ABSTRACT
Phlegmasia cerulea dolens (PCD) is a rare, life-threatening manifestation of deep vein thrombosis (DVT). PCD is characterized by limb swelling, ischemia, pain and cyanosis. It can lead to gangrene requiring amputations with high mortality rates. Here, we report a case of a patient with PCD in the setting of lung transplantation. A 55-year-old female ex-smoker with ILD secondary to rheumatoid arthritis complicated by post-COVID fibrosis 6 months prior was referred for lung transplant. She had recovered from a cerebral vein thrombosis around the time of her COVID. An acute pulmonary embolism during evaluation prompted therapeutic anticoagulation. She was accepted for lung transplant but deactivated for four weeks due to COVID re-infection. During this time, she developed a pelvic hematoma. She was reactivated and underwent bilateral lung transplant. Her initial post-operative course was complicated by prolonged ventilator weaning. On post op day 23, she developed a nonocclusive thrombus in the left common femoral vein. Due to her history of spontaneous bleeding on anticoagulation, an IVC filter was placed. The next day, the patient noted pain in bilateral lower extremities and inability to move her left leg. On exam, her bilateral lower extremities were cool to touch with decreased sensation and pulses as well as skin mottling extending to the lower abdomen. CTA showed no evidence of vascular compromise. The next day, labs showed increasing creatine kinase and worsening anemia. Repeat ultrasound showed occlusive thrombus in bilateral lower extremities with reduced ABI's and no detectable TBI's. Vascular surgery was consulted. She was placed on anticoagulation with heparin. Imaging 24 hours later showed no flow beyond the left proximal calf concerning for phlegmasia. She underwent IVC filter removal, percutaneous ilio-caval and bilateral femoral suction thrombectomy, and bilateral lower extremity four compartment fasciotomies. Repeat ultrasound showed extensive ileofemoral and IVC DVT with ongoing phlegmasia. The care team considered left above the knee amputation, but the patient was transitioned to comfort care given worsening multiorgan failure including poor neurological status. To the best of our knowledge, ours is the first reported case of PCD in a patient post-lung transplant. In this case, it was prudent to place an IVC filter but perhaps it contributed to the PCD. [ABSTRACT FROM AUTHOR] Copyright of Journal of Heart & Lung Transplantation is the property of Elsevier B.V. and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use. This abstract may be abridged. No warranty is given about the accuracy of the copy. Users should refer to the original published version of the material for the full abstract. (Copyright applies to all Abstracts.)
ABSTRACT
Donor derived cell free DNA (ddcfDNA) is a noninvasive blood test used to assess the risk of allograft rejection in both lung and heart transplant recipients. The normal value for lung transplant recipients with a quiescent graft is <0.5%, while that for heart transplant recipients is <0.12%. There is no data on the expected normal level for combined organ transplants including heart and lung transplants. Here we present longitudinal ddcfDNA data on two combined heart/lung transplant recipients. Immunosuppression regimens for both consisted of prednisone, tacrolimus, and mycophenolate after basiliximab for induction. Patient 1 is a 25 year old female who received combined bilateral lung and heart transplant for primary ciliary dyskinesia and severe MR. Her 1 month ddcfDNA level was 2.1%, which correlated with A4 cellular rejection. Her 2 month ddcfDNA level was 1% and then was under the 0.5% from 3 months onward. She has not had any further cellular or AMR. Cardiac allograft function has been normal on serial echos. Patient 2 is a 35 year old female who received combined bilateral lung and heart transplant for scleroderma related ILD with PAH. Her 1 month ddcfDNA level was 2%, with A3 cellular rejection. Her ddcfDNA level at 2 months was 1.2%, she had DSA that was treated. Her 3 month level was 0.84%, at which time she had a non-covid coronavirus. Since month 4 her ddcfDNA has remained under 0.5% and she has not had any recurrent cellular or AMR. Cardiac allograft function was initially normal, declined to mildly impaired at 2 months, has since recovered and remains normal on serial echos. ddcfDNA is a useful tool for assessing allograft dysfunction in both lung and heart transplant recipients. It is conceivable that due to the size and immunogenicity of the lung allograft, there is little increase in ddcfDNA in these recipients above that of isolated lung transplant recipients. Our experience with these two recipients does attest to this theory. However, larger studies are necessary to evaluate this further. [ABSTRACT FROM AUTHOR] Copyright of Journal of Heart & Lung Transplantation is the property of Elsevier B.V. and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use. This abstract may be abridged. No warranty is given about the accuracy of the copy. Users should refer to the original published version of the material for the full abstract. (Copyright applies to all Abstracts.)
