Co-exposure to urban particulate matter and aircraft noise adversely impacts the cerebro-pulmonary-cardiovascular axis in mice

Worldwide, up to 8.8 million excess deaths/year have been attributed to air pollution, mainly due to the exposure to fine particulate matter (PM). Traffic-related noise is an additional contributor to global mortality and morbidity. Both health risk factors substantially contribute to cardiovascular, metabolic and neuropsychiatric sequelae. Studies on the combined exposure are rare and urgently needed because of frequent co-occurrence of both risk factors in urban and industrial settings. To study the synergistic effects of PM and noise, we used an exposure system equipped with aerosol generator and loud-speakers, where C57BL/6 mice were acutely exposed for 3d to either ambient PM (NIST particles) and/or noise (aircraft landing and take-off events). The combination of both stressors caused endothelial dysfunction, increased blood pressure, oxidative stress and inflammation. An additive impairment of endothelial function was observed in isolated aortic rings and even more pronounced in cerebral and retinal arterioles. The increase in oxidative stress and inflammation markers together with RNA sequencing data indicate that noise particularly affects the brain and PM particularly affects the lungs. Noise also increased levels of circulating stress hormones adrenaline and noradrenaline, while PM increased levels of circulating cytokines CD68 and MCP-1. The combination of both stressors has additive adverse effects on the cardiovascular system that are based on PM-induced systemic inflammation and noise-triggered stress hormone signaling. We demonstrate an additive upregulation of ACE-2 in the lung, suggesting that there may be an increased vulnerability to COVID-19 infection. The data warrant further mechanistic studies to characterize the propagation of primary target tissue damage (lung, brain) to remote organs such as aorta and heart by combined noise and PM exposure.Copyright © 2023

A CLINICAL CASE OF SARS-CoV-2 INFECTION COMPLICATED BY NEPHROGENIC PULMONARY EDEMA AND COVID-ASSOCIATED PNEUMONITIS, ALVEOLITIS.

COVID-19 is a highly transmissible disease with severe course especially in patients with nephrogenic hypertensive disease and chronic kidney disease due to a higher incidence of all-type infections than in the general population. The aim of the study is to describe a clinical case of SARS-CoV-2 infection complicated by nephrogenic pulmonary edema and COVID-associated pneumonitis, alveolitis. Description of the case. Patient K.S., born in 1975, was hospitalized 24 hours after symptom onset at emergency hospital due to complaints of increased blood pressure up to 180-200/110-120 mm Hg, temperature up to 38.7degreeC, dry cough, feeling of heaviness in the chest, change in urine color. PCR smear for SARS-CoV-2 was positive. Computed tomography revealed a pattern of bilateral COVID-associated pneumonitis, alveolitis, with 75% involvement. The electrocardiogram revealed signs of left ventricular myocardial hypertrophy. Ultrasound examination showed numerous cysts in the kidneys. Urinalysis at admission: leukocytes - 499, erythrocytes - 386. Glomerular filtration rate (CKD-EPI: 29 ml/min/1.73 m2) and corresponds to stage IV of chronic kidney disease. Coagulogram: fibrinogen: 32.3 (1.6-4.0) g/l, D-dimer: 663 (0-250). Despite the treatment, the patient's condition worsened, the phenomena of cardiopulmonary and renal insufficiency increased, which led to a fatal outcome. During a virological study of sectional material: SARS-CoV-2 coronavirus RNA was found in the lung and kidneys. Signs of bilateral COVID-associated pneumonitis, alveolitis with diffuse cellular infiltrates in combination with changes in the alveolar apparatus, signs of pulmonary edema were revealed. Heart-related signs - swelling of the interstitium, fragmented muscle fibers, some of them hypertrophied, a wave-like deformation of cardiomyocytes, blurring of the transverse striation. Arteries with thickened sclerosed walls. In the kidneys - diffuse damage to the proximal tubules of the nephron with areas of cortical and proximal necronephrosis, areas of fibrinoid swelling. Conclusion. The cause of death of a 45-year-old patient was a severe course of bilateral COVID-associated pneumonitis, alveolitis, which contributed to the development of renal medullary hypoxia and type 1 cardiorenal syndrome, which led to early nephrogenic pulmonary edema.Copyright © 2023 Saint Petersburg Pasteur Institute. All rights reserved.

