Current Prescribing Practices in Psoriatic Arthritis - Comparison between the Uk and Europe

Background/Aims Psoriatic arthritis (PsA) is a multi-system disease with a range of management options. Treatment may vary by geographic location. We compared disease characteristics and prescribing practices in the UK and Europe in the post-Covid era. Methods The ASSIST study was a cross-sectional observational study of PsA patients aged 18 years and older selected from 24 centres across 5 countries (UK, France, Germany, Italy and Spain) between July 2021 and March 2022 (IRAS: 287039). Patients attending a face-to-face appointment with a diagnosis of PsA made by a rheumatologist were selected by systematic sampling at each centre and treated in routine clinical practice. Patient and disease characteristics, current treatment and treatment decisions (medications unchanged, switched, added or reduced) were recorded. The analysis was descriptive, with no imputation of missing data. Results 503 patients were included, with arthritis subtype, patient age, disease activity and duration shown (Table 1). Physician- and patient-reported disease severity was highest in the UK, where median patient age was lowest. Conventional synthetic (cs) DMARDS constituted a higher percentage of current PsA treatment in UK than continental Europe (66.4% vs 44.9%), whereas biologic use was more frequent in Europe (68.1% vs 36.4%). Adalimumab was the most commonly used biologic in the UK and Spain. Adalimumab and secukinumab were equally used in Germany, and ixekizumab and adalimumab were joint-first in Italy. Implementing change to the current PsA treatment was most common in the UK, predominantly being a treatment increase. This may reflect the higher level of disease activity or younger patient age in the UK than other countries, as treatment escalation is more likely earlier in the disease course. In the UK, treatment escalation was more commonly achieved by medication addition (26.2%) than medication switch (14%) or dose increase (7.5%). In Europe, medication addition and switch were of more similar frequency (10.9% vs 9.85%). Conclusion Disease characteristics and treatment strategies varied between countries, but particularly between UK and the rest of Europe. In contrast to mainland Europe, csDMARDs predominated in the UK, perhaps reflecting current NICE guidelines. Treatment escalation was most common in the UK, in keeping with higher disease activity. (Table Presented).

A Case of Ocular Myasthenia Gravis Seen by Rheumatology as Suspected Mononeuritis Multiplex in an Adult Male Shortly after Pfizerbiontech Sars-Cov-2 Vaccination

Background/Aims Myasthenia gravis (MG) is an antibody-mediated autoimmune disease targeting proteins at the postsynaptic membrane of the neuromuscular junction. MG is thought to occur in genetically susceptible individuals following an environmental trigger. SARS-CoV-2 infection has been associated with new-onset autoimmune disease, new-onset MG, and exacerbations of pre-existing MG, with molecular mimicry between SARS-CoV-2 epitopes and autoantigen-induced autoreactivity thought to be part of the underlying mechanism. We report a case of newonset ocular MG following first dose Pfizer-BioNTech BNT162b2 SARS-COV2 vaccination which was referred to rheumatology as suspected mononeuritis multiplex. Methods A 53-year-old man of East Asian ethnicity presented to the emergency department (ED) with sudden onset diplopia and left lateral gaze restriction 7 days after receiving his first dose of the Pfizer-BioNTech BNT162b2 SARS-COV2 vaccination. He had longstanding myopia and dry eyes but no other medical history, no regular medications or significant family history. He was a current smoker, with a 50-pack year history. He did not drink alcohol or use any recreational drugs. He was found to have an isolated left VI cranial nerve (CN) palsy with an otherwise normal ocular and physical examination. Blood tests were unremarkable apart from raised cholesterol, and he was discharged with a suspected self-limiting microvascular CN lesion. Three weeks later he presented to ED with worsening diplopia, increasingly restricted eye movements, headache, nausea, vomiting and blurred vision. Ophthalmology assessment noted new right sided CN III and VI palsy, persistent left CN VI palsy, and vertical diplopia in all fields of gaze. Neurological and physical examination were normal. Bloods including an autoimmune screen were unremarkable. SARS-CoV-2 Spike antibodies were positive consistent with SARS-CoV-2 vaccination but not infection. Intracranial and thoracic imaging were unremarkable. He was referred to and seen by both rheumatology and neurology as a case of suspected mononeuritis multiplex. Results A diagnosis of ocular MG was confirmed with positive serum acetylcholine receptor antibodies, and he was started on prednisolone, and pyridostigmine to good effect. Daily forced vital capacity (FVC) showed no respiratory muscle involvement, and nerve conduction studies and electromyography were normal, excluding secondary generalisation. Conclusion A review of the literature found 14 reported cases of new-onset MG all within 4 weeks following SARS-CoV-2 vaccine. Whilst these cases provide interesting insights into the pathogenesis of autoimmune conditions such as MG, they are not epidemiological studies to inform vaccine safety. Ultimately, current evidence suggests that the risks of SARS-COV-2 infection outweigh the risk of vaccine-related adverse events, therefore we suggest clinicians should be aware of potential new-onset autoimmune conditions, but support the safety of SARSCOV2 vaccination. Further, research into possible immunological mechanisms behind this phenomenon, including identifying potential epitopes inducing molecular mimicry, could help establish the likelihood of a causative link.

