First Case Mild Symptoms COVID-19 in Rural Central Java Area: Case Report of an Indonesian Patient

BACKGROUND: SARS-CoV-2 virus infection is a pandemic that began to emerge in December 2019 in various countries with high death rates of 4-9% until now. In March 2020, Indonesia found its first case where the condition of the infection kept spreading to various regions in Indonesia. Different regional conditions in Indonesia make it difficult to manage this virus infection. The capability of the regional hospitals to detect this virus infection with their facilities and infrastructure is required. CASE PRESENTATION: A 17-year-old man came to the Ajibarang Regional Hospital with complaints of coughs and colds felt for 4 days and fever for 2 days. Physical examination found a good general condition, moderate pain, the temperature of 38.8degreeC, pharyngeal hyperemia, and minimal lung crackles sound. Laboratory tests showed normal leukocytes, platelet, and hemoglobin levels. Chest radiograph was suggestive of bronchitis. The patient was hospitalized for approximately 4 days until the fever resolved and was discharged. Five days after the patient was discharged from the hospital, the results of the viral load examination using real-time polymerase chain reaction confirmed positive for Coronavirus Disease 2019 (COVID-19). CONCLUSION(S): This case showed unusual conditions of a mild clinical COVID-19 infection, laboratory results that did not support viral infections, as well as radiology examination of only bronchitis. The viral load test was found to be positive. Therefore, the diagnosis of the COVID-19 infection requires a comprehensive interpretation of complete history taking, clinical examination, laboratory, and radiology examinations for clinicians working with limited hospital facilities and infrastructures.Copyright © 2023 Edward Kurnia Setiawan Limijadi, Inge Cahya Ramadhani, Dian Tunjungsari Hartutiningtyas, Gara Samara Brajadenta.

Infectious mononucleosis combined with SARS-CoV-2 infection.

A clinical analysis of COVID-19 cases combined with acute respiratory diseases is presented. The aim of the study was to analyze clinical and laboratory data of patients with combined COVID-19 infection. In patient A. infected with SARS-CoV-2 without X-ray confirmation of lung damage, acute tonsillitis, polyadenopathy, hepatosplenomegaly, moderate leukocytosis, lymphomonocytosis and the presence of reactive lymphocytes were detected. Serological and molecular biological studies were carried out for the purpose of differential diagnosis. A positive test result for IgM antibodies to EBV was obtained. The method of polymerase chain reaction (PCR) revealed EBV DNA in blood plasma. The result of the determination of heterogeneous IgG antibodies to the EBV caspid antigen is negative. Clinical symptoms of the patient with coronavirus infection COVID-19, confirmed by radiological and serological screening, included: fever, sore throat, hyperemia and hypertrophy of the palatine tonsils, hepatomegaly, changes of the cellular composition of the blood. At the same time, the lymph nodes in the neck, chest and abdominal cavity were not enlarged;the presence of reactive lymphocytes and plasma cells was not detected. Serological markers of EBV were also not detected. A PCR test for Epstein-Barr virus DNA was negative.Copyright © 2022 Infectious Diseases: News, Opinions, Training.

Worse Arterial Stiffness, and Not Endothelial Dysfunction, Is Associated with Pasc

Background: COVID-19 survivors can experience lingering symptoms known as PASC that appear in different phenotypes. The etiology remains elusive and endothelial dysfunction has been postulated as a main driver of PASC. Method(s): Prospective cohort including COVID- and COVID+ with (COVID+PASC+) or without (COVID+PASC-) PASC. We measured endothelial function using Endopat, an FDA approved test, with derived reactive hyperemic index RHI (endothelial dysfunction<=1.67) and arterial elasticity (augmentation index standardized at 75 bpm or AI@75;(lower =better). PASC symptoms were categorized into three non-exclusive phenotypes: Cardiopulmonary CP (postexertional malaise, shortness of breath, cough, palpitations), Neurocognitive N (change in smell/taste, neuropathy, 'brain fog', headache), and General G (fatigue, gastrointestinal or bladder problems). Result(s): We included 491 participants with 109 of the 186 with confirmed COVID+ experiencing PASC. Median number of days between COVID diagnosis and study visit was 249 days (IQR: 144, 510). Among COVID+PASC+, the median number of symptoms was 7.0 (IQR: 3.0,13.0);97 experienced symptoms categorized as G, 90 as N, and 87 as CP. COVID+ PASC+ had the lowest RHI (1.77+/-0.47) and the largest proportion [46.79% (n=51)] with RHI<=1.67 (Figure). AI@75 was the lowest in COVID- (3.11+/-15.97) followed by COVID+PASC- (3.57 +/- 16.34). Within COVID+PASC+, the mean AI@75 among G was 10.11+/-14.85, 11.36+/-14.67 with N, and highest (12.01 +/- 14.48) with CP. Symptoms' number was positively associated with AI@75 (p=0.01). The estimated mean difference in AI@75 between COVID+ PASC+ with CP and COVID+ PASC- was 8.44+/-2.46 (p=0.001), between COVID+ PASC+ with CP phenotype and COVID- was 8.9+/-1.91 (p< .0001), and between COVID+ PASC+ with CP phenotype and COVID+ PASC without CP phenotype was 7.51+/-3.75 (p=0.04) Conclusion(s): PASC was associated with worse arterial elasticity and within PASC, the cardiopulmonary phenotype had the highest arterial stiffness. (Figure Presented).

