A pre-existing case of HBV infection with elevated HBV DNA after COVID-19 pneumonia treatment.

The patient presented with fever and appetite loss. Computed tomography (CT) revealed a moderate grade 2 pneumonia. Besides, further blood examination showed his HB antigen as negative, anti-HBs/c anti-body as positive, and HBV DNA level as 1.0 LIU/mL. Therefore, he was diagnosed with COVID-19. Administered treatments comprised oxygen inhalation and steroid therapy, including pulses, remdesivir, and baricitinib, which improved pneumonia. Interestingly, one month posttreatment, his HBV DNA level in-creased to 1.4 LIU/mL, followed by a further increase to 1.7 LIU/Ml, showing an improvement. Tenofovir alafenamide fumarate was thus administered. In clinical practice, immunosuppressive therapy is used for patients with moderate-to-severe COVID-19 pneumo-nia. However, close attention should also be paid to the elevation of blood HBV DNA levels during and after treatment.Copyright © 2022 The Japan Society of Hepatology.

High-Dose Steroids in COVID-19 Related Acute Respiratory Distress Syndrome: A Proposed Protocol

Introduction: The introduction of dexamethasone in the treatment of COVID-19 began in late 2020 after evidence emerged demonstrating that treatment with corticosteroids reduced mortality in those infected with severe COVID-19.1 Current guidelines suggest the use of Dexamethasone 6mg OD for 7-10 days for those requiring oxygen. A small proportion of patients in the intensive care unit do not respond to the usual dosing of dexamethasone. A treatment often advocated following discussion with the regional ECMO centre was high-dose steroid therapy.2-3 No guidance existed regarding the use of high-dose steroids in ARDS secondary to COVID-19. We believed there was inconsistency in patient selection, screening, dosing and monitoring. A protocol was needed to simplify this process. Objective(s): To develop a simple protocol for the use of high-dose steroids in COVID-19 related ARDS that provided the user with information on: 1. When to consider high-dose steroids 2. The precautions that should be taken to exclude infection prior to commencing high-dose steroids 3. The monitoring required while receiving high-dose steroids 4. A proposed treatment regimen Methodology and Results: A literature review of treatment regimens for high-dose steroids in COVID-19 ARDS was undertaken. We also included trials involving non-COVID-19 ARDS.3-4 A local evidence-based protocol for the use of high-dose steroids in COVID-19 related ARDS was designed. Following peer review by the wider MDT the protocol was first trialled, reviewed, and then adopted. An extended guideline with scientific context together with a quick reference bedside poster were launched. Conclusion(s): The protocol provided a user-friendly summary of the information required to safely use high-dose steroids for the treatment of COVID-19 related ARDS. The algorithm has now been adopted in several units and has been submitted for consideration as a network wide resource. Feedback from users has been positive and we will seek to review and update this guidance as further evidence emerges in this evolving condition.

Rituximab in a Large Uk Centre during the Covid-19 Pandemic: The Effects of Employing a Reduced Dosing Regimen on Clinical Response in Rheumatoid Arthritis Patients

Background/Aims When the COVID-19 pandemic began, steps were taken to minimise risk to those vulnerable to severe outcomes. For immunosuppressed patients with rheumatoid arthritis (RA), consideration was given to reducing risk whilst mindful of compromising control of their underlying condition. At Leeds Teaching Hospitals NHS Trust, patients receiving rituximab (RTX) were considered for a reduced dose regimen. A retrospective study, using real-world data, was undertaken to assess the impact of lower doses of RTX on response to treatment. Methods The clinical records of all patients with RA who had received RTX between March 2020 and March 2021 were reviewed. Demographics and previous RTX exposure were recorded. The dose of RTX given during the specified period was noted. Response to treatment was recorded pragmatically by physicians as good, partial or none, based on patient reported VAS for disease activity and swollen and tender joint counts, given the limitations placed on face-to-face patient review due to the pandemic. The time to subsequent RTX treatment and the need for steroid treatment for flares was also studied. Results The number of patients treated with RTX was 282, of whom 89 patients received full dose (1g x 2 infusions), 192 patients received half dose (500mg x 2 infusions). The mean age was 61 years. 77% were female. 9% were RTX-naive, 80% had previously had full dose. Follow-up data were available for 185/192 of the group receiving 1g and 88/89 of the group receiving 2g. Clinical outcomes were as follows for the two groups (1g RTX vs 2g RTX): no response 10.3% vs 9.1%;partial response:34.9% vs 20% %;good response: 54.8% vs 70.9%. The mean length of response was 7.5 months in the patients receiving 1g of RTX compared to 8.6 months in the group receiving 2g of RTX. Similar number of patients required steroid for a flare after receiving Ig of RTX (23.9%) compare to those receiving 2g of RTX (25.8%). Conclusion A majority of patients receiving RTX for RA at either standard or reduced dose reported clinical response. Those receiving lower dose RTX were more likely to report a partial response whilst those receiving full dose were more likely to report a good response. Duration of response and need for steroid therapy for flare of RA between treatments did not significantly differ between groups. Further analysis of factors that may influence clinical response to lower dose RTX is ongoing, which could guide tailored therapy regimens should the need arise again.

