A rare case of central post-stroke pain in a patient with migraine and lacunar infarcts in the medulla oblongata

Studies about headaches associated with acute ischemic stroke in patients suffering from migraine were limited, and therefore we present a clinical case of central post-stroke pain (CPSP) in a 47-year-old woman with migraine and lacunar infarcts in the medulla oblongata and also possible mechanisms of CPSP in patients with migraine. Magnetic resonance imaging of the brain revealed lacunar infarction in the medulla oblongata on the right (vertebral artery basin) and a single focus of gliosis in the parietal lobe on the right. Magnetic resonance angiography of cerebral vessels showed the fetal type of structure of both posterior cerebral arteries. This clinical case is a complex clinical situation of a combination of secondary headaches (post-stroke) in a patient with a primary headache (migraine), which was successfully treated by the combined administration of first-line drugs for the treatment of neuropathic pain in a patient with lacunar infarcts in the medulla oblongata. The treatment of CPSP is a difficult task due to the insufficiently unexplored mechanisms of development, the most effective approaches are those aimed at reducing the increased excitability of neurons.Copyright © 2023, Indian Association of Biomedical Scientists. All rights reserved.

Associations between Tobacco Use, Surges, and Vaccination Status over Time in the COVID-19 Era.

Because COVID-19 is a respiratory and cardiovascular disease, understanding behaviors that impact cardiopulmonary health, such as tobacco use, is particularly important. While early studies suggested no change in prevalence of tobacco use as COVID-19 emerged, pandemic fatigue, shifting levels of COVID-19 transmission, and vaccine availability have all changed since the start of the pandemic. The current study examined whether time, COVID-19 surges, and/or vaccination status were associated with likelihood of daily and non-daily tobacco use over the first 24 months of the pandemic. Data were obtained from electronic health records of healthcare visits (n = 314,787) to four Southern California VA healthcare systems. Multinomial logistic regression analyses indicated that the likelihood of reporting both daily and non-daily tobacco use (versus non-use) increased over time. Daily and non-daily tobacco use were less common at visits that occurred during COVID-19 surges, as well as among veterans vaccinated against COVID-19. Our findings provide new insight into changes of tobacco use patterns and correlates across the first two years of this pandemic, and understanding these associations may facilitate understanding of health-related behaviors and inform clinical treatment of tobacco use disorder during the COVID-19 pandemic.

A CASE OF LUNG TRANSPLANT WITH RECENTLY INFECTED SARS-COV-2 DONOR LUNGS

SESSION TITLE: Lung Transplantation Cases SESSION TYPE: Rapid Fire Case Reports PRESENTED ON: 10/18/2022 10:15 am - 11:10 am INTRODUCTION: A shortage of lungs persists despite the addition of increased-risk donors to the transplantation pool. Waitlist mortality increased from 14.7 to 16.1 deaths per 100 waitlist years from 2019 to 2020. (1) Novel strategies are needed to further expand the donor pool. We report a case of intentional transplant of recently infected acute respiratory virus syndrome 2 (SARS-CoV-2) donor lungs to a patient with end-stage Idiopathic Pulmonary Fibrosis (IPF). CASE PRESENTATION: A 67 year old man with IPF, former tobacco and alcohol abuse, hypertension and gastroesophageal reflux disease underwent a sequential bilateral lung transplant on cardiopulmonary bypass. His post-operative course was complicated by Pseudomonas Aeruginosa pneumonia and bilateral pleural effusions status-post bilateral chest tube placement. He was extubated 4 days after surgery and had his chest tubes removed within 1 week. He discharged on room air 17 days after transplant and appeared well at his 3 week post-operative clinic visit. The donor lungs came from a 28 year old woman with chronic hepatitis C and recent asymptomatic SARS-CoV-2 infection. She tested positive for SARS-CoV-2 on reverse transcriptase polymerase chain reaction (RT-PCR) nasopharyngeal (NP) swabs at 12 and 7 days prior to surgery. She had negative SARS-CoV-2 results on lower respiratory tract testing via bronchioalveolar lavage (BAL) at 7 and 2 days prior to surgery. Recipient RT-PCR NP testing was negative on post-operative days 3, 10, and 17. Two subsequent BAL samples were negative in the first week post-operation. The recipient consented to transplant and was aware of the donor's recent SARS-CoV-2 and chronic hepatitis C infections. Infectious disease did not recommend any SARS-CoV-2 anti-viral therapy or post-exposure prophylaxis. Hepatology prescribed treatment for donor derived hepatitis C viremia on discharge. DISCUSSION: Emerging pathogens present a challenge in minimizing donor-derived diseases. The utilization of lungs, including patients with recent SARS-CoV-2 infection, should be considered carefully. Institutional guidelines vary in donor exclusion criteria based on history of prior SARS-CoV-2 infection, severity of prior infection, timing of last SARS-CoV-2 result, and type of screening test. (2,3) We report a case of intentional lung transplant with asymptomatic SARS-CoV-2 infection on NP swab 1 week prior to transplant and negative lower respiratory tract testing 2 days prior to transplant. Our recipient patient has remained SARS-CoV-2 free at 3 weeks post-operation on serial testing. We propose that the timing of recent donor infection, even within 10 days of positive results, is less important as infectious status based on lower respiratory tract testing at the time of transplant. CONCLUSIONS: We demonstrate that donor lung donation following very recent asymptomatic SARS-CoV-2 infection can be done safely with good short-term outcomes. Reference #1: (1) 2020 Annual Data Report. Scientific Registry of Transplant Recipients https://srtr.transplant.hrsa.gov/annual_reports/2020/Lung.aspx Accessed [03/23/22] Reference #2: (2) Querrey, M, Kurihara, C, Manerikar, A, et al. Lung donation following SARS-CoV-2 infection. Am J Transplant. 2021;21: 4073– 4078. https://doi.org/10.1111/ajt.16777 Accessed [03/23/22] Reference #3: (3) Summary of Current Evidence and Information– Donor SARS-CoV-2 Testing & Organ Recovery from Donors with a History of COVID-19. Version Release Date: January 21, 2022. US Department of Health & Human Services. Organ Procurement and Transplantation Network https://optn.transplant.hrsa.gov/media/kkhnlwah/sars-cov-2-summary-of-evidence.pdf Accessed [03/23/22] DISCLOSURES: No relevant relationships by Thomas Meehan No relevant relationships by Jagadish Patil No relevant relationships by Huddleston Stephen