Sex Modifies the Effect of Covid-19 and Pasc Status on Arterial Stiffness

Background: Sex differences in immunological responses to COVID-19 infection and mechanisms that may contribute towards post-acute sequelae of SARS-Co-V2 (PASC) have been reported. However, evidence on the effects of COVID infection on vascular dysfunction and PASC are limited. Method(s): FDA approved EndoPAT device was used to measure endothelial function [Reactive Hyperemia Index (RHI)] and arterial stiffness [Augmentation Index standardized at 75 beats/min (AI@75;higher AI = worse arterial elasticity)] in an adult cohort (age >=18 years) with a history of COVID-19 infection (COVID+) or confirmed SARS-CoV2 antibody negative (COVID-). Generalized linear regression was used to compute estimates of RHI and AI@75. Adjusted models included age, sex, race, blood pressure, lipids, body mass index (BMI), smoking status, and pre-existing comorbidities. Two-way interactions were used to determine if the effects of COVID or PASC status on endothelial function depends on age, sex, race, smoking status, or prevalent comorbidities. Result(s): 61.99% (n=305) of study participants were COVID- and 187 (38.01%) were COVID+. Among COVID+, 57.22% (n=107) were female, 31.72% (n=59) were non-white race, and the average age was 46.64+/-13.79 years. COVIDparticipants had a smaller proportion (38.03%) of female sex (p< .0001), lower BMI [COVID+ (30.79+/-8.95 kg/m2) vs. COVID- (27.76+/-5.89 kg/m2);p< .0001], and higher proportion of smokers [COVID+ (17.78%) vs. COVID- (58.22%);p< .0001]. The average follow-up was 349.68+/-276.76 days and 109 (22.15%) COVID+ experienced PASC. 42.48% (n=80) of COVID+ and 41.64% (n=127) of COVID- had RHI<= 1.67 (p=0.8). The average AI@75 among COVID+ without PASC was 3.63+/-16.24, with PASC was 10.5+/-14.72, and 3.11+/-15.97 among COVID- (p=0.0001). Male sex had the lowest AI@75 (-0.08+/-14.9) compared to female sex (10.75+/-15.3;< .0001). In adjusted models, PASC, female sex had 8.14+/-2.95 higher AI@75 compared to PASC, male sex (p=0.006), 18.58+/-2.99 higher AI@75 compared to COVID+ without PASC, male sex (p< .0001), 13.81+/-2.11 higher AI@75 compared to COVID-, male sex (p< .0001), and 4.97+/-2.28 higher AI@75 compared to COVID-, female sex (p=0.03). Sex was not associated with RHI or modified the effect of COVID or PASC status on endothelial function Conclusion(s): The effect of COVID and PASC status on arterial stiffness depends on sex. Female sex is associated with increased arterial stiffness (worse arterial elasticity) in the post-acute phase of COVID-19. (Figure Presented).

Predictors and clinical consequences of heart damage in CMR in patients after COVID-19