Multi-center validation of an artificial intelligence system for detection of COVID-19 on chest radiographs in symptomatic patients.

OBJECTIVES: While chest radiograph (CXR) is the first-line imaging investigation in patients with respiratory symptoms, differentiating COVID-19 from other respiratory infections on CXR remains challenging. We developed and validated an AI system for COVID-19 detection on presenting CXR. METHODS: A deep learning model (RadGenX), trained on 168,850 CXRs, was validated on a large international test set of presenting CXRs of symptomatic patients from 9 study sites (US, Italy, and Hong Kong SAR) and 2 public datasets from the US and Europe. Performance was measured by area under the receiver operator characteristic curve (AUC). Bootstrapped simulations were performed to assess performance across a range of potential COVID-19 disease prevalence values (3.33 to 33.3%). Comparison against international radiologists was performed on an independent test set of 852 cases. RESULTS: RadGenX achieved an AUC of 0.89 on 4-fold cross-validation and an AUC of 0.79 (95%CI 0.78-0.80) on an independent test cohort of 5,894 patients. Delong's test showed statistical differences in model performance across patients from different regions (p < 0.01), disease severity (p < 0.001), gender (p < 0.001), and age (p = 0.03). Prevalence simulations showed the negative predictive value increases from 86.1% at 33.3% prevalence, to greater than 98.5% at any prevalence below 4.5%. Compared with radiologists, McNemar's test showed the model has higher sensitivity (p < 0.001) but lower specificity (p < 0.001). CONCLUSION: An AI model that predicts COVID-19 infection on CXR in symptomatic patients was validated on a large international cohort providing valuable context on testing and performance expectations for AI systems that perform COVID-19 prediction on CXR. KEY POINTS: • An AI model developed using CXRs to detect COVID-19 was validated in a large multi-center cohort of 5,894 patients from 9 prospectively recruited sites and 2 public datasets. • Differences in AI model performance were seen across region, disease severity, gender, and age. • Prevalence simulations on the international test set demonstrate the model's NPV is greater than 98.5% at any prevalence below 4.5%.

Extracorporeal Membrane Oxygenation for Refractory Asthma Exacerbations With Respiratory Failure.

BACKGROUND: Asthma exacerbations with respiratory failure (AERF) are associated with hospital mortality of 7% to 15%. Extracorporeal membrane oxygenation (ECMO) has been used as salvage therapy for refractory AERF, but controlled studies showing its association with mortality have not been performed. RESEARCH QUESTION: Is treatment with ECMO associated with lower mortality in refractory AERF compared with standard care? STUDY DESIGN AND METHODS: This is a retrospective, epidemiologic, observational cohort study using a national, administrative data set from 2010 to 2020 that includes 25% of US hospitalizations. People were included if they were admitted to an ECMO-capable hospital with an asthma exacerbation, and were treated with short-acting bronchodilators, systemic corticosteroids, and invasive ventilation. People were excluded for age < 18 years, no ICU stay, nonasthma chronic lung disease, COVID-19, or multiple admissions. The main exposure was ECMO vs No ECMO. The primary outcome was hospital mortality. Key secondary outcomes were ICU length of stay (LOS), hospital LOS, time receiving invasive ventilation, and total hospital costs. RESULTS: The study analyzed 13,714 patients with AERF, including 127 with ECMO and 13,587 with No ECMO. ECMO was associated with reduced mortality in the covariate-adjusted (OR, 0.33; 95% CI, 0.17-0.64; P = .001), propensity score-adjusted (OR, 0.36; 95% CI, 0.16-0.81; P = .01), and propensity score-matched models (OR, 0.48; 95% CI, 0.24-0.98; P = .04) vs No ECMO. Sensitivity analyses showed that mortality reduction related to ECMO ranged from OR 0.34 to 0.61. ECMO was also associated with increased hospital costs in all three models (P < .0001 for all) vs No ECMO, but not with decreased ICU LOS, hospital LOS, or time receiving invasive ventilation. INTERPRETATION: ECMO was associated with lower mortality and higher hospital costs, suggesting that it may be an important salvage therapy for refractory AERF following confirmatory clinical trials.

