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Introduction: Hepatic inflammatory pseudotumor (HIP), albeit rare, is an important pathology to be included in differentials for hepatic masses. The benign nature and treatment of this disease process should be considered especially in comparison to malignant hepatic processes. Case Description/Methods: A 66-year-old male with pre-existing history of compensated Hepatitis C cirrhosis status post direct-acting antivirals with sustained virologic response presented in shock after a syncopal episode. Initial work up revealed leukocytosis, thrombocytopenia, acute renal injury, elevated liver enzymes, and COVID-19 positive test. Patient underwent initial liver ultrasound revealing intrahepatic and extrahepatic biliary ductal dilation. Subsequent MRCP demonstrated diffuse thickening of intra and extra hepatic bile ducts suggestive of cholangitis and several hepatic masses concerning for abscesses versus possible metastatic cholangiocarcinoma. Patient improved symptomatically with antibiotics and supportive care. A liver biopsy was performed with pathology showing lymphoplasmacytic inflammation and fibroblastic infiltration suggestive of hepatic inflammatory pseudotumor. A repeat MRCP one week later showed interval decrease in size of liver lesions and repeat liver function tests also showed improvement. Patient was discharged on a course of ciprofloxacin and metronidazole. Patient had repeat MRCP 3 months after discharge, with further significant improvement in size of liver lesions. After multi-disciplinary discussion the plan was for further surveillance with imaging and labs in 2 months. Discussion(s): Inflammatory pseudotumors are benign and non-neoplastic lesions that can occur in any organ. They can appear as a malignant lesion when they arise in the liver and an accurate identification can allow for conservative management and prevent unnecessary invasive procedures. Hepatic inflammatory pseudotumors are often seen with concomitant infection or inflammatory processes. Liver biopsies distinguish these tumors from other malignant processes as they demonstrate a characteristic dense inflammatory infiltrate interspersed in stroma of interlacing bundles of myofibroblasts. This case highlights the importance of maintaining HIP on the differential diagnosis. (Figure Presented).
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Objective: In the midst of the severe acute respiratory syndrome coronavirus 2 pandemic, which causes coronavirus disease 2019, there is a recognized need to expand critical care services and beds beyond the traditional boundaries. There is considerable concern that widespread infection will result in a surge of critically ill patients that will overwhelm our present adult ICU capacity. In this setting, one proposal to add "surge capacity" has been the use of PICU beds and physicians to care for these critically ill adults. Design(s): Narrative review/perspective. Setting(s): Not applicable. Patient(s): Not applicable. Intervention(s): None. Measurements and Main Results: The virus's high infectivity and prolonged asymptomatic shedding have resulted in an exponential growth in the number of cases in the United States within the past weeks with many (up to 6%) developing acute respiratory distress syndrome mandating critical care services. Coronavirus disease 2019 critical illness appears to be primarily occurring in adults. Although pediatric intensivists are well versed in the care of acute respiratory distress syndrome from viral pneumonia, the care of differing aged adult populations presents some unique challenges. In this statement, a team of adult and pediatric-trained critical care physicians provides guidance on common "adult" issues that may be encountered in the care of these patients and how they can best be managed in a PICU. Conclusion(s): This concise scientific statement includes references to the most recent and relevant guidelines and clinical trials that shape management decisions. The intention is to assist PICUs and intensivists in rapidly preparing for care of adult coronavirus disease 2019 patients should the need arise. Copyright © 2020 Lippincott Williams and Wilkins. All rights reserved.
