BEYOND RESPONSE: REIMAGINING THE LEGAL ACADEMY'S ROLE IN DISASTER RECOVERY AND PREPAREDNESS

This Article proposes expanding the legal academy's role in responding to disasters and emergencies, specifically through creating disaster clinics that take a communitybased lawyering approach. The Article is one of the first to identify the need for community-based disaster legal clinical education that goes beyond the immediate response phase. It also proposes creating a disaster legal pipeline from the clinic through post-graduation employment. The Article furthers the literature's discussion of the need for sustained disaster legal education. As the global pandemic caused by COVID-19 coronavirus continues to impact vulnerable populations and the frequency of natural disasters continues to increase, this Article provides a blueprint to law school faculty and administrators on the process of starting a new clinic or redesigning an existing clinic into a long-term disaster-related clinic. Additionally, the Article provides a timeline of disaster legislation that has evolved to provide a robust background for seminar courses. The Article draws from the author's expertise in creating two disaster clinics and multiple disaster and environmental justice courses. © 2023,Cleveland State Law Review. All Rights Reserved.

Skin and Bones: Pushing the Event Horizon

Architect Alexis Rochas, founder of Stereobot, has a history of producing spectacular light shows and urban interventions using space-frame technology. Art and architecture writer Eva Menuhin records the firm's creative trajectory and further explores their recent developments, using the same techniques, that can provide homes for those hit by disaster, whether financial or physical, or both. Copyright © 2023 John Wiley & Sons, Ltd.

Predictive Value of Specific Cytokines for Lethal Covid-19 Outcome

In our study, we aimed to evaluate the significance of specific cytokines in blood plasma as predictive markers of COVID-associated mortality. Materials and methods. In plasma samples of 29 patients with PCR-confirmed COVID-19 we measured the concentrations of 47 molecules. These molecules included: interleukins and selected pro-inflammatory cytokines (IL-1alpha, IL-1beta, IL-2, IL-3, IL-4, IL-5, IL-6, IL-7, IL-9, IL-12 (p40), IL-12 (p70), IL-13, IL-15, IL-17A/CTLA8, IL-17-E/IL-25, IL-17F, IL-18, IL-22, IL-27, IFNalpha2, IFNgamma, TNFalpha, TNFbeta/Lymphotoxin-alpha(LTA));chemokines (CCL2/MCP-1, CCL3/MIP-1alpha, CCL4/MIP-1beta, CCL7/MCP-3, CCL11/Eotaxin, CCL22/MDC, CXCL1/GROalpha, CXCL8/IL-8, CXCL9/MIG, CXCL10/IP-10, CX3CL1/Fractalkine);anti-inflammatory cytokines (IL-1Ra, IL-10);growth factors (EGF, FGF-2/FGF-basic, Flt-3 Ligand, G-CSF, M-CSF, GM-CSF, PDGF-AA, PDGFAB/BB, TGFalpha, VEGF-A);and sCD40L. We used multiplex analysis based on xMAP technology (Luminex, USA) using Luminex MagPix. As controls, we used plasma samples of 20 healthy individuals. Based on the results, we applied Receiver Operating Characteristic (ROC) analysis and Area Under Curve (AUC) values to compare two different predictive tests and to choose the optimal division point for disease outcome (survivors/non-survivors). To find optimal biomarker combinations, we as used cytokines concentrations as dependent variables to grow a regression tree using JMP 16 Software.Results. Out of 47 studied cytokines/chemokines/growth factors, we picked four pro-inflammatory cytokines as having high significance in evaluation of COVID-19 outcome: IL-6, IL-8, IL-15, and IL-18. Based on the results received, we assume that the highest significance in terms of predicting the outcome of acute COVID-19 belongs to IL-6 and IL-18. Conclusion. Analyzing concentrations of IL-6 and IL-18 before administering treatment may prove valuable in terms of outcome prognosis. Copyright © Arsentieva N.A. et al., 2022.

Definitive Management of Cervical Cancer Patients at an Urban Institution During the COVID-19 Pandemic - Brachytherapy Treatment During the Surge