ANTISYNTHETASE SYNDROME PRESENTING AS INTERSTITIAL LUNG DISEASE: A CASE OF ANCHORING BIAS DURING THE COVID-19 PANDEMIC

SESSION TITLE: Dyspne Mysteries SESSION TYPE: Rapid Fire Case Reports PRESENTED ON: 10/18/2022 01:35 pm - 02:35 pm INTRODUCTION: Anti-synthetase (AS) syndrome is characterized by interstitial lung disease (ILD), arthritis, myositis, fever, or Raynaud's phenomenon in the presence of an AS autoantibody (1). At least 70% of patients with AS syndrome develop ILD (2), and it represents the major cause of mortality in these patients with a 10 year survival rate of 73%. In a small cohort study, the anti-PL-12 antibody subtype was found to be strongly associated with ILD (3). CASE PRESENTATION: A 35 year old female with a history of tobacco use disorder presented to the hospital with three months of recurrent subjective fevers, non-productive cough, and dyspnea on exertion. She denied arthralgias, muscle weakness and hemoptysis. She initially presented to her primary care physician with these symptoms and was prescribed amoxicillin for streptococcal pharyngitis. The patient continued to be symptomatic and was treated empirically for COVID-19 pneumonia twice despite two negative COVID-19 tests and without any significant clinical improvement in her respiratory status. On admission, she was febrile, tachycardic, and had a new oxygen requirement with bilateral coarse breath sounds on exam. She had no leukocytosis and her COVID-19 test was negative. CT angiography of the chest showed extensive mixed reticular and airspace opacities with peribronchial predilection and peripheral sparing (figure 1). A bronchial alveolar lavage was notable only for neutrophilia (19%) and eosinophilia (4%). Rheumatological workup revealed elevated rheumatoid factor, positive antinuclear antibody (1:40), weakly positive anti–Sjögren's-syndrome-related antigen A antibody (50 AU/ml), undetectable anti-Jo-1 antibody and positive anti-PL-12 antibody. Pulmonary function testing revealed a TLC of 40% and DLCO of 28%, consistent with a restrictive pattern. Considering the patient's organizing pneumonia, positive antibodies, and findings of "mechanic's hands,” the patient was diagnosed with anti-synthetase syndrome with ILD. She was started on oral prednisone and mycophenolate mofetil. On follow-up, she was noted to have symptomatic improvement and stable hypoxia without clinical signs of disease progression. DISCUSSION: During the coronavirus pandemic, the resemblance of COVID-19 pneumonia to other diseases, in the absence of conscious suspicion for other etiologies, can lead to anchoring and availability bias thereby delaying diagnosis and appropriate treatment. Additionally, anti-synthetase syndrome should be considered in the differential diagnosis of ILD even in the absence of arthritis and myositis, as respiratory symptoms are often the first presenting signs. CONCLUSIONS: Increased responsibility is required of diagnosticians to exercise due diligence and active recognition of COVID availability and anchor bias to avoid missing crucial diagnoses. Reference #1: Cojocaru, Manole, Inimioara Mihaela Cojocaru, and Bogdan Chicos. "New insights into antisynthetase syndrome.” Maedica 11.2 (2016): 130. Reference #2: Marco, Joanna L., and Bridget F. Collins. "Clinical manifestations and treatment of antisynthetase syndrome.” Best Practice & Research Clinical Rheumatology 34.4 (2020): 101503. Reference #3: Kalluri, Meena, et al. "Clinical profile of anti-PL-12 autoantibody: cohort study and review of the literature.” Chest 135.6 (2009): 1550-1556. DISCLOSURES: No relevant relationships by Mario Flores No relevant relationships by David Jackson No relevant relationships by Lisa Saa No relevant relationships by Abu Baker Sheikh

