Ventilation rates measured by capnography during out-of-hospital cardiac arrest resuscitations and their association with return of spontaneous circulation.

BACKGROUND: Clinical guidelines for adult out-of-hospital cardiac arrest (OHCA) recommend a ventilation rate of 8-10 per minute yet acknowledge that few data exist to guide recommendations. The goal of this study was to evaluate the utility of continuous capnography to measure ventilation rates and the association with return of spontaneous circulation (ROSC). METHODS: This was a retrospective observational cohort study. We included all OHCA during a two-year period and excluded traumatic and pediatric patients. Ventilations were recorded using non-invasive continuous capnography. Blinded medically trained team members manually annotated all ventilations. Four techniques were used to analyze ventilation rate. The primary outcome was sustained prehospital ROSC. Secondary outcomes were vital status at the end of prehospital care and survival to hospital admission. Univariable and multivariable logistic regression models were constructed. RESULTS: A total of 790 OHCA were analyzed. Only 386 (49%) had useable capnography data. After applying inclusion and exclusion criteria, the final study cohort was 314 patients. The median ventilation rate per minute was 7 (IQR 5.4-8.5). Only 70 (22%) received a guideline-compliant ventilation rate of 8-10 per minute. Sixty-two (20%) achieved the primary outcome. No statistically significant associations were observed between any of the ventilation parameters and patient outcomes in both univariable and multivariable logistic regression models. CONCLUSIONS: We failed to detect an association between intra-arrest ventilation rates measured by continuous capnography and proximal patient outcomes after OHCA. Capnography has poor reliability as a measure of ventilation rate. Achieving guideline-compliant ventilation rates remains challenging.

Fighting Poverty in Times of Crisis in Europe

The debt crisis sparked a growing interest in resilience as a means to address socioeconomic hardship in Europe. This research used qualitative secondary analysis of three emblematic cases to examine resilience processes in countries with diverse welfare regimes: Poland, Portugal and Ireland. The goal is to undertake a comparative analysis of the lived experiences of households in situations of hardship, while addressing the influence of sociopolitical frameworks on social agency. Under an economic recession and reduced social investment, findings show that resilience processes had only marginal positive effects, consisting mostly of survival practices to cope with increased levels of poverty and social risk, regardless of national setting. Instead of leading to sustained improvements in their lives, resilience processes increased the vulnerability of individuals. In the aftermath of the COVID-19 pandemic, the authors discuss why policy-makers remain attracted to resilience as a social response to crises and how it is shaping the European Union's social policy. © 2022 Copyright 2022 by Koninklijke Brill NV, Leiden, The Netherlands.

