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CASE: A 26-year-old male presented to the hospital with 2 weeks of difficulty ambulating, bilateral lower extremity rash, and diffuse myalgia with arthralgia. Symptoms began suddenly with lower extremity pain and difficulty getting up from his chair. He denied sensory changes, and pain was most prominent at the hips and knees. He also noticed a new rash on his thighs and mild bleeding from his gums. All other review of systems were negative. He denied family history of autoimmune disease and was without any personal chronic medical conditions. He was the primary caretaker of his grandmother and had stayed isolated at home throughout the COVID-19 pandemic. Vital signs were normal, and physical exam revealed 3/5 right hip flexion, 4/5 left hip flexion, and 4/5 right knee flexion and extension. Inspection of his rash demonstrated follicular hyperkeratosis, perifollicular erythema, and corkscrew hairs. Initial lab work revealed anemia, hypothyroidism, hypotonic hyponatremia, hypocalcemia, an elevated CK, ESR, and CRP. Extensive infectious and autoimmune workup was unrevealing. Further interview revealed that his diet consisted of soy milk, potato chips, crackers, peanut butter, and water in the preceding 6 months. This was intentionally done to reduce exposure to SARS- CoV-2. Further evaluation revealed Vitamin C, Vitamin D, Zinc, and Iron deficiencies. His presenting symptoms and rash were ultimately attributed to hypothyroid myopathy and Scurvy. Following thyroid replacement therapy, dietary education, and nutritional supplementation, he experienced improvement in his symptoms and rash. IMPACT/DISCUSSION: It has become evident that the COVID-19 pandemic has had significant psychosocial impact on the public, with substantial portions of our population experiencing increased fear and anxiety. Interestingly, a longitudinal study by Pan et al. found that Dutch patients without prior mental health disorders, such as our patient, had a more significant increase in depression, anxiety, and worry during the pandemic. To add to this, a study by Izzo et al. found that a substantial part of their study population had turned to unhealthy nutritional behaviors during the pandemic. Furthermore, Nguyen et al. demonstrated that increased health literacy was protective against the negative psychological impacts of the COVID-19 pandemic. Our case presents an outcome of merging pandemic fears with poor health literacy. It also highlights the critical role of the clinician as historian. Conceptualizing the patient's clinical presentation with their daily life ultimately led to appropriate diagnostic workup and treatment. CONCLUSION: As the COVID-19 pandemic continues, its broader and less apparent effects will continue to be seen. Clinicians must remain vigilant in assessing the changes in their patients' daily lives with open and invested communication. Early identification of potentially harmful changes and improved health education could prevent potential complications.
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Background: With an increasing use of parenteral systemic anti-cancer therapy (SACT) for a growing cancer population, cytotoxic aseptic units in theUKare experiencing an increase in workload. Having finite production capacity, it is imperative to use resources efficiently to meet the growing demand for SACT. UCLH (University College London Hospitals) Macmillan Cancer Center is one of the largest cancer centers in London, providing chemotherapy treatment for around 350 patients with haematology or oncology conditions in day care unit each week. SACT provided at UCLH are either manufactured locally in UCLH cytotoxic unit or outsourced from commercial aseptic units. Nurses working in the day care unit noticed and reported increases in daily SACT wastage. Wastage of 1 item had increased to around 5 items since the Covid-19 pandemic. The aim of this improvement work was therefore to reduce wastage, and this would be achieved using quality improvement (QI) methodology. QI team was formed, and SMART objective agreed: reduce parenteral SACT wastage by 50% for day case treatments by 31st May 2021. Methods: During the pandemic new patient pathways were established. Using process mapping of these: doctor consultation to administration of SACT, it was identified that wastage was occurring due to 1) patients being unwell on the day of treatment, 2) unsatisfactory blood results and 3) weight changes. As a team we decided that the process to improve would involve obtaining advance weights for patients. We adopted the IHI (Institute for Healthcare Improvement) model for improvement with a series of PDSA (Plan-do-study-act) cycles. Our first change for PDSA cycle 1 was regular weight documentation by day care staff using a checklist To improve on these results we educated the oncology pharmacy team on weight checking when preparing for clinics and during SACT verification. Daily wastage and compliance to weight documentation were recorded throughout a three-week baseline data collection period and the two PDSA cycles. Results: The baseline data showed average daily wastage of 4 infusions. Following PDSA cycle 1 the number of SACT wastage reduced to 3 infusions a day. After PDSA cycle 2, this reduced to 2.2. The compliance to weight documentation improved from a baseline of 30% (n=80) to 95% (n=215). Discussion: There was a reduced SACT wastage following the PDSA cycles. It is unclear whether regular weight documentation and education on weight check have led to the improvement. Although the project aim has not been achieved, PDSA cycle 1 and 2 were thought to be good practice to ensure appropriate SACT dose prescribed while reducing patient waiting time in the unit. Therefore, both changes are likely to be sustainable. Similar improvement work can be carried out over a longer timeframe in the future to establish whether these changes can make a positive impact on improving SACT wastage.
