COMPARATIVE EFFICACY OF VARIOUS ANTICOAGULANTS IN COVID-19 INDIAN SUBJECTS: AN OBSERVATIONAL STUDY

Background: To assess the efficacy of various anticoagulants being prescribed in the COVID 19 induced hypercoagulability, so as to know optimally effective anticoagulant. Methods: This was a Indian observational study conducted in our covid centre at vijayawada,Andhra Pradesh between june 2020 to January 2021 . Results: A total of 100 COVID 19 subjects were included. The patients were found to be matched with respect to age, gender, diet and past history of various illnesses. Gender wise more males (60 patients)are affected when compared to females(40 patients). Age group more affected are less than or equal to 50yrs . Comorbidites like Diabetes(67patients),cardiac problems(62patients), dyslipidemia(62patients) were seen. Risk factors like smoking(52patients), alcoholism(50patients) noticed. Almost all subjects are RTPCR positive. IL- 6,CRP,LDH high in most subjects. Ferritin and PT/INR are normal in more subjects. Out of 100 patients oxygen is required in 48 subjects and BIPAP/CPAP required in 26 subjects. Death occurred in 24 patients (2 with CVA,22 with myocardial infraction). Mortality rate is more in vegetarians. More patients in our study belongs to CORADS score 4 and 5. D-dimer are increased in 67subjects. IL-6 are increased in 68patients . Frequency of subjects with raised D-dimer (p = 0.049) and CRP (p = 0.002) levels were found to be benefitted on receiving nattokinase. However, no other parameters such as IL-6 (p = 0.068) ferritin (p = 0.396), ESR (p = 0.278), PT/INR (p = 0.47) LDH (p = 0.34) or CORADS staging achieved such significant association. Also need of interventions such as Oxygen (p = 0.001), BIPAP/CPAP (p < 0.0001) were low in patients on nattokinase. No significant difference was noted in follow up investigations such as PT/INR (p = 0.31) and other markers (D-dimer, IL-6, LDH, CRP) (p = 0.55). No bleeding episodes were reported in subjects on nattokinase. Significant low rate of death was found in subjects who received nattokinase (p < 0.0001) and rivaroxaban (p < 0.0001). Also, significantly higher mortality rate was observed in subjects who required to be put on oxygen (p < 0.0001) as well as BIPAP/CPAP (p < 0.0001). Conclusions: Nattokinase simultaneously effects several key favourable benefits for thrombosis, hypertension, atherosclerosis, hyperlipidaemia, platelet aggregation, and neuroprotection in patients with COVID 19 infection. (Figure Presented).

URINARY BIOMARKER ANALYSES ON JAPANESE, MEDITERRANEAN AND EURO-WESTERN POPULATIONS: WHICH IS BETTER FOR POSTPANDEMIC LONGEVITY?

Objective: Since nutrition could extend lifespan even in stroke-prone rats developing stroke genetically, our WHO-Collaborating Center for Primary Prevention of Cardio-vascular Diseases (CVD) started world-wide hearth examination to investigate nutrition good for healthy longevity by collecting 24-hour urine (24U) samples. Design: Urinary biomarkers of nutritions, sodium for salt, potassium (K) for vegetables and fruits, isoflavones(Is) for soy, taurine(Ta) for fish and magnesium (Mg) for beans and nuts were analyzed in 24U among 4211 participants (49.7% females(F)), aged 48-56 years in 50 populations from 22 countries according to WHO-CARDIAC(Cardiovascular Diseases and Alimentary Compression) Study Protocol, and studied comparatively in 6 Japanese(J), 6 Mediterranean(M) populations from Greece, Italy(2), Spain(2), Portugal and 6 Euro-Western(EW) populations from Sweden, Ireland, Scotland, Canada, Australia, New Zealand. Results with Discussion: The quintile analyses of Ta and Mg/creatine ratio in the world were inversely associated with CVD risks. The Odds ratios of obesity, hypercholesterolemia and hypertension in the lowest quintile of both Ta and Mg were 6.3, 4.6 and 1.8, respectively. J and M populations had significantly higher Ta and Mg therefore, lower CVD risks than EW, but J and M took more salt increasing the risk of stroke (Table 1). Despite the high salt intake, M had the merit of significantly high K intake to attenuate the adverse salt effect. J had a merit to take Is from soy containing Mg. Since Is intake was inversely associated with lower BMI in the world populations, high Japanese Mg intake was related to high Is intake which was inversely associated with obesity in Japan. In fact, the Japanese populations who took significantly higher T and Mg had lower BMI as well as higher HDL and folic acid in the blood, expected to prevent atherosclerosis and dementia. In contrast to M and EW, particularly severe obesity over BMI 30 was obviously less in J, ranking 182nd among 190 populations (WHO). The mortality rates of COVID-19 were significantly positively related to the ratio of severe obesity among 20 major countries in the world and this mortality was obviously lower in J, suggestive of the potential of J diet for post-pandemic longevity. Conclusion: 24U biomarker analyses indicated low-salted J and M diets are recommendable for CVD prevention. J diet is so far better than M diet because of lower CVD risks such as obesity and lipidemia, which were proven by urinary biomarkers to be related with traditional fish and soy intakes.

A Review of Phytochemistry and Pharmacology on Moringa Oleifera

Natural extracts have been of very interest since ancient times due to their enormous medicinal use and research attention. Moringa oleifera is well known as miracle tree as it consists of high nutritive values. Originally from India is widely distributed in many tropical regions, in the pacific region, west Africa as well as central America. India is the major supplier of Moringa worldwide, accounting for around 80% of global demand. It is a multipurpose plant cultivated for medicinal applications. It contains rich sources of Vit- A, B1, B2, B3 and C, It also has calcium, potassium, iron, magnesium, zinc and phospherus. Moringa species contain various phytoconstituents such as alkaloids, saponins,tannins, steroids.phenolic acids( gallic, vanillic and p-coumaric acids) and flavanoids(catechin), tocopherol ,glucosinolates and terpenes. Investigations of ethanol extract of the leaves gives lutein, B-carotene,phytyl fatty acids, esters, poly phenols, B- sitosterols,triglycerols,fatty acids and saturated hydrocarbons. Leaves were obtained by super critical extraction with CO2 using ethanol as a cosolvent, temperature 35-80 0C.The phenolic acids( gallic, vanillic and p- coumaric acids) and flavanoids(catechin) were identified in all extracts. Extracts obtained at 35 degrees shows the highest values of total phenolic compounds. The activities of plant include Anti-oxidants, anti-cancer, anti-microbial, anti-viral,anti- hyperglycemic,anti-hyperlipidemic,anti-inflammatory,anti-hypertension, anti-spasmodic and others. Due to covid-19 pandemic, the global Moringa products market size is estimated to be worth USD 5167.2 million in 2022. Leaf powder is expected to exceed USD 6 billion by 2025 on account of increasing demand in the dietary supplement and food applications.

