ABSTRACT
Background. Murine Typhus remains endemic in southern California and in southern Texas where it is transmitted by fleas, with opossums serving as the amplifying host. In Texas, the disease is increasingly recognized in municipalities outside its historic rural range and is spreading in a northward distribution. Since its expansion, we have observed increased cases in the Dallas-Fort Worth (DFW) area and aim to describe murine typhus in North Texas from 2011-2021. Methods. Leveraging the electronic health record, we retrospectively identified 482 individuals tested for murine typhus by Rickettsia typhi (R. typhi) serology in 2 Dallas hospitals. We subsequently collected epidemiologic characteristics, clinical features, and outcomes of 58 patients with positive R. typhi serologies ( >1:64). Results. Of the 58 patients with positive R. typhi serology, 39 (67%) were male, 45 (78%) were White, and 23 (40%) were Hispanic. Seventy-nine percent had symptom onset between May and November, and 36/58 (62%) were diagnosed in 2020 and 2021. Twenty-six (45%) had exposure to dogs, 18 (31%) to cats, and 13 (22%) to opossums. Twelve (21%) patients were immunocompromised. Fifty-two (90%) had fever, 35 (60%) headache, 26 (45%) nausea and vomiting, 26 (45%) rash, 25 (43%) myalgia, 20 (34%) cough, and 17 (29%) abdominal pain. In 2020 and 2021, 35/36 (97%) patients were additionally tested for COVID-19, and 29/35 (83%) patients had more than one negative SARS-CoV-2 test prior to R. typhi serologies being sent. Twenty-one out of fifty (42%) had an abnormal chest x-ray (CXR) and 28/30 (93%) had an abnormal chest computed tomography (CT). Nine (16%) had hypoxia, 9 (16%) required an intensive care unit, and 3 (5%) required mechanical ventilation. No patients died within 30 days of diagnosis. Conclusion. Our study highlights the expansion of murine typhus in North Texas (Figure 1) and demonstrates the heightened need for clinicians to be aware of this disease in the appropriate epidemiologic and clinical settings. We also describe increasing rates of respiratory findings, demonstrated through over half of patients having at least one respiratory symptom, and 93% having an abnormal chest CT (findings traditionally associated with severe disease).
ABSTRACT
At University Hospitals of Leicester NHS Trust (UHL), unfractionated heparin (UFH) has previously been monitored using activated partial thromboplastin time (aPTT) measurements in line with international practice. Prior to the COVID-19 pandemic, heparin assays using Anti-Xa methodology were used to monitor heparin activity in selected cases following approval by a haematologist. These tests were performed in the specialist haematology laboratory by specifically trained staff. Patients diagnosed with COVID-19 have a complex coagulopathy, leading to both prolongation and shortening of aPTT and reduced reliability in heparin monitoring compared with Anti-Xa assays ( Adie & Farina, 2021;Hardy et al., 2020 ). 1,2 In response to the pandemic, to ensure reliable monitoring of treatment, UHL transitioned from using aPTT monitoring to Anti-Xa assay testing. To enable Anti-Xa assay testing in the routine fast track laboratory a new operational procedure with a simplified assay needed to be validated;the initial work had commenced in January 2020 in response to clinician request. Verification of the modified sample centrifugation procedure and a hybrid Anti-Xa assay for UFH and low molecular weight heparin (LMWH) was completed in June 2020. New protocols and staff training in the fast track laboratory took place and the transition was completed in December 2020. To compare the effect this change had at UHL, and the laboratory's ability to adapt, Anti-Xa assay request data were compared between 2018 and 2020 over a 3-month period (October-December ). The findings are presented in Table 1. The study found a 12 times increase in Anti-Xa requests in 2020. The majority of these were for patients receiving extracorporeal membrane oxygenation (ECMO) requiring UFH from our specialist centre located at Glenfield Hospital;these patients required regular monitoring and repeated Anti-Xa assays. We also found a significant increase in requests to monitor prophylactic/intermediate dose heparin treatment in 2020, again with a significant number of these patients receiving ECMO, whereas in 2018 the majority of Anti-Xa assay requests were for treatment dose heparin monitoring. By transitioning from aPTT based to Anti-Xa based heparin monitoring available 24/7 in the fast track laboratory, patients had more reliable monitoring of their heparin activity . This has changed standard of care at UHL, which was of particular benefit to the patients on ECMO and continuous heparin monitoring. Due to the fact that part of the planning and verification work occurred prior to the COVID-19 pandemic the transition of this assay was completed reasonably quickly when the clinical need for this assay to be available on a 24/7 basis became urgent. We will continue to monitor data on therapeutic impact and bleeding episodes..
