ABSTRACT
Background. Multisystem inflammatory syndrome in children (MIS-C) following SARS-CoV-2 infection shares features with other inflammatory states, notably Kawasaki Disease. The rickettsial infection murine typhus is also in the differential for MIS-C in endemic areas. As the therapeutic approaches differ, it is essential to distinguish these disorders soon after presentation, well before confirmatory serologic testing results. Our objective was to develop an algorithm to accurately predict MIS-C versus typhus. Methods. Retrospective review extracted demographic, clinical, and laboratory features available within 6 hours of presentation for 133 MIS-C and 87 typhus patients. 33 features were broken into 44 inputs and passed through an attention module to compute importance. Inputs were then entered into machine learning algorithms as MIS-C or typhus. Patients were divided into training and test cohorts respecting proportions in the dataset. An equation was built to calculate the 'MET' (MIS-C versus endemic typhus) score. Results. MIS-C patients were younger (8.4 v 11.2 years, p< 0.0001) and the majority (71%) presented on day 4-6 of fever;most typhus patients (84%) presented with >=6 days (mean 4.9 v 7.3 days, p< 0.0001). Typhus patients were more likely to have rash (86% v 51%, p< 0.0001) and MIS-C patients red eyes (71% v 36%, p< 0.0001), other features were similar. MIS-C patients had higher C-reactive protein levels (17.7 v 9.8 mg/dL), procalcitonin (14.0 v 0.48 ng/mL), fibrinogen (558 v 394 mg/ dL) and neutrophil-to-lymphocyte ratio (12 v 3.5), all p< 0.0001, other parameters were similar. MIS-C patients were also more likely to have elevated troponin (0.48 v 0.01 ng/mL, p< 0.0001) and require intensive care (66% v 6%, p< 0.0001). A long short term memory network outperformed 6 other models (99% accuracy using all 33 elements). The MET score predicted MIS-C versus typhus with 90% accuracy using only 10 features (sensitivity 90%, specificity 90%). Conclusion. The clinical and laboratory similarities between typhus and MIS-C present challenges, but they can be reliably distinguished using artificial intelligence with as little as 10 features. Our ongoing interprofessional collaboration aims to make the MET score readily available to clinicians for use in patient encounters.
ABSTRACT
During the COVID-19 global pandemic, Taiwan has been universally praised for its policy actions in preventing its initial outbreak there from Wuhan and for its strict measures in containing its communal spread locally. Memory of the SARS crisis played a major role, but people in Taiwan forget that SARS was initially considered a problem confined mostly to Hong Kong. Taiwanese did not seem urgently aware, until infections multiplied locally. Taiwan's health authorities eventually adopted a draconian quarantine policy, but mainly as a political tactic to contain the widespread panic, as though the dam had suddenly burst. In retrospect, the extremity and internal contradictions of the policy are remarkable, but they are instructive. The initial reaction of unprepared governments, most notably in the US, during COVID-19 mirrors this same ineptitude. Enabling hysteria and resorting to scapegoating were in turn diversions to cover up their inability to prevent a crisis. In the US, racism emerged, China and the WHO were blamed, people were even urged not to wear masks to avoid a run on short supplies. This is the tip of the political iceberg, if one adds tightened immigration and economic effects on the U.S. elections.
ABSTRACT
Introduction: Most children who contract SARS-CoV-2 infection are asymptomatic or mildly symptomatic. However, a subset go on to develop a potentially life-threatening hyperinflammatory condition called multisystem inflammatory syndrome in children (MIS-C) 4-6 weeks after COVID-19. The mechanisms by which MIS-C occurs are not yet clear, resulting in hesitation to vaccinate this subset of children against SARS-CoV-2 due to concerns for a reoccurrence of hyperinflammation. Objectives: To evaluate outcomes following SARS-CoV-2 vaccination in patients who were previously diagnosed with MIS-C after COVID-19. Methods: Medical records of patients who were treated for MIS-C at our institution were retrospectively reviewed. Details for those who were subsequently vaccinated against SARS-CoV-2 were extracted. Results: A total of 164 patients were treated for MIS-C between May 2020 and May 2021. 22 patients were 16 years of age or older and an additional 30 patients were age 12-15 years, resulting in a total of 52 patients eligible for SARS-CoV-2 vaccination. 10 (19%) of these patients were vaccinated using the Pfizer-BioNTech product in our COVID-19 vaccine clinic. The age of the patients ranged from 12 to 17 years. 8 were male, and 8 were from racial/ethnic minority groups. All were generally healthy (3 asthma, 1 repaired congenital heart disease) prior to their MIS-C diagnosis. The patients presented between July 2020 and February 2021 with a febrile illness, and fulfilled the case definition for MIS-C established by the Centers for Disease Control and Prevention, including all 10 having positive SARS-CoV-2 serologic testing and 9 with myocarditis or coronary changes (measured by troponin elevation and/or electrocardiographic or echocardiographic evidence). 8 presented in shock or with hypotension, and 6 were admitted to the intensive care unit (ICU), among which 3 required vasoactive medications and 2 intubation. ICU length of stay ranged from 2-15 days, and total hospital stay from 2-23 days. All 10 patients were treated with corticosteroids, 8 received intravenous immunoglobulin, and 5 anakinra. All patients had normal cardiac function without coronary artery dilation at the time of last cardiology follow-up. The patients were vaccinated an average of 199 days from MIS-C hospitalization discharge (range 83 to 337 days). Thus far, a median of 57 days (range 1 to 117 days) has elapsed since 9 of the 10 patients completed the second vaccine dose. None has developed a recurrence of MIS-C or a hyperinflammatory condition. No significant adverse events have occurred following vaccination. Conclusion: These 10 patients who experienced MIS-C after COVID-19 have tolerated vaccination against SARS-CoV-2 without the subsequent development of a similar hyperinflammatory state providing critical information as the COVID-19 pandemic continues to rage across the globe. As we move toward vaccination for children younger than 12 years, a growing number of prior MIS-C patients (average age 8-9 years) will become eligible for vaccination. Given the risk of re-infection with SARS-CoV-2 and the known additive protection from re-infection provided by vaccinating previously infected individuals, it is imperative that patients with a history of MIS-C be offered vaccination against SARS-CoV-2.