ABSTRACT
Prognostic markers are the biomarkers used to measure the disease progression and patient outcome regardless of treatment in coronavirus disease 2019 (COVID-19). This study aimed to analyze laboratory parameters as prognostic markers for the early identification of disease severity. In this study, 165 patients attending Sukraraj Tropical and Infectious Disease Hospital with COVID-19 were enrolled and divided into severe and non-severe groups. The demographic data, underlying co-morbidities, and laboratory findings were analyzed and compared between severe and non-severe cases. The correlation between the disease criticality and laboratory parameters was analyzed. Cut-off values of parameters for severe patients were speculated through the receiver operating characteristics (ROC) curve, and regression analysis was performed to determine the risk factors. Patients with severe COVID-19 infection had significantly higher absolute neutrophil count, neutrophil-lymphocyte ratio (NLR), platelet-lymphocyte ratio (PLR), ferritin, positive carbohydrate reactive protein (CRP), glucose, urea, creatinine, and aspartate aminotransferase, while lower absolute lymphocyte count, absolute eosinophil count (AEC), and red blood cell count in comparison to non-severe infection. ROC analysis gave a cut-off value (sensitivity, specificity) of age, AEC, NLR, PLR, and ferritin as 47.5 years (70.2, 64.7%), 335 cells/mm(3) (74, 67%) 3.3 (68.4, 63.7%), 129 (77.2, 51%), and 241 ng/mL (74.0%, 65.0%) respectively. Risk factor analysis showed higher age, low AEC, high ferritin, and positive CRP as independent risk factors associated with severe COVID-19 infection. Hematological and inflammatory markers, including novel NLR and PLR, should be assessed to aid clinicians in the early identification of severe cases, prioritization of cases, and effective management to decrease the mortality of COVID-19 patients.
ABSTRACT
Purpose: Although, much has been written about COVID risk and immunization efficacy in transplant recipients, there is little data on the impact of COVID on transplant professionalism. Method(s): A survey about the impact of COVID on professional development was sent to transplant providers. There were 138 responses (10% response rate) with equal representation from transplant nephrologists, pulmonologists, surgeons, cardiologists and advanced practice providers. Responses were evenly divided between gender and across regions of the US. Result(s): 75% of respondents reported that COVID has had a negative impact on their own education with the primary reasons given being 'virtual fatigue' and not taking time off to attend virtual meetings leading to lack of engagement. 40% of respondents reported that staffing shortages made it difficult to attend virtual meetings. When asked about any positive impact of COVID on their education 43% said the ability to view sessions on their own time without travel requirements was positive. The impact of COVID on fellows' education was seen with reduced disease specific education due to focus on COVID and reduced fellow time on the wards (55% & 48% respectively).74% of respondents reported a negative impact on their professional relationships within their own center. The primary reasons were physical and emotional fatigue (43%) and staffing shortages (37%). The inability to socialize outside the work setting also had a significant impact. Fortunately, few had family or colleagues ill with COVID, but 3 reported death of co-workers or family members. Though most reported no positive impact on their work relationships (62%), "bunker mentality" and increased patience with colleagues were reported by 35%. 64% of respondents reported fatigue and lack of opportunity to see colleagues outside their own institution as a negative impact on those relationships. 76% described no positive impact on those relationships. 60% of respondents related a negative impact on their own research as there was no time to focus on research and/or most non-COVID research stopped, leading to lack of connection with research colleagues. 81% of respondents reported 'burnout' and 18% reported Post Traumatic Stress Syndrome (PTSD). When asked what the most significant impact of COVD on professionalism the overwhelming responses were emotional and physical fatigue and isolation from colleagues. The emotional stress of family and colleagues ill and sometimes dying from COVID takes a toll. Conclusion(s): In summary, in addition to the stress and physical toll the pandemic created for health care providers, transplant professionals reported a loss of ability to advance the field of transplantation due to the inability to attend professional meetings, participate in transplant-related research, and network with colleagues on topics other than COVID related care.