Current status of guideline based screening and monitoring for HBV reactivation in patients with COVID-19 pneumonia treated with immunosuppressive agents

Background and Aim: Immunosuppressive agents (e.g., baricitinib [BAR], tricizumab [TCZ]) and steroids are used for treating coronavirus disease 2019 (COVID-19) pneumonia. These immunosuppressive agents are known to cause HBV reactivation. The current guidelines recommend HBV screening and HBV reactivation monitoring in Japan. However, the status of compliance among treated patients with COVID-19 pneumonia remains unclear. Herein, we report the status of compliance with the current guidelines on HBV reactivation. Method(s): We investigated the implementation of HBV screening and HBV reactivation monitoring for patients who received immunosuppressive agents in our hospital from April 2021 up to June 2021. Background factors related to the presence or absence of screening were analyzed. Result(s): There were 123 patients who received immunosuppressive agents in our hospital from April 2021 up to June 2021. The patients median age was 63 years old (31-95 years), and 90 patients were men. BAR/steroid therapy was given in 115 patients and TCZ/steroid therapy in 8 patients. Of the 123 patients in whom HBs antigen level was measured, 2 patients were positive for HBs antigen. Anti-HBc/ HBs antibodies were measured in all 121 HBsAg-negative patients according to the guidelines. Of 32 patients who were positive for either or both anti-HBc/HBs antibodies, HBV DNA was measured in 31 patients. Of 34 patients who required regular reactivation monitoring, 30 did not receive regular monitoring (6 died in the hospital, 11 were transferred to other hospitals, and 13 were terminated of their treatment early in the outpatient department of the hospital). Only 4 patients were monitored according to the guidelines. Of the 4 patients monitored, 1 was positive for HBs antigen and was given a nucleic acid analogue. In 1 patient, HBV DNA increased from signal-positive to 1.4 LIU/mL and then to 1.7 LIU/mL and nucleic acid analogue was started. The remaining 2 patients had undetectable HBV DNA or remained signal-positive. Conclusion(s): The HBV reactivation monitoring rate at the start of COVID-19 pneumonia treatment was high. However, HBV reactivation monitoring after the COVID-19 pneumonia treatment was difficult because most patients were transferred to other hospitals or had their treatment terminated.

Relationship Between Day of Starting Steroid and Clinical Outcome in Hospitalized Covid-19 Patients

Various guidelines recommend steroid in only severe COVID-19 patients. But in hospitals steroids are being rampantly used even at the beginning of symptom onset. Some studies indicate starting steroid only in severe and/or patients on mechanical ventilation while some suggest starting in first 5-7 days to stave off cytokine storm. Hence this study was undertaken with the aim to study the relationship between initiation of steroid therapy and clinical outcome in hospitalized COVID-19 patients. The data for this study was collected from the medical records of patients diagnosed with COVID-19 in a tertiary care hospital. Evaluation of relationship between day of initiating steroid therapy and dose with the clinical outcome was done in terms of all-cause mortality, duration of hospital stay, requirement of assisted ventilation, requirement of ICU and requirement of oxygen therapy. Patients were categorized according to the day of initiating steroid after symptom onset or RTPCR or RAT positivity date, whichever was earlier in 4-7 days group, 8-10 days group and 11-14 days group. And according to dose given of methylprednisolone per day in 40 mg and 80 mg groups. All-cause mortality was significantly less in 8-10 days group (25.78%) compared to 4-7 days (38%) and 11-14 days group (39.68%) and significantly less in 40 mg group (26.67%) compared to 80 mg group (38.46%). Starting steroid between 8-10 days and in low dose (40 mg) is more beneficial in terms of all-cause mortality.Copyright © 2023, Global Research Online. All rights reserved.

