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Background: The novel corona virus disease 2019 (COVID-19) presented as an emergent threat to global health. It was necessary to identify level of public awareness on disease prevention to mitigate the pandemic. Until then, no vaccine or effective drug were available for the control, prevention, and treatment of COVID-19. Preventive measures were the only way out. Objective(s): a) To study knowledge of people regarding COVID-19. b) To study attitude of people towards lockdown. c) To assess practices of people in taking preventive measures for COVID-19. Method(s): A cross sectional study was carried out among general population. Sample size was calculated using the formula 4pq/l2 where, p= proportion of people having knowledge regarding COVID-19 THAT IS 50%. Minimum calculated sample size was 205. Data was collected using pre- tested, structured questionnaire through online portal. Study was approved by Institutional Ethics committee. Result(s): The present study included a total of 249 subjects in which subjects' age varies from 18-65+ years. Maximum number of subjects held a graduate degree 214 (86%). More than 80% study subjects were aware about contagious nature of COVID-19, practice of social distancing, usage of sanitizer and vaccination. 66.7% subjects were using N95 marks and more than 60% were vaccinated. 69% opined that strict lockdown should be enforced. Conclusion(s): Present study had some shortfall in knowledge among subjects regarding some aspects of COVID-19. Therefore, there was an obligation for awareness that can be directed via health education and training programs. Copyright © 2022 Wolters Kluwer Medknow Publications. All rights reserved.
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Objectives: There are limited studies examining the effectiveness of virtual intensive outpatient programs (IOPs). We examined outcome differences on self-reported scales between teens completing a fully virtual IOP at the start of the COVID-19 pandemic and those completing a hybrid program once restrictions were eased. Method(s): A baseline sample of 133 teen patients enrolled in a San Jose community clinic's virtual and hybrid IOP from April 2020 to May 2022 was obtained from our electronic health record. Propensity scores were generated to match patients based on similar characteristics (age, sex, and time in program), and differences in survey scores were analyzed between the 2 groups at week 4 (n = 52) and week 7 (n = 39). Parent scores were also compared (n = 31 and 20, respectively). Result(s): By teen report, there were no significant differences detected by delivery format at 4 or 7 weeks for mood (p =.19,.17), stress (p =.07,.12), sleep (p =.38,.47), appetite (p =.43,.99), safety (p =.21,.14), parent interaction (p =.44,.46), peer interaction (p =.96,.89), or school (p =.51,.80). There were no significant differences for parent report at the same time periods: mood (p =.83,.35), stress (p =.81,.62), sleep (p =.97,.86), appetite (p =.45,.77), safety (p =.90,.58), parent interaction (p =.44,.39), peer interaction (p =.94,.50), or school (p =.66,.97). Teens did report significant positive changes in mood (p =.01) and sleep (p =.5) in the hybrid program, school (p =.03) in the virtual program at 4 weeks, and in mood (p =.01) at 7 weeks in the hybrid program. Parents reported significant changes in mood in both the virtual (p =.04) and hybrid (p =.01) programs at 7 weeks. Conclusion(s): According to our data, no significant overall differences in improvement were seen between either mode of delivery. Given that both modes of delivery showed significant positive changes in mood at 4 and 7 weeks by both parent and teen self-reports, it seems that IOP treatment was helpful irrespective of the mode of delivery. Future studies comparing a hybrid model to an in-person program will help clarify the significance that the mode of delivery of treatment in an IOP setting has on self-reported improvement ratings. Additionally, it would be prudent to look at dropout rates in different settings. ADOL, TVM, DTT Copyright © 2022
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Aim and objectives: To compare the mortality and outcome of patients with acute kidney injury (AKI) associated with leptospirosis and/or COVID-19 pneumonia. Materials and methods: The study was conducted by the Department of Nephrology in a tertiary care setup with 97 patients with acute kidney injury over a period of 3 months from July 2020 to September 2020. All the patients were divided into 3 main categories: 1. Leptospirosis with AKI. 2. COVID-19 pneumonia with AKI and 3. Patients having both leptospirosis and COVID-19 pneumonia with AKI. AKI was defined and staging was done as per KDIGO guidelines. Need for renal replacement therapy as well mechanical ventilation was noted. Thereby, the outcome and mortality were compared among the three groups. Results: Out of 97 patients included in the study, 57 (53.6%) patients had leptospirosis with AKI (group I), 25 (25.8%) patients had COVID-19 pneumonia with AKI (group II), whereas 20 (20.6%) patients suffered from leptospirosis and COVID-19 pneumonia with AKI (group III). There was a statistically significant difference between mortality rates in patients with leptospirosis, COVID, and both infections (χ2 = 6.210, p = 0.045). The mortality rate was 25% in leptospirosis patients and 52% in patients with COVID. This difference was statistically significant (p = 0.019). The mortality rate among patients with both leptospirosis and COVID was 45%. 15.4% of patients of group I required renal replacement therapy (RRT) in comparison to 16% of patients of group II and 35% of patients of group III. There was no statistically significant difference noted between the 3 groups (p value = 0.149). Mechanical ventilation requirement: Group I - 14/52 patients (26.9%). Group II - 7/25 (28%). Group III - 13/20 (65%). There was a significant difference in the number of patients requiring mechanical ventilation among the three groups (χ2 = 9.930, p = 0.007) with group III requiring the highest. Conclusion: AKI in patients with dual infection with leptospirosis and COVID-19 results in an increased need for mechanical ventilation without a concomitant increase in the need for RRT. Despite this, the mortality remains the highest in patients with COVID-19 and AKI as compared to those with dual infection and AKI.
