OUTCOMES FROM CATHETER-DIRECTED EMBOLECTOMY VERSUS SURGICAL PULMONARY EMBOLECTOMY FOR PATIENTS WITH ACUTE PE

SESSION TITLE: Late Breaking Procedures Posters SESSION TYPE: Original Investigation Posters PRESENTED ON: 10/18/2022 01:30 pm - 02:30 pm PURPOSE: Mortality from intermediate risk (IR) Pulmonary Embolism (PE) ranges from 1.9% to 14.5% and exceeds 31% in high risk (HR) PE. Catheter based therapies for IR PE offer an alternative to parenteral thrombolysis, and catheter directed embolectomy (CDE) may be associated with a low risk of bleeding. Surgical Pulmonary Embolectomy (SPE) is performed when thrombolysis is contraindicated or advanced therapies for IR, or HR PE have failed. Our aim was to compare the safety and efficacy of CDE versus SPE. METHODS: We performed a retrospective review of 34 consecutive patients with acute PE diagnosed by Chest CT angiography (CTA) admitted to three urban teaching hospitals from 8/2019-12/2021, who received FlowTriever Retrieval/Aspiration suction thrombectomy (CDE), or SPE. RESULTS: 15 patients received SPE, and 19 patients received CDE. Indications for SPE included failed CDE due to cardiac arrest n=1, failed catheter thrombolysis n=1, hemodynamic instability, and CTA evidence of chronic thrombi, or distal thrombi not accessible to CDE. All SPE had high clot burden, and echo evidence of RV failure. All following data are presented as SPE vs CDE. There was no statistically significant difference between both cohorts with respect to;female (%) (47 Vs 58), race, initial systolic BP (126 Vs 122 mmHg), and heart rate (101 Vs 99/min). Mean age was higher for CDE (56.4 Vs 67.6, p< 0.05). SPE patients had higher rate of dyspnea (93% Vs 53%) and longer duration of symptoms. PESI score (105 Vs 131) and PESI class were similar (p> 0.05). SPE patients included 53% IR and 47% HR, and CDE patients included 53% IR and 47% HR. On CTA, saddle PE was seen in SPE group (53% Vs 39%, p = 0.63) and 1 patient from SPE group and 2 patients from CDE group had clot in transit. Mean troponin 0.41 Vs 0.28, BNP 275 Vs 317, and D-dimer 8.5 Vs 16.5 were not significantly different. Procedure time was shorter for CDE (median 243 Vs 93 minutes, p<0.001). Median hospital length of stay (LOS) was similar (7.7 Vs 7 days p= 0.579), but median ICU LOS was shorter in CDE group (128 Vs 46.3 hours p<0.001). Survival rate on discharge was 93.4% Vs 89.5% (SPE Vs CDE). Causes of 30-day post procedure mortality included cardiac arrest due to RV failure and hypotension after CDE (10.5%). There was no 30-day post procedure mortality in the SPE cohorts. One death occurred 60 days post SPE for massive PE, from complications related to severe COVID-19 pneumonia. Major bleeding (need for 2 units PRBC) occurred in 27% Vs 5.3% following SPE Vs CDE. CONCLUSIONS: Acute PE patients who received CDE were older, had a shorter duration of symptoms, less dyspnea, reduced procedure time and shorter ICU stay vs SPE treated patients, but similar length of stay. CLINICAL IMPLICATIONS: CDE and SPE provided satisfactory results and SPE was effective for patients who had worse dyspnea, distal and or more chronic thrombo-emboli. DISCLOSURES: No relevant relationships by Samuel Acquah No relevant relationships by Hafiza Noor Ul Ain Baloch No relevant relationships by Madeline Ehrlich No relevant relationships by Yoshiko Ishisaka No relevant relationships by Omar Lattouf no disclosure on file for Robert Lookstein;No relevant relationships by Janet Shapiro No relevant relationships by David Steiger

The characteristics and outcomes of critically ill patients with COVID-19 who received systemic thrombolysis forpresumed pulmonary embolism: An observational study

