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SESSION TITLE: Racial Disparities in Pulmonary Embolism Risk Factors and Mortality in the SESSION TYPE: Original Investigations PRESENTED ON: 10/17/2022 1:30 pm - 2:30 pm PURPOSE: Racial disparities in pulmonary embolism (PE) related mortality rates have been reported for decades in the United States (US). The risk factors contributing to the observed disparity remain unclear. Our objective is to examine recent PE-related mortality trends and PE risk factors by race. We hypothesize racial disparity gap in PE-related mortality and risk factors has persisted and might have widened with the COVID 19 pandemic. METHODS: The Centers for Disease Control and Prevention (CDC) wide-ranging online data for epidemiologic research for both underlying cause of death (UCOD) and multiple causes of death (MCOD) in the US between the years 1999-2020 was used for this study. Non-Hispanic black (NHB) and non-Hispanic white (NHW) decedents aged 25 years and older with an ICD-10 code for PE (I26) were included. Age-adjusted mortality rates (AAMR) with 95% Confidence Intervals (CIs) were computed by race for age groups, year, Health & Human Services (HHS) regions, and urbanization and PE risk factors. Risk factors examined were trauma, cancer, cardiovascular diseases, obesity, sepsis, chronic lower respiratory diseases, and COVD-19 among PE decedents. RESULTS: Between the years 1999-2020, PE was the UCOD in 168,540 decedents, with 137,128 (81.4%) NHWs and 31,412 (18.6%) NHBs. The overall age-adjusted mortality rate (AAMR) decreased from 1999(5.3;95% CI, 5.2 - 5.4) to 2009(3.6;95% CI, 3.5 - 3.7), and then increased from 2010(3.8;95% (3.7 - 3.8) to 2020(4.2;95% CI, 4.1 - 4.3).There was a steep rise in the overall AAMR for 2020 (4.2;95% CI, 4.1 - 4.3) compared to the year prior 2019 (3.9;95% CI, 3.8 - 4.0) with highest annual % change among NHBs when compared to NHWs (NHB men (13%), NHB women (15%), NHW men (8.3%), NHW women (6%).) NHB men (AAMR 7.2;95% CI, 7.1-7.4) and NHB women (AAMR 6.6;95% CI, 6.5-6.7) had 2-fold higher AAMR compared to NHW men (AAMR 3.8;95% CI, 3.8-3-9) and NHW women (AAMR 3.7;95% CI, 3.7-3.7). Similar trends were also noted in geographical regions. The highest AAMRs were in HHS regions 3, 4, 5,6, 7, and 8. Within these HHS regions, NHBs and NHWs who resided in small metro and non-metropolitan areas had the highest AAMRs. However, NHB-NHW disparity in AAMR was seen in all 10 HHS regions and Urbanization. When risk factors such as trauma, cancer, obesity, cardiovascular diseases, sepsis, and chronic lower respiratory diseases were each mentioned as MCOD with PE decedents, rates varied by risk factor but NHBs had consistently higher AAMR than NHWs. CONCLUSIONS: We showed that PE-related mortality has increased over the past decade and racial disparities persisted and varied by gender, region, urbanization, and risk factors. The decades-long disparity observed in PE-related mortality may be narrowed by allocating resources to the management of common comorbidities. CLINICAL IMPLICATIONS: Racial disparity in PE-related mortality is related to comorbidities listed in MCOD data. DISCLOSURES: No relevant relationships by Isaac Ikwu No relevant relationships by Alem Mehari No relevant relationships by Lamiaa Rougui
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INTRODUCTION:Coronavirus-2 disease 2019 (COVID-19) is a novelty virus that caused a worldwide pandemic. It can cause mild to critical illness requiring intensive care unit (ICU) admission. In the United States, Black and Hispanic individuals comprise a disproportionately high number of infections and deaths due to COVID-19, likely related to underlying social and healthcare disparities.1,2 There are limited studies identifying predictors of outcome among COVID-19,3 in minority patients. The aim of this study was to identify the predictors of mortality among laboratory confirmed COVID-19 minority patients with severe clinical disease admitted to the ICU. METHODS:Clinical data at the time of ICU admission was extracted from electronic records for a total of 95 sequentially admitted patients to the medical ICU with confirmed COVID-19 diagnoses. Demographics, comorbidities, laboratory values that included inflammatory markers, ICU course, mortality and discharge status data were collected. The primary outcome was ICU mortality treated as a binary outcome. Summary characteristics were described based on survival status with a test of significance using ANOVA, kwallis and chisquare as appropriate. A univariate logistic regression was used to identify mortality predictor variables of statistical significance which were then included in a final multivariate regression model. Inflammatory markers were added individually to this finalized model to avoid collinearity. Findings were summarized using odds ratios and confidence intervals. RESULTS:The mean (SD) age was 61.54(14) years, 34(36%) were men, 67(71%) were African Americans and 20 (16%) were Hispanic. Most common comorbidities were hypertension 55 (58%) and diabetes 46 (48%). Fifty-three (56%) were intubated, 23 (25%) required pressor support, and 15 (16%) patients had their initial blood culture positive. Inflammatory markers were elevated in most all patients which was associated with mortality. ICU mortality was 48% (45 patients). Univariate analysis identified age ≥ 65yrs (odds ratio [OR]=1.25;95% CI,1.02-1.52;p= 0.032), higher SOFA scores of 2 and 3{ (OR=1.74, 95% CI ,1.05-2.89,p=0.035) and (OR=1.90,95%CI,1.1-3.29;p=0.024 respectively)}, vasopressor use ( OR=1.77;95%CI,1.44-2.18;p<0.001), severe ARDS (OR=;1.45;95%CI,1.05-2.01;p=0.027), mechanical ventilation use (OR=1.46;95%CI,1.22-1.79;p<0.001), procalcitonin>2.5ng/ml (OR=1.84;95% CI, 95%CI,1.03-3.29;p=0.042), ferritin>2000ng/ml (OR=1.45;95% CI,1.12-1.89;p=0.007), CRP>20mg/dl (OR=1.67 OR=;95CI,1.3-2.13;p<0.001) and LDH>400 (OR=1.68;95%C,1.26-2.23;p<0.001) as predictors of ICU morality. Of these, only age ≥ 65yrs, mechanical ventilation and vasopressor use remained statistically significant independent predictors of mortality in multivariable regression model. CONCLUSIONAmong predominantly minority patients with severe COVID-19 admitted to the ICU, older patients who become intubated, requiring vasopressor support and/or had elevated biomarkers of inflammation had a significantly higher ICU mortality.