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SESSION TITLE: Pulmonary Vascular Disease Posters SESSION TYPE: Original Investigation Posters PRESENTED ON: October 18-21, 2020 PURPOSE: To investigates the association between the use of anticoagulation and mortality among hospitalized patients with COVID-19 in order to provide clinical insights. METHODS: An electronic search was conducted in Pubmed, Scopus, and Medrxiv (preprint articles), using the search strategy included all MeSH terms and free keywords found for “coronavirus 2019” OR “COVID-19” OR “2019-nCoV” or “SARS-CoV-2”, AND “anticoagulation” OR “heparin” OR “enoxaparin” OR “apixaban” OR “rivaroxaban” between 2019 and present time without language restriction. The title, abstract, and full text of all documents captured with these search criteria were scrutinized, and those reporting the rate of anticoagulation in COVID-19 patients were included in this meta-analysis. The reference list of these identified studies was also analyzed (forward and backward citation tracking) for detection gother potential eligible articles. A meta-analysis was performed with Comprehensive Meta-Analysis software (version 3.3.070) in accordance with the PRISMA guidelines. RESULTS: Overall, 286 documents could be initially identified based on our search criteria and from the reference list, 283 of which were excluded after title, abstract, or full text reading, since they were reviewed articles, commentaries, or other editorial materials, or they did not provide the information on mortality associated with the use of anticoagulation. Therefore, 3 studies could finally be included in our meta-analysis, totalling 5297 patients, 2969 of which received anticoagulation. In summary, the odds ratio of mortality was 0.85 [random effect;95% confidence interval (CI) 0.41-0.99, p<0.05], indicating that on an average, patients receiving anticoagulation had a 15% less likelihood of dying compared to those without anticoagulation. The variation in effect size was assessed by Q-value (8.36, df=2), I² (76.1%), and T² (0.11). Based on the Q-value, we rejected the null hypothesis that the true effect size is identified in all studies. Based on the I², 76.1% of the variance in observed effects reflects variance in true effects rather than sampling error. Publication bias, a concern where studies included in the analysis could be a non-random subset of all studies, were assessed by the Begg’s (p=0.60) and Egger’s test (p=0.07), which demonstrated no significant publication bias. CONCLUSIONS: In conclusion, the results of this preliminary meta-analysis suggested that anticoagulation to be associated with a reduction in mortality in patients with COVID-19. Our study is not without limitations. Given the novelty of the COVID-19 pandemic, many clinical trial studies were not available at the time of analysis and we had to rely on observational studies, which were less reliable, to evaluate the risk of death. CLINICAL IMPLICATIONS: The use of anticoagulation was associated with a reduction in mortality in patients with COVID-19 DISCLOSURES: No relevant relationships by Yasmin Herrera, source=Web Response No relevant relationships by Kam Sing Ho, source=Web Response no disclosure on file for Bharat Narasimhan;No relevant relationships by Archana Pattupara, source=Web Response No relevant relationships by Joseph Poon, source=Web Response No relevant relationships by Justin Poon, source=Web Response
