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The coronavirus disease 2019 (COVID-19) pandemic has created an urgency for an effective vaccine. The current approved mRNA vaccines offered by Pfizer-BioNTech (BNT162b2) and ModernaTX (mRNA-1273) have shown few side effects in general population studies. People living with multiple sclerosis (MS) were not specifically represented in the above studies. The MS community is extremely interested in knowing, how these vaccines are tolerated by this population. We retrospectively identified 102 consecutive MS patients at our center that had been fully vaccinated against COVID-19 with the current mRNA vaccines. We compared the reported side effects (SE) with the clinical trial data from Pfizer-BioNtech and ModernaTX. In addition to local and systemic reactogenicity, we recorded clinical relapses and pseudo-relapses to encompass any neurological SE. Overall, our patient population reported significantly less SE for both vaccine variants as compared with general population studies, except for a higher incidence of fever in mRNA-1273 recipients (25% vs. 16%). Of the 62 patients that received the BNT162b2 vaccine variant, there were 2 cases of pseudo-relapse (3.2%). Of the 40 patients that received the mRNA-1273 vaccine, there were 4 patients that reported a pseudo-relapse (10%). Recovery to pre-vaccination neurological baseline occurred in all subjects within 96h without receiving specific treatments. No clinical relapses occurred in association with these vaccines. There was no association between a patient's disease-modifying therapy, age, sex, or race and their risk of suffering from a pseudo-relapse after COVID-19 vaccination. In summary, the risk for clinical relapses was absent in our cohort. The risk of transient neurological worsening was very low (average 5.9%). Our data may help inform patients and clinicians about the tolerability and safety of COVID-19 mRNA vaccines in people living with MS.
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TOPIC: Critical Care TYPE: Fellow Case Reports INTRODUCTION: Venous thromboembolism (VTE) and arterial thrombosis (AT) are known complications associated with critically ill COVID-19 patients. We report a case of a patient that developed an acute aortoiliac thrombosis and acute limb ischemia despite high-dose VTE prophylaxis and was subsequently found to have chronic lymphocytic leukemia (CLL). CASE PRESENTATION: A 62-year-old male with coronary artery disease and diabetes was admitted to the intensive care unit for acute hypoxemic respiratory failure from COVID-19 pneumonia. He was treated with Remdesivir, dexamethasone 6mg daily, and enoxaparin 30mg twice daily. On hospital day 5, he developed acute left lower extremity pain with sensory and motor loss and bilateral lower extremities became cold and pale. He had no palpable femoral or popliteal pulses and posterior tibial and dorsalis pedis pulses were not detected by doppler. A CTA demonstrated an acute, nearly occlusive thrombus at the level of the distal infrarenal aorta with extension to bilateral iliac and femoral arteries. The patient was taken emergently to the operating room and underwent percutaneous thrombectomy and left lower extremity fasciotomy. On further review, he was noted to have significant lymphocytosis (83% on admission), an unexpected finding for a patient with COVID-19. As a result, peripheral flow cytometry was performed and demonstrated CD5 positive B-cell leukemia. The patient eventually discharged to acute rehab after a 42-day hospitalization. DISCUSSION: Since the start of the pandemic, the thrombotic complications of COVID-19 have been a major research focus given the high incidence and associated increased risk of mortality. Most of the research has centered around VTE as the incidence among ICU patients with COVID-19 is estimated at 20-30%. The rate of AT is much less with an overall incidence between 2-4% and only 0.4% associated with acute limb ischemia. Our patient was at higher risk for thrombotic complications given his underlying but undiagnosed CLL. His lymphocytosis was striking, particularly because lymphopenia is the usual finding in patients with COVID-19, and further work up revealed the CLL diagnosis. CONCLUSIONS: Thrombotic complications are common and carry a higher risk of mortality in patients with COVID-19. While the rate of AT is much less compared with VTE, critical care practitioners must remain vigilant, particularly when patients are receiving mechanical ventilation and unable to report symptoms, and be mindful of other conditions, potentially undiagnosed, that may further predispose to thrombosis. REFERENCE #1: Jiménez D, García-Sanchez A, Rali P, Muriel A, Bikdeli B, Ruiz-Artacho P, Le Mao R, Rodríguez C, Hunt BJ, Monreal M. Incidence of VTE and Bleeding Among Hospitalized Patients With Coronavirus Disease 2019: A Systematic Review and Meta-analysis. Chest. 2021 Mar;159(3):1182-1196. REFERENCE #2: Malas MB, Naazie IN, Elsayed N, Mathlouthi A, Marmor R, Clary B. Thromboembolism risk of COVID-19 is high and associated with a higher risk of mortality: A systematic review and meta-analysis. EClinicalMedicine. 2020 Dec;29:100639. REFERENCE #3: Tan BK, Mainbourg S, Friggeri A, Bertoletti L, Douplat M, Dargaud Y, Grange C, Lobbes H, Provencher S, Lega JC. Arterial and venous thromboembolism in COVID-19: a study-level meta-analysis. Thorax. 2021 Feb 23:thoraxjnl-2020-215383. DISCLOSURES: No relevant relationships by Amanda Jobe, source=Web Response No relevant relationships by Mohamed Ramez Mourad, source=Web Response
ABSTRACT
RATIONALE: Despite the decline in the number and variety of procedures performed by general internal medicine (IM) physicians, procedural training remains an integral part of IM residency training. With previous success in improving the education and comfort of central venous catheter (CVC) placement among graduating 3rd year IM residents due to the development of a robust simulation-based curriculum for CVC placement, we desired to also develop a similar curriculum for paracentesis and thoracentesis. The aim of this project was to develop a simulation-based curriculum for paracentesis and thoracentesis to adequately train residents to safely and independently perform these common bedside procedures. METHODS: Using the CVC simulation-based curriculum as a framework, review of simulation literature and local facility protocols, a comprehensive checklist, pre-learning document and instructional video were developed for each procedure. Each checklist included details for procedural planning (supplies, informed consent, imaging review, time out), sterile preparation and procedure steps. The checklists were submitted to IM, Hepatology, and Pulmonary content experts for review. Residents were provided with the checklists, pre-learning documents and videos prior to a scheduled point-ofcare ultrasound (POCUS) workshop. Residents were also asked to complete pre-and post-workshop knowledge assessments. The workshop allowed for direct application of the checklists to safely complete each procedure in a simulation environment under the instruction of experienced physicians. RESULTS: Thirteen IM residents (9 PGY-1s, 3 PGY-2s, and 1 PGY-3) attended the POCUS workshop in March 2020. Prior to the workshop, residents self-reported, on average, 3.4 observed paracenteses with 1.6 performed and 2 observed thoracenteses with 0.33 performed. Ten residents completed a 12-question pre-workshop knowledge assessment with an average score of 50.8%. Twelve residents completed the same assessment after the workshop, and the average score improved to 68.2%. Resident perceived skill rating in using ultrasound and in performing bedside paracentesis and thoracentesis improved after the workshop (Table 1). Due to COVID-19, the workshop scheduled for May 2020 was cancelled and transitioned to a virtual platform which limited further data collection. CONCLUSIONS: Structured, simulation-based procedural education that teaches best practice and allows for deliberate practice and feedback has consistently been shown to improve the procedural skills of trainees. After completion of the paracentesis and thoracentesis workshop, residents demonstrated improvement in procedure knowledge, ultrasound use, and procedural skills, and we believe that our structured curriculum will provide residents with the necessary framework to perform these procedures safely at the bedside.