Mortality from COVID-19 in patients with lung cancer

The World Health Organization declared coronavirus infectious disease-2019 (COVID-19) linked to the severe acute respiratory syndrome (SARS-CoV-2), a global pandemic in March 2020. The pandemic outbreak has led to the most unprecedented and catastrophic loss of human life in the recent history. As of January 2021, there were more than 100 million cases of COVID-19 and more than two million deaths worldwide. Compared to the general population, patients with cancer are at a higher risk of poor outcomes from COVID-19. In large cohort studies, mortality from COVID-19 in patients with cancer can be as high as 40%. In addition to clinical variables (older age, male sex, and co-morbidities) that are associated with mortality in general population, cancer patients are uniquely vulnerable to severe COVID-19 due to immunosuppression from cancer and its therapy, and disruption of routine clinical care. Among patients with cancer, the lung cancer population is at a higher risk of poor outcomes and mortality from COVID-19 for several reasons. For instance, lung is the main target organ in COVID-19 that can lead to respiratory failure, patients with lung cancer have baseline poor lung function from chronic obstructive pulmonary disorder and smoking. In addition, some of the lung cancer treatment side-effects like pneumonitis, may obscure the diagnosis of COVID-19. In this article, we systematically review the most impactful cohort studies published to date in patients with cancer and COVID-19. We describe the rates of mortality in patients with cancer and COVID-19 with a special focus on the lung cancer population. We also summarize the factors associated with poor outcomes and mortality in patients with lung cancer and COVID-19.Copyright © The Author(s) 2021.

Ndegree39 - Fulminant life-threatening myopathy of the genetic origin

Objectives: Acute myopathy are seen in critically ill patients, in severe SARS-CoV2 pneumonia requiring mechanical ventilation, and other infection illness, toxin and drug-induced complications, or systemic inflammation. Periodic paralysis or carnitine disorders are known genetic causes of acute muscular weakness, besides genetically determined muscle diseases rarely have an acute clinical course. Content: Case presentation: 61-years old, healthy woman, after a one-time vaccination against Covid-19 about 2 weeks earlier, was admitted to the Neurological Department due to symptoms lasting for 2 days. On the first day of the disease she complained of vertigo and double vision, on the following day dysarthia and dysphagia appeared, she stopped walking. On the second day of hospitalization, the patient required mechanical ventilation. The initial diagnosis of Guillaine-Barre syndrome was not confirmed in the electrophysiological and laboratory (CSF) studies. Myopathic pattern with polyphasic potentials of short duration and low amplitude was observed in EMG, without spontaneous activity. In the electron microscope numerous fat drops between bundles of myofibrils in most muscle fibers were seen. She received intravenous immunoglobulins, and steroid therapy, together with high doses of vitamin B2 with very good motor improvement. Multiple acyl-CoA dehydrogenase deficiency (MADD) was suspected, and the Whole Exome Sequencing (WES) was performed. Conclusion(s): The authors note the possibility of acute, life-threatening myopathy, which may be caused by a genetic defect. MADD is a very rare genetic entity which can manifest for the first time very suddenly, especially in the presence of triggers, including but not limited to after vaccinations. Keywords: Acute myopathy;Multiple acyl-CoA dehydrogenase deficiency;Vitamin B2.Copyright © 2023

Pseudomembranous colitis in patients with COVID-19 (review).