ABSTRACT
SESSION TITLE: COVID-19 Infections: Issues During and After Hospitalization SESSION TYPE: Original Investigations PRESENTED ON: 10/17/2022 01:30 pm - 02:30 pm PURPOSE: It has been established that recipients of solid organ transplants have worse outcomes compared to the general population from COVID-19 infections. We sought to determine the course and outcomes of lung transplant recipients (LTR) with COVID-19 infections based on vaccination status and treatments. METHODS: We performed a retrospective study of all LTR from Inova Fairfax Hospital with COVID-19 infections. Infection was confirmed based on symptoms and testing from an urgent care, hospital, or home kit. Patients with presumed but unconfirmed COVID-19 infections were excluded. The study timeframe was the two-year period: 3/1/2020 - 2/28/2022. Data collected included patient demographics, transplant type, immunosuppression, immunization status, episodes of rejection, donor derived cell-free DNA (dd-cfDNA) values (where available), spirometric data, outpatient/inpatient treatments, hospitalization data, and outcomes including death, infections, and other complications. The severity of illness was based on the 8-point ordinal scale. RESULTS: There were 45 LTR who tested positive during the study period;22 male and 23 female, average age of 57 and mean time from transplant of 4 years. 11 of the patients were unvaccinated (UV), 2 partially vaccinated (PV), 11 vaccinated non-boosted (VNB), and 21 vaccinated and boosted (VB). In total, 34 (76%) LTR required hospitalization. Of those hospitalized: 7 UV, 1 PV, 11 VNB, and 15 FV. In addition, 7 of those hospitalized required intubation with only 1/7 surviving to discharge. Overall, 8/45 (17.8%) patients died from COVID-19: 3 UV, 1PV, 1 VNB, 3VB. Infectious complications included 3 cases of PCP, 1 empyema, and 1 reactivation of CMV. For individuals who had spirometry at least 2 weeks after diagnosis (n =25), FVC decreased in 17 LTR by an average of 0.17 L, the FEV1 decreased in 14 LTR by an average of 0.14 L. On repeat spirometry testing (n=14), FVC further decreased in 9 LTR by 0.25 L and the FEV1 further decreased in 7 LTR by 0.13 L. CONCLUSIONS: A large proportion of LTR with COVID-19 infections require hospitalization (76%) with a high associated mortality rate and a sustained lung function decline seen in many who survive. The high mortality was independent of vaccination status, likely reflecting the inability of LTR to mount an immune response. A high index of suspicion and monitoring for superimposed infections, especially PCP, appears prudent. The sustained decline in lung function raises the notion of COVID-19 as a precipitating factor for chronic lung allograft dysfunction (CLAD). CLINICAL IMPLICATIONS: LTR who contract COVID-19 infection represent a high-risk population, even in those fully vaccinated, with potential for hospitalization, death, loss of lung function, and infectious complications. In this population, new algorithms for immunosuppression, monitoring and treatments may help to improve outcomes. DISCLOSURES: No relevant relationships by Shambhu Aryal No relevant relationships by A. Whitney Brown, value=Honoraria Removed 04/03/2022 by A. Whitney Brown No relevant relationships by A. Whitney Brown, value=Honoraria Removed 04/03/2022 by A. Whitney Brown No relevant relationships by A. Whitney Brown, value=Consulting fee Removed 04/03/2022 by A. Whitney Brown No relevant relationships by Jessica Chun No relevant relationships by Meg Fregoso No relevant relationships by Vikramjit Khangoora Advisory Committee Member relationship with Boehringer Ingelheim Please note: 2019-2021 Added 04/03/2022 by Christopher King, value=Consulting fee Advisory Committee Member relationship with Actelion Please note: 2019-2022 Added 04/03/2022 by Christopher King, value=Consulting fee Advisory Committee Member relationship with United Therapeutics Please note: 2019-2022 Added 04/03/2022 by Christopher King, value=Consulting fee Speaker/Speaker's Bureau relationship with Actelion Please note: 2019-2022 Added 04/0 /2022 by Christopher King, value=Consulting fee Speaker/Speaker's Bureau relationship with United Therapeutics Please note: 2020-22 Added 04/03/2022 by Christopher King, value=Consulting fee Consultant relationship with Veracyte Please note: $1001 - $5000 by Steven Nathan, value=Honoraria Removed 03/29/2022 by Steven Nathan Consultant relationship with United Therapeutics Please note: $5001 - $20000 by Steven Nathan, value=Consulting fee Consultant relationship with Bellerophon Please note: $5001 - $20000 by Steven Nathan, value=Consulting fee Speaker/Speaker's Bureau relationship with Roche-Genentech Please note: $5001 - $20000 by Steven Nathan, value=Honoraria Speaker/Speaker's Bureau relationship with Boerhinger-Ingelheim Please note: $20001 - $100000 by Steven Nathan, value=Honoraria No relevant