POST-COVID-19 CHANGES MASKED A MALIGNANCY: INVASIVE MUCINOUS ADENOCARCINOMA

SESSION TITLE: Challenges in Lung Tumors SESSION TYPE: Rapid Fire Case Reports PRESENTED ON: 10/18/2022 10:15 am - 11:10 am INTRODUCTION: Patients can have a variety of post Coronovirus induced disease (COVID) associated interstitial lung diseases (ILD) ranging from cystic lung disease to fibrinous organizing pneumonia. However, very little is known about malignancies that have been overshadowed by post COVID associated pulmonary changes. We present one such case of insidious invasive mucinous adenocarcinoma of the lung that was masked by post COVID related changes. CASE PRESENTATION: A 70 year old female with COPD, systolic heart failure and significant tobacco use disorder presented with progressively worsening hypoxemic respiratory failure. She has had 4 hospitalizations in past year all for acute on chronic hypoxemic respiratory failure following COVID. She has been on Supplemental Oxygen 3L/min since her infection with SARS-COV2. Patient was found to have worsening bibasilar ground glass opacities (GGO) on CT of chest over the past 1 year since having COVID. She was treated with several rounds of steroids without any relief. Patient had a PET scan that showed a very avid left upper lobe consolidation. Given these worsening abnormalities and symptoms, she underwent bronchoscopy with transbronchial biopsy guided by the positive PET scan and fluoroscopy. However, during bronchoscopy she had copious secretions which were therapeutically cleared helping relieve some of patient's hypoxemia. All her cultures and Fungitell assay on bronchoalveolar lavage were negative. However, post biopsy pathology came back positive for Invasive Mucinous Adenocarcinoma. Patient was treated with chemo and radiation therapy with good response against her malignancy and significant relief in her hypoxemia. DISCUSSION: COVID associated pneumonia is well known to cause chronic hypoxemic respiratory failure. Post COVID related pulmonary changes range from organizing pneumonia to fungal pneumonia. However, patients should start to recover with time as inflammatory changes resolve on CT scan with adequate steroids or anti-fungals. If patients continue to deteriorate then a prompt work-up that rules out other infections and even malignancies is warranted as seen in our patient. This case brings forth an important consideration for aggressively pursuing an adequate work-up in the face of worsening GGO on the CT and patient's continual deterioration due to her hypoxemic respiratory failure. Our patient was able to be adequately diagnosed with malignancy and was then started on chemotherapy that allowed for adequate control of her hypoxemic respiratory failure and helped improve her quality of life. CONCLUSIONS: Post COVID related pulmonary changes can be from a variety of ILD and infections. However, clinician should be vigilant in considering malignancy as a possible etiology of post COVID related changes and initiate an adequate work-up to help evaluate for cancer that can be masked amongst post COVID related ILD. Reference #1: Beck KS, Sung YE, Lee KY, Han DH. Invasive mucinous adenocarcinoma of the lung: Serial CT findings, clinical features, and treatment and survival outcomes. Thorac Cancer. 2020 Dec;11(12):3463-3472. doi: 10.1111/1759-7714.13674. Epub 2020 Oct 5. Reference #2: Matsui T, Sakakura N, Koyama S, Nakanishi K, Sasaki E, Kato S, Hosoda W, Murakami Y, Kuroda H, Yatabe Y. Comparison of Surgical Outcomes Between Invasive Mucinous and Non-Mucinous Lung Adenocarcinoma. Ann Thorac Surg. 2020 Nov 24:S0003-4975(20)32001-4. doi: 10.1016/j.athoracsur.2020.09.042. Epub ahead of print. Reference #3: Lee MA, Kang J, Lee HY, Kim W, Shon I, Hwang NY, Kim HK, Choi YS, Kim J, Zo JI, Shim YM. Spread through air spaces (STAS) in invasive mucinous adenocarcinoma of the lung: Incidence, prognostic impact, and prediction based on clinicoradiologic factors. Thorac Cancer. 2020 Nov;11(11):3145-3154. doi: 10.1111/1759-7714.13632. Epub 2020 Sep 25. DISCLOSURES: No relevant relationships by Danya Ahmed No relevant relationships by David Chambers No rele ant relationships by Jalal Damani No relevant relationships by Deon Ford No relevant relationships by Rachaita Lakra

UNDERSTANDING THE NEED FOR A BROAD DIFFERENTIAL DIAGNOSIS: A CASE OF PNEUMONIC TULAREMIA

SESSION TITLE: Disseminated Bacterial Infections SESSION TYPE: Rapid Fire Case Reports PRESENTED ON: 10/18/2022 10:15 am - 11:10 am INTRODUCTION: Tularemia is a rare infectious disease caused by Francisella Tularensis that typically affects the skin, eyes, lymph nodes, and lungs. There are a variety of forms of tularemia with varying rates of contagiousness and mortality. Respiratory tularemia has a high mortality rate if left untreated and presents with non-specific viral like symptoms occurring in conjunction with respiratory symptoms: cough, hemoptysis, and pleuritic chest pain. In this COVID ARDS era, it is important to evaluate a broad differential diagnosis. Therefore, the authors describe a patient presenting with flu-like respiratory symptoms whom was ultimately was diagnosed with acute respiratory distress syndrome (ARDS) due to F. Tulerensis. CASE PRESENTATION: A 44-year-old male presented with a four-day history of night sweats, shortness of breath, a productive cough which progressed to hemoptysis, and oliguria. Prior to admission, his initial symptoms were treated as chronic sinusitis with varied antibiotics. Social history including tobacco abuse and deer hunting 1 month prior to presentation. Vitals were stable except for tachycardia, hypoxia, and tachypnea. Laboratory findings were significant for AKI, lactic acidosis, mild transaminitis, hyperbilirubinemia, and leukocytosis with predominant neutrophilia. Thoracic CTA showed bilateral diffused pulmonary edema without evidence of pulmonary embolism. Due to the patient's worsening respiratory status, he was intubated for support. The patient progressed to Severe ARDS per Berlin Criteria eventually requiring pronation and continuous paralyzing. Bronchoscopy was performed with bronchial lavage. Bacterial, viral, and fungal cultures did not show growth while vasculitic work-up was negative. Empiric antibiotic treatment did not show improvement until the patient was diagnosed with F. Taularensis via serological testing with an IgM of 20 U/mL, and patient was transitioned to gentamycin. Ultimately, the patient was extubated, transitioned to oral doxycycline, and discharged home. DISCUSSION: Approximately 250 cases of tularemia are reported to CDC each year. Respiratory tularemia has a mortality rate up to 30% if not treated. For this reason, F. tularensis is a potential biological weapon and is categorized as a Group A pathogenic agent. Serological testing may be negative early in disease progression;therefore, early inflammatory markers with clinical suspicion are essential to diagnose the disease early in its course. DNA microarray has high specificity and sensitivity for rapid diagnosis of tularemia while being cost effective. After prompt diagnosis, intravenous aminoglycosides;such as gentamycin or streptomycin;must be started. CONCLUSIONS: In the above case, we illustrate the gradual onset and rapid patient deterioration when treatment is delayed;yet, there is rapid recovery once appropriate treatment is used. Reference #1: 1. Ranjbar, Reza, Payam Behzadi, and Caterina Mammina. "Respiratory tularemia: Francisella tularensis and microarray probe designing.” The open microbiology journal 10 (2016): 176. Reference #2: 2. Akhvlediani, N., I. Burjanadze, D. Baliashvili, T. Tushishvili, M. Broladze, A. Navdarashvili, S. Dolbadze et al. "Tularemia transmission to humans: a multifaceted surveillance approach.” Epidemiology & Infection 146, no. 16 (2018): 2139-2145. Reference #3: 3. Tularemia in British Columbia: A case report and review. Issue: BCMJ, vol. 52, No. 6, July August 2010 (Pages 303- 307). Megan Isaac-Renton, BSc, Muhammad Morshed, PhD, SCCM Eleni Galanis, MD, MPH, FRCPC Sunny Mak, MSc Vicente Loyola, MD, FRCPC, Linda M.N. Hoang, MD, MHSc, FRCPC DISCLOSURES: No relevant relationships by Munish Adhikari No relevant relationships by Ashma Ul Husna No relevant relationships by Yan Jiang No relevant relationships by Divya Kharel No relevant relationships by Gregory Polcha

