Acute Fibrinous Organizing Pneumonia in a COVID-19 Patient: A Case Report

Background: Coronavirus disease 2019 (COVID-19), caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), has varied clinical and radiographic manifestations. Severe initial viral infection, cytokine release, opportunistic infection and post-viral inflammation may all contribute to progressive symptoms and severe lung injury. Acute fibrinous and organizing pneumonitis (AFOP), a rare pattern of acute lung injury characterized by intra-alveolar fibrin ball, has so far been reported associated with infections, connective tissue diseases, drugs and toxins, hematologic malignancy, altered immune status and inhalation injury. Case Report: The authors report a case of 26-year-old man with severe COVID-19 pneumonia that clinical and radiographic imaging worsened after episode of cytokine storm. The diagnosis of AFOP was confirmed by transbronchial biopsy, and the patient was successfully treated with high-dose corticosteroids. Conclusion(s): AFOP can be found in severe COVID-19 patients especially when clinical deterioration occurs later in disease course. Clinical suspicion is needed for prompt diagnosis and treatment. High-dose corticosteroid is an effective medication.Copyright © 2023 JOURNAL OF THE MEDICAL ASSOCIATION OF THAILAND.

Perceived impacts of the Covid-19 pandemic on protected area management and conservation outcomes in Mexico

Protected areas are under immense pressure to safeguard much of the remaining global biodiversity and can be strained by unpredicted events such as the Covid-19 pandemic. Understanding the extent of the effects of the pandemic on protected area management and conservation outcomes is critical for recovery and future planning to buffer against these types of events. We used survey and focus group data to measure the perceived impact of the pandemic on protected areas in Mexico and outline the pathways that led to these conservation outcomes. Across 62 protected areas, we found substantial changes in management capacity, monitoring and tourism, and a slight increase in non-compliant activities. Our findings highlight the need to integrate short-term relief plans to support communities dependent on tourism, who were particularly vulnerable during the pandemic, and to increase access to technology and technical capacity to better sustain management activities during future crises.

Personas, the Pandemic, and Inclusive, Synthetic, Smart City Planning

In the era of COVID-19, planners, and more broadly, city administrators and policy makers, have learned to cope with the accelerated pace of change, the broad band of uncertainty, and the need for rapid decision-making strategies. In the context of ever more diverse communities and greater reliance on technology as an effective response to the social and public health challenges of the pandemic, "smart" cities harness distributed communication and service delivery technologies to enhance the quality of urban life. The voices of citizens from marginalized and under-served populations, such as older adults and people with disabilities, are vital to the development of inclusive smart cities. In this paper, expanding an inclusive policy design approach is proposed that uses `personas' to actively engage those citizens.

Evaluation of a new enteral feeding tube nurse clinic at the Weston Park Hospital Radiotherapy department

