationally, measures focusing on setting a safe nurse-to-patient ratio have been devel-oped. Factors that increase the need for nursing staff are the increasingly demanding nursing care of patients in hospitals following advances in technology, the ageing of the population, and the increasing numbers of patients and their co-morbidities. The COVID-19 pandemic constitutes a new significant determinant of increase in the need for qualified nursing staff. The COVID-19 pandemic has caused major organizational issues in healthcare systems world-wide, even in the developed countries with their reasonably well-organized primary and secondary healthcare sys-tems. Staffing plans during the COVID-19 pandemic should focus on the care needs of patients with COVID-19, and should include the deployment and allocation of skilled clinical staff. Healthcare systems internationally need to take immediate and effective action regarding the availability of qualified nursing staff, to be better prepared for future public health threats. Copyright © Athens Medical Society.
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Objective: To discuss the challenges in establishing the paediatric neurology service locally in a resource-limited setting and how we overcame these limitations. Methods/Challenges: (1) Discussion of the service prior to 2020;(2) Training of paediatricians and the local medical board drafted pathway for subspecialty registration;(3) The difficulties in securing posts within the health system (as well as the discrepancies amongst different regions within Trinidad and Tobago);(4) Discussion of a tiered referral system;(5) Limitations in services (including investigations and treatment options);(6) The effects of COVID-19 on a new sub-specialty service. Results/Discussion Points: Prior to 2020, there was no established paediatric neurology service. Changes in local medical board paediatric training from 2020 and the impacts on sub-specialty pathway registration. Discussion on the need for a national service provision due to the discrepancies amongst RHA trained consultants. The development of paediatric epilepsy surgery service within the Caribbean. This would influence the tiered referral system both locally and regionally. The routes for accessing investigations that are not available within the public healthcare setting, including genetic testing. Pathways for accessing treatment on a case-by-case basis. The impact of COVID-19 on service provision'negative and positive aspects. Conclusion(s): With the established local training pathway for paediatrics, as well as opportunities to extend our subspecialty knowledge base in developed countries e.g. UK, Canada, we can improve the services provided. Despite being an independent nation, we are grateful to our Commonwealth leaders for continuing to guide our professional tutelage.
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The availability of sufficient, efficient nursing staff and the development of nursing services are crucial in the provision of high quality care to healthcare services users. Provision of adequate nursing staff is of vital importance as it affects patient outcomes and safety. Limited nursing staff and a low ratio of nurses per patient are associated with an increased risk of patient death. Understaffing affects the staff members themselves, the patients and the health-care organizations, and, internationally, measures focusing on setting a safe nurse-to-patient ratio have been devel-oped. Factors that increase the need for nursing staff are the increasingly demanding nursing care of patients in hospitals following advances in technology, the ageing of the population, and the increasing numbers of patients and their co-morbidities. The COVID-19 pandemic constitutes a new significant determinant of increase in the need for qualified nursing staff. The COVID-19 pandemic has caused major organizational issues in healthcare systems world-wide, even in the developed countries with their reasonably well-organized primary and secondary healthcare sys-tems. Staffing plans during the COVID-19 pandemic should focus on the care needs of patients with COVID-19, and should include the deployment and allocation of skilled clinical staff. Healthcare systems internationally need to take immediate and effective action regarding the availability of qualified nursing staff, to be better prepared for future public health threats. Copyright © Athens Medical Society.
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Introduction: Antimicrobial resistance (AMR) is a global threat. The Global South has illustrated gaps and challenges in contextual interventions to tackle AMR due to economic development and existing legislation on antimicrobial use. Community pharmacists are vital healthcare professionals in primary care settings to promote Antibiotic Smart Use (ASU). Objective(s): The aim of this study was to explore their experiences and aspirations around ASU to tailor sustained interventions. Method(s): Virtual online focus group discussions (FGDS) were conducted to explore the views of part- and full-time community pharmacists in Thailand who were systematically recruited to ensure their eligibility to fit with Appreciative Inquiry (AI) theory. Out of a pool of eligible participants, those who had scored above average (> 74%) and above in the attitude questionnaire - the earlier part of the project - were quota sampled and purposively invited to take part. A specific topic guide was developed using the four domains of AI (Discovery, Dream, Design and Destiny), to provide insights into their thought processes and their recommendations for the facilitation of ASU in community pharmacies. Qualitative data were analysed using Nvivo12, using thematic framework analysis with a deductive approach. Result(s): Twenty one community pharmacists participated. Seven themes around ASU emerged in the Discovery Domain of AI. There are pharmacists' practices for non-prescribed antibiotic dispensing, professional experience, work environment, commercialisation and business, commonly used non-prescribed antibiotics, visibility of the National Plan for tackling AMR, and learning points from the COVID19 pandemic. The participants dreamed about the ideals of ASU in the community pharmacy in five themes which are establishing One Health stakeholders- regulating the supply chain, following developed countries as role models, reviewing legislation, and forming witness checks and balances in healthcare professionals. Then the participants designed interventions and strategies on five themes: insurance system, incentive intervention, re-classification of antibiotics, and organisational unity for supporting ASU. The Destiny domain consisted of five themes that would allow sustainable ASU in their settings: the need for ASU literacy, primary care, AMR attitudes and behaviour change strategies, communication of ASU progression and resource management, and trust in pharmacists as a key to building customer loyalty. Conclusion(s): Four domains of Appreciative Inquiry provided community pharmacists with the opportunity to share their experiences and aspire to desired changes to promote ASU in the pharmacy setting and broadly across the country. This framework reflected contextual interventions and strategies with bottom-up brainstorming linked to top-down approaches. The requirement of literacy, along with strategies for changing for public and healthcare providers, could elevate ASU in community pharmacies. Integration of community pharmacy into a part of government primacy care unit and communication of the ASU progression with them might promote engagement with the remaining business aspects.
