Longitudinal Follow-up of Pulmonary Function in Patients Hospitalized with Pulmonary Covid-19

Purpose of Study: The post-acute sequelae of COVID-19, as a multisystemic disease have been described in adults. Although some studies have described the pulmonary complications up to 3 months post-COVID infection, longitudinal data on pulmonary sequalae are sparse. The objective of this review was to summarize the findings of studies that included a longitudinal follow-up of patients with moderate to severe pulmonary COVID-19 infection. Methods Used: We performed a literature search using Pubmed, Google Scholar and Medline using key words: "pulmonary function test", PFT?, "long-COVID", longitudinal? and sequalae?. We included studies of adult patients (>18 years of age) who had been hospitalized with acute COVID-19 infection and had at least two follow-ups with PFT measurements, including one follow-up at least 6 months post-infection. Studies that did not account for co-morbidities and other lung diseases or those which only included one-time follow-up were excluded. Summary of Results: Five studies satisfied our inclusion criteria (See Table). The studies showed persistent lung injury for at least 3 months after discharge, with decreased forced expiratory volume (FEV1), total lung capacity (TLC), forced vital capacity (FVC), diffusion vital capacity of the lungs for carbon monoxide (DCLO) and carbon monoxide transfer coefficient (KCO). Although these values improved at 6 and 12 months of follow-up, those with more severe disease continued to have decreased DLCO suggestive of restrictive lung damage. Studies that included symptomatic assessment revealed that a minority of patients continued with fatigue and dyspnea uf to 12 months after the infection. The limitations of the studies include availability of data from a single center, small sample size and the variability in controlling for different co-morbidities. In addition, baseline PFT measurement before COVID-19 infection was not available for most patients. Most of the studies were done at the time that the Delta variant was dominant, therefore the data may not be applicable to other variants. Conclusion(s): Our literature review shows that some adult patients hospitalized with acute covid pulmonary infection continue to have abnormal PFTs for up to 12 months after infection. Although PFTs improve overtime, a minority of patients with more severe disease on admission continue with abnormal functional abnormalities, specifically restrictive ventilatory pattern with impaired DLCO at 12 months of follow-up. It is important that patients hospitalized with moderate to severe pulmonary COVID-19 infection be followed up and managed for at least 12 months after the initial infection. Larger prospective studies including different variants of COVID-19 that take into account various co-morbidities and different management strategies are warranted.

Pulmonary complications following COVID-19 infection.

In the relatively short period of time since December 2019, hundreds of millions of people globally have been infected with SARS-CoV-2, irrespective of their age, gender or ethnicity. Over that time, numerous mutations of various degrees of virulence and patho-genicity have occurred. The course of COVID-19 infection, an acute disease caused by the virus, is rather varied, ranging from asym-ptomatic or symptoms of common viral respiratory diseases to critical, with multiorgan failure and high mortality in high-risk patients. The overall mortality of the disease is 1-2 %. Unlike other viral respiratory diseases, this infection is often associated with frequent and rather diverse clinical manifestations developing after the acute phase of the infection, that is, more than 28 days after its onset. These complications are observed in both individuals with mild illness treated at home and inpatients with severe to critical illness. They develop both early after acute infection and some time after recovering from the disease. This rather heterogeneous group of pathologies may affect various organs and organ systems, with respiratory tract involvement being the most common and one of the most serious complications. Severe respiratory post-COVID-19 complications often include respiratory tract infections, in particular pneumonia.Copyright © 2022, Trios spol. s.r.o.. All rights reserved.

SASA 2023 Congress

The proceedings contain 34 papers. The topics discussed include: comparison of intra-arterial blood pressures versus two noninvasive measuring systems: a cross-sectional analytic study employing Bland-Altman and error grid analyses;prevalence of vitamin D deficiency amongst anesthesia providers at the Universitas Academic Hospital;chemical and physical stability of an admixture of anesthetic drugs;postoperative pulmonary complications in adult surgical patients in low- and middle-income countries: a systematic review and meta-analysis;the prevalence of SARS-CoV-2 infection in an academic department of anesthesiology;evaluation of the use of a 3D printed video laryngoscope for tracheal intubation in a manikin;the prevalence of caregiver anxiety in theatre at universitas academic hospital;the spectrum of disease and short-term outcomes of obstetric patients with cardiac disease at a tertiary hospital in South Africa;and almost 30% reduction in carbon footprint using volatile anesthesia - a quality improvement project introducing low-flow anesthesia in a regional hospital.

Microbiological profile of post covid patients admitted in tertiary care center with pulmonary infections

The second wave of COVID 19 started in India in the month of February 2021 lasted till June 2021. The second wave of COVID 19 was devastating in India. There were many fatalities. But the patient who recovered of COVID pneumonia also had many pulmonary complications, pulmonary infections being the most common. The use of steroids and immunosuppressive agents were considered to be one the causative factors. At our center, we did retrospective analysis of patients who were admitted with pulmonary infections in month of June and July 2021 and had history of COVID during second wave. There were in total 98 patients. The sputum and bronchial wash analysis were done for these patients. Out of 98 patients, 38 diagnosed to have tuberculosis, 18 mucormycosis, 10 aspergillosis, 22 bacterial infection (Pseudomonas and klebsiella), 2 non tubercular mycobacteria, 2 nocardiosis, 6 had mixed infections (2 NTM and Klebsiella, 3 TB with Aspergillosis and 1 Aspergillosis with mucor). Thus, it was concluded, that post covid status predisposed to pulmonary infections with not only common organism like Tuberculosis (being endemic in India) but also rare organism like mucor, nocardia, NTM. Though most of the patients received steroids and immunosuppressive therapy, 22 patients had mild COVID and didn't receive any steroids or immunosuppressive therapy. Thus, implying that steroids and immunosuppressive therapy are not the only cause of increased incidence of pulmonary infections. More such observations from different centers are required for confirmation of the observations.