Phytomedicines for Covid-19: Opportunities and Obstacles

COVID-19 is a disease caused by SARS-CoV-2 that can trigger respiratory tract infection. Due to its tendency to affect the upper respiratory tract (sinuses, nose and throat) or lower respiratory tract (windpipe and lungs), this disease is life-threatening and affects a large number of populations. This virus's unique and complex nature enhances the scope to look into the direction of herbal plants and their constituents for its prevention and treatment. The herbal remedies can have preventive as well as therapeutic actions. This review focuses on various aspects of using herbal medicines for COVID-19, as herbal constituents may also have adverse effects. Various studies revealed that some medicinal plants show life-threatening adverse effects, so selecting plants, and their related studies should be appropriate and strategic. This article includes various factors that should be considered before herbal drug use in COVID-19 patients. These are clinical trials, safety, molecular mechanism, and self-medication, which have been elaborated. This article also discusses the targets of covid-19 and different coronavirus strains. As before, treatment diagnosis of the disease is very important. Various patents have been filed and granted for its proper diagnosis so that its treatment can be easy.Copyright © 2022 Society of Pharmaceutical Sciences and Research. All rights reserved.

COVID 19 IMPAIRS ENDOTHELIAL FUNCTION IN PATIENTS WITH CHRONIC KIDNEY DISEASE ON HEMODIALYSIS

Introduction: Cardiovascular events are the leading cause of mortality in patients with chronic kidney disease on hemodialysis (CKD-HD). Recent evidence suggests that coronavirus-19 disease (COVID-19) would induce vascular endothelial function alterations to increase cardiovascular risk. However, whether COVID-19 contributes to endothelial dysfunction in patients with CKD-HD is unclear. Objective: To assess whether COVID-19 worsens endothelial function in a cohort of patients with chronic kidney disease on hemodialysis. Materials and Methods: Patients with chronic kidney disease on hemodialysis were divided into those without COVID-19 (CKD;n = 68) and mild COVID-19 (CKD-C19;n = 11, WHO criteria and PCR+). Informed consent was obtained. Systolic (SBP), diastolic (DBP) and mean (MAP) blood pressures, heart rate (HR), and endothelial function (EF) were evaluated for reactive hyperemia. It was determined dry weight, height, fat mass index (FMI), muscle mass index (MMI), and body mass index (BMI). Results were compared with normal people without CKD (Control = C, n = 10). Results: CKD and CKD-C19 presented a high SBP compared to the controls and without differences between them (C: 119 ± 3, n = 10 vs. CKD: 145 ± 2, n = 68 vs. CKD-C19: 143 ± 3 mmHg, n = 11;p < 0.05 vs. C). Patients CKD-C 19 presented greater endothelial dysfunction compared to CKD and the control group (EF: CKD-C19:2 ± 1, n = 11 vs CKD:4.5 ± 1, n = 28 vs. C:12.1 ± 1, n = 10;p < 0.05). In CKD and C-C19 an increase in BMI was observed in conjunction with an increase in fat mass, without differences in the muscle mass index between both groups (X2:p: NS). No association was observed between EF and BMI or IMG. Conclusions: The present study indicates that COVID-19 would aggravate endothelial dysfunction in patients with chronic kidney disease on hemodialysis. This would not be related to increased BMI or elevated blood pressure. However, more studies are needed to determine the role of COVID-19 on vascular function in this population. (Table Presented).

A RARE CASE OF POSTERIOR REVERSIBLE ENCEPHALOPATHY SYNDROME (PRES)