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Introduction: SARS-CoV-2, the causative organism for COVID-19, uses ACE2 to enter human cells. Pancreatic ductal, acinar and islet cells also express ACE-2;therefore, involvement of the pancreas is plausible. Elevated lipase and cases of acute pancreatitis related to COVID-19 have been reported in previous studies. Patients with chronic pancreatitis (CP) have a low-grade inflammatory state and pancreatic parenchymal fibrosis, which may predispose them to pancreatic injury and worse COVID-19 outcomes. However, large studies reporting the incidence and outcomes of COVID-19 in patients with chronic pancreatitis are lacking. Methods: A retrospective cohort study was performed using TriNetX (a multiinstitutional research network). Prevalence and Incidence Rate Ratio (IRR) (cases/ personday) of COVID-19 were charted for patients with CP between January 2020 and July 2021. Patients diagnosed with COVID-19 during this period were stratified into two groups based on the presence of CP (CP cohort and non-CP cohort). Outcomes of COVID-19 in the CP cohort were compared to the non-CP cohort after 1:1 propensity score matching (PSM) for age, gender, race, diabetes, ischemic heart disease, hypertension, lung disease, cirrhosis, smoking, and alcohol abuse. Results: A total of 4420 patients with CP diagnosed with COVID-19 were identified and compared to 1,169,773 patients without CP. A large proportion of patients with CP were diagnosed with COVID-19 and the IRR peaked between December 2020-January 2021 and then declined subsequently (Figure 1). Patients in the CP cohort were older and had a higher prevalence of multiple comorbidities (Table 1). In crude, unmatched analysis, COVID-19 patients with CP had higher mortality (4.96% vs 2.16%;RR: 2.29, 95% CI:2.02-2.61), need for hospitalization (RR: 3.64, 95% CI:3.47-3.83), critical care need (RR: 3.16, 95% CI:2.86-3.50), and acute kidney injury (AKI) (RR: 3.96, 95% CI:3.71-4.24) compared to patients without CP (Table 1). No residual imbalance was noted (SMD <0.1 for all covariates) after PSM. After PSM, no difference in mortality or rate of mechanical ventilation was noted, however, patients with CP had a significantly higher risk of hospitalizations (RR: 1.51, 95% CI:1.39-1.64) and AKI (RR: 1.28, 95% CI:1.16-1.42) (Table 1). No difference in mortality, hospitalization, and critical care was noted for patients with alcohol-induced CP vs other etiologies. Conclusion: Patients with CP have high mortality and risk of poor outcomes after COVID-19 due to the presence of a significant burden of comorbidities and risk factors for severe COVID-19. In addition, CP is independently associated with higher healthcare utilization and complications such as AKI in patients with COVID-19. (Figure Presented) Figure 1: Prevalence and Incidence rate (cases/person-day) of COVID-19 in patients with chronic pancreatitis (Table Presented) Table 1. Characteristics and outcomes of patients with COVID-19 in matched and unmatched Chronic Pancreatitis (CP) and non-CP cohorts
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Background: Different arrhythmias have been reported in patients with COVID-19 due to the complication of the disease, and medications used in the management of COVID-19. Remdesivir was approved by FDA for the management of COVID-19 patients in October 2020. There are several case reports suggesting remdesivir causing bradyarrhythmia in COVID-19 patients. Objective: To increase the knowledge and awareness among healthcare professions (HCPs) about the risk of arrhythmias associated with the use of remdesivir. Methods: We used the FDA Adverse Events Reporting System (FAERS) database to find bradyarrhythmia as a reported adverse event (AE) due to remdesivir until October,2021. Total 6,504 events were reported, out of which 5,996 (92.2%) were reported by HCPs. These AEs were included and further analyzed. Results: Out of 5,996 AEs reported with remdesivir, total 537 (9.0%) events were bradyarrhythmia. There were 74 (1.27%) events reported for atrial fibrillation, and 24 (0.04%) for ventricular tachycardia attributed to the use of remdesivir. Reported events of bradyarrhythmia were further divided and analyzed into men vs women, and different age groups of years 18-64, 65-85, >85. Total events of bradyarrhythmia among men (238, 6.5%) vs women (141, 6.4%) were not significantly different. Among all the age groups, more events were reported in younger women in the age group of 18-64 (12.3%) vs 65-85 (7.9%) vs >85 (6.9%). Conclusion: Multiple studies have shown COVID-19 associated tachyarrhythmias, likely secondary to the myocardial damage due to hypoxia. Few studies have also suggested bradyarrhythmias in these patients. Our analysis of the FAERS database also showed many reported AEs of bradyarrhythmia attributed to the use of remdesivir. Postulated mechanisms include;medication side effects, damage to the SA node as a complication of the COVID-19 disease process, and electrolyte imbalance due to the renal failure. Close surveillance of these patients with early diagnosis can lead to prompt discontinuation of the medication, which can further decrease the mortality related to bradyarrhythmias. Further studies are required to identify the at-risk population and to better understand the risk of bradyarrhythmia associated with remdesivir.
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Background: Patients with underlying malignancy are considered to be at a higher risk of severe illness from COVID-19. