Sea swimming and snorkeling in tropical coastal blue spaces and mental well-being: Findings from Indonesian island communities during the COVID-19 pandemic

The COVID-19 pandemic has considerable mental health impacts. Immersive nature-based interventions, such as swimming or snorkeling, may help mitigate the global mental health crisis caused by the pandemic. To investigate this, we collected cross-sectional data from residents of coastal villages (n = 308) in Kepulauan Selayar, Indonesia. Analysis of Covariance (ANCOVA) was used with mental well-being as the outcome variable, operationalized as the Mental Component Summary (MCS) scores from the SF-12 (12-item Short Form Health Survey). After adjusting for covariates, the activity of sea swimming or snorkeling was found to be significantly associated with better mental well-being (η2 = 0.036;p < 0.01). Predictive margins analysis revealed that those who engaged in sea swimming or snorkeling for one to three days a week gained a 2.7 increase in their MCS scores, compared to those who did not. A non-linear dose-response relationship was detected: for those swimming or snorkeling more than three days per week, there was only an increase of 1.7 MCS score compared to the 0-day. Overall this study contributes to the expanding of evidence base, showing that interactions with blue spaces can be beneficial for mental health, especially in a potentially stressful time such as the current pandemic.

Incidence and Impact of Ventilator Associated Multidrug Resistant Pneumonia in Patients with SARS-COV2.

Introduction: Ventilator Associated Pneumonia (VAP) is associated with significant cost, morbidity, and mortality. There is limited data on the incidence of VAP, appropriate antibiotic timing, and the impact of multidrug resistant VAP in intubated Coronavirus disease-19 (COVID-19) patients. Methods: A retrospective study was conducted at 2 tertiary urban academic centers involving 132 COVID-19 patients requiring invasive mechanical ventilation (IMV). The epidemiology of VAP, the impact of prior empiric antibiotic administration on the development of Multidrug Resistant Organism (MDRO) infections, and the impact of VAP on patient outcomes were studied. Results: The average age of the patients was 60.58% were males, 70% were African-Americans and two-thirds of patients had diabetes, hypertension, or heart disease. The average Body Mass Index (BMI) was 32.9. Forty-one patients (27%) developed VAP. Patients with VAP had a significantly higher Sequential Organ Failure Assessment (SOFA) score prior to Intensive Care Unit (ICU) admission. Sixty percent received empiric antibiotics before initiation of IMV, mostly on hospital admission, and 81% received empiric antibiotics at the time of intubation. The administration of empiric antibiotics was not associated with a higher prevalence of VAP. The prevalence of VAP was 22 per 1000 days on ventilation. No difference in mortality was seen between VAP and non-VAP groups at 49% and 57% respectively (p = 0.4). VAP was associated with increased ICU length of stay (LOS), 30 vs. 16 days (p < 0.001), and longer hospital LOS 35 vs. 17 days (p < 0.001). 40% of VAPs were caused by MDROs. The most common organism was Staphylococcus aureus (28%), with almost half (48%) being methicillin resistant Staphylococcus aureus (MRSA). Conclusion: VAP was a common complication of patients intubated for COVID-19 pneumonia. Most patients received empiric antibiotics upon the hospital and/or ICU admission. There was a 40% incidence of multidrug resistant pneumonia. Patients who developed VAP had almost twice as long hospital and ICU LOS.