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Background. Skilled nursing facility (SNF) residents comprised 11% of all COVID-19 cases in the United States;however, they account for 43% of deaths with case fatality rates (CFR) of 26.0-33.7%. Methods. We report an outbreak of COVID-19, from June 15 to July 21, 2020 in a 159-bed SNF with a staff of 172 that resulted in an infection rate of 97% in residents and 23% in HCWs (Figure 1). A retroactive review outlined mitigation efforts, discussed challenges, identified risk factors among residents and health care workers (HCW) for acquisition of COVID-19, and reviewed opportunities for improvement (Figure 2). Results. Factors that contributed to the outbreak: delay in test results had an impact on cohorting;suboptimal adherence to the principles of infection prevention and control (IPC) and minimal adherence monitoring;strict criteria were used to screen for infection;the underappreciated transmissibility of COVID-19 from presymptomatic and asymptomatic persons;symptomatic HCWs who continued to work;the changing guidance on, the suboptimal use of, and an inadequate supply of personal protective equipment;poor indoor air quality due to ventilation challenges;and the important role of community/family/interfacility spread on the outbreak. Whole genome sequencing, performed in 52 samples, identified a common strain that was also found in clusters of 2 other facilities: 1 in the same geographic location, the other in a different geographic location but whose HCWs had the same zip codes as the facility (Figure 3). Certified nursing and restorative nursing assistants had the highest risk of infection with an odds ratio (OR) of 4.02 (confidence interval 1.29-12.55, p value: 0.02) when compared to registered and licensed vocational nurses. The residents' CFR was 24%. The OR for death was increased by 10.5 (10.20-11.00) for every decade of life as was morbid obesity (BMI > 35) with an OR of 8.50. BMI as a continuous variable increased risk of mortality for every additional unit, OR 1.07 (Tables 1, 2). Conclusion. While implementation of optimal IPC measures in the pre-COVID-19 vaccination era had no impact on the infections in residents who were likely already infected or exposed at the onset of the outbreak, these measures along with non-pharmacologic strategies were effective in halting the spread among HCWs.
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Background. The coronavirus-19 disease (COVID-19) outbreak has had a particularly devasting effect on skilled nursing facility (SNF) residents and healthcare workers (HCWs). While representing only 11% of COVID-19 cases, the residents accounted for 43% of deaths in the United States. Methods. We report a retrospective review of the support provided by our local health department (LHD) to long-term care facilities in response to the COVID-19 pandemic. This group comprised of staff from healthcare-associated infections (HAI);the Medical Operations Center (MOC);Testing, Tracing, and Treatment (T3);and the Healthcare Provider Status Taskforce (Table 1 outlines their functions). The HAI team with the State Public Health Department provided infection prevention and control (IPC) outbreak investigation, education, recommendations, and ongoing access to technical assistance. The T3 team focused on rapid response testing and tracing;the HPSTF team collected data and issued questionnaires;the MOC responded to staffing and PPE requests;and the Long-Term Care Facility sector presented routine telebriefings to update the facilities on public health guidance, share resources, and answer questions during and in between briefings. Table 1. Sectors and Function of Response Teams to COVID-19 Results. From March 2020 through May 2021, there were 504 outbreaks in LTCFs;the HAI team performed 281 outbreak investigations (Figure 1). In the same period, 308,264 molecular tests were performed using various platforms;laboratory services were outsourced during peak testing requests (Figure 2);"strike teams were deployed to facilitate testing on 404 occasions. Self-reported fully vaccination rate for SNF staff was 73% (March 2021) and 76% for residents (April 2021). There were 568 staff requested;total orders for PPE were 4,839 and 16,892,823 PPE items were fulfilled (Figure 3). In addition to knowledge gaps in IPC, other challenges included shifting IPC guidance, PPE shortages, timeliness of test results that impacted cohorting, community acquisition of disease with transmission to residents, interfacility spread among staff, staffing shortages, and vaccine hesitancy issues. Figure 1. Number of Outbreaks and Number of Outbreak Investigations Figure 2. Number of Tests Performed by the Public Health Laboratory and the Number of Visits by "Strike Teams" Figure 3. Personal Protective Equipment Fulfillment during COVID-19 Pandemic Conclusion. The management of the recent COVID-19 outbreaks required a multi-pronged approach. Lessons learned are applicable to other highly transmissible infectious diseases.