Using Iterative RE-AIM to enhance hospitalist adoption of lung ultrasound in the management of patients with COVID-19: an implementation pilot study.

BACKGROUND: Lung ultrasound (LUS) is a clinician-performed evidence-based imaging modality that has multiple advantages in the evaluation of dyspnea caused by multiple disease processes, including COVID-19. Despite these advantages, few hospitalists have been trained to perform LUS. The aim of this study was to increase adoption and implementation of LUS during the 2020 COVID-19 pandemic by using recurrent assessments of RE-AIM outcomes to iteratively revise our implementation strategies. METHODS: In an academic hospital, we implemented guidelines for the use of LUS in patients with COVID-19 in July 2020. Using a novel "RE-AIM dashboard," we used an iterative process of evaluating the high-priority outcomes of Reach, Adoption, and Implementation at twice monthly intervals to inform revisions of our implementation strategies for LUS delivery (i.e., Iterative RE-AIM process). Using a convergent mixed methods design, we integrated quantitative RE-AIM outcomes with qualitative hospitalist interview data to understand the dynamic determinants of LUS Reach, Adoption, and Implementation. RESULTS: Over the 1-year study period, 453 LUSs were performed in 298 of 12,567 eligible inpatients with COVID-19 (Reach = 2%). These 453 LUS were ordered by 43 out of 86 eligible hospitalists (LUS order adoption = 50%). However, the LUSs were performed/supervised by only 8 of these 86 hospitalists, 4 of whom were required to complete LUS credentialing as members of the hospitalist procedure service (proceduralist adoption 75% vs 1.2% non-procedural hospitalists adoption). Qualitative and quantitative data obtained to evaluate this Iterative RE-AIM process led to the deployment of six sequential implementation strategies and 3 key findings including (1) there were COVID-19-specific barriers to LUS adoption, (2) hospitalists were more willing to learn to make clinical decisions using LUS images than obtain the images themselves, and (3) mandating the credentialing of a strategically selected sub-group may be a successful strategy for improving Reach. CONCLUSIONS: Mandating use of a strategically selected subset of clinicians may be an effective strategy for improving Reach of LUS. Additionally, use of Iterative RE-AIM allowed for timely adjustments to implementation strategies, facilitating higher levels of LUS Adoption and Reach. Future studies should explore the replicability of these preliminary findings.

Science communication during COVID-19: when theory meets practice and best practices meet reality

This paper synthesizes the efforts of an interdisciplinary, University-convened communication task force in the U.S. that used science communication theory to develop an effective strategy during the early stages of the COVID-19 pandemic. We outline recommendations for researchers and practitioners who are, or are interested in, implementing theory-based communication practices while describing how we dealt with the unforeseen realities we faced. Overall, we recommend that effective public health and science communication should be based on theory and formative evaluation while relying on established infrastructure, real-time data, a deep understanding of intended target audiences, and intentional coordination with community partners.

#AUAMatch: The impact of COVID-19 on social media use in the urology residency match