The Trust provides cancer services for patients across the region. Approximately 300 patients each year receive radiotherapy for head and neck cancer, approximately 50% of these patients have enteral feeding tubes placed. Historically, Dietitians provided support for all patients with enteral feeding tubes receiving radiotherapy treatment and the local nursing service provided by the enteral tube feeding contract provider provided community clinical support. Due to increasing patient numbers and increased Dietetic workload, a new “enteral feeding tube nurse clinic” was introduced, run by the local enteral tube feeding homecare nurse, with the intention of supporting patients with enteral feeding tubes. This clinic has been running since 2019 and is a “drop-in clinic” which both staff and patients’ can access for support, including troubleshooting advice on feeding tubes, moving patients from bolus feeding to pump feeding or even giving patients reassurance that they are caring for their enteral feeding tube correctly. This is a unique service built in conjunction with the Dietetic team, designed to meet local patient’s needs. In 2020 a review took place to evaluate the level of patient satisfaction of care from the enteral feeding tube nurse clinic, to establish the confidence of patients in caring for their feeding tubes and to explore feedback from patients to develop the service further. The review took the form of a patient questionnaire, given to patients during the last week of their radiotherapy treatment. Survey questionnaire forms assessing: the patient’s satisfaction with the support and service (5-point scale: 1 not at all satisfied -5 very satisfied);how confident they felt after receiving the support (5-point scale: 1 not at all satisfied -5 very satisfied), and;about their experience overall (free text), were handed out to patients in clinic over a 6-week period. The questionnaire was completed by 12 patients. For satisfaction with the support and service 10/12 (83%) of patients scored 5: very satisfied, with the remaining 2 patients scoring 3: neutral. Comments from patients included: “nurses always willing to help”, “excellent nurses, great, quick, professional job-no fuss”, “help available whenever it is needed”, “very happy with the care provided”, “every time I have requested their help, I have had a prompt reply and always each problem has been addressed”. For confidence with enteral tube feeding procedures, 100% of patients scored 5: very confident. Comments from patients included: “I feel much happier with the tube”, “very confident in cleaning and rotation, and excellent instructions from nurses”. When asked about their experience overall, patient comments included “Thank you for all your support”, “expert care, friendly, informative”, “fantastic prompt treatment”, “grateful that I have had the support”, “friendly, professional staff are always willing to help and always have said ‘if you need me, just ask, at any time”. Due to Covid-19 the clinics had to temporarily stop, however the Dietitians and Consultants missed the instant and direct access to the homecare nurse for enteral feeding tube support, suggesting that the clinic was also highly valued by the healthcare professionals working at the clinic. In August 2021 the clinics started again and there are plans to expand the service later this year. In summary, the enteral feeding tube nurse clinic was positively evaluated by the patients attending the radiotherapy clinic. The overwhelming feedback was that having contact with an enteral tube feeding homecare nurse at least weekly throughout their radiotherapy treatment allowed them to have rapid access to support, advice, reassurance, and training if their feeding requirements changed. Due to the success of this clinic, development of similar clinics in other areas should be considered.

The development and use of e-learning modules to support care home staff caring for enterally tube fed patients

Education is increasingly being accessed digitally, as demonstrated by the success of e-Learning for Healthcare or e-LfH, a health education England programme developed in partnership with the NHS and professional bodies1. Within digital learning, e-learning is a popular medium as it offers users an opportunity to learn at one’s own pace, at a convenient time and place, revisiting as often as required, giving flexibility, and freedom to continue a professional development journey. A plan was therefore formed to develop e-learning to provide important support for enteral tube feeding for care home staff in a simple, convenient, and easily accessible format. Before development of the e-learning, qualitative and quantitative research was undertaken with key stakeholders to assess the acceptability of e-learning for care home staff in the field of enteral tube feeding. Following launch of the e-learning, views and feedback were analysed. Qualitative interviews were conducted with six care home managers across the UK to understand the challenges faced in providing education on enteral tube feeding for care home staff. Difficulties identified included: releasing staff from day-to-day activities;high turn-over of staff resulting in frequent training required for new employees;access to workplace digital devices, and;staff unable to complete their full duties until training was completed and documented. An online survey was conducted to gain quantitative information from an enteral tube feed companies’ homecare nurse team to evaluate the concept of online e-learning for care home staff. 13 homecare nurses responded, (approx. 10%) and 80% felt online training would be valuable for care home staff. Using these learnings an enteral tube feeding e-learning course was developed by the company’s homecare nurse team consisting of six, short interactive modules. Six Dietitians across the UK in both acute and community settings were consulted on the content, which they reviewed and refined ensuring a balanced view of practices and procedures were included. COVID-19 accelerated the requirement for online learning as face-to-face activity and care home access was restricted and the modules were launched earlier than planned in March 2020. A simple registration process granted access to the modules through a variety of electronic devices such as tablets and laptops. Between March 2020 to July 2021, 5,152 individuals registered and completed at least one module, with 3,661 (71%) completing the introductory course and the first 3 modules. Several NHS Trusts have added the e-learning link to their intranet sites as mandatory training for new starters. Feedback has been positive: “E-learning is going down a treat at the moment”;“11 of my staff completed the training. We found it really useful, the system was easy to navigate, gave us information that we didn’t know and helped us to understand the different types of feeding systems available. I would recommend this training as we all felt it gave us more confidence in supporting a person using a feeding system”. The high uptake of the e-learning and positive feedback demonstrate that these e-learning modules are a popular and acceptable form of education for care home staff and are suitable to be used across a variety of settings. The initial research helped to ensure that the e-learning modules which were developed, fully met the needs of care home staff and therefore provide important support in a simple, convenient, and easily accessible format. References 1. e-Learning for Healthcare.

