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Introduction: In March 2020, to prevent the risk of infection from SARS-CoV-2 in people with multiple sclerosis (MS) on Ocrelizumab, notably associated with an immunosuppressed state, the Association of British Neurologists (ABN) advised delaying the infusions until the recovery of CD19+ cells to over 1% of the total lymphocyte population. The indication is based on observations from multinational experience using Rituximab, suggesting that an Ocrelizumab infusion may remain effective at controlling MS for longer than 6 months. Objective(s): We will analyse data on the delayed time intervals between Ocrelizumab infusions, the rate of relapses and signs of disease activity or progression reported for 209 patients in the audited period. Aim(s): We aim at assessing the efficacy of dosing Ocrelizumab according to CD19+ cell count in terms of MS control. Method(s): The study was designed as a clinical audit. 209 patients under the care of the MS centre of the Queen Elisabeth Hospital Birmingham were included in the audit. The protocol suggested by the ABN was applied to all of them from mid-March 2020 onwards. 2 years after, we collected data on the time intervals between the infusions, the relapses and radiological findings reported for the 209 subjects in the audited period. Result(s): A total of 424 Ocrelizumab infusions were administered. 123 (29%) were first infusions. 301 (71%) were either second, third, fourth, fifth or sixth infusions. Of those 301 infusions, 235 (78,07%) were administered after 8 months or more from the preceding one, whereas 66 (21,92%) were performed at a time interval of 6-7 months. Of 209 patients, 8 (3,82%) experienced a clinical relapse not supported by radiological signs of disease activity or progression. 4 patients (1,91%) presented clinical manifestations of a relapse confirmed by radiological findings of disease activity or progression. For 1 patient (0,47%) the magnetic resonance imaging showed evidence of increased lesion load not associated with any new clinical sign or symptom. In addition, 4 patients (1,91%) reported subjective feelings of worsening MS that they attributed to infusions being delayed and were re-established on standard sixth-month interval infusions. Conclusion(s): Ocrelizumab dosing according to CD19+ cell count monitoring remained effective at controlling MS in the majority of the 209 patients included in the audit while preventing unnecessary exposure to SARS-CoV-2 infection related to hospital attendance.
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SESSION TITLE: Sepsis: Beyond 30cc/kg and Antibiotics SESSION TYPE: Rapid Fire Original Inv PRESENTED ON: 10/19/2022 11:15 am - 12:15 pm PURPOSE: Sepsis is the leading cause of hospitalization and mortality in the United States. In addition, sepsis is, by volume, the leading cause of 30 day readmissions across all payer mix in the United States. The risk factors for 30 day readmissions are multifactorial and often portends poor outcomes and increase hospitalization costs. We trialed a pilot program of enhanced sepsis discharge education which consisted of direct patient education prior to discharge, providing a Sepsis Education brochure with tips on self management at home as well as a QR code to direct patients to institutional website in case they needed further assistance, and finally a disposable thermometer to maintain an accurate temperature log to aid in monitoring for signs and symptoms of sepsis. Our primary goal was educate patients about their diagnosis and reduce sepsis readmissions in all non-medicare patients being discharged home. METHODS: The pilot was implemented at on one med/surg unit in our 550-bed tertiary, academic medical center starting in March 2021 and progressively expanded hospital wide over the next six months. The sepsis administrative coordinator screens new in-patient admissions for sepsis (non-Medicare) patients daily and informs medical/surgical unit coordinators of potential candidates. Med/surg coordinators will confirm if patients meet criteria for follow-up (non-Medicare, being discharged to home), provide discharge education and enter the patient in a log for continued surveillance. Subsequently, the administrative coordinator then follows up with a phone call 7-10 days after discharge during which, they assess the patient for worrisome symptoms, confirms