ABSTRACT
Background: Pancreatic involvement in patients with Coronavirus 2019 (COVID-19) has been reported in the literature. The pancreatic injury in COVID-19 patients might be a result of the direct cytopathic effect of viral replication or indirectly related to the immune response to the viral infection. Methods:Westudied 183 patients diagnosed with symptomatic SARS-CoV-2 and admitted to COVID-19 facilities in Qatar. We included only the patients with documented positive SARS-COV-2 PCR and measured lipase levels. The cohort was categorized into two groups based on the serum lipase level. The cutoff was the elevation of the serum lipase more than three times the upper limit of normal. Patients with lipase levels below the cutoff were included in the first group, and those with lipase levels above the cutoff were included in the second group. The primary outcome was mortality. The secondary outcomes were disease severity on presentation and markers of disease progression. Markers of disease progression (Table 1) included the development of acute respiratory distress syndrome (ARDS), shock, multi-organ failure, the requirement for ICU admission, mechanical ventilation, continuous renal replacement therapy (CRRT), and extracorporeal membrane oxygenation (ECMO). Results: Our study population had a mean age of 49 and a mean BMI of 28. There was a male predominance in the study sample (more than 91%), reflecting the country's demographics. There was no statistically significant difference between the two groups in the mean age, BMI, gender distribution, or patients' reported symptoms. There was an increased prevalence of diabetes mellitus (DM) and hypertension (HTN) in our study population (45.4% and 44.8%). Apart from the increased prevalence of chronic liver disease in the second group, there was no statistically significant difference in the prevalence of comorbidities (e.g., DM, HTN) between the two groups (Table 1). The second group showed a statistically significant increase in mean creatinine, troponin, procalcitonin, ferritin, and amylase compared to the first group. On the other hand, the mean hemoglobin, sodium and albumin were lower (Table 2). Interestingly, more patients in the second group received tocilizumab and oseltamivir (Table 1). The mortality rate in our study population was 15.3%, with a higher mortality rate in the second group (Table 1). Almost 50% of the patients developed ARDS. Multiple markers of disease progression, including the development of ARDS, shock, and multi-organ failure;requirement for ICU, mechanical ventilation, and CRRT were increased in the second group compared to the first group. Also, the mean length of stay was higher in the second group (Table 1). Conclusion: Based on our study, hospitalized patients with COVID-19 who had higher lipase levels had a higher mortality rate and higher risk for disease progression. (Table Presented)
ABSTRACT
RATIONALE: The Center for Medicare and Medicaid requires hospitals to report compliance with a sepsis treatment bundle as part of its Inpatient Quality Reporting Program. Cleveland Clinic Foundation (CCF) Fairview hospital reported a Sepsis Core Measure Compliance (SEP-1) of 25% and a mortality averaging 20% in 2017. Both were very dismaying. METHODS: Starting in 2018 a sepsis committee was convened with a plan for several quality initiatives. Real-time audits and peer to peer education were provided to caregivers on the failed cases. A sepsis alert in the Electronic medical record system and a sepsis checklist were initiated. In 2020 a Code sepsis team was created with 24 hours response and follow-up on all sepsis alerts. As the CCF enterprise decided in 2020 to focus on mortality reviews, our hospital adopted rather a hybrid model reviewing all failed compliance cases of the one hour antibiotic in addition to mortality cases reviews. Several educational and awareness sessions were entertained with the residents, advanced practice providers, hospitalists, intensivists and nursing teams. Seventy Registered Nurses received training in 2018 and forty-three in 2021. Sepsis Champions were designated encompassing all stakeholders. Collaboration with Emergency Room caregivers to provide hand-off communication on sepsis alert patients to the medical-surgical providers ensured continuity of care. A sepsis order set was revised and went live in September 2021. Beginning of 2022, A dedicated full time quality coordinator and program manager for sepsis was appointed. RESULTS: Despite the Coronavirus 19 infection (COVID 19) pandemic where Cleveland Clinic Fairview Hospital was designated as the tertiary referral academic center for northwestern Ohio and despite the inclusion of COVID 19 mortality within the sepsis mortality data, comparing 2017 to 2021, SEP-1 measures compliance improved from 25% to 60.4% and sepsis mortality decreased from 20% to 15.38%. The one hour antibiotic compliance averaged 78.89% in 2021. With the above performance and impact on survival, Cleveland Clinic Fairview Hospital was leading the CCF Hospitals both in compliance and Mortality. Several of the above Fairview hospital quality initiatives and approaches were later adopted across the Cleveland Clinic Hospitals. CONCLUSION: A sepsis dedicated committee, quality/program manager and a code sepsis team with a focus on the evidence base components of the sepsis core measures, all helped improve compliance and decrease mortality. Future research is needed to highlight the impact of each of those quality and educational initiatives on outcomes and performance. Word Count: 400 (Figure Presented).
