Introduction:the study aims to better understand the COVID-19 prescription treatments and over the counter regimens in Yemen in view of limited published data and limited availability of COVID-19 testing. Methods:A 34 question web-based survey was distributed on social media outlets targeting people in Yemen. Data aggregation, analysis, and visualization were performed using Tableau and Microsoft Excel. Results:2341 individuals reported symptoms concerning for COVID-19 infection, with 25.4% reporting a chronic medical condition. Female patients were less likely to receive medications for treatment in all age groups examined. Azithromycin was the most prescription medication prescribed (32.8%) and vitamin C being the most supplement used (62%). Around 5.5% were on Hydroxychloroquine prophylaxis prior to their diagnosis and only 12.9% of them continued using after diagnosis. Conclusions:This study provides some important information about the commonly observed treatments and prescription patterns during the COVID-19 pandemic in Yemen during May- July of 2020. The study reflects the influence of global trends in medication prescription even in resource-limited countries.

Like elsewhere around the globe, SARS-CoV-2 infection is spreading in rural Egypt. Due to high sensitivity and specificity, the gold standard of diagnostics is reverse transcription polymerase chain reaction PCR (RT-PCR). Rural areas without access to certified laboratories cannot take advantage of RT-PCR testing, and thus are dependent upon rapid antigen testing, a point-of-care test that requires less training and can produce results within 15 minutes. Rapid antigen testing can give an advantage to medical teams in rural settings by affording effective and early control of SARS-CoV-2 infection spread. We sought to assess the contribution of different COVID-19 testing procedures in rural Egypt. We conducted a prospective cohort study in a rural lab in Giza, Egypt. Approximately 223 individuals with potential SARS-CoV-2 infection were involved in the study during the pandemic peak in Giza, Egypt, from March 4 – May 30, 2021. Subjects were subjected to RT-PCR and rapid antigen testing, and the performance of each testing procedure was compared. Between March 4 – May 30, 2021, approximately 223 symptomatic individuals were included in this study. 190 patients (85.2%) were indicated as PCR positive for SARS-CoV-2, while 33 (14.8%) were PCR negative. In comparison, a rapid antigen test showed 178 out of 223 patients (79.8%) were indicated as positive, or 94% of the PCR-positive individuals. In Giza, a rural area of Egypt, RT-PCR had an optimal balance of sensitivity and specificity, however, the turnaround time was a limiting factor. Antigen testing, performed as a rapid point-of-care test, can play an effective role in rural outbreak control due to its ease of use and rapid results.

Objective Several studies show that chronic opioid dependence leads to higher in-hospital mortality, increased risk of hospital readmissions, and worse outcomes in trauma cases. However, the association of outpatient prescription opioid use on morbidity and mortality has not been adequately evaluated in a critical care setting. The purpose of this study was to determine if there is an association between chronic opioid use and mortality after an ICU admission. Design A single-center, longitudinal retrospective cohort study of all Intensive Care Unit (ICU) patients admitted to a tertiary-care academic medical center from 2001 to 2012 using the MIMIC-III database. Setting Medical Information Mart for Intensive Care III database based in the United States. Patients Adult patients 18 years and older were included. Exclusion criteria comprised of patients who expired during their hospital stay or presented with overdose; patients with cancer, anoxic brain injury, non-prescription opioid use; or if an accurate medication reconciliation was unable to be obtained. Patients prescribed chronic opioids were compared with those who had not been prescribed opioids in the outpatient setting. Interventions None. Measurements and main results The final sample included a total of 22,385 patients, with 2,621 (11.7%) in the opioid group and 19,764 (88.3%) in the control group. After proceeding with bivariate analyses, statistically significant and clinically relevant differences were identified between opioid and non-opioid users in sex, length of hospital stay, and comorbidities. Opioid use was associated with increased mortality in both the 30-day and 1-year windows with a respective odds ratios of 1.81 (95% CI, 1.63-2.01; p<0.001) and 1.88 (95% CI, 1.77-1.99; p<0.001), respectively. Conclusions Chronic opioid usage was associated with increased hospital length of stay and increased mortality at both 30 days and 1 year after ICU admission. Knowledge of this will help providers make better choices in patient care and have a more informed risk-benefits discussion when prescribing opioids for chronic usage.