ELEVATED ANION GAP AS A MARKER OF SEVERE SARS-COV-2 INFECTION IN PREGNANT PATIENTS WITHOUT DIABETES: A CASE SERIES

SESSION TITLE: Biological Markers in Patients with COVID-19 Posters SESSION TYPE: Original Investigation Posters PRESENTED ON: 10/18/2022 01:30 pm - 02:30 pm PURPOSE: In December 2019, a disease caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) resulted in a global pandemic. The literature has been slowly growing in the subgroup of pregnant women but the metabolic derangements of pregnancy and SARS-CoV-2 have not been well described. METHODS: In this case series, we review 9 patients with severe SARS-CoV-2 infections admitted to the medical ICU at a single institution between 2020-2022, during the delta variant wave. RESULTS: Of the nine critically ill patients, the mean age was 32 ± 6.4 years with fetal age on admission of 27 ±2.81 weeks and 29 ±2.91 weeks at delivery. Average CRP of 114 ± 25 mg/L. In eight of 9 patients (89%), there was an anion gap metabolic acidosis (AGMA) on admission. The average albumin-corrected anion gap was 18±1.93. 75% of patients had mild ketonuria based on urinalysis. However, 50% had documented symptoms of nausea, vomiting, or diarrhea. While betahydroxybutyrate was checked in 2 patients, neither were abnormal. One had lactic acidosis, but none required vasopressors at time of identification. No renal failure or diabetes was noted and only two had abnormal glucose tolerance tests. At delivery, average PEEP was 10± 4 cmH2O with an average respiratory rate of 28 ± 4 breaths per minute. All patients with AGMA delivered early resulting in preterm delivery. 75% of the fetuses showed signs of distress at the time of delivery, which was the primary indication for delivery in 37.5% of deliveries. 37.5% of deliveries were due to significant maternal hypoxia. The only patient without AGMA did not deliver early. CONCLUSIONS: After excluding renal failure, toxin ingestion, and lactic acidosis, only ketosis can weakly explain the AGMA. There have been several studies that highlighted the association between COVID and ketone production. In pregnancy, placental production of glucagon and human placental lactogen and subsequent insulin resistance increases susceptibility to ketosis. A recent study posited that COVID could cause placental abnormalities. Therefore, pregnant women may be more susceptible to significant ketosis because of COVID infection. In one of our cases, the combination of hypoxia and acidosis could not be managed safely by the ventilator and resulted in early delivery. CLINICAL IMPLICATIONS: Ketosis and an elevated anion gap could be a marker for more severe outcomes in pregnant patients with COVID. This case series highlights the challenges of managing the metabolic demands of critically ill pregnant patients infected with SARS-CoV-2. DISCLOSURES: No relevant relationships by Calli Bertschy no disclosure on file for Joey Carlin;No relevant relationships by Jessica Ehrig No relevant relationships by Shekhar Ghamande no disclosure on file for Jordan Gray;No relevant relationships by Abirami Subramanian

Lung Cancer Screening Patients Experiences and Satisfaction: Quantitative and Qualitative Findings From a Survey Study

Introduction: In 2015, H. Lee Moffitt Cancer Center & Research Institute (MCC) launched a lung cancer screening program for high-risk individuals based on National Comprehensive Cancer Network guidelines. To identify successes and barriers of this program from the patient perspective, we conducted a survey study to measure patient experiences and satisfaction with lung cancer screening. Methods: In August 2020, a survey and cover letter were mailed to 576 patients who completed one or more lung cancer screenings at MCC. In addition to demographics, smoking history, and impact of the COVID-19 pandemic to get screened, the survey included 34 quantitative questions using a 5-point Likert scale and six open-ended questions. The quantitative questions measured patient satisfaction and experiences across 6 domains: appointment process, clinical staff interactions, communication, visit with the provider, screening results, cost, and clinic facility/overall satisfaction. Results were quantified using descriptive statistics. The six open-ended items elicited barriers and facilitators related to returning for screening, experiences with other cancer screenings, positive and negative experiences with the low-dose computed tomography (LDCT) visit, and suggestions for improving the process of LDCT screening visits. Content analysis using the constant comparison method was applied to the text and coded based on the a priori codes of the open-ended questions. Results: Among the 212 patients (37% completion rate) who completed the survey, 97.6% were white, 48.6% were female, and the mean age was 69 years. In the communication domain, 81.1% “strongly agreed/agreed” that the lung cancer screening process was clearly explained, 92.5% “strongly agreed/agreed” that the potential harms and limitations were clearly explained and 76.9% “strongly agreed/agreed” that the process for follow-up screening was clearly explained. For the provider questions, 71.7% “strongly agreed/agreed” that the provider was willing to listen carefully and 68.4% “strongly agreed/agreed” that the instructions were easy to understand. For results and costs, 78.3% “strongly agreed/agreed” the screening results were clearly explained and 70.8% “strongly agreed/agreed” that the cost of the screening was justified. Regarding overall satisfaction, 88.2% “strongly agreed/agreed” they would recommend lung cancer screening at MCC. Patients who had Medicare insurance or paid out-of-pocket had higher agreement about helpfulness of the staff who assisted them with billing or insurance compared to patients who had private insurance coverage (79.4% Medicare coverage, 60.0% private, and 75.0% self-pay: P-value=0.025). In the qualitative findings, respondents provided generally positive comments about their lung cancer screening experience. Negative comments were related to desire for more information about results, long wait times for results, and billing issues. Conclusions: This study provided insights about patient experiences and satisfaction with lung cancer screening which are important, given the low uptake of this life-saving modality. Ongoing patient-centered feedback may improve the lung cancer screening experience and increase follow-up screening rates. Keywords: survey, screening, patient satisfaction

