Using DTI tractography to guide tDCS interventions in a complex acquired brain Injury neurorehabilitation protocol - a case report

51-year-old man (C.P.) had a diffuse-axonal-injury after falling from a 5-meter height, followed by a 22-minute anoxia due to a cardiac arrest. In the ICU, he tested positive to COVID-19, and needed intubation. After coronavirus infection, C.P. presented Guillain-Barre syndrome. 2months after discharge, he was admitted to rehabilitation. DTI tractography for evaluation of the structural integrity of white matter tracts revealed: i) Lesions in the basal ganglia;ii) Sequelary lesions in the right frontal, cortical, subcortical, temporal, parieto-occipital and cerebellar hemispheres;iii) Asymmetry of the corticospinal tracts - less fibers on the left;iv) Poor definition of the fibers of the right arcuate fasciculus;v)Asymmetrical thinning of the cortico-ponto-cerebellar tracts, worse on the left, and more discreetly in the spinocerebellar tracts. Based on this, C.P. underwent 4 different 30-session tDCS protocols consisting of twice-daily 20min 2mA sessions (10min interval), 5days/week (120sessions total), combined with physiotherapy, cognitive, swallowing and speech therapy. Montages: Pr1 (anode: Cz - 5x10cm;cathode: 10th Thoracic Vertebra - 5x7cm);Pr2 (1 - anode:C3;cathode:Fp2 / 2 - anode: Cerebellum;cathode:Fp2);Pr3 (anode:F3;cathode:Fp2) and Pr4 (anode:Cp5;cathode:Fp2). Except for Pr1, electrode size for all protocols were 5x7cm. We used the Coma Recovery Scale (CRS-R) and Rancho Los Amigos Scale (RLAS) for clinical assessments at the baseline and after every 10 sessions until the end of the intervention. At the baseline, C.P. presented a minimal responsive state of consciousness (CRS-R: 3;RLAS: Level 1) and tolerated well the tDCS interventions. CRS-R scores gradually improved in various domains during the treatment. At the end, RLAS score was level 5 and CRS-R, 19. Our preliminary results suggest DTI tractography may be a potential biomarker to guide more personalized tDCS interventions for complex cases of patients with acquired brain injuries. A second DTI tractography will be made in the future for comparison purposes. Research Category and Technology and Methods Clinical Research: 9. Transcranial Direct Current Stimulation (tDCS) Keywords: Acquired Brain Injury, Traumatic Brain Injury, COVID-19, Guillain Barre SyndromeCopyright © 2023

Lung Transplantation for COVID-19-Associated Lung Injury (CALI): An International Registry

Background. SARS-CoV-2 can result in a range of infections from asymptomatic disease to progressive COVID-19 and death. In some pts with CALI, lung transplantation (LTx) may be lifesaving. Up to 10% of LTx in the US is currently for pts with CALI. Understanding the characteristics and outcomes of these pts is critical. Methods. A open-access electronic registry was established to collect deidentified data from pts who have undergone LTx for CALI from centers globally. The study was IRB approved at Northwestern with a wavier for consent (no PHI is collected sites could submit data about pre-Tx, peri-Tx and post-Tx course). Follow-up for 1-yr post-LTx was collected. Results. To date, 89 pts with complete day 30 post-LTx data have been entered into the registry. Pt demographics and pre-Tx status are shown in Table 1. 3 pts required oxygen prior to COVID-19. Most sites required neg PCR tests prior to listing (11 (12.4%) required no - PCRs, 11 (12.4%) required 1 and 61 (68.5%) required 2). LTx occurred 137 days post-infection and none developed COVID-19 in the first 30 d;4 were given monoclonal antibodies post-tx. Post-tx ICU LOS averaged 24.5 d with total post-tx hospitalization of 37.6 d (See Table 2). Most experienced infectious and noninfectious morbidity. Most (47.8%) required an additional 30 days of rehab. 2 pts died within 30 days due to sepsis and anoxia. 5 died between day 30 and 90 and an additional 12 died between day 90 and 365. Conclusion. The contribution of cases to this international registry is ongoing. While outcomes of LTx for CALI are generally good, patients experience prolonged post-transplant hospitalization, rehabilitation and significant morbidity and infections are common. (Table Presented).