Background : Coronavirus disease 2019 (COVID-19) is associated with abnormal hemostasis, autopsy evidence of systemic microthrombosis, and a high prevalence of venous thromboembolic disease (VTE). Tissue plasminogen activator (tPA) has been used in COVID-19 patients with severe hypoxia with high clinical suspicion of pulmonary embolism (PE). Aims : We aimed to describe the clinical outcomes of critically ill COVID-19 patients who received tPA. Methods : A retrospective cohort study was conducted on 6,095 hospitalized COVID-19 patients in the Mount Sinai Health System at 5 hospitals in New York. 57 patients with COVID-19, who were admitted from 3/10 to 4/27, 2020 and received tPA for presumed PE were included in the analysis. Baseline demographic and clinical characteristics, indication for tPA, and overall mortality were reported. Results : Among the 57 patients who received tPA, the mean age was 60.8 ± 10.8 years, and 71.9% (41/57) were male. PE was suspected among 75.4% (43/57) of patients with supporting findings who had rapidly worsening hypoxia or hypotension. Right ventricular (RV) strain was present in 15.8% (9/57), deep venous thrombosis (DVT) in 7.0% (4/57), increased dead space ventilation (V d ) in 31.6% (18/57) of patients. RV strain and RV thrombus were present in 3.5% (2/57), RV strain and DVT in 5.3% (3/57), RV strain and increased V d in 8.8% (5/57), and DVT and increased V d in 3.5% (2/57) of patients. No chest CT angiography was performed for any patients due to clinical instability from critical illness. Following tPA infusion, 49.1% (28/57) of patients demonstrated improvement in either of PaO 2 /FiO 2 ratio, blood pressure or partial arterial carbon dioxide. Bleeding complication was seen in 1 patient. Six patients (10.5%) survived to hospital discharge. Overall mortality was 89.5% (51/57). Conclusions : The overall mortality of critically ill COVID-19 patients who received tPA for presumed PE was 89.5 %. The utility of tPA for this indicaition warrants further studies.

A NOVEL EVIDENCE-BASED PREDICTOR TOOL FOR HOSPITALIZATION AND LENGTH OF STAY: INSIGHTS FROM PATIENTS WITH COVID-19 IN NEW YORK CITY