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SESSION TITLE: Critical Care Posters SESSION TYPE: Original Investigation Posters PRESENTED ON: October 18-21, 2020 PURPOSE: Diabetes has been shown in recent studies to be highly prevalent in critically ill patients with severe coronavirus disease 2019 (COVID-19). However, data comparing clinical outcomes in diabetic and non-diabetic patients remained limited. We aim to compare characteristics and clinical outcomes of diabetic and non-diabetic critically ill patients with severe COVID-19. METHODS: Following institutional review board approval, we identified 115 patients who were admitted to the intensive care unit (ICU) for severe COVID-19. De-identified patient data was retrospectively collected and analyzed using Stata version 15.1 (StatCorp). Data reported here are those which are available through April 28 2020. RESULTS: We identified 115 patients who were admitted to the ICU for severe COVID-19. The population had a mean age of 63.44 years, 67% were male, the mean BMI was 33.30. The mean duration of symptoms prior to hospitalization was 6.35 days. Comorbidities were common, 68 patients had a Charlson comorbidities index equal to or above 3. The most common comorbidities included hypertension (65%), diabetes (41%) and hyperlipidemia (35%). The most common symptoms were dyspnea (81%), cough (75%) and fever (68%). When comparing the 47 diabetic and the 68 non-diabetic patients in our study, there was a similar number of patients requiring invasive (65% diabetic;51% non-diabetic) and non-invasive mechanical ventilation (36% diabetic;48% non-diabetic). There were no significant differences in their clinical management. Both populations had similar rates of shock requiring vasopressors (57% diabetic;48% non-diabetic) and renal failure requiring renal replacement therapy (27% diabetic;25% non-diabetic). There were no significant differences in the rate of acute kidney injury (61% diabetics;40% non-diabetics) and acute hepatic injury between both groups (27% diabetics;22% non-diabetics). Diabetic patients had significantly higher rates of troponin elevation (89% diabetics;70% non-diabetic). After propensity score matching, diabetics were more likely to experience in hospital mortality (OR 2.94 CI 1.32;6.52, p-value 0.008) and were less likely to be discharged from the hospital (OR 0.38 CI 0.17;0.83, p-value 0.02) when compared with non-diabetics. CONCLUSIONS: Diabetics experience higher rates of mortality and are less likely to be discharged when compared with non-diabetic patients. CLINICAL IMPLICATIONS: Further studies to evaluate management strategies in diabetic patients with severe COVID-19 may be useful given the increased risk for mortality in this population. DISCLOSURES: No relevant relationships by Yasmin Herrera, source=Web Response No relevant relationships by Kam Sing Ho, source=Web Response No relevant relationships by Raymonde Jean, source=Web Response No relevant relationships by Joseph Poon, source=Web Response
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SESSION TITLE: Medical Student/Resident Critical Care Posters SESSION TYPE: Med Student/Res Case Rep Postr PRESENTED ON: October 18-21, 2020 INTRODUCTION: The rapid and unprecedented spread of severe acute respiratory syndrome coronavirus disease 2019 (COVID-19) has significantly limited our understanding of this disease. As the pandemic continues to evolve, cardio-pulmonary symptoms predominate, however new atypical manifestation of COVID are increasingly recognized. CASE PRESENTATION: A previously healthy 70-year-old man presents with a witnessed episode of new-onset seizures. Per family accounts, the episode lasted three minutes with tonic-clonic movements of all extremities, followed by a period of confusion. He had endorsed worsening fatigue and headaches with a declining appetite over the preceding two weeks. There was no history of cough, respiratory symptoms, sick contacts or prior similar episodes. Travel history was significant for a trip to California two weeks prior. He denied any medication, health supplement or illicit substance use. Past medical, surgical and family histories were unremarkable. On examination, the patient was obtunded and afebrile (37.3°C). He appeared visibly dyspneic, with an SpO2 of 85% on room air and RR of 34 /minute, but remained hemodynamically stable. Lung auscultation revealed scattered bilateral crackles while the neurological exam was non-focal. Clinically the patient appeared euvolemic. Computed tomography of the brain was unrevealing with no additional explanation for his prolonged