Organs from Donors with Positive SARS-CoV-2 NAT+ Testing: A Report from the Ad Hoc Disease Transmission Advisory Committee

Purpose: Decision to transplant organs from SARS-CoV-2 NAT+ donors(N+D) balances risk of donor-derived infection with the scarcity of available organs to meet the needs of waitlisted candidates. Method(s): OPTN Ad Hoc Disease Transmission Advisory Committee (DTAC) reports on the use of organs from N+D from the onset of required SARS-CoV-2 lower respiratory tract(LRT) testing for lung donors (May 27, 2021) through August 31, 2021. OPTN data were analyzed for donors with a positive LRT or upper respiratory tract (URT) test reported in DonorNet discrete data fields (N+D), compared with donors who did not have positive LRT or URT in the discrete data fields (N-D). Result(s): Organs were recovered from 120 N+D (all OPTN Regions and 40/57 OPOs (70%)). Median donor age was 42 (IQR: 32-52) for N+D and 43 (30-56) for N-D. There was a greater proportion of DCD N+D than N-D (37.5% vs 28.3%, p=0.04). Underlying COD of anoxia and other were different (N+D 31.7%, 16.7% vs N-D 48%, 2.7%, respectively). Transplanted N+D and N-D did not differ by KDPI, LDRI or LVEF for kidney(KT), liver(LT) or heart(HT), respectively (Table 1). Median time from donor admission to first reported test (any result) was 0 and 4 days for URT and LRT, respectively. N+D recovery occurred a median of 2 (IQR: 1-6) days from last positive test. 246 organs (152KT, 50LT, 22HT, 22other) were transplanted from 107 N+D compared to 8969 organs from 3348 N-D. Recipients from N+D and N-D were similar in age, MELD/PELD (LT) and medical urgency status (HT). Median time from listing to transplant similar for N+D for all organs. The match run sequence number for final acceptor was higher for N+D for all organ types (Table 2). Median length of stay was similar for N+D and N-D for KT and LT (5d and 12-13d, respectively). For HT, median stay was shorter for N+D (30 vs 34d). For N+D, 3 of 50 LT died within 30d of transplant. During this timeframe, no PDDTEs were reported for any N+D at the time of transplant. Conclusion(s): N+D and N-D were similar in terms organ quality characteristics. Recipients receiving organs from N+D had higher match run sequence numbers, suggesting use of organs from N+D is not widespread across centers;however, with small numbers, this data will need to be verified. We cannot assess the relatedness of the three early mortality events in N+D recipients to donor or recipient characteristics. However, these data highlight the importance of ongoing outcome review of N+D recipients. (Figure Presented).

Outcomes of Liver Transplantation from Deceased Donors with Coronavirus-Disease 2019 and Late Complications of Infection

Background: The transplant patients should be considered a main high-risk population during the COVID-19 outbreak due to the use of immunosuppressive regimens and comorbidities. Objective: This study aimed to evaluate the possibility of COVID-19 transmission by liver transplantation from a donor with a late complication of COVID-19 to the recipients. Methods: This descriptive study was conducted on all the recipients of liver transplantation who had an acute liver failure or were the models for the End-Stage Liver Disease (MELD) higher than 20. Results: In general, 36 liver transplantation was performed during the study period. Out of these patients, only 14 cases (deceased donors) had hemorrhagic cerebrovascular accidents, and other donors died of trauma (n=7) and anoxia (n=15). All patients showed negative results for polymerase chain reaction (PCR) (two negative 24 h PCR), whereas their high-resolution computed tomography (HRCT) test revealed that they had previously lung involvement with COVID-19 as the late complication of the disease. Conclusion: This study supports the safety of continuing donation and transplant process during the outbreak even the transplant donor be infected previously with the COVID-19, which is reinforced by other similar pieces of evidence.

Efficacies of Nitrogen Removal and Comparisons of Microbial Communities in Full-Scale (Pre-Anoxic Systems) Municipal Water Resource Recovery Facilities at Low and High COD:TN Ratios