Methods: Out-hospital clinic patients (pts) recovered from COVID-19 were prospectively recruited and underwent cardiac magnetic resonance (CMR) examination with a protocol including: Edema, hyperemia, and necrosis or scar-derived from signal intensity assessment in T2-weighted, early gadolinium enhancement (EGE) and late gadolinium enhancement (LGE) CMR images. Result(s): A total of 702 patients (mean age 50+/-12 years, 62% female) were included. The median (IQR) time interval between COVID-19 diagnosis and CMR was 13 (8-22) weeks. In none pts signs of edema, hyperemia and necrosis derived from signal intensity assessment in T2-weighted and early gadolinium enhancement was found. LGE was found in 152 (22%). LGE+ patients had significantly lower left ventricular (LV) ejection fraction (58.5+/-7.7 vs 61.1+/-7.9%, p<0.001) and greater LV end-diastolic (117.0+/-52.2 vs 103,0+/-36.3 ml, p=0.023) and end-systolic (50.3+/-28.0 vs 41.0+/-17.5 ml, p=0.010) volumes when compared with LGE- patients. In the resting electrocardiogram (ECG) fragmented QRS was observed significantly more frequently (46% vs 25%, p<0.001) in LGE+ group, whereas in 24h Holter ECG neither single premature, nor complex ventricular extrasystole burden did not differ between groups (p>0.05). There were observed no differences between symptoms of COVD-19 and comorbidities between LGE+ and LGE- pts. In the multivariable logistic regression analysis: Fragmented QRS [OR and 95% CI: 2.85 (1.93-4.21)] and any ST-T segment deviation in resting ECG [OR: 1.93 (1.15-3.25)] were identified as independent predictors of LGE, even after adjustment for comorbidities and COVID-19 symptoms. Conclusion(s): 1. In patients with fibrosis after COVID-19 reduced left ventricular ejection fraction and greater volume of the heart was found. 2. Fragmented QRS and ST-T abnormalities were independent predictors for LGE in patients after COVID-19.

Impairment of Microcirculation and Endothelial Function in Children with Multisystem Inflammatory Syndrome (MIS-C)/Pediatric Inflammatory Multisystem Syndrome (PIMS): A Long-Term Study

Background: Multisystem inflammatory syndrome in children (MIS-C)/pediatric inflammatory multisystem syndrome(PIMS) is a rare but severe hyper inflammation following exposure to SARS-CoV-2. The exact pathogenesis is unknown, butSARS-CoV-2 is linked to vascular-endothelial pathology. We therefore longitudinally analyzed endothelial function and microcirculation in children with MIS-C/PIMS. Method(s): Overall 17 pediatric patients with MIS-C/PIMS (mean age: 9.4 +/- 4.5 years;30% female) were included in our study. They were examined during the acute phase and in follow-up visits after 3 and 6 months. We assessed the reactive hyperemia index (RHI) as a surrogate for the endothelial function using the Endo PAT device. The microcirculation was visualized using sublingual sidestream dark field (SDF) imaging, which permits analyzing the microvascular flow index (MFI)(0 = no flow, 1 = intermittent, 2 = sluggish, 3 = continuous). Result(s): During the acute phase of MIS-C/PIMS both, macrovascular and microvascular markers were distinctively restricted. Mean RHI was 1.11 +/- 0.25 indicating limited endothelial function in comparison to a group of healthy controls(mean RHI = 1.36 +/- 0.22;n = 14;mean age: 12.8 +/- 2.2 years;50% female). After 3 months, mean RHI improved to 1.42+/-0.45 and even increased to 1.75 +/- 0.66 after 6 months. SDF imaging revealed an impaired microcirculatory flow during the acute phase (mean MFI: 2.45 +/- 0.28), which surprisingly did not improve after three months (mean MFI: 2.45 +/- 0.33).Six months after the acute phase, the microvascular flow ameliorated toward a more continuous flow (mean MFI: 2.66 +/- 0.29). Conclusion(s): Our preliminary results indicate an impaired microcirculation and endothelial function in children with MIS-C/PIMS. The process of full vascular recovery seems to take several months. More research in this field is necessary to better understand the patho physiology and the time course of this rare new SARS-CoV-2-related syndrome.

Comparative analysis in resolving the symptoms in patients with laryngitis posterior treated with PPI and levocitirizine and PPI and desloratadine

Background: Living in a covid 19 pandemic lockdown, and the "new normal" over all, is a stressful situation for all of us. As an ENT specialist I confronted a higher incidence of laryngitis posterior and GERD patients amoung the patients with previous allergic diathesis from March 2020 until December 2020 compared with the previous years. Method(s): Two different treatments of the patients with laryngitis posterior and GER patients in the clinical hospital of Bitola, between March 2020 and December 2020. The first treatment consists of esomeprazole and levocitirizine, and the second consists of esomeprazole and desloratadine. These treatments were applied to two different groups -first group comprising 24 patients, and the second one comprising 29 patients. The follow up was a month after a given therapy. Result(s): All the patients were evaluated a month after treatment. First part of the evaluation was subjective and the patients had to answer if they are feeling better on the scale from 1 to 5. The second part was fiberlaryngoscopy and the evaluation of the interarytenoid space. Only 15% (3 patients) of the first group were feeling completely good, and 34% (10 patients) from the second group. The finding of laryngoscopy and evaluation of the interarytenoide space was without hyperemia and oedema in 50% (12 patients) from the first group and 69% (20 patients) in the second group. Conclusion(s): The comparison of the results of the two groups shows that the patients in the second group, treated with esomeprazole and desloratadin are feeling better more than twice from the first group, and for almost more than 20% have no more hyperemia and oedema compared to the first group. In order to enhance the results of the patients' treatment further follow up all patients is necessary.