AIM: to estimate the features of pseudomembranous colitis in patients with COVID-19, diagnostics, conservative treatment and surgery for complications. PATIENTS AND METHODS: a retrospective analysis of 396 patients with pseudomembranous colitis (PMC) in patients with new coronavirus infection was carried out for the period from March 2020 to November 2021. Among them there were 156 (39.3%) males, females - 240 (60.6%), moderate and severe forms of COVID-19 occurred in 97.48%. The diagnosis of PMC was established due to clinical picture, laboratory, instrumental methods (feces on Cl. difficile, colonoscopy, CT, US, laparoscopy). RESULT(S): the PMC rate in COVID-19 was 1.17%. All patients received antibiotics, 2 or 3 antibiotics - 44.6%, glu-cocorticoids were received by all patients. At 82.8%, PMC developed during the peak of COVID-19. To clarify the PMC, CT was performed in 33.8% of patients, colonoscopy - 33.08%, laparoscopy - in 37.1% (to exclude bowel perforation, peritonitis). Conservative treatment was effective in 88.8%, 76 (19.1%) patients had indications for surgery (perforation, peritonitis, toxic megacolon). Most often, with peritonitis without clear intraoperative confir-mation of perforation, laparoscopic lavage of the abdominal cavity was performed (60 patients - 78.9%, mortality - 15.0%), colon resection (n = 6 (7.9%), mortality - 66.6%), ileo-or colostomy (n = 8 (10.5%), mortality - 37.5%), colectomy (n = 2 (2.6%), mortality - 50.0%). The overall postoperative mortality rate was 22.4%, the incidence of surgical complications was 43.4%. In addition, in the postoperative period, pneumonia was in 76.3%, thrombosis and pulmonary embolism in 22.3% of patients. In general, the overall mortality in our patients with PMC was 11.4%, with conservative treatment - 8.8%. CONCLUSION(S): pseudomembranous colitis is a severe, life-threatening complication of COVID-19. In the overwhelm-ing majority of patients, conservative therapy was effective, but almost 1/5 of patients developed indications for surgery, the latter being accompanied by high mortality and a high morbidity rate. Progress in the treatment of PMC, apparently, is associated with early diagnosis, intensive conservative therapy, and in the case of indications for surgery, their implementation before decompensation of the patient's condition and the development of severe intra-abdominal complications and sepsis.Copyright © 2022, Association of Coloproctologists of Russia. All rights reserved.

Staging of COVID-19 disease, using selected laboratory profiles for predictionprevention and management of severe SARS-CoV-2 infection in Africa-review

There are many uncertainties on the future management of the coronavirus disease 19 (COVID-19) in Africa. By July 2021, Africa had lagged behind the rest of the world in Covid-19 vaccines uptake, accounting for just 1.6% of doses administered globally. During that time COVID 19 was causing an average death rate of 2.6% in Africa, surpassing the then global average of 2.2%. There were no clear therapeutic guidelines, yet inappropriate and unnecessary treatments may have led to unwanted adverse events such as worsening of hyperglycemia and precipitating of ketoacidosis in administration of steroid therapy. in order to provide evidence-based policy guidelines, we examined peer-reviewed published articles in PubMed on COVID 19, or up-to date data, we focused our search on publications from 1st May 2020 to 15th July, 2021. For each of the studies, we extracted data on pathophysiology, selected clinical chemistry and immunological tests, clinical staging and treatment. Our review reports a gross unmet need for vaccination, inadequate laboratory capacity for immunological tests and the assessment of individual immune status, clinical staging and prediction of disease severity. We recommend selected laboratory tools in the assessment of individual immune status, prediction of disease severity and determination of the exact timing for suitable therapy, especially in individuals with co-morbidities.Copyright © 2023 Sendagire H et al.

Epidemiology of COVID-19-Associated Mucormycosis.

Purpose of the Review: To describe the epidemiology and risk factors for Coronavirus disease-19 (COVID-19)-associated mucormycosis (CAM) based on current published literature. Recent Findings: COVID-19 is associated with an increased risk of secondary infections. Mucormycosis is an uncommon invasive fungal infection that typically affects people with immunocompromising conditions and uncontrolled diabetes. Treatment of mucormycosis is challenging and is associated with high mortality even with standard care. During the second wave of the COVID 19 pandemic, an abnormally high number of CAM cases were seen particularly in India. Several case series have attempted to describe the risk factors for CAM. Summary: A common risk profile identified for CAM includes uncontrolled diabetes and treatment with steroids. COVID-19-induced immune dysregulation as well as some unique pandemic specific risk factors may have played a role.