Peculiarities of Periodontal Pocket Microbiome in Patients with Generalized Periodontitis in the Post-Covid Period

The oral cavity, like the lungs, is often referred to as the <<ecological niche of commensal, symbiotic, and pathogenic or-ganisms,>> and the emigration and elimination of microbes between them are constant, ensuring a healthy distribution of saprophytic microorganisms that maintains organ, tissue, and immune homeostasis. The prolonged hospital stays due to COVID-19 complications, cross-infection, oxygenation therapy through the mask or incubation, and long-term intravenous infusions limit the patient's ability to care about the oral cavity, regularly clean teeth, floss interdental, etc., which creates extremely favorable conditions for colonization by aerobic and anaerobic pathogens of the oral cavity and periodontal pockets and leads to the rapid progression of chronic generalized periodontitis in this category of patients in the future. The goal of the study was to assess the state of the microbiome of the periodontal pockets of dental patients in the post-covid period. Methods. The object of the study was 140 patients with generalized periodontitis of the I and II stages of development in the chronic course (GP), among which 80 patients had coronavirus disease in the closest past. The patients were randomized by age, sex, and stage of GP development. The diagnosis of periodontal disease was established according to the classification by Danilevskyi. The bacteriological material for aerobic and facultative anaerobic microflora and yeast-like fungi was collected from periodontal pockets with a calibrated bacteriological loop and immediately seeded on blood agar. Results. Significant qualitative and quantitative changes in the nature of the oral microbiocenosis were observed in patients with GP after the recent coronavirus disease, compared with similar patients who did not suffer from COVID-19. We have noticed almost complete disappearance of bacteria that belong to the transient representatives of the oral microflora such as Neisseria, corynebacteria (diphtheria), micrococci, and lac-tobacilli. The main resident representatives of the oral microflora, i.e., alpha-hemolytic Streptococci of the mitis group, were found in all healthy individuals and patients of groups A and C, but in 30.0 +/- 4.58% of patients in group B, alpha-hemolytic streptococci in the contents of periodontal pockets are present in quantities not available for detection by the applied method (<2.7 lg CCU/mL). In terms of species, Streptococcus oralis and Streptococcus salivarius are more characteris-tic in gingival crevicular fluid in healthy individuals (93.8% of selected strains). In 68.4 +/- 3.32% of patients in group A, 64.0 +/- 3.43% of patients in group B, and 67.5 +/- 3.76% of patients in group C, the dominant species were Streptococcus gordonii and Streptococcus sanguinis (p<0.01), which increased pathogenic potential as they produce streptolysin-O, inhibit complement activation, bind to fibronectine, actively form biofilms on the surface of tooth enamel and gum epithelial surface, and can act as an initiator of adhesion of periodontal pathogens. The other representatives of the resident microflora of the oral cavity - Stomatococcus mucilaginosus and Veillonella parvula for the patients of group C are also found in periodontal pockets with a significantly lower index of persistence and minimal population level. In the post-covid period, both the population level and the frequency of colonization of periodontal pockets by Staphylo-cocci and beta-hemolytic Streptococci decreases rapidly. For these patient groups, unlike for those that did not suffer from COVID-19, we did not find any case of colonization with Staphylococcus aureus, as well as beta-hemolytic Streptococci and Epidermal staphylococcus were also absent. The most characteristic in the post-covid period is a decrease in the proportion of alpha-hemolytic Streptococci, an increase in the proportion of yeast-like fungi of Candida species, as well as the appearance of a significant number of gram-negative rod-shaped bacteria (Enterobacteria and Pseudomonads). In periodontal patien s, the microbial count is approximately 2 orders of magnitude lower than in those with GP who did not suffer from COVID-19 (p<0.05). Conclusions. The overpassed coronavirus disease due to intensive antibiotic therapy leads to a marked decrease in the number of viable saprophytic microorganisms in the periodontal pockets of patients with GP. In the post-covid period for the patients with GP, there is a decrease in the level of colonization of periodontal pockets by species of resident oral microflora - alpha-hemolytic Streptococci, reduction of resident micro-organism's species, and almost complete disappearance of transient microflora. On the other hand, the frequency of colonization of periodontal pockets by fungi species, enterobacteria, and pseudomonads significantly increases. There are more expressed disorders in the periodontal pocket's microbiome for the patients with a severe and complicated course of coronavirus disease, such as post-covid pulmonary fibrosis, which requires reconsideration of approaches to therapeutic and pharmacological treatment in this category of patients.Copyright © 2022, Zabolotny Institute of Microbiology and Virology, NAS of Ukraine. All rights reserved.

Intra-hospital complications during SARS-CoV2 infection

Introduction: The SARS-CoV2 virus has a respiratory tropism. Although pulmonary complications are most often in the foreground, other complications affecting other organs have been observed and associated with a greater bad prognosis. The aim of this work was to report the various complications observed in patients hospitalized with COVID-19 pneumonia. Method(s): We carried out a retrospective study from the records of patients treated for pneumonia COVID-19 hospitalized between March 2020 and July 2021. Result(s): We collected 578 patients aged between 18 and 98 years old. Thoracic complications were dominated by bronchial superinfection(4.3%), pericarditis(3.3%), pneumomediastinum(1.2%) and pneumothorax(0.8%). Among the thromboembolic complications, we counted 30 pulmonary embolisms(5.2%), 7 acute limb ischemia (1.2%), 2 strokes(0.3%) and 1 venous thrombosis deep(0.1%). Cardiac arrhythmias were observed in 6% of cases. Bradycardia sinusitis was observed in 14 patients (2.4%) and first degree atrioventricular block in 4 patients (0.7%). Acute heart failure occurred in 31 patients (5.3%). Neurological disorders were observed in 23 patients with agitation (4%) and hallucinations (1%). Acute renal failure was the most common metabolic complication (20%) followed by rhabdomyolysis (28%) and cytolysis hepatic (36%). Two patients presented with diabetic ketoacidosis (0.3%). Complications cardiac, neurological and renal were associated with a worse prognosis (p=0.001) and the pulmonary complications with longer hospitalization (p=0.01). Conclusion(s): SARS-CoV2 infection is a polymorphic disease. Identification of the different complications respiratory and extra respiratory is essential for rapid multidisciplinary care.