TOPIC: Chest Infections TYPE: Original Investigations PURPOSE: Coronavirus disease 2019 (COVID-19) has infected more than 150 million people worldwide. Predictive models for key outcomes can optimize resource utilization and patient outcome as outbreaks continue. We aimed to design and internally validate a web-based calculator predictive of hospitalization and length of stay (LOS) in a large cohort of COVID-19 positive patients presenting to the Emergency Department (ED) in a New York City health system. METHODS: The study cohort consisted of consecutive adult (>18 years) patients presenting to the ED of one of the Mount Sinai Health System hospitals between March, 2020 and April, 2020 who were diagnosed with COVID-19. Logistic regression was utilized to construct predictive models for hospitalization and prolonged (>3 days) LOS. Discrimination was evaluated using area under the receiver operating curve (AUC). Internal validation with bootstrapping was performed, and a web-based calculator was implemented. RESULTS: From 5859 patients, 65% were hospitalized. Independent predictors of hospitalization included older age (OR=6.29;95% CI [1.83-2.63], >65 vs. 18-44), male sex (OR=1.35 [1.17-1.55]), chronic obstructive pulmonary disease (OR=1.74;[1.00-3.03]), hypertension (OR=1.39;[1.13-1.70]), diabetes (OR=1.45;[1.16-1.81]), chronic kidney disease (OR=1.69;[1.23-2.32]), elevated maximum temperature (OR=4.98;[4.28-5.79]), and low minimum oxygen saturation (OR=13.40;[10.59-16.96]). The mean LOS was 7.3 days (SD=5.3 days;median=6 days;IQR=6 days). Predictors of extended LOS included older age (OR=1.03 [1.02-1.04], per year), chronic kidney disease (OR=1.91 [1.35-2.71]), elevated maximum temperature (OR=2.91 [2.40-3.53]), and low minimum percent oxygen saturation (OR=3.89 [3.16-4.79]). AUCs of 0.881 and 0.770 were achieved for hospitalization and LOS, respectively. Elevated levels of CRP, creatinine, and ferritin were key determinants of hospitalization and LOS (p<0.05). A calculator was made available under the following URL: https://covid19-outcome-prediction.shinyapps.io/COVID19_Hospitalization_Calculator/ CONCLUSIONS: This study yielded internally validated models with good discrimination that predict both the need for hospitalization in COVID-19 patients presenting to the ED, and the risk of prolonged hospitalization among admitted patients. Older age, chronic kidney disease, fever, and oxygen desaturation predicted the need of hospitalization and extended LOS. Additional predictors for hospitalization included male gender, chronic obstructive pulmonary disease, hypertension, and diabetes. CLINICAL IMPLICATIONS: We developed a practical tool predicting hospitalization risk in patients presenting to the ED diagnosed with COVID-19. This tool can be used to optimize resource allocation, help guide quality of care, and assist in designing future studies on the triage and management of patients with COVID-19. DISCLOSURES: No relevant relationships by Jeeyune Bahk, source=Web Response No relevant relationships by Maan El Halabi, source=Web Response No relevant relationships by James Feghali, source=Web Response No relevant relationships by Kam Sing Ho, source=Web Response No relevant relationships by Judy Huang, source=Web Response No relevant relationships by Joseph Mathew, source=Web Response no disclosure on file for Bharat Narasimhan;No relevant relationships by Georgina Osorio, source=Web Response No relevant relationships by David Steiger, source=Web Response No relevant relationships by Paulino Tallón de Lara, source=Admin input No relevant relationships by Juan Wisnivesky, source=Web Response

Acute venous thromboembolism occuring many months following acute COVID-19

Introduction: Patients with severe coronavirus disease 2019 (COVID-19) develop a coagulopathy associated with elevated D-dimer levels, venous thromboembolism (VTE), disseminated intravascular coagulation (DIC) and bleeding. Autopsy studies of COVID-19 patients have demonstrated fibrin thrombi in small vessels and capillaries. Increase in proinflammatory cytokines secondary to COVID-19 may play a direct role in creating a prothrombotic state. VTE rates have been described in greater than 20-30% despite prophylactic anticoagulation. There is a paucity of literature describing VTE after hospital discharge in patients with COVID-19. Recommending extended thromboprophylaxis post discharge has been considered in COVID-19 patients at low bleeding risk. We hypothesized that the hypercoagulable state conferred by COVID-19 may last many months following discharge. Methods: We analyzed data from 9 consecutive patients, post diagnosis COVID-19, admitted with acute VTE to two hospitals in the Mount Sinai Health System, New York City. Results: COVID-19: 55.5% patients had COVID-19 that did not require hospitalization. No patients developed VTE. The mean age was 63 years, and 33.3% were female. Risk factors for VTE in addition to recent COVID-19 included obesity (44%), prior VTE (22.2%), active malignancy (11.1%), sickle cell disease (11.1%). Patients hospitalized for the index diagnosis COVID-19 had elevated mean D-dimer (75%) and CRP. Two (50%) patients received corticosteroid therapy. Two patients were discharged on therapeutic anticoagulation for a pre-existing condition. VTE Admission: The mean time of the last positive PCR swab COVID-19 test and admission for VTE was 88 days (SE: 32 days). All patients presented with SOB, 33.3% had a cough. Mean D-dimer level was 6.8 ug/mL (SE: 2.8), of which two had levels above the standard reference range of 20 ug/mL. Five (55.5%), and four (44.4%) patients were classified as Intermediaterisk, and low-risk for mortality, respectively as per ESC guidelines. Two (22.3%) had lower extremity DVT. All were treated with systemic anticoagulation, one patient received catheter directed thrombolysis, and none developed major bleeding during hospitalization. Discharge treatment included DOAC (77.7%), Low Molecular Weight Heparin (11.1%), and coumadin (11.1%). All patients survived to discharge, and there were no major bleeding events. Conclusion: VTE can occur after a significant time following acute COVID-19 in patients hospitalized and those treated as outpatients. The hypercoaguable state conferred by COVID-19 may last many months after the acute illness. Extended VTE prophylaxis should be considered for patients following COVID-19 if the bleeding risk is low, and there are additional independent risk factors for VTE.