Despite the dramatic increase in antimicrobial resistance, there is a dearth of antibiotics in development and few pharmaceutical companies working in the field. Further, any new antibiotics are likely to have a short shelf life. Ab-based interventions offer alternatives that are not likely to be circumvented by the widely prevalent antibiotic resistance genes. Bovine colostrum (BC)—the first milk after parturition, rich in nutrients and immune components—promotes gut integrity and modulates the gut microbiome. We developed a hyperimmune BC (HBC) enriched in Abs to a highly conserved LOS core region of Gram-negative bacteria by immunizing pregnant cows with a vaccine comprised of detoxified LOS from Escherichia coli O111 Rc (J5) mutant non-covalently complexed to group B meningococcal outer membrane protein (J5dLOS/OMP). This vaccine generated robust levels of anti-J5 LOS Ab in the colostrum. When given orally to neutropenic rats challenged orally with Pseudomonas aeruginosa, administration of HBC improved survival compared to non-immune rats, while both BC preparations improved survival compared to PBS controls. Elevated circulating endotoxin levels correlated with mortality. HBC and to a lesser extent non-immune BC reduced bacterial burden from the liver, lung, and spleen. We conclude that HBC and to a lesser extent BC may be effective supplements that improve outcome from lethal gut-derived disseminated infection and may reduce transmission of Gram-negative bacilli from the gastrointestinal tract.

### Summary box WHO is the global leader in international public health with roles which include detecting and responding to acute health emergencies, ensuring preparedness for emergencies by identifying, mitigating and managing risks, supporting the development of tools essential for outbreaks, and supporting the delivery of essential health services in fragile settings. WHO works with its 194 Member States, across six regions, and from more than 150 offices with headquarters in Geneva.1 Governance takes place through the World Health Assembly, which is the supreme decision-making body; and the Executive Board, which gives effect to the decisions and policies of the Health Assembly. The Organisation is headed by the Director-General, who is appointed by the Health Assembly on the nomination of the Executive Board. This Board consists of 34 technically qualified members elected for 3-year terms. The main functions of the Board …

Introduction: Coronavirus infectious disease 2019 (COVID-19) is currently one of the most important public health crises affecting the global human population. It continues to spread widely, as the world still lacks specific treatments and a vaccine for the virus. The scenario of COVID19 in Yemen seems obscure due to the lack of adequate data, therefore, we developed an electronic questionnaire and distributed it online among Yemeni people. The aim of this study was to understand the COVID-19 epidemiological situation in Yemen better since there is currently limited published data and limited availability of COVID-19 testing. Methodology: A 34-question web-based survey was distributed on social media outlets targeting people in Yemen. Data aggregation, analysis, and visualization were performed using Tableau and Microsoft Excel. Results: 2,341 individuals reported symptoms concerning for COVID-19 infection, with 25.4% reporting a chronic medical condition. Diabetes, hypertension, asthma, and immune deficiency were associated with increased severity of the disease, while obesity, cardiovascular disease, kidney disease, and liver disease were not. Only 37 individuals (1.6%) had a confirmatory COVID-19 PCR test. The presence of high fever, dyspnea, chest pain, and dysphagia were symptoms that tended to be correlated to worse clinical outcomes. Conclusions: This study provides some important information about the early overspread of COVID-19 within the Yemeni community in May, June, and July of 2020. It shows that online questionnaires may help in collecting data about pandemics in resource-limited countries where testing availability is limited.

