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Introduction: In this study we aimed to monitor the risk of breakthrough COVID-19 infection in pwMS on different Disease Modifying Therapies (DMT) included in RELACOEM, a LATAM registry of MS and NMOSD patients infected with and vaccinated against COVID-19. Method(s): retrospective cohort study conducted between May 2021 and December 2021. The primary outcome was the appearance of infection during the follow-up time (at least three months after complete vaccination (second dose)). Specific information was requested (vaccine received, dose, date, symptoms, COVID- 19 infection, need for hospitalization, ventilatory assistance, treatment, and evolution). The primary objective of the analysis was to compare the incidence of breakthrough SARS-CoV-2 infections among the vaccinated pwMS in each DMT group. These conditions entail a PCR-confirmed test, and a time lag of at least 14 days from a full vaccination cycle (after the second vaccination dose). Cumulative incidence was reported by Kaplan Meier survival curves as well as incidence density. Result(s): A total of 857 pwMS patients from eight countries in LATAM were included. Mean age was 44.3 +/-12 years. The most frequent treatment used was fingolimod in 171 (19.9%). Most frequent first and second dose received was Astra-Zeneca (33%). During follow-up, a total of 28 COVID-19 cases were observed for a total exposure time of 150.965 days. The overall cumulative incidence was 3.2% (SE 0.22%) with an overall incidence density (ID) of 1.8 x 10.000 patients/day (95%CI 0.2-3.2). Compared to other DMTs, the incidence rate of breakthrough infections was significantly higher on ocrelizumab (6.02 (95%CI=5.65-7.16, RR=5.17 95%CI 3.27-7.12) and rituximab (6.94 (95%CI=6.15-9.12, RR= 5.93 95%CI 3.55-7.32) compared with other DMTs. No significant differences in the risk of breakthrough were observed for vaccine subtypes. Conclusion(s): An increased risk of breakthrough COVID-19 infections was observed in patients treated with ocrelizumab and rituximab.
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Objective: The objective of the study was to evaluate the incidence of COVID-19 infections after vaccination in NMOSD patients included in RELACOEM, a LATAM registry of MS and NMOSD patients infected and vaccinated for COVID-19. Method(s): Retrospective cohort study developed between May 2021 to December 2021. The primary outcome was the appearance of infection during the follow up time (at least three months after complete vaccination (second dose)). Data was collected through the contact between the treating physician and the patient. Specific information was requested (vaccine received, dose, date, symptoms, COVID-19 infection, need for hospitalization, ventilatory assistance, treatment, and evolution). The primary objective of the analysis was to compare the incidence of breakthrough SARS-CoV-2 19 infections among the vaccinated pwMS in each DMT group. These conditions entail a PCR-confirmed test, and a time lag of at least 14 days from a full vaccination cycle (after the second vaccination dose). Cumulative incidence was reported by Kaplan Meier survival curves as well as incidence density. Result(s): A total of 49 NMOSD patients from eight countries in LATAM were included. Mean age was 43.8 +/-13 years. The most frequent treatment use was rituximab in 29 (59.2%). The mean follow up after the second dose was 149 +/- 32 days. Most frequent first and second dose received was Pfizer (28.6%), followed by Sinopharm (24.5%). During follow up a total of 2 COVID-19 cases were observed for a total exposure time of 8627 days. Cumulative incidence was 4.1% (SE 0.87%) with an overall incidence density of 2.31 x 10.000 patients/day (95%CI 1.13-3.71). Both cases occurred in patients under rituximab (2/29, exposure time 4208, IR 4.7 x 10,000 patients/day 95%CI 3.5-5.1). No hospitalizations were reported for both cases. Conclusion(s): We observed an ID of COVID-19 infection after vaccination of 2.31 x 10.000 patients/day in NMOSD patients.