Tsukamurella and mycobacterium tuberculosis pneumonia co-infection

Case Report: Tsukamurella species are aerobic, partially acid fast saprophytes commonly isolated from soil and water. They are opportunistic pathogens known to infect multiple organs and can contribute to significant pathologies such as bacteremia, peritonitis, and respiratory tract infections. Moreover, Tsukamurella shares certain characteristic properties to Mycobacterium tuberculosis and Actinomyces species, including the acid fast stain, which can contribute to misdiagnosis of patients. A 68 year old female patient presented to the ED for shortness of breath, fatigue, and weight loss for 6 months. The patient's past medical history includes pulmonary fibrosis, type 2 diabetes, coronary artery disease with stent, hyperlipidemia, hypertension, and M. tuberculosis infection when she was 3 years old in Finland. On admission, labs revealed thrombocytosis (reactive 555 000/microL), leukocytosis (14 450/microL), and microcytic anemia (9.4 microg/dl). Moreover, C reactive protein was elevated and procalcitonin was normal (0.06 microg/l);a COVID-19 PCR was negative. An X-ray revealed severe patchy and interstitial infiltrates throughout both lungs with parenchymal scarring and pleural thickening in the periphery of the left mid-lung zone with multifocal pneumonia. Blood and sputum cultures were performed under the impression of pneumonia, and treatment with azithromycin and ceftriaxone was started. A M. tuberculosis infection was suspected due to a positive AFS. Further chest CT suggested multifocal pneumonia within the left lung in addition to apparent cavitary lesions versus bulla, a chronic interstitial lung disease with traction bronchiectasis, calcified right lower lung nodule, and calcified hilar lymph nodes suggesting a history of granulomatosis diseases. A bronchoscopy with Bronchoalveolar lavage was performed. The initial sputum specimen direct smear showed acid-fast stain positive with Actinomyces growth, and Penicillin G was added to the treatment. Samples were sent to the state department lab, and biopsy revealed granulomatous inflammation negative for malignant cells. One month later, the patient's sputum culture showed Tsukamurella for High-performance liquid chromatography (HPLC). Moreover, a rifampicin sensible M. tuberculosis complex by NAA was also positive six weeks later. The patient was started on a complete TB regimen and continued in the outpatient pulmonology clinic with the addition of levofloxacin for three months and rifampicin substituted for rifabutin. As demonstrated in the case above, a Tsukamurella infection can present similarly to a Mycobacterium infection. Patients may be misdiagnosed or potentially be co-infected. Our patient was further tested and appropriately treated for Tsukamurella after further extensive diagnostic screenings. Due to a high rate of missed cases, it is important to keep Tsukamurella infection on the differential diagnosis as the patient presentation may initially appear to be a Mycobacterium or other pulmonary infection. Copyright © 2023 Southern Society for Clinical Investigation.

Incidence of acute myocardial infarction and Hurricane Katrina: Sixteen years after the storm

Purpose of Study:We aimed to evaluate the incidence of acute myocardial infarction (AMI) in New Orleans in the sixteen years after Hurricane Katrina. Methods Used: This was a single-center, retrospective study performed at Tulane University Health Sciences Center of patients admitted for AMI during two years prior to Hurricane Katrina and sixteen years after Hurricane Katrina. The pre-Katrina and post-Katrina cohorts were compared according to pre-specified demographic and clinical data. Summary of Results: In the sixteen-year post-Katrina period, there were 3696 admissions for AMI out of a total census of 128 276 (2.9%) compared to 150 admissions out of a census of 21 079 (0.7%) in the pre-Katrina group (p < 0.0001). The post-Katrina group had a higher prevalence of known coronary artery disease (CAD) (43.8% vs. 30.7%, p < 0.0001), diabetes mellitus (40.7% vs. 28.7%, p < 0.002), hypertension (80.1% vs. 74.0%, p < 0.05), hyperlipidemia (54.2% vs. 44.7%, p < 0.0001), smoking (54.2% vs. 39.3%, p < 0.0002), drug abuse (18.7% vs. 6.7%, p < 0.0002), and psychiatric disease (15.3% vs. 6.7%, p < 0.0004). The post-Katrina group was more often prescribed aspirin (49.6% vs. 31.3%, p < 0.0001), betablocker (46.9% vs. 34.0%, p < 0.004), ACE inhibitor or ARB (51.9% vs. 36.0%, p < 0.0004), and statin (52.6% vs. 28.0%, p < 0.0001) but with higher medication nonadherence (15.8% vs. 7.3%, p < 0.0001). The post- Katrina patients were also more likely to be unemployed (75.6% vs 22.7%, p < 0.0001) and non-married (56.3% vs. 52.7%, p < 0.0001). Rates of STEMI were lower in the post-Katrina group (29.1% vs 42.0%, p < 0.002). There was no significant difference in terms of sex, being uninsured, or prior coronary artery bypass grafting. Four patients were COVID positive in the post-Katrina cohort. Conclusion(s): There was a fourfold increase in the incidence of AMI sixteen years after Hurricane Katrina. Prevalent psychosocial, behavioral, and traditional CAD risk factors were significantly higher among the post- Katrina group. These findings will continue to add to the growing body of literature demonstrating the adverse cardiovascular outcomes that occur after a natural disaster. Despite this, further research is required to explain the underlying mechanisms to help mitigate future cardiac morbidity. This study will help enable cardiovascular clinicians to further understand the needs and dynamic changes that can occur following natural disasters. Copyright © 2023 Southern Society for Clinical Investigation.