Evaluating the Risk of Retinal Vascular Occlusion among COVID-19 patients

Purpose : SARS-CoV-2, the viral infection that causes COVID-19, is known to induce a hypercoagulable state in patients. While there have been isolated reports of retinal vascular occlusion among patients with a pre-existing COVID-19 infection, research into this topic remains scant. Therefore, the purpose of this study is to investigate the shortterm prevalence and risk for retinal vascular occlusion between COVID-19 and influenza A patients. Methods : TrinetX is a national, federated database that was utilized in this retrospective cohort analysis. At the time of the study, electronic medical records from over 80 million patients across 57 healthcare organizations were analyzed to create two cohorts of patients. At the time of the analysis, 1,224,770 patients with a previous history for COVID19 were compared to 61,555 patients with a previous history for influenza A. Then, 1:1 propensity score matching (PSM) was utilized to balance each cohort by demographics and comorbidities (age, sex, BMI, history of hypertension, chronic lower respiratory disease, diabetes mellitus, nicotine dependence, heart failure, and alcohol related disorders). Adjusted risk ratios (aRR) using 95% confidence intervals (CI) were used to assess risk of retinal vascular occlusion 120 days after initial diagnosis for COVID-19 or influenza A. Results : Before PSM, COVID-19 patients were at significantly lesser risk for retinal vascular occlusion within 120 days of initial diagnosis than influenza A patients (aRR [95% CI] = 0.58 [0.42,0.8];p<0.001). However, the incidence for influenza patients to develop retinal vascular occlusion was very small (0.1%). After PSM, two balanced cohorts of 61,555 patients were compared to one another and revealed that there is no significant difference in developing a retinal vascular occlusion after a previous diagnosis of COVID19 or influenza A (0.92 [0.58,1.46];p=0.725). Likewise, the incidence for retinal vascular occlusion remained very small (0.1% between both cohorts) (Table 1). Conclusions : This is the first large-scale study investigating the risk of retinal vascular occlusion among COVID-19 and influenza A patients. We found that each cohort was at similar risk for developing retinal vascular occlusion within 120 days. Likewise, the incidence for retinal vascular occlusion was miniscule among patients in this study.

Risk of Corneal Graft Rejection in COVID-19 Vaccinated Patients in the 120-day postoperative period: A Multi-Healthcare System Analysis

Purpose : To compare corneal transplant failure in patients who have been vaccinated against COVID-19 to a control group of patients who have received an influenza vaccination. Methods : A retrospective cohort study was conducted using TriNetX, a federated electronic health records research network comprising data from more than 50 health organizations in the United States. Patients who underwent corneal transplantation and either COVID-19 vaccination or Influenza A vaccination were identified by CPT and medication codes and separated into cohorts based which vaccination they had received. COVID-19 vaccination was defined as receiving either 2 doses of Moderna or Pfizer COVID19 Vaccine or 1 dose of J&J's COVID-19 Vaccine. Cohorts were matched for age, gender, body mass index, and medical comorbidities (essential hypertension, diabetes mellitus, chronic lower respiratory diseases, heart failure, nicotine dependence, and alcohol related disorders). The primary outcome was corneal graft failure at 120 days after corneal transplantation surgery. The relative risk for this outcome was compared between each cohort before and after 1:1 propensity score matching. Results : A study population of 784 corneal transplant patients who received COVID-19 vaccination and a control population of 1661 patients who received Influenza A vaccination were identified. After propensity matching, 715 matched patients from each cohort were compared. The incidence of corneal transplant failure rate was 1.8% for the COVID-19 vaccine cohort and 1.6% for the Influenza A cohort. While the rate of corneal transplant failure was slightly lower in COVID-19 vaccine recipients in comparison to Influenza vaccine recipients (RR=0.92%, CI 0.42-2.01), this result was not statistically significant (p 0.84). Conclusions : While there have been several case reports of corneal graft failure after COVID-19 or COVID-19 vaccination, there appears to be no statistically significant impact of the COVID-19 vaccine on corneal transplant failure in this retrospective cohort study. Additionally, corneal graft rejection in vaccinated patients was rare in our study.

Transcranial Magnetic Stimulation for Long-Term Smoking Cessation: Preliminary Examination of Delay Discounting as a Therapeutic Target and the Effects of Intensity and Duration.