SESSION TITLE: COVID-19 Case Report Posters 3 SESSION TYPE: Case Report Posters PRESENTED ON: 10/19/2022 12:45 pm - 01:45 pm INTRODUCTION: We are presenting a rare case of Posterior Reversible Encephalopathy Syndrome (PRES) without traditional risk factors in a patient with Covid 19. CASE PRESENTATION: Patient is a 41 y/o F with a past medical history of obesity, seizure disorder, epilepsy, hyperlipidemia and asthma who was admitted for Covid 19 pneumonia. Patient was transferred to the ICU on day #5 and intubated on day #8. Patient was given remdesivir, dexamethasone and baricitinib. Patient required intermittent vasopressors as her blood pressure varied between hypotensive and normotensive. Rarely her blood pressure increased to a hypertensive range. Patient had a thrombotic event on day #19 in her right upper extremity secondary to continuous renal replacement to manage acute renal failure. On Day #24, patient became unresponsive without sedation with an EEG showing moderate to severe slowing. On day #26 patient had a decreased response to stimuli leading to an MRI to evaluate for Posterior Reversible Encephalopathy Syndrome (PRES). MRI highlighted abnormal signal in the brain parenchyma concentrated mainly in the posterior brain consistent with PRES. On day #31 patient exhibited seizure like diffuse tremor. Blood pressure ranged from 90/72 to 137/84 hospital days #20-31. Status epilepticus was evaluated by an long term monitoring EEG showed diffuse slowing and occasional sharp wave activity in the right posterior cerebellum and occipital region without active seizures. On day #39 patient was found to have an acute hemorrhagic stroke of the left temporal region which resolved on day #43. On day #47 patient was transferred to a tertiary care center for tracheostomy placement and discharged on day #55 to a LTACH for rehab. DISCUSSION: PRES is a rare but severe complication of Covid 19 infection. Previous cases showed variability in underlying causes. Our patient showed significant endothelial dysfunction leading to multiple thrombotic events[1]. While our patient had rare hypertensive episodes, they were not persistent nor severe, nor were they present at the time of her seizure activity[1][2]. In comparison to previous cases, our patient had overlapping risk factors such as renal failure, obesity and dyslipidemia[1]. Our patient showed common clinical manifestations of PRES such as seizures, focal neurological deficits, and altered mental status with previous cases[1]. Our patient was not given tocilizumab in contrast with previous cases, however was given corticosteroids[1][2]. CONCLUSIONS: The above is a rare case of PRES without traditional risk factors. Providers must keep a wide differential diagnosis in patients with Covid 19. Reference #1: Lallana, S., Siegler, J. E., Chen, A., Requena, M., Rubiera, M., & Sanchez, A. (2021). Response to correspondence concerning "posterior reversible encephalopathy syndrome (PRES) associated with covid-19.” Journal of Clinical Neuroscience, 92, 189–190. https://doi.org/10.1016/j.jocn.2021.08.006 Reference #2: Kishfy, L., Casasola, M., Banankhah, P., Parvez, A., Jan, Y. J., Shenoy, A. M., Thomson, C., & AbdelRazek, M. A. (2020). Posterior reversible encephalopathy syndrome (PRES) as a neurological association in severe covid-19. Journal of the Neurological Sciences, 414, 116943. https://doi.org/10.1016/j.jns.2020.116943 DISCLOSURES: No relevant relationships by Arka Bhattacharya No relevant relationships by Benjamin Silverman

BP CONNECT: REFERRING UROGYNECOLOGY PATIENTS WITH HIGH BLOOD PRESSURE FOR PRIMARY CARE FOLLOW-UP

Introduction: Elevated blood pressure (BP) is the leading modifiable risk factor for cardiovascular disease (CVD), the leading cause of death in women. Timely referral to primary care from subspecialty care occurs infrequently. BP Connect, a staff protocol for specialty clinics, almost doubled timely primary care follow-up for rheumatology patients with elevated BP (AOR 1.9, 1.4 - 2.5;from 29% to 42%). Objective: To evaluate the feasibility and impact of implementing BP Connect in urogynecology and gynecology clinics. Methods: In two academic urogynecology and gynecology clinics, the BP Connect intervention trained medical assistants and nurses to Check (re-measure) BPs above 140/90, Advise patients of links between BP and CVD, and Connect patients with confirmed high BP for timely primary care follow-up. Implementation included (1) tailored staff engagement focus groups;(2) staff education defining elevated BP (above 140/90) and CVD risk;(3) electronic health record (EHR) alerts prompting staff to re-measure elevated BPs and order timely (within 4 weeks) follow-up for confirmed high BP;(4) staff feedback (monthly audits);and (5) patient education and tools (brochure and BP log). Clinic staff were surveyed pre- and post-implementation about confidence and comfort with BP discussion and referral. Descriptive analyses compared rates of BP re-measurement, offers for and fulfillment of timely primary care follow-up in the 6 months before (08/2020-02/2021) and after (02/2021-08/2021) BP Connect implementation. Multivariable logistic regression, controlling for age, insurance, hypertension, and CVD, evaluated impacts on timely primary care follow-up. Results: BP was elevated in 676 pre-implementation and 708 post-implementation visits. Table 1 describes demographic and relevant medical history for these patient visits. The only statistically significant difference between the pre- and post-implementation visits was a higher proportion insured by Medicaid during pre-implementation (16% vs. 10%). The rate of BP re-measurement increased from 19% pre- to 75% post-implementation (p less than .0001). During postimplementation, among visits where patients had confirmed high BP, staff provided patient education in 83% and offered referral for primary care follow-up in 60% of instances. Overall, the rate of timely primary care follow-up for high BP increased from 28% before to 48% after implementation (p less than .0001) despite implementation during the COVID pandemic. BP Connect implementation resulted in a 12-fold increase in BP re-measurement among patients with high BP and a 2-fold increase in timely follow-up with primary care (Table 2). Staff confidence to do something about high BP increased from 27 to 67%;comfort discussing high BP with patients increased from 27 to 83%, and comfort coordinating referral to primary care for high BP increased from 9 to 42% (all p less than .05). Conclusions: BP Connect implementation was feasible in academic urogynecology and gynecology clinics and doubled the likelihood of patients with high BP having timely primary care follow-up without creating undue burden on subspecialty clinics. The impact of BP Connect in urogynecology and gynecology clinics on timely primary care follow-up was almost identical to that seen in the rheumatology clinics where the intervention was initially developed and tested. Future work will examine adaptation and expansion of BP Connect to other specialties and health systems (Table Presented).