follow up appointments, medication compliance and review of temperature log. If the patient needs clinical assistance, they will refer to the patient to the hospital sepsis clinical coordinator or patient’s outpatient physicians. RESULTS: We compared sepsis discharges and 30day readmissions (all excluding COVID-19 cases) from March 1, 2019 – Dec 31, 2019 to March 1, 2021 – Dec 31, 2021. Readmissions amongst Medicare patients discharged home was 15.9 % (110 / 962) in 2019 vs 11.9% (83 / 696) in 2021. For non-medicare patients, the rate was 13.2% (41/311) in 2019 vs 13.1% (51/390) in 2021. In our pilot program, the readmission rate in medicare patients was 17.2% (28/163) versus 5.6% (5/90) in non-medicare patients. CONCLUSIONS: This program captures a patient population which may have been lost to follow-up. Implementation of the enhanced Sepsis Discharge Education led to at least a 30 patient reduction in readmissions yielding an approximate cost savings of $594,000. CLINICAL IMPLICATIONS: Providing educational support, instructions, and follow up calls upon discharge improves medication adherence, compliance, and maintains patient follow up thus reducing readmissions and improving hospital resource utilization and overall cost. DISCLOSURES: No relevant relationships by Laura Freire No relevant relationships by Nirav Mistry No relevant relationships by Caitlin Tauro
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Guided-inquiry experiments are an important tool for helping students develop scientific practices such as hypothesizing and problem solving. In organic chemistry, these types of experiments can help students learn how to connect the theory of the reaction to the observation and data to decide how the reaction is proceeding or if it needs adapting. Due to a reduction of in person teaching during the COVID-19 pandemic, we developed a set of virtual inquiry-based organic chemistry experiments where students make the same decisions as they would do with a hands-on inquiry experiment. Thus, these simulations allow students to learn similar problem-solving skills. In this paper, we provide details of the simulations and the educational outcomes when they were used to replace hands-on inquiry experiments. We also include suggestions for its use postpandemic. © 2021 American Chemical Society and Division of Chemical Education, Inc.
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INTRODUCTION: Neutrophil lymphocyte ratio (NLR) is elevated in response to stressful stimuli and has been shown to be associated with poor prognosis in both benign & malignant disorders. Literature regarding NLR as a prognostic marker in COVID19 are limited. Our study was aimed to investigate the relationship between NLR & survival outcomes in patients hospitalized with Coronavirus disease 2019 (COVID19). METHODS: Ours was a single center, retrospective observational study, which included 472 nasopharyngeal swab SARS-CoV-2 RT-PCR positive patients. NLR was derived from the admission complete blood count & was divided into 5 sub-groups as (0-0.99, 1-2.99, 3-9.99, 10-19.99, >20). Demographics, comorbid conditions, and outcomes such as need for mechanical ventilation, length of stay and inpatient mortality were assessed. Statistics were performed using STATA. Significance was assigned at p<0.05. RESULTS: The mean age was 71.16 years in NLR >10 group as compared to 60.3 years in patients with normal NLR 1-2.99. Male patients were found to have much higher NLR than females (65.12% vs 34.88% in NLR 10-19.99, 64.86% vs 35.14% in NLR>20;p-value: 0.05). Among comorbidities, COPD patients were found to have higher NLR (18.92% of NLR>20 vs 10.71% of NLR 1-2.99;p-value:0.02). Rate of endotracheal intubation and need for mechanical ventilation was significantly higher with increasing NLR (0% vs 7% vs 14% vs 17% vs 32%;p-value: 0.03). Inpatient mortality was significantly higher in patients who had NLR>20 (70.27% of NLR>20 vs 16.07% of NLR 1-3 p-value <0.0001). On multivariate regression, patients with NLR>20 had 4 times higher odds of mortality;however, the p-value was not significant (4.07±2.78 p-value: 0.175). CONCLUSIONS: Increasing NLR in COVID19 patients is associated with increased ICU admission, intubation & inpatient mortality. Further studies are warranted to establish NLR, which is readily available & inexpensive, as a potential prognostic indicator in COIVD19 patients.