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A 25 year old man presented with three days of cough, shortness of breath, and pleuritic chest pain. Initial vital signs in the ED were normal, and exam demonstrated tonsillar erythema without exudate. Labs revealed a leukocytosis of 18.9k/muL, D-dimer of 690 ng/mL, C-reactive protein of 5.7 mg/dL, and lactate elevated to 2.9 mmol/L. High-sensitivity troponin, NT-proBNP, and SARS-CoV-2 RT-PCR were all negative. Presenting electrocardiogram demonstrated PR elevation in aVR with diffuse ST-segment elevation in the inferior and anterolateral leads. Point-of-care echocardiogram demonstrated normal biventricular function without pericardial effusion. CTPA was negative for pulmonary embolism, and he was observed for presumed acute viral pericarditis. Fourteen-hours later, he became febrile to 38.3degreeC, tachycardic to 133 bpm, and hypotensive to 97/65 mmHg with diffuse abdominal pain. Repeat lactate was 9.0 mmol/L. This prompted an emergent CT scan which now showed a new large pericardial effusion and bilateral pleural effusions (Panel A). Repeat echocardiogram confirmed a large circumferential pericardial effusion with early signs of tamponade including right atrial inversion in late diastole (Panel B). Emergent pericardiocentesis yielded 560 mL of brown, purulent fluid (Panel C) with immediate improvement in hemodynamics. Bacterial gram stain and culture grew Haemophilus influenzae (Panel D). Immunodeficiency screening was negative. Transient severe biventricular systolic dysfunction was noted, consistent with sepsis-induced cardiomyopathy. He completed a targeted antibiotic course with partial recovery of his ejection fraction by discharge. Purulent pericarditis is rare in developed countries, and invasive H. influenzae in a young, immunocompetent adult is particularly unusual. This case illustrates the importance of early diagnosis and management of purulent pericarditis given its potential for rapid progression and high mortality. (Figure Presented).
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Background. The COVID-19 pandemic has strained healthcare systems worldwide and is now a leading cause of death. Remdesivir is the first antiviral shown to decrease time to recovery in a randomized placebo-controlled trial. Other studies have conflicting results and the World Helath Organization does not recommend the routine use of Remdesivir in hospitalized patients. The herogeneity of these studies and their populations makes interpretation of the available data difficult, with standard of care in different countries as the main confounding factor. Thus, it is imperative for low and middle income countries to study the role of remdesivir within their healthcare systems. We seek to further understand the impact of COVID-19 in a cohort in the Dominican Republic. Methods. This is a retrospective review of patients admitted for COVID-19 to a tertiary center in the DR between August 2020 to March. 2021. Patients with clinical findings consistent with COVID-19 pneumonia and a positive molecular test for SARS-CoV-2 were included in the study. Results. A total of 59 cases were reviewed, of which 40 were treated with remdesivir and 19 with remdesivir plus tocilizumab. Patients were more commonly male (69.5%) and ages ranged from 71-80 years (34.5%), 61-70 (20.7%), 51-60 (20.7%), 41-50 (10%), >81 (8.6%) and 18-30 (1.7%). Hypertension was the most common comorbidity (Figure 1). The average length of stay was 16.5 days, and 2.1 days. Mechanical ventilation was needed in 33.9%. Tocilizumab was administered in 32%. Mortality for the cohort was 29% (Figure 2). Mortality in patients treated with remdesivir alone was 22%, compared to 6.8% in those receiving tocilizumab and remdesivir. Comorbidities Mortality by length of stay Conclusion. In our cohort, the use of remdesivir was associated with higher mortality than remdesivir in combination with tocilizumab. The mortality in our cohort was high (29%) compared to the 11.9% reported in in the placebo group of the ACTT-1 study. Furthermore, studies have consistently shown benefit earlier in the disease course and with lower oxygen needs. Our cohort had high rates of mechanical ventilation. Thus, the modest benefit seen in developed countries may be harder to show in resource limited settings and the number needed to treat is likely much higher. Remdesivir did not appear to have an impact in our cohort.