Maternity services' responses to the COVID-19 pandemic: how Public Health England guidance was implemented in practice.

INTRODUCTION: The rapidly evolving COVID-19 pandemic required systemic change in how healthcare was delivered to minimize virus transmission whilst maintaining safe service delivery. Deemed at 'moderate-high risk', maternity patients are an important patient group that require consideration. Public Health England (PHE) issued national guidance on how to adjust these services. AIM: To explore how maternity units in England implemented PHE guidance. METHODS: An online survey of 22 items was distributed to individuals that had worked on an England-based maternity unit during the COVID-19 pandemic. The questionnaire was designed and tested by the multidisciplinary research team. Data was collected from November 2020 to July 2021. FINDINGS: Forty-four participants across 33 maternity units responded. Ninety-three percent were able to test all women requiring an overnight stay for COVID-19. Only 27% reported birth partners were tested for COVID-19. Only 73% reported they were able to isolate all COVID-19-positive patients in single rooms. Eighty-four percent stated they were aware of current PHE guidance on personal protective equipment (PPE) and 82% felt 'confident' in donning/doffing of PPE. Priorities for the future include rapid testing and a focus on community service provision. CONCLUSIONS: PHE COVID-19 guidance was implemented differently in maternity units across England due to the varying resources available at each trust leading to variable ability to test and isolate patients as recommended. More specific, tailored guidance for infection control measures against COVID-19 is needed for maternity settings due to their unique position.

Implementation of Public Health England infection prevention and control guidance in maternity units in response to the COVID-19 pandemic.

BACKGROUND: This study aimed to explore the successes and barriers to the implementation of Public Health England (PHE) infection prevention and control guidance in English maternity units during the COVID-19 pandemic. METHODS: Qualitative semi-structured interviews with obstetricians, midwives and neonatologists who worked in a maternity unit in England, UK, between March 2020 and July 2021. A thematic analysis was performed. RESULTS: Successes to the implementation of PHE guidance were related to existing infrastructure, training satisfaction, and organisational culture where subthemes considered the importance of a multidisciplinary approach, COVID-19 dedicated roles and hospital-wide communication. Barriers to implementation related to the applicability of the guidance with subthemes highlighting contradictions between updates, specialties and hospitals, undesirable timings and frequency of guidance updates, reductions in staff compliance and delayed implementation. Finally, the layout of some units made it difficult to implement various aspects of the guidance (e.g., social distancing), and many detailed issues related to information technology compatibility, a lack of availability and accessibility to appropriate personal protective equipment (PPE), and variations in testing arrangements between units. CONCLUSIONS: This research provides information on the experiences of healthcare professionals working on maternity units during the COVID-19 pandemic. Findings illustrate the importance of effective hospital-wide communication and the need for consistent, easily understood guidance. These results will be used to inform the content of an expert panel consensus meeting.