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SESSION TITLE: Medical Students/Residents' COVID-19 SESSION TYPE: Med Student/Res Case Report PRESENTED ON: October 18-21, 2020 INTRODUCTION: The novel coronavirus disease 2019 (COVID-19) caused by the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) has been detected in nasopharyngeal swabs (NPS), sputum, bronchoalveolar lavage, blood, feces and ocular fluid(1). To date, there are no reported cases of SARS-CoV-2 isolated in pleural fluid, that is associated with a life-threatening complication, empyema. CASE PRESENTATION: He is a 64-year-old male with a known history of type 2 diabetes mellitus and hypertension who presented with a three-day history of progressive shortness of breath and generalized weakness which was preceded by a dry cough for a few weeks. He otherwise had no complaints or ill-contacts. On presentation, he was noted to be hypoxemic (saturation 93% on 4 liters of oxygen), tachycardic and afebrile. Initial exam was significant for mild respiratory distress and bilateral crackles on lung auscultation. Labs showed an elevated white blood cell count (11.6 x 10 6 ), troponin, D-dimer, ferritin and C-reactive protein. Serum interleukin-6 was elevated at 17.26 pg/mL. However, creatine phosphokinase, lactate dehydrogenase, transaminases and quantiferon gold were within normal limits. A chest x-ray was done that showed bilateral patchy infiltrates and a follow-up computerized tomography (CT) of the chest showed diffuse ground glass opacity with a large thick-walled septated mass in the left lower thorax. He was subsequently admitted for hypoxic respiratory failure likely secondary to COVID-19 pneumonia with superimposed bacterial infection complicated by possible empyema. Nasopharyngeal swab for SARS-CoV-2 was positive. Thoracentesis with chest tube placement revealed purulent material with pH of 6.5, that then later also tested positive for SARS-CoV-2. Final pleural fluid cultures grew pan sensitive Streptococcus pneumoniae. Pleural adenosine deaminase was elevated, however acid-fast bacilli cultures were no growth. He was treated with empiric antibiotics and the chest tube was removed after adequate drainage of empyema. He was discharged on room air to complete a course of oral antibiotics, self-quarantine and to follow-up in the pulmonary clinic after two weeks. DISCUSSION: Empyema is defined by the presence of bacteria or pus in the pleural space and is a well-documented sequela of pneumonia with mortality of up to 20%(2). The isolation of SARS-CoV-2 within the pleural fluid with a superimposed bacterial infection highlights the increased risk of self-quarantine and delayed treatment pose to the management of high-risk patients. The MuLBSTA score, a 90-day mortality predictor for viral pneumonia, recognizes co-bacterial infection as an additional risk factor for mortality(3). CONCLUSIONS: The presence of SARS-CoV-2 in body fluids such as pleural fluid has not yet been reported, nor are the implications known in regard to shedding duration and prognostication. Reference #1: Wang W, Xu Y, Gao R, et al. Detection of SARS-CoV-2 in Different Types of Clinical Specimens. JAMA. 2020;323(18):1843-1844. doi:10.1001/jama.2020.3786 Reference #2: Morris DE, Cleary DW, Clarke SC. Secondary Bacterial Infections Associated with Influenza Pandemics. Front Microbiol. 2017;8:1041. doi:10.3389/fmicb.2017.01041 Reference #3: Guo L, Wei D, Zhang X, et al. Clinical Features Predicting Mortality Risk in Patients With Viral Pneumonia: The MuLBSTA Score. Front Microbiol. 2019;10. doi:10.3389/fmicb.2019.02752 DISCLOSURES: No relevant relationships by Sahai Donaldson, source=Web Response No relevant relationships by Lorenzo Leys, source=Web Response No relevant relationships by Vishal Poddar, source=Web Response No relevant relationships by Lamiaa Rougui, source=Web Response