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Background: In March 2020, guidelines recommended that breast cancer (BC) centres suspend nonemergent surgeries because of the COVID-19 pandemic, including delaying surgeries for estrogen-receptor positive (ER+) BCs with neoadjuvant endocrine therapy (NET). The objective of this study was to evaluate the oncologic outcomes of patients with BC who were affected by these guidelines. Methods: All female patients with stage I-II BC receiving NET during the COVID-19 pandemic at 2 referral-based academic BC centres were prospectively identified. Clinical and pathologic data were collected. Patients were matched to a historical cohort of patients with stage I-II ER+ BC treated with upfront surgery within 35 days between 2010 and 2013. Primary outcomes were pathologic upstaging compared with clinical staging before NET initiation. Results: Thirty patients who received NET and 200 randomly selected historical patients were matched on the basis of preoperative tumour grade and pathologic features. Alter matching, 29 patients who received NET and 53 patients who received upfront surgery remained. The median age in each group was 65 and 66 years, respectively (p = 0.33). Most patients (79.3% and 81.1%) had invasive ductal carcinoma with a median clinical tumour size of 0.9 cm versus 1.7 cm (p = 0.005). Median time to surgery was 73 days in the NET group and 27 days in the upfront surgery group (p < 0.001). Twenty-three patients who received NET (82.2%) had the same or lower pT stage compared with 36 (67.9%) patients who received upfront surgery (p = 0.31). Only 3 (10.3%) patients who received NET had an increase in pN stage compared with 16 (30.2%) control patients (p = 0.06). Overall, 3 (10.3%) patients who received NET had a stage increase on final pathology versus 15 (28.3%) in the control group (p = 0.16). Conclusion: Despite experiencing delays to surgery that were over 2.5 times longer, patients with ER+ BC receiving NET did not experience significantly different pathologic upstaging during the COVID-19 pandemic. These findings support the use of NET in stage I-II ER+ BC if substantial delays in surgery are projected.
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Session Description: A landmark study found that in intensive care units (ICUs), tracheostomy incidents accounted for up to half of all airway-related deaths and hypoxic brain damage. Multidisciplinary adult and pediatric tracheostomy teams have achieved dramatic reductions in adverse events and improved patient outcomes, but dissemination of highly reliable practices has lagged. This panel addresses this gap by providing a strategy for rapid performance improvement with specific building blocks for enhancing care. Five key drivers-multidisciplinary ward rounds, standardized protocols, interdisciplinary education and staff allocation, patient and family involvement, and using data to drive improvement-can result in transformative change. We present data from 4 institutions, providing turnkey solutions and lessons learned from the creation of teams. We cover from the index procedure to decannulation and discharge, discussing obstacles encountered and how they are overcome. After presenting institution-level experience, we report on the largest implementation of these principles to date, drawing on prospectively captured patient-level global data from nearly 10,000 cases. We take a deep dive into a 3-year-long, 20-hospitalwide multipronged implementation that involved mixedmethods analysis, data tracking, and benchmarking to demonstrate powerful, statistically significant effects of reducing hospital and ICU length of stay, ventilator duration, time to cuff deflation, time to first vocalization, time to first oral intake, prevalence of anxiety and depression, and cost savings, projected at >$15,000 per patient. While heterogeneity is a defining feature of tracheostomy, we demonstrate how across age and geographies, multidisciplinary teams are a game changer in tracheostomy care. In addition, the imperatives of the COVID-19 pandemic have necessitated additional measures in relation to aerosol-generating procedures. We curate salient data and present practical evidence-based recommendations. Outcome Objectives: (1) Present building blocks and discuss obstacles to creating a multidisciplinary tracheostomy care team. (2) Leverage data-science and ongoing efforts to improve tracheostomy outcomes. (3) Compare the approaches of different hospital systems in the creation of tracheostomy care teams in the context of COVID-19.