ABSTRACT
Background. Tocilizumab is an interleukin-6 monoclonal antibody with widespread use in rheumatologic conditions. Observational studies have shown a promising role of Tocilizumab in severe COVID-19 patients with cytokine storm syndrome. Data about tocilizumab use in pregnant patients is limited. We report two outcomes of two pregnant patients with COVID-19 in the second trimester who received tocilizumab Methods. A 24-year-old 20 weeks pregnant lady with a history of asthma and gestational diabetes mellitus presented with three days history of fever, cough and shortness of breath (Figure 1). She was clinically stable but later developed ARDS and developed increased oxygen demand up to 10 liters/min. She received Tocilizumab on. Patient was observed in a high dependency unit but did not require mechanical ventilation. Patient was discharged home with full recovery and later delivered a healthy baby. Timeline of medicines used during hospital (Figure 2). Case 2: 39-year-old 23 weeks pregnant lady presented with seven days history of fever cough and shortness of breath (Figure 1). On presentation, she had progressive worsening hypoxic respiratory failure and was intubated. Patient had her nasopharyngeal swab for CODI-19 RT PCR was positive. The patient had severe ARDS requiring ECMO (extracorporeal membrane oxygenation) for respiratory support. Tocilizumab 400 mg was given on the presentation, along with other medications (Figure 3). Patient had regular monitoring of fetus;however, she had intrauterine fetal demise on day 14. Patient It is unclear if IUFD was due to using of tocilizumab or severity of COVID19 itself. The patient stayed in ICU for 20 days and was discharged after full recovery. Figure 1. Case 1 treatment timeline. Abberviations: Azithro: Azithromycin, HCQ: Hydroxychloroquine, CQ: Chloroquine, LPV/r: lopinavir/Ritonavir, Osel: Oseltamivir, MP: Methylprednisolone, Ampi-sulb: Ampicillin-sulbactam, TCZ: tocilizumab Figure 2. Case 2 treatment timeline Results. Learning points: Tocilizumab use in pregnant patients with severe COVID-19 pneumonia during the second trimester improved maternal outcomes in our cases. Tocilizumab use may be associated with worse fetal outcomes, including intrauterine fetal demise (IUFD). Conclusion. The pharmacological management of pregnant patients with severe COVID-19 pneumonia poses significant challenges. The use of Tocilizumab may improve maternal outcomes but may also increase the risk of worse fetal outcomes. Caution should be exercised in using this agent, and risks and benefits should be discussed with the patients.
ABSTRACT
BACKGROUND & AIMS: The effectiveness of currently available SARS-CoV-2 vaccines in patients with inflammatory bowel disease (IBD) remains unknown. We aimed to determine the effectiveness of the Pfizer-BNT162b2 mRNA vaccine in a nationwide cohort of patients with IBD in Qatar. METHODS: Using a cohort design, we compared 476 IBD patients vaccinated identified between January 1, 2021, and March 31, 2021, with 476 matched unvaccinated controls (matched on age and date of SARS-CoV-2 testing). Study outcomes included documented SARS-CoV-2 infection, symptomatic COVID-19, and COVID-19 related hospitalization. We also studied the side effects of the vaccination, including the effect on IBD exacerbation and hospitalizations related to adverse events. RESULTS: Total follow-up was 23,289 person-days for the vaccinated and 23,653 person-days for the unvaccinated group. Vaccine effectiveness >14 days [AAB1] after the second dose was 85.1% (95% CI: 65.2, 93.6) for confirmed infection, and 87.1% (95% CI: 63.6, 95.4)[AAB2] for symptomatic infection. No patient required hospitalization >14 days after the second vaccine dose. Estimated vaccine effectiveness between 22 to 35 days after the first dose was 14.8% (95% CI: -151.5, 71.2) [AAB3] for any documented infection, and 59.8% (95% CI: -106.1, 92.2) for symptomatic COVID-19 disease. For patients taking biologics with or without immunomodulators, vaccine effectiveness >14 days after the second dose was 94% (95% CI: 53.1, 99.2), and 92.7% (95% CI: 45.1, 99.0) for any documented infection and symptomatic COVID-19 respectively. Vaccine effectiveness was 87.4% (95% CI: 46.0, 97.1) for any documented infection and 91.7% (95% CI: 37.2, 98.9) for symptomatic COVID-19 during the same period for patients taking immunomodulators alone. None of the vaccinated patients required intensive care unit admission or died. No patient had IBD exacerbation or required hospitalization for vaccinationrelated adverse events. CONCLUSION: In a nationwide cohort of IBD patients, the BNT162b2 mRNA vaccine was safe and highly effective.