Predictors of Persistent Fibrotic-Like Abnormalities in Survivors of Covid-19 Acute Respiratory Distress Syndrome (ARDS)

Rationale: A subset of COVID-19 patients will go on to have unremitting disease after recovering from the acute phase. Clinical parameters associated with the development and persistence of post-COVID sequela are largely unknown. We sought to determine the frequency of post-acute COVID lung sequelae and associated clinical factors in a subset of patients recovering from severe COVID-19. Methods: Of 88 COVID-19 ARDS subjects with no known prior lung disease who were hospitalized requiring mechanical ventilation between March-July 2020 and had a chest CT during their acute COVID-19 hospitalization, a subset of 19 patients who had post-discharge chest CTs were included. A thoracic radiologist visually scored the degree of opacity attributed to fibrotic-like changes, indicated by traction bronchiectasis and honeycombing, on the pre-discharge/inpatient CT (IPCT) and most recent outpatient CT (OPCT) for each patient. A significant difference was defined as a change in fibrosis score of >20%. Clinical data were collected and analyzed to evaluate for associations. Data represented as number of patients (percent of cohort) and mean ± standard deviation. Results: 17 of 19 patients were included in the analysis;the 2 excluded had no fibrosis on either CT. Mean time between IPCT and OPCT was 9 ± 6 months. 6 (35.3%) had either complete resolution or improvement of fibrosis (1 resolved, time to OPCT 14 months;5 improved, time to OPCT 10 ± 4 months), while 11 (64.7%) had either worsened or unchanged (2 worsened, time to OPCT 14 ± 5 months;9 unchanged, time to OPCT 7 ± 6 months). Compared with the worsened/unchanged group, the resolved/improved group had 73% higher fibrosis scores on IPCT, were more likely to have received Tocilizumab (66.7% vs 27.3%) and higher doses of steroids while hospitalized. The worsened/unchanged cohort had a higher prevalence of current or former smokers and longer hospital (76.3 ± 51.4 vs 63.8 ± 18.6 days) and ICU (61.2 ± 54.0 vs 55.7 ± 17.8 days) lengths of stay (LOS). Duration of mechanical ventilation and oxygen requirement at discharge were similar between groups. Conclusion: In this cohort of severe COVID-19 patients with radiologic evidence of fibrosis on IPCT, nearly two-thirds had persistent or increased fibroticlike changes on OPCT while over one-third improved or resolved over a mean follow-up of 9 months. Positive smoking history, longer hospital and ICU LOS, infrequent treatment with Tocilizumab, and lower total steroid doses were trends seen in subjects whose CT abnormalities persisted or increased.

Randomized, Double-Blind Trial of the Efficacy and Safety of Pirfenidone in Patients with Fibrotic Hypersensitivity Pneumonitis

Rationale: Fibrotic hypersensitivity pneumonitis (FHP) is an irreversible lung disease with high morbidity and mortality. We sought to evaluate the safety and effect of pirfenidone on disease progression in such patients.Methods: In a phase 2 double-blind, single-center trial, we randomly assigned, in a 2:1 ratio, adults with FHP to receive either oral pirfenidone (2403 mg/day) or placebo for 52 weeks. Patients had to have CT lung fibrotic abnormalities affecting ≥5%, worsening respiratory symptoms, and either an increase in the extent of fibrosis on CT or relative decline in the FVC% of ≥5% within the 24-months before screening. The primary endpoint was the mean change from baseline to week 52 in %FVC. Secondary endpoints included progression-free survival (PFS, time to the first occurrence of any one of the following: a relative decline of ≥10% in FVC and/or DLCO, acute exacerbation, a decrease of ≥50 m in the 6-minute walk distance, increase in background prednisone by ≥10 mg or introduction of corticosteroids and/or steroid-sparing drugs, or death), change from baseline to week 52 in FVC slope and mean %DLCO, all-cause hospitalizations, CT progression of lung fibrosis, and safety. Results: After 40 patients had been randomized (mean age 67.1 years, 42.5% males) the study was stopped due to slow recruitment due to the COVID-19 pandemic. At baseline, demographics, smoking and inciting antigen exposure history, lung function, 6-minute walk distance, extent of CT lung fibrosis, and immunosuppressive therapy were balanced in both groups. There was no significant difference between the pirfenidone and placebo groups after adjusting for baseline %FVC and concomitant immunosuppressive therapy (p=0.88) in mean change from baseline to week 52 in %FVC. Secondary endpoints showed no difference between groups in change from baseline to week 52 in FVC slope, mean %DLCO, all-cause hospitalization and CT progression of lung fibrosis. However, a decrease in PFS favored pirfenidone (Table). The percentages of patients with any adverse events (AE) were similar in both groups. Nausea and rash, respectively, led to transient dose reduction of study treatment in 2 patients in the pirfenidone group. There were no treatment-related serious AE or AE leading to discontinuation of study treatment. No death occurred in the pirfenidone group and one death (respiratory) occurred in the placebo group. Conclusions: The trial was under powered to detect a difference in the primary endpoint. Pirfenidone was found to be tolerable and safe and compared to placebo reduced PFS in patients with FHP.