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Background: After an historical absence of data, studies on MS epidemiology in Latin America (LATAM) have consistently increased since the foundation of LACTRIMS in 1999. The socioeconomic and political health impact of MS in the region remains to be established. Objectives: To assess the presence of MS frequencies in the different regions of LATAM and its reflection in local health policies and neurological care and education on the disease. Methods: Thematic presentations from 10 biennial LACTRIMS meetings (2000-2019) and recent publications on Latin American epidemiology cited in PubMed (2012-2020) assessing content for societal effects and policy provided the framework for this study. Official statement of principles (SOP) from 16 MS organizations representing 14 different countries from the Latin American MS organizations Network (LATEM) were included. Since 2018, LATEM's positions derive from input led by ASOGEM (Guatemala);APEMED (Paraguay);ALEM (Colombia) and ABEM (Brazil). Other groups explored for SOP) were 'Renacer' (Dominican Republic), ESMUP (Peru), ALCEM and EMA (Argentina), EMUR (Uruguay), FEMMEX (Mexico) and FUCACEM (MS Central American and Caribbean Foundation). Determination of societal impact was assessed by the development of registered local neurological MS study groups, or events of significance including legal accomplishments or governmental determinations improving education and care of MS. Results: The MS International Federation and the WHO place the prevalence of disease for the majority of countries in LATAM from very low (0-5/100,000) to low-to-moderate (5.5-20/100,000). Two areas, a Monterrey's suburb in northeast Mexico (25° N), and Buenos Aires, Argentina (34° S) show moderate frequencies (30/100,000), while the highest prevalence in LATAM is noted in Puerto Rico (77.7/100,000). Countries with a large geographic extensions show zonal differences. Prevalence data from 15 countries is available. Only four national incidence studies: Panama, Uruguay, Chile and Argentina, exist. A study from the six Central American countries and three Spanish-speaking Caribbean country islands (Cuba, Puerto Rico and Dominican Republic) show high index of EDSS disability > 3.5 (37%) among the subjects included in these series, hence potentially reflecting into additional socioeconomic burden to the local communities. Eight CTRIMS national associations have developed in the region, all functioning as LACTRIMS' chapters. Another multinational study group from Central America and the Caribbean emerged recently as a forum (FOCEM). Recent virtual discussions emphasized every effort to avoid the COVID-19 pandemic to disrupt access to MS therapies in the region. The organizations play a determining role in preventing the indiscriminate approval by uninformed local health agencies of medications lacking safety and efficacy evidence, i.e. biosimilar products (ASOGEM). Conclusions: The emergence of MS in the Americas, despite its reportedly low epidemiologic frequencies, has affected importantly the socioeconomic health regional systems. Initiatives to integrate the neurological community with MS organizations and stakeholders to improve MS education, its management, and access to quality therapy in LATAM appear thus far to be a regionwide unifying tendency.
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Background Our 2019 survey showed 50% of geriatricians had burnout by Maslach Burnout Inventory (MBI), 79% had electronic medical record (EMR) frustration, 54% spent >60 minutes on the EMR outside of workday and 32% spent >60 minutes/day on clerical work. The COVID-19 pandemic added to the strain. In September 2020, 69% of our geriatricians reported in-basket management makes them feel “most overwhelmed.” Prior research shows the benefit of nonphysician staff reviewers for in-basket messages. We will improve geriatrician well-being and productivity with a new Patient Coordinator In-basket Scrubber Intervention. Methods We will target 21 geriatricians providing primary care to older adults at three outpatient sites. We will recruit and train two Patient Coordinators (PCs) who will lead a novel In-basket Scrubber intervention. Initially, the PCs will be the first contact to scrub (screen and send to correct team member) all in-basket messages from the call center. They will identify inefficient communication patterns, code messages by “team member” and “domain” and determine the destination and/or outcome of the messages. The PCs will train administrative assistants (AAs) to assess, complete and/or appropriately redirect providers' in-basket messages to team nurses, social workers or the physician. We will also target our telehealth workflow to improve scheduling and appointment confirmation, reduce no-shows and convert canceled visits to tele-visits, thereby increasing reimbursable visits. Results Results forthcoming. At months 0, 6, 12, and 18, we will assess physician EMR burden, well-being, and productivity. Measures include: EMR burden (Number of Inbox Inputs per workday, Time in Inbox per workday, Work after Work 7pm to 7am);Well-being (Subjective Inbox Burden, Maslach Burnout Inventory);Productivity (In-person visits Televisits, Medicare Annual Wellness Visits, advance care planning bills, chronic care management bills, work relative value units). We expect the intervention to reduce EMR burden and improve well-being and productivity. We also expect new revenue to offset costs. By reducing clerical burden and optimizing billable time for care coordination, we expect to double our Chronic Care Management billing (estimated $75,000/year). Conclusions We will improve geriatrician well-being through a new In-basket Scrubber Intervention.
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Introduction: Covid-19-associated rhabdomyolysis has not been clearly established;therefore, clinicians might have low clinical suspicion for rhabdomyolysis Case Description: We are presenting five cases where Covid-19 patients became very catabolic and developed rhabdomyolysis associated with acute kidney injury (AKI). Symptoms were shortness of breath, fever, generalized malaise one week before the presentation. At the time of admission all patients had fever, tachycardia, tachypnea and were hypoxemic. One day later they were intubated for tachypnea and worsening oxygen saturation. They were admitted to the intensive care units and were treated with intravenous hydration. All the patients eventually required pressor support. AKI developed 10 days after onset of the symptoms and it was attributed to cytokine storm, ischemic acute tubular necrosis, and rhabdomyolysis. Intravenous furosemide was attempted with poor responses. Renal replacement therapy (RRT) was needed approximately three days after development of AKI. Continues renal replacement therapy (CRRT) was the modality used. After 3 days of interrupted therapy due to clotting, there was not improvement and overall high mortality. Discussion: Rhabdomyolysis has been associated with many infectious diseases, including viral infections. The direct viral invasion and circulating viral toxins may directly destroy muscle cell membranes leading to rhabdomyolysis. However theexcessive immune response and cytokine storms which often seen in COVID-19 can promote to high catabolic state and rhabdomyolysis and therefore it will contribute to rapid worsening on renal function. Early detection and promptly supportive treatment with RRT may help to improve the vital prognosis of COVID-19.