Background: Repetitive transcranial magnetic stimulation (rTMS) is a novel treatment for smoking cessation and delay discounting rate is novel therapeutic target. Research to determine optimal therapeutic targets and dosing parameters for long-term smoking cessation is needed. Due to potential biases and confounds introduced by the COVID-19 pandemic, we report preliminary results from an ongoing study among participants who reached study end prior to the pandemic. Methods: In a 3 × 2 randomized factorial design, participants (n = 23) received 900 pulses of 20 Hz rTMS to the left dorsolateral prefrontal cortex (PFC) in one of three Durations (8, 12, or 16 days of stimulation) and two Intensities (1 or 2 sessions per day). We examined direction and magnitude of the effect sizes on latency to relapse, 6-month point-prevalence abstinence rates, research burden, and delay discounting rates. Results: A large effect size was found for Duration and a medium for Intensity for latency to relapse. Increasing Duration increased the odds of abstinence 7-8-fold while increasing Intensity doubled the odds of abstinence. A large effect size was found for Duration, a small for Intensity for delay discounting rate. Increasing Duration and Intensity had a small effect on participant burden. Conclusion: Findings provide preliminary support for delay discounting as a therapeutic target and for increasing Duration and Intensity to achieve larger effect sizes for long-term smoking cessation and will provide a pre-pandemic comparison for data collected during the pandemic. Clinical Trial Registration: [www.ClinicalTrials.gov], identifier [NCT03865472].

A Comparison of Virtual versusIn-person Curriculum on Student Knowledge and Perceptions of E-cigarettes

Background: E-cigarettes are the most commonly used tobacco product by U.S. adolescents. Prior research shows that school-based e-cigarette prevention education was associated with reduced actual and intended use of e-cigarettes. During the COVID-19 pandemic, such e-cigarette education was delivered through virtual teaching in addition to in-person classes. The purpose of this study is to assess the effectiveness of e-cigarette prevention curriculum delivered virtually compared to in-person sessions in improving e-cigarette-related knowledge and reducing adolescents' intent to try e-cigarettes. Methods: A 30- minute educational presentation on e-cigarettes based on the Stanford Tobacco Prevention Toolkit was delivered to middle and high school students in Alabama from November 2020-May 2021. Study participants were divided into two groups based on the mode of receiving the presentation: 1) by an in-person educator (“in-person group”) and 2) by an off-site educator presenting through a recorded video or a video chatting platform (“virtual group”). The presentation covered e-cigarette contents, health effects, nicotine addiction and marketing. Using a quasi-experimental pre- and post-intervention group study we assessed students' e-cigarette-related knowledge and perceptions on 15 questions, and intent to try e-cigarettes. Descriptive statistics were summarized for the total sample, in-person group and virtual group. Within-subject and within-group analyses were conducted for all perceptions and intent to try Amelia Warnock, MPH;Shelby Kile, MPH;Shivani Mathur Gaiha, PhD;Clementino Vong Do Rosario, n/a;Kennon Brake, n/a;tobacco products using McNemar's chi-squared exact tests of paired proportions. Between-group analyses were conducted using multi-level mixed-effects regression models to assess treatment effects by group and time on perceptions, addictiveness and intent to try e-cigarettes after adjusting for school-level clustering effects. Independent variables included grade (high school vs middle school) and race/ethnicity. Results: Study participants were drawn from 10 schools and included 1031 total participants. 745 participants were in the virtual group (72.3%) and 286 participants were in the in-person group (27.74%). See participant characteristics in Table 1. Within-subject and within-group analyses showed positive significant changes after education in 8 out of 15 e-cigarette-related perceptions (for both groups), increase in perceived addictiveness among the virtual group and reduced intent to try e-cigarettes, particularly among the in-person group. Within-subject changes were more pronounced among high school participants. Time x group interaction effects show the in-person presentation was more effective compared to the virtual group at improving knowledge of e-cigarette nicotine content and delivery through aerosol and health effects (see Table 2). There was no significant difference in the treatment effect by study group on perceived addictiveness and intent to try e-cigarette products. Conclusion: In our study, a one session in-person educational presentation was not more effective than virtual on student knowledge, perceived addictiveness and intended behavior. There were select aspects of knowledge that improved among students receiving in-person education. (Table Presented).