Comparing the efficacy of meglumine acridon acetate and pentanedioic acid imidazolyl ethanamide in the outpatient treatment for ARVI during the COVID-19 pandemic.

This study compared the efficacy of different therapies for ARVI during the COVID-19 pandemic. Objective. To compare clinical efficacy of Cycloferon and Ingavirin in children aged 4-17 years treated in outpatient facilities during the epidemic season of SOVID-19. Patients and methods. This study included 101 patients who provided 143 oro-and nasopharyngeal swabs tested using certified PCR tests. Of them, 128 samples (89.5%) were positive, whereas 15 samples (10.5%) were negative. We identified the most common viruses circulating in January-May 2021, including (seasonal) coronaviruses (35.9%), rhinoviruses (20.3%), and other viruses. We also analyzed respiratory viruses that have circulated in Moscow during the last 6 years and found higher levels of seasonal coronaviruses. The most common ARVI symptoms in 2021 were fever, rhinitis, pharyngeal hyperemia, and fatigue. Fewer children had headache, cough, and enlarged lymph nodes. Results. We compared ARVI treatment with broad-spectrum antivirals in children aged between 4 and 17 years. Children in group 1 (n = 51) received Cycloferon, while children in Group (n = 50) received Ingavirin. Study participants were diagnosed with ARVI and moderate nasopharyngitis. Children from the Cycloferon group demonstrated a more significant dynamics of such clinical symptoms as headache (p < 0.05), cough (p < 0.01), rhinitis (p < 0.01), abundant mucus (p < 0.001), and enlarged lymph nodes (p < 0.001) than children from the Ingavirin group (there was a significant difference in the duration of these symptoms). Only 2 children from group 1 required antibiotics (3.4%), whereas in group 2, 11 children needed antibacterial therapy (22%).Copyright © 2022, Dynasty Publishing House. All rights reserved.

Comparing the efficacy of meglumine acridon acetate and pentanedioic acid imidazolyl ethanamide in the outpatient treatment for ARVI during the COVID-19 pandemic

This study compared the efficacy of different therapies for ARVI during the COVID-19 pandemic. Objective. To compare clinical efficacy of Cycloferon and Ingavirin in children aged 4–17 years treated in outpatient facilities during the epidemic season of СOVID-19. Patients and methods. This study included 101 patients who provided 143 oro-and nasopharyngeal swabs tested using certified PCR tests. Of them, 128 samples (89.5%) were positive, whereas 15 samples (10.5%) were negative. We identified the most common viruses circulating in January–May 2021, including (seasonal) coronaviruses (35.9%), rhinoviruses (20.3%), and other viruses. We also analyzed respiratory viruses that have circulated in Moscow during the last 6 years and found higher levels of seasonal coronaviruses. The most common ARVI symptoms in 2021 were fever, rhinitis, pharyngeal hyperemia, and fatigue. Fewer children had headache, cough, and enlarged lymph nodes. Results. We compared ARVI treatment with broad-spectrum antivirals in children aged between 4 and 17 years. Children in group 1 (n = 51) received Cycloferon®, while children in Group (n = 50) received Ingavirin®. Study participants were diagnosed with ARVI and moderate nasopharyngitis. Children from the Cycloferon group demonstrated a more significant dynamics of such clinical symptoms as headache (p < 0.05), cough (p < 0.01), rhinitis (p < 0.01), abundant mucus (p < 0.001), and enlarged lymph nodes (p < 0.001) than children from the Ingavirin group (there was a significant difference in the duration of these symptoms). Only 2 children from group 1 required antibiotics (3.4%), whereas in group 2, 11 children needed antibacterial therapy (22%).

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).

Clinical profile and outcome of multisystem inflammatory syndrome in children (MIS-C) associated with COVID-19 infection: a single-center observational study from South India