Dietary Changes Among Japanese Adults Since the Spread of COVID-19

Preventive measures adopted for COVID-19 have brought about significant changes in lifestyle and have affected dietary habits worldwide.To examine the factors relating to dietary changes among Japanese adults since the spread of COVID-19.A cross-sectional questionnaire survey was conducted via the internet in November 2020. All 6,000 participants, comprising 3,044 male and 2,956 female adults, aged 20–64 years, who registered with a research company received the questionnaire on email.The questionnaire included items on demographic characteristics, socioeconomic factors, past medical history, COVID-19 infection situation of their family and neighbors, fear of COVID-19, and lifestyle habits and healthy changes in dietary habits since the spread of COVID-19. The participants were given multiple choices in answers: changed to healthier, changed to unhealthier, and no-change. Multinomial logistic regression analysis was conducted to examine factors associated with dietary changes.Of the participants, 1,215 (20.3%) answered that their dietary habits became healthier, 491 (8.2%) answered as unhealthy, while a majority of them (4,294, 71.6%), said their dietary habits remained unchanged. The results of the multinomial logistic regression analysis with unchanged as the reference indicated that healthier and unhealthier dietary change were negatively associated with age (OR [95% CI]: 0.89[0.84-0.95], 0.89 [0.81-0.97]) and positively associated with the past medical history of dyslipidemia (1.44 [1.11-1.86], 1.74 [1.23-2.46]) and fear of COVID-19 (1.05 [1.04-1.07], 1.02 [1.01-1.04]). Unhealthy change was positively associated with living alone, COVID-19 infection of colleagues, stress, and BMI, while annual household income, COVID-19 infection of oneself and friends, health literacy, frequency of exercise, and smoking were positively associated with healthier dietary changes.This study suggested that the factors determining healthy and unhealthy dietary change since the spread of COVID-19 were age, COVID-19 infection, and fear of COVID-19.Health, Labour and Welfare Policy Research Grants, Special Research (Grant Number JP 20CA2040).

AIBD Abstracts 2022

The proceedings contain 134 papers. The topics discussed include: sarcopenia is associated with social determinants of health in patients with inflammatory bowel disease;predictor of thromboembolic complications in patients with ulcerative colitis and measures for their prevention;patient perspectives on the COVID-19 pandemic, its impact on inflammatory bowel disease treatment, and overall well-being one year later;characteristics and outcomes of patients with IBD admitted to high vs low safety net burden hospitals: a nationwide analysis;serrated epithelial change: to follow or not to follow?;how can we predict the development of antibodies to infliximab in Crohn's disease?;Crohn's disease: what to do after anti-tumor necrosis factor-a therapy fails?;endoscopic scores as predictors of treatment failure in ulcerative colitis;management of hyperlipidemia induced by primary biliary cholangitis;development of shingles on tofacitinib despite completion of recombinant VZV vaccination series;impact of marijuana in ulcerative colitis with Nstemi hospitalizations: insights from national inpatient sample 2016-2019;and association of quality of life with clinical remission, HEMR, and bowel urgency in patients with ulcerative colitis treated with Mirikizumab.

Relato De Experiencia Da Doacao De Plasma Convalescente De Covid-19 No Hemocentro Coordenador Do Rio Grande Do Norte- Hemonorte

Objetivos: Descrever a experiencia da producao e distribuicao de plasma convalescente de COVID-19 realizadas na unidade coordenadora da Hemorrede publica do Estado do Rio Grande do Norte, para uso na pesquisa clinica intitulada como: "Estudo aberto de plasma convalescente em individuos com COVID-19 grave". Material e Metodos: A selecao dos doadores foi realizada pelo Instituto de Medicina Tropical da UFRN, atraves dos criterios estabelecidos pela RDC ndegree 34/2014, PRC ndegree 05/2017 e Nota Tecnica ndegree 13/2020. Com a finalidade de remover o plasma contendo os anticorpos contra o SARS-CoV-2 e de preferencia assintomatico ha 14 dias. A coletas foram realizadas com o uso da maquina de aferese, obedecendo todos os criterios estabelecidos em legislacao;e o volume coletado foi determinado pelo equipamento, de acordo com peso e altura do doador. O volume maximo a ser coletado foi de 600mL, podendo ser fracionado em duas unidades com pelo menos 200 mL. Em seguida, foram congelados em ate 4 horas apos a coleta, armazenados e identificados apos liberacao da sorologia como "Plasma Experimental Convalescente - PEC", conforme nota Tecnica da ANVISA. Para facilitar a comunicacao, foi criada uma planilha on line do Google drive, compartilhada entre os setores de processamento/distribuicao, de aferese e pelos responsaveis pela pesquisa, contendo todas as informacoes da doacao e a disponibilidade para uso. Resultados: Foram realizados 24 agendamentos de candidatos a doacao de plasma convalescente, dos quais 18 realizaram a coleta no periodo entre 26/06/2020 e 03/09/2020. Foram produzidas 28 bolsas com volume variando de 200 a 300 mL por bolsa com os tipos sanguineos: A+ (12);A- (04);AB+ (2) e O+ (10). Das 28 bolsas, 11 foram liberadas para a transfusao e 17 foram expurgadas (01 por lipemia, 01 por rompimento e 15 por validade). Discussao: Em 06 de julho de 2020, quando registrado a primeira onda de casos positivos para SARS-CoV-2 no Estado, com 55.925 casos acumulados, uma media movel - 7 dias com 835 casos e 26 obitos por dia (Fonte de dados: SESAP/RN, LAIS/HUOL/UFRN);a equipe do Hemonorte foi capaz de montar um fluxo para a coleta por aferese, processamento, armazenamento e ter disponivel para liberacao a primeira unidade de PEC de forma a manter um estoque disponivel deste hemocomponente para uso na pesquisa experimental ate a data do seu vencimento. Conclusao: Com os processos de trabalho mapeados, rotinas de treinamento implantadas e com o fluxo de comunicacao facilitados apos a implantacao da ISSO 9001:2015, foi possivel atender em tempo habil a demanda da producao de Plasma Convalescente no periodo inicial da pandemia quando havia um esforco cientifico global para combater o SARS-CoV-2. A planilha compartilhada facilitou a comunicacao entre os envolvidos no processo, principalmente devido a necessidade de isolamento social. Todas as bolsas solicitadas foram atendidas, as demais ficaram disponiveis ate o mes setembro de 2021, porem a maioria nao foi utilizada. Nao e possivel afirmar, de forma conclusiva, qual a real relevancia desse tratamento, devido a falta de dados clinicos que permita a analise final das transfusoes. Copyright © 2022

Safety and immunogenicity of inactivated COVID-19 vaccine in patients with metabolic syndrome: A cross-sectional observational study.