Impact of clinic-provided home blood pressure monitors during COVID-19 pandemic on blood pressure in underserved adults over 50 years old

Introduction: While virtual primary care appointments were essential during COVID-19 pandemic, routine vitals were not available, prohibiting the assessment of hypertension control. As a potential solution, a federally qualified health center in Omaha, Nebraska, provided validated home blood pressure monitors (HBPM) to patients at no-cost. Research Question or Hypothesis: Did providing a validated HBPM to underserved patients over the age of 50 during COVID-19 result in lower blood pressure (BP) compared to those without a HBPM? Study Design: Retrospective, cohort study using data from electronic health records. Methods: This study included patients over 50 years old with hypertension or elevated BP. Intervention patients were provided a HBPM between 3/16/2020 and 9/15/2021 (index date). Primary outcome was change in systolic BP (SBP) and diastolic BP (DBP) from baseline to 6-month follow-up. Baseline characteristics and outcomes were compared between groups using inferential statistics as appropriate for the data. Multivariable linear regression analyses were used to assess the association of receiving a HBPM and BP change controlling for baseline BP and other confounders. Results: A total of 60 HBPM and 121 comparison patients were included. Mean (sd) baseline SBP did not differ between HBPM and comparison patients at 146 mmHg (26.0) and 147 mmHg (23.8) respectively, p = 0.858. Mean (sd) baseline DBP was lower in the HBPM group at 79 mmHg (13.5) vs 84 mmHg (12.5), p=0.013. SBP change from baseline was -13.7 mmHg (28.7) and -12.8 mmHg (26.2) (p = 0.832) while DBP change was -3.6 mmHg (12.7) versus -5.7 (14.2) (p = 0.346) in HBPM and comparison groups respectively. In multivariable analysis, the HBPM group had a significantly greater reduction in SBP at follow-up versus comparison patients (coefficient: -7.20 [95% CI -13.79, -0.62]). Conclusion: HBPM was a useful tool for maintaining or improving BP in underserved patients during COVID-19.

HYPERTENSION IN THE TIME OF COVID: PIVOTING TO AN ASYNCHRONOUS QI INTERVENTION FOR HOME BLOOD PRESSURE MONITORING

BACKGROUND: Hypertension (HTN) affects 29% of US adults, however in-office blood pressure (BP) readings are often inaccurate leading to clinical inertia. Repeating BP within 6 weeks leads to quicker control but patients and primary care practices have limited resources for frequent visits. Home blood pressure monitoring (HBPM) is accurate and convenient. In reviewing HTN burden at a suburban Maryland primary care practice, we found 19% of patients had an encounter BP >140/90, and a sample chart review estimated half were advised to self-monitor but lacked standardized follow up. We aimed to implement a quality improvement program to increase HBPM among our patients. METHODS: We engaged stakeholders (practice leadership, frontline staff) and content experts (HTN, patient engagement) to develop educational materials on HBPM and reporting results via the patient portal. We planned in office implementation, identifying patients with elevated BP during encounters and utilizing nurses to provide counseling. However, with COVID-19, we pivoted to asynchronous outreach and home delivery of BP cuffs. We developed messaging, delivered via the patient portal, for patients with uncontrolled HTN, controlled HTN, and elevated BP readings without HTN. Eligible patients, covered by a single insurance that provides reimbursement for BP cuffs, had HTN on their problem list and/or a BP >140/90 during an encounter between Jan-Oct 2020. For interested patients, we placed BP cuff orders and sent the educational materials. RESULTS: We identified 243 eligible patients who received outreach about HBPM;4 did not have patient portal access and received letters with no responses. Of the remaining 239 patients, 77% (N=183) read the electronic message and 43% (N=103) responded. Among responders, 81% (N=83) requested a cuff and 14% (N=14) reported having an up-to-date device. Among patients with a cuff, 18% (N=17) reported a BP reading to their primary care physician, with systolic and diastolic readings on average 11 and 6 mmHg lower, respectively, than the most recent in-office measurement. Initial review found some patients did not receive a cuff after the order resulting from delayed order processing and patients not scheduling delivery. CONCLUSIONS: Patients with elevated BP readings or HTN responded to messaging through the patient portal and were interested in receiving BP cuffs for HBPM. However, many patients did not report BP values after a device was ordered. Next steps include addressing barriers to delivery of the cuffs and incorporating follow up visits, including with our clinical pharmacist, to encourage reporting of HBPM. We will use lessons learned from this pilot to plan outreach and encourage self-monitoring during the COVID-19 era.