Background: Multisystem inflammatory syndrome in children (MIS-C) is a post-infectious sequelae of acute COVID-19 infection affecting children. This study was done over a period of 12 months from December 2020 to November 2021 to describe the clinical presentation, laboratory abnormalities, and outcome of children with MIS-C. Method(s): Seventy-eight children below 12 years of age who satisfied the WHO diagnostic criteria for MIS-C were included in the study. Clinical parameters were recorded at admission. Relevant laboratory investigations, radiological studies, and outcome were documented. Result(s): The most commonly affected age group was 6-12 years with a female predominance. COVID RTPCR was negative in all patients. Most cases presented 2-6 weeks after the onset of acute COVID-19 infection. Lethargy, poor feeding, vomiting, abdominal pain, loose stools, cough, and cold are common symptoms of MIS-C syndrome in children and the common signs were rash, conjunctival congestion, hypotension, tachycardia, tachypnea, and hypoxemia. Gastrointestinal system was the commonly affected followed by the hepatic, renal, and cardiovascular systems. Coronary artery abnormalities were seen in 20% of cases. IVIg was the mainstay of therapy used in 95% of patients. Mortality was 1.3%. Cases responded well to IVIg and steroids. Conclusion(s): Overall, the short-term outcome was favorable with low mortality in our study cohort. One-fifth of children had coronary artery abnormalities during acute phase underscoring the need for long-term follow-up. Copyright © 2022, The Author(s).

Successful Management of Children Presenting with Multisystem Inflammatory Syndrome Following Sars-Cov-2 Infection: Case Reports

BACKGROUND AND AIM: Multisystem inflammatory syndrome in children (MIS-C) is a syndrome of fatal multisystem inflammation. This case report aims to describe our successful experience in managing children with MIS-C associated with previous SARS-CoV-2 infection and to help clinicians identify the spectrum of MIS-C signs and symptoms. METHOD(S): Case Reports RESULTS: A 6-year-old previously healthy boy was referred to our hospital with fever, dyspnea, vomiting, and abdominal pain for seven days before admission. Leucocytosis, elevated inflammatory and cardiac biomarkers were noted. Renal and liver function decreased. An echocardiogram showed dilated LV with EF 30% and a normal chest x-ray. High anti-SARSCoV- 2 titer (>250 U/mL) with negative for SARS-CoV-2 RTPCR was in accordance with the previous infection 8 weeks prior. He received intravenous furosemide, dobutamine, ceftriaxone, intravenous immunoglobulin (IVIG), and heparin in the pediatric intensive care unit and was discharged on the 11th day of treatment. The second case was a 10-yearold boy admitted to the hospital with a high fever (41.5O C), conjunctival hyperemia, diarrhea, and diffused abdominal pain for two days before hospitalization. History of COVID-19 was noted in the previous 4 weeks. Laboratory blood examination showed thrombocytopenia, elevated inflammatory markers, D-dimer, NT-pro BNP, negative for SARS-CoV-2 RT-PCR, and positive for IgG SARS-CoV2. Echocardiogram and chest x-ray were unremarkable. He received ceftriaxone, IVIG, Methylprednisolone, and enoxaparin. The patient was discharged after eight days of hospitalization. CONCLUSION(S): These two cases presented MIS-C following a history of mild COVID-19 infection. The successful management relied on the proper and timely administration of IVIG, corticosteroid, and anticoagulant.

The effect of covid-19 vaccine on the endothelial function

Background: Covid-19 vaccine was associated with several complications such as thromboembolic complications. The exact mechanism is not well established. Since covid 19 virus caused severe endothelial dysfunction, we suspect that the vaccine with a similar immunological response may cause this dysfunction. Aim(s): To study the effect of covid-19 vaccine on endothelial function. Method(s): We conducted a prospective study. The endothelial function was clinically assessed using a post-occlusive reactive hyperemia protocol with finger thermal monitoring device. Endothelial quality index (EQI) was assessed at inclusion before the first dose of coronavirus vaccine and 30 days later. Result(s): 20 patients were included in our study. Their mean age was 41 years old [23-65]. The sex ratio was 3/2. They were all healthy individuals. The Majority, 75% of our patients, have impaired their endothelial function 30 days after the first dose of covid-19 vaccine. Conclusion(s): The Covid-19 vaccine effect on endothelial function may be responsible for its complications. Key words: Covid-19 vaccine, endothelial dysfunction.

Circulating Serum Cystatin C as an Independent Risk Biomarker for Vascular Endothelial Dysfunction in Patients with COVID-19-Associated Multisystem Inflammatory Syndrome in Children (MIS-C): A Prospective Observational Study.

