4-Organ Sofa Score as Tool to Triage Crrt Use in Covid-19 Patients during Crisis Standards of Care

INTRODUCTION: Acute kidney injury requiring renal replacement therapy (AKI-RRT) is associated with high mortality, especially in the setting of COVID-19. During the peak of the delta wave in New Mexico in late 2021, crisis standards of care were declared and strategies to ration care were explored. Our hypothesis is that a simplified SOFA score in patients with COVID-19 and AKI-RRT may predict short-term mortality. METHOD(S): We retrospectively analyzed all COVID-19 patients started on CRRT for AKI in the medical ICU at our center between April 2020 and July 2021. A 4-organ SOFA score (4OSS), with renal and neurologic sub-scores excluded, was calculated at the time of CRRT initiation. Neurologic sub-score was excluded because it is subjective, inconsistently documented, and confounded by the frequent use of sedation and paralysis in severe COVID-19. ECMO patients were included and assigned the maximum respiratory sub-score. Patients started on RRT at an outside hospital, found to be incidentally COVID-positive, or on chronic dialysis were excluded. P values were obtained using 1-sided Mann-Whitney U tests. RESULT(S): 63 total COVID-19 patients on CRRT were identified with 73% 30-day mortality and 83% in-hospital mortality. The median 4OSS was 8 in both in-hospital survivors and non-survivors with interquartile range [IQR] of 4-9 and 7-9.75, respectively (difference between groups non-significant, p = 0.075). The median 4OSS was 7 [5.5- 8.5] and 8 [7-10] in 30-day survivors and non-survivors, respectively (p = 0.018). Those with 4OSS of >=10 (n=13, 20.6%) had 100% in-hospital mortality. CONCLUSION(S): Similar to other analyses of SOFA score in COVID-19, 4OSS at CRRT initiation in patients with COVID-19 and AKI-RRT appears to have limited prognostic ability, with substantial overlap in scores between survivors and non-survivors. However, while additional multicenter studies are needed, 4OSS of >=10 may identify a group of about 20% of COVID-19 patients with AKI-RRT and mortality approaching 100%. Given the absence of a superior validated metric, a 4OSS of >=10 may be a reasonable tool for triage of CRRT in the setting of crisis standards of care and CRRT machine or supply shortages. At a minimum, 4OSS could inform goals of care discussions prior to CRRT initiation in patients with COVID-19 complicated by AKI-RRT.

COVID-19 Associated Optic Neuritis

Purpose : While severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) is well known for its respiratory complications, ocular manifestations are emerging. This case report describes a patient with bilateral optic neuritis associated with coronavirus disease 2019 (COVID-19). Methods : A 46-year-old male presented with two weeks of pain with eye movement immediately after testing positive for COVID-19 and four days of bilateral blurry vision. Data including history, ocular examination, Humphrey visual field testing (HVF), magnetic resonance imaging (MRI), and serological testing was collected. Results : Visual acuity (VA) was 20/100 in the right eye (OD) and 20/70 in the left eye (OS) with pinhole VA of 20/40 in each eye. Pupil exam, intraocular pressures, and confrontational visual fields were normal. Ocular motility was full, however the patient endorsed pain with eye movement in all directions. The right optic nerve had blurred disc margins while the left optic nerve was unremarkable on exam. Color vision was decreased to 13/15 by Ishihara testing in each eye. MRI of the brain and orbits revealed bilateral thickening and T2 hyperintensity and hyperenhancement of the intercanalicular and intraorbital optic nerves with sparing of the nerve sheath and no demyelinating lesions (Figure 1). Bilateral central scotomas were seen on HVF (Figure 2). At this point, the patient's clinical picture was concerning for optic neuritis associated with COVID-19. A complete blood count, comprehensive metabolic panel, myelin-oligodendrocyte glycoprotein antibody, and aquaporin 4 antibody were unremarkable. Testing for tuberculosis, sarcoidosis, syphilis, thyroid disease, and rheumatologic and autoimmune disorders was normal. The patient was treated with corticosteroids. Within three to six weeks, the patient's symptoms and abnormal exam findings resolved. Conclusions : Infectious pathogens and their subsequent inflammation can cause optic neuritis. It is postulated that T cells release inflammatory mediators and cytokines that cross the blood brain barrier and lead to destruction of myelin, neuronal cell death, axonal degeneration, and vision loss. SARS-CoV-2 could cause a similar inflammatory response leading to optic neuritis and is important to consider in cases without a clear etiology.