Background and aims: The prevalence of metabolic syndrome (MS), wich mainly including hypertension, hyperglycemia, hyperlipidemia, remains high, and the safety and antibody response of inactivated coronavirus disease 2019 (COVID-19) vaccination in patients with metabolic syndrome (MS) is still inconsistency, therefore it is necessary to explore the safety and antibody responses of inactivated COVID-19 vaccination in MS patients in clinical practice. Methods: 157 adults patients who were suffering from MS and 117 health controls (HC) at an interval of at least 21 days after full-course (2nd dose) vaccination were enrolled. The safety of inactivated COVID-19 vaccination was evaluated through collected adverse events (AEs) by questionnaire. The immunogenicity of included participant to inactivated COVID-19 vaccination was represented by serum seropositivity rate of anti-receptor binding domain (RBD) IgG, SARS-CoV-2 neutralizing antibodies (CoV-2 Nab) and titers of anti-RBD IgG, CoV-2 Nab. The B cells, mainly including RBD-specific B cells, RBD-specific memory B cell (MBC), RBD+ resting MBC cells, RBD+ activated MBC cells, RBD+ atypical MBC cells (atyMBCs), and RBD+ intermediate MBC cells, were also analyzed. Results: In terms of safety, all AEs in MS patients were mild and self-limiting, and the incidence was comparable to that of HC participants, with overall AEs within seven days reported in 9.6% (15/157) of 3H and 11.1% (13/117) of HC. Both groups experienced no serious adverse events. As for immunogenicity of MS patients to inactivated COVID-19 vaccination, compared with health controls, the seroprevalence of anti-RBD IgG and CoV-2 Nab was significantly decreased in MS patients (p = 0.000, p = 0.003, respectively), while the titers of anti-RBD IgG (AU/ml) and CoV-2 Nab (µg/ml) were also significant lower in MS patients (p = 0.014, p = 0.002, respectively). As for frequencies of B cells, MS patients had lower frequencies of RBD-specific B cells, RBD+ resting MBCs, and RBD+ intermediate MBCs (p = 0.003, p = 0.000, p = 0.000, respectively), but had a higher frequencies of RBD+ atypical MBCs (p = 0.000) than HC. In comorbidity number subgroups analysis of MS, except frequencies of RBD+ resting MBC cells, RBD+ activated MBC cells and RBD+ intermediate MBC cells had significant difference among three groups (p = 0.035, p = 0.042, p = 0.046, respectively), antibody response had no significant difference among 1H, 2H, and 3H groups (p > 0.05). And took 70 years old as a boundary, also no statistically significant differences (p > 0.05) were found in age subgroups. Lastly, comprehensive analysis in MS patients indicated that interval time after 2nd dose vaccine was the statistical significant factor which impacting antibody response in MS individuals. Conclusions: Inactivated COVID-19 vaccines were well-tolerated, but induced a poorer antibody response against SARS-CoV-2 in MS patients comparing to HC participants. Patients with MS should therefore be more proactive in receiving inactivated COVID-19 vaccine, and a booster vaccination may be considered necessary. Clinical trial registration: https://clinicaltrials.gov/, identifier: NCT05043246.

Surveillance of Side Effects after Two Doses of COVID-19 Vaccines among Patients with Comorbid Conditions: A Sub-Cohort Analysis from Saudi Arabia.

Background: Individuals with underlying chronic illnesses have demonstrated considerable hesitancy towards COVID-19 vaccines. These concerns are primarily attributed to their concerns over the safety profile. Real-world data on the safety profile among COVID-19 vaccinees with comorbid conditions are scarce. This study aimed to ascertain the side-effects profile after two doses of COVID-19 vaccines among chronic-disease patients. Methodology: A cross-sectional questionnaire-based study was conducted among faculty members with comorbid conditions at a public educational institute in Saudi Arabia. A 20-item questionnaire recorded the demographics and side effects after the two doses of COVID-19 vaccines. The frequency of side effects was recorded following each dose of vaccine, and the association of the side-effects score with the demographics was ascertained through appropriate statistics. Results: A total of 204 patients with at least one comorbid condition were included in this study. A total of 24 side effects were reported after the first dose and 22 after second dose of the COVID-19 vaccine. The incidence of at least one side effect was 88.7% and 95.1% after the first and second doses of the vaccine, respectively. The frequent side effects after the first dose were pain at the injection site (63.2%), fatigue (58.8%), fever (47.5%), muscle and joint pain (38.7%), and headache (36.3%). However, pain at the injection site (71.1%), muscle and joint pain (62.7%), headache (49.5%), fever (45.6%), and stress (33.3%) were frequent after the second dose. The average side-effects score was 4.41 ± 4.18 (median: 3, IQR: 1, 6) and 4.79 ± 3.54 (median 4, IQR: 2, 6) after the first and second dose, respectively. Female gender, diabetes mellitus, hypertension, hyperlipidemia, comorbidity > 2, family history of COVID-19, and the AstraZeneca vaccine were significantly associated with higher side-effect scores. Only 35.8% of study participants were satisfied with the safety of COVID-19 vaccines. Conclusions: Our analysis showed a high proportion of transient and short-lived side effects of Pfizer and AstraZeneca vaccines among individuals with chronic illnesses. However, the side-effects profile was comparable with the safety reports of phase 3 clinical trials of these vaccines. The frequency of side effects was found to be associated with certain demographics, necessitating the need for further investigations to establish a causal relationship. The current study's findings will help instill confidence in the COVID-19 vaccines among people living with chronic conditions, overcome vaccine hesitancy, and increase vaccine coverage in this population.

Effect of Comorbidities on the Infection Rate and Severity of COVID-19: Nationwide Cohort Study With Propensity Score Matching.