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AIM: The aim was to evaluate the feasibility of protective measures for infants of low-income SARS-CoV-2 positive breastfeeding mothers. BACKGROUND: Breastfeeding mothers with SARS-CoV-2 positive should avoid exposing the infant through protective measures (PM), but it could be challenging in a low-income population. METHODS: A prospective, multicenter study was conducted between July and October 2020 (BRACOVID). The participants were recruited at birth and interviewed through a structured questionnaire at seven and 14 days in the home environment. The feasibility of PM during breastfeeding at home was defined by guidelines recommendations (mask using, handwashing, and distancing from newborn when not breastfeeding). Three groups according to the feasibility of guidelines: complete guidelines feasibility (CG): all PM; partial guidelines feasibility (PG): at least one PM feasible; no guidelines (NG): infeasibility to all of PM. Flu-like neonatal symptoms, mothers' breastfeeding practices. We evaluated the association between PM feasibility and socioeconomic factors. RESULTS: 117 infected mothers from 17 Brazilian hospitals were enrolled. 47 (40%) mothers followed all recommendations, 14 (11.9%) could not practice at least one recommendation, and 50 (42.7%) did not execute any of them. The breastfeeding rate was 98%. Factors associated with infeasibility were monthly family income < 92.7 dollars/person, high housing density (>1 inhabitant/room), teenage mothers, responsive feeding, and poor schooling. Regarding infants' flu-like symptoms, 5% presented symptoms at fourteen days (NG group). CONCLUSION: The guidelines were not applied to infants of SARs-CoV-positive mothers in 54.6% of the dyads since the recommendations were unviable in their environments. During pandemics, we should look for feasible and effective guidelines to protect neonates from low-income populations. IMPLICATIONS FOR NURSING MANAGEMENT: Poor socioeconomic conditions lead to the unfeasibility of protective measures for infants of low-income SARS-CoV-2 positive breastfeeding mothers during the isolation period in the pandemics. The orientations and the support provided to dyad should consider the socioeconomic factors to guide feasible measures in the home environment and promote adequate protections; only an individual approach will allow a safe environment for low-income infants.
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Mucormycosis is a potentially fatal disease caused by a fungus of the order Mucorales, most commonly involving the nasal sinuses, orbits, brain, lungs, and skin. The disease affects mostly immunosuppressed individuals and patients with chronic diseases such as diabetes. The prevalence of mucormycosis is 80 times higher (0.14 per 1000) in India compared to developed countries. Since the outbreak of the COVID-19 pandemic, there has been a sudden surge in the number of mucormycosis cases, especially on the Indian subcontinent. This can be attributed to what we consider to be the perfect iatrogenic recipe: a combination between the immunosuppression caused by COVID-19, the large prevalence of uncontrolled diabetes and the simultaneous use of corticosteroids. Other factors include the excessive use of antibiotics, antifungal drugs and zinc supplements, invasive ventilation, poor hygiene and sanitization as well as the use of industrial oxygen in hospitals. As a result, an overwhelmingly large number of COVID-19 patients have developed mucormycosis during the pandemic. A review of the literature suggests that all efforts should be made to keep tight control of glycemia in COVID-19 patients along with judicious use of corticosteroids. The treatment of mucormycosis involves a combination of medical and surgical therapy, with the early initiation of antifungal drugs and aggressive surgical debridement of the affected tissues. Copyright © 2022 Mandip Singh Bhatia et al., published by Sciendo.