relationships by Alan Nyquist No relevant relationships by Michelle Schreffler Speaker/Speaker's Bureau relationship with United Therapeutics Please note: 2020-2022 Added 04/01/2022 by Oksana Shlobin, value=Consulting fee Speaker/Speaker's Bureau relationship with Bayer Please note: 2020-2022 Added 04/01/2022 by Oksana Shlobin, value=Honoraria Speaker/Speaker's Bureau relationship with Janssen&Janssen Please note: 2020-2022 Added 04/01/2022 by Oksana Shlobin, value=Honoraria Consultant relationship with Altavant Please note: 2020-2022 Added 04/01/2022 by Oksana Shlobin, value=Consulting fee Consultant relationship with Acceleron Please note: 2020-2022 Added 04/01/2022 by Oksana Shlobin, value=Honoraria Consultant relationship with United Therapeutics Please note: 2020-2022 Added 04/01/2022 by Oksana Shlobin, value=Honoraria No relevant relationships by Anju Singhal No relevant relationships by Christopher Thomas
ABSTRACT
Introduction: The COVID-19 vaccines have documented transient side effects, including injection site soreness, redness, headache, fatigue, and fever. In addition, there have been few reported long-term side effects, including Guillain-Barre, pericarditis, and cerebral venous sinus thrombosis. We present a rare case of severe insomnia as a long-term side effect following COVID-19 vaccination. Report of Cases: A 59-year-old female with a past medical history of well-controlled hypothyroidism and migraine presented to the sleep center with four months of insomnia. She had a history of COVID infection in November 2020 with only mild symptoms of sore throat and fatigue. The patient finished her two-shot series of the Moderna COVID-19 vaccine in April 2021. Immediately following the vaccination, the patient had severe trouble falling and staying asleep. Her insomnia was resistant to multiple medications including zolpidem Immediate-release(IR), Controlledrelease( CR) formulas, zaleplon, eszopiclone, trazodone, melatonin, clonazepam, suvorexant, and lemborexant. However, magnetic resonance imaging (MRI) brain imaging only showed nonspecific white matter disease. She had no mood disorders or psychosocial stressors, and the patient had excellent sleep hygiene measures. However, insomnia caused severe impairment of her daily life activities to a point where she was almost seeking inpatient admission for her insomnia. During the COVID-19 pandemic, the effects on sleep have been significant, particularly insomnia. Prescriptions for sleep medications have increased. Many have attributed the rise of insomnia to pandemic-related stress, disturbance of circadian rhythm from home confinement, and worsening mental health. Conclusion: To our knowledge, there have not been documented side effects of insomnia on the COVID-19 vaccines, with some studies suggesting sleep deprivation reducing their effectiveness. As vaccination efforts continue worldwide, awareness of side effects from vaccines is paramount for clinicians facing the challenges in patient care.This case demonstrates that chronic insomnia can be a side effect of the COVID-19 vaccines. Therefore, further surveillance of patients and side effects from COVID-19 vaccination is warranted as insomnia can have significant clinical and psychosocial consequences.
ABSTRACT
Background Assessment drives learning. Student assessment cannot be neglected in the long ongoing online learning during COVID-19 pandemic to motivate and assess students’ learning. Hence Patan Academy of Health Sciences (PAHS) conducted online assessment to medical undergraduates amidst limitations. Objective To measure the perception of online assessment of students which will provide applicable insights for the further improvement. Method This is a single center, cross-sectional and descriptive study. A Google form containing a semi-structured questionnaire was sent to MBBS students of Basic Science at PAHS who attended online classes and online examination. The responses from close ended questions expressed in percentage and Chi-square test was used to find the association. Open ended questions were analyzed using Braun and Clarke’s thematic analysis. Result Of 118 students that responded, 75% passed the online examination. A majority of students (73%) stated that online exam motivated them in learning process and it could be a good alternative during pandemic time. However the most of students (56%) were unsatisfied with the modality of online assessment and reasons that they mentioned were technical problems (89%), inadequate online proctoring (77%), insufficient examination time (58%), lack of orientation to exam, lack of computer skills. Technical problem was worse in rural areas. Conclusion Even though online assessment motivated students’ learning during online classes, a large number of students were unsatisfied with assessment modality. © 2021, Kathmandu University. All rights reserved.