The Effect of Corticosteroid Therapy on Choroidal Thickness in Patients With Covid-19 Infection: A Prospective, Comparative, and Observational Study.

BACKGROUND: Coronavirus disease 2019 (Covid-19) has many different ocular manifestations. This study evaluates the effects of the disease and the steroid used in this disease on ocular structures. PURPOSE:  To evaluate the effects of Covid-19 and the steroids used in the treatment of severe infection on ocular structures and choroidal thickness. METHODS: This prospective study included 76 eyes of 76 patients who were hospitalized due to Covid-19 and 30 eyes of 30 healthy volunteering controls. Group I included 35 eyes who were hospitalized due to moderate-to-severe involvement that received steroid treatment, group II included 41 eyes with moderate involvement that did not require steroid treatment, and group III included 30 eyes with age- and gender-matched control subjects. Ophthalmological examination and imaging results of the patients obtained in the third week and third month after the diagnosis were compared between the groups. RESULTS: Mean age of all participants was 40.2 ± 6.1 years. In the third week after the diagnosis of Covid-19, choroidal thickness in all regions (subfoveal, nasal, and temporal) was significantly greater in group I than in group II (for all, p<0.001). Moreover, choroidal thicknesses were significantly higher in group I and group II than in the control group (for all, p<0.001). In the third month, all the groups had similar choroidal thickness values (for subfoveal, nasal, and temporal; p=0.058, p=0.111, p=0.079, respectively). CONCLUSION: Our findings showed that Covid-19 infection causes choroidal thickening by affecting the choroidal layer and that steroid treatment further increases this thickness in the acute period. In addition, the reversal of this thickening to the normal level within a period of three months indicates that the effect of the disease on the choroid is reversible.

Erythema nodosum following the first dose of AstraZeneca COVID-19 vaccine

Introduction (contexte de la recherche): Erythema nodosum (EN) is a type IV delayed hypersensitivity reaction to a variety of antigens stimuli. In fact, EN is commonly caused by a range of conditions, including infections and vaccines. EN induced by COVID-19 vaccines is rarely reported. Objectif: Herein, we report an original clinical observation of EN occurring after the first dose of AstraZeneca COVID-19 vaccine (vaxzevria), a viral vector vaccine, without recurrence after the second dose. Methodes: This case was notified on August 2021 to Tunisian National Centre of Pharmacovigilance and was analyzed according to the French updated method for the causality assessment of adverse drug reactions. Resultats: A 46-year-old woman with no medical history, presented with diffuse erythematous painful and nodular lesions, located symmetrically over her legs. Eleven days before, she had received the first dose of vaxzevria which was followed by a sudden asthenia, and oedema over her lower limbs. The patient reported no recent infectious episodes. She had no known drug allergy. Skin examination showed multiple, tender, erythematous nodules, which ranged from 3 to 4 cm in diameter located over the tibial area. Some were regressive according to biligenesis shades. Laboratory tests including a complete blood count, renal and hepatic tests and antistreptolysin O titer were carried out and were negative except an elevated c-reactive protein of 45 mg/dL. The dermatological examination found lesions on both legs to be consistent with EN and started therapy with prednisone 40 mg daily for one week, subsequently gradually tapered and suspended, with complete regression of lower limb skin lesions within 10 days. No skin biopsy was performed due to the typical clinical presentation, color evolution and a complete response to steroid therapy. The patient subsequently received the second dose after two months without the reappearance of EN. Conclusion(s): In this case the role of vaccine was suspected in front of a temporal association between the first dose of vaccine and the onset of EN and the absence of another etiology. However, the good evolution of this skin manifestation will help reassure patients in the safety of vaccine administration.Copyright © 2023

Experiences of Covid19 Disease and Vaccination in Hungarian Myositis Patients: Anti-Jo-1 Is a Risk Factor for Hospitalization