Radiological sequelae in patients with ARDS due to SARSCoV-2 pneumonia

Research Questions: To describe the prevalence of radiological sequelae, 1 year after admission, of patients with pneumonia and adult respiratory distress syndrome (ARDS) due to SARS-CoV-2 and avaluate their relationship with ventilatory support and/or corticosteroids (CC) Material(s) and Method(s): Observational study of patients with pneumonia and ARDS due to SARS-CoV-2 who required admission to the ICU/IRCU of Granollers Hospital between March and May 2020. We collect clinical and radiological data, the treatment received (ventilatory support and CC) and radiological features (thoracic CT) at 12 months Results: Of a total of 109 admitted patients, 23 died during hospital stay. 78 patients were followed up. 69% were men;mean age 61 (+/-11) years. 49% required invasive ventilation (IV), 27% non-invasive positive pressure support (NIV), and 24% high-flow nasal cannula oxygen therapy (HFNC). 66% received CC therapy Of the 71 patients who were followed up at year, 31% presented normal radiology, 7% ground glass opacities, 53.5% reticulum and 8.5% fibrosis. In relation to residual/fibrotic sequelae, a higher proportion was observed in >60 years (73.9% vs 40%;p=0.005) and in patients who required IV, compared to NIV and HFNC (73.5% vs 61.9 vs 37.5%;p=0.05), with no significant differences in the use of CC (72.1% vs 55.6%;p=0.156) In the multivariate analysis, age (>60 years) and invasive ventilation were associated with the presence of pulmonary sequelae (OR 3.92 [95% CI 1.31-11.75]) and (OR 3.85 [95% CI 1.01-14.64]) Conclusion(s): 8.5% of patients presented pulmonary fibrosi at 1 year. Age (>60) years and invasive ventilation were related to a higher frequency of pulmonary radiological sequelae, regardless of administration of CC.

HLA Class I allele is associated with a lower risk to develop Post-COVID19 interstitial lung manifestations

Introduction: The HLA Class I genes codify crucial molecules in developing the immunological response against pathogenic agents such as SARS-CoV-2. We aimed to assess HLA-A alleles associated with COVID-19 subsequent pulmonary complications as interstitial lung manifestations (ILM). Material(s) and Method(s): 209 Mexican mestizo patients with a positive RT-PCR test for SARS-CoV-2 and confirmed clinical diagnosis of COVID-19 were included. The participants were monitored three months after the hospital discharge through tomography;They were divided into two groups, 1) patients who developed ILM post-COVID19 (n = 85) and 2) those patients without tomographic evidence of ILM (n = 124). The HLA-A locus was genotyped by endpoint PCR using Micro SSP Generic HLA Class I kits. The clinical and demographic variables were analyzed by SPSS software. The alleles and genotypes were analyzed by 2 x 2 contingency tables, the value of p was obtained by Yates' correction. Result(s): There is no significant difference in age, sex, BMI, hospitalization days, PAO2/FIO2, or invasive mechanical ventilation. The alleles HLA-A*02:01, *24:02, and *68:01 are the most frequent in both study groups, grouping more than 60% of the alleles identified. On the other hand, the frequency of the HLA-A*01:01 allele was decreased in the group with interstitial lung manifestations at 3 months of discharge, compared to the group without interstitial lung manifestations (p= 0.004, OR = 0.13, IC95% 0.03-0.58). There is no significant difference in the genotypic frequencies. Conclusion(s): Subjects carrying the HLA-A*01:01 allele have a lower risk of developing interstitial lung manifestations posterior from COVID-19.

Post Coronavirus Disease 2019 (COVID-19) pulmonary fibrosis: a 12 months follow-up study

Background: limited data exist on the prevalence of radiographic abnormalities after COVID-19 pneumonia, and the extent to which High Resolution CT (HRCT) features correlate with symptoms and function after 12-month from hospitalization remains unclear. Aim(s): To prospectively assess and characterize, among all discharged patients with COVID-19, those with persisting pulmonary sequalae after 12-month follow-up. Method(s): 354 patients were evaluated in our post-COVID-clinic from June 2020 to January 2021. Symptoms and functional parameters were recorded. According to the absence or presence of HRCT abnormalities after 12-months, patients were categorized as recovered (REC) or not recovered (NOT-REC) and the extension of radiographic changes was scored. Result(s): 296/354 patients(84%) completed the 12-month follow up. 21/296(7%) presented pulmonary sequelae with a mean extension of interstitial changes of 11% of the whole lung. REC displayed a median full recovery time of 131(60-203) days. Compared to REC, NOT-REC were mainly current smokers [3(14%) vs.12(4%);p=0.05], with a longer in-hospital stay [13 (7.5-40.5) vs.10.0(6.0-16.0);p=0.02], need for a higher maximal FiO2 during hospitalization [60(29-100) vs. 33 (21-65);p<0.004] and higher intensity medical care [10(48%) vs.48(17%);p<0.001]. Conversely, lung function did not differ [FVC 97%(88-109) vs.93(82-105),p=0.32;FEV1 102% (86-116) vs. 96(85-106);p=0.11]. Conclusion(s): A low percentage of patients discharged for COVID-19 pneumonia showed fibrotic-like changes at 12month follow-up, yet with preserved lung function. They are mainly current smokers, with a higher level of medical care during hospitalization and a prolonged in-hospital stay.