OSIMERTINIB PNEUMONITIS MASQUERADING AS COVID-19 PNEUMONIA

TOPIC: Critical Care TYPE: Medical Student/Resident Case Reports INTRODUCTION: Osimertinib induced lung disease may present as a COVID pneumonia. We herein present a case of a 71 year old patient with hypoxic respiratory failure initially treated for COVID pneumonia, to be later diagnosed with Osimertinib induced pneumonitis. CASE PRESENTATION: A 71 year old gentleman with a 20 pack-year smoking history, epidermal growth factor receptor mutated stage IV non-small cell lung cancer with brain metastasis treated with Osimertinib, presented to the emergency room in March 2021 with shortness of breath for three days. On presentation, his oxygen saturation was 87% on room air and increased to 92% with 6 liters per minute (L/min) of oxygen. Contrast Computed Tomography (CT) scan of the chest excluded pulmonary embolism but revealed multifocal patchy opacities along with an interval increase in the size of his primary tumor and pulmonary nodules. Laboratory investigations revealed the absence of leukocytosis with lymphopenia and slightly elevated lactate dehydrogenase and C-reactive protein. COVID pneumonia was suspected despite a negative nasopharyngeal SARS-CoV-2 PCR test. The patient was then started on treatment with Methylprednisolone (20 mg/day twice daily) and Remdesivir (200mg/day followed by 100 mg/day) due to high suspicion for COVID despite the negative test. Given the patient's immunosuppressed state, broad-spectrum antibiotics were also given for a possible bacterial infection. Over the next 24 hours, his oxygen requirements continued to escalate to 15 L/min through high flow nasal cannula. He was then transferred to the intensive care unit for management of hypoxic respiratory failure. Despite treatment for COVID and bacterial pneumonia, the patient's oxygen requirements did not improve. As a result, other differential diagnoses were investigated. Methylprednisolone pulse therapy (1g/day for three days) was started for suspected Osimertinib induced pneumonitis. His oxygenation and symptoms significantly improved over the next 48 hours to 4 L/min. Patient was discharged on Prednisone 60 mg/day and oxygen therapy was discontinued six days after initial presentation. DISCUSSION: We present a case of osimertinib induced pneumonitis. This diagnosis was confirmed based on the rapid clinical improvement following the initiation of high dose steroids. Few case reports in the literature describe this adverse complication and its incidence remains unclear [1]. In our case, pneumonitis developed after approximately five months of Osimertinib treatment in a patient with no previous parenchymal lung disease. Given that this complication could be life-threatening, it should be given urgent attention and the correct treatment should be administered as early as possible [2]. CONCLUSIONS: In conclusion, despite a typical presentation of a hypoxic respiratory failure in the era of the COVID pandemic, other differential diagnosis should always be considered. REFERENCE #1: Matsumoto Y, Kawaguchi T, Yamamoto N, et al. Interstitial Lung Disease Induced by Osimertinib for Epidermal Growth Factor Receptor (EGFR) T790M-positive Non-small Cell Lung Cancer. Intern Med. 2017;56(17):2325-2328. doi:10.2169/internalmedicine.8467-16 REFERENCE #2: Fan M, Mo T, Shen L, Yang L. Osimertinib-induced severe interstitial lung disease: A case report. Thorac Cancer. 2019;10(7):1657-1660. doi:10.1111/1759-7714.13127 DISCLOSURES: No relevant relationships by Eliane Alhalabi, source=Web Response No relevant relationships by Jayna Gardner - Gray, source=Web Response No relevant relationships by Vritti Gupta, source=Web Response