COVID VACCINE-INDUCED RHABDOMYOLYSIS. A CASE OF RECURRENT RHABDOMYOLYSIS

CASE: A 46-year-old African-American female was evaluated for generalized body aches five days after receiving second dose of COVID mRNA-1273 (Moderna) vaccine. Six months prior, she received her first dose of Ad26 (Johnson & Johnson) vaccine without sequelae, Family history includes maternal systemic lupus erythematous. Patient has a history of cystic acne and, most notably, frequent episodes of muscle aches and weakness. In 2006 and 2016, patient was hospitalized for episodes of rhabdomyolysis after receiving influenza vaccine. Autoimmune myositis was ruled out. She has never received statin medication. In late 2017, she was admitted for rhabdomyolysis after upper respiratory tract infection. She reported dark urine but no rash or arthralgia. Patient had elevated CK 107,737 U/L, AST 379 U/L, and ALT 115 U/L. Her renal function, sed rate, TSH, HIV, influenza, direct Coombs, protein electrophoresis, and antinuclear antibodies were negative or within normal limits. She was treated with IV fluids, pain medication, and discharged. In her current admission for rhabdomyolysis, she presented with dark urine, CK 130,702 U/L, AST 692 U/L, ALT 208 U/L, and D-dimer 1,544 ng/mL. No acute renal injury was noted. Patient was treated with intravenous crystalloids and pain medication. CK and transaminases steadily trended down. Patient was discharged as she was asymptomatic and CK had dropped significantly. IMPACT/DISCUSSION: Rhabdomyolysis can be an adverse event to vaccine administration, most commonly influenza vaccination. Detection of SARS-CoV-2 inside skeletal muscle has not been documented. Reports on COVID- 19 vaccine-induced rhabdomyolysis focus on the type of vaccine the patient received, the number of doses that triggered the event, CK level, and presence of risk factors for developing rhabdomyolysis. Although no pathophysiologic mechanism has been established, several hypotheses exist to explain muscle damage including genetic factors, autoimmune reactions to the virus nucleic material, or external adjuvant. This has been described as autoimmune/inflammatory syndrome induced by adjuvants. Our patient had a history of recurrent episodes of rhabdomyolysis after receiving influenza and COVID immunizations, as well as viral infection. CONCLUSION: The mechanism of our patients' reaction is unknown. Reported cases support autoimmunity as the major risk factor for vaccinerelated rhabdomyolysis. This patient had elevated CK level on subsequent episodes of rhabdomyolysis fitting the pattern where a more exaggerated response of the immune system is observed every time patient is re-exposed to known insult. Genetic predisposition may also play a role. AfricanAmericans have higher prevalence of slow acetylation and carnitine palmitoyltransferase II deficiency, a disorder of fatty acid. The myopathic form presents with high CK values. Therefore, patients should be counseled to seek medical attention when symptoms occur and physicians should consider vaccination as a possible cause.

Rapid and Sustained Decline in CXCL-10 (IP-10) Annotates Clinical Outcomes Following TNF-α Antagonist Therapy in Hospitalized Patients with Severe and Critical COVID-19 Respiratory Failure

Background. TNFα and IFN-γ may synergize to induce cytokine-driven lethal hyperinflammation and immune exhaustion in COVID-19 illness. Methods. To assess TNFα-antagonist therapy, 18 hospitalized adults with hypoxic respiratory failure and COVID-19 pneumonia received single-dose infliximab-abda therapy 5mg/kg intravenously between April and December 2020. The primary endpoint was time to increase in oxygen saturation to fraction of inspired oxygen ratio (SpO2/FiO2) by ≥ 50 compared to baseline and sustained for 48 hours. Secondary endpoints included 28-day mortality, dynamic cytokine profiles (Human Cytokine 48-Plex Discovery Assay), secondary infections, duration of supplemental oxygen support and hospitalization. Hospitalized patients with SARS-COV2 infection and pneumonia that were referred to the infliximab-abda study team for evaluation. Results. Patients were predominantly in critical respiratory failure (15/18, 83%), male (14/18, 78%), above 60 years (median 63 yrs, range 31-80), race-ethnic minorities (13/18, 72%), lymphopenic (13/18, 72%), steroid-treated (17/18, 94%), with a median ferritin of 1953ng/ml. Sixteen patients (89%) met the primary endpoint within a median of 4 days, 15/18 (83%) recovered from respiratory failure, and 14/18 (78%) were discharged in a median of 8 days and were alive at 28-day follow-up. Deaths among three patients ≥ 65 years age with pre-existing lung disease or multiple comorbidities were attributed to secondary lung infections. Mean plasma IP-10 levels declined sharply from 9183 pg/ml to 483 pg/ml at Day 3 and 146 pg/ml at Day 14/discharge. Significant declines in IFN-γ, TNFα, IL-27, IL-6 (baseline above 10pg/ml), CRP and ferritin were specifically observed at Day 3 whereas other cytokines were unaffected. Among 13 lymphopenic patients, six (46%) had resolution of lymphopenia by day 3, and 11 by day 14. CXCR3-ligand (IP-10 and CXCL-9) declines were strongly correlated among patients with lymphopenia reversal (Day 3, Pearson r: 0.98, p-value: 0.0006). following treatment with infliximab-abda. The status of the patient at last follow-up (discharged, alive or dead) is indicated. ECMO: extracorporeal membrane oxygenation Control of inflammatory markers and cytokines following infliximab therapy Values from individuals are connected with solid lines, with deceased individuals indicated in red. Statistics: n=18, paired ratio t-test compared to baseline;∗: P<0.05, ∗∗: P<0.01, ∗∗∗: P<0.001, ∗∗∗∗: P<0.0001, n.s.: not significant. Conclusion. Consistent with a central role of TNFα, the clinical and cytokine data indicate that infliximab-abda may rapidly abrogate pathological inflammatory signaling to facilitate clinical recovery in severe and critical COVID-19. Randomized studies are formally evaluating infliximab therapy in this context. Funding: National Center for Advancing Translational Sciences.