BACKGROUND: A vaccine against COVID-19 has been developed; however, COVID-19 transmission continues. Although there have been many studies of comorbidities that have important roles in COVID-19, some studies have reported contradictory results. OBJECTIVE: This study was conducted using real-world data from COVID-19 patients in South Korea and aimed to investigate the impact of patient demographics and comorbidities on the infection rate and severity of COVID-19. METHODS: Data were derived from a nationwide South Korean COVID-19 cohort study with propensity score (PS) matching. We included infected individuals who were COVID-19-positive between January 1, 2020, and May 30, 2020, and PS-matched uninfected controls. PS matching was performed to balance the baseline characteristics of each comorbidity and to adjust for potential confounders, such as age, sex, Charlson Comorbidity Index, medication, and other comorbidities, that were matched with binary variables. The outcomes were the confirmed comorbidities affecting the infection rate and severity of COVID-19. The endpoints were COVID-19 positivity and severe clinical outcomes of COVID-19 (such as tracheostomy, continuous renal replacement therapy, intensive care unit admission, ventilator use, cardiopulmonary resuscitation, and death). RESULTS: The COVID-19 cohort with PS matching included 8070 individuals with positive COVID-19 test results and 8070 matched controls. The proportions of patients in the severe group were higher for individuals 60 years or older (severe clinical outcomes for those 60 years or older, 16.52%; severe clinical outcomes for those of other ages, 2.12%), those insured with Medicaid (Medicaid, 10.81%; other insurance, 5.61%), and those with disabilities (with disabilities, 18.26%; without disabilities, 5.07%). The COVID-19 infection rate was high for patients with pulmonary disease (odds ratio [OR] 1.88; 95% CI 1.70-2.03), dementia (OR 1.75; 95% CI 1.40-2.20), gastrointestinal disease (OR 1.74; 95% CI 1.62-1.88), stroke (OR 1.67; 95% CI 1.23-2.27), hepatobiliary disease (OR 1.31; 95% CI 1.19-1.44), diabetes mellitus (OR 1.28; 95% CI 1.16-1.43), and cardiovascular disease (OR 1.20; 95% CI 1.07-1.35). In contrast, it was lower for individuals with hyperlipidemia (OR 0.73; 95% CI 0.67-0.80), autoimmune disease (OR 0.73; 95% CI 0.60-0.89), and cancer (OR 0.73; 95% CI 0.62-0.86). The severity of COVID-19 was high for individuals with kidney disease (OR 5.59; 95% CI 2.48-12.63), hypertension (OR 2.92; 95% CI 1.91-4.47), dementia (OR 2.92; 95% CI 1.91-4.47), cancer (OR 1.84; 95% CI 1.15-2.94), pulmonary disease (OR 1.72; 95% CI 1.35-2.19), cardiovascular disease (OR 1.54; 95% CI 1.17-2.04), diabetes mellitus (OR 1.43; 95% CI 1.09-1.87), and psychotic disorders (OR 1.29; 95% CI 1.01-6.52). However, it was low for those with hyperlipidemia (OR 0.78; 95% CI 0.60-1.00). CONCLUSIONS: Upon PS matching considering the use of statins, it was concluded that people with hyperlipidemia could have lower infection rates and disease severity of COVID-19.

COVID 19 Effects on Patients with Compensated Cirrhosis

Background: The coronavirus disease 19 (COVID-19) is a highly transmittable and pathogenic viral infection caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), which emerged in Wuhan, China and spread around the world. Genomic analysis revealed that SARS-CoV-2 is phylogenetically related to severe acute respiratory syndrome-like (SARS-like) bat viruses, therefore bats could be the possible primary reservoir.The intermediate source of origin and transfer to humans is not known, however, the rapid human to human transfer has been confirmed widely. There is no clinically approved antiviral drug or vaccine available to be used against COVID-19. However, few broad-spectrum antiviral drugs have been evaluated against COVID-19 in clinical trials, resulted in clinical recovery.The liver, the largest internal organ in the body, is essential in keeping the body functioning properly. It removes or neutralizes poisons from the blood, produces immune agents to control infection, and removes germs and bacteria from the blood. It makes proteins that regulate blood clotting and produces bile to help absorb fats and fat-soluble vitamins. Several studies have shown a significant risk of mortality in patients with cirrhosis and in liver transplantation recipients.2, 3, 4 The severity of presentation and risk of mortality is more in patients with decompensated cirrhosis.5,6 COVID-19 had lead to a significant decrease in number of liver transplant surgeries being performed, which would lead to an increased wait list mortality in these patients.

A review: The phytochemistry, pharmacology, and pharmacokinetics of Curcumae Longae Rhizoma (Turmeric)

Curcumae Longae Rhizoma (CLR) is the rhizome of Curcuma longa L. Pharmacological studies show that CLR can be used to treat cervical cancer, lung cancer, lupus nephritis, and other conditions. In this paper, we review botany, traditional application, phytochemistry, pharmacological activity, and pharmacokinetics of CLR. The literature from 1981 to date was entirely collected from online databases, such as Web of Science, Google Scholar, China Academic Journals full-text database (CNKI), Wiley, Springer, PubMed, and ScienceDirect. The data were also obtained from ancient books, theses and dissertations, and Flora Reipublicae Popularis Sinicae. There are a total of 275 compounds that have been isolated from CLR, including phenolic compounds, volatile oils, and others. The therapeutic effect of turmeric has been expanded from breaking blood and activating qi in the traditional sense to antitumor, anti-inflammatory, antioxidation, neuroprotection, antibacterial, hypolipidemic effects, and other benefits. However, the active ingredients and mechanisms of action related to relieving disease remain ill defined, which requires more in-depth research and verification at a clinical level.

CoVID-19 Vaccine Efficacy in Heart Transplant Recipients, a Single Center Experience

Purpose: Transplant recipients have worse CoVID-19 survival compared to the general population, and thus are recommended to be vaccinated and boosted. Determinants of vaccination efficacy have not been well studied in heart transplant patients. Method(s): This was a prospective study of heart transplant recipients vaccinated against SARS-CoV-2 with one of the 2-dose mRNA vaccine series. Antibodies (Ab) were quantified by anti-Spike ELISA pre- and post-vaccination. Clinical data was extracted from electronic medical records. Differences in Ab detection and timing of Abs were assessed for statistical significance using Fisher's exact tests for categorical variables and t-tests for continuous variables. Result(s): Of the total 54 participants recruited from Jan 2021 to present, 6 patients were Ab positive prior to vaccination and 11 did not provide a pre-vaccination sample but were Ab positive post-vaccination. Almost half of participants (48%, n=26) received a booster 3rd dose. The mean age at vaccination was 58 +/- 11, 20% (n=11) were female, 70% (n=38) were Caucasian, and median time since transplant was 4 years (interquartile range: 2-11 years). Of the 37 Ab-negative individuals enrolled, none developed detectable Abs after a single vaccine dose and only 9 (24%) developed Abs after the 2nd vaccine dose. Interestingly in this small group, 6/9 (66%) of participants had delayed seroconversion of approximately 3 months. Unexpectedly, hyperlipidemia was positively associated with a detectable antibody response (p = 0.05) after the 2nd dose. There was also a trend toward higher age (p=0.06) and BMI (p=0.08) being associated with lack of response to the 2-dose series. Importantly, of the 28 patients who had no Ab response to the 2-dose vaccination regimen, 11/17 (65%) became Ab positive after the booster, increasing the vaccine response rate in this pre-vaccine Ab-negative group to 20/37 (54%). Looking at the total cohort of 54 participants, the overall positivity rate regardless of antigen sources (i.e., including those previously infected or for whom no pre-vaccine sample is available) is 68.5% (37/54) with a trend suggesting that absence of Ab response may be associated with prednisone treatment (p=0.06). Conclusion(s): Heart transplant recipients exhibit a low response rate to the initial 2-dose mRNA vaccines (24%), but the 3rd dose induces a response in the majority of those who failed to respond to the 2-dose series increasing overall response to over 50%. Similar to observations in the general public, non-response tended to be associated with older age and higher BMI. However, further/larger studies are needed to identify key determinants of vaccine efficacy in this population to guide management.