Pulmonary function and tomographic features in adult survivors of severe COVID-19 pneumonia: a prospective study of 12-month follow-up

Introduction: There is a lack of data on long-term sequelae of severe COVID-19 pneumonia beyond clinical followup at 6 months. Aim(s): To describe the evolution of pulmonary sequelae at 3, 6 and 12 months in severe COVID-19 survivors in terms of pulmonary function and high-resolution computed tomography (HRCT) of the chest. Method(s): 84 subjects (74% male, median age: 63 [49-70]) hospitalized for COVID-19 pneumonia (January 2021- January 2022) were evaluated at 3, 6 and 12 months after discharge with spirometry, lung diffusing capacity (DLCO), 6-minute walking test (6MWT) and HRCT. Result(s): At 3, 6 and 12 months, 64%, 70% and 80% of patients were found to have normal spirometry (FVC: 83+/-6%, 96+/-2%, 97+/-2%]);DLCO <80% was found in 66% (mean 77+/-1%), 63% (mean 74+/-2%) and 43% (mean 81+/-1%) of subjects;6MWT performance was normal in 70% (median 494 m [582-472]), 84% (median 552 m [487- 583]) and 100% (median 557 m [496-588]) of subjects. However, after 1 year of discharge, 50% of patients had persistent oxygen desaturation at the end of the 6MWT. HRCT abnormalities were detected at 3, 6 and 12 months in 87%, 60% and 43% of patients. The most prevalent HRCT patterns at 12 months were ground-glass opacities (71%), subpleural reticulation and atelectasis (35%) and bronchiectasis (10%). Conclusion(s): A high prevalence of persistent lung function and HRCT abnormalities was found in survivors of severe COVID-19 pneumonia. Evaluation at 3, 6 and 12 months showed progressively improving values of spirometry, DLCO and 6MWT over time. However, long-term HRCT anomalies and exercise-induced desaturation suggest persistent interstitial phenomena of unknown implications.

Therapeutic Management of Advanced Hodgkin Lymphoma in Patients with Pulmonary Comorbidities

Introduction: Hodgkin lymphoma (HL) accounts for 30% of all lymphomas. The standard of care in the first-line treatment of advanced HL remains chemotherapy regimens containing bleomycin, a drug associated with lung toxicity. Brentuximab vedotin (BV), an anti-CD30 antibodydrug conjugate, combined with AVD (Adriamycin, Vinblastin and Dacarbazin) has been approved as a treatment for patients with untreated CD301 stage IV HL. No data (outside of clinical trials) were found on this use of BV-AVD in routine clinical practice. In this report, we describe 4 cases of HL treated with BV-AVD as first-line therapy. Material(s) and Method(s): Cases reported by the hematology department. Data were collected from CHIMIO software and medical records from 6/29/2021 to 3/21/2022. Results and discussion: Four patients (3 men, 1 woman, mean age 59 years [52-67], performance status 1-2) with advancedHL (2 stage III, 2 stage IV, all CD30+) were treated with BV-AVD as first-line treatment. Two patients had lung disease (1 HIV with a history of pneumocystis, tuberculosis and 1 emphysema) and 2 patients had active smoking, a major risk factor for lung disease. Three complete responses and one partial response were achieved, with no relapse to date. Treatment was well tolerated, with no pulmonary complications, no BV-induced neurotoxicity greater than grade 1, and no neutropenia (G-CSF prophylaxis). Although the drug is not reimbursed in this therapeutic indication in our country, our data suggest that BV-AVD is an attractive first-line treatment option in clinical practice for patients with advanced HL and risk factors for pulmonary complications, even in patients older than 60 years. Conclusion(s): Based on these results and in the context of the COVID pandemic, we redefined our therapeutic strategy for the front-line treatment of advanced HL with the BV-AVD indication in patients with pulmonary frailty.

Antimicrobial Therapy and COVID-19 - the 'Great Confrontation'

The problem of antimicrobial therapy (AMT) for the new coronavirus infection has been the cornerstone of practical healthcare since its emergence to the present day. The article summarizes a number of problems concerning the unjustified prescription of AMT based on the data of foreign and domestic studies, as well as actual clinical practice. On the one hand, viral damage to the lung tissue during COVID-19 is difficult to distinguish from community-acquired or secondary bacterial pneumonia;it prompts clinicians to prevent possible bacterial complications in the lungs by prescribing broad-spectrum antibiotics starting from the first day. On the other hand, the presence of clear clinical and biological markers of bacterial pneumonia;and COVID-19 makes it possible not to use antibiotics in routine practice, at least in the early stages of treatment. The introduction of procalcitonin as a biomarker of bacterial infection in COVID-19 into everyday clinical practice has a reasonable, methodical, and scientific approach to prescribing antibiotics.

Does The Suffering End After Cure From Covid?