Determination of reliable whole-lung CT features for robust standard radiomics and delta-radiomics analysis in a crab-eating macaque model of COVID-19: stability and sensitivity analysis

As of 14 December 2021, severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), the virus that causes coronavirus disease 2019 (COVID-19), caused nearly 269 million confirmed cases and almost 5.3 million deaths worldwide. Chest computed tomography (CT) has high diagnostic sensitivity for the detection of pulmonary disease in COVID-19 patients. Toward timely and accurate clinical evaluation and prognostication, radiomic analyses of CT images have been explored to investigate the correlation of imaging and non-imaging clinical manifestations and outcomes. Delta (∆) radiomics optimally performed from pre-infection to the post-critical phase, requires baseline data typically not obtained in clinical settings;additionally, their robustness is affected by differences in acquisition protocols. In this work, we investigated the reliability, sensitivity, and stability of whole-lung radiomic features of CT images of nonhuman primates either mock-exposed or exposed to SARS-CoV-2 to study imaging biomarkers of SARS-CoV-2 infection. Images were acquired at a pre-exposure baseline and post-exposure days, and lung fields were segmented. The reliability of radiomic features was assessed, and the dynamic range of each feature was compared to the maximum normal intra-subject variation and ranked. © 2022 SPIE

The appropriateness and usefulness of COVID-19 short message services directed at the public in Nigeria

The study carried out an assessment of the perceptions of health professionals in Nigeria on the awareness messaging on COVID-19 directed at the public using the SMS (Short Message Service) Technology. The researcher focused on health professionals in the metropolitan areas of Nigeria as the respondents. A structured questionnaire titled "health professionals' perception on awareness of messaging on COVID-19" was used to collect data from the respondents. The mode of data collection was a questionnaire survey administered online. The findings suggest that health professionals who participated in the survey have a very positive perception of the usefulness and appropriateness, coverage, and impact of the COVID-19 broadcast messages from the Nigerian Centre for Disease Control (NCDC);their responses show that the short messages were sent to Nigerians from different backgrounds and locations to inform the populace about the outbreak of COVID-19, prevention, knowledge about early symptoms, how to reduce the spread of COVID-19 in case of infection and what to do in case of emergency. Additionally, the research outcomes show that SMS broadcast was the leading channel of information dissemination and reception for COVID-19 response as against the traditional channel of information dissemination on radio, TV, and others. These findings have highlighted the importance and value of digital health services such as SMS technology in responding to health emergencies.

Characteristic and quantifiable COVID-19 like abnormalities in CT- and PET/CT-1 imaged lungs of SARS-CoV-2 infected crab eating macaques (Macaca fascicularis)

Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) is causing an exponentially increasing number of coronavirus disease 19 (COVID-19) cases globally. Prioritization of medical countermeasures for evaluation in randomized clinical trials is critically hindered by the lack of COVID-19 animal models that enable accurate, quantifiable, and reproducible measurement of COVID-19 pulmonary disease free from observer bias. We first used serial computed tomography (CT) to demonstrate that bilateral intrabronchial instillation of SARS CoV-2 into crab-eating macaques (Macaca fascicularis) results in mild-to-moderate lung abnormalities qualitatively characteristic of subclinical or mild-to-moderateCOVID-19 (e.g., ground-glass opacities with or without reticulation, paving, or alveolar consolidation, peri-bronchial thickening, linear opacities) at typical locations (peripheral>central, posterior and dependent, bilateral, multi-lobar). We then used positron emission tomography (PET) analysis to demonstrate increased FDG uptake in the CT-defined lung abnormalities and regional lymph nodes. PET/CT imaging findings appeared in all macaques as early as 2 days post exposure, variably progressed, and subsequently resolved by 6-12 days post exposure. Finally, we applied operator-independent, semi-automatic quantification of the volume and radiodensity of CT abnormalities as a possible primary endpoint for immediate and objective efficacy testing of candidate medical countermeasures.

A RANDOMIZED, DOUBLE-BLINDED, PLACEBO-CONTROLLED, PHASE 2 STUDY OF SAFETY, TOLERABILITY, AND EFFICACY OF PIRFENIDONE IN PATIENTS WITH RHEUMATOID ARTHRITIS INTERSTITIAL LUNG DISEASE

TYPE: Late Breaking TOPIC: Diffuse Lung Disease PURPOSE: The TRAIL1 trial was a randomized, double-blinded, placebo-controlled, phase 2 study of safety, tolerability and efficacy of pirfenidone in patients with RA-ILD. METHODS: The TRAIL1 trial recruited patients aged 18 to 85 years with established RA-ILD at 33 sites in 4 countries. The primary endpoint was the incidence of the composite of decline from baseline in percent predicted forced vital capacity (FVC%) of 10% or greater or death during the 52-week treatment period. Safety was reflected by differences between the treatment arms for the rate of adverse events, serious adverse events, acute exacerbations, hospitalizations, and all-cause mortality. RESULTS: With a randomization target of 270 participants, the study was stopped due to slow recruitment exacerbated by the COVID-19 pandemic. A total of 231 subjects provided consent and 123 were randomized. The proportions who met the primary endpoint were 11% on pirfenidone vs. 15% on placebo [OR=0.67 (0.22, 2.03), p=0.48]. Subjects on pirfenidone had a slower rate of decline in lung function as measured by estimated annual change in FVC(ml)(-66 vs. -146, p=0.0082) and FVC% (-1.02 vs. -3.21, p=0.0028) (Table and Figure 1). There was no significant difference in the rate of treatment-emergent serious adverse events. CONCLUSIONS: Although TRAIL1 was underpowered to detect a difference in the composite primary endpoint, pirfenidone was found to be safe and slowed decline of FVC over time in subjects with RA-ILD. CLINICAL IMPLICATIONS: This trial shows that prifenidone is safe in patients with rheumatoid arthritis-associated interstitial lung disease and slows the decline of forced vital capacity over time. DISCLOSURE: Nothing to declare. KEYWORD: Interstitial lung disease

Exploring Mental Health during the Initial COVID-19 Lockdown in Mumbai: Serendipity for Some Women.

Background: This study explored how low-income women already distressed by reproductive challenges were affected during the initial lockdown conditions of the COVID-19 pandemic in Mumbai, India. Methods: Women with reproductive challenges and living in established slums participated in a longitudinal mixed-methods study comparing their mental health over time, at pre-COVID-19 and at one and four-months into India's COVID-19 lockdown. Results: Participants (n = 98) who presented with elevated mental health symptoms at baseline had significantly reduced symptoms during the initial lockdown. Improvements were associated with income, socioeconomic status, perceived stress, social support, coping strategies, and life satisfaction. Life satisfaction explained 37% of the variance in mental health change, which was qualitatively linked with greater family time (social support) and less worry about necessities, which were subsidized by the government. Conclusions: As the pandemic continues and government support wanes, original mental health issues are likely to resurface and possibly worsen, if unaddressed. Our research points to the health benefits experienced by the poor in India when basic needs are at least partially met with government assistance. Moreover, our findings point to the critical role of social support for women suffering reproductive challenges, who often grieve alone. Future interventions to serve these women should take this into account.

Pediatric Inflammatory Multisystem Syndrome Temporally Associated with SARS-CoV-2.