EFFECTS OF COVID-19 ON DIABETES AND HYPERTENSION MONITORING AND CONTROL IN PRIMARY CARE

BACKGROUND: Drops in chronic disease performance metric occurred during the COVID-19 pandemic in 2020. We evaluated changes in diabetes and hypertension disease control and disease non-assessment during the year prior and the initial year of COVID in a large group of Chicago-area primary care practices and evaluated factors associated with non-assessment. METHODS: Design: Retrospective observational studies of two cohorts, one with diabetes mellitus, and one with hypertension. Participants: Patients in the denominator for the medical group's performance measures for diabetes control or hypertension control on March 31, 2020 who also had continued contact with the health system (telephone, visit, medication refill, patient portal message) between April 1, 2020 and March 31, 2021. Main Measures: Diabetes not poorly controlled (HbA1C done in the past year and ≤9.0), diabetes cohort;Controlling High Blood Pressure (office blood pressure measured in the past 12 months and the most recent blood pressure was <140/90mmHg), hypertension cohort. Weexamined rates of poor control due to uncontrolled disease or lack of assessment. For patients with measurements in both the year preceding and the year following March 31, 2020, we calculated changes in HbA1C and weight (diabetes cohort) and systolic blood pressure and weight (hypertension cohort). RESULTS: In the diabetes cohort of 16,015, control was 78.0% in the year prior to March 31, 2020 and fell to 69.4% the following year. For the 57,346 patients in the hypertension cohort, the corresponding rates were 64.0% and 52.1%. For diabetes, 10.5% of the cohort had no HbA1C in the pre-COVID year and 22.0% had no HbA1C in the subsequent year. For hypertension, rates of non-assessment were 6.3% and 22.9%, respectively. Significant predictors of non-assessment in the first COVID year for diabetes and hypertension included younger age (18-49 year old, ORs 1.42, 1.11), having ≥ 1 telehealth visit (ORs 2.29, 7.82), and having ≥ 1 office visit (ORs 0.02, 0.005). Among diabetes patients who had HbA1C and weight measurements in both years, both declined?mean difference for HbA1C was -0.08 (95%CI -0.05 to -0.10) and weight -0.77 kg (CI -0.34 to -0.88). Among hypertension patients with blood pressure and weight measurements in both years, mean difference systolic blood pressure increased by 0.77 mmHg (CI 0.60 to 0.94) and weight decreased -0.30 kg (CI -0.25 to -0.35). CONCLUSIONS: During the first year of the COVID, many more patients with diabetes and hypertension did not have basic assessments of their disease control compared to the prior year, and type of visits (telehealth and office) was strongly associated with non-assessment. Among diabetes patients who were assessed there was no evidence of worsening disease HbA1C or weight. Systolic blood pressure increased slightly among hypertensive patients.

