ABSTRACT
Objective/Background: Hyperglycemia in hospitalized patients with COVID-19 is linked to increased morbidity and mortality. With increasing use of glucocorticoid (GC) therapy for COVID-19 hypoxemia, clinicians are challenged with an increased prevalence of hyperglycemia. Methods: We developed an insulin protocol to aid front line providers in the management of GC-induced hyperglycemia for hospitalized adults with COVID-19. The protocol was based on expert opinion and was available from March 2021 onward. Glycemic and clinical outcomes were obtained for patients treated with GC and retrospectively compared to historical controls treated with GC admitted up to 6 months prior to protocol implementation. Glycemic parameters for finger stick glucose values (FSG) were defined as hypoglycemia <70 mg/dL, euglycemia 70-180 mg/dL, mild hyperglycemia 180-250 mg/dL and severe hyperglycemia >250 mg/dL. To account for differences in the quantity of total FSG between groups, we adjusted for length of stay and calculated the proportion of FSG per patient. Results: 130 patients with COVID-19 and GC induced hyperglycemia from before (n=65) and after (n=65) protocol implementation were matched 1: 1 based on age, weight, and sex. There were no significant differences in other baseline patient characteristics. Significantly more patients in the protocol group had mean FSG in the euglycemic range (16.9% vs 38.5%, p=0. 006), and there was a decrease in patients with mean glucose in the mild hyperglycemia range that trended toward significance (50.8% vs 35.4%, p=0. 076). The protocol group had a significantly lower proportion of hypoglycemic FSG per patient (0. 003 vs 0. 008, p=0. 044). Patients in the protocol group had more euglycemic FSG per patient, but this did not reach significance (0.413 vs 0.350, p=0.239). Similarly, the proportion of mild hyperglycemic FSG per patient trended lower in the protocol group (0.315 vs 0.272, p=0.291). There were no significant differences in severe hyperglycemia per patient (0.311 vs 0.328, p=0.828). The protocol group had a significantly higher utilization of basal-bolus insulin regimen (n=43 vs n=63, p<0. 0001) with an increase percentage of bolus insulin utilization in peak total daily dose (70.2% vs. 62.4%, p=0. 08). Total peak day insulin dose trended lower in the protocol group (0.25 vs 0.32 U/kg, p=0.36). Conclusion: A novel insulin protocol for the management of GC-induced hyperglycemia in hospitalized COVID-19 patients is an effective tool to achieve reductions in hypoglycemic events and higher utilization of standard of care basal-bolus insulin regimens without increased hyperglycemia or total daily dose of insulin.Presentation: Sunday, June 12, 2022 12:30 p.m. - 2:30 p.m.
ABSTRACT
Background: Metformin is the most commonly used diabetes medication and at supratherapeutic levels can result in a severe type-A metabolic lactic acidosis known as metformin-associated lactic acidosis (MALA). Treatment of MALA includes aggressive fluid resuscitation, supporting blood pressure and correcting acidosis. Renal replacement therapy (RRT), usually hemodialysis (HD) is recommended in severe cases with refractory acidosis (with elevated lactate), altered mental status, or shock. To our knowledge, this is the second report of metformin half-life during treatment with continuous veno-venous hemodiafiltration (CVVHDF). Case report: A 53-year-old man died following a reported acute on chronic ingestion of 80 g of his metformin tablets resulting in severe, refractory shock and MALA. His peak serum metformin concentration was 53mcg/mL (therapeutic range 1-2mcg/mL), peak lactic acid concentration was 49.7 mmol/L, and arterial pH nadir was 7.06. Serial serum metformin concentrations were obtained while on RRT;both HD and CVVHDF. The switch from HD to CVVHDF was done due to staffing shortages during the COVID-19 pandemic. The patient died despite aggressive therapy with renal replacement therapy and multiple vasopressors on hospital day five. Serial metformin concentrations during CVVHDF suggested a half-life of 33-h. Discussion(s): Hemodialysis has been reported to clear metformin at a rate greater than 200mL/min and continuous venous-venous hemofiltration (CVVH) at greater than 50mL/min. In this case, metformin levels appear to follow first-order elimination kinetics during CVVHDF with an estimated half-life of 33 h. Comparatively, metformin has a half-life of 4.7-5.5 h during HD. To our knowledge, this is the second report of estimated metformin half-life while using the CVVHDF form of continuous renal replacement. The previous case report measured a half-life of 16.5 h on CVVHDF. This case report shows CVVHDF decreases half-life of metformin and provides first order elimination in the setting of overdose. Conclusion(s): The early initiation of HD appears warranted but prognostic indicators have not been well established. In the absence of HD availability, other forms of RRT (e.g., CCVHDF) can be used and may provide first-order elimination of metformin.