Purpose: Locally advanced cervical cancer was defined by an international consensus panel as a high priority malignancy during the COVID-19 pandemic, recommending prompt initiation of definitive treatment and completion of treatment (PMID 32563593). The objective of this study was to study the clinical outcomes of patients (pts) with cervical cancer treated with definitive chemoradiation (CRT) and brachytherapy (BT) at our institution in 2019 (pre-COVID) and in 2020 (peri-COVID). Material(s) and Method(s): This was a retrospective cohort study of pts with FIGO Stage IB2-IVA cervical cancer at our institutions from 1/1/2019 to 12/31/2020. Pts received CRT followed by intracavitary brachytherapy (IC) with two operative insertions one week apart, or interstitial (IS) BT with one operative insertion. BT treatment was planned using image-guided CT or MR delineation. Pre-COVID was defined by initiation of CRT in 1/2019-12/2019, and peri-COVID was defined by initiation in 1/2020-10/2020. Process changes peri-COVID included limited on-site staff (e.g., minimal OR staff, no trainees, remote physics team), universal implementation of COVID-19 testing prior to surgery, and CT instead of MR-delineation based treatment. Outcomes of interest were time to treatment initiation and completion and differences in treatment planning modality or dosimetry. Fisher's exact and Mann Whitney U tests were used with significance p<0.05. Result(s): Thirty-one pts were included, with 18 patients undergoing treatment pre-COVID and 13 peri-COVID. The median age at diagnosis pre-COVID was 57.7 (range 23-77) and for peri-COVID, 45.5 (range 28-62, p=0.06). There were no differences in non-English speaking pts (44% vs 59%, p=0.71) or uninsured pts (11% vs 33%, p=0.184) between the two cohorts. Median time to initiation of treatment from biopsy diagnosis was 52 days (range 13-209) in 2019 and for peri-COVID, 55.5 (range 20-173, p=0.71). During COVID, four pts had delayed initiation to treatment >100 days: two related to fertility, and one due to fear of COVID-19. For this pt, tumor size progressed from 2.3 cm to 4.2 cm maximal dimension. One pt treated in 2020 tested positive following treatment and did not require hospital admission. All pts except one completed CRT with RT: 25 pts pelvic RT (45 Gy), 3 pelvic and para-aortic RT (45 Gy with 57.5 Gy concomitant boost to nodes), 8 pts pelvic RT (45Gy) with sequential parametrial boost (50.4-59.4 Gy) using IMRT with no dose differences between pre and peri-COVID (Table 1). No pts required treatment breaks and the median overall treatment time was 50 days (range 31-85) in 2019 vs 50 days (range 43-63) in 2020 (p=0.710). Conclusion(s): Despite the significant burden of the COVID-19 pandemic on our health care system, all cervical cancer pts receiving CRT met standard of care including CRT and BT within the recommended time frame with no significant differences in dosimetric treatment parameters pre- and peri-COVID. Delays in treatment initiation of treatment initiation were seen in 30% of pts in the peri-COVID period, suggesting that patients may have had increased barriers to access care. More follow-up is needed to determine how the Covid pandemic impacted cervical cancer outcome measures. Copyright © 2022

NOVEL CORONAVIRUS INFECTION IN THE FIRST TRIMESTER OF PREGNANCY: PERINATAL AND MATERNAL OUTCOMES

Objective: To investigate the characteristic features of the course of pregnancy, labor, and perinatal outcomes in women who had a new coronavirus disease 2019 (COVID-19) in the first trimester of pregnancy. Material(s) and Method(s): The first stage of the study consisted of a retrospective analysis of the COVID-19 registry of pregnant and postpartum women from the Ural Federal District (UFD) for 2020-2021. A total of2347patients had COVID-19 in the first trimester of pregnancy in the UFD in 2020-2021. The second stage of the study was a single center cross-sectional comparative study in two independent groups. The study group included 131 patients who had COVID-19 in the first trimester of pregnancy;the comparison group comprised 216 patients who gave birth before COVID-19 pandemic (2019). The analysis included the course of pregnancy, labor and delivery, neonatal health status, and histological examination of 10placentas of women in the study group. Result(s): Pregnancy was terminated in 19.4% of patients who developed severe COVID-19 in the first trimester. Spontaneous miscarriages were registered in 9.2% of the women with mild and moderate COVID-19. In two cases in patients who had COVID-19 before 6 weeks, fetal malformations were detected that were incompatible with life, which are extremely rare in the population. COVID-19 in the first trimester of pregnancy increased the risk of gestational hypertension (OR=3.3;95% CI 1.6-6.6;p<0.001) and threatened preterm birth (OR=3.4;95% CI 1.4-8.0;p=0.004). The mean gestational age at delivery was significantly lower [38.4 (2.0), p<0.001] than in patients who gave birth before the COVID-19 pandemic. The newborns showed a significant decrease in anthropometric parameters and Apgar scores at 1 [7 (6:8), p=0.035] and 5 [8 (7:8), p<0.001] minutes compared to the newborns of the comparison group. At the same time, there were signs of both maternal and fetal blood flow abnormalities in the placenta. Conclusion(s): Women who had COVID-19 in the first trimester of pregnancy may be at increased risk of adverse perinatal and maternal outcomes. Copyright © A group of authors, 2022.