AN UNUSUAL CASE OF HEMOPHAGOCYTIC LYMPHOHISTIOCYTOSIS ASSOCIATED WITH M.CHIMAERA OR LARGE CELL NEUROENDOCRINE CARCINOMA

CASE: 56-year-old Caucasian male presented to the hospital with worsening weakness, exertional dyspnea, dry and nonproductive cough, and a 5-pound weight loss in 2 weeks associated with loss of appetite. He has a significant medical history of mitral valve repair in July 2014, status post bioprosthetic mitral valve replacement in August 2019- culture-negative treated with ceftriaxone, vancomycin, and doxycycline for 6 weeks complicated with CVA, atrial flutter, tobacco abuse, alcohol abuse. His shortness of breath worsened quickly with O2 saturations dropping to 85% and had to be placed on BiPAP followed by high flow nasal cannula/ noninvasive ventilation and became febrile. He was then transferred to ICU for acute hypoxemic respiratory failure. Differentials could be very broad ranging from infections like visceral leishmaniasis, atypical/tuberculous mycobacteria, histoplasmosis, Ehrlichia, Bartonella, Brucella, adeno, disseminated HSV, hematological like Langerhans cell histiocytosis, multicentric Castleman disease. In this patient, differentials included hemophagocytic lymphohistiocytosis, COVID-19. Covid was negative x2. His lab abnormalities as well as diagnostic testing revealed hemophagocytic lymphohistiocytosis. He was empirically started on antibiotics and dexamethasone 20 mg to be continued for 2 weeks then taper if the patient has continued improvement. Dexamethasone was tapered over 8 weeks. On later admissions, Carious test was positive for M. chimaera, and core biopsy of the lung nodule showed large cell neuroendocrine carcinoma. IMPACT/DISCUSSION: Hemophagocytic lymphohistiocytosis (HLH) is a rare but very dangerous condition, characterized by abnormal activation of the immune system, causing hemophagocytosis, inflammation, and potentially widespread organ damage. The primary (genetic) form, caused by mutations affecting lymphocyte cytotoxicity, is most commonly seen in children. Secondary HLH is commonly associated with infections or malignancies. Most current information on diagnosis and treatment is based on pediatric populations. The HLH-2004 diagnostic criteria are the most commonly used diagnostic criteria and were developed for children;but used in adults as commonly as in children, although there is a gap in the knowledge. The HLH-2004 diagnosis criteria state that diagnosis of HLH can be established if either a molecular diagnosis is made consistent with HLH or diagnostic criteria for HLH is fulfilled, which includes meeting 5 of 8 criteria. These are lab and clinical findings including fever, splenomegaly, significant cytopenia, hypertriglyceridemia and/or hypofibrinogenemia, hemophagocytosis in bone marrow/spleen or lymph nodes, low or no NK cell activity, ferritin >500 ug/L or sCD25 >2400 U/mL. CONCLUSION: HLH is a disease that needs to be diagnosed and treated promptly, it is fatal otherwise. Treatment is mostly tailored to the patient's root cause, treat the cause, and symptomatic treatment with dexamethasone and etoposide.

NOT EVERYTHING IS COVID

CASE: 45-year-old African American female with history of hypertension, hypothyroidism and prior tobacco abuse was admitted to hospital with shortness of breath and hypoxia. She was diagnosed with COVID-19 pneumonia due to her respiratory symptoms, CT scan findings of bilateral pulmonary infiltrate and positive COVID IgG antibodies although a PCR test was negative. The patient was discharged and later seen in pulmonary clinic where on further questioning she complained of fatigue, bilateral wrist and knee pain, and exertional dyspnea. On auscultation, bilateral rales were noted in the lower lung fields. She was noted to desaturate upon ambulation. PFTs (pulmonary function tests) revealed severe restrictive spirometry and severe gas transfer defect. A HRCT revealed bilateral infiltrates suggestive of organizing pneumonia. CPK was elevated at 449. Serologies were positive for ANA and antijo1 and negative for other connective tissue diseases. The patient was diagnosed with anti-synthetase syndrome (ASS). She was treated with oxygen, steroids and tacrolimus with reported improvement in her symptoms. IMPACT/DISCUSSION: ASS is a rare chronic systemic autoimmune disorder that predominantly affects females with a median age of 50. It is characterized by autoantibodies against aminoacyl-tRNA synthetase enzyme. The role of these autoantibodies in the development of ASS is not fully understood. Several autoantibodies have been identified including anti-Jo1, anti-EJ, antiOJ, anti-PL7, anti-PL12, anti-SC, anti-KS, anti-JS, anti-HA, anti-YRS. Among them, anti-Jo1 is the most common. The ASS is characterized by myositis, interstitial lung disease( ILD), arthritis, fever, Raynaud's phenomenon, mechanic's hand plus positive serologic testing of the Anti- aminoacyl-tRNA synthetase enzyme. The majority of the patients with Anti- Jo-1 antibodies develop ILD. An organizing pneumonia pattern can be seen in the settings of connective tissue disease and is commonly found in those with the ASS. ILD may be the first manifestation of the disease. CONCLUSION: We present a case of a 45 year old female mistakenly diagnosed with COVID pneumonia who on further evaluation was found to have ILD secondary to Antisynthetase Syndrome, a form of inflammatory myositis. An organizing pneumonia pattern on HRCT can be found in many settings other than COVID pneumonia. Careful attention to the history, physical examination, lab findings and COVID test results remain important in identifying etiologies other than COVID 19 for a patient's respiratory symptoms during the pandemic. Delays in diagnosis can be quite harmful to patients.

PATIENTS WITH COMPENSATED CIRRHOSIS AND COVID-19 HAVE A HIGHER SHORT-TERM RATE OF DECOMPENSATION AND MORTALITY BUT THOSE WHO SURVIVE COVID-19 HAVE NO DIFFERENCE IN OUTCOMES AT 1 YEAR: A MULTICENTER RESEARCH NETWORK STUDY

INTRODUCTION Patients with liver disease, notably cirrhosis, are at a higher risk for hospitalizations and mortality after COVID-19. However, previous studies did not report long-term outcomes;furthermore, the effect of COVID-19 on underlying liver disease and long-term prognosis and risk for decompensation is hitherto unknown. We aimed to compare the short and long-term outcomes of patients with compensated cirrhosis with and without COVID-19. METHODS A retrospective cohort study was performed using TriNetX (a multiinstitutional research network). Patients with compensated cirrhosis who were tested for COVID-19 were identified between January 2020 and December 2020. These patients were then stratified into two groups based on results of COVID-19 testing;compensated cirrhosis who tested positive (COVID-19 group) and compensated cirrhosis who tested negative and were never diagnosed with COVID-19 (non-COVID-19 group). The primary outcomes were risk for decompensation of cirrhosis, need for inpatient/ ICU services and mortality. Clinical outcomes were compared at 3 months in the two groups (short term outcomes). Patients who survived at 3 months were then followed up to 1 year (long term outcomes). Outcomes were compared after 1:1 propensity score matching (PSM) to account for the confounding variables (age, gender, race, diabetes, ischemic heart disease, hypertension, chronic kidney disease, chronic lower respiratory disease and nicotine dependence). RESULTS We identified a total of 18228 patients with compensated cirrhosis who were tested for COVID-19 during the study period. Of these, 1217 patients tested positive for COVID-19 and were included in the COVID-19 group, and the remaining 17011 were included in the non-COVID-19 group. There were significant differences in characteristics, however, after PSM, both groups were well matched (Table 1). Patients in the COVID-19 group had a significantly higher risk of mortality at 3 months and the risk remained high even after PSM (Table 2). COVID- 19 group had a higher risk for decompensation, inpatient or ICU care. However, follow up of survivors at 1 year did not show an increased risk of mortality, decompensation, inpatient or ICU care in both unmatched and matched analysis (Table 2). . CONCLUSION Our study showed that patients with compensated cirrhosis who tested positive for COVID-19 are at higher risk of decompensation and poor outcomes in the short-term secondary to acute insult from COVID-19 disease. However, for patients who survive the acute COVID-19 insult, long-term outcomes including the risk of decompensation, mortality or need for hospitalization are similar when compared to cirrhosis patients who never acquired COVID- 19 disease. This study demonstrates that patients with cirrhosis who survive COVID-19 may not have worsening of their underlying liver disease or long-term prognosis. (Table Presented)Baseline characteristics of the two study cohorts before and after propensity score matching (Table Presented) Clinical outcomes of the two study cohorts before and after propensity score matching