Extended Reality Based Remote Learning Experience During Pandemic: Effectiveness and Barriers

The COVID-19 pandemic has impacted almost all sectors due to lockdown measures taken by governments across the globe to curtail the spread of virus. It has disrupted the regular teaching and learning process, as students miss face-to-face learning experience. However digital technologies have mitigated the negative impact these lockdowns would have otherwise caused. The challenges faced because of remote learning can be handled by incorporating XR related technologies to enhance the collaborative learning experience for remote learners. The XR technologies and their applications in educational institutions are still in their nascent stages but show great potential and are all set to create a paradigm shift in the way education and training is perceived. The chapter will provide an insight on how schools, universities, and enterprise learning can be made more engaging by reviewing different techniques adopted to effectively engage the remote learners using immersive technologies. It also focuses on advantages, adoption challenges and framework for using XR in education especially during these testing times. © 2022, The Author(s), under exclusive license to Springer Nature Switzerland AG.

Early Tracheostomy in Morbidly Obese COVID-19 Patients: A Case Series and Discussion of Institutional Practices.

Tracheostomies are often utilized in critically ill patients on prolonged mechanical ventilation, to enhance respiratory function and facilitate ventilator weaning. Many coronavirus disease 2019 (COVID-19) patients develop serious respiratory illness requiring ventilator management. In the early phase of this pandemic, the risk of disease spread lead to the development of conservative guidelines which advocated delaying tracheostomy at least two to three weeks from intubation and, preferably, with negative COVID-19 testing. The morbidly obese patient population, however, presents a unique scenario in which early tracheostomy may be beneficial. In this article, we discuss our institution's current practices along with clinical outcomes with reference to intensive care literature and propose that early tracheotomy in COVID-19 patients should be considered on a case by case basis.

The Ocean Decade-Opportunities for Oceans and Human Health Programs to Contribute to Public Health

For more than 4.5 billion people, approximately 15% of their daily per capita intake of animal protein comes from marine products.5 Seafood provides a source of micronutrients and omega-3 fatty acids essential for good physical and mental health. Studies over the past 10 years have demonstrated that spending time in highquality "blue" spaces (through leisure activities or living in a coastal environment) directly supports and enhances health and well-being, combatting obesity and mental health problems, particularly in deprived populations.6 This highlights an enormous potential for these well-being promotion initiatives and healthcare interventions to address both preexisting and emerging health issues beyond the lifetime of the pandemic. There is now a tremendous opportunity and public momentum for health professionals to join with ocean researchers to help policymakers, the business community, and the wider public to address systemic global challenges in a new way (http://bit.ly/2ZDFMS3).7 We need international alliances, transdisciplinary collaborations, and global governance that support innovative, systemic ways of managing ocean resources. ACKNOWLEDGMENTS The research was supported in part by the European Union's Horizon 2020 research and innovation programme (grants 774567 [H2020 SOPHIE Project] and 666773 [H2020 BlueHealth Project]);the UK Natural Environment Research Council and the UK Research and Innovation's Global Challenges Research Fund for the Blue Communities Project;the Blue Climate Initiative Health and Wellbeing Subgroup (https://www.blueclimateinitiative.org);the University of Girona;the City Council of Roses;the Catalan Fishmonger's Association;the Roses Fishers' Association;the Town Council of Tossa de Mar;and the government of Catalonia (the sponsors of the Roses Oceans and Human Health Chair).

