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INTRODUCTION: Tracheostomy is the most frequent surgical procedure performed in critically ill patients, mostly in patients requiring prolonged mechanical ventilation. We aimed to describe the outcomes associated with tracheostomies in critically ill COVID-19 patients admitted to our ICU. METHOD(S): We studied a cohort of adult patients admitted with the diagnosis of COVID-19 to a mixed ICU between 03/2020 and 06/2021. We collected patients' demographics, severity of illness, ICU resource utilization, and outcomes. Descriptive statistics were reported. RESULT(S): A total of 275 patients with confirmed COVID-19 were admitted to our ICU during the study period. Among them, 26 patients (9.45%) underwent tracheostomy. There were 10 females (38.4%) with an average age of 60 years (range 53-67). Median body mass index was 31 (range 26-41). Patients identified themselves as African American (39%), Caucasian (27%), and the remaining as other or declined to answer. Median Sequential Organ Failure Assessment (SOFA) score on admission was 10 (range 8-12) and max SOFA score was 13 (range 11-17). Mean mechanical ventilation-days was 19 days (range 12-23). Median ICU length of stay (LOS) was 41 days (range 31-48) and hospital LOS was 46 days (range 32-60). The ICU and hospital mortality rates were 23% and 27% respectively. There were no procedural causes of death. CONCLUSION(S): Although the mortality of the patients that underwent tracheostomies was relatively high, these patients were less than 3% of the total cohort of COVID-19 patients admitted to the ICU and had lower mortality than expected adjusted for their severity of illness based on the SOFA score.
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STATEMENT OF PROBLEM/QUESTION: Individuals at risk for HIV often face barriers to routine outpatient care which were exacerbated during the COVID-19 pandemic, creating a need and an opportunity to leverage hospital admissions for HIV screening. DESCRIPTION OF PROGRAM/INTERVENTION: This resident-led quality improvement project ran from 10/01/2020 to 6/30/2021 and aimed to increase rates of HIV screening among inpatients on the Medicine service at Zuckerberg San Francisco General Hospital (ZSFG), an urban safety net hospital. The QI intervention was informed by an initial gap analysis and consisted of three components: provider education, targeted outreach including biweekly performance metrics with peer comparisons, and electronic health record (EHR) optimizations. A pre-existing multidisciplinary care team was available to provide follow-up for positive test results, facilitating rapid linkage to HIV care. MEASURES OF SUCCESS: Given the high prevalence of HIV risk factors in this population, appropriate screening was defined as having an HIV test within the past 6 months. Our target for appropriate HIV screening was 55% of hospitalized patients on the Medicine service without a known HIV diagnosis, an increase of 10% from baseline. As a secondary goal, we sought to increase resident education about HIV as measured by pre- and post- intervention surveys. FINDINGS TO DATE: Among patients admitted during the intervention period (N = 1701), there was a 17.6% absolute increase in HIV screening rates compared to baseline (N = 885) (45.3% v. 62.9%, p < 0.001). To assess the impact of our intervention on previously identified differences in screening rates by gender, race, and language, we conducted post-intervention subgroup analyses. These results demonstrated persistently lower screening rates among females (59.6% v. 64.6%, p = 0.044), Asians (55.0% v. 64.5, p < 0.01), and patients speaking Chinese-based languages (53.5% v. 63.8, p = 0.01). Comparisons of pre- and post-intervention survey data showed an increase in provider comfort and knowledge across all domains assessed. KEY LESSONS FOR DISSEMINATION: Quality improvement interventions including education, targeted outreach, and EHR optimization can increase HIV screening rates of hospitalized patients. We found that despite improvement in overall screening rates, disparities persisted for women, Asians, and non-English speaking patients. Targeted interventions to address these disparities in HIV screening are needed. Inpatient providers are well-poised to help address HIV screening gaps, particularly for underserved patient populations who may face increased barriers to routine HIV prevention services.
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Objective: Assess the SARS-CoV2 Spike antibody response in multiple sclerosis (MS) patients on high efficacy immunotherapies. Background: There is limited knowledge about SARS-CoV2 mRNA vaccine response in MS patients on immunotherapy. Design/Methods: Patients with MS, aged 18-65, on fingolimod, siponimod, ofatumumab, or ocrelizumab for at least 3 months prior to first mRNA SARS-CoV2 vaccine (Pfizer or Moderna) were offered enrollment. A cohort of healthy controls who received the mRNA vaccines were also enrolled. Blood samples for the SARS-CoV2 Spike antibody (Anti-SARS-CoV2 S, RocheElecsys) were collected 2-3 months after the second mRNA vaccine. The proportion who seroconverted (antibody>0.4 U/ml), and SARS-CoV2 Spike antibody levels were assessed. Results: A total of 39 MS patients (6 fingolimod, 33 ocrelizumab) and 31 controls were included in this interim analysis. 33%(13/39) of MS patients seroconverted, compared to 100%(31/31) in the control group, with an estimated risk difference of -0.67,(95% confidence interval: -0.81, -0.52;Fisher's exact test, p=9.0∗10-10 ). There was no difference in seroconversion rates between MS patients who received the Pfizer (34%, 10/29) versus the Moderna vaccine (30%, 3/10) (95% confidence interval -0.38, 0.29;Fisher's exact test=1). Seroconversion was found in 100% (31/31) of controls, 66.7% (4/6) of fingolimod-treated patients, and 27.3% (9/33) of ocrelizumab-treated patients (three group comparison, Fisher's exact test p-value =2.7∗10 -10). The median Spike antibody level was <0.4 U/ml in MS patients, and 1,663 U/ml in controls (Wilcoxon rank sum test, p-value= 1.0∗10-12 ). The median Spike antibody level in the ocrelizumab group was <0.4 U/ml, 3.45 U/ml in the fingolimod group, and 1,663 U/ml in the control group (Kruskal Wallis test, p-value=5.9∗10-12 ). Total IgG correlated with Spike antibody levels in the ocrelizumab-treated group only (Spearman correlation, p=0.025). Conclusions: MS patients on ocrelizumab and fingolimod have significantly lower rates of seroconversion, and lower median Spike antibody levels in response to the mRNA SARS-CoV2 vaccines compared to controls.
