Dizziness After COVID-19 Infections or Vaccinations

Objective: To explore the underlying reasons of dizziness experienced by patients after having the COVID-19 infections or vaccinations. Background: At our dizziness center, we saw a spike of dizziness consults after patients were diagnosed with COVID-19 infections or received COVID-19 vaccinations. The symptoms included dizziness, vertigo, and imbalance. This study aims to examine if the infection, vaccination, or antibodies from such could be the reason for the dizziness complaints or if other factors explain patients' dizziness. Design/Methods: Patients were identified using a combination of retrospective chart review to identify patients with diagnoses of dizziness, COVID-19, and COVID-19 vaccinations from our database, coupled with referrals from ongoing clinical consultations who we believed to exhibit dizziness symptoms related to their COVID-19 infections or vaccinations within four weeks of dizziness onset. Patients all had brain MRI and extensive vestibular testing, including: VNG, Rotary Chair, audiograms, and consultation with an experienced neuro-otologist. Results: Of the 40 patients examined, 20 began experiencing dizziness after testing positive for COVID-19 and 20 reported dizziness after receiving the vaccines. All patients had brain MRI, but no MRI findings indicated inflammatory changes from infections or antibody reactions. Only five of 40 patients had abnormal VNG indications of uncompensated peripheral vestibulopathy which could be related to virus infections or antibody reactions. Thirty out of 40 patients had histories of anxiety, depression, other mood disorders, or family histories of mood disorders. Based on the clinical history and examinations, along with MRI findings and comprehensive vestibular testing, 75% of the 40 patients had diagnoses of persistent perceptual positional vertigo (PPPV), which was most likely related to patients' underlying anxiety, depression, or mood disorders. Conclusions: We believe that the COVID-19 infections or vaccinations may trigger PPPV as stressors, but mostly not due to the virus infections or its antibody reactions.

Delivering Unemployment Assistance in Times of Crisis: Scalable Cloud Solutions Can Keep Essential Government Programs Running and Supporting Those in Need

The COVID-19 public health emergency caused widespread economic shutdown and unemployment. The resulting surge in Unemployment Insurance claims threatened to overwhelm the legacy systems state workforce agencies rely on to collect, process, and pay claims. In Rhode Island, we developed a scalable cloud solution to collect Pandemic Unemployment Assistance claims as part of a new program created under the Coronavirus Aid, Relief and Economic Security Act to extend unemployment benefits to independent contractors and gig-economy workers not covered by traditional Unemployment Insurance. Our new system was developed, tested, and deployed within 10 days following the passage of the Coronavirus Aid, Relief and Economic Security Act, making Rhode Island the first state in the nation to collect, validate, and pay Pandemic Unemployment Assistance claims. A cloud-enhanced interactive voice response system was deployed a week later to handle the corresponding surge in weekly certifications for continuing unemployment benefits. Cloud solutions can augment legacy systems by offloading processes that are more efficiently handled in modern scalable systems, reserving the limited resources of legacy systems for what they were originally designed. This agile use of combined technologies allowed Rhode Island to deliver timely Pandemic Unemployment Assistance benefits with an estimated cost savings of $502,000 (representing a 411% return on investment). © 2020 Owner/Author.

One year outcomes of heart failure multispecialty multidisciplinary team virtual meetings

Heart Failure is frequently associated with several comorbidities such as ischaemic heard disease, diabetes mellitus, chronic obstructive pulmonary disease, chronic kidney disease and frailty. This level of complexity is best dealt with by a multispecialty multidisciplinary team (MDT) model. This was a single centre observational study (January 2020-December 2020) that was undertaken in a British university hospital looking at effect of HF multispecialty virtual MDT meetings on HF outcomes. Patients acted as their own controls outcomes compared for equal period pre versus post MDT meeting. The multi-specialty meeting was conducted once monthly via video-conferencing. It consisted of heart failure cardiologists (from primary secondary and tertiary care), heart failure specialist nurses (hospital and community), nephrologist, endocrinologist, palliative care specialists, chest physician, pharmacist, pharmacologist and geriatrician. Recommendations were made as consensus from the multispecialty meeting. The main outcome measures were 1) number of hospitalisations and 2) outpatient clinic attendances 3) cost savings. A total of 189 patients were discussed from January-December 2020. This was uninterrupted during the COVID-19 pandemic. The mean age was 70.3±18.1 years and median follow-up 6 months (range 1-13 months). The mean Charlson Co-morbidity score was 5.3±1.2 and Rockwood Frailty Score was 4.9±1. The mean number of outpatient clinic attendances avoided was 1.7±0.4. This reduced inconvenience to patients, saved patients money (transport and parking costs) and led to carbon footprint reduction. The MDT meeting total costs were £15,400 and the 31 clinic appointments they generated cost an estimated £3720. However, the MDT meetings prevented 277 clinic appointments (cost saving £33,352). Finally, the mean number of hospitalisations pre-MDT was 0.7 Vs 0.2 post MDT (p<0.01) with a saving of around 730 bed days (estimated cost-saving £260,000). The HF multispecialty virtual MDT approach provides seamless integration of primary care community services with secondary and tertiary care. Consensus decision from MDT meetings provides holistic approach for HF patients with comorbidities and frailty, and reduces inconvenience to patients by preventing the need to attend multiple specialty clinics. This approach can also lead to significant cost-savings to the healthcare system.