altered mentation. Chest-radiography revealed bilateral air-space opacities. Labs indicated mild leukocytopenia (3.2 x109/L) with lymphopenia (0.6 x109/L) and a profound hyponatremia of 104 mEq/L. Renal and liver parameters were normal. Workup of his hyponatremia revealed a serum and urine osmolality of 230 mOsm/kg and 693 mOsm/Kg respectively with a urine sodium of 58 mmol/L. TSH and Cortisol levels were normal. Inflammatory markers were significantly elevated as summarized in Table 1. Influenza PCR, respiratory viral PCR panel, legionella urine antigen and blood cultures were all negative;however, the COVID-19 PCR assay was subsequently found to be positive. Based on the patient’s clinical and biochemical data, he was diagnosed with severe symptomatic hyponatremia secondary to SIADH in the setting of COVID-19 pneumonia. DISCUSSION: SIADH in the setting of pneumonia has been extensively studied and reported. A number of potential mechanisms have been postulated including extensive cytokine release, hypoxemia, nausea and stress. Additionally, inflammation (IL-6 in particular) itself has been reported to directly impair osmoregulation leading to hyponatremia. We hypothesize that milder forms of hypercytokinemia and hyper-inflammation could result in a number of less dramatic atypical presentations including SIADH. CONCLUSIONS: A high index of suspicion and awareness of this association is essential to mitigate SIADH related complications as cases of COVID-19 continue to rise. Reference #1: Edmonds, Z. V. (2012). Hyponatremia in pneumonia. Journal of Hospital Medicine, 7(S4). doi: 10.1002/jhm.1933 Reference #2: Swart RM, Swart RM, Hoorn EJ, Betjes MG, Zietse R. Hyponatremia and Inflammation: The Emerging Role of Interleukin-6 in Osmoregulation. NEP. 2011;118(2):p45–51. DISCLOSURES: No relevant relationships by Yasmin Herrera, source=Web Response No relevant relationships by Kam Sing Ho, source=Web Response no disclosure on file for Bharat Narasimhan;No relevant relationships by Archana Pattupara, source=Web Response No relevant relationships by Joseph Poon, source=Web Response no disclosure on file for James Salonia;
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SESSION TITLE: Critical Care Posters SESSION TYPE: Original Investigation Posters PRESENTED ON: October 18-21, 2020 PURPOSE: Severe acute respiratory syndrome coronavirus-2 (SAR-CoV-2) is a novel virus that causes coronavirus disease 2019 (COVID-19). Previous studies have detected high levels of pro-inflammatory cytokines in COVID-19 patients, including interleukin-6 (IL-6). Tocilizumab is a humanized monoclonal antibody against IL-6 receptors and has been identified as a potential therapeutic agent for COVID-19. We aim to describe the treatment response of critically ill COVID-19 patients who received tocilizumab. METHODS: Following institutional review board approval, we identified 67 critically ill patients with laboratory confirmed COVID-19 infection who received tocilizumab. Decisions regarding clinical management, including tocilizumab administration, were made solely at the discretion of the treating provider. De-identified patient data was retrospectively collected and analyzed using Stata version 15.1 (StatCorp). Data reported in this study are those which are available through April 25 2020. RESULTS: We identified 67 critically ill patients with COVID-19 who were given tocilizumab (mean age 57 years (53-61), 71% male). At the time of tocilizumab administration, 42 patients required invasive mechanical ventilation, 11 required non-invasive mechanical ventilation, 11 required high flow nasal cannula and 3 patients required non rebreather mask or nasal cannula oxygen support. Three days after tocilizumab administration, 53 patients had no change in oxygen support requirements, 13 patients had reduced oxygen support requirements, and 2 patients required higher levels of oxygen support. For patients who remained on mechanical ventilation, there was a decrease in mean FIO2 requirement by 8.98%. There was a significant