From vaping and smoking: Risk assessment of new tobacco and nicotine releasing systems

90% of all e-cigarette users use tobacco cigarettes instead of quitting smoking and, due to sweet-flavored liquids and advertising as a lifestyle product, young never-smokers are increasingly using these new products. Even though e-cigarettes may also contain lower levels of harmful substances, no e-cigarette was free from potentially toxic and carcinogenic substances, and there is also evidence that e-cigarettes contain new toxic substances;in 2019, they led to EVALI in the USA with 68 deaths. In the steam from tobacco heaters, 295% increased amounts of carcinogenic acenaphthene compared to tobacco cigarettes were found. The use of nicotine-containing e-cigarettes and tobacco heaters did not reduce tobacco-related diseases. Shisha lead to a similar nicotine addiction potential, a considerably higher pollution, and carbon monoxide exposure. Shiazzo steam stones have a significantly lower health risk than shishas with the same risk of carbon monoxide poisoning. The consumption of e-cigarettes by adolescents and young adults led to a 5-fold increased risk of contracting COVID-19, in combination with tobacco cigarettes even to a 7-fold increased risk. The new tobacco or nicotine-releasing substances are neither harmless to health nor suitable for smoking cessation.

An uncommon cause of ischemic strokeintracranial internal carotid artery dissection

Background Intracranial internal carotid artery (ICA) dissection is a spontaneous or trauma-induced cause of stroke. Intracranial dissections, less common than extracranial, affect younger age groups and cause larger strokes. Case presentation 47-year-old female with a past medical history of poorly controlled type two diabetes, hypertension, and nicotine dependence presented to the emergency department with over twelve hours of left-sided weakness. With no known trauma, she woke up from a nap the day prior with weakness that has progressed, prompting her visit to the hospital. She denied paresthesia, dysarthria, shortness of breath, or chest pain but had bifrontal headache. On examination, she had left-sided hemiparesis with a right-sided gaze preference. Initial CT without contrast demonstrated evolving infarct. MRI revealed multifocal infarcts involving right parietal cortex, deep white matter and basal ganglia. Carotid Doppler showed 100% occlusion of the right ICA. CTA of head revealed asymmetric narrowing of the right cervical ICA thought to represent proximal propagation of the dissection into cavernous sinus without visible dissection flap. Attempts to transfer to a higher center in surrounding area hospitals for neuroradiological intervention were unsuccessful because of lack of ICU beds due to occupation with high numbers of COVID 19. Anticoagulation therapy was withheld due to large area of acute stroke and risk of hemorrhagic conversion. Dual antiplatelet therapy with aspirin and clopidogrel was started and high dose statin. Frequent neurological examinations were performed throughout her hospital stay;however, she remained stable and was discharged with home health and outpatient physical therapy. Workup for genetic risk factors for dissection remained negative. The patient was counseled on the importance of smoking cessation and chronic care management to reduce her risk of future events. Discussion ICA dissection accounts for 2.5% of all strokes and 20% of strokes in patients under 40. Most notably, over 80% of dissection cases are due to trauma, connective tissue, or vascular disorders. Other risk factors associated with dissection include, but are not limited to, recent infection, hypertension, and smoking. Dissections result in separation between arterial wall layers creating an intramural hematoma. Enlarged thrombus formation may lead to TIA or ischemic stroke. Rupture of the hematoma may lead to subarachnoid hemorrhage. Non-contrast head CT with CTA of the head and neck is the high sensitivity imaging modality of choice. Standard approach to stroke treatment is followed for patients presenting with ischemic stroke or TIA. Antithrombotic or anticoagulation treatment is acceptable for extracranial dissection. Antiplatelet therapy and/or surgical interventions are preferred for intracranial dissections. Repeat neurovascular imaging is recommended three to six months after initial event to assess the status of dissection.