BLOOD PRESSURE MEASUREMENT AMONG PATIENTS WITH PERIPARTUM CARDIOMYOPATHY;CONTROL AND BARRIERS DURING FOLLOW UP

Objective: To identify the frequency of blood pressure (BP) control among patients with peripartum cardiomyopathy (PPCM), barriers for follow up, and causes for elevation of BP. Design and method: Data about BP values, control, follow up, and treatment were prospectively documented for patients with PPCM who were presented to the cardio-maternal unit between 2015 - 2020. Baseline BP values were compared with the second readings between six months to one year postpartum. Adherence to medication and identifying the causes of elevated BP were reported. Results: Among 64 patients with PPCM presented to the unit, loss of follow up reported in 59.4% of patients;60.5% for unknown cause, 21.1% due to COVID-19 pandemic, and 18.4 due to death. For 26 (40.6%) patients who adhered to follow up, the mean age was (32.5 ± 7), 61.5% patients had normal BP at baseline and during follow up, while 38.5% of them had elevated BP at baseline or during follow up (cutoff 140/90);30% showed reduced BP to normal values comparing to their baseline measurements, and 70% developed increased in BP values during follow up (Table 1). All patients with increased BP measurements during follow up had hypertension associated with pregnancy, however, only 28.6% of them had known history of hypertension before pregnancy. Most common anti-hypertensive drug used post delivery was angiotensin-converting enzyme inhibitors 77%. Causes for increased BP measurements during follow up were obesity 57.1%, stress 28.6%, and use of oral contraceptive pills 14.3%. Conclusions: Among patients with PPCM with elevated BP at baseline, control of BP was reported in less than one-third of the patients. However, data for more than half of the patients was missing due to loss of follow up which is related to COVID-19 pandemic or mortality, but for the majority of patients the cause was unknown. Factors associated with elevated BP were obesity, stress, and use of oral contraceptive pills. Therefore, future enhancement in patient education regarding the importance of follow up and life style modifications is essential for better BP control among patients with PPCM. (Figure Presented).

The Relationship Between Metabolic Syndrome and Acute Respiratory Distress Syndrome: An Ancillary Analysis of the ARDSNet and PETAL Databases

Rationale: Acute respiratory distress syndrome (ARDS) remains heterogeneous with continued difficulty discerning at-risk sub-phenotypes. Metabolic Syndrome (MetS), like ARDS, is a heterogeneous inflammatory state, commonly referred to as meta-inflammation, and is characterized by metabolic determinants of health including insulin resistance, obesity, dyslipidemia, and hypertension (HTN). Although some metabolic risk factors (e.g., obesity) are associated with ARDS, MetS has never been studied in non-COVID19 ARDS. Our objective was to determine the prevalence and risk associated with MetS among ARDS trial participants. We hypothesized MetS, identified by the clustering of obesity, HTN, and diabetes mellitus (DM), may be used to identify an ARDS sub-phenotype.Methods: An ancillary analysis of 4,708 subjects were reviewed from the ALTA, ALVEOLI, EDEN, FACTT, LaSRS, SAILS, and PETAL-ROSE trials recorded in the Biologic Specimen and Data Repository Information Coordinating Center (BioLINCC) database. MetS was classified by obesity (BMI > 30), history of diabetes, and history of hypertension or elevated blood pressure. Non-MetS patients were those without all three metabolic criteria. Cholesterol and hemoglobin A1c levels were not available and are a noted limitation. MetS prevalence, as well as each individual metabolic risk factor, was calculated across all studies. We compared 90-day mortality between patients with and without MetS as well as for each metabolic determinant of health. Complete case analysis was used to account for missing variables. Student's t-test and Pearson's chi-squared test were used for continuous and categorical variables, respectively. Multivariable logistic regression analyses included age, gender, and race, but further covariates are anticipated in future analyses.Results: Among 4,708 subjects enrolled across 7 studies, 4,406 were included in a complete dataset. There were 463 patients (9.8%) with MetS and 3,943 (89.5%) without. Prevalence of DM, HTN, and obesity were 23.8%, 42.2%, and 43.7%, respectively. Crude 90-day mortality rates were increased for subjects with DM (32.9% vs. 28.9%, p<0.05) and HTN (32.2% vs. 28.0%, p<0.01), but were decreased for subjects with obesity (27.7% vs. 31.4%, p<0.01). In adjusted analyses, 90-day mortality was significantly reduced for subjects with MetS as compared with non-MetS (adjusted odds ratio, 0.73 [95% CI 0.58-0.92], p<0.01).Conclusions: In preliminary analyses evaluating over 4,400 subjects from randomized controlled trials in ARDS, a MetS phenotype was associated with a significantly decreased risk of 90-day mortality when compared to ARDS patients without MetS. Metabolic determinants of health, in particular MetS, are understudied in critical illness and may provide insight to improve phenotyping characteristics.