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Introduction: SARs-CoV-19 infection (COVID-19) is associated with various neurologic symptoms. A full range of neurologic outcomes in patients with multiple sclerosis (MS) and related disorders (MSRD) following COVID-19 illness is not well understood. Objectives: To investigate neurologic outcomes in patients with MSRD post COVID-19. Methods: This was a retrospective medical records review study of adult patients with MSRD who had confirmed COVID-19 infection at the Brigham MS Center, between March 9, 2020 and April 1, 2021. We reviewed demographics, MS history, COVID-19 outcomes, neurologic symptoms, and MRI data. Neurologic worsening post-COVID-19 was defined as having a relapse, pseudo-relapse, new brain MRI activity, worsening of preexisting MS symptoms, or development of other long-term neurologic symptoms. Results: 111 patients, 85 (77%) females, with a mean [SD] age of 49 [12.2] years, and a mean [SD] EDSS of 3.4 [2.7] were identified. 72 (65%) had relapsing remitting MS, 21 (19%) had secondary and 8 (7%) had primary progressive MS, 2 (2%) had clinically isolated syndrome, and 8 (7%) had related disorders. 17 (15%) patients were asymptomatic, 63 (57%) had mild COVID-19 defined as symptoms not requiring hospitalization, 22 (20%) had moderate COVID-19 requiring hospitalization, 3 (3%) had severe COVID-19 requiring ICU admission, 2 (2%) died due to COVID-19 and 4 (4%) had unknown COVID-19 outcomes. 85 (77%) completely recovered from COVID-19. 41 patients (37%) had neurologic worsening post COVID-19. Of those with neurologic worsening, 19 (46%) had pseudo-relapses, 2 (4.8%) had relapses, and 27 (66%) patients reported worsening of preexisting MS symptoms, or other new longterm neurologic symptoms at the last follow up visit. 55 patients had brain MRI scans post COVID-19 with a mean [SD] between MRI and infection of 144.6 [107.8] days. 5 patients had new lesions on T2 or T1Gd+ scans. Neurologic worsening was associated with moderate or severe COVID-19 (p=0.0006), treatment for COVID-19 (p=0.0061), and incomplete COVID-19 recovery (p=0.0267) but not with age, sex, MS type, ethnicity, disease duration, EDSS, vitamin D use, or type or presence of disease modifying therapy. Conclusions: COVID-19 severity and lack of complete systemic recovery was associated with new or worsening neurologic symptoms in 37% of MSRD patients.
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Objective: To create an inclusive and supportive virtual learning environment for a preclinical neurology and psychiatry course for medical students working remotely. Background: The COVID-19 pandemic has impacted medical education tremendously, and many standard courses have unexpectedly needed to trans form to virtual formats using available resources and emergent technology. Distance learning has been criticized as impersonal and inaccessible. Design/Methods: We organized a novel virtual curriculum around four themes: 1) Communication: Prior to the course, faculty members created videos introducing themselves to students. Communication was maximized through daily announcements summarizing key points, virtual office hours, built-in question-and-answer periods after class, weekly student feedback opportunities, and a virtual message board. 2) Respect for Student Circumstances: Timing of the course was adjusted and shortened, with time spent on screen interactive. All didactic content was delivered asynchronously for flexibility. 3) Diversity and Inclusion: Optional sessions focused on race in medicine, health of immigrants and asylum seekers, sexual and gender minority health, and adults with disabilities. Students were empowered to revise teaching cases to reflect a more representative and diverse patient population. 4) Appropriate assessments: Exams were open book. Analytical, multistep questions maintained a challenging and enriching educational experience. Results: This was the year's highest student-rated course overall, even surpassing traditional inperson pre-COVID courses, and the highest rated course in specific learning environment questions including, 'respecting diversity' and 'showing respectful interaction with students.' 91.4% of students agreed that this course consistently engaged them to apply critical thinking to solve problems and 92.2% of students agreed that assessments were fair and accurate evaluations of their ability. Remaining challenges included further incorporation of diversity and inclusion topics into the mandatory curriculum and delivering individualized student feedback. Conclusions: Virtual learning environments pose new challenges but also create new opportunities for students to feel supported and take an active role in their education.