INTRODUCTION: Multisystem inflammatory syndrome in children (MIS-C) is a new clinical entity that has emerged in the context of the COVID-19 pandemic. Despite the less severe course of the disease, varying degrees of cardiovascular events may occur in MIS-C; however, data on vascular changes occurring in MIS-C are still lacking. Endothelial dysfunction (ED) is thought to be one of the key risk factors contributing to MIS-C. BACKGROUND: We conducted a prospective observational study. We investigated possible manifestations of cardiac and endothelial involvement in MIS-C after the treatment of the acute stage and potential predictive biomarkers in patients with MIS-C. METHODS: Twenty-seven consecutive pediatric subjects (≥9 years), at least three months post-treated MIS-C of varying severity, in a stable condition, and twenty-three age- and sex-matched healthy individuals (HI), were enrolled. A combined non-invasive diagnostic approach was used to assess endothelial function as well as markers of organ damage using cardiac examination and measurement of the reactive hyperemia index (RHI), by recording the post- to pre-occlusion pulsatile volume changes and biomarkers related to ED and cardiac disease. RESULTS: MIS-C patients exhibited a significantly lower RHI (indicative of more severe ED) than those in HI (1.32 vs. 1.80; p = 0.001). The cutoff of RHI ≤ 1.4 was independently associated with a higher cardiovascular risk. Age and biomarkers significantly correlated with RHI, while serum cystatin C (Cys C) levels were independently associated with a diminished RHI, suggesting Cys C as a surrogate marker of ED in MIS-C. CONCLUSIONS: Patients after MIS-C display evidence of ED, as shown by a diminished RHI and altered endothelial biomarkers. Cys C was identified as an independent indicator for the development of cardiovascular disease. The combination of these factors has the potential to better predict the cardiovascular consequences of MIS-C. Our study suggests that ED may be implicated in the pathophysiology of this disease.

Immunological Potency, Efficacy, and Tolerance of “Gam-COVID-Vac” Vaccine among Students: Prospective Study

Background. Students, as the most active and mobile part of population, often unite into educational and informal groups, move to other regions or countries, and present a specific risk group for the spread of new coronavirus infection. Thus, they require preventive vaccination. objective. the aim of the study is to study the immunological potency, tolerance, and efficacy of GamCOVID-Vac vaccine among students of Krasnodar. methods. 119 seronegative students (18–30 years old) were examined. SARSCoV-2 IgG (ELISA method) was determined 1, 3, and 6 months after two completed rounds of vaccination. Post-vaccination adverse events and COVID-19 cases were evaluated in the study. results. SARS-CoV-2 IgG level 1 month after vaccination ranged from 6.15 to 19.38 and was to 16.39 (AU/mL) ± 1,12. Immunological potency values ranged from 4.407 to 21.5 (AU/mL) (14.74 ± 2.93) 3 months after. IgG titers were in the range of 4.14 to 17.71 (AU/mL) (10.97 ± 4.69) 6 months after. Adverse events after vaccination were revealed in 34 respondents (28.6%). Among them, local (hyperemia, pain, edema) — 21 (17.6%): slight — 90.4%, major — 9.6%;general (fever, weakness, algor, headache, arthralgia, myalgia) — 13 (10.9%): slight — 69.2%, major — 30.8%. The increase in vaccination coverage in students from 30.3 to 79.1% reduced the COVID-19 morbidity from 3.81 to 1.57%. conclusion. Gam-COVID-Vac vaccine induced stable humoral response, demonstrated sufficient safety, and reduced morbidity 2.4-fold.

Vascular Response to a Cardiac Rehabilitation Program Adapted for COVID-19

Background: Cardiac Rehabilitation (CR) is a supervised exercise and risk factor modification program for patients with cardiac conditions. Endothelial dysfunction is often present and is associated with worsening cardiac prognosis, and several studies have indicated that standard onsite CR has improved endothelial function in heart disease patients. However, during the COVID-19 pandemic, many CR programs transitioned to a virtual or hybrid model of care to increase safety of CR programs. Objective(s): The objective of this study was to determine vascular function of patients with coronary artery disease (CAD) measured before and after 4 months of outpatient CR using a virtual model of care. Method(s): Virtual CR included 1 virtual group session/week by videoconferencing and hybrid CR included 1 session/week (4 on-site and 12 virtual group sessions) for a total of 16 weeks. CAD patients (6 females, 4 males) mean age 68.1+/-7.5 years rested in a supine position to measure 1) brachial artery flow-mediated dilation (FMD), 2) microvascular function, and 3) augmentation index (AI) using ultrasound sonography (n=8) and an EndoPAT 2000 (n=9). Two patients completed virtual CR and the rest underwent hybrid CR. These measurements were obtained concurrently using an ultrasound transducer at the brachial artery proximal to a blood pressure cuff on the forearm with EndoPAT cuffs on the index fingers during 5-minute intervals of baseline, occlusion, and recovery. FMD results were analyzed using automated Cardiovascular Suite software. AI and Reactive Hyperemia Index (LnRHI) were determined using automatic analysis via the EndoPAT 2000. Anthropometrics, blood pressure, and food intake were recorded at each visit. Patients were advised to refrain from strenuous exercise, alcohol, caffeine, and highly saturated foods at least 12 hours prior to the study appointment. One tailed paired t-tests were conducted between baseline and completion. Result(s): Adherence to CR averaged 10.3+/-3.2 out of 16 sessions. FMD improved from (2.75+/-1.71% to 5.63+/-4.37%, p=0.048) while there was no improvement in AI (14.2+/-18.8 to 13.2+/-19.6, p=0.45) or LnRHI (0.56+/-0.12 to 0.52+/-0.20, p=0.24). Conclusion(s): While there was no improvement in LnRHI or AI after CR, FMD improved in CAD patients after 4 months of adapted CR. Our results indicate that while virtual and hybrid models of CR may not be sufficient for improving microvascular function and aortic stiffness in CAD, there is an improvement of endothelial function. Future studies should examine the effects of adherence, duration and exercise intensity within these alternative models of CR on aortic and microvascular improvements.