One year outcomes of heart failure multispecialty multidisciplinary team virtual meetings

Background/Introduction Heart Failure is frequently associated with several comorbidities such as ischaemic heard disease, diabetes mellitus, chronic obstructive pulmonary disease, chronic kidney disease and frailty. This level of complexity is best dealt with by a multispecialty multidisciplinary team (MDT) model. Methods This was a single centre observational study (January 2020-December 2020) that was undertaken in a British university hospital looking at effect of HF multispecialty virtual MDT meetings on HF outcomes. Patients acted as their own controls outcomes compared for equal period pre versus post MDT meeting. The multi-specialty meeting was conducted once monthly via video-conferencing. It consisted of heart failure cardiologists (from primary secondary and tertiary care), heart failure specialist nurses (hospital and community), nephrologist, endocrinologist, palliative care specialists, chest physician, pharmacist, pharmacologist and geriatrician. Recommendations were made as consensus from the multispecialty meeting. The main outcome measures were 1) number of hospitalisations and 2) outpatient clinic attendances 3) cost savings. Results A total of 189 patients were discussed from January- December 2020. This was uninterrupted during the COVID- 19 pandemic. The mean age was 70.3 ± 18.1 years and median follow-up 6 months (range 1-13 months). The mean Charlson Co-morbidity score was 5.3 ± 1.2 and Rockwood Frailty Score was 4.9 ± 1. The mean number of outpatient clinic attendances avoided was 1.7 ± 0.4. This reduced inconvenience to patients, saved patients money (transport and parking costs) and led to carbon footprint reduction. The MDT meeting total costs were £15,400 and the 31 clinic appointments they generated cost an estimated £3720. However, the MDT meetings prevented 277 clinic appointments (cost saving £33,352). Finally, the mean number of hospitalisations pre-MDT was 0.7 Vs 0.2 post MDT (p<0.01) with a saving of around 730 bed days (estimated cost-saving £260,000). Conclusion The HF multispecialty virtual MDT approach provides seamless integration of primary care community services with secondary and tertiary care. Consensus decision from MDT meetings provides holistic approach for HF patients with comorbidities and frailty, and reduces inconvenience to patients by preventing the need to attend multiple specialty clinics. This approach can also lead to significant cost-savings to the healthcare system.

Status quo after one year of COVID-19 pandemic in otolaryngological hospital-based departments and private practices in Germany.

PURPOSE: The COVID-19 pandemic has affected healthcare systems worldwide. Data on the impact on otolaryngological clinics and private practices is sparse. This study aimed to present data on healthcare worker (HCW) screening, status of HCW, pre-interventional testing, the use of personal protective equipment (PPE) and the economic impact of the pandemic. METHODS: Otolaryngological private practices and hospital-based departments were surveyed nationwide using an online questionnaire. Participating facilities were recruited via the German Society for Oto-Rhino-Laryngology and the German Association for Otolaryngologists in Bavaria. RESULTS: 365 private practices (2776 employees) and 65 hospitals (2333 employees) were included. Significantly more hospitals (68.7%) than practices (40.5%) performed pre-interventional testing in their outpatients (p < 0.00). Most inpatients were tested in practices and hospitals (100.0% and 95.0%; p = 0.08). HCW screening was performed in 73.7% of practices and in 77.3% of hospitals (p = 0.54). Significantly more HCW infections were reported in private practices (4.7%) than in hospital (3.6%; p = 0.03). The private or home environment was the most frequent source of infection among HCW in hospitals (44%) and practices (63%). The use of PPE increased over the course of the pandemic. The number of procedures and the revenue decreased in 2020. CONCLUSION: The rate of pre-interventional testing among outpatients in otolaryngological practices is low and HCW infections were found to be more frequent in practices than in hospitals. In addition, a high rate of infections in otolaryngological HCW seems to stem from the private or home environment.