Survey results of lung cancer screening patient experiences and satisfaction

Background: In 2014, Moffitt Cancer Center (MCC) in Tampa, Florida launched a lung cancer screening program for high-risk individuals meeting USPSTF inclusion criteria. To reveal successes and potential limitations of this program, we conducted a survey to measure lung cancer screening patient experiences and satisfaction. Methods: In August 2020, a survey was mailed to 576 patients who completed one or more lung cancer screenings at MCC. The survey collected demographics and smoking history and measured patient satisfaction and experiences in 6 domains: the appointment process, clinical staff interactions, communication, visit with the provider, screening results and cost, and the clinic facility/overall satisfaction. There were also questions on the impact of the COVID-19 pandemic. A 5-point Likert scale was used to measure satisfaction with clinical staff and clinic facility/overall satisfaction (1= excellent to 5= poor) and other domains (1=strongly agree to 5=strongly disagree). Results were quantified using descriptive statistics. Results: Among the 160 patients that completed the survey, 96.3% were White, 93.1% were non-Hispanic, 46.9% were female, 78.1% were former smokers, and the mean age was 69 years. For the appointment process, 91.2% "strongly agreed/agreed" it was easy to make an appointment and 92.5% "strongly agreed/agreed" the clinic check-in process was efficient. Next, nearly 93% reported the courtesy of the clinical staff was "excellent/very good". For communication, while 90% "strongly agreed/agreed" that the lung cancer screening process was clearly explained, 63.2% "strongly agreed/agreed" that the potential harms and limitations were clearly explained and 71.2% "strongly agreed/agreed" that the process for follow-up screening was clearly explained. For the provider questions, 71.3% "strongly agreed/agreed" that the provider was willing to listen carefully and 66.3% "strongly agreed/agreed" that the instructions regarding follow-up were easy to understand. For results and costs, 79.4% "strongly agreed/agreed" the screening results were clearly explained and 70% "strongly agreed/agreed" that the cost of the screening was justified. Regarding overall satisfaction, 87.6% "strongly agreed/agreed" they would recommend lung cancer screening at MCC. Finally, 10.6% of patients were concerned about getting a lung cancer screening during the COVID-19 pandemic and only 8.1% reported that the COVID-19 pandemic prevented them from getting a lung cancer screening. Conclusion: Generally, for all 6 domains, patients reported favorable satisfaction and experience with lung cancer screening at MCC. However, higher rates of "neither agree/disagree" and "prefer not to answer" were observed for items related to communication and visit with the provider items suggesting improvements may be warranted, particularly related to future visits.

Qualitative findings from a survey on patient experiences and satisfaction with lung cancer screening

Background: In 2014, Moffitt Cancer Center initiated a lung cancer screening program for high-risk individuals who meet USPSTF inclusion criteria. As of January 2020, 576 patients have completed one or more lung cancer screenings. However, approximately 40% of lung cancer screening patients were noncompliant with their recommended follow-up. To understand reasons for lack of follow-up screening and to determine patient satisfaction and experiences, we conducted a survey with open-ended items to assess patient experiences and satisfaction among lung cancer screening patients. Methods: In this analysis, we report on findings from the qualitative portion of the survey. Six open-ended items elicited barriers related to returning for screening, experience with other cancer screenings, positive and negative experiences with the LDCT visit, as well as suggestions for improving the process of LDCT screening visits. Content analysis using the constant comparison method was applied to the text and coded based on the a priori codes of the open-ended questions. Results: As of November 2020, 190 people responded to the quantitative survey and 77 provided responses to one or more open-ended questions. Thirty-five respondents provided general positive comments about their lung cancer screening experience with typical responses of "positive" and "good experience". Twenty respondents mentioned that the staff was "caring", "knowledgeable", and "great staff". Ten respondents mentioned that they were "always treated well", "treated with respect", "high quality care". Negative comments were provided by 32 respondents in the areas of: "wanting more information on results" or "waiting too long for results" (N=7), "inefficient scheduling issues" (N=6), and billing issues (N=5). Additionally, six patients reported COVID-related issues impacted their lung cancer screening experience. Suggestion for improvements included: on-line appointments or text or email reminders (N = 10), lower costs (N=6), and uncertainty about remaining qualified for lung cancer screening due to age or current/prior medical conditions (N=5). Conclusion: Overall, findings provide insights about patient experiences and satisfaction for lung cancer screening. Suggestions for improvement centered on better scheduling systems and appointment reminders as well as the ability to speak to a clinician to better understand results and future eligibility. Ongoing patient-centered feedback may improve the lung cancer screening experience and increase follow-up screening rates.