USE OF POINT-OF-CARE ULTRASONOGRAPHY (POCUS) TO PREVENT DILTIAZEM-INDUCED CARDIOGENIC SHOCK

SESSION TITLE: Using Imaging for Diagnosis Case Posters SESSION TYPE: Case Report Posters PRESENTED ON: 10/19/2022 12:45 pm - 01:45 pm INTRODUCTION: Point of care ultrasonography (POCUS) uses an ultrasound technique that helps physicians augment physical examination findings and guide clinical decision-making at the bedside. We present a case that became a watershed moment for internal medicine residents at Abington Jefferson Hospital to use POCUS for every patient with atrial flutter/fibrillation with RVR prior to initiating diltiazem drip. CASE PRESENTATION: A 73-year-old male presented to the emergency department with complaints of palpitations. He was tachycardic with a heart rate in the 150s, and his rhythm was irregular. His basic labs were normal;an electrocardiogram investigation showed that he was experiencing an atrial flutter with 2:1 and 3:1 blocks. Chest X-ray was clear. He was given IV metoprolol 10 mg twice without achieving rate control and then started on a diltiazem drip, which initially improved his heart rate to 70s with rhythm changing to atrial flutter with 4:1 block. However, he started to become hypoxic, requiring intubation and then hemodynamically unstable, requiring initiation of pressors. Postintubation CXR indicated bilateral diffuse pulmonary edema and vascular congestion. Subsequently, he had Pulseless electrical activity (PEA) arrest. Return of spontaneous circulation (ROSC) was achieved after 3 minutes of chest compression and one round of epinephrine injection. Transthoracic echocardiogram showed an ejection fraction of 10%. He had a right heart catheterization which showed a CI of 1.7 and elevated PCWP and RVP. He was started on milrinone for ionotropic support and needed norepinephrine, vasopressin and phenylephrine to sustain his blood pressure. DISCUSSION: Atrial flutter and fibrillation are routinely seen arrhythmias in hospital settings. Patients with irregular rhythm who are in rapid ventricular rate and normotensive are often given IV metoprolol few times and then started on a diltiazem drip if RVR continues. Diltiazem not only decreases heart rate (negative chronotropic) but also decreases ventricular squeeze (negative ionotropic). It is contraindicated in patients with reduced ejection fraction. Patients’ ejection fraction values are not always known, especially if they have never had a transthoracic echocardiogram in the past or prior records are not available. POCUS helps physicians and residents to access and estimate LV function quickly and augments clinical decision making at the bedside. CONCLUSIONS: Internal Medicine Residents at Abington Hospital have made it a part of their protocol to always perform bedside ultrasonography in patients with atrial flutter/fibrillation with rapid ventricular rate before initiating diltiazem drip to prevent further avoidable cardiogenic shocks. Reference #1: Fey H, Jost M, Geise AT, Bertsch T, Christ M. Kardiogener Schock nach bradykardisierender Therapie bei tachykardem Vorhofflimmern : Fallvorstellung einer 89-jährigen Patientin [Cardiogenic shock after drug therapy for atrial fibrillation with tachycardia : Case report of an 89-year-old woman]. Med Klin Intensivmed Notfmed. 2016 Jun;111(5):458-62. German. doi: 10.1007/s00063-015-0089-9. Epub 2015 Oct 6. PMID: 26440099. Reference #2: Bitar ZI, Shamsah M, Bamasood OM, Maadarani OS, Alfoudri H. Point-of-Care Ultrasound for COVID-19 Pneumonia Patients in the ICU. J Cardiovasc Imaging. 2021 Jan;29(1):60-68. doi: 10.4250/jcvi.2020.0138. PMID: 33511802;PMCID: PMC7847790. Reference #3: Murray A, Hutchison H, Popil M, Krebs W. The Use of Point-of-Care Ultrasound to Accurately Measure Cardiac Output in Flight. Air Med J. 2020 May-Jun;39(3):218-220. doi: 10.1016/j.amj.2019.12.008. Epub 2020 Jan 14. PMID: 32540116. DISCLOSURES: No relevant relationships by Fnu Aisha No relevant relationships by Lucy Checchio No relevant relationships by Ans Dastgir No relevant relationships by Shravya Ginnaram No relevant relationships by Syeda Hassan No relevant relationships by Chaitra Janga No relev nt relationships by Rameesha Mehreen No relevant relationships by Rahat Ahmed Memon No relevant relationships by Binod Poudel No relevant relationships by Shreeja Shah