Introduction & Objective: Social Media (SoMe) use has rapidly expanded within the urological community over the last decade and has become an important tool in the residency application process. SoMe was particularly relevant to medical students during the 2020-2021 application cycle, as the COVID- 19 pandemic limited in-person interactions. In this study, we examined changes in SoMe use among urology residency applicants before and after the pandemic. Methods: We distributed surveys to all individuals who applied to our residency program for application cycles ending in 2018, 2019, and 2021. The surveys included questions about applicants' SoMe use and their perceptions of programs' SoMe use. We evaluated the ways applicants used SoMe during the application process, both before (2018/2019) and after (2021) the COVID-19 pandemic. The primary outcome was SoMe use for professional purposes. Results: We received survey responses from 33% (162/496) and 29% (84/294) of applicants from the 2018/2019 and 2021 cohorts, respectively. There was a significant increase in professional SoMe use in the 2021 cohort (80%) compared with the 2018/2019 cohort (44%) (p< 0.001).When controlling for age and gender, applicants in 2021 were more likely to use SoMe for professional purposes (odds ratio 4.68, p < 0.001). Applicants more frequently used Twitter (p< 0.001) and LinkedIn (p = 0.036) and less frequently usedDoximity (p< 0.001) in 2021 compared to 2018/2019. In 2021 compared to 2018/2019, a larger proportion of applicants used SoMe to connect directly with residents (69% vs 34%, p < 0.001) and with faculty members (65% vs 15%, p < 0.001). Applicants in 2021 compared to 2018/2019 more often found SoMe to be useful for making decisions about applying to (33% vs 10%), interviewing at (26% vs 7%), and ranking programs (20% vs 9%) (all p < 0.05). Twitter was the most common platform for applicants to access program information, increasing from 38% to 71%. Of the 2021 survey respondents who reported using SoMe, 74% (59/80) reported that application changes due to the pandemic directly caused them to increase their SoMe use. Overall, 31%of applicants felt that SoMe engagement had a positive impact on the application process, and 61% would like to see similar or more interaction between applicants and programs in future cycles. Conclusions: The COVID-19 pandemic ushered in a period of unprecedented SoMe usage among urology applicants, who used it to learn about and connect with residency programs in new ways. The use of SoMe by residency programs has become an important component of trainee recruitment and is likely to continue in the future.

#auamatch: The impact of COVID-19 on social media use in the urology residency match

INTRODUCTION AND OBJECTIVE: Social Media (SoMe) use has rapidly expanded within the urological community over the last decade and has become an important tool in the residency application process. SoMe was particularly relevant to medical students during the 2020-2021 application cycle as the COVID-19 pandemic limited inperson interactions. In this study, we examined changes in SoMe use among urology residency applicants before and after the pandemic. METHODS: We distributed surveys to all individuals who applied to our residency program for application cycles ending in 2018 2019, and 2021. The surveys included questions about applicants' SoMe use and their perceptions of programs' SoMe use. We evaluated the ways applicants used SoMe during the application process, both before (2018/2019) and after (2021) the COVID-19 pandemic. The primary outcome was SoMe use for professional purposes. RESULTS: We received survey responses from 33% (162/496) and 29% (84/294) of applicants from the 2018/2019 and 2021 cohorts respectively. There was a significant increase in professional SoMe use in the 2021 cohort (80%) compared with the 2018/2019 cohort (44%) (p<0.001). When controlling for age and gender, applicants in 2021 were more likely to use SoMe for professional purposes (odds ratio 4.68 p<0.001). Applicants more frequently used Twitter (p<0.001) and LinkedIn (p=0.036) and less frequently used Doximity (p<0.001) in 2021 compared to 2018/2019. In 2021 compared to 2018/2019, a larger proportion of applicants used SoMe to connect directly with residents (69% vs 34%, p<0.001) and with faculty members (65% vs 15%, p<0.001). Applicants in 2021 compared to 2018/2019 more often found SoMe to be useful for making decisions about applying to (33% vs 10%), interviewing at (26% vs 7%), and ranking programs (20% vs 9%) (all p<0.05). Twitter was the most common platform for applicants to access program information increasing from 38% to 71%. Of the 2021 survey respondents who reported using SoMe, 74% (59/80) reported that application changes due to the pandemic directly caused them to increase their SoMe use. Overall, 31% of applicants felt that SoMe engagement had a positive impact on the application process, and 61% would like to see similar or more interaction between applicants and programs in future cycles. CONCLUSIONS: The COVID-19 pandemic ushered in a period of unprecedented SoMe usage among urology applicants, who used it to learn about and connect with residency programs in new ways. The use of SoMe by residency programs has become an important component of trainee recruitment and is likely to continue in the future.