Rationale Factors associated with one-year mortality after recovery from critical illness are not well understood. Clinicians generally lack information regarding post-hospital discharge outcomes of patients from the intensive care unit, which may be important when counseling patients and families. Objective We sought to determine which factors among patients who survived for at least 30 days post-ICU admission are associated with one-year mortality. Methods Single-center, longitudinal retrospective cohort study of all ICU patients admitted to a tertiary-care academic medical center from 2001–2012 who survived ≥30 days from ICU admission. Cox’s proportional hazards model was used to identify the variables that are associated with one-year mortality. The primary outcome was one-year mortality. Results 32,420 patients met the inclusion criteria and were included in the study. Among patients who survived to ≥30 days, 28,583 (88.2%) survived for greater than one year, whereas 3,837 (11.8%) did not. Variables associated with decreased one-year survival include: increased age, malignancy, number of hospital admissions within the prior year, duration of mechanical ventilation and vasoactive agent use, sepsis, history of congestive heart failure, end-stage renal disease, cirrhosis, chronic obstructive pulmonary disease, and the need for renal replacement therapy. Numerous effect modifications between these factors were found. Conclusion Among survivors of critical illness, a significant number survive less than one year. More research is needed to help clinicians accurately identify those patients who, despite surviving their acute illness, are likely to suffer one-year mortality, and thereby to improve the quality of the decisions and care that impact this outcome.

1Memorial Hospital of Rhode Island, Providence, RI, 2Memorial Hospital of Rhode Island, Pawtucket, RI, 3Brown University School of Medicine, Providence, RI

Ninety years ago, Gregory Shwartzman first reported an unusual discovery following the intradermal injection of sterile culture filtrates from principally Gram-negative strains from bacteria into normal rabbits. If this priming dose was followed in 24 h by a second intravenous challenge (the provocative dose) from same culture filtrate, dermal necrosis at the first injection site would regularly occur. This peculiar, but highly reproducible, event fascinated the microbiologists, hematologists, and immunologists of the time, who set out to determine the mechanisms that underlie the pathogenesis of this reaction. The speed of this reaction seemed to rule out an adaptive, humoral, immune response as its cause. Histopathologic material from within the necrotic center revealed fibrinoid, thrombo-hemorrhagic necrosis within small arterioles and capillaries in the micro-circulation. These pathologic features bore a striking resemblance to a more generalized coagulopathic phenomenon following two repeated endotoxin injections described 4 yr earlier by Sanarelli. This reaction came to be known as the generalized Shwartzman phenomenon, while the dermal reaction was named the localized or dermal Shwartzman reaction. A third category was later added, called the single organ or mono-visceral form of the Shwartzman phenomenon. The occasional occurrence of typical pathological features of the generalized Shwartzman reaction limited to a single organ is notable in many well-known clinical events (e.g., hyper-acute kidney transplant rejection, fulminant hepatic necrosis, or adrenal apoplexy in Waterhouse-Fredrickson syndrome). We will briefly review the history and the significant insights gained from understanding this phenomenon regarding the circuitry and control mechanisms responsible for disseminated intravascular coagulation, the vasculopathy and the immunopathy of sepsis.