Background. Pandemic caused by severe acute respiratory syndrome coronavirus 2 (COVID19) raises a smash barrier for clinicians and patients since 2 years. Limited information is available on disease course after COVID19 infection or vaccination in patients with idiopathic inflammatory myopathies (IIM). Objective(s): The primary goals of the current research were to assess frequency and outcome of COVID19 disease and to determine the vaccination rate and effect in our IIM cohort. Secondary objectives were to search for risk factors of infection, predictive factors of hospitalization and to assess incidence of pots-vaccination adverse events and breakthrough infections. Methods. We identified the confirmed COVID19 positive patients and assessed disease course and outcome on 01/06/2021 in our cohort then patients were prospectively followed. Incidence and complications of infection and vaccination were determined by questionnaires and using the database. Anti-SARS-CoV-2 spike protein electrochemiluminescent immunoassay has been used to assess seroconversion. Disease activity was determined by physician global activity. Results. A total of 176 patients were screened and 101 participated in the study. By 01/06/2021, the COVID infection rate was 34.7%, which was significantly higher than the national prevalence at that time (8.2%). A third of these infections occurred asymptomatically or mild, but 20% of the infected patients were hospitalized, one patient died. Longer disease duration (8.67 vs. 17.87 years;p=0.003) and higher incidence of anti-Jo-1 antibody (57% vs. 10%;p=0.018) were significantly associated with hospitalization. All patients became seropositive after COVID19 infection regardless of immunosuppressive therapy or symptoms severity, meanwhile 72.3% of patients became seropositive after vaccination. Different vaccines induced various titer of antibody against the spike protein. Significantly higher antibody titers was detected after Pfizer-BioNTech (177.1 U / ml vs. 81.1 U / ml;p=0.001) and numerically lower ones after AstraZeneca (45.05 U/ml vs. 126.93 U/ml p=0.054) vaccination compared to others. Patients receiving steroid therapy had significantly decreased post-vaccination antibody response compared to those without steroid treatment (94.03 U/ml vs. 165.6 U/ ml;p=0.008). We did not found short term vaccine related major adverse events. Long term data by 15/02/2022 revealed more infections (42.57%), where anti-Jo1 positivity still showed significant association with hospitalization (50% vs. 9%;p=0.0103). Breakthrough infection was detected in 9,25 % of the vaccinated patients, which was significantly more often after Astra Zeneca vaccination (40 % vs. 7%, p=0.017). All the fatal (n=3) COVID infections occurred in patients with seronegativity to anti-spike protein regardless vaccination. We identified 7,4 % post vaccination disease relapse needing therapy changes and 24,7% new autoantibody positivity. Conclusions. Based on our results, myositis may be associated with an increased risk of COVID19 disease. Independent risk factor for hospitalization for unvaccinated people is anti-Jo1 positivity. Anti-SARS-CoV2 vaccines are safe, tolerable, could prevent complicated infections and strongly recommended for IIM population. Further investigation is required to assess clinical significance of post-vaccination disease flare.

A Case Report Of The Effects Of Chemotherapy On Post-heart-transplant Gene Expression Profiling

Introduction: Malignancies are a major complication of heart transplant (HT). Noninvasive surveillance after HT using gene expression (GEP) profiling and donor derived cell free DNA (dd-cfDNA) are noninferior to biopsy and are widely utilized. The interpretation of % dd-cfDNA, is not well understood in malignancies with a conceptual increase in the recipient fraction. The effect of chemotherapy on GEP in the setting of post-HT surveillance has not been described to the best of our knowledge. Hypothesis: Induction of chemotherapy will cause global transcriptional reduction in GEP. Method(s): GEP was performed with AlloMap (AM, CareDx), which evaluates expression levels of 11 mononuclear cell genes, involved in lymphocyte activation, T-cell priming, cell migration, hematopoietic proliferation, steroid sensitivity, and platelet activation. Scores range from 0-40, higher scores have a stronger correlation with rejection. At our center a total of 995 draws were analyzed from 2019-2022. In parallel dd-cfDNA, which informs about graft injury was analyzed using AlloSure (AS, CareDx). Case Events: A 71-year-old male HT recipient for nonischemic cardiomyopathy and no rejection history was diagnosed with metastatic gastric adenocarcinoma at 16 months post-HT. Following diagnosis, mycophenolic acid was stopped, prednisone 5 mg was started, and tacrolimus trough goal was gradually lowered to 4-6 given infectious complications. Palliative chemotherapy with folinic acid, fluorouracil (5-FU), oxaliplatin (FOLFOX) was initiated at 18 months post-HT with planned dose reduction of oxaliplatin and holding of 5-FU bolus to reduce risk of myelosuppression given comorbidities. Oxaliplatin was stopped at 18 months post HT. Due to COVID he last received 5-FU at 33 months post-HT. Graft function remained stable and DSA negative. At 36 months post-HT, he developed a bowel obstruction without surgical options for interventions and expired shortly thereafter. Result(s): With initiation of prednisone and following chemotherapy there was a drastic decrease in AM scores (Fig. A). Steroid therapy led to an 18% decline in AM scores, the greatest decrease occurred with chemotherapy, with 67% decline from the mean when compared to all center patients (Fig B). Dd-cfDNA levels remained stable during the course aside from one early elevation. Conclusion(s): To the best of our knowledge this is the first published case on the effect of chemotherapy on GEP profiling in the setting of post-HT surveillance. This case advises caution when interpreting GEP in the setting of chemotherapy showing great reduction in GEP scores. While dd-cfDNA levels remained relatively stable after malignancy diagnosis and treatment initiation further studies will need to inform on the use of both GEP and dd-cfDNA in these patients.Copyright © 2022