Retrospective Analysis of Quantitative Faecal Immunochemical Testing (Qfit) Levels in Colorectal Malignancy during the Covid-19 Pandemic, and Correlations between Qfit Value and Site of Neoplasia

Aim: Routine endoscopic services were significantly reduced in response to the COVID-19 pandemic. As a response, two-week- wait referral for patients with rectal bleeding suspicious of colorectal cancer, incorporated qFIT as a tool to identify patients that may require further investigation. This study aimed to analyse the accuracy and sensitivity of qFIT as a tool to identity malignant colorectal neoplasia. Correlations between qFIT, anatomical site of neoplasia and haemoglobin status (Hb) was similarly considered. Method(s): Participants were included if they had confirmed colorectal adenocarcinoma or adenoma detected via the two-week- wait referral system alongside a qFIT score. A qFIT score of >=10mg/g was interpreted as positive. Exclusion criteria included anal cancers, neuroendocrine cancers, small bowel tumours and participants without a qFIT level. Participants with polyps and confirmed rectal, sigmoid and/or colonic cancer were included. Haemoglobin level at diagnosis, colonoscopy report and histological outcomes were analysed. Result(s): 3664 patients were referred in on the two-week- wait pathway in 2020. Of these 372 (10%) were coded as having a gastrointestinal tumour or polyp cancer diagnosis. 119 (32%) of participants fulfilled the criteria to be amenable for review. Of these 10 (8.4%) participants only had a polyp, while 109 (91.6%) participants had colorectal adenocarincoma +/-polyps. A total of 12 (11%) participants with colorectal adenocarcinoma had a qFIT level of <=10mg/g, with 2 (16%) of these having concurrent anaemia. There was no demonstratable level of qFIT that correlated with right versus left sided colonic tumours. Conclusion(s): Symptomatic patients with a qFIT of >=10mg/g should undergo further investigation for malignant colorectal neoplasia. This study found that qFIT did not reliably predict the site of neoplasia. A qFIT of <=10mg/g was present in 11% of participants with colorectal adenocarcinomas and is therefore not a sensitive tool in excluding colorectal neoplasia.

Ocular Evaluation of Newborns Whose Mother Died Due to Sars-Cov-2 (Covid-19) Infection

BACKGROUND AND AIM: In the pregnancies of severe SARS-CoV-2, which resulted in maternal death, the fetus is more vulnarable in terms of being affected by systemic complications. The aim of this study is to evaluate the ocular findings of newborns whose mothers passed away due to SARS-CoV-2, by considering possible different modes of involvement. METHOD(S): Single-center retrospective observational study. A total of 9 newborns were evaluated ophthalmologically. Demographic data, polymerase chain reaction(PCR) test results and ophthalmological findings were collected. RESULT(S): Gestational age at ranged from 27 to 37 weeks (mean 31,55 +/- 3,16 weeks), and the birth weights varied from 990 g to 2160 g (mean 1481+/-397g). Mean ICU stay was 28.7 days. Positive PCR was positive for SARS-CoV-2 in 2 newborns.Ocular examination was performed within the first 30 days. Neonatal conjunctivitis (n=2), corneal edema (n=1), retinopathy of prematurity (ROP) (n=6) (treatment requiring ROP n=3) and intraretinal bleeding(n=2)was observed.One of the babies with a positive result had ROP that did not require treatment, and the other had conjunctivitis with intraretinal hemorrhage. CONCLUSION(S): Despite numerous studies, the impact of SARS-CoV-2 on the fetus remains unclear in many ways. Case reports indicate that maternal-fetal vertical transmission is not common.Exposure to intrauterine inflammation and placental changes may cause multisystemic problems in the neonatal period in exposed infants.The need for intensive care in the mother increases the possibility of fetal vascular malperfusion, premature birth rate and related problems.The detected ocular pathologies are not specific to SARS-CoV-2 infection.Additional controlled studies are required to correlate the findings with the disease. (Figure Presented).

An Epidemiologic and Racial Disparity Evaluation of Continuous Infusion Sedation in the Icu

INTRODUCTION: Sedative medications are frequently utilized to relieve stress and anxiety, control agitation, and/or improve ventilator synchrony in patients requiring mechanical ventilation. However, many sedative agents have the potential to cause short- and long-term harm. Observational data have described associations between race and negative outcomes in patients with sepsis. It is unclear if race is associated with sedation administration practices. The purpose of this study was to investigate whether Black race is associated with differences in exposure to continuous infusion sedatives compared to White race. METHOD(S): A single-center, retrospective, cohort study was performed in adult patients admitted to the medical or surgical intensive care unit (ICU) with community-onset sepsis between June 1, 2018 and June 1, 2021. Data were collected from the electronic health record. The primary outcome was the cumulative dose of fentanyl received by continuous infusion between day 1-14 of ICU admission. The cumulative doses of other continuous infusion sedatives were described as secondary outcomes. A linear regression model assessed the association of race and the primary outcome while controlling for relevant confounding variables. RESULT(S): 772 patients were included. Black patients had a higher median modified APACHE II score (18 vs. 17, p< 0.001), Charlson Comorbidity Index (4 vs. 3, p=0.003), COVID-19 diagnosis incidence (18.5% vs. 7.1%, p< 0.001), and renal disease incidence (44.9% vs. 27.8%, p< 0.001) at baseline. No difference was observed in the amount of fentanyl received by continuous infusion between day 1-14 of ICU admission between Black and White patients (7085 mcg vs. 6426 mcg, p=0.37). Similarly, no association between Black race and the total amount of propofol (p=0.65), dexmedetomidine (p=0.67), or midazolam (p=0.08) via continuous infusion was observed. A linear regression model observed no significant association between race and the primary outcome. CONCLUSION(S): Black race was not associated with increased exposure to continuous infusion sedatives compared to White race. This is the first known study to investigate racial disparities in sedation strategies in mechanically ventilated adults in the ICU with sepsis.