PHENOBARBITAL-INDUCED ACUTE LIVER INJURY

SESSION TITLE: Drug-Induced and Associated Critical Care Cases Posters 2 SESSION TYPE: Case Report Posters PRESENTED ON: 10/19/2022 12:45 pm - 01:45 pm INTRODUCTION: Drug-induced hepatotoxicity is a well-known occurrence from a variety of different medications. However, phenobarbital (PHB) induced hepatotoxicity has not been well studied, and acute liver injury from PHB even less so. In this case, although our patient had many reasons to develop acute liver failure, including alcohol and toluene exposure, timing and investigations seem to point to PHB being responsible. CASE PRESENTATION: Patient is a 39 y.o male with past medical history significant for hepatitis A and B, hyperlipidemia and alcohol abuse who was found unresponsive by EMS after friends reported witnessing patient drinking alcohol and sniffing paint thinner. Patient remained unresponsive on arrival and was intubated and transferred to the MICU. Patient was afebrile with BP 100/55 and otherwise normal vital signs. Significant labs on presentation included a WBC of 8.15, CO2 of 16, lactic acid of 3.6 and mildly elevated transaminases (ALT: 59, AST: 48). Urine toxicology was positive for marijuana. EKG, chest x-ray and CT Head without contrast unremarkable. COVID negative. Video EEG was negative except for generalized slowing. On hospital day 3, patient was increasingly agitated, at which point phenobarbital was started due to concerns for alcohol withdrawal. Hepatic function panel the following mornings showed significant increases in transaminases (ALT: 972 and 5,746, AST: 790 and 4,805) and total bilirubin (6.8 and 11.4), and mild increase in alkaline phosphatase (112 and 125), respectively. Hepatitis panel, acetaminophen level and salicylate level were unremarkable. RUQ ultrasound was also negative for pathology. Gastroenterology was consulted, who recommended starting NAC protocol. Phenobarbital was discontinued. Hepatic function panel the following morning showed significant improvement. Liver transplant was considered, however LFTs continued to downtrend and remainder of hospital course was unremarkable. DISCUSSION: PHB is an anticonvulsant developed primarily for seizure management. However its use has expanded to alcohol withdrawal and even sedative withdrawal. Studies have demonstrated in vitro liver toxicity as well as idiosyncratic reactions and acute liver failure in children (1) (2), with minimal documentation in adults. And while there has even been histological analysis with linkage of chronic phenobarbital use to hepatic necrosis and granulomatous formation (3), there has been minimal documentation regarding acute liver failure in an adults taking phenobarbital. CONCLUSIONS: In conclusion, it is clear that phenobarbital played a significant role in this patient's liver injury and may need to be considered in future episodes of acute liver injury with unclear etiology. Reference #1: Li AM, Nelson EA, Hon EK, Cheng FW, Chan DF, Sin NC, Ma KC, Cheung KL, Fok TF. Hepatic failure in a child with anti-epileptic hypersensitivity syndrome. J Paediatr Child Health. 2005 Apr;41(4):218-20. doi: 10.1111/j.1440-1754.2005.00591.x. PMID: 15813878;PMCID: PMC7166358. Reference #2: Roberts EA, Spielberg SP, Goldbach M, Phillips MJ. Phenobarbital hepatotoxicity in an 8-month-old infant. J Hepatol. 1990 Mar;10(2):235-9. doi: 10.1016/0168-8278(90)90058-y. PMID: 2332596. Reference #3: Di Mizio Di Mizio, G., Gambardella, A., Labate, A., Perna, A., Ricci, P., & Quattrone, (2007). Hepatonecrosis and cholangitis related to long-term phenobarbital therapy: An autopsy report of two patients. Seizure, 16(7), 653–656. https://doi.org/10.1016/j.seizure.2007.05.008 DISCLOSURES: No relevant relationships by Zachary Banbury No relevant relationships by Michael Basir No relevant relationships by Inessa Bronshteyn No relevant relationships by Kyle Foster No relevant relationships by Anna-Belle Robertson