Background Multisystem involvement of Covid-19 has been known since beginning of the pandemic. Multisystem after-effects or sequelae of covid-19 have been noted and the term 'long Covid' encompasses these signs and symptoms. This leads to prolonged morbidity which have not been adequately addressed by Covid guidelines.The primary aim of our study was to know the spectrum of different sequelae patients have endured after recovery from acute Covid-19 and study their impact on their quality of life. Methods It was a longitudinal observational study of a cohort of 146 patients who recovered from Covid-19 illness. Patients were enrolled within a week of their onset of Covid symptoms and were followed up monthly for a duration of 6 months with a detailed clinical and investigational pulmonary, cardiac, neurological and psychiatric assessment anda final follow-up after a year. Impact on quality of life was assessed using EQ-5D-3L questionnaire. Those lost to follow up were excluded from the analysis. Results 120/146 patients qualified for final analysis. Pulmonary sequelae (40%) were the majority among the patients, followed by psychiatric (25%), neurological (21.7%) and opportunistic infections (5.8%). 4/120 died within a year. 62/120 patients documented worsening in quality of life. Sequelae like pulmonary fibrosis, PTSD had the worst impact on the quality of life.95% severe, 54.5% moderate and 25% mild Covid patients reported deterioration in QoL score respectively. Conclusion Study indicates health related consequences from Covid-19 extend far beyond acute infection andmake significant impact on their quality of life, regardless of the severity of the disease. Copyright © 2023 Wolters Kluwer Medknow Publications. All rights reserved.

Effect of Preadmission Proton Pump Inhibitor (Ppi) on the Clinical Outcome of Covid -19 Hospitalised Patients during the Pandemic at the James Cook University Hospital, Middlesbrough, Cleveland, United Kingdom

Introduction: The primary objective of this study was to assess whether proton pump inhibitor (PPI) use at pre-admission affected clinical outcomes among covid 19 hospitalised patients. Aims & Methods: Prospectively captured data was analysed to include patients (>18 year) at the hospital with covid 19 infection . PPI data was derived from hospital and primary care records and the study period is over between February 2020 and February 2021.Clinical outcomes of covid 19 patients who were on proton pump inhibitors preadmission were compared with that of covid 19 patients who were not on proton pump inhibitors at the same time. The primary endpoint of the study was 60-day mortality, intensive care unit admission, high dependency unit admission as well as the development of covid-19 complications. Additional endpoints included length of critical care admission. Result(s): A total of 305 patients were included in the study,158 were on proton pump inhibitors and 147 not on proton pump inhibitor at index admission. There were 101 males and 57 females with a mean age of 61.65 in the PPI group, and in the no-PPI group there were 92 males and 55 females with a mean age of 57.28. The mean length of stay was9.98 in the PPI group and 11.83 in the non-PPI group. There was a slightly increased mortality rate of 29.93% in the non-PPI group compared with 28.48 % in the PPI group. Intensive Care Unit (ITU) and High Dependency Unit (HDU) admissions were higher in the non-PPI group (64.62%,30.6% respectively) than in the PPI group (58.22%,27.21%). Complications were more common in the non-PPI group;84.3% had pulmonary complications,7.3% had thromboembolic complications. In the PPI group 72.15% had pulmonary complications which was over 10 % less than in the non-PPI group, 4.4% had thromboembolic complications which was 1.66 times less than the non-PPI group. Conclusion(s): In Our study PPI usage at index admission failed to show any worsening of outcomes in Covid 19 hospitalised patients, as opposed to recent published papers. This proposed causation needs further evaluation via well conducted prospective studies.

Global Overview of the Management of Acute CHOLEcystitis during the COVID-19 Pandemic: The CHOLECOVID Study

Introduction: National guidance issued in response to COVID-19 resulted in adoption of non-surgical modes of treatment in emergency surgery, including acute cholecystitis (AC). The CHOLECOVID Study is the definitive global audit of the management and outcomes of AC during COVID19. Method(s): Patients >18 years with acute cholecystitis during two predefined 8-week time periods, pre-pandemic (P1, 12/09/19- 12/11/19) and during the pandemic (P2, 12/03/20-12/05/20), were included. The primary outcome was 30-day all-cause mortality. Secondary outcomes included severity of AC, radiological diagnostic modalities implemented, definitive management and pulmonary complications. Result(s): 9,783 patients were included from 40 countries. 30-day mortality was higher in P2 (1.7%vs2.4%;p<0.015). Higher rates of moderate and severe AC were seen in P2 (30.1%vs35.1%, p<0.001;3.7%vs4.1%, p<0.001). First-line CT imaging was more common in P2 (36.3%vs46.3%;p<0.001). Cholecystostomy rates were higher in P2 (5.8%vs8.8%;p<0.001), with a reduction in cholecystectomy (23.4% vs 44.2%, p<0.001). Overall 4.6% (n=193) of P2 patients were COVID-19 positive, with overall mortality of 0.7% (n=30). Following adjustment using a natural effects mediation analysis, a diagnosis of acute cholecystitis during the pandemic was associated with almost 30% higher odds of death compared to the pre-pandemic. Conclusion(s): During the COVID-19 pandemic, a small increase in mortality among AC patients was noted, when compared to the pre-pandemic cohort. Patients during the COVID-19 pandemic presented with more severe AC, resulting in altered trends in diagnosis and management. Clear pathways are required to prevent disruption of services and safely manage AC moving forward, in the face of the ongoing COVID-19 pandemic. Copyright © 2022

DOES COVID-19 INCREASE THE RISK OF DEVELOPING CYSTIC LUNG DISEASE?