OBJECTIVES: To know the clinical presentation and outcome of children with pediatric inflammatory multisystem syndrome temporally associated with SARS-CoV- 2 (PIMS-TS) at a pediatric tertiary care center in Chennai. METHODS: Clinical and biochemical parameters of 65 children with PIMS-TS treated between July and October 2020 were studied. All children had their COVID RT-PCR and IgG COVID antibodies tests done. RESULTS: Mean age of the study group was 5.65 ± 3.68 y. Fever with red eyes, rash, vomiting, abdominal pain, and shock were common presenting features. Sixty percent of the study group had Kawasaki/incomplete Kawasaki features. Sixty-seven percent of the study group had coronary dilatation, 41% presented with shock, and 25% had left ventricular dysfunction. Coronary aneurysms were documented in 58% of the study group (z score more than 2.5). Respiratory presentation with pneumonia was seen in 10%. Four children presented with acute abdomen. Acute kidney injury, acute liver failure, hemolysis, pancytopenia, macrophage activation syndrome, encephalopathy, and multiorgan dysfunction syndrome (MODS) were other features. Forty-three percent required noninvasive oxygen support and 15.4% required mechanical ventilation. Intravenous immunoglobulin (73.8%) and methylprednisolone (49.8%) were used for therapy. Mortality in the study was 6%, which was due to MODS. CONCLUSIONS: Acute febrile illness with mucocutaneous and gastrointestinal manifestations should have PIMS-TS as a possible differential diagnosis and needs evaluation with inflammatory markers and SARS-CoV-2 antibodies.

Respiratory disease, and treatment / thematic poster session COVID-19 as a cause of pulmonary fibrosis

Rationale: Long term sequelae of COVID-19, especially pertaining to lung structure and function, are largely unknown. Patients with severe COVID-19 who develop acute respiratory distress syndrome (ARDS) requiring prolonged mechanical ventilation are likely at highest risk. We sought to determine the incidence of radiographic markers of lung fibrosis and associated risk factors in a cohort of patients with severe COVID-19. Methods: The Electronic Medical Record at New York University was queried for subjects without a history of interstitial lung disease who had a positive SARS-CoV-2 PCR, required mechanical ventilation, and had a chest computed tomography (CT) conducted during their hospitalization for COVID-19. Clinical and laboratory data was collected. CT scans were blindly read by a thoracic radiologist using a novel scoring system where fibrotic changes were defined as consolidation and/or ground glass with traction, and honeycombing. The prevalence of fibrosis was established and analyses were done to evaluate for clinical associations. Data is represented as number of patients (percent of cohort), and mean ± standard deviation). Results: 88 patients were included, 61 (69.3%) had fibrotic changes on CT done 50.3 ± 33.6 days after admission, while 27 (30.7%) had no fibrosis seen on CT done 41.5 ± 26.0 days after admission. There were no significant differences in demographics or medical history between the subgroups. The fibrotic subgroup required mechanical ventilation for a longer duration than the non-fibrotic subgroup (52.8 ± 33.2 vs 32.1 ± 18.8 days) and had higher plateau pressures 21 days after intubation (26.6 ± 6.0 vs 16.5 ± 5.4 cmH2O). P/F ratios were similar on day of intubation (145.4 ± 55.5 fibrotic vs 145.7 ± 64.1 non-fibrotic), however the fibrotic subgroup had lower P/F ratios 7 days after intubation (146.3 ± 57.0 vs 182.1 ± 63.3), 14 days after intubation (166.3 ± 83.7 vs 236.8 ± 84.3), and 21 days after intubation (170.8 ± 90.5 vs 249.5 ± 103.0). The fibrotic subgroup also had higher peak ferritin (8899.92 ± 11461.3 vs 6715.6 ± 9680.1 ng/mL) and LDH (1031.67 ± 628.9 vs 929.0 ± 493.3 U/L). Conclusion: In our cohort of severe COVID-19 patients, over two-thirds had fibrotic changes on CT chest. Longer duration of mechanical ventilation, higher plateau pressures 21 days after intubation, lower P/F ratios 7 days or more after intubation, and higher peak ferritin and LDH levels were associated with presence of fibrosis. .