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INTRODUCTION: The host immune responses try to confront Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) with all the potential cells and cytokines. Eventually, natural killer cells and T cells become exhausted, decreasing their counts, leading to lymphopenia. This study aims to assess the clinical utility of the absolute lymphocyte count (ALC) at admission in predicting outcome in patients with COVID-19. METHODS: Ours was a single-center, retrospective observational study, which included 463 nasopharyngeal swabs SARS-CoV-2 RT-PCR positive patients. Absolute lymphocyte count was retrieved from the admission complete blood count & was divided into 3 sub-groups (<500, <1000, and >1000 cells/μL). Demographics, comorbid conditions, and outcomes such as the need for mechanical ventilation, length of stay, and inpatient mortality were assessed. Statistics were performed using STATA. Significance was assigned at p<0.05. RESULTS: 13.82% of patients had ALC count<500, 44.71% had <1000 and 41.25% had more than 1000. Mean age in ALC group<500 was higher (71±1 years vs 65± 1.1 years in ALC group <1000 and 59.9+/-1.3 in ALC group >1000). Profound lymphopenia (<500 cells/μL) was more common in males compared to females (71.88 % vs 28% p value 0.01). ALC count <500, was associated with higher rate of non-invasive (45.31% vs 26.56% for ALC <1000, p-value: 0.01) as well as invasive ventilation (26.5% with ALC <500 vs 19% with ALC <1000 vs 10.4% with ALC with >1000;p-value: 0.01). Inpatient mortality was significantly higher in cohort with ALC <500 (51.56% with ALC <500 vs 33.3% with ALC <1000 vs 24.08% with ALC >1000;p-value 0.05). On multivariate regression, ALC was not a independent predictor of mortality (ALC<500, OR: 1.56±0.75, p-value: 0.44). CONCLUSIONS: Lymphopenia at admission in COVID19 patients is associated with an increased need for non-invasive & invasive ventilation & inpatient mortality. Currently, clinical trials assessing GM-CSF as a possible therapeutic option is underway.
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INTRODUCTION: Coronavirus disease 2019 (COVID- 19) caused by the SARS-CoV-2 virus has emerged as one of the greatest challenges to humanity in recent history. Older people have shown to have poor outcomes in recent studies. Our study looks at the characters and outcomes in patients of different age groups admitted to our center. METHODS: Our study is a single-center, retrospective, observational study of 471 COVID-19 patients (confirmed with a positive nasopharyngeal swab for SARS-CoV2 RT PCR) admitted to our hospital. Patients were divided into 3 groups based on Age (0-45 years, 46-65 years, and >65 years). Demographic characteristics and in-hospital outcomes were compared between these groups. STATA was used to perform statistics. Statistical significance was assigned at p=<0.05. RESULTS: 471 patients were included in the study of which 79 (16.77%), 159 (33.76%), and 233 (49.47%) belonged to the age group of 0-45 years (Group A), 46- 65 years (Group B) and >65 years (Group C) respectively. On comparison of pre-existing comorbidities, patients in group B and group C had a higher incidence of baseline comorbidities (Diabetes, Hypertension, Heart failure, COPD rates were 33.96% vs 43.1%, 55.35% vs 81.12%, 9.01% vs 20.59%, 2.5% vs 11.21% respectively). On comparing in-hospital outcomes, the mean time to mechanical ventilation from admission was 3.25 (±1.31) days, 2.42 (±0.68) days and 2.75 (±0.53) days for group A, B and C respectively. 74 (15.71%) patients required intubation during hospitalization of which 7.5%, 32.5%, and 60% belonged to groups A, B, and C respectively. The overall mortality rate among intubated patients was 90.54% among which 8.15%, 31.08%, and 60.81% belonged to groups A, B, and C respectively. The inhospital mortality rate was 32.48% of which 3.27%, 17.65%, and 79.08% belonged to groups A, B, and C respectively. In-hospital mortality rate for group A, B and C were 6.33%, 16.98% and 51.93% respectively (p <0.0001). However, on multivariate regression analysis, age was not an independent predictor of in-hospital mortality for any age group. CONCLUSIONS: Patients >65 years of age have higher co-morbidities and worse in-hospital outcomes. However, age is not an independent predictor of mortality and each patient should be evaluated individually while making an important treatment decision.