decrease in mean IL-6 by 129, CRP by 63, WBC by 1.71. Seven days after tocilizumab administration, 39 patients had no change in oxygen support requirements, 27 patients had reduced oxygen support requirements and 1 patient required higher levels of oxygen support. For patients who required mechanical ventilation, there was a decrease in mean FIO2 requirement by 13.36%. There was a significant decrease in mean IL-6 by 130, CRP by 107, WBC level by 2.87. There was no significant change in daily max temperature at day 3 or 7. CONCLUSIONS: In this cohort of 67 patients treated with tocilizumab for severe COVID-19, improvement in oxygen support requirements was seen in 13 patients at day 3 and 27 patients at day 7. Improvement in FIO2 and several markers of inflammation including WBC, CRP and IL-6 were seen at day 3 and 7. Further studies such as randomized placebo controlled trials of tocilizumab will be required to better measure its efficacy and safety in patients with COVID-19. CLINICAL IMPLICATIONS: Tocilizumab use in critically ill patients may reduce oxygen support requirements and laboratory markers of inflammation. Further studies are required to establish efficacy and safety. DISCLOSURES: No relevant relationships by Yasmin Herrera, source=Web Response No relevant relationships by Kam Sing Ho, source=Web Response No relevant relationships by Raymonde Jean, source=Web Response No relevant relationships by Joseph Poon, source=Web Response
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SESSION TITLE: Chest Infections Posters SESSION TYPE: Original Investigation Posters PRESENTED ON: October 18-21, 2020 PURPOSE: To study the impact of hydroxychloroquine on mortality and to determine the incidence of associated adverse effects among patients with COVID-19. METHODS: We performed a systemic search in PubMed, Scopus, Embase, and Google Scholar, and medRxiv (pre-print) using all available MeSH terms for COVID-19 and hydroxychloroquine. Two independent authors assessed the quality of studies, extracted data from included studies, and analyzed them using CMA version 3.3.070. RESULTS: In summary, the risk ratio of mortality was 0.95 [random effect;95% confidence interval (CI) 0.52-1.72, p=0.85], indicating that on an average, patients receiving hydroxychloroquine had a 5% less likelihood of dying compared to those without hydroxychloroquine. However, this impact on mortality was not statistically significant given that the confidence interval was between 0.52-1.72 (p=0.85). The variation in effect size was assessed by Q-value (16.9, df=4), I² (76.4%), and T² (0.56). Based on the I², 76.4% of the variance in observed effects reflects variance in true effects rather than sampling error. Publication bias, a concern where studies included in the analysis could be a non-random subset of all studies, were assessed by the Begg’s (p=0.5) and Egger’s test (p=0.95), which demonstrated no significant publication bias. Among patients who received hydroxychloroquine, 79.2% of patient tested negative for SARS-CoV-2 on nasopharyngeal PCR by day 5 (endpoint: viral clearance, random effect;95% C.I 56.6-91.4), and 67.5% of patients from randomized clinical trials tested negative for SARS-CoV-2 by day 6 (random effect;95% C.I 44.1-80.9). The Q-value was 41.2 (df=3), I² was 92.7%, and T² was 1.33 from the observational studies. Given that the confidence interval was overlapping between the hydroxychloroquine and the control group, we could not conclude there was a considerable difference in viral clearance to hydroxychloroquine. Finally, the use of hydroxychloroquine was not without risks. We report an overall adverse event rate of 8.2% (random effect;95% CI 3.1-20.0) and diarrhea was the most common event. CONCLUSIONS: Hydroxychloroquine has not shown significant clinical benefits for the treatment of COVID-19 and larger clinical trials are needed. CLINICAL IMPLICATIONS: Despite promising results from in vitro studies, hydroxychloroquine has not shown comparable clinical benefits among COVID-19 