STANDARDIZING HYPERTENSION MANAGEMENT AS A STRATEGY TO IMPROVE RATE OF BLOOD PRESSURE CONTROL AND REDUCE RACIAL DISPARITIES IN AN URBAN PRIMARY CARE TEACHING PRACTICE

STATEMENT OF PROBLEM/QUESTION: Although hypertension is a leading cause of preventable cardiovascular disease, rates of blood pressure (BP) control remain suboptimal, particularly among racial and ethnic minority groups. DESCRIPTION OF PROGRAM/INTERVENTION: The COVID-19 pandemic has led to delays in chronic disease management and has exacerbated pre-existing racial disparities in BP control. Our quality improvement project aimed to improve BP control rates in our clinic. Our initial root cause analysis identified several contributors to suboptimal BP control in our clinic: 1) lack of follow up, 2) patient nonadherence, and 3) lack of home BP monitoring capability for telehealth encounters. To address these, we designed a comprehensive intervention which included: 1) a standardized 2 week follow up interval for patients with elevated BPs, 2) a standardized quicktext to be used at BP follow up appointments to reduce variability in provider management, and 3) home BP cuff distribution, free of cost, to those lacking this equipment. We followed the first 200 BP cuff recipients through a 6-month period. MEASURES OF SUCCESS: Our outcome measure was the percent of patients with controlled BP (defined as <140/90) through the 6-month follow up period. Our process measure was the percent of patients who had a BP follow up appointment during this time. Race-stratified data was monitored to ensure we were not worsening racial disparities in BP control. FINDINGS TO DATE: Three patients expired during the 6-month follow up period. Of the remaining 197 patients, the rate of overall BP control was 20% (39/197) at time of cuff distribution. This overall rate of BP control improved to 51% (101/197) at the 6-month time period. 85% (168/197) successfully followed up within the 6-month timeframe. In the initial cohort, 75% (147/197) identified as Black, 14% (27/197) identified as White, and the remaining 11% (23/197) identified as Hispanic/Latinx, Native American/Alaskan, biracial, multiple, or other;each of these groups achieved similar BP control rates during the 6-month follow up period [51% (75/147), 52% (14/27), and 52% (12/23), respectively]. KEY LESSONS FOR DISSEMINATION: Standardization of care and successful follow up are key elements in improving BP control in the outpatient setting. Our results also suggest that standardizing provider workflows and reducing barriers to telehealth visits can also decrease racial disparities in BP control. Our next steps including identifying patients who remain uncontrolled and leveraging additional system resources, including community health workers, for continued support outside of the office setting.

Effect of surgical and N95 facial masks on exercise tolerance, heart rate, respiratory rate and blood oxygen saturation

Background - Although wearing masks is inevitable these days, the effects of wearing them on physiologic parameters have not been reported. This study aimed to assess the effects of wearing no mask, a three-layer standard surgical mask, and wearing an N95 mask on blood oxygen saturation, aerobic tolerance, and performance during exercise. Methods - Twenty-one participants were enrolled in the study. Each participant was monitored with electrocardiography (ECG) while performing an exercise tolerance test using the Bruce treadmill protocol. Testing was conducted three times on different dates. Participants did not use any mask in the first test but did wear surgical and N95 masks during the second and third tests respectively. Respiratory rate (RR) was assessed for 10 seconds and then multiplied by 6. Heart rate (HR) was monitored by ECG, and oxygen saturation levels were monitored (O2Sat) via digital pulse-oximetry. Assessments were done before warm-up, at the middle and end of each Bruce stage, and as well at 1, 2, and 5 minutes into recovery (masks were worn during recovery). Results - HR, RR, and O2Sat measured data were all significantly different between the three trials at end-stage 3 of Bruce treadmill protocol (p<0.05). Although HR was still higher through the recovery period in the N95 trial in comparison with other trials (p<0.05), RR and O2Sat measured data were not different in the recovery phase. Conclusion - HR, RR, O2Sat and exercise tolerance are significantly affected by wearing surgical and N95 masks.

The Umah Pitu Ruang concept: Environmental adaptation and the Covid-19 pandemic

This paper discusses how to adapt the concept of space from Umah Pitu Ruang in the past to modern Gayo houses today, especially to deal with the dynamics of the Covid-19 pandemic case. At the same time, it brings the environmental adaptation of the houses. This research uses descriptive qualitative method. Data collection is done by collecting literature, observation and interviews. The data collected through literature, observation, and interviews will then be analyzed and then described what is found in Umah Pitu Ruang, a modern house, and what the implications are for a healthy home. Although physically, Umah Pitu Ruang is difficult to re-apply nowadays, but some of the spatial concepts of Umah Pitu Ruang can still be adapted for today, including during the COVID-19 pandemic through a sharper perspective. The architecture of the past can provide lessons through local wisdom, one of which is culture. In this discussion we can conclude that the culture that exists in Umah Pitu Ruang can be adapted to the present with a contemporary approach.