PNEUMOMEDIASTINUM AS A COMPLICATION OF COVID-19: MAY NOT NEED INTERVENTION

SESSION TITLE: Late-breaking Abstract Posters SESSION TYPE: Original Investigation Posters PRESENTED ON: October 18-21, 2020 PURPOSE: Evaluate patients with pneumomediastinum (PTM) as a complication of coronavirus 2019 (Covid-19) infection and their outcomes. METHODS: Data was obtained by retrospective analysis of a database of Covid-19 patients, admitted to two New York hospitals from March 25th to April 26th, 2020. Identified 13 patients with PTM as a complication of Covid-19. RESULTS: Median age of patients was 67 years, 7 (54%) were men, and 1 patient had pre-existing emphysema. Presenting symptoms included dyspnea (13/13, 100%), fever (10/13, 77%), and cough (9/13, 69%);none had chest pain. Median presenting SaO2/FiO2 ratio was 359. Pneumomediastinum was diagnosed on presentation in 2 patients (15%), during hospitalization but prior to invasive mechanical ventilation in 4 patients (31%), and after invasive mechanical ventilation in 7 patients (54%). Six patients had CT scans confirming the diagnosis of PTM. Twelve of the 13 patients were initiated on mechanical ventilation at median 5.5 days. Four patients (31%) developed pneumothoraces and 1 patient required bilateral chest tube drainage. Tension pneumothorax, tension pneumopericardium, and chest wall compartment syndrome were not observed in our cohort. Pneumomediastinum self-resolved in 5 patients (38%) while on mechanical ventilation. (Fig. 1) Seven out of 12 intubated patients (58%) underwent prone ventilation without worsening of PTM. One patient was discharged home, 10 patients expired, and 2 patients remain hospitalized. CONCLUSIONS: Pneumomediastinum is a known sequelae of noncompliant lungs in severe acute respiratory distress syndrome (ARDS), typically in the setting of positive pressure delivered with invasive mechanical ventilation. Our cohort had a low prevalence of predisposing risk factors such as emphysema, and a high mortality. Pneumomediastinum was not strongly associated with mechanical ventilation, as nearly half (6/13) of the patients developed PTM prior to intubation. CLINICAL IMPLICATIONS: In our cohort, findings of PTM may be attributed to two main etiologies converging: damage from Covid-19 and self-inflicted increases in transpulmonary pressures. We postulate that impaired surfactant production from type II pneumocytes may predispose to atelectrauma leading to diffuse alveolar injury and risk of rupture, unlike in typical ARDS where barotrauma occurs in the context of poorly compliant lungs. Moreover, the increased work of breathing and pronounced cough seen in Covid-19 pneumonia may lead to increased transpulmonary pressures resulting in PTM. Reductions in transpulmonary pressures after intubation with initiation of sedation and neuromuscular blockade may explain the resolution of PTM in spite of invasive ventilation. Given the high mortality we observed, early identification and initiation of methods to reduce transpulmonary pressures is imperative to reduce risk of further complications. DISCLOSURES: No relevant relationships by Young Im Lee, source=Web Response No relevant relationships by Nan Li, source=Web Response No relevant relationships by Joseph Mathew, source=Web Response No relevant relationships by Lina Miyakawa, source=Web Response No relevant relationships by Paru Patrawalla, source=Web Response No relevant relationships by Paru Patrawalla, source=Web Response No relevant relationships by Adam Rothman, source=Web Response No relevant relationships by Vishad Sheth, source=Web Response No relevant relationships by David Steiger, source=Web Response No relevant relationships by Jigna Zatakia, source=Web Response