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Background: Angiotensin converting enzyme (ACE 2) receptor has been implicated as an entry point for severe acute respiratory syndrome coronavirus 2 (SARS-COV-2) causing pandemic coronavirus disease 2019 (COVID-19). Experts have postulated the potential benefits of using ACEI/ARB to reduce the severity of acute lung injury and as the treatment of hypertension in COVID-19. However, there is limited data in showing the renal outcomes after the use of angiotensin converting enzyme inhibitors (ACEIs) and angiotensin II receptor blockers (ARBs) in COVID-19 patients. Methods: This is a retrospective, single center study of 300 patients diagnosed with COVID-19 confirmed by real-time reverse transcription polymerase chain reaction. Four groups were divided based on ACEI/ARB exposure. Group 1 (n=51 patients;17%) were initiated on ACEIs/ARBs during hospitalization, group 2 (n=58 patients;19%) were on ACEIs/ARBS at home and discontinued, group 3 (n=76 patients;25%) were on ACES/ ARBS at home and continued during hospitalization and group 4 (n=116 patients;38%) were never treated with ACEIs/ARBS. The primary end points including the incidence of AKI using KDIGO definition, hyperkalemia, the necessity of dialysis and the secondary end points being the length of total hospital stays, the recovery rate, mortality rate were compared between group 1,2,3 with 4 using adjusted odd ratios (ORs). Results: In group 1, the use of ACEI/ARB has 4 times higher risk of developing AKI than the control group 4 (P= 0.001, 95% CI of 1.70-9.59). and is 4.6 times for stage 2 or above AKI (P= 0.001;95% CI of 1.8-11.5). OR for hyperkalemia is 5.7 (P= 0.001, 95% CI of 2.09-15.5) and for hemodialysis is 3.7 (P= 0.02, 95% CI of 1.2-11.2). Their mortality rate is increased 2.9 times (P=0.026, 95% CI of 1.23-7.44). In group 2, the incidence of AKI is 7.5 times higher (P= <0.001, 95% CI of 3.3-17) and 3.5 times (P=0.001, 95% CI of 1.6-7.7) for stage 2 above AKI. OR for the initiation of hemodialysis and the mortality rate are not statistically significant after adjusted with variables. In group 3, no statistically significant data were found. Conclusions: Our findings suggest that the initiation of ACEI/ARB in COVID 19 patients have increased risk of AKI, hyperkalemia, necessity of dialysis and mortality rate.
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Background: Coronavirus disease 2019 (COVID-19) emerged from China in late 2019 as a respiratory disease of unknown cause. A novel coronavirus 2019-CoV was implicated as the cause. A high proportion of patients goes into septic shock from COVID- 19infection and develop acute kidney injury (AKI) which often requiring continuous renal replacement therapy (CRRT). Clinical experience has suggested that these patients are hypercoagulable with studies showing increased rates of thrombosis. This complicates the administration of CRRT as this leads to more frequent clotting of the dialysis catheter and sequelae of blood loss, time off dialysis, and increased use of resources Methods: We retrospectively audited all patients admitted at our center from February to April 2020 who developed severe AKI requiring CRRT and compared the number of CRRT clotted in the first 7 days in COVID-19 negative (N = 49) and positive (N = 55) patients. Pediatric patients were excluded from this analysis. We also collected data on other variables which may influence rate frequency such as location of catheter, INR, and presence of systemic anticoagulation Results: We found that patients who tested positive for COVID-19 had a higher number of clotting events in the first 7 days of CRRT (3.51 vs 1.63, p < 0.00008). This population had higher incidence of AKI vs ESRD, number of pressor, and PEEP. Also, COVID 19 patients on anticoagulation has decreased clotting frequency compare to COVID 19 positive patients not on anticoagulation (2.7 vs 4.3, P <0.05) Conclusions: This data confirms our clinical experience that coagulopathy in COVID-19 positive patients lead to a greater incidence of CRRT clotting and the use of systemic anticoagulation was effective in reducing the number of clotting events.