Impact of the COVID-19 Pandemic on Healthcare-Associated Infections (HAI) by Race and Ethnicity in a Large Network of Community Hospitals: A Call to Action

Background. Inequities in healthcare among racial and ethnic minorities are globally recognized. The focus has centered on access to healthcare, equitable treatment, and optimizing outcomes. However, there has been relatively little investigation into potential racial and ethnic disparities in HAI. Methods. We performed a retrospective cohort analysis of select HAI prospectively-collected by a network of community hospitals in the southeastern US, including central line-associated bloodstream infection (CLABSI), catheterassociated urinary tract infection (CAUTI), and laboratory-identified Clostridioides difficile infection (CDI). Outcomes were stratified by race/ethnicity as captured in the electronic medical record. We defined the pre-pandemic period from 1/1/2019 to 2/29/2020 and the pandemic period from 3/1/2020 to 6/30/2021. Outcomes were reported by race/ethnicity as a proportion of the total events. Relative rates were compared using Poisson regression. Results. Overall, relatively few facilities consistently collect race/ethnicity information in surveillance databases within this hospital network (< 40%). Among 21 reporting hospitals, a greater proportion of CLABSI occurred in Black patients relative toWhite patients in both study periods (pre-pandemic, 49% vs 38%;during pandemic, 47% vs 31%;respectively, Figure 1a), while a higher proportion of CAUTI and CDI occurred in White patients (Figures 1b-c). Black patients had a 30% higher likelihood of CLABSI than White patients in the pre-COVID period (RR, 1.30;95% CI, 0.83-2.05), which was not statistically significant (Table 1). However, this risk significantly increased to 51% after the start of the pandemic (RR, 1.51;95% CI, 1.02-2.24). Similar trends were not observed in other HAI (Tables 2-3). Conclusion. We found differences in HAI rates by race/ethnicity in a network of community hospitals. Black patients had higher likelihood of CLABSI, and this likelihood increased during the pandemic. Patient safety events, including HAI, may differ across racial and ethnic groups and negatively impact health outcomes. (Figure Presented).

Invasive fungal disease in patients with severe COVID-19 infection at a midwestern academic medical center

Background. Invasive fungal diseases (IFD) have been described in patients (pts) with severe coronavirus disease 2019 (COVID), albeit with geographic variability in rates. Methods. We performed a retrospective study to determine rates of & risk factors for IFD occurring within 30 days (d) of COVID diagnosis (dx) in adults requiring critical care for severe COVID between 5/11/20 & 2/7/21. Mortality was assessed at 90 d following COVID dx and at 84 d after IFD dx, if applicable. ECMM/ISHAM criteria were used for COVID-associated pulmonary aspergillosis (CAPA) and EORTC/ MSGERC criteria were used for other IFD and treatment response. Results. 218 pts were included;median age was 62 (19 - 91) & 63% were men. Underlying conditions included solid organ transplant (Tx) (16;7%), allogenic stem cell Tx (3;1%), malignancy (21;10%), & exposure to either high-dose steroids (HDS) (11;5%) or T- or B-cell suppressants (29;13%) within 90 d prior to COVID dx. 209 (96%) pts had respiratory failure & 127 (58%) required mechanical ventilation. 15 (7%) required extracorporeal membrane oxygenation. COVID treatment consisted of corticosteroids in 205 (96%) & tocilizumab in 10 (5%). 12 (6%) pts developed IFD. 6 pts had CAPA (2 probable, 4 possible);50% were men, median age 64.5 (48 - 83). Mean time to CAPA dx from COVID dx was 17 d (+/- 14d). All pts had received corticosteroids for COVID but only 1 pt received > 30d of HDS by the time of IFD dx. Mortality at 84 d from CAPA dx was 67%. 5 (2%) pts had central venous catheter associated candidemia;80% were men & median age 61 (55 - 77). Mean time from COVID to candidemia dx was 29 d (+/-12 d). All pts with Candida infection had received steroids for COVID. Mortality at 84 d from candidemia dx was 60%. A 35-year-old man with prolonged exposure to HDS had Paecilomyces pneumonia;he was alive at 84 d after IFD dx. No cases of mucormycosis were identified. All-cause mortality in the entire cohort was 38% at 90 d after COVID dx. Mortality among pts who developed IFD was 58% at the same time point. Conclusion. Rates of IFD in pts with severe COVID were low and most pts with IFD after COVID had CAPA or catheter-associated candidemia. All but one pt with CAPA had no risk factors for IFD. In pts with severe COVID, mortality was higher among pts who developed IFD than those who did not.