Optimal topical drug for COVID-19 therapy in children

Objective. To evaluate the efficacy of a benzydamine-containing drug in children with COVID-19. Patients and methods. This observational randomized study included 88 children with confirmed mild or moderate COVID-19. The experimental group comprised 44 children who received drugs containing benzydamine, whereas the control group comprised 44 children who received other local treatments. The groups were matched for age, sex, disease severity, main manifestations, and systemic therapy received. Results. Children in the experimental group demonstrated faster recovery than those from the control group (after 6.20 ± 2.93 days vs 7.36 ± 3.17 days, respectively;р < 0.05). Virus elimination occurred earlier in children receiving benzydamine than in controls (3.93 ± 2.48 days vs 5.27 ± 3.64 days, respectively;р < 0.05. Benzydamine significantly reduced the duration of pharyngeal hyperemia (by 2.29%), sore throat (by 1.77 days;р < 0.05), and fever (by 0.93 days;р < 0.05) compared to other local treatments. Conclusion. Benzydamine significantly increases the efficacy of COVID-19 treatment.

LEFLUNOMIDE-INDUCED COLITIS IN IMMUNOSUPPRESSED PATIENT WITH SYSTEMIC LUPUS ERYTHEMATOSUS AND RHEUMATOID ARTHRITIS

Background: Leflunomide is an oral disease-modifying antirheumatic drug (DMARD), with anti-inflammatory and immunomodulatory properties that has been in use since 1998. Common leflunomide side-effects include gastrointestinal symptoms (nausea, abdominal pain and diarrhea), occurring in 10-20% of patients treated with leflunomide. Scarce evidence exists that leflunomide can cause colitis. Aims: We present the case of a 61-year-old female, with Lupus Erythematosus who presented with colitis induced by long-term leflunomide treatment. Methods: Case report and review of literature Results: A 61-year-old female was seen by the gastroenterology team with complaints of diarrhea ongoing for 6 weeks associated with 10 lb weight loss. The patient had a complex medical history, including lupus, hypothyroidism, asthma, atrial fibrillation, recurrent C. difficile infection, Bell's palsy and avascular necrosis secondary to long-term corticosteroid therapy. Previous immunosuppressive therapies included prednisone, mycophenolic acid (Myfortic), hydroxychloroquine, azathioprine, mycophenolate (CellCept) but due to multiple intolerances, she was initiated on leflunomide in 2014 and has been maintained on it since. Stool analysis ruled out infectious causes. COVID-19 testing was also negative. A CT of the abdomen revealed pancolitis. This was confirmed on colonoscopy, which revealed mild, Mayo 1 pancolitis and normal terminal ileum. She was initiated on Mezavant as a treatment for possible ulcerative colitis. However, during the hospitalization her symptoms, worsened and bloody diarrhea was noted. She underwent a subsequent endoscopic evaluation which revealed more severe disease, Mayo 2-3 colitis, with mucosal hyperemia and ulcerations, as well as effacement of the vasculature. Initial pathology results revealed mild colitis, but repeat pathology results revealed moderate active colitis, with cryptitis, crypt abscesses and significant apoptosis consistent with drug-induced colitis. Given these findings, the diagnosis of leflunomide-induced colitis was made. Leflunomide was therefore discontinued, the patient was initiated on a higher dose of corticosteroids and cholestyramine was initiated. Following these measures, her diarrhea resolved. Conclusions: Leflunomide may cause diarrhea in up to 33% of patients. Challenges related to the diagnosis of leflunomide-induced colitis exist, including the rarity of the diagnosis, a not completely understood mechanism for acute leflunomide-induced diarrhea, as well as variable endoscopic and histologic findings associated with the diagnosis. This report illustrates a case of leflunomide-induced colitis which should be considered in patients on leflunomide, who present with symptoms of abdominal pain and diarrhea, even years after medication initiation.