At a low COD:TN ratio (≤5) in influent, maintaining a longer HRT (≥9 h) and longer SRT (≥30 d) are suggested to improve higher N removal efficiency in case of operation at low DO (Dissolved oxygen) level (0.9 ± 0.2 mg-O2/L). However, in case of operation at high DO level (4.0 ± 0.5 mg-O2/L), short HRT (1 h) and typical SRT (17 d) make it possible to achieve nitrogen removal. On the other hand, at a high COD:TN ratio (≥8.4), a typical HRT (9–15 h), SRT (12–19 d), and DO level (1.3–2.6 mg-O2/L) would be applied. Microbial distribution analysis showed an abundance of AOA (Ammonia-oxidizing archaea) under conditions of low DO (≤0.9 mg-O2/L). Nitrosomonas sp. are mostly found in the all investigated water resource recovery facilities (WRRFs). Nitrosospira sp. are only found under operating conditions of longer SRT for WRRFs with a low COD:TN ratio. In comparison between abundances of Nitrobacter sp. and Nitrospira sp., abundances of Nitrobacter sp. are proportional to low DO concentration rather than abundance of Nitrospira sp. A predominance of nosZ-type denitrifiers were found at low DO level. Abundance of denitrifiers by using nirS genes showed an over-abundance of denitrifiers by using nirK genes at low and high COD:TN ratios.

COVID-19: Therapeutic challenges for the largest hospital in Malawi

Introduction Infection rates from Covid (C) are lower than in Europe, but they are a major challenge for Malawi. C seems to be an urban disease here. People are treated in the larger urban hospitals. Objective To evaluate challenges and success in the countries largest referal center: Queens hospital (Q) in Blantyre Methods: Unstructured interviews with the Hospital Director of Q, H.o.D and Research Director of Anaesthesia at the University, H.o.D Anaesthesia at Q and various stakeholders as well as 2 on site visits 2020/21 Results Human Ressources: Fear not to have enough physicians and nurses, not to have the ability to keep them healthy, attitude of some staff to use the situation to generate additional holidays, frightened staff. Politics: Resist pressure from VIPs to admit patients for ventilationa rare ressource, failure to prevent the import of infections at the border, syphering of money dedicated to the fight against C, duplication of efforts with the District Health Office, no relief through district hospitals. Technicalities: Bedspace in hospital, outside tents, supply chain my not hold, even when items are available, ICU/HDU space, Personal Protective Equip-ment for colleagues Oxygen: Initial lack of oxygen, later: not enough cylinders in country to fill despite the technical ability, the technical limitation of high-flow to 15 l/min, inability of the oxygen plant to fill additional cylinders when too many pa tients received piped oxygen (pressure/flow. Medicine: No modern treatment available, influence on other diseases, patient could not be collected by ambulance with O2 oxgen. International arrogance: Organizations working in Queens without speaking to the hosp. director, misreporting through organizations in publications and mis-communication with them, impression they wanted to show the situation worse in order to generate for their own funding. Vaccination: to convince villagers to be vaccinated against a disease they have never seen (urban) fair distributrion, lack oft hem, to have thrown them away due to the conviction that the pandemic was over at a certain point Successes: Low death rate of 25-34 %, ability to follow the policy not to ventilate Covid patients, VAT-reduction on all medical items against C, all admitted patients able to receive O2, timely installation of the only non-commercial O2-producing unit in the country, piping of several wards, so that cylinders were far less necessary, the ability to provide more cylinders, good coopoeration of the hospitals workers, nurses, doctors and managerial structures under the hospital director and the hosp. directors ability to connect with politics.

The invention of hypoxia.

The word "hypoxia" has recently come to the attention of the general public on two occasions, the Nobel Prize in Medicine or Physiology in 2019 and the recent COVID-19 pandemic. In the academic environment, hypoxia is a current topic of research in biology, physiology, and medicine: in October 2020, there were more than 150,000 occurrences of "hypoxia" in the PubMed database. However, the first occurrence is dated to 1945, while the interest for the effects of oxygen lack on the living organisms started in the mid-19th century, when scientists explored high altitude regions and mainly used the terms "anoxia" or "anoxemia." I therefore researched online through multiple databases to look for the first appearance of "hypoxia" and related terms "hypoxemia" and "hypoxybiosis" in scientific literature published in English, German, French, Italian, and Spanish. Viault and Jolyet used "Hypohématose" in 1894, but this term has not been used since. Hypoxybiosis first appeared in 1909 in Germany, then hypoxemia in 1923 in Austria, and hypoxia in 1938 in Holland. It was then exported to the United States where it appeared in 1940 in cardiology and anesthesiology. The clinical distinction between anoxia and hypoxia was clearly defined by Carl Wiggers in 1941. Hypoxia (decrease in oxygen), by essence variable in time and in localization in the body, in contrast with anoxia (absence of oxygen), illustrates the concept of homeodynamics that defines a living organism as a complex system in permanent instability, exposed to environmental and internal perturbations.