SESSION TITLE: Late Breaking Chest Infections Posters SESSION TYPE: Original Investigation Posters PRESENTED ON: 10/18/2022 01:30 pm - 02:30 pm PURPOSE: (1) Assess the characteristics of COVID-19 patients who developed pulmonary cysts, bullae, blebs, and pneumatoceles. (2) Investigate outcomes of patients who developed cystic lung disease from COVID-19. METHODS: A literature search using Pubmed, Cochrane, and Embase was performed for case reports from 2020 to 2022 describing COVID-19 patients who developed lung cysts, bullae, blebs and pneumatoceles. The following data were extracted: patient demographics, presence of underlying lung disease, history of smoking, maximum oxygen requirements during acute illness, imaging findings, complications, and patient mortality. RESULTS: 65 publications (11 case series and 54 case reports) with a total sample size of 76 patients were analyzed. The mean age of patients was 52.2 ± 15.8 years. A majority of the cases were males (n=67, 88.2%). Twelve (15.8%) cases had an underlying lung disease, such as COPD or asthma, and 16 (21.1%) cases had a history of smoking tobacco. We categorized severity of illness based on the levels of oxygen requirement defined as: (1) mild - 0 to 2 liters of oxygen, (2) moderate - greater than 2 liters of oxygen to face mask/venturi mask and (3) severe - high flow nasal cannula, non-invasive ventilation, or mechanical ventilation. The majority of patients (n=40, 52.6%) had severe illness while 7 (9.2%) and 17 (22.4%) presented with mild and moderate disease, respectively. Of the 25 (32.9%) patients who required invasive mechanical ventilation, duration of ventilator days was provided for 14 patients, with a median of 40 days (interquartile range=54). Twenty-one (27.6%) patients were found to have cysts on imaging, 26 (34.2%) were found to have bullae, 3 (3.9%) were found to have blebs, 15 (19.7%) were found to have pneumatoceles, and 11 (14.5%) were found to have more than one of the aforementioned findings. A total of 53 (69.7%) patients developed pneumothorax and 12 (15.8%) developed pneumomediastinum. Seventeen (22.4%) patients were on the mechanical ventilator while pulmonary complications occurred. Additionally, 41 (53.9%) required chest tube placement, 16 (21.1%) required surgical intervention including open thoracotomy or video assisted thoracoscopy. A total of 47 (61.8%) cases reported either resolution of symptoms and complications, or improved imaging findings following interventions. The rate of inpatient mortality was 11.8%. CONCLUSIONS: Patients with severe COVID-19 may have a higher risk for developing cystic lung disease, hence, increasing the risk for complications such as pneumothorax and pneumomediastinum. CLINICAL IMPLICATIONS: Patients who had severe COVID-19 may benefit from closer follow up and serial imaging for early detection of cystic lung disease. DISCLOSURES: No relevant relationships by Kavita Batra No relevant relationships by Rajany Dy No relevant relationships by Christina Fanous No relevant relationships by Wilbur Ji No relevant relationships by Max Nguyen No relevant relationships by Omar Sanyurah

POST-COVID PULMONARY COMPLICATIONS IN THE OUTPATIENT SETTING: ARE WE PREPARED FOR THE AVALANCHE?

SESSION TITLE: What Lessons Will We Take From the Pandemic? SESSION TYPE: Rapid Fire Original Inv PRESENTED ON: 10/19/2022 11:15 am - 12:15 pm PURPOSE: Post COVID pulmonary complications can be attributed to severe inflammatory response that can result in pulmonary fibrosis. It is somewhat predictable in patients with severe illness, advanced age and comorbidities. However, a little is known about pulmonary complications in younger patients with mild illness followed up at outpatient clinics. We aim to shed light on post COVID pulmonary complications in patients who did not require hospitalization but had significant outpatient visits. METHODS: This study is based upon a retrospective chart review of patients who presented to Pulmonology Clinic at Cayuga Medical Associates with respiratory symptoms associated with COVID-19 disease. Mild illness was defined as symptoms of dyspnea on exertion or fatigue or shortness of breath that have not required oxygen and lasted for less than or equal to two months. Moderate illness was defined as symptoms of mild illness lasting for more than two months without oxygen supplementation. Severe illness was defined as hypoxia requiring home oxygen. We have excluded the patients who were hospitalized for COVID pneumonia. RESULTS: Of 23 patients (56.52% female) with COVID illness seen at Pulmonology Clinic in one-year duration, 13.04% had COPD, 26.09% had asthma and 21.74% had OSA. Median age was 33 with mean BMI 27.61.13.04% were current smokers. 39.13% required a PFT among which 77.78% had normal results. 21.74% of the total patients who never had OSA as an underlying diagnosis, required sleep study, among which 60% had mild OSA and 20% had severe OSA. 13.04% were already on oral steroids for other diseases. Majority of the patients had normal chest x-ray findings. 39.13% had CT chest, majority of which showed normal findings and few with diffuse ground glass opacities. 8.70% developed palpitations along with respiratory symptoms. At six months follow up, 43.48% had mild illness who were managed with conservative management such as incentive spirometry, deep breathing techniques, prone positioning and as needed short acting bronchodilator treatments. 43.48% had moderate illness who were treated with short course of oral steroids in addition to conservative management. 13.04% had severe illness who required home oxygen up to 2 L for two months maximum. Most common pulmonary complaint was dyspnea on exertion, seen in 43.48%. 17.39% had fatigue. 21.74% had sleep apnea symptoms. Median duration of symptoms was two months. CONCLUSIONS: Our study outlines the incidence of post COVID pulmonary complications in patient group where these complications are least expected. CLINICAL IMPLICATIONS: Post COVID pulmonary complications appear to be of significant concern in patients visiting outpatient clinics. The heterogeneity in management of those complications needs a serious attention. The feasibility and implementation strategy of post COVID-19-care-clinic with proper management guidelines should be brought to streamline practice. DISCLOSURES: No relevant relationships by Sameer Acharya No relevant relationships by Ali AKRAM No relevant relationships by Samjhauta Bhattarai No relevant relationships by Lavanya Kodali