MULTIDISCIPLINARY APPROACH USING CATHETER DIRECTED MECHANICAL THROMBECTOMY IN TREATMENT OF A PULMONARY EMBOLISM WITH CLOT IN TRANSIT

TOPIC: Pulmonary Vascular Disease TYPE: Fellow Case Reports INTRODUCTION: Clot in transit (CIT) is a term associated with pulmonary embolism (PE) used to describe thrombus found in the right atrium or ventricle on echocardiography. We present a case of CIT treated in a multidisciplinary approach with catheter-directed mechanical thrombectomy. CASE PRESENTATION: A 60 year old male with a history of unprovoked PE off anticoagulation presented with dyspnea and syncope. At presentation, he was tachycardic to 130 but normotensive and not hypoxemic. Troponin-I was elevated at 0.06 ng/mL and B type-NP at 96 pg/mL. SARS-CoV-2 PCR was negative. CT angiography revealed extensive acute bilateral PE with increased RV/LV ratio of 1.9. A stat transthoracic echocardiography (TTE) found a dilated right ventricle with severely reduced systolic function, positive McConnell sign, a tricuspid annular plane systolic excursion (TAPSE) < 1cm, and a serpiginous mobile echodensity in the right atrium consistent with a CIT. A stat ultrasound of the legs also revealed extensive deep venous thrombosis in the proximal left femoral vein extending to the popliteal vein. After a multidisciplinary PE response team discussion, the patient was taken emergently to the catheterization lab. Prior to transport, VA ECMO safety lines were preemptively placed to facilitate ECMO initiation in case of decompensation. With the ECMO circuit primed and the ECMO team, cardiac anesthesiologist, and cardiothoracic surgery on standby, the patient underwent percutaneous mechanical thrombectomy utilizing the Inari Flowtriever® system. With adjunctive TTE guidance, the right atrial clot was first extracted in its entirety with no hemodynamic deterioration. This was followed by aspiration of clot from the right and left pulmonary arteries. Pulmonary artery pressures and cardiac index improved, and the procedure ended with placement of an IVC filter. The patient was transferred to the ICU and was started on enoxaparin at 1mg/kg twice a day. He was discharged on day 4 with rivaroxaban. DISCUSSION: CIT is a rare phenomenon with a prevalence rate of around 4% and is considered a medical emergency given its high mortality rate of 25-40%. While treatment guidelines are limited, anticoagulation alone has shown to be insufficient to treat CIT effectively. While there is data supporting the use of catheter directed therapies for PE, data on its use for CIT is scarce but growing. Furthermore, the preparation of advanced support prior in conjunction with the use of catheter directed therapy may be beneficial in case of life-threatening decompensation. CONCLUSIONS: Catheter-directed mechanical thrombectomy may be effective and safe as shown in this case, but requires a team capable of advanced therapies like ECMO and urgent surgical intervention if needed. REFERENCE #1: Otoupalova E, Dalal B, Renard B. Right heart thrombus in transit: a series of two cases. Crit Ultrasound J. 2017;9(1):14. doi:10.1186/s13089-017-0069-9. REFERENCE #2: Garvey S, Dudzinski DM, Giordano N, Torrey J, Zheng H, Kabrhel C. Pulmonary embolism with clot in transit: An analysis of risk factors and outcomes. Thromb Res. 2020 Mar;187:139-147. doi: 10.1016/j.thromres.2020.01.006. Epub 2020 Jan 10. PMID: 31991381. REFERENCE #3: Dhulipala V R, Fayoda B O, Kyaw H, et al. (August 04, 2020) Thrombus in Transit: Extract or Dissolve?. Cureus 12(8): e9550. doi:10.7759/cureus.9550. DISCLOSURES: No relevant relationships by Mara Caroline, source=Web Response No relevant relationships by Eliot Friedman, source=Web Response No relevant relationships by Eric Gnall, source=Web Responseresearch relationship with Inari Please note: April,2021 to presen Added 04/29/2021 by Lee Greenspon, source=Web Response, value=Grant/Research Support No relevant relationships by Patrick Ho, source=Web Response

Air dispersal of multidrug-resistant Acinetobacter baumannii: implications for nosocomial transmission during the COVID-19 pandemic.