Magnet-related foreign body aspiration in two children requiring thoracotomy: A concerning report

With the increase in use of smaller magnets in gadgets and toys at home, magnets pose a growing aspiration risk in children. We present two simultaneous cases of magnet-related foreign body aspiration (FBA) in two children, in two different cities: Karachi, and Lahore. They presented with similar signs and symptoms: tachypnea, tachycardia and asymmetric breath sounds on auscultation. They were initially diagnosed with the help of a chest X ray. Both the cases were complicated by failed bronchoscopy attempts due to the slippery texture of the magnet. Due to the failed bronchoscopy, both patients had a prolonged and complicated course including a 24–48 hour stay in the PICU prior to magnet removal. They eventually had to undergo thoracotomy for successful removal of the magnet. Both had an unremarkable post-operative course and were discharged in good health.

Gaisbock in 2021

Case Report The purpose of the study is to explore the possible diagnosis of Gaisbock in a patient with long-standing erythrocytosis and hypertension. Methods Used Case Study Summary of Results A 40-year-old Caucasian man with obesity was admitted with recurrent leg swelling and increasing oxygen requirements two weeks after hospitalization with COVID-19 pneumonia. Upon review of the patient's history, he was found to have untreated hypertension over several medical encounters and an erythrocytosis spanning ten years. Recent medical history included a diagnosis of deep vein thrombosis (DVT) in the same leg two and a half months prior and was treated with Xarelto. The patient reported a history of low testosterone for 12 years. However, he had not used any testosterone supplementation for the last nine months. He reported daytime fatigue, frequent bouts of nighttime awakenings, and frequent snoring. The patient never had a sleep study or used a CPAP. The patient used half a can of chewing tobacco daily for thirteen years, and he smoked one pack per day for ten years but quit 12 years ago. He worked strenuous jobs in the construction industry most of his life. On this admission, the patient's lab work was notable for hemoglobin of 18.7 gm/dL (13.7-17.5) and a normal erythropoietin level of 5.7 MIU/mL (2.6-18.5) without thrombocytosis or leukocytosis and a positive factor V Leiden mutation. His blood pressure was 132/91 mmHg. On review of previous records, the patient was found to have consistently elevated hemoglobin The patient had a stocky, ruddy appearance without hepatosplenomegaly. Conclusion Erythrocytosis can be categorized as primary, secondary, or relative. Patients with relative erythrocytosis have a decreased plasma volume with a relative increase in hemoglobin. Additionally, elevated hemoglobin levels have been associated with hypertension. Gaisbock's syndrome, first described in 1905, is characterized by hypertension and erythrocytosis without splenomegaly, leukocytosis, or thrombocytosis. It is associated with mild obesity, elevated blood pressure, and increased blood viscosity, which may explain why these patients often develop cardiovascular complications. Patients with relative erythrocytosis are at a higher risk for thromboembolic complications. In this case, Gaisbock's syndrome was suspected because the patient had had a stocky, plethoric appearance with persistently elevated hemoglobin and blood pressure with a normal erythropoietin level. Gaisbock's syndrome establishes a relationship between benign erythrocytosis, hypertension, and an increased risk for cardiovascular events. (Table Presented).

COVID-19 Vaccination in Adults with Immune Thrombocytopenia (ITP): Data from the Platelet Disorder Support Association (PDSA) Patient Registry