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Keywords: telehealth, digital placements, interprofessional practice Purpose: The UK lockdown for COVID-19 in March 2020 led to withdrawal of students from practice placements risking student progression. Therapist educators at the University of Huddersfield created a student-led service to support the local community while developing future-oriented skills including person-centred care, health coaching and interprofessional practice. People facing health and wellbeing challenges during lockdown were recruited from local charities. Physiotherapy (PT) and Occupational Therapy (OT) students worked in pairs with participants via video link with supervision from qualified academic staff. This poster presents the outcomes from a student survey of the initial pilot phase of this project, focusing on the experience of telehealth as a practice placement and the development of students’ confidence in a variety of domains. Methods: A quantitative survey was undertaken via the survey software Qualtrics XM, which was distributed via email to all students who had attended a telehealth placement in the pilot phase of the project. Data were gathered and analysed by the lead author with support from the wider project team. Results: 17 PT and 17 OT students attended telehealth placements, of whom 32 were in the second year of their degree training. 15 OT and 11 PT students responded to the survey (n = 26). They reported significant increases in confidence with telehealth and interprofessional working, use of health coaching and understanding of professional roles. Specifically, OT students developed skills in exercise rehabilitation, and PT students developed their understanding of an occupational focus in these interventions. All students developed their confidence in person-centred goal setting and health coaching, and 85% (n = 22) of students reported that the telehealth experience would change how they engaged with service users in future practice placements. Communication skills specific to the setting were a key area of development for all students, particularly the creativity required to assess and design person-centred interventions on a virtual platform. Prior to their telehealth experience, 50% of respondents (n = 13) did not feel confident working clinically with a student from another profession, whereas 100% reported feeling fairly or very confident in this area after the experience. The majority of students agreed that working in this manner had helped them to develop their understanding of others’ roles, and all reported having a better understanding of professional boundaries. Conclusion(s): Student-led, virtual services reflect the change in service provision following the coronavirus pandemic and offer excellent and distinctive learning opportunities for students, coupled with the development of communication and coaching skills in a different setting to conventional practice placements. Interprofessional student placements may improve person-centredness and occupational relevance of interventions for Physiotherapy students, alongside a deeper understanding of professional boundaries and roles. Impact: This pilot project has paved the way for permanent inclusion of telehealth practice placement experiences for PT and OT students in our institution, helping them to develop a skill set to prepare them for the future of global service provision. Funding acknowledgements: No funding was obtained to support this pilot project.
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Keywords: Telehealth;Digital placements;Interprofessional practice Purpose: The UK lockdown for COVID-19 in March 2020 led to withdrawal of students from clinical placement risking student progression. Therapist educators at the University of Huddersfield created a student-led service to support the local community while developing future-oriented skills including person-centred care, health coaching and interprofessional practice. People facing health and wellbeing challenges during lockdown were recruited from local charities. Physiotherapy (PT) and Occupational Therapy (OT) students worked in pairs with participants via video link with supervision from qualified staff. This presentation describes the teams’ experiences of developing this novel approach to practice placements and the pragmatic solutions found to the challenges faced. Methods: A technology-enabled, student-led telehealth placement was piloted twice in the summer of 2020. The service evaluation of this pilot project is presented in an experiential manner. What follows are the reflections of the team developing the service, and the pragmatic solutions to the challenges faced by the team will be shared. Student and participant evaluation data are presented in other publications for which ethical approval was obtained. Results: Seventeen PT and 17 OT students received placements, supported by a team of 10 academic staff from 4 professions. Specific training was scheduled for key health coaching and person-centred goal-setting topics alongside the practicalities of assessment and delivery of interventions via a digital platform. The majority of students reported a positive placement experience and all of the 56 participants that responded would recommend the service. The academic staff and students had to adapt to a placement that was delivered in a remote format. Key themes that will be reflected upon include: participant recruitment, governance, technology platforms, interprofessional working, supervision models and the students’ anxieties about the placement. Conclusion(s): Interprofessional, student-led, virtual services reflect the change in service provision following the coronavirus pandemic and offer excellent and distinctive learning opportunities for students. Setting up the pilot service in a short timeframe created a unique set of challenges for the developing team. Impact: Despite the inherent challenges, this pilot project has paved the way for permanent inclusion of telehealth practice placement experiences students in our institution, helping students to develop a skill set that helps to prepare them for the future of global service provision. The project also led the team to gain funding to explore how we can further enable effective learning environments within primary care. Funding acknowledgements: No funding was obtained for this initial pilot project.