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Introduction: An understanding of disruptions to health care delivery in real time is critical for monitoring volumes and outcomes. Currently outcomes are evaluated via timeconsuming reviews of patient records. This study aims to demonstrate the utility of a novel electronic medical record (EMR) dashboard via the impact of COVID-19 on pediatric otolaryngology procedures. Method: An EMR dashboard utilizing surgical encounters driven by Current Procedural Terminology groupings was used to enable real-time viewing of summaries and trends in a multicenter academic health system. The number of pediatric adenoidectomies, tonsillectomies, and tympanostomy tube placements (PETs) for an 11-month period was compared between 2019 and 2020 to assess COVID-19 impact. Return to emergency department (ED) within 30 days, 30-day readmission/observation rates, return to operating room (OR), and postoperative bleeding were assessed with chi-square analysis. Results: The EMR dashboard was reviewed for all patients <19 years for all providers and hospitals within the health system for defined procedure groupings. In 2019 264 adenoidectomies, 937 tonsillectomies, and 1134 PETs were performed vs a 2020 volume of 158, 563, and 664, respectively, at a 40% volume decline. For 2019 vs 2020, postoperative tonsillectomy bleed rates were 3.3% vs 5.2%;return to the ED rates were 11.1% vs 12.1%;30-day return to OR rates were 2.6% vs 4.6%;and observation/readmission rates were 2.2% vs 2.1% (P = .539). For all 3 procedures, no statistical difference was identified between years for any complication. There were no mortalities. Conclusion: In contrast to time-intensive chart review, the novel EMR dashboard confers rapid analysis and identification of surgical volumes for pediatric otolaryngology cases. Despite selection bias for more complicated cases due to cancellation of elective procedures, the EMR dashboard provides real-time reassurance that complication rates remained stable during the COVID-19 pandemic. We expect this EMR dashboard will improve our ability to monitor changes in surgical delivery.
ABSTRACT
Introduction: This study aims to demonstrate the utility of a novel electronic medical record (EMR) dashboard by assessing the impact of COVID-19 on surgical volume and shortterm postoperative outcomes of head and neck surgical patients undergoing free flap reconstruction. Method: An EMR dashboard grouped surgical encounters by Current Procedural Terminology codes to view summaries and trends in real time at a tertiary academic institution. Outcomes of head and neck surgical patients undergoing microvascular free flap reconstruction, primarily for cancer diagnoses, were compared between 2019 and 2020 to assess COVID-19 impact. Hospital length of stay was assessed with t test, and 30-day return to emergency department (ED), readmission/ observation, return to operating room, and postoperative bleeding were assessed with Fisher exact test. Results: In 2019 190 free flap procedures were performed compared with 131 procedures in 2020, a 31.1% volume decline. Mean hospital length of stay for free flap procedures was 8.6 ± 6.0 days in 2019 and 9.1 ± 6.6 days in 2020 (P = .482). For 2019 vs 2020, return to ED rates were 21.6% vs 27.5% (P = .369);observation/readmission rates were 18.4% vs 10.7% (P = .117);postoperative hemorrhage rates were 5.8% vs 12.2% (P = .070);return to OR rates were 3.2% vs 8.4% (P = .753);and mortality rates were 0% vs 1.5% (P = .169), respectively. For all complications, there was no statistical difference detected between years. Conclusion: The novel EMR dashboard provided summaries of changes to surgical volume and postoperative outcomes in real time. Surgical volume for head and neck free flap procedures decreased significantly during the COVID-19 pandemic. Despite selection bias for more complicated cases due to cancellation of both elective and nonelective procedures, complication rates in our cohort remained stable indicating no adverse effects on patient safety.