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Purpose Cytomegalovirus (CMV) is one of the main causes of infection after solid organ transplantation but CMV infection after vaccination for COVID has not been previously reported. The purpose of our study was to study cases of CMV DNAemia noted after COVID-19 mRNA vaccination in our thoracic organ transplant recipients. Methods Between March 1, 2021, and June 30, 2021, we identified 7 cases of CMV infection in thoracic organ transplant recipients within 30 days of COVID-19 mRNA vaccination. Descriptive statistics was used to study these cases. Results Our findings are summarized in the table. Of our patients, 3 were lung recipients, 3 were heart recipients while one was a dual heart-kidney recipient. Three patients received the mRNA-1273 (Moderna) vaccine while others received the BNT162b2 (Pfizer) vaccine. Age ranged from 42 to 73 years. Two of the lung transplant recipients and one heart recipient were CMV high-risk status (Donor+/Recipient-), while the others were recipient-seropositive for CMV. The median time to PCR detection of CMV DNAemia from the second dose of mRNA vaccine was 16 days with a range of 4 days to 30 days. None of these recipients had post-transplant CMV infection detected previously. All patients were off antiviral prophylaxis and on their standard immunosuppressive regimen at the time of vaccination. Symptoms were variable but ranged from asymptomatic to acute respiratory failure. However, all patients had resolution of CMV DNAemia by the censor date with a range of 7 days to 45 days. Therapy included reduction of immunosuppression, intravenous ganciclovir, and oral valganciclovir. The median peak CMV DNA PCR in the cohort was 15,900 IU/ml with a range of 272 IU/ml to 175,973 IU/ml. None of the recipients developed IgG antibodies to SARS-CoV-2 in response to vaccination. There were no documented cases of COVID-19 in these transplant recipients. Conclusion CMV DNAemia after COVID-19 mRNA vaccination in solid organ transplant recipients may be an under-recognized phenomenon. Although the risk-benefit assessment strongly favors COVID-19 vaccination, due to the greater risk of adverse events with COVID-19 infection care teams should consider active monitoring for CMV disease activity in these patients. In some cases, CMV prophylaxis may be warranted depending on patients’ risk profile. Our findings warrant study in a larger prospective study.
ABSTRACT
Purpose Prior observational data suggest that donor-derived cell-free DNA (dd-cfDNA) increases in lung transplant acute rejection and infection. The performance of dd-cfDNA in routine clinical care remains undefined. In response to the COVID-19 pandemic, to mitigate the risk of exposing patients to infection, four centers used dd-cfDNA for surveillance instead of surveillance bronchoscopy, providing a unique opportunity to assess the performance of dd-cfDNA in routine clinical care. Methods As part of routine care during the COVID-19 pandemic, four lung transplant centers implemented a home-based surveillance program using plasma dd-cfDNA (Allosure®) in preference to surveillance bronchoscopy. Based on prior data, dd-cfDNA > 1% triggered further work-up including bronchoscopy. dd-cfDNA testing was also performed in response to a decline in forced expiratory volume in 1 second (FEV1), symptoms or treatment follow up. Data was retrospectively analyzed from 4/1/2020 - 9/1/2020 to assess the performance of dd-cfDNA in diagnosing a composite of ACR, AMR and/or infection. Results 169 patients underwent 380 dd-cfDNA measurements over the study period. The mean age was 58.5 years, 54% of patients were male and 82% bilateral lung transplants. 99 (58%) patients were <1 year post-transplant. 327 of 380 dd-cfDNA values were drawn for surveillance reasons. 31 patients had a surveillance level > 1%. Of these, 19/31 (61%) had evidence of ACR, AMR or infection. 115 patients had surveillance levels that remained < 1% over the study period with 109/115 (95%) displaying no clinical evidence of ACR, AMR, infection or decline in FEV1 or symptoms. The remaining 23 patients had levels drawn for clinical indications (non-surveillance). 45 surveillance bronchoscopies were performed with concomitant dd-cfDNA (23 triggered by dd-cfDNA > 1%). For diagnosis of ACR, AMR or infection in these patients, dd-cfDNA > 1% yielded a sensitivity of 84%, specificity of 77%, positive predictive value of 73% and negative predictive value of 87%. Conclusion In this study, dd-cfDNA identified ACR, AMR and/or infection in asymptomatic lung transplant patients that may not have been identified by clinically indicated biopsy alone. Low levels of dd-cfDNA may also be useful in ruling out AMR, ACR and/or infection, supporting its use as a potential non-invasive marker for surveillance monitoring.