UNUSUAL CASE OF ANTI-SYNTHETASE SYNDROME CORRELATED WITH EXPOSURE TO COVID-19 INFECTION OR VACCINE

SESSION TITLE: Systemic Disease with Diffuse Lung Symptoms Case Posters SESSION TYPE: Case Report Posters PRESENTED ON: 10/17/2022 12:15 pm - 01:15 pm INTRODUCTION: Since its first detection at Wuhan, China, SARS-CoV-2 (novel coronavirus 2019) has engulfed the world with more than 100 million cases and manifestations of COVID19 have been evolving over time. Various post COVID19 syndromes are being recognized. Reactive arthritis, connective tissue disorders such as myositis and pulmonary complications have been correlated with exposure to COVID infection. We describe the case of antisynthetase syndrome in a patient correlated with exposure to COVID infection or vaccine. CASE PRESENTATION: A 68 year old female with history of hypertension and exposure to COVID infection in the family member, presented with 2-3 months worsening generalized body ache/pain started 2 weeks after receiving second dose of mRNA vaccine. Patient also reported dyspnea and leg swelling for 1 month. Upon presentation, she was placed on 4 liter oxygen via nasal cannula. Chest x-ray concerning for infiltrates, possibly COVID. CT chest no pulmonary embolism but evidence of pneumonia superimposed on chronic appearing bronchiectasis. Flu and Covid testing were negative. Patient was started on IV antibiotics for community acquired pneumonia. Labs showed elevated ESR, CRP and CK level. No fever, weakness, mechanics hands, rash or Raynaud's phenomenon. Infectious work up remained negative. No lymphadenopathy on CT chest to suggest sarcoid. ACE level normal. ANA and anti aminoacyl-tRNA synthetase antibody positive but other ENA were negative. HMG-COA ab negative. MPO/PR3 neg. Echocardiogram was unremarkable. Work up was suggestive of Anti synthetase syndrome with interstitial lung disease(ILD), a form of dermatomyositis. Patient was started on intravenous steroid with good improvement in symptoms and later transitioned to oral prednisone. Patient was discharged on minimal home oxygen with plan to start immunosuppressive medications. DISCUSSION: We are unsure if our patient had COVID19 infection since COVID testings were negative (antigen, antibody and nucleic acid detection ). The likelihood of autoimmune and rheumatic diseases in COVID19 survivors is a big issue. COVID19 infection may unmask previously undiagnosed rheumatic conditions and precipitate de novo disease, both of which may persist after resolution of the initial infection. Corticosteroids remain the cornerstone of early treatment with initial doses at 1mg/kg of the ideal body weight. In an effort to reduce steroid related side effects, other immunosuppressive agents should be considered at the outset of therapy, particularly when treating anti-synthetase syndrome with manifestations of ILD. CONCLUSIONS: Patients with anti-synthetase syndrome with ILD could have correlation with exposure to COVID infection or vaccination, and are steroid responsive. It is likely that clinical improvement may result from prompt suppression of inflammatory systemic response by corticosteroid. Reference #1: 1. Ahmed S, Zimba O, Gasparyan AY. COVID-19 and the clinical course of rheumatic manifestations. Clin Rheumatol. 2021;40(7):2611-2619. doi:10.1007/s10067-021-05691-x Reference #2: 2. Witt LJ, Curran JJ, Strek ME. The Diagnosis and Treatment of Antisynthetase Syndrome. Clin Pulm Med. 2016;23(5):218-226. doi:10.1097/CPM.0000000000000171 DISCLOSURES: No relevant relationships by ELINA MOMIN No relevant relationships by Mohammedumer Nagori

OUT OF THIN AIR: A CASE OF SEVERE SUBCUTANEOUS EMPHYSEMA, PNEUMOMEDIASTINUM, AND PNEUMOTHORAX ASSOCIATED WITH COVID-19

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: One of the greatest challenges of the coronavirus (COVID-19) pandemic has been deciphering its unique properties, such as the propensity to infect and damage lung epithelium, thereby increasing susceptibility to pulmonary complications.(1, 2) A 2020 cohort study comparing patients with acute respiratory distress syndrome (ARDS) from COVID-19 and ARDS from other causes showed a significantly higher rate of subcutaneous emphysema and pneumomediastinum in the COVID-19 group, suggesting these diagnoses may be due to direct viral damage rather than exposure to positive pressure alone.(3) Presented here is a patient with no underlying lung pathology who was diagnosed with COVID-19 and developed severe subcutaneous emphysema, pneumomediastinum, and pneumothorax. CASE PRESENTATION: A 74 year old male with a history of hypertension presented to the emergency room with a 5-day history of difficulty breathing, cough, fever, chills, and weakness. He tested positive for COVID-19, required non-invasive positive pressure ventilation (NIPPV), and was started on ceftriaxone, doxycycline, and daily dexamethasone. He received a five-day course of remdesivir and one dose of convalescent plasma. By day 9, a chest x-ray revealed a left apical pneumothorax, bilateral subcutaneous emphysema, and pneumomediastinum. On day 12, his respiratory status deteriorated, necessitating invasive mechanical ventilation. A chest CT showed extensive subcutaneous emphysema involving the chest, supraclavicular and axillary regions, and abdominal wall, as well as extensive pneumomediastinum and a moderate left pneumothorax. A left-sided thoracostomy tube was placed and he was proned per ICU protocol. He required placement of a second left-sided chest tube due to persistent worsening pneumothorax. On day 28, despite all aggressive measures, he expired from acute hypoxemia. DISCUSSION: Although this patient was exposed to NIPPV, the severe degree of lung pathology was inconsistent with the amount of positive pressure administered. Furthermore, he lacked underlying pulmonary disease that would compromise his lung compliance to this magnitude. Combining evidence that COVID-19 can cause epithelial lung damage, the patient's absence of pulmonary risk factors, and his severe degree of lung damage incongruent with his exposure to positive pressure, is reasonable to extrapolate that a significant portion of his lung pathology was a result of direct damage from COVID-19. CONCLUSIONS: Patients with COVID-19 may be at higher risk for the development of subcutaneous emphysema, pneumomediastinum, and pneumothorax, likely due to direct viral effect. Lung damage seen may be disproportionate to exposure of positive pressure and may also be seen in the absence of any underlying pulmonary comorbidities. Awareness of this observed pathophysiology may help guide clinicians to optimize ventilator management as well as anticipate potential complications. Reference #1: Hu B, Guo H, Zhou P, Shi ZL. Characteristics of SARS-CoV-2 and COVID-19 [published correction appears in Nat Rev Microbiol. 2022 Feb 23;:]. Nat Rev Microbiol. 2021;19(3):141-154. doi:10.1038/s41579-020-00459-7 Reference #2: Miró Ò, Llorens P, Jiménez S, et al. Frequency, Risk Factors, Clinical Characteristics, and Outcomes of Spontaneous Pneumothorax in Patients With Coronavirus Disease 2019: A Case-Control, Emergency Medicine-Based Multicenter Study. Chest. 2021;159(3):1241-1255. doi:10.1016/j.chest.2020.11.013 Reference #3: Lemmers DHL, Abu Hilal M, Bnà C, et al. Pneumomediastinum and subcutaneous emphysema in COVID-19: barotrauma or lung frailty?. ERJ Open Res. 2020;6(4):00385-2020. Published 2020 Nov 16. doi:10.1183/23120541.00385-2020 DISCLOSURES: No relevant relationships by Shanaz Azad No relevant relationships by Sarah Monaghan No relevant relationships by Brandon Nance No relevant relationships by Samantha Peterson