EFFICACY OF EARLY PRONE POSITIONING IN PATIENTS WITH COVID-19 PNEUMONIA REQUIRING SUPPLEMENTAL OXYGEN, HIGH FLOW NASAL CANNULA, OR NONINVASIVE VENTILATION

SESSION TITLE: Respiratory Care Posters SESSION TYPE: Original Investigation Posters PRESENTED ON: October 18-21, 2020 PURPOSE: To assess the effect of awake prone positioning (PP) in non-intubated patients with COVID-19 pneumonia and acute hypoxic respiratory failure on oxygenation, escalation to ICU, and mortality. METHODS: A prospective observational cohort study was conducted on a dedicated COVID-19 respiratory step-down unit within an urban, tertiary care, teaching hospital from 4/30/20-5/31/20. The unit was managed by internal medicine residents and hospitalists. Inpatients with documented COVID-19 pneumonia and those under investigation who required supplemental oxygen (nasal cannula, non-rebreather face mask, high flow nasal cannula, non-invasive ventilation) were encouraged to self-prone for at least 30 minutes and up to 4 hours per day (in 2, 2 hour sessions) for 3 to 5 days. Exclusion criteria: inability to provide verbal consent, inability to self-prone or change position, primary team’s safety concerns, inability to protect airway, impending intubation, acute VTE diagnosed in the past 48hr, hypotension, recent intubation or ICU stay during the current admission. SpO2, oxygen delivery modality, and S/F ratios were monitored during PP and until discharge. All patients received usual COVID-19 care according to local institutional guidance. RESULTS: 22 patients were screened for study inclusion, 14 patients were enrolled, 1 could not tolerate PP due to back pain and 2 were transferred to the ICU within 24 hours of enrollment. Of the 11 subjects ultimately analyzed, 55% were male, 45% were female, median age was 55. 2 had underlying lung disease and 2 had no comorbid conditions. 2 died during admission (both DNI), 9 were discharged home, and none were intubated. Only one required home oxygen on discharge. 9 of 11 patients (82%) successfully completed at least 3 days of PP. The median cumulative time spent prone was 10 hours, the mean was 10.3 hours (range: 4 hours-13.5 hours). Of the 9 who survived, 100% demonstrated an improvement in S/F ratio with PP and 8 of 9 patients (89%) continued to maintain improved S/F ratios after completing the PP intervention. CONCLUSIONS: PP is generally well tolerated, and no patients experienced desaturation with PP. Our experience is similar to others who proned patients with ARDS who required HFNC or NIV. While the optimal duration of PP remains unclear, patients who can tolerate at least 4 hours of PP appeared to maintain their S/F ratio gains through discharge. A non-sustained or lack of S/F response to PP appeared associated with worse outcomes. The impact of PP on escalation to ICU in our study remains unclear. CLINICAL IMPLICATIONS: PP is an easily implemented, low cost, and low risk intervention that could potentially aid in improving oxygenation in patients with severe COVID-19 pneumonia who have not been intubated and require varying levels of supplemental oxygen support. A lack of improvement in oxygenation with PP may also aid in identifying patients with worse outcomes. DISCLOSURES: No relevant relationships by Jacob Bell, source=Web Response No relevant relationships by Abhinav Bhalla, source=Web Response No relevant relationships by Patricia Dharapak, source=Web Response No relevant relationships by Tsz Keung Eng, source=Web Response No relevant relationships by Justin Gasper, source=Web Response No relevant relationships by Dewan Giri, source=Web Response No relevant relationships by Steven Lim, source=Web Response No relevant relationships by Paru Patrawalla, source=Web Response No relevant relationships by Paru Patrawalla, source=Web Response No relevant relationships by David Steiger, source=Web Response No relevant relationships by Anqi Zheng, source=Web Response

HYDROXYCHLOROQUINE AND COVID-19: A META-ANALYSIS

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

THE MOUNT SINAI COVID-19 EXPERIENCE: 4,300 HOSPITALIZED PATIENTS IN NEW YORK CITY

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