patients. To date, many of these findings are derived from observational studies and data from ongoing larger clinical trials will be invaluable in determining the ultimate utility of hydroxychloroquine as adjunctive therapy versus COVID-19. DISCLOSURES: No relevant relationships by Yasmin Herrera, source=Web Response No relevant relationships by Kam Sing Ho, source=Web Response No relevant relationships by Archana Pattupara, source=Web Response No relevant relationships by Justin Poon, source=Web Response No relevant relationships by Joseph Poon, source=Web Response No relevant relationships by David Steiger, source=Web Response
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SESSION TITLE: Chest Infections Posters SESSION TYPE: Original Investigation Posters PRESENTED ON: October 18-21, 2020 PURPOSE: To understand the characteristics, comorbid conditions, and clinical outcome of patients hospitalized with coronavirus disease 2019 (COVID-19) in the US. METHODS: This analysis included data from 7 acute care hospitals in the Mount Sinai Health System, which serves approximately 3.5 million patients in the New York metropolitan area. We included all consecutively hospitalized adults between March 1st to May 10th, 2020, who had a positive polymerase-chain-reaction testing (RT-PCR) for SARS-CoV-2 infection by nasopharyngeal or oropharyngeal swab and who had a completed hospital course (discharged alive or died) at time of analysis, May 15th, 2020. Initial testing for SARS-CoV-2 was conducted by the New York State Department of Health until March 15, 2020, when internal testing was available at the Mount Sinai laboratory. Patients who died or who were transferred to another facility within 24 hours after hospital admission were excluded from the analysis. The study used de-identified data from the Mount Sinai Data Warehouse (MSDW) ‒ “COVID-19 Project”. The Mount Sinai COVID-19 Clinical Research Protocol Review Committee approved this study and the institutional review board of Icahn School of Medicine at Mount Sinai exempted the research project from approval as it is a retrospective review of already collected, de-identified data. RESULTS: A total of 4,903 consecutive admissions with RT-PCR confirmed COVID-19 were admitted to seven Mount Sinai Hospitals between March 1st to May 10th, 2020. Among these 4313 patients 1270 died during their hospitalization while 3043 were successfully discharged as demonstrated in Figure 1. The mean age of the study population was 65.08 ± 16.8, with a male predominance (56.6%) as outlined in Table 1. Hypertension, diabetes, chronic kidney disease, smokers, a history of chronic obstructive pulmonary disease, and a history of smoking were significantly more common among non-survivors (all p<0.05). Inflammatory biomarkers were examined in patients on admission (Table 1). Survivors were more likely to have a lower mean level of CRP, D-dimer, procalcitonin. CONCLUSIONS: In this case series, we described our early clinical experience with COVID-19. We illustrated the characteristics, comorbid conditions, and clinical outcome of sequentially hospitalized patients with confirmed COVID-19 in New York City. CLINICAL IMPLICATIONS: In this case series that included 4313 patients hospitalized with COVID-19 in New York City, 56% were male and 45% were Hispanics. The most common comorbidities were hypertension (35%) and diabetes (23%), and 56% had a Charlson Comorbidity Index of 3 or greater. While 72% of hospitalized patients had moderate disease and 13% required intubation. Overall, 70.5% (n=3043) of Covid-19 patients were discharged and 29.4% (n=1270) died at the time of analysis. DISCLOSURES: No relevant relationships by Yasmin Herrera, source=Web Response No relevant relationships by Kam Sing Ho, source=Web Response No relevant relationships by Archana Pattupara, source=Web Response No relevant relationships by Joseph Poon, source=Web Response No relevant relationships by Justin Poon, source=Web Response No relevant relationships by David Steiger, source=Web Response