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Introduction: Vedolizumab has rarely been associated with pulmonary disease in patients with inflammatory bowel disease.1,2 Vedolizumab is a monoclonal antibody that inhibits α4β7-integrin on the surface of T lymphocytes from binding to mucosal vascular addressin cell adhesion molecule 1 (MAdCAM-1) in gastrointestinal tissue.3 It is also known to inhibit α4β7-integrin from binding fibronectin in pulmonary tissue, which may induce upregulation of T-lymphocyte expression of α4β1-integrin, which has a specificity for vascular cell adhesion molecule 1 (VCAM-1) in pulmonary tissue.2 Case report: A 63-year-old White man with Montreal classification E24 ulcerative colitis (UC) presented to a university teaching hospital with 1 week of progressive shortness of breath and a non-productive cough. He was diagnosed with UC 21 years earlier and had been treated with 300 mg intravenous vedolizumab 8-weekly for 4 years and 20 mg oral methotrexate for 3 years for an associated inflammatory arthropathy. Other medical conditions included mild chronic renal impairment and a 30-pack-year smoking history. Initial investigations showed a C-reactive protein (CRP) level of 175 mg/L and white cell count of 8.6 × 109/L. Computed tomography (CT) imaging of the chest showed extensive consolidative changes throughout both lungs, consistent with acute respiratory distress syndrome (ARDS). Over a 3-day period, he developed type two respiratory failure, with a pH of 7.14 and partial pressure of oxygen of 75 mmHg on an arterial blood gas, requiring intubation and mechanical ventilation in the intensive care unit. Extensive investigations, including sputum culture and Pneumocystis jirovecii DNA polymerase chain reaction (PCR) testing performed on two bronchoalveolar lavage samples, respiratory viral PCR testing performed on a nasopharyngeal aspirate, urinary legionella and pneumococcal antigens, anti-neutrophilic cytoplasmic antibodies, extractable nuclear antigens, and double-stranded DNA, failed to identify an infective or inflammatory cause. An elevated anti-nuclear antibody titer of 1:640 with nucleolar pattern was not thought to be clinically relevant. Investigations occurred before the coronavirus disease 2019 (COVID-19) pandemic. After poor response to empirical antibiotic therapy, the patient responded to intravenous glucocorticoid therapy, while vedolizumab and methotrexate were ceased. He improved with oral prednisolone, which was gradually reduced to 3 mg daily over 9 months. His exercise tolerance improved to 2 km of walking per day. Improvement in respiratory function was also reflected in serial pulmonary function tests. Initial testing showed a moderately severe restrictive deficit, with a forced expiratory volume (FEV1) of 1.58 (54.1% predicted), forced vital capacity (FVC) of 1.68 (44.8% predicted), and carbon monoxide diffusing capacity (DLCO) of 9.71 (39.9% predicted). After 9 months, FEV1 was 1.97 (68.0% predicted), FVC was 2.15 (57.5% predicted), and DLCO was 15.07 (65.8% predicted). Conclusion:We describe a patient who presented with ARDS 17 days after receiving vedolizumab, making this the first reported case in a patient with UC. This case highlights the need to consider vedolizumab as a rare cause of ARDS in patients with UC.