High incidence of barotrauma in critically ill patients with COVID-19

INTRODUCTION: Intubated patients with acute respiratory distress syndrome are thought to have a 5-12% incidence of barotrauma, even with protective ventilation. However, little is known about the incidence of barotrauma in COVID-19. Due to high rates of observed barotrauma at this center, this retrospective cohort study aims to better characterize the incidence of barotrauma and identify predisposing factors such as inflammatory markers and disease severity indices for this high-mortality complication. METHODS: Inclusion criteria were as follows: age over 18 years, positive RT-PCR for SARS-CoV2, admission to the ICU between 03/15/2020 and 06/15/2020, and a score of 5 or higher on the World Health Organization's Ordinal Scale or respiratory rate over 30 breaths per minute on admission. Data were collected for the following categories developed by an internal committee of pulmonary/critical care faculty and housestaff based on similar studies: age, sex, body mass index, ferritin, d-dimer, APACHE II score, SOFA score, blood gas, ventilation mode and settings. Patients with evidence of barotrauma (pneumothorax, pneumomediastinum, pneumopericardium, subcutaneous emphysema) on imaging had additional respiratory data points collected. RESULTS: 78 patients met inclusion. Among 38 patients who received invasive mechanical ventilation (IMV) 12 had barotrauma (32%). Of 40 patients who did not receive IMV 3 had barotrauma (8%). Of 15 cases of barotrauma, 8 had pneumothorax (2 bilateral, 6 unilateral), 9 had pneumomediastinum, 4 had pneumopericardium, 6 had subcutaneous emphysema. 8 were found incidentally on imaging for non-respiratory indication. Mortality in the barotrauma group was 72% for IMV & 50% for non-IMV (3 patients transferred to other hospital, 3 remain hospitalized) compared to 50% for IMV & 8% for non-IMV in patients without barotrauma. Further analysis pending at submission, data to be finalized prior to presentation. CONCLUSIONS: Barotrauma may be an underappreciated complication of COVID-19, perhaps serving as an independent predictor of disease severity or low lung compliance. Many theories have been presented for the physiology of COVID-19 respiratory failure, but barotrauma could be evidence of or a herald sign for the low compliance phenotype.

PNEUMOMEDIASTINUM AND PNEUMOTHORAX DUE TO NONINVASIVE POSITIVE PRESSURE VENTILATION IN COVID-19 PNEUMONIA

SESSION TITLE: Medical Student/Resident Disorders of the Pleura Posters SESSION TYPE: Med Student/Res Case Rep Postr PRESENTED ON: October 18-21, 2020 INTRODUCTION: Barotrauma as a consequence of high alveolar pressures is well described in invasive mechanically ventilated (IMV) patients with pneumonia or pneumonitis. Limited data exists on the incidence of barotrauma in patients with Coronavirus Disease 19 pneumonia (COVID-19). We present a case of barotrauma occurring in a non-intubated patient with COVID-19 receiving noninvasive positive pressure ventilation (NPPV). CASE PRESENTATION: A 43-year-old male with obesity presented with 2 days of cough and dyspnea. Polymerase chain reaction (PCR) testing confirmed COVID-19. He initially required 5L of oxygen (O2) per minute by nasal cannula. Due to worsening hypoxemic respiratory failure (HRF) on day 3, the patient was placed on high-flow nasal cannula (HFNC) at 90% FiO2 at a flow rate of 30 L/min. By day 7, the patient had worsening HRF and increased work of breathing. He was transitioned to continuous positive airway pressure (CPAP) at 100% FiO2 with continuous pressure set at 12 cm H2O. On day 13, he developed tachycardia and desaturation. Chest CT found gas dissecting along the axial interstitium resulting in pneumomediastinum, bilateral pneumothoraces, and extensive subcutaneous emphysema. The lung parenchyma exhibited coarse ground glass opacities and early evidence of fibrotic changes. Chest tubes were placed in each hemithorax with resolution of his pnemothoraces after 5 days. His O2 requirements decreased, and he was transferred to a rehabilitation hospital on 10 L/min O2 by facemask on day 25. DISCUSSION: Barotrauma leading to pneumomediastinum and pneumothoraces are a well-documented complication of mechanical ventilation.1 In an effort to mitigate the morbidity and mortality associated with mechanical ventilation, many clinicians have shifted toward using NPPV in HRF in COVID-19, however NPPV may not necessarily protect patients against a complication more commonly associated with IMV.2,3 Progressive and cumulative alveolar injury may predispose COVID-19 patients to barotrauma regardless of mode of ventilation.3 CONCLUSIONS: Due to the mortality associated with IMV in COVID-19, many clinicians have shifted toward using NPPV to manage HRF. However, patients receiving NPPV may still be subject to complications such as barotrauma. Additionally, given our evolving understanding of COVID-19 and the pulmonary parenchymal distortion seen in many patients, a deterioration in respiratory status should prompt clinicians to search for evidence of barotrauma, even in patients receiving NPPV. Reference #1: Mentzer SJ, Tsuda A, Loring SH. Pleural mechanics and the pathophysiology of air leaks. J Thorac Cardiovasc Surg. 2018;155(5):2182-2189. Reference #2: Xu XP, Zhang XC, Hu SL, et al. Noninvasive Ventilation in Acute Hypoxemic Nonhypercapnic Respiratory Failure: A Systematic Review and Meta-Analysis. Crit Care Med. 2017;45(7):e727-e733. Reference #3: Sun R, Liu H, Wang X. Mediastinal Emphysema, Giant Bulla, and Pneumothorax Developed during the Course of COVID-19 Pneumonia. Korean J Radiol. 2020;21(5):541-544. DISCLOSURES: no disclosure on file for Nikhil Barot;No relevant relationships by Michael Kahn, source=Web Response No relevant relationships by Nader Kamangar, source=Web Response No relevant relationships by Jay Thetford, source=Web Response