ABSTRACT
Background: Colorectal cancer (CRC) screening disruptions have been observed with the COVID-19 pandemic, putting patients at risk for more advanced-stage disease at the time of diagnosis. We estimated the impact of increased use of stool-based tests for screening during the COVID-19 pandemic on near-term clinical outcomes in a simulated United States (US) population. Methods: A previously developed budget impact model was adapted to assess the impact of increasing use of multi-target stool DNA [mt-sDNA] or fecal immunochemical [FIT] tests to offset the COVID-19 related disruption in colonoscopy screening. Adults, ages 50 - 75 years, at average risk for CRC were included over a 3-year time horizon (2020 - 2023) to explore the impact of increased screening for CRC using mt-sDNA or FIT, from the perspective of a US payer. Compared to the base case (S0;85% colonoscopy and 15% non-invasive tests), the estimated number of missed CRCs and advanced adenomas (AAs) were determined for four COVID-19-affected screening scenarios: S1, 9 months of CRC screening at 50% capacity, followed by 21 months at 75% capacity;S2, S1 followed by increasing stool-based testing by an average of 10% over 3-years;S3, 18 months of CRC screening at 50% capacity, followed by 12 months of 75% capacity;and S4, S3 followed by increasing stool-based testing by an average of 13% over 3-years. Results: Increasing the proportional use of mt-sDNA, the detection of AAs improved by 6.0% (Scenario 2 versus 1) to 8.4% (Scenario 4 versus 3) and the number of missed CRCs decreased by 15.1% to 17.3% respectively. Increasing FIT utilization improved the detection of AAs by 3.3% (Scenario 2 versus 1) to 4.6% (Scenario 4 versus 3) and the number of missed CRCs decreased by 12.9% (Scenario 2 versus 1) to 14.9% (Scenario 4 versus 3). Across all scenarios, the number of AAs detected was higher for mt-sDNA than for FIT, and the number of missed CRCs was lower for mt-sDNA than for FIT. Conclusions: Using home-based stool tests for average-risk CRC screening can mitigate the consequences of reduced colonoscopy screening resulting from the COVID-19 pandemic. Use of mt-sDNA led to fewer missed CRCs and more AAs detected, compared to FIT.
ABSTRACT
Background. The Walter Reed National Military Medical Center (WRNMMC) established a consolidated COVID-19 screening area (CSA) beginning in March 2020 to provide beneficiary and staff testing via a drive-through site. Testing was available to all patients and WRNMMC staff regardless of beneficiary status. Presented is a descriptive analysis of our testing operations and positivity rates within a closed medical system from March 2020 to April 2021. Methods. For quality and process improvement, we compiled daily testing logs from March 2020 to April 2021 from the CSA. These logs included patient demographics, reason for testing, test result, testing platform, and occupational status at the hospital. We determined positivity rates in various subgroups -asymptomatic, symptomatic, pre-operative, in order to track testing use and access. Additionally, we compared the overall positivity rate to the surrounding civilian community by pulling data from the Maryland Department of Health's COVID database. Results. Over the course of nearly 14 months of testing availability, 34,694 beneficiaries were screened with 41,582 individual tests. After May 2020, the monthly overall positivity rate varied from 1.99% to 11.92%, peaking in December 2020 (with high rates in November 2020, 7.52% and January 2021, 9.53%), correlating with or exceeding elevated positivity rates in Montgomery County (November 2020: 4.91%;December 2020: 6.48%;January 2021: 6.51%). When examining only symptomatic individuals, the positivity rate is notably much higher, with monthly rates varying from 6.40% to 21.10%, with a similar peak in December 2020. After full implementation of pre-operative screening for procedures with aerosolization potential in June 2020, the range of positivity rates was 0.28%-1.66%. Since vaccination for COVID-19 became widely available beginning in Feb 2021, the preoperative positivity rate has remained below 0.85%. Conclusion. Our institutional experience is unique in its ability to offer universal access to COVID-19 testing for beneficiaries and staff of the DoD under direction of the ID service. Our process serves as a model for public and occupational health response, and may guide lab resource and real-time staffing management in support of COVID-19 diagnostics at a medical center.