Epidemiology and Antimicrobial Treatment Impact of Procalcitonin in Patients with COVID-19

Background. Procalcitonin (PCT) is often measured in patients with signs of bacterial infection. PCT is often elevated in bacterial pneumonia and septic shock and usually low in viral infections. Recent studies have found a correlation between PCT and disease severity in COVID-19, and most patients receive antibiotics despite bacterial co-infection being rare. We sought to characterize PCT trends in COVID-19, assess its relation to bacterial pneumonia, and assess its relation to clinical decision making around antimicrobial use. Methods. We included patients >=18 hospitalized at Michigan Medicine (3/1/20- 10/31/21), positive for COVID-19, with >= 1 PCT measurement. Structured query was used to retrospectively extract data. Patients started on an antibiotic underwent retrospective chart review by 2 reviewers for presence of bacterial pneumonia (bPNA), and were classified as having proven, probable, possible, or no bPNA (Figure 1). Multivariable models controlling for time from start of the pandemic, demographics, and comorbidities were used to determine associations of PCT and bPNA with antimicrobial use. Figure 1: Flow diagram of patients included in analyses Results. 793 patients met inclusion criteria, with 224 (28.2%) initiated on antibiotics. Of these 224, 33 (14.7%) had proven/probable bPNA, 125 (55.8%) had possible bPNA, and 66 (29.5%) had no bPNA. On average, patients had 2.6 +/-3.7 (mean +/-SD) PCT measurements, with 4.1 +/-5.2 if on antibiotics vs. 2.0 +/-2.6 if not. Initial PCT was higher in those on antibiotics and highest in those with proven/probable bPNA (Table 1). After adjustment for confounders, initial PCT was associated with antibiotic initiation (OR 1.68, 95% CI 1.47-1.91, p < 0.0001) (Table 2). Initial PCT (RR 1.11, 95% CI 1.03-1.20, p=0.008), change in PCT over time (RR 1.03, 95% CI 1.01-1.05, p=0.007), and bPNA category (RR 1.51, 95% CI 1.23-1.84, p < 0.0001) were associated with antibiotic duration (Table 3). Conclusion. PCT was elevated in patients with COVID-19, but more pronounced with bPNA. Antibiotics were started in > 25% of patients, regardless of bPNA. PCT trends associate with the decision to initiate antibiotics and treatment duration, independent of bPNA and comorbidities. Future prospective studies should determine if PCT can be used to safely make decisions around antibiotic treatment for bacterial infection during COVID-19.

Bacterial Co-infection and Empirical Antibiotic Therapy in Patients with COVID-19

Background. Understanding the rate and composition of bacterial co-infection is important to determine antibiotic therapy in SARS-CoV-2 infection, but those vary according to healthcare settings and regional differences. We evaluated the rate of bacterial co-infection in hospitalized patients with COVID-19 in a single tertiary hospital in South Korea. Methods. In this retrospective study, all the adult patients with COVID-19 hospitalized between Feb 2020 and Dec 2021 were included. Bacterial co-infection rate was assessed by results of sputum cultures, blood cultures, pneumococcal urinary antigen, Legionella urinary antigen, sputum Legionella pneumophilia PCR, and sputum multiplex PCR for Mycoplasma pneumoniae and Chlamydia pneumoniae. Characteristics and outcomes of patients were evaluated according to antibiotics exposure prior to hospitalization. Results. Of 367 adult patients, 300 (81.7%) patients having sputum culture results were included in the analysis. Of these, 127 (42.3%) had a history of antibiotic exposure within 1 month before hospitalization. The coinfection rate within 48 hours of hospitalization was confirmed in 8.3% (25/300): 6.4% (11/163) of patients without prior antibiotic exposure and 11% (14/127) of patients with prior antibiotic exposure. In the group without prior antibiotic exposure, pathogens responsible for community-onset infections were isolated, whereas nosocomial pathogens were predominantly isolated in the antibiotic-exposed group. Empirical antibiotics were used in 144 (66%) of 275 patients without positive results for microbiological tests. Empirical antibiotic use in patients without positive results for microbiological tests was not significantly associated with 30-day mortality or in-hospital mortality after adjusting covariates including age, sex, comorbidity, anti-inflammatory treatment, and COVID-19 severity. Conclusion. In this study with a high rate of microbiological testing, bacterial coinfection was not frequent, and the results varied depended on previous exposure to antibiotics. Given the rarity of bacterial co-infection and the lack of potential benefits of empirical antibiotic therapy, the antibiotic use in patients with COVID-19 should be restricted as an important target of antibiotic stewardship. (Table Presented).