SURVIVAL OUTCOMES OF INTUBATED COVID-19 PATIENTS WHO UNDERGO CPR: A SYSTEMATIC REVIEW

SESSION TITLE: Acute COVID-19 and Beyond: from Hospital to Homebound SESSION TYPE: Original Investigations PRESENTED ON: 10/18/2022 02:45 pm - 03:45 pm PURPOSE: In-hospital cardiac arrest (IHCA) has been reported to be as high as 75%, with pooled worldwide case fatality rates (CFR) of COVID-19 patients in the ICU estimated as 37%. To our knowledge, there has not been any systematic reviews specifically investigating world-wide survival outcomes of intubated COVID-19 adult patients who undergo IHCA and receive cardiopulmonary resuscitation (CPR). The aim of our study was to evaluate the outcomes of such patients up until hospital discharge. METHODS: A systematic literature search using relevant keywords was performed for original articles published in Embase, Medline and Pubmed Central databases from 2019 to February 6 2022. Patients aged 18 and older who had COVID-19 and were intubated prior to undergoing cardiac arrest were included. Extracted data were summarized in a table showing publication details and country, study designs, total sample size, comorbidities, age, gender, initial cardiac rhythm during cardiac arrest, initial survival after CPR and survival outcomes up until discharge. STATISTICAL ANALYSIS We performed descriptive statistics using Microsoft Excel. Where applicable, measures such as mean, frequency, proportion and range were used. Case fatality rate was also calculated. Methological quality was assessed using Joanna Briggs Institute (JBI) critical appraisal tools. Interrater accuracy and reliability were assessed using Cohen’s kappa. RESULTS: We screened 912 deduplicated articles, of which 38 studies met our criteria for final inclusion. There were 230 total patients, of which 174 patients (75.7%) were intubated. Out of those, 161 patients (70%) underwent CPR and only 4 survived. CFR defined as total number of intubated COVID-19 patients who underwent CPR and died (n= 157) divided by total number of intubated COVID-19 patients who underwent CPR (n=161) was calculated to be 97.5% (95% Cl: 95.1 – 99.92%). Mean age of intubated COVID-19 patients who underwent CPR was 54 years, with 27.5% being females and 72.5% males. The most reported comorbidities of intubated COVID-19 patients who underwent CPR were hypertension (37.5%), diabetes (30%), prior lung pathology (17.5%), obesity(7.5%), hyperlipidemia (5%), stroke (5%), Coronary Artery Disease (CAD) (2.5%). CONCLUSIONS: Our CFR were higher than has been previously recorded for ICU patients with COVID-19. This suggests that COVID-19 patients on mechanical ventilation who deteriorate to the point of going into cardiac arrest are a particularly vulnerable population, and CPR in this subset of COVID-19 patients may be nearly futile. More studies are needed to investigate preventive and management strategies to mitigate such poor outcomes. CLINICAL IMPLICATIONS: Knowledge of survival outcomes in intubated COVID-19 adult patients can help facilitate early plan of care discussions given the limited resources many hospitals experienced during the pandemic. DISCLOSURES: No relevant relationships by Stephen Avera No relevant relationships by Marshaleen Henriques King No relevant relationships by Sorochi Iloanusi No relevant relationships by Chinedu Ivonye No relevant relationships by Ifeoma Ogbuka No relevant relationships by Titilope Olanipekun

COVID-19-ASSOCIATED PULMONARY MUCORMYCOSIS PRESENTING AS SPONTANEOUS PNEUMOTHORAX: A RARE PRESENTATION

SESSION TITLE: COVID-19 Case Report Posters 1 SESSION TYPE: Case Report Posters PRESENTED ON: 10/17/2022 12:15 pm - 01:15 pm INTRODUCTION: Mucormycosis is an angio-invasive fungal infection with substantial morbidity and mortality. While diabetes and immune suppression remain well-known risk factors for mucormycosis, COVID-19 is now emerging as its independent predictor. CASE PRESENTATION: A 43-year-old male, with a history of hyperlipidemia and alcoholism, presented to the hospital with complaints of progressive dyspnea on exertion, productive cough, intermittent fever, anorexia, and chest pain over the course of 2 weeks. About 5 weeks prior to the current presentation, he was tested positive for COVID-19 by a polymerase chain reaction (PCR) based test and remained in quarantine at home. He was not vaccinated against COVID-19. He had no known immunosuppressive disease. On initial examination, he was ill-appearing and had a temperature of 101 F, blood pressure 138/83 mmHg, respiratory rate 22/minute, pulse 102/minute, and saturation of 91% on 2 L nasal cannula oxygen. A computerized tomography (CT) scan of the chest revealed small bilateral pneumothorax (2 cm and 5mm) along with extensive ground-glass opacifications in all lobes. In the next 24 hours, the right-sided pneumothorax progressed to tension pneumothorax requiring pigtail pleural drainage catheter placement. The drained pleural fluid had more than 100,000/uL total nucleated cells (91% neutrophils, 2% lymphocytes, and 1% eosinophils) and ultimately cultures grew Rhizopus spp. He was started on intravenous liposomal amphotericin-B infusion (5 mg/kg daily). On hospital discharge, he was switched to oral posaconazole (started with loading 300 mg delayed-release tablet twice a day, followed by 300 mg dosing of delayed-release posaconazole tablets daily) to complete the long term treatment course. DISCUSSION: Most of the reported cases of mucormycosis in COVID-19 were in patients with either diabetes or receiving steroids. This is a rare presentation of COVID-19–associated pulmonary mucormycosis (CAPM) as spontaneous pneumothorax, in the absence of known immunosuppression history. COVID-19 results in a considerable increase in cytokines, particularly interleukin-6 (IL-6), which increase free iron by increasing ferritin levels due to increased synthesis and decreased iron transport. Also, concomitant acidosis increases free iron by reducing the ability of transferrin to chelate iron and this available iron becomes a considerable resource for mucormycosis. [1] Also, Mucorales adheres to and invades endothelial cells by specific recognition of the host receptor glucose-regulator protein 78 (GRP-78). Acidosis associated with severe COVID-19 triggers GRP-78 and fungal ligand spore coating homolog (CotH) protein expression on endothelial cells, both contributing to angioinvasion, hematogenous dissemination, and tissue necrosis. [2] CONCLUSIONS: Mucormycosis can present as spontaneous pneumothorax after recent COVID-19 and clinicians should be aware of rare clinical presentation. Reference #1: Singh AK, Singh R, Joshi SR, et al. Mucormycosis in COVID-19: A systematic review of cases reported worldwide and in India. Diabetes Metab Syndr Clin Res Rev 2021;15:102146. doi:10.1016/j.dsx.2021.05.019 Reference #2: Baldin C, Ibrahim AS. Molecular mechanisms of mucormycosis—The bitter and the sweet. PLOS Pathog 2017;13:e1006408. doi:10.1371/journal.ppat.1006408 DISCLOSURES: No relevant relationships by Faran Ahmad No relevant relationships by AYESHA BATOOL No relevant relationships by Zachary DePew No relevant relationships by Neil Mendoza