COVID-19 Developed During Systemic Steroid Therapy for Vogt-Koyanagi-Harada Disease: A Case Report.

PURPOSE: The use of immunomodulatory therapy in the setting of coexistence of uveitis and coronavirus disease (COVID-19) remains controversial. We report a case of COVID-19 during systemic steroid therapy for Vogt-Koyanagi-Harada disease (VKH). CASE REPORT: A 43-year-old female was diagnosed with VKH and started on steroid pulse therapy (1,000 mg/day) followed by high-dose oral corticosteroids. Two weeks after discharge from the hospital, she was readmitted to the intensive care unit with severe acute respiratory syndrome due to SARS-CoV-2 infection confirmed by PCR test, and fortunately both VKH and COVID-19-induced respiratory disease improved. CONCLUSION: Given the absence of international agreement on how to manage COVID-19 patients with steroid-dependent VKH, existing clinical guidelines should be reviewed thoroughly to formulate useful strategies for managing VKH patients on steroid treatment who contract COVID-19. Furthermore, the outcomes of patients with steroid-dependent autoimmune uveitis including VKH who develop COVID-19 should be analyzed.

Evaluation of steroid therapy in COVID-19 patients; in the right dose at the right time to the right patients.

Background: Although there is still no universally accepted treatment agent, steroids have been administered chronologically at every dose and at every stage of the COVID-19 pandemic. Aim: We aimed to evaluate the clinical efficacy of high-dose steroid therapy and its effect on mortality in COVID-19 patients with severe pneumonia, severe Acute Respiratory Distress Syndrome (ARDS), and septic shock. Patients and Methods: : Patients with severe pneumonia, septic shock, and ARDS due to COVID-19 who were followed up in the intensive care unit were retrospectively reviewed. Results: The study population was divided into two groups; the methylprednisolone pulse group (MP) (n = 55) and the dexamethasone group (Dex) (n = 39). When the values before and after treatment were compared; there was a statistically significant increase in the neutrophil/lymphocyte ratio after treatment in the MP group (p = 0.006). Although it was not statistically significant in the MP group, There was a numerical increase in D-dimer levels (p = 0.28). Thromboembolic complications developed in 2 patients in the MP group. The mortality outcomes of the groups were statistically similar (p = 0.943). Conclusion: We recommend steroids use in the condition that it is indicated in the critically ill group with the poor general condition. Since there is no significant difference between high-dose pulse steroid treatment and standard treatment doses, we think that the risk of complications should not be taken into account and high doses should not be used.

Switching from intravenous to subcutaneous infliximab: Clinical and patient experience outcomes