Angiotensin-converting Enzyme 2 Expression Increased in Ischemic Myoblasts as a Response to Impaired Hypoxic Response

Background: Angiotensin-converting enzyme 2 (ACE2), the pulmonary epithelial receptor for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), plays a significant role in attenuating muscle fibrosis in dystrophic muscle models. Evidence suggests ACE2 is downregulated in prolonged hypoxia by hypoxia-inducible factor 1-alpha (HIF1-alpha). We hypothesize that myoblasts affected by chronic ischemia would have attenuated ACE2 expression, potentially modifying the detection of and response to SARS-CoV-2 infection in muscle tissue. This holds an important impact for peripheral arterial disease (PAD) patients who are also at risk for severe coronavirus disease 2019 (COVID) infection based on age. Method(s): Cells were harvested from ischemic and perfused muscle during lower extremity amputations and bypasses in PAD patients. Myoblasts (Pax7-/MyoD+) were isolated using preplating technique and cell sorting. Commercially available healthy donors myoblasts (PAD-) were purchased (Cook MyoSite). All experiments were performed in normoxic (20% O2) and hypoxic (1% O2) conditions. ACE2 expression was quantified via immunofluorescence staining after five days differentiation. HIF1-alpha ELISAs (Elabscience) were performed on cell lysates after 24 hours of proliferation. Cell lysis in response to exposure to COVID spike protein (RayBiotech) was assessed using lactate dehydrogenase assays (Invitrogen). Analysis of variance with post hoc analysis confirmed statistical significance (alpha = 0.05). Result(s): Hypoxia exposure induced significant increase in HIF1-alpha expression in perfused myoblasts (P <.05). Hypoxia also increased ACE2 expression in ischemic (n = 6) compared to perfused (PAD-, n = 2;perfused PAD, n = 5) (P <.05) myoblasts (Figure, A). Lactate dehydrogenase concentration suggestive of cell lysis and cytotoxicity was higher in perfused than ischemic myoblasts. Myoblasts from perfused muscle also had higher cell lysis from COVID spike protein exposure while ischemic cells exposed to COVID spike proteins seemed to survive (Figure, B). Conclusion(s): Chronically ischemic myoblasts from PAD muscle increased ACE2 expression in response to additional hypoxia. This may suggest greater susceptibility of ischemic muscle to SARS-CoV-2 effects in the setting of additional hypoxic insults like pneumonia. While cytotoxicity was not a feature of spike protein exposure in ischemic PAD cells, this might suggest cell survival in the setting of viral infection, which is unfavorable. Further research is needed to understand whether cell survival mechanisms exist in PAD myoblasts exposed to COVID infection. [Formula presented] Copyright © 2022

Determinants of sexual dysfunction in women recovered from COVID-19

Introduction: While several studies have assessed the impact of the COVID-19 pandemic on sexuality and sexual behavior in the general population, very few studies have assessed sexuality in patients recovered from Sars-Cov 2 infection. Objective(s): The objectives of our study were to assess factors associated with sexuality dysfunction in women recovered from covid-19. Method(s): This is a case-control study. The women in the case group have been infected with Sars-Cov 2, and cured for one to two months at the time of the study, women in the control group have not been infected with Sars-Cov 2. We assessed depression, anxiety, post-traumatic stress disorder (PTSD) and sexuality in both groups using the Beck Depression Inventory (BDI), the Coronavirus Anxiety Scale (CAS), the Post traumatic stress disorder Checklist Scale (PCLS) and the Female Sexual Function Index (FSFI). Result(s): In total, we recruited 30 women in the case group and 30 women in the control group. An FSFI score <26.55 and corresponding to impaired sexual function was found in 63.33% of women in the case group versus 53.33% of women in the control group (p=0.009). Factors influencing sexual activity were depression (OR = 17.86, CI95% = [1.1-290.12]) and PTSD (OR = 18.51, CI95% = [1.43-240.30]). Conclusion(s): Depression and PTSD are significantly associated with sexual dysfunction in women recovered from COVID-19, even in mild or pauci-symptomatic clinical forms.

Treatment Seeking Behavior among Post-COVID-19 Patients in Bangladesh

The COVID-19 pandemic continues its devastating reign over the world, and Making effective strategies for determining and containing the virus has grown more crucial. Although developed nations can effectively control the spread and severity of the pandemic, less developed countries have difficulty implementing similar measures because of various issues such as understanding, attitudes, and behaviour for covid-19 intervention. Similarly, Bangladesh experience challenges in executing contagious virus management due to different intervention seeking knowledge and behaviour. This study explored the intervention-seeking behaviour of the Covid-19 treatment protocol who recovered from this deadly virus in Bangladesh. This quantitative study adopted a cross-sectional design, whereas a convenient sampling approach was utilized to collect data from 54 adult residents of Rajshahi and Chittagong in Bangladesh and conducted face-to-face or telephone-based depth interviews. Among 54 participants, males were n=40 (74.1%), and their mean age was 42.02 years. Common symptoms were cold n=12 (22.2%), fatigue n=8 (14.8%), fever n=7 (13%), coughing n=4 (7.4%) due to COVID-19 infection. The maximum isolation length was 8-14 days, n=30 (55.6%), and the mean was 15.24 days. Regarding intervention, Medicine was prescribed among n=35 (64.8%), and only n=2 (3.7%) received respiratory physiotherapy;home remedies n=25 (46.3%). While using Medicine, n=22 (40.7%) was highly concerning treatment behaviour among people with recovered from Covid-19. Medicine-taking is a popular and convenient method for intervention-seeking behaviour among people affected by Covid-19 in Bangladesh. The finding suggests that combating the covid-19 pandemic requires education and awareness about treatment-taking behaviour because only Medicine cannot decline the negative health impact of post-covid-19. Besides, proper rehabilitation is crucial in promoting the quality of life of the person with post-covid-19. Copyright © 2022, Anka Publishers. All rights reserved.