COVID-19 IN LUNG TRANSPLANT RECIPIENTS: A SINGLE CENTER EXPERIENCE

SESSION TITLE: Lung Transplantation: New Issues in 2022 SESSION TYPE: Rapid Fire Original Inv PRESENTED ON: 10/19/2022 11:15 am - 12:15 pm PURPOSE: Immunosuppressed patients are more susceptible to severe infection due to COVID-19. Management of lung transplant recipients is especially difficult due to constant exposure of the graft to the environment, leading to increased risk of rejection and requiring higher levels of maintenance immunosuppressive regimens. Mortality rates for lung transplant recipients with COVID-19 infection have ranged from 15% to 40% in published case series. We report our centers experience in managing lung transplant recipients with COVID-19 infections in a moderate-volume lung transplant center in Grand Rapids, Michigan. METHODS: This is a single center review of all lung transplant recipients with a COVID-19 diagnosis from March 2020 to December 2021. Recipients’ demographics and baseline characteristic, as well as their management, post infectious complications, and mortality data, were reviewed. RESULTS: In 2019, our center performed 48 lung transplants. During the study period, 42 of the 219 (19%) lung transplant recipients followed at our center had COVID-19 infections diagnosed by nasal or nasopharyngeal PCR testing. Twenty-four (57%) were male, mean age of 60.5 (range 25-77). Thirty-six (86%) patients had bilateral lung transplants. The diagnosis leading to their transplantation were COPD (N=18, 43%), idiopathic pulmonary fibrosis (N=12, 29%), cystic fibrosis (N=5, 12%), other pulmonary fibrosis (N=3, 7%), alpha-1 antitrypsin deficiency (N=2, 5%), Sarcoidosis (N=1, 2%), and ARDS (N=1, 2%). Almost all patients were on standard three drug immunosuppressive regimens which included a steroid, calcineurin inhibitor, and nucleotide-blocking agent, at the time of diagnosis. Mean time from transplant to diagnosis of COVID-19 was 34.6 months (range 1 to 104 months). Fifteen (36%) of the patients were unvaccinated. Once diagnosed, patients were advised to monitor their home spirometry and vitals at least daily. They were evaluated weekly via telemedicine by a physician or advanced practice provider. They received the following treatments: monoclonal antibody (N=31, 74%), increased steroids (N=5, 12%), remdesivir (N=2, 5%), Tocilizumab (N=1, 2%). Eleven (26.2%) patients required hospitalization, 4 (10%) required ICU admission and intubation. Mean length of stay was 7.5 days (median of 3 days). Three (7%) patients required oxygen at discharge. Of the 42 infected patients, 3 (7.1%) died on day 3, 16 and 326 days from the date of infection. CONCLUSIONS: Our center reports a lower mortality rate than previously published data in lung transplant recipients infected with COVID-19. We attribute this to availability of the vaccine, early detection and treatment, as well as close monitoring of the patients. CLINICAL IMPLICATIONS: Though COVID-19 infection can have devastating complications in lung transplant recipients, vaccinations and monoclonal antibody treatment reduce morbidity and mortality in this population. DISCLOSURES: No relevant relationships by Phillip Camp research relationship with United Therapeutics Please note: 2016- ongoing by Reda Girgis, value=Grant/Research research relationship with Pfizer Please note: 2014-2020 by Reda Girgis, value=Grant/Research Speaker/Speaker's Bureau relationship with Boehringher Ingelheim Please note: 2016-ongoing by Reda Girgis, value=Honoraria Speaker/Speaker's Bureau relationship with Genentech Please note: 2016-ongoing by Reda Girgis, value=Honoraria no disclosure on file for Ryan Hadley;No relevant relationships by Sheila Krishnan No relevant relationships by Edward Murphy No relevant relationships by Gayathri Sathiyamoorthy