[Formula presented] BACKGROUND AND AIMS Immune thrombocytopenia (ITP) is an autoimmune bleeding disorder causing low platelet counts (PC) and increased bleeding. COVID-19 vaccines are a major concern for ITP patients who fear vaccination might exacerbate their thrombocytopenia. To assess these concerns, PDSA developed a survey to explore how COVID-19 vaccinations impact individuals with ITP. Methods Data was collected using the ITP-COVID-19 web-based survey part of the Platelet Disorder Support Association's ITP Natural History Study. As of June 2021, 338 adult ITP patients had completed the survey. Data was analyzed with descriptive statistics and chi-squared tests. Results The majority of the 338 participants were female (78%) between 18-64 years of age (83%);118 (35%) participants reported they were in remission, and 79 (24%) reported they had undergone splenectomy. Viral Disease: Forty participants (12%) were diagnosed with COVID-19: 7 (18%) reported their PC increased from baseline, 20 (50%) reported their PC was unaffected, and 13 (32%) reported their PC decreased. Of the 20 participants who reported a PC change (increase or decrease) following a positive COVID-19 test, 13 (65%) reported their PC returned to baseline within four weeks following vaccination. Four patients (10%), all between the ages of 41-50 years, were hospitalized: 2 received dexamethasone, 1 received IVIG, and 1 required oxygen. Two of the 4 had been treated for ITP with corticosteroids within the last 6 months. Three out of 4 were female, and no additional autoimmune conditions were reported however, and 2 out of 4 reported co-morbid conditions including increased blood pressure, under-active thyroid, and allergies. No deaths occurred. Vaccination impacts: 267 (79%) participants reported receiving at least one vaccine dose at survey completion, and 137 (41%) of participants reported they were fully vaccinated: Pfizer (45%), Moderna (38%), other (17%). Following at least one vaccine dose, platelet increases were reported by 37 (15%), 127 (53%) reported no change, and decreases were reported by 77 (32%);26 did not answer. Of the 114 participants who reported a PC change following dose 1 (D1), 82 addressed the time for their PC to return to baseline;69 (84%) reported their PC returned to baseline within four weeks. Following dose two (D2), PC increases were reported by 18 (13%), 82 (60%) were unchanged, and 37 (27%) saw a decrease. Of 55 participants who reported a PC change following D2, 44 addressed the time for their PC to return to baseline with 31(71%) indicating their PC returned to their normal within four weeks. Changes in PC following receipt of D1 vs D2 were not statistically significantly (X 2=1.01, p=.31). Following at least D1, three participants reported bleeding symptoms including epistaxis, wet purpura, petechiae, bruising, and a gastrointestinal internal bleed in an asplenic 64-year-old female with alpha-gal allergy. Twenty-four (9%) participants of 262 who answered the question, reported adverse effects other than bleeding including chills and fever. Two women, aged 35 and 47, developed a blood clot after receiving the Pfizer vaccine, despite reporting no past personal or family history of hypercoagulability. Fourteen participants (13 females;1 male) reported platelet decreases >100,000/µL following vaccination, but only one received rescue treatment. Two had a pre-existing autoimmune disorder and eight a previous splenectomy. Eight received the Pfizer vaccine, five Moderna, and one AstraZeneca. Thirty (21%) participants reported a past change in platelets following a non-COVID vaccine;23/30 shared their experience following receipt of D1 of a COVID-19 vaccine including 11 (48%) who experienced a platelet decrease, 4(17%) an increase, and 8 (35%) reporting no change. Conclusion The results are very reassuring for ITP patients that the risks of aggravated thrombocytopenia due specifically to getting COVID-19 infection or vaccine are small. There were only three cases of bleeding and two of clotting;all were well-treate . Decreases in PC following viral infection and vaccine receipt did occur, but they were rarely substantial and most resolved within four weeks. These very positive findings should reduce vaccine hesitancy among ITP patients and encourage them to be vaccinated. Disclosures: MacWhirter - DiRaimo: JD has not personally received any payment personally, but PDSA has received grants and consultancy fees from Novartis, grant and honorarium from Amgen, grant and consultancy fees from Pfizer and UCB, and grants from Argenx, Principia, Rigel, and CSL Behr: Consultancy, Honoraria, Other. Kruse: CK has not personally received payment but reports that PDSA received grants and consultancy fees from Novartis, grant and honorarium from Amgen, grant and consultancy fees from Pfizer and UCB, and grants from Argenx, Principia, Rigel, and CSL Behring: Consultancy, Honoraria, Other. Bussel: UCB: Consultancy, Membership on an entity's Board of Directors or advisory committees, Other: DSMB;CSL: Other: DSMB;Momenta/Janssen: Consultancy, Membership on an entity's Board of Directors or advisory committees;Amgen: Consultancy, Membership on an entity's Board of Directors or advisory committees;Novartis: Consultancy, Membership on an entity's Board of Directors or advisory committees;Argenx: Consultancy, Membership on an entity's Board of Directors or advisory committees;UptoDate: Honoraria;Principia/Sanofi: Consultancy, Membership on an entity's Board of Directors or advisory committees;Rigel: Consultancy, Membership on an entity's Board of Directors or advisory committees;Dova/Sobi: Consultancy, Membership on an entity's Board of Directors or advisory committees;RallyBio: Consultancy, Membership on an entity's Board of Directors or advisory committees. Kruse: Alex has not personally received any payment but reports that PDSA received grants and consultancy fees from Novartis, grant and honorarium from Amgen, grant and consultancy fees from Pfizer and UCB, and grants from Argenx, Principia, Rigel, and CSL Behri: Consultancy, Honoraria, Other.