Background: Intravenous (IV) infliximab (IFX) monotherapy is associated with significant loss of response. Therapeutic drug monitoring shows an association with low serum trough drug levels and development of anti-IFX antibodies. Combination therapy with immunomodulators is not always possible, and IFX dose escalation leads to higher drug costs and time pressure on infusion units. Both approaches have raised heightened patient safety concerns due to the Covid-19 pandemic. Subcutaneous (SC) IFX pharmacokinetics lead to improved drug trough levels, which could lead to better clinical outcomes. Method(s): The NHS Greater Glasgow and Clyde biologics database was used to identify selected patients currently treated with IV IFX for IBD for suitability for SC switch. Patients were contacted to allow informed choice to opt in or out of switch. Baseline clinical data was collected, and patients were reviewed at week 8 and week 24 for assessment of clinical disease activity scores, IFX trough levels/anti-drug antibody levels, and faecal calprotectin. Patient experience outcomes were assessed using a quality of life questionnaire (CUCQ-8). Result(s): 31 patients consented to switch;F:M = 17:14. The majority of patients (16) had Crohn's disease, with 13 with UC and 2 IBDU. Mean duration of disease was 9.1 years and duration of prior IV therapy was 3.3 years. 28 patients were reviewed at week 8 and 24 at week 24. At week 24, 71% of patients were in clinical remission (Harvey-Bradshaw index score <5 or partial Mayo score <2), 96% had CRP <5 mg/Land 87% had FCP <250mug/g. 21% of patients had subtherapeutic IFX trough levels at baseline, all had increased by week 8 and there were no subtherapeutic levels measured by week 24. One patient had detectable antibodies at week 24, compared with 9 patients at baseline. Three patients required oral steroid therapy during the 24-week follow up period. There were no hospital admissions, significant infections or adverse reactions within the cohort. 15 patients submitted CUCQ-8 scores, of these 7 patients' scores had worsened at week 8 but by week 24 13/15 were stable or improved compared to baseline. Conclusion(s): Switching from IV to SC infliximab is welcomed by most patients. The efficacy, tolerability, increased drug level and safety which has previously been demonstrated is reproduced in our cohort. This study is the first to explore patient experience outcomes. The finding of initial worsening of the CUCQ-8 score, but overall improvement by week 24 opens further opportunity for engaging patient involvement in switch programmes.

Liver and COVID-19 - A Review and Clinical Approach

Liver enzyme abnormalities occur frequently in patients diagnosed with Coronavirus disease 2019 (COVID-19). It has been suggested that patients with severe acute liver injury are more likely to be admitted to intensive care, require intubation or renal replacement therapy and their mortality rate is higher than patients without severe acute liver injury. This review article explores the possible aetiologies of liver dysfunction seen in patients with COVID-19 and also the effect of COVID-19 on patients with pre-existing liver disease. Finally, we suggest clinical approaches to treating a patient with liver enzyme disturbance and COVID-19 and also caring for patients who require liver transplantation in the COVID-19 era.Copyright © 2022 Bentham Science Publishers.

The Importance of CMV Reactivation in COVID-19-Related ARDS Patients

Objectives: Cytomegalovirus (CMV) reactivation is a significant cause of morbidity and mortality in critically ill patients. Existing or newly developed immunosuppression appears to be the main factor for reactivation. COVID-19 patients with acute respiratory distress syndrome can be affected by a variety of conditions that cause immunosuppression. Clarifying CMV reactivation and notably its predictive features became important during the epidemic. Method(s): This is a retrospective, observational, and cohort study. All COVID-19 patients admitted to the ICU between March 11, 2020 and March 11, 2021 were analyzed. All of the information was gathered from the hospital's electronic records. CMV reactivation was defined as CMV DNA >=1000 copies/ml in tracheal samples. The patient population was analyzed in two groups, namely, patients with CMV reactivation and patients without reactivation. Result(s): During the study period, 99 of all COVID-19 ARDS patients fulfilled the inclusion criteria, and CMV reactivation was detected in 55 (55.6%) of them. Age, BMI, APACHE-II score, hypertension, chronic respiratory disease, the usage of interleukin blockers, the duration of steroid usage, procalcitonin (PCT), and CD-8 T-cell levels differed significantly from the patients without CMV reactivation. Furthermore, the reactivation group had longer ICU stays, longer durations of mechanical ventilation, and higher mortality. Conclusion(s): CMV can be reactivated in critically ill COVID-19 ARDS patients, which appears to correlate with worse outcomes. Obesity, the usage of IL-blockers and steroids >12 days, high PCT, and low CD-8 T-cell levels appear to be risk factors. Critically ill COVID-19 patients should be closely monitored with regard to immunosuppression and CMV status.Copyright © 2022 by The Cardiovascular Thoracic Anaesthesia and Intensive Care.