Contact with blue-green spaces during the COVID-19 pandemic lockdown beneficial for mental health.

There is growing evidence that ecosystem services and especially the exposure to the natural world (blue-green spaces) have potential benefits for mental health and well-being. The COVID-19 pandemic and the measures adopted to control it provide a natural experiment to investigate the links between nature exposure and mental health under extreme conditions. Using a survey distributed online, we tested the following hypotheses: 1) People will show greater symptoms of depression and anxiety under lockdown conditions that did not allow contact with outdoor nature spaces; 2) Where access to public outdoor nature spaces was strictly restricted, (2a) those with green/blue nature view or (2b) access to private outdoor spaces such as a garden or balcony will show fewer symptoms of depression and anxiety, and a more positive mood. Based on 5218 responses from 9 countries, we found that lockdown severity significantly affected mental health, while contact with nature helped people to cope with these impacts, especially for those under strict lockdown. People under strict lockdown in Spain (3403 responses), perceived that nature helped them to cope with lockdown measures; and emotions were more positive among individuals with accessible outdoor spaces and blue-green elements in their views. These findings can help decision-makers in developing potential future lockdown measures to mitigate the negative impacts, helping people to be more resilient and maintain better mental health, using the benefits that ecosystem services are providing us.

Design, development and evaluation of Artificial Breathing Capability Device (ABCD): A novel innovation for respiratory support

Objective: The paucity of mechanical ventilators necessitates development of innovative respiratory support devices. Methods: We developed the Artificial Breathing Capability Device (ABCD) to automate compression of self-inflating bags (SIB), while controlling peak inspiratory pressure (PIP), ventilation rate (VR) and inspiration to expiration time (I:E) ratio (as in a conventional ventilator). ABCD has additional smart features including self-regulatory checks, auto cut-off during cough, endotracheal tube disconnection and blockage alarms, and SIB disconnection alarm. ABCD was tested non-stop for 60 days with 396 user combinations, using adult-size and paediatric-size SIB. The device was evaluated for robustness, reliability and precision. Results: ABCD did not have mechanical, electrical or electronic failures during continuous testing under various ambient conditions, confirming robustness. Reliability and precision evaluated by the proportion of user combinations showing <10% deviation from the set parameters showed: PIP 100%, VR 100% and I:E 84.3% with an adult SIB. The corresponding proportions with a paediatric-size SIB were 85.4%, 100% and 95.5%. With both SIB, the only combinations showing >10% deviation were outside the physiologic range. Conclusion: ABCD is a safe, efficacious and cost-effective option, which could be considered for adults and children in the context of ventilator shortages especially during the COVID-19 pandemic. © Author(s) (or their employer(s)) 2020. No commercial re-use. See rights and permissions. Published by BMJ.

Crystallographic and electrophilic fragment screening of the SARS-CoV-2 main protease.

COVID-19, caused by SARS-CoV-2, lacks effective therapeutics. Additionally, no antiviral drugs or vaccines were developed against the closely related coronavirus, SARS-CoV-1 or MERS-CoV, despite previous zoonotic outbreaks. To identify starting points for such therapeutics, we performed a large-scale screen of electrophile and non-covalent fragments through a combined mass spectrometry and X-ray approach against the SARS-CoV-2 main protease, one of two cysteine viral proteases essential for viral replication. Our crystallographic screen identified 71 hits that span the entire active site, as well as 3 hits at the dimer interface. These structures reveal routes to rapidly develop more potent inhibitors through merging of covalent and non-covalent fragment hits; one series of low-reactivity, tractable covalent fragments were progressed to discover improved binders. These combined hits offer unprecedented structural and reactivity information for on-going structure-based drug design against SARS-CoV-2 main protease.