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INTRODUCTION: Systemic inflammation elicited by a cytokine storm is considered a hallmark of coronavirus disease 2019 (COVID-19). This study aims to assess the clinical utility of the lymphocyte-to-C-reactive protein (CRP) ratio (LCR), typically used for gastric & colorectal cancer prognostication. METHODS: Ours was a single center, retrospective observational study, which included 321 nasopharyngeal swab SARS-CoV-2 RT-PCR positive patients. LCR was derived from the admission complete blood count & was divided into 2 sub-groups (<99.99 vs >100). Demographics, comorbid conditions, and outcomes such as need for mechanical ventilation, length of stay and inpatient mortality were assessed. Statistics were performed using STATA. Significance was assigned at p<0.05. RESULTS: LCR <99.99 group had more elderly patients as compared to LCR >100 group (67.74% vs 54.01% of patients >60 years of age). Male patients were found to have lower LCR than females (60.75% vs 39.25% with LCR <99.99;p-value: 0.03). Among comorbidities, patients with history of cancer were found to have higher LCR (7.53% of LCR <99.99 vs 13.24% of LCR >100;p-value:0.03). Lower LCR was associated with higher rate of non-invasive (36.56% with LCR <99.99 vs 19.12% with LCR >100;p-value: 0.01) as well as invasive ventilation (17.74% with LCR <99.99 vs 11.76 with LCR >100;p-value: 0.01). Inpatient mortality was significantly higher in patients who had LCR <99.99 (39.25% with LCR <99.99 vs 22.63% with LCR >100;p-value <0.03). On multivariate regression, patients with LCR <99.99 had 2 times higher odds of mortality;however, this finding did not reach statistical significance. (2.27± 0.81 p-value: 0.15). CONCLUSIONS: Decreasing LCR in COVID19 patients is associated with increased need for non-invasive & invasive ventilation & inpatient mortality. Further studies are warranted to establish LCR, which is readily available & inexpensive, as a potential prognostic indicator in COIVD19 patients.
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INTRODUCTION: Coronavirus disease 2019 (COVID-19) is a multisystem infection caused by SARS-CoV-2 Virus. Recent studies have demonstrated poor outcomes in patients with diabetes mellitus (DM). We sought to assess the in-hospital outcomes of COVID19 patients with DM at our centre. METHODS: Ours was a single centre, retrospective, observational study of 470 COVID-19 patients admitted to our hospital. We divided these patients into 2 groups;those with DM and those without. We compared demographic characteristics, comorbid conditions, and in-hospital outcomes between the two groups. Statistics were performed using STATA. Statistical significance was assigned at p<0.05. RESULTS: Out of the 470 patients included in the study, 35.53% of patients had DM. Mean age of patients with and without DM was 68.35years±1.08 vs 61.71±1.05years respectively. 8.72% of patients were on pharmacological therapy. The diabetic cohort had a higher prevalence of hypertension, heart failure compared to the non-diabetic cohort (88.02 vs49.5% p-value:0.004, 22.9% vs 9.31% p-value: 0.04). Other comorbidities such as OSA, CKD, COPD, Asthma were comparable between both groups. The DM group had a higher level of inflammatory markers during the course of hospitalisation (D-dimer 3802.68± 1499 vs 3448.13 ±1139, CRP: 12.60±0.76 vs 11.85±0.60, ESR: 73.66±10.41 vs 58.04±7.10). The DM group had a significantly higher need for mechanical ventilation (18.56% vs 13.29%, p<0.03), and subsequent in-hospital mortality (43.35% vs 25.74% p<0.05). On multivariate regression, diabetics had 2.64 higher odds of in-hospital mortality, however, the p-value was not significant (Write ODDS Ratio and Confidence interval p-value: 0.116). CONCLUSIONS: Overall inpatient mortality was higher in patients with DM, likely driven by an increased need for mechanical ventilation. Our study positively adds to the existing literature that DM is a significant risk factor for higher morbidity and mortality in COVID-19 patients.
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Background: This case series assesses characteristics and outcomes of patients with confirmed novel coronavirus (SARS-CoV-2, COVID-19) infection and end stage renal disease (ESRD) requiring hemodialysis during the COVID-19 pandemic. Methods: This is a single center retrospective study of 24 ESRD patients on hemodialysis who were admitted to Saint Barnabas Medical Center, a 597-bed acute care hospital in Livingston, New Jersey, and with a confirmed COVID-19 diagnosis between February 1st to April 5th, 2020. The characteristics, clinical course, and outcome were assessed and compared. In addition, a subgroup analysis was made between patients who expired (n=8) versus those who lived (n=16). Results: The overall mortality rate was 33.3% vs. 21% in the general population with COVID-19. Among the 4 (16%) patients who required ICU admission and prolonged pressor support and invasive mechanical ventilation, 2 (50%) patients were successfully extubated and discharged from the hospital while the other 2 (50%) patients died. There were no statistical differences in laboratory values between patients who survived versus patients who died except C-reactive protein (CRP), p=0.002. Conclusions: We report a mortality rate of 33.3% in our case series of 24 patients with ESRD on dialysis with concurrent COVID-19 infection. There was a statistical difference in CRP value between patients who died versus survived. Fifty percent of intubated patients were successfully extubated and discharged.