POST-COVID-19 ASPERGILLOSIS

SESSION TITLE: Post-COVID-19 Infection Complications SESSION TYPE: Case Report Posters PRESENTED ON: 10/17/2022 12:15 pm - 01:15 pm INTRODUCTION: Since the start of Covid-19 pandemic, several respiratory microorganisms have been identified that cause coinfection with Sars-Cov-2. Bacteria like Staphylococcus aureus and viruses like influenza are some of the identified pathogens. Rarely, fungal infections from Aspergillus are also being reported. CASE PRESENTATION: 59-year-old male with past medical history of hypertension and hyperlipidemia was admitted for shortness of breath and was found to be positive for Covid-19. He received Remdesivir, dexamethasone & tocilizumab. He required non-invasive ventilation via continuous positive airway pressure but continued to remain hypoxemic with elevated procalcitonin, he was treated with cefepime for bacterial pneumonia. Patient required emergent intubation and eventually underwent tracheostomy. He developed methicillin-resistant Staphylococcus aureus pneumonia for which he received vancomycin. He was eventually discharged to long term acute care facility. Patient was readmitted after 2 months due to worsening respiratory status. Computed Tomography Angiography of chest was negative for pulmonary embolism but showed pleural effusion. He underwent thoracentesis which showed exudative effusion with negative cultures. Echocardiogram showed right heart failure. Patient's symptoms were believed to be due to Covid-19 fibrosis. He required home oxygen and also received pulmonary rehabilitation. One year after the initial Covid-19 infection, he developed pulmonary hypertension and was referred for lung transplant consultation. However, he developed severe hemoptysis requiring intubation and vasopressors. Galactomannan was positive, Karius digital culture revealed Aspergillus Niger for which he received voriconazole. He was not deemed a suitable candidate for lobectomy. Patient developed arrhythmia and had prolonged QT interval so voriconazole was switched to Isavuconazole. He continued to have hemoptysis and his condition did not improve so family requested to transition care and patient passed away. DISCUSSION: Several studies have proven co-infection of Aspergillus with Covid-19. This case highlights Aspergillus infection approximately 1 year after initial Covid-19 infection. Sars-Cov-2 causes damage to airway lining which can result in Aspergillus invading tissues. IL-6 is increased in severe Covid-19 infection. Tocilizumab is an anti-IL-6 receptor antibody that has been approved for treatment of Covid-19 pneumonia. However, IL-6 provides immunity against Aspergillus so use of tocilizumab decreases protection against Aspergillosis which is usually the reason for co-infection. However, in this case patient developed fungal infection later during Covid-19 fibrosis stage. CONCLUSIONS: Recognizing fungal etiology early on is important in Covid-19 patients as mortality is high and appropriate intervention can reduce morbidity and mortality. Some patient may eventually require lung resection. Reference #1: Kakamad FH, Mahmood SO, Rahim HM, Abdulla BA, Abdullah HO, Othman S, Mohammed SH, Kakamad SH, Mustafa SM, Salih AM. Post covid-19 invasive pulmonary Aspergillosis: a case report. International journal of surgery case reports. 2021 May 1;82:105865. Reference #2: Nasrullah A, Javed A, Malik K. Coronavirus Disease-Associated Pulmonary Aspergillosis: A Devastating Complication of COVID-19. Cureus. 2021 Jan 30;13(1). Reference #3: Dimopoulos G, Almyroudi MP, Myrianthefs P, Rello J. COVID-19-associated pulmonary aspergillosis (CAPA). Journal of Intensive Medicine. 2021 Oct 25;1(02):71-80. DISCLOSURES: No relevant relationships by Maria Haider Baig

INFECTIOUS COMPLICATIONS AFTER TOCILIZUMAB IN PATIENTS WITH COVID: A REAL-WORLD EXPERIENCE

SESSION TITLE: COVID-19: Other Considerations in Management SESSION TYPE: Original Investigations PRESENTED ON: 10/18/2022 02:45 pm - 03:45 pm PURPOSE: Since its emergence in December 2019, severe acute respiratory syndrome coronavirus 2 (SARS-COV-2) has spread across the world, claiming millions of lives. With the publication of RECOVERY trial and REMAP-CAP trial, tocilizumab is recommended as additional therapy in select COVID populations by various professional societies. Although not observed initially in several randomized trials, concerns regarding serious secondary infections have been raised. Hereby, we seek to describe the epidemiology of infectious complications after tocilizumab in COVID patients admitted to a tertiary community hospital and to determine related risk factors for infections. METHODS: A retrospective cohort study was conducted among COVID patients requiring noninvasive or invasive ventilation who received tocilizumab at our hospital between June 2020 to December 2021. We define infectious complications as positive culture grown on a specimen that was also treated with antibiotics by the primary team. Baseline demographics and laboratory values are obtained through electronic medical records. Continuous outcomes are analyzed with parametric and non-parametric testing. Categorical variables are analyzed using the Chi-Square test. Risk factors are identified through Probit regression analysis and stepwise analysis. Statistics are performed using SPSS and STATA. RESULTS: 52 patients are identified with a median age of 63 and 46.2% female sex. Median hospital admission time since COVID diagnosis is 2 days and median tocilizumab administered time is 6.5 days. Common comorbidities include hypertension (63.5%), hyperlipidemia (50%) and diabetes (44.2%). Infectious complications are documented in 30 patients (57.7%), with 29 episodes of pneumonia, 7 episodes of urinary tract infection, and 4 episodes of bacteremia. Common organisms include MSSA (21%), Pseudomonas aeruginosa (19%), Klebsiella species (13%) and MRSA (5%). There are 9 cases of multidrug-resistant bacterial infection and 3 episodes of invasive fungal infection (1 Candidemia and 2 invasive aspergilloses). 22 patients (43.3%) died in the hospital before discharge with a median alive time after tocilizumab of 16.5 days. Hyperglycemia on admission (defined as a random glucose >200 mg/dl), hypertension and antibiotic use before tocilizumab are independent risk factors associated with infectious complications during regression analysis. Age >65 is the single most significant factor associated with death in the hospital. CONCLUSIONS: In real-world experience, infectious complications are not uncommon in COVID patients who receive tocilizumab. Our analyses show that potential risk factors for developing infections include a history of hypertension, hyperglycemia on admission and antibiotic use before tocilizumab. CLINICAL IMPLICATIONS: More rigorous criteria in patient selection and patient monitoring should be explored in future trials involving tocilizumab in COVID patients. DISCLOSURES: No relevant relationships by Zauraiz Anjum No relevant relationships by Ming-Yan Chow No relevant relationships by Ahmed Elkhapery No relevant relationships by Hafsa Faisal No relevant relationships by Lakshmi G Nair No relevant relationships by Charoo Iyer No relevant relationships by Hongli Liu No relevant relationships by Chengu Niu No relevant relationships by Kaiwen Zhu