E. COLI PNEUMONIA WITH PNEUMATOCELE, EMPYEMA NECESSITANS, AND BRONCHOPLEURAL FISTULA IN A PATIENT WITH SEVERE COVID-19

SESSION TITLE: Medical Student/Resident Chest Infections Posters SESSION TYPE: Med Student/Res Case Rep Postr PRESENTED ON: October 18-21, 2020 INTRODUCTION: Tocilizumab, an interleukin-6 inhibitor used in rheumatologic disease and cytokine release syndrome, is one of many investigational drugs used for coronavirus disease-19 pneumonia (COVID). While the safety profile has been well studied, there is little known about its effect on opportunistic infections (OI) risk in patients with COVID. We present a 43-year-old man with COVID who received tocilizumab and subsequently developed cavitating lung lesions suspicious for invasive aspergillosis. CASE PRESENTATION: A 43-year-old man with diabetes mellitus was admitted for hypoxemic respiratory failure (HRF). Nasopharyngeal swab polymerase chain reaction was positive for COVID. He was placed on high-flow nasal cannula (HFNC), and on day 10 he was intubated for worsening HRF. He was treated with ceftriaxone, azithromycin, methylprednisolone, convalescent plasma, and tocilizumab. Antibiotics later included ertapenem due to E. coli with extended-spectrum beta lactamase (ESBL) found in sputum culture. He was extubated on day 15 and oxygen requirements were weaned to HFNC. However, bronchial aspirate cultures from day 14 grew mold and subsequent serologies were positive for Aspergillus. Chest computerized tomography (CT) was notable for the development of multiple new cavitary lesions concerning for invasive pulmonary aspergillosis. The patient was initially treated with voriconazole and later with amphotericin B due to liver enzyme elevation. The patient’s oxygen requirements initially decreased, however on day 30 the patient suffered an aspiration event and was reintubated. Subsequent CT was concerning for worsening of cavitary lung disease. Bronchoalveolar lavage was collected, which tested positive for Aspergillus galactomannan. On hospital day 31, the patient suffered a left-sided tension pneumothorax requiring tube thoracostomy. At the time of submission the patient remains critically ill. DISCUSSION: Influenza-associated pulmonary aspergillosis (IAPA) is a known complication of severe influenza.1,2 Similarly, COVID-associated pulmonary aspergillosis (CAPA) may become an emerging problem given the overwhelming inflammation and use of experimental immunosuppressive therapies in COVID.1,2 While tocilizumab has not been shown to increase risk of Aspergillus infection in rheumatologic disease, it has not been studied in COVID and the risk of OI in an already-susceptible group may outweigh the benefits of using this drug in patients with COVID.3 If CAPA is similar to IAPA, BAL galactomannan is the gold standard for diagnosis.2 CONCLUSIONS: As the medical community searches for COVID treatments, these patients’ potentially inherent vulnerability to OI may be under-appreciated. When using immunosuppressive agents to curtail the inflammatory cascade, the risk of OI must be considered and agents like tocilizumab must be further studied in this context. Reference #1: Koehler P, Cornely OA, Böttiger BW, et al. COVID-19 associated pulmonary aspergillosis. Mycoses. 2020;63(6):528-534. Reference #2: van Arkel ALE, Rijpstra TA, Belderbos HNA, van Wijngaarden P, Verweij PE, Bentvelsen RG. COVID-19 associated pulmonary aspergillosis. Am J Respir Crit Care Med. 2020;online May 2020. Reference #3: Kourbeti IS, Ziakas PD, Mylonakis E. Biologic therapies in rheumatoid arthritis and the risk of opportunistic infections: a meta-analysis. Clin Infect Dis. 2014;58(12):1649-57. DISCLOSURES: No relevant relationships by Michael Kahn, source=Web Response No relevant relationships by Nader Kamangar, source=Web Response No relevant relationships by Jay Thetford, source=Web Response No relevant relationships by Richard Watson, source=Web Response