AIM: To describe the nosocomial transmission of Air, multidrug-resistant, Acinetobacter baumannii, nosocomial, COVID-19 Acinetobacter baumannii (MRAB) in an open-cubicle neurology ward with low ceiling height, where MRAB isolates collected from air, commonly shared items, non-reachable high-level surfaces and patients were analysed epidemiologically and genetically by whole-genome sequencing. This is the first study to understand the genetic relatedness of air, environmental and clinical isolates of MRAB in the outbreak setting. FINDINGS: Of 11 highly care-dependent patients with 363 MRAB colonization days during COVID-19 pandemic, 10 (90.9%) and nine (81.8%) had cutaneous and gastrointestinal colonization, respectively. Of 160 environmental and air samples, 31 (19.4%) were MRAB-positive. The proportion of MRAB-contaminated commonly shared items was significantly lower in cohort than in non-cohort patient care (0/10, 0% vs 12/18, 66.7%; P<0.001). Air dispersal of MRAB was consistently detected during but not before diaper change in the cohort cubicle by 25-min air sampling (4/4,100% vs 0/4, 0%; P=0.029). The settle plate method revealed MRAB in two samples during diaper change. The proportion of MRAB-contaminated exhaust air grills was significantly higher when the cohort cubicle was occupied by six MRAB patients than when fewer than six patients were cared for in the cubicle (5/9, 55.6% vs 0/18, 0%; P=0.002). The proportion of MRAB-contaminated non-reachable high-level surfaces was also significantly higher when there were three or more MRAB patients in the cohort cubicle (8/31, 25.8% vs 0/24, 0%; P=0.016). Whole-genome sequencing revealed clonality of air, environment, and patients' isolates, suggestive of air dispersal of MRAB. CONCLUSIONS: Our findings support the view that patient cohorting in enclosed cubicles with partitions and a closed door is preferred if single rooms are not available.

Retraction: Impacts of social distancing on cancer care during the COVID-19 pandemic: Hong Kong experience (Palliative & Supportive Care DOI: 10.1017/S1478951520000541)

Cambridge University Press would like to issue a retraction for the preliminary accepted manuscript publication of this article (Chan et al. 2020a). The article was simultaneously submitted and later published in BMJ Supportive & Palliative Care (Chan et al. 2020b), and Cambridge University Press did not have appropriate permission to publish the Accepted Manuscript version of this article. © 2021 Cambridge University Press. All rights reserved.

A Randomized Study of Bortezomib, Cyclophosphamide and Dexamethasone Induction (VCD) Versus VCD and Daratumumab Induction Followed By Daratumumab Maintenance (VCDD) for the Initial Treatment of Transplant-Ineligible Patients with Multiple Myeloma (AMaRC 03-16)