SESSION TITLE: Critical Care 4 SESSION TYPE: Med Student/Res Case Rep Postr PRESENTED ON: 10/09/2018 01:15 PM - 02:15 PM INTRODUCTION: Neuroleptic malignant syndrome (NMS) is a rare life-threatening neurologic emergency characterized by mental status changes, rigidity, fever, and dysautonomia. The incidence rate of NMS is 0.02-3% among patients taking typical or atypical neuroleptic agents; however, clozapine-induced NMS is a rarely-reported and unique entity as it doesn’t present with the four cardinal clinical features of NMS. We present a rare case of clozapine-induced NMS with the four cardinal features of NMS. CASE PRESENTATION: A 45-year-old man with history of schizoaffective disorder and catatonia was transferred from a local psychiatric hospital to the emergency department (ED) for evaluation of fever and altered mental status. Two days prior to the transfer, he was started on clozapine. In the ED, he had a temperature of 39.1° Celsius, blood pressure of 100/57 mmHg, respiratory rate of 24 breaths-per-minute, and heart rate of 118 beats-per-minute. The patient was diaphoretic, drooling, and shivering. He was lethargic with Glasgow Coma Scale of 8 and was therefore intubated. At that point, the rest of the examination was non-significant. Initial laboratory work-up including creatinine phosphokinase (CPK) was non-significant. Computed tomography (CT) scan of the head was normal. Lumbar puncture was performed and cerebrospinal fluid analysis was unremarkable. The patient was admitted to the intensive care unit (ICU) where he continued to develop fevers despite the use of antipyretics, cooling blankets, an d aggressive intravenous hydration. The fever spikes were associated with intermittent episodes of sinus tachycardia and fluctuations of his blood pressure. On day two, he developed rigidity, and blood work-up was significant for CPK level of 4419 U/L. He was started on benzodiazepines and dantrolene for a presumed diagnosis of NMS. However, his rigidity and fever didn’t improve. On day four, he developed ventilator-associated pneumonia. After a week in the ICU with no success in liberation of mechanical ventilation, family decided to shift care to comfort measures only. The patient perished a few hours later. DISCUSSION: Clozapine is considered among the most potent neuroleptic agents, with use reserved for treatment-resistant cases. Although it has many side effects, there are very few case reports about clozapine-induced-NMS. Risk factors for developing clozapine-induced NMS include young age, male gender, and history of catatonia. CONCLUSIONS: It is important to be aware of these risk factors for early recognition and treatment of NMS, given its high mortality rate of 10-30%. Reference #1: Clozapine-induced neuroleptic malignant syndrome: review and report of new cases.P. Sachdev, J. Kruk, M. Kneebone, D. KissaneJ Clin Psychopharmacol. 1995 Oct; 15(5): 365–371. DISCLOSURES: No relevant relationships by Abdullah Chahin, source=Web Response No relevant relationships by Faeq Kukhon, source=Web Response No relevant relationships by Mahmoud Mowafy, source=Web Response No relevant relationships by Magaly Sazani, source=Web Response No relevant relationships by Abraham Walusimbi, source=Web Response

Purpose: Atrial fibrillation with rapid ventricular response (RVR) is common during critical illness. In this study, we explore the comparative effectiveness of three commonly used drugs (metoprolol, diltiazem, and amiodarone) in the management of atrial fibrillation with RVR in the intensive care unit (ICU). Methods: Data pertaining to the first ICU admission were extracted from the Medical Information Mart for Intensive Care III database. Patients who received one of the above pharmacologic agents while their heart rate was > 110 bpm and had atrial fibrillation documented in the clinical chart were included. Propensity score weighting using a generalized boosted model was used to compare medication failure rates (second agent prior to termination of RVR). Secondary outcomes included time to control, control within 4 h, and mortality. Results: One thousand six hundred forty-six patients were included: 736 received metoprolol, 292 received diltiazem, and 618 received amiodarone. Compared with those who received metoprolol, failure rates were higher amongst those who received amiodarone (OR 1.39, 95% CI 1.03–1.87, P = 0.03) and there was a trend towards increased failure rates in patients who received diltiazem (OR 1.35, CI 0.89–2.07, P = 0.16). Amongst patients who received a single agent, patients who received diltiazem were less likely to be controlled at 4-h than those who received metoprolol (OR 0.64, CI 0.43–097, P = 0.03). Initial agent was not associated with in-hospital mortality. Conclusions: In this study, metoprolol was the most commonly used agent for atrial fibrillation with RVR. Metoprolol had a lower failure rate than amiodarone and was superior to diltiazem in achieving rate control at 4 h.

Severe legionella pneumonia poses a diagnostic challenge and requires early intervention. Legionnaire's disease can have several presenting signs, symptoms, and laboratory abnormalities that suggest that Legionella pneumophila is the pathogen, but none of these are sufficient to distinguish L pneumophila pneumonia from other respiratory pathogens. L pneumophila is primarily an intracellular pathogen and needs treatment with antibiotics that efficiently enter the intracellular space.

BackgroundNational pneumococcal vaccine uptake rates remain well below the Healthy people 2020 target goals. This study aims to assess uptake rates at a residents' community clinic and to identify factors affecting the likelihood of receiving the vaccine.