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Background and aims: Malnutrition is a common comorbidity in cirrhotic patients and confers a poorer prognosis. Vitamin C (VC) is a micronutrient essential for human health. Vitamin C deficiency (VCD) can lead to scurvy and may impair immune and liver functions. Although previously thought to be rare in developed countries, VCD is now well described in patients with pneumonia, COVID19 and upper gastrointestinal bleeding (UGIB). The prevalence and clinical significance of VCD in cirrhosis remains poorly studied. Method: Patients with cirrhosis admitted to 3 metropolitan tertiary centres in Australia were prospectively included over a 10-month period in 2021. Fasting VC levels were collected on admission and we recorded demographic data and clinical outcomes. The primary outcomes were the prevalence of VCD (defined as VC level <23 mcmol/L) and severe VCD (SVCD), defined as <11 mcmol/L. Secondary outcomes included mortality, intensive care admission, length of stay (LOS) and rate of infection. Results: 117 patients were included. Mean age was 57.1 ± 13.9 years, 59.0% were male and 23.9% belonged to the lowest socioeconomic decile. The most common aetiologies of cirrhosis were alcohol (62.4%), viral hepatitis (24.0%) and non-alcoholic fatty liver disease (18.8%). Median MELD scorewas 29 (IQR 22–36) and Child Pugh (CP) grades were 12.8% A, 46.2% B and 41.0% C. Most patients (74.4%) were hospitalised with complications of decompensated cirrhosis, including ascites (59.0%), encephalopathy (31.6%) and variceal bleeding (11.1%). Median VC level was 34mcmol/L (IQR 16–55) and did not differ with age, gender, or aetiology of cirrhosis. Increasing CP grade correlated with significantly lower median VC levels (CP-A 46.0 mcmol/L vs. CPB 36.5 mcmol/L and CP-C 20.5 mcmol/L, p = 0.026). The prevalence of VCD and SVCD were 39.3% and 17.1% respectively. SVCD was more prevalent in patients with a body mass index <25 (28.3% vs 13.0%, p = 0.036). In-hospital mortality was 12.8% and did not differ by VCD status, however in the subgroup of patients presenting with UGIB, SVCD correlated with significantly higher mortality (50% vs 4.1%, p = 0.045). Bacteraemia was more frequent in patients with VCD (13.3% vs. 1.4%, p = 0.014) and SVCD (26.3% vs 2.1%, p < 0.001), which remained significant at multivariate analysis (OR for every 1mcmol/L increase in VC, 0.91 (95% CI: 0.83–0.99), p = 0.037). Overall infection rateswere higher in patients with SVCD (40.0% vs. 27.8%) although thiswas nonsignificant (p = 0.279). Median hospital LOS was 10 (IQR 6–18) days and did not differ by VCD status. (Figure Presented) Conclusion: VCD is common in hospitalised cirrhotic patients and prevalence increases with severity of liver disease. VCD increases the risk of infective complications and higher mortality was observed in patients with UGIB and SVCD. Further studies are required to assess the significance of VCD in cirrhosis and the impacts of VC replacement.
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CASE: Ms.X is a 31-year-old female with an unremarkable medical history who presented to the general medicine clinic with palpitations that started 3 days after taking her second dose of Pfizer Covid vaccine. The palpitations ocurred exclusively when standing, with no associated chest pain, dizziness, or presyncope. History is negative for tobacco smoking, drug or alcohol use, and consumption of energy or caffeinated beverages. The physical examination was notable for moist mucous membranes and normal volume examination. Orthostatic vitals were remarkable for an increase in HR by 30 beats with minimal change in BP. EKG showed a normal sinus rhythm, and lab workup inclusive of a CBC, CMP, and TSH was unremarkable. As such, the patient was referred for tilt-table testing. Within 8 minutes of upright tilting, HR was137 from a baseline of 77, and BP was 144/108 from 125/71. A looprecorder was inserted which revealed presence of patient triggered episodes of sinus tachycardia upon standing. The patient was started on propranolol 10 mg every 4-6 hours while awake with almost complete resolution of palpitations. IMPACT/DISCUSSION: The incidence of POTS is 0.2-1% in developed countries, with a 5:1 female-male ratio. It presents with orthostatic symptoms like light-headedness, presyncope, and palpitations. It can occasionally present with non-orthostatic symptoms like nausea, bloating, and diarrhea. The pathophysiology is not well-understood but is postulated to be due to an autoimmune disorder, abnormally increased sympathetic activity, and/or sympathetic denervation leading to central hypovolemia and reflex tachycardia. It is a diagnosis of exclusion, but table-tilt test is used to help confirm it. The onset is typically precipitated by immunological stressors like viral infections, vaccination, and pregnancy. Recently, several case reports have been published describing POTS following infection with COVID-19 infection. This was described as long-COVID postural tachycardia syndrome by the American Autonomic Society. However, the association of POTS with COVID-19 vaccine is unclear. Only one case report was published describing the development of POTS after COVID-19 mRNA vaccine. Information relating to this remain limited, and approach to diagnosis and treatment is variable. Our understanding of this condition in relation to vaccination is mostly extrapolated from previously published reports describing it in relation to HPV vaccine. As more people continue to take the vaccine, physicians should be alert to the diagnosis. CONCLUSION: POTS is a frequently underdiagnosed or misdiagnosed disorder. It is characterized by an increase in HR by 30 within 10 minutes of standing . In rare instances, it has been described as a postvaccination adverse immune phenomena, and more recently related to mRNA COVID-19 vaccination. Increased recognition, diagnosis, and reporting will contribute to better understanding and treatment.