[Formula presented] Introduction Daratumumab, when added to standard of care regimens in relapsed and untreated myeloma, has consistently demonstrated significant improvements in response rates, induction of MRD negative responses and progression-free survival (PFS) while proving highly tolerable with minor increases in overall regimen toxicity. In non-transplant eligible patients daratumumab has been added in randomized studies to lenalidomide and dexamethasone (Rd) and bortezomib, melphalan and prednisolone (VMP) backbones, but not to the VCD regimen. Furthermore, the randomized studies excluded a significant proportion of patients with comorbidities so the benefit of daratumumab in a frail, elderly myeloma population remains untested. Methods Inclusion criteria included untreated patients with symptomatic myeloma who were considered ineligible for high-dose chemotherapy with autologous stem cell transplantation due to either age >65years or the presence of comorbidities. Any degree of renal impairment, including dialysis dependence, was allowed as were patients with a prior history of systemic malignancy that had been disease-free for 2 years. Patients were randomized 1:1 to receive VCD or VCDD. VCD consisted of nine 5-week cycles of V 1.3 mg/m2 SC on Days 1, 8, 15 and 22;C 300mg/m2 PO on Days 1, 8, 15 and 22 and D 20 mg PO on Days 1, 8, 15 and 22. VCDD consisted of nine 5-week cycles of VCD plus daratumumab 16 mg/kg IV on Days 1, 8, 15 and 22 of cycles 1 and 2, Days 1 and 15 of cycles 3 to 6 and Day 1 of cycles 7 to 9, followed by daratumumab maintenance 16 mg/kg IV every 4 weeks until progression. The primary endpoint was PFS with secondary endpoints being response rates, MRD, overall survival, toxicity and quality of life. Results A total of 129 patients were randomized, but 7 did not commence intended therapy. The following modified ITT analysis is based on the 122 randomized patients, 58 in the VCD group and 64 in the VCDD group, who received therapy. Baseline characteristics were balanced between the two arms. Median age was 76 years (range, 62-91yrs), with 19% being ≥80 years of age. 30% were female. ECOG performance status was 0 (34%),1 (26%), 2 (16%) and unknown (25%). ISS stage was I (16%), II (36%), III (23%) and unknown (24%). The estimated median potential follow-up is 12.6 months. At the time of this report, the COVID-19 pandemic had impacted collection of site data. As a result, the following outcome data is provisional with a full data set to be available for presentation of the formal pre-planned interim analysis by the time of the ASH meeting. Overall response rate was 86% for VCD and 93% for VCDD. There was no significant difference between response rates after 4 cycles of induction for the VCD and VCDD arms: CR 3% vs 2%, VGPR 31% vs 41%, PR 51% vs 50%, MR 11% vs 7%, PD 3% vs 0%. Median PFS for the entire cohort (Fig A) was 21.8 months (95%CI 17.1-31.6 months). Median PFS for those treated with VCD was 18.9 months (95%CI 15.3-NR) and was 26.3 months (95%CI 17.1-31.6 months) for those treated with VCDD. In both arms combined, median PFS was 26.3 vs 21.9 months for those aged <75 vs ≥75 yrs, and not reached, 21.8 months and 19.9 months for those with ISS stage I, II and III, respectively. 19% of patients in the VCD group and 16% of patients in the VCDD group ceased therapy early, predominantly due to adverse events or death. SAEs during the induction period occurred in 44% and 52% of patients in the VCD and VCDD arms, respectively. There were 13 patients with SAEs due to infection in the VCD group and 20 in the VCDD group. Grade 3 or 4 peripheral neuropathy was uncommon, with only one case in the VCD arm. Conclusions The VCD schedule as detailed in this study appears efficacious, well tolerated and deliverable to an elderly myeloma population. The addition of daratumumab does not compromise chemotherapy delivery and may improve PFS. Formal interim analysis of the trial data will be presented at the meeting. [Formula presented] Disclosures: Mollee: Amgen: Membership on an entity's Board of D rectors or advisory committees;BMS/Celgene: Membership on an entity's Board of Directors or advisory committees;Takeda: Membership on an entity's Board of Directors or advisory committees;Pfizer: Membership on an entity's Board of Directors or advisory committees;Caelum: Membership on an entity's Board of Directors or advisory committees;Janssen: Membership on an entity's Board of Directors or advisory committees, Research Funding. Reynolds: Novartis AG: Current equity holder in publicly-traded company. Janowski: Janssen: Membership on an entity's Board of Directors or advisory committees;BMS/ Celgene: Membership on an entity's Board of Directors or advisory committees;Amgen: Membership on an entity's Board of Directors or advisory committees;AstraZenica: Consultancy. Quach: Amgen, Celgene, karyopharm, GSK, Janssen Cilag, Sanofi.: Membership on an entity's Board of Directors or advisory committees;GlaxoSmithKline, Karyopharm, Amgen, Celgene, Janssen Cilag: Honoraria;GlaxoSmithKline, Karyopharm, Amgen, Celgene, Janssen Cilag: Consultancy;Amgen, sanofi, celgene, Karyopharm, GSK: Research Funding. Campbell: Amgen, Novartis, Roche, Janssen, Celgene (BMS): Research Funding;AstraZeneca, Janssen, Roche, Amgen, CSL Behring, Novartis: Consultancy. Gibbs: Janssen, BMS/Celgene, Amgen, Takeda, Pfizer, Caelum, Abbvie and Eidos: Membership on an entity's Board of Directors or advisory committees. D'Rozario: Abbvie: Membership on an entity's Board of Directors or advisory committees;BMS/ Celgene: Membership on an entity's Board of Directors or advisory committees. Wallington-Beddoe: Amgen: Membership on an entity's Board of Directors or advisory committees. Weber: Amgen: Membership on an entity's Board of Directors or advisory committees. Spencer: Celgene, Janssen and Takeda: Speakers Bureau;AbbVie, Celgene, Haemalogix, Janssen, Sanofi, SecuraBio, Specialised Therapeutics Australia, Servier and Takeda: Consultancy;Amgen, Celgene, Haemalogix, Janssen, Servier and Takeda: Research Funding;AbbVie, Amgen, Celgene, Haemalogix, Janssen, Sanofi, SecuraBio, Specialised Therapeutics Australia, Servier and Takeda: Honoraria. OffLabel Disclosure: Daratumumab as initial treatment of myeloma

Multi-Level Stakeholder Perspectives on Determinants of Point of Care Ultrasound Implementation in a US Academic Medical Center.