The ENDORSE feasibility pre-pilot trial: Assessing an innovative integrated platform, implementing serious games strategy and artificial intelligence-based telemedicine for glycemic control improvement

Introduction: Following the trend of digital health applications, implemented especially during the COVID-19 pandemic, the ENDORSE project, is designed as an innovative integrated platform for supporting clinical decision making and telemedicine in children with Type 1 Diabetes Mellitus (T1DM), utilizing explainable artificial intelligence along with gamification and mobile technologies. Objective(s): Assessment of preliminary data from the prepilot phase of the ENDORSE feasibility trial. Method(s): ENDORSE platform utilizes various data sources such as glucose sensors (Flash Glucose Monitoring-FGM), smart insulin pen caps, activity trackers, mobile apps, Electronic Health Records and a newly developed serious game. A 13 T1DM children and adolescents (8 females, on multiple daily injections, mean diabetes duration 2, 57 years, mean HbA1c 7, 6%, mean Body Mass Index +1, 2 SDS, mean monitoring days: 151), followed in our Diabetes Center, were assessed regarding adherence to the study protocol. They all had internet access and only one has used a diabetes mobile application before. Result(s): As shown in Table 1, most of the patients used the Smart Insulin Pen Cap to document insulin and food data and many performed mobile FGM scanning, while the engagement to the ENDORSE serious game, aiming at training in self-disease management, along with the activity trackers is highly variable. Conclusion(s): ENDORSE platform along with changes in daily diabetes care practices like CGM usage, is expected to improve diabetes management through facilitating training, monitoring and feedback to the patients and their caregivers. In order to further improve its adherence and acceptance, factors such as the level of digital literacy and the need of a personalized experience to improve usability, should be also taken into consideration.

ALS Following COVID-19 Infection: A Case Report

Case Diagnosis: A 72-year-old female who had COVID-19 in December 2020 who subsequently began to have signs and symptoms of ALS in January 2021. Case Description or Program Description: A 73-year-old female with untreated psoriatic arthritis, hypertension, hyperlipidemia, hypothyroidism, and recent COVID-19 infection (12/2020) was admitted on 7/28/2021 for rapidly declining functional status and multiple falls. Symptoms started as right hand weakness in January 2021 and subsequently she began to have recurrent falls resulting in multiple ED visits. On exam she had reduced facial temperature sensation, spastic quadriparesis (right> left), generalized hyperreflexia, positive Hoffman's and pectoralis reflexes bilaterally, upgoing toes bilaterally, and reduced hemisensory loss to temperature and vibration (right> left). CSF and EMG studies were consistent with ALS. Labs regarding autoimmune disease and genetic etiology were unremarkable. On the neurology unit, the patient was subsequently started on riluzole and weaned off Sinemet. PT and OT were involved. Initially, pre-gait attempts were limited by fatigue and all ADLs were maximum assist. Setting(s): Acute Inpatient Rehabilitation Unit Assessment/Results: During acute rehabilitation stay, patient progressed to minimum assist with ambulation using pneumatic support walker for 30ft. Additionally, patient progressed to modified independent with ADLs. However, patient remained moderate to maximum assist with both bed mobility and transfers. At day 17, patient was discharged home with appropriate DME, home therapies and aide, as well as 24/7 family support. Discussion (relevance): This is the first reported case, to our knowledge, of the onset of ALS promptly following COVID-19 infection. Conclusion(s): ALS may be considered on the differential diagnosis in patients with clinical signs and symptoms of functional decline and both upper and lower motor neuron deficits following COVID-19.

No Evidence for Persisting or Progressive Kidney Disease After Non-Severe COVID-19

Background: Diverse abnormal findings have been described after non-severe coronavirus disease 2019 (COVID-19) but kidney outcomes remain largely unknown. Here we analyze various kidney parameters after non-severe COVID-19 to test the hypothesis of a relevant kidney sequela. Method(s): This cross-sectional study investigates patients after non-severe COVID-19 and matched control subjects without prior COVID-19. Patients were recruited by the population-based Hamburg City Health Study (HCHS) as well as its associated COVID program. The HCHS is a prospective population-based cohort study on randomly selected residents of the city of Hamburg, Germany. During the COVID-19 pandemic the study also invited patients at least 4 months after a PCR proven severe acute respiratory syndrome coronavirus type 2 (SARS-CoV-2) infection via newspaper announcements and an official COVID-19 test center. All patients had to be between 45 and 74 years of age. Matching was performed by age, sex, and education. Main outcomes were eGFR, albuminuria, Dickkopf3, hematuria, and pyuria. Descriptive analysis and mixed regression models were performed with adjustment for multiple testing by Bonferroni corrections. Result(s): The non-COVID cohort consisted of 1328 subjects, the post-COVID cohort of 443 patients in median 9 months after SARS-CoV-2 infection. Most patients had mild COVID-19. Only 31 patients were hospitalized with COVID-19 and no patient was treated on an intensive care unit. The risk for chronic kidney disease (CKD), defined by an eGFR < 60 ml/min/1.73m2, (OR 0.9, adjusted p=1.000) or severely increased albuminuria (OR 0.79, adj. p=0.893) was not increased in the post-COVID compared to the non-COVID cohort. This also applied for early CKD stages. However, mean eGFR was mildly lower in post-COVID subjects, even after adjusting for known risk factors (beta -1.84, adj. p=0.032). We found no elevation of hematuria, pyuria, and proteinuria for the post-COVID cohort suggesting no systematic ongoing kidney involvement. Urinary Dickkopf3 even tended to be lower in post-COVID patients indicating no risk for ongoing GFR decline in this cohort (beta -72.19, adj. p=0.072). Conclusion(s): While there is a subclinical eGFR drop after non-severe COVID-19, we found no evidence for a relevant kidney sequela nor ongoing renal involvement.