ABSTRACT
Background. Respiratory syncytial virus (RSV) is the most common cause of lower respiratory tract infection (LRTI) in infants. Nirsevimab is a single-dose monoclonal antibody with extended half-life that was shown to protect preterm infants 29 to < 35 weeks gestation against RSV LRTI. However, most medically attended (MA) cases occur in otherwise healthy, term infants for whom there is currently no effective RSV prevention strategy. We report the primary analysis of efficacy and safety, along with the impact of nirsevimab in late preterm and term infants (≥ 35 weeks gestation) in the phase 3 MELODY study (NCT03979313). Methods. Infants were randomized 2:1 to receive one intramuscular injection of nirsevimab (50 mg if < 5 kg;100 mg if ≥ 5 kg at dosing) or placebo entering their first RSV season. The primary endpoint was the incidence of MA RSV LRTI over 150 days postdose. Cases met predefined clinical criteria of disease severity and were confirmed by real-time reverse-transcriptase PCR. Safety was evaluated through 360 days postdose. Enrollment started on 23 July 2019 and was suspended following the declaration of the COVID-19 pandemic by the WHO on 11 March 2020. Results. Overall, 1490 infants were randomized and included in the intent-totreat population;1465 (98%) completed the 150-day efficacy follow-up, and 1367 (92%) completed the 360-day safety follow-up. The incidence of MA RSV LRTI was 1.2% (n=12/994) in the nirsevimab group and 5.0% (n=25/496) in the placebo group, giving nirsevimab an efficacy of 74.5% (95% confidence interval [CI]: 49.6, 87.1;p< 0.0001). Nirsevimab averted 93.6 (95% CI 63.0, 124.0) MA LRTIs per 1000 infants dosed. Nirsevimab was well tolerated, with similar rates of adverse events (87.4% nirsevimab;86.8% placebo) and serious adverse events (6.8% nirsevimab;7.3% placebo) between groups. Conclusion. In this phase 3 study, a single dose of nirsevimab protected late preterm and term infants against MA RSV LRTI over an RSV season with a favorable safety profile. Approximately 11 infants need to be immunized to prevent 1 case of LRTI;nirsevimab has the potential to be an important intervention to reduce the burden of RSV LRTI in healthy infants.
ABSTRACT
Older adults with type 1 diabetes (OAwT1D) face challenges such as hypoglycemia, cognitive dysfunction, and physical limitations. Limited data on their technology use is available. We evaluated technology preferences in OAwT1D stratified by tech-savviness. Adults ≥ 65 years old (n=26) were enrolled at two sites during the COVID-19 pandemic. Subjects were stratified as tech-savvy or non-tech savvy based on the Pew Technology Survey. Health-related quality of life was assessed by the SF-36 Survey. Semi-structured telephone interviews were conducted (n=23) and analyzed for thematic content using ATLAS.ti v8.0. Individuals were all well-educated;those in the tech-savvy group were younger, more likely to be employed, and reported better physical functioning (Table 1). Per interview data, all subjects used a computer, smartphone, or the internet;the non-savvy group relied more on others to help download information or navigate content. Subjects preferred in-person training, menu systems with data access in 3 steps, flexibility of data access and entry, and/or a help menu. For device management, 6/23 subjects downloaded their data to share with care teams and 14/23 subjects cited healthcare providers as their primary tech support. OAwT1D have unique preferences for technology use and training. Customized training for device use and patient support should be considered to maximize device benefits in this high-risk group.
ABSTRACT
In this article, we explore whether women's underrepresentation among political and workplace decision-makers may subject female citizens and employees to Covid-19-related decisions that are at odds with their preferences. We find that women overall, as well as female political party members, workers, and workplace leaders, share a distinctively female perspective that more heavily emphasizes caution with respect to Covid as compared to men. Given the limited representation of women leaders across most industries and in politics, Covid regulations are thus likely to be less cautious than would be the case if there were an equitable representation of women across leadership roles. We argue that female employees, in particular, face a representational “double whammy” for Covid: gender imbalances in workplace leadership creates inequities that are compounded - rather than being redressed - by unequal political representation. We conclude by addressing how this dynamic may enhance the movement of women away from Republican candidates moving forward. © 2020 Thieme Medical Publishers, Inc.. All rights reserved.