ABSTRACT
Background After fleeing to Pennsylvania during the NYC pandemic, a patient avoided COVID-19, but contracted West Nile Virus (WNV). WNV is an arthropod-borne arbovirus that first appeared in North America in 1999. 80% of those infected are asymptomatic, 20% develop febrile illness, and < 1% develop neuroinvasive disease. We present a case of WNV in an older adult who developed neuroinvasive disease with associated movement disorder and bladder dysfunction. Case description: An 87 year old woman with history of hypothyroidism, CAD, CVA, atrial fibrillation, CKD, and mild cognitive impairment presented to a hospital with altered mental status (AMS). She stabilized and was discharged home. Due to reoccurring fevers and AMS, she was readmitted with a temperature of 101.5F. Physical exam showed obtundation, grimacing upon palpation of suprapubic region, unintentional tremor in upper extremities, and negative Brudzinski and Kernig signs. Labs were unremarkable. Chest x-ray, and contrast (CT) angiogram of chest were negative;non-contrast CT abdomen showed no source for infection. MRI of the brain showed chronic changes suggesting microvascular ischemic disease, chronic small left cerebellar infarct and moderate parenchymal volume loss. Given AMS and history of suspected recent insect bite, patient was empirically treated for viral, bacterial, and vectorborne meningitis. Fevers persisted and patient's mental status fluctuated. Lumbar puncture was suggestive of viral meningitis. Eventually, West Nile Virus IgM was positive in CSF, IgG was negative. Other serologies were negative. Antibiotics and antivirals were discontinued. Mental status slowly improved but due to persisting urinary retention she was discharged home with an indwelling urinary catheter. Eventually both the urinary retention and tremors resolved. Conclusion: WNV neuroinvasive disease is suspected to follow viral penetration of the blood-brain barrier and direct invasion of neurons. This patient's WNV meningoencephalitis was confirmed by detection of WNV IgM in CSF. Her symptoms included AMS, dyskinesia/tremors (present in up to 90% of WNV-seropositive patients), and acute urinary retention (bladder dysfunction occurs in 3-63% of patients with neuroinvasive disease).
ABSTRACT
Background Our 2019 survey showed 50% of geriatricians had burnout by Maslach Burnout Inventory (MBI), 79% had electronic medical record (EMR) frustration, 54% spent >60 minutes on the EMR outside of workday and 32% spent >60 minutes/day on clerical work. The COVID-19 pandemic added to the strain. In September 2020, 69% of our geriatricians reported in-basket management makes them feel “most overwhelmed.” Prior research shows the benefit of nonphysician staff reviewers for in-basket messages. We will improve geriatrician well-being and productivity with a new Patient Coordinator In-basket Scrubber Intervention. Methods We will target 21 geriatricians providing primary care to older adults at three outpatient sites. We will recruit and train two Patient Coordinators (PCs) who will lead a novel In-basket Scrubber intervention. Initially, the PCs will be the first contact to scrub (screen and send to correct team member) all in-basket messages from the call center. They will identify inefficient communication patterns, code messages by “team member” and “domain” and determine the destination and/or outcome of the messages. The PCs will train administrative assistants (AAs) to assess, complete and/or appropriately redirect providers' in-basket messages to team nurses, social workers or the physician. We will also target our telehealth workflow to improve scheduling and appointment confirmation, reduce no-shows and convert canceled visits to tele-visits, thereby increasing reimbursable visits. Results Results forthcoming. At months 0, 6, 12, and 18, we will assess physician EMR burden, well-being, and productivity. Measures include: EMR burden (Number of Inbox Inputs per workday, Time in Inbox per workday, Work after Work 7pm to 7am);Well-being (Subjective Inbox Burden, Maslach Burnout Inventory);Productivity (In-person visits Televisits, Medicare Annual Wellness Visits, advance care planning bills, chronic care management bills, work relative value units). We expect the intervention to reduce EMR burden and improve well-being and productivity. We also expect new revenue to offset costs. By reducing clerical burden and optimizing billable time for care coordination, we expect to double our Chronic Care Management billing (estimated $75,000/year). Conclusions We will improve geriatrician well-being through a new In-basket Scrubber Intervention.