COVID-19 Mediated Exacerbation of Complex Regional Pain Syndrome Treated With Spinal Cord Stimulator

Introduction: Complex regional pain syndrome (CRPS) is a debilitating condition characterized by disproportionate pain to the inciting event, changes in sensation, autonomic abnormalities, and motor dysfunction, as defined by the Budapest criteria. It is difficult to treat, often requiring trials of multiple medications or more invasive measures such as a spinal cord stimulator (SCS) to manage symptoms. The onset of symptoms typically follows tissue damage and may be exacerbated by further injury or systemic stressors. One such stressor appears to be COVID-19 infection, which has already been implicated in cases of neuropathic pain. We present a case of a 60-year-old woman with CRPS type I status post SCS placement with a flare-up attributable to COVID-19 infection. Methods: We describe the following patient's case in pertinent detail. The patient's written consent was obtained prior to the undertaking of this report. Results: A 60-year-old woman presented with a right-sided rotator cuff tear with subsequent repair in 2018 which incited pain and related symptoms. CRPS was diagnosed when her symptoms progressed to right thumb numbness as well as right hand color changes, numbness, and weakness. An SCS was placed in August 2019 which provided pain relief, but the patient presented with exacerbation of symptoms in December 2020, coinciding with COVID-19 infection. She experienced migration of symptoms into the right shoulder which has been significantly interfering with work and sleep. She continued to report pain, swelling, stiffness, dry skin, and temperature changes in her right hand. Conclusion: COVID-19 has been found to present with a widely variable clinical presentation with equally varied sequelae, termed Post-Acute Sequelae of SARS-CoV-2 infection (PASC). Human coronaviruses are known to possess neuroinvasive capabilities, typically manifesting as anosmia in the case of COVID-19 but may also present as neuropathic pain. If not attributable to direct viral invasion, the pathophysiologic underpinnings may be related to proinflammatory cytokines and pain-generating neuropeptides. Our case suggests that COVID-19 infection may play a role in exacerbating symptoms of CRPS. Disclosure: Gabrielle Fernandez, BA: None, Ganiru Anunike, BA: None, Nitin Goyal, MD: None

In-vitro Assessment of Antiviral Activity of the Herbo Mineral Capsule, Fema SakthiTM, against Human Coronavirus (HCoV) on VERO Cells

Introduction: With the spread of COVID-19 pandemic, healthcare workers and patients look for alternate medicines including Siddha, Ayurveda, Unani and other forms of traditional medicines as we still do not have promising antiviral drugs for COVID-19. Objective: To evaluate the in-vitro antiviral activity of Fema Sakthi™ (FS) by eliciting the inhibition of cytopathic effect of Human Coronavirus (HCoV) on African Green Monkey kidney cells (VERO cells). Materials and Method: The cytopathic effect (CPE) was performed on Vero cells with Human Coronavirus 229E, a type of Coronavirus associated with respiratory infections. The Median Tissue Culture Infectious Dose (TCID50) was evaluated using Reed-Muench method. 100 TCID50 of HCoV 229E viral suspensions were added to VERO cell culture to induce the cytopathic effect. Uninfected and untreated cells were used as control and five concentrations (62.5, 125, 250, 500 & 1000 µg/mL) of Fema Sakthi™ (FS) were used to study the anti-viral activity. After incubation for 72 hours, the cell viability was observed under the inverted microscope after staining with 0.1% crystal violet. Results: Fema Sakthi™ (FS) was found to exhibit inhibition of cytopathic effect at lower concentrations (62.5, 125 and 250 µg/mL) but at higher concentrations (500 and 1000 µg/mL), the formulation itself was cytotoxic to the cells. Conclusion: This preliminary study showed that FS has antiviral activity at lower concentrations 62.5, 125 and 250 µg/mL on the VERO cells. However, further specific studies have to be carried out to confirm the anti-viral activity and clinical efficacy using other preclinical and clinical models of Human Coronavirus (HCoV) including COVID-19. Copyright (c) 2022: Author(s).