P.0338 Chronotype and area-specific deficits in mental health

Background: The COVID-19 pandemic has caused a palpable rise in mental health conditions, including greater anxiety, depression and stress. There have been many suggested driving factors for this rise, from unemployment to exposure to negative news. However, during the pandemic there have been both a rise in drug consumption and a shift to a later chronotype. Chronotype is a measure of the timing of an individual's behavioural patterns, with early and late chronotypes being more colloquially known as ‘early larks’ and ‘night owls’ respectively. Later chronotype has often been associated with increased drug consumption and there have not yet been investigations into the influence of these factors on the rise of mental ill-health during the COVID-19 pandemic. Objectives: We aimed to investigate the effect of chronotype on mental health in the general public. The Munich Chronotype Questionnaire (MCTQ) was used to assess the chronotype of each participant. The 21-item Depression Anxiety Stress Scale (DASS21) was used to assess mental health. As it is known that drug consumption increases with later chronotype, we then assessed whether increased drug consumption was responsible for these relationships. We used the Alcohol Use Disorders Identification Test (AUDIT), Revised Cannabis Use Disorders Identification Test (CUDIT-R) and the Fagerström Test for Nicotine Dependence (FTND) to quantify alcohol, cannabis and tobacco use respectively. We hypothesised that a later chronotype would be associated with poorer mental health and that total drug consumption would mediate this relationship. Methods: This was a cross-sectional study in the Cambridge county area (N=209), with data collection being completed using an online survey. The MCTQ gathers data regarding sleep timing throughout the week, allowing us to generate a mid-sleep time which has been validated as an indicator of chronotype. The DASS21 with its individual subscales allowed us to generate scores for depression, anxiety, stress and overall mental health. We then completed multiple regression analysis to investigate the associations between chronotype and these mental health measures. Mediation pathway analysis was used to examine whether total drug consumption was responsible for the significant associations. Total drug consumption was calculated by summing the scores from the AUDIT, CUDIT-R and the FTND. Results: Multivariate regression analyses revealed that chronotype was significantly associated with overall mental health score (β=0.16, p=0.022) and anxiety (β=0.18, p=0.009). Chronotype was not significantly associated with depression or stress. Causal mediation analysis showed that overall drug consumption mediated both relationships. Conclusion: The association between later chronotype and poorer mental health is driven by increased anxiety rather than depression or stress. However, these relationships can be explained by the increased drug consumption that occurs in these late chronotypes. These results can inform counselling and future treatments for late chronotypes that focus on reducing their drug consumption. The evidence that anxiety drives the relationship with mental health will also allow healthcare professionals to screen for anxious symptoms to identify those that require interventions more effectively. No conflict of interest

Predictors of clinical decompensation in patients presenting with COVID-19 in an urban hospital health system

Introduction: Severe acute respiratory syndrome coronavirus 2 (SARSCoV- 2) has resulted in a pandemic which has infected more than 128 million people and led to over 2.8 million deaths worldwide. Although the introduction of efficacious vaccines has led to overall declines in the incidence of SARS-CoV-2 infection, there has been a recent increase in infections once more due to the appearance of mutant strains with higher virulence. It therefore remains vital to identify predictors of poor outcomes in this patient population. Purpose: The objective of our study was to identify predictors of prolonged hospitalization, intensive care unit (ICU) admission, intubation, and death in patients infected with SARS-CoV-2. Methods: We conducted a retrospective analysis of all patients hospitalized with SARS-CoV-2 at our health system that includes one tertiary care center and two community hospitals located in the Chicago metropolitan area. The main outcome was a composite endpoint of hospitalization >28 days, ICU admission, intubation, and death. Explanatory variables associated with the primary outcome in the bivariate analysis (p<0.05) were included in the multivariable logistic regression model. Statistical analysis was performed using IBM SPSS 25.0. Results: Between March 1, 2020 and May 31, 2020, 1029 patients hospitalized with SARS-CoV-2 were included in our analysis. Of these patients, 379 met the composite endpoint. Baseline demographics are described in Table 1. Of note, our cohort consisted of a predominantly minority patient population including 47% Hispanic, 17% African American, 16% Caucasian, and 16% other. In bivariate analysis, age, hypertension, tobacco and alcohol abuse, obesity, coronary artery disease, arrhythmias, valvular heart disease, dyslipidemia, hypertension, stroke, diabetes, documented thrombosis, troponin, CRP, ESR, ferritin, LDH, BNP, D-dimer >5x the upper limit of normal, lactate, and right ventricular outflow tract velocity time integral <9.5 were significant. After multivariable adjustment, explanatory variables associated with the composite endpoint included troponin (OR 2.36;95% CI 1.08-5.17, p 0.03), D-dimer (OR 1.5;95% CI 1.23-1.98, p<0.01, lactate (OR 1.58;95% CI 1.28-1.95, p<0.01), and documented thrombosis (OR 3.56;95% CI 1.30-8.70, p<.05). Race was not a predictor of poor outcomes in the bivariate or multivariate analysis (Table 2). Conclusions: In a large urban cohort with a predominantly minority population, we identified several clinical predictors of poor outcomes. Of note, race was not a predictor of the primary endpoint in this study. While recent literature has demonstrated worse outcomes among racial minorities infected with SARS-CoV-2, our data suggests these variations are related to social determinants of health rather than biologic causes. (Figure Presented).

Changes in Tobacco Use Patterns among Veterans in San Diego during the Recent Peak of the COVID-19 Pandemic.

The prevalence of tobacco use increases in times of stress; however, during the initial stage of the COVID-19 pandemic, tobacco use rates stayed the same in most populations. Previous work focused on the initial months of the pandemic, while this study examined the changes in tobacco use during a later peak period of the pandemic. We used data from 61,852 visits to the VA San Diego Healthcare System from November 2019 to February 2021, divided into pre-, early, and peak pandemic periods. Multinomial logistic regression was used to test whether the odds of being a daily or non-daily tobacco user varied over time, by demographic group, or with the presence of specific psychiatric diagnoses. Younger Veterans had a greater reduction in the prevalence of non-daily tobacco use between the early and peak periods, while older Veterans had a rise in daily use from pre- to the early pandemic, which returned to baseline during the peak. Individuals with substance use disorder and serious mental illness diagnoses were more likely to report tobacco use, but psychiatric diagnoses did not predict change over time. These findings demonstrate factors that potentially contribute to changes in tobacco use during a public health crisis and may help guide future targeted cessation efforts.