There is growing interest from multiple specialties, including internal medicine, to incorporate diagnostic point of care ultrasound (POCUS) into standard clinical care. However, few internists currently use POCUS. The objective of this study was to understand the current determinants of POCUS adoption at both the health system and clinician level at a U.S. academic medical center from the perspective of multi-level stakeholders. We performed semi-structured interviews of multi-level stakeholders including hospitalists, subspecialists, and hospital leaders at an academic medical center in the U.S. Questions regarding the determinants of POCUS adoption were asked of study participants. Using the framework method, team-based analysis of interview transcripts were guided by the contextual domains of the Practical Robust Implementation and Sustainability Model (PRISM). Thirty-one stakeholders with diverse roles in POCUS adoption were interviewed. Analysis of interviews revealed three overarching themes that stakeholders considered important to adoption by clinicians and health systems: clinical impact, efficiency and cost. Subthemes included two that were deemed essential to high-fidelity implementation: the development of credentialing policies and robust quality assurance processes. These findings identify potential determinants of system and clinician level adoption that may be leveraged to achieve high-fidelity implementation of POCUS applications that result in improved patient outcomes.

A case of idiopathic pauci-immune pulmonary capillaritis: A rare form of diffuse alveolar hemorrhage

Diffuse alveolar hemorrhage (DAH) is a life-threatening condition associated with various systemic diseases. Evaluation includes determining an underlying etiology. Isolated pauci-immune pulmonary capillaritis (IPIPC) without clinical, serological, or histological evidence of an underlying systemic process is an extremely rare cause of DAH. In limited case series, treatment is similar to treatment of DAH secondary to vasculitis or autoimmune disease and consists of immunosuppression. Prognosis is generally favorable. We present a case of a healthy male with IPIPC who, despite treatment, had persistent and ultimately fatal DAH. A 64-year-old male presented with mild dyspnea and scant hemoptysis. Review of systems was unremarkable. There was no history of travel or exposures. Hemoglobin was 12.0 g/dL, creatinine was 0.9 mg/dL, and urinalysis was normal. CT scan of the chest showed bilateral patchy ground glass opacities. Nasal swab for SARS-CoV-2 was negative. Bronchoscopy confirmed diffuse alveolar hemorrhage. He was started on methylprednisolone 1g daily for 3 days, followed by 1 mg/kg daily. Coagulation studies, ANA, RF, ANCA, and anti-GBM antibodies were negative. ESR was normal, but CRP was elevated at 29 mg/L. His echocardiogram was normal. Six days after bronchoscopy, he underwent a surgical lung biopsy. Pathology showed mostly bland alveolar hemorrhage with scattered areas of neutrophilic infiltration of the alveolar walls. Immunostaining was negative. Cyclophosphamide 2 mg/kg was initiated on day 14. The patient was maintained on nasal oxygen but had persistent slow alveolar bleeding. On day 22, plasmapheresis was initiated. Despite after 5 treatments of plasmapheresis, bleeding persisted. Cyclophosphamide was discontinued and rituximab was initiated. Over the next four weeks, bleeding accelerated with worsening hypoxemia, which ultimately led to intubation. The patient spent two weeks on the ventilator with need for daily blood transfusions. Gas exchange worsened with progressive hypoxemia and hypercapnia. Nine weeks after his initial presentation, the patient expired after family requested for palliative extubation. Autopsy showed hemorrhagic lungs without evidence of infection or malignancy. Isolated pauci-immune pulmonary capillaritis is rare. Since it was first described in 1995, there have been a limited number of cases described in literature. Current treatment recommendations are similar to treatment of DAH due to vasculitis, which include corticosteroids combined with cyclophosphamide or rituximab. Prognosis is generally favorable. Progressive and relentless hemorrhage as described in this case is unusual.

COVID-19 vaccination in haematology patients: an Australian and New Zealand consensus position statement.

Australia and New Zealand have achieved excellent community control of COVID-19 infection. In light of the imminent COVID-19 vaccination roll out in both countries, representatives from the Haematology Society of Australia and New Zealand and infectious diseases specialists have collaborated on this consensus position statement regarding COVID-19 vaccination in patients with haematological disorders. It is our recommendation that patients with haematological malignancies, and some benign haematological disorders, should have expedited access to high-efficacy COVID-19 vaccines, given that these patients are at high risk of morbidity and mortality from COVID-19 infection. Vaccination should not replace other public health measures in these patients, given that the effectiveness of COVID-19 vaccination, specifically in patients with haematological malignancies, is not known. Given the limited available data, prospective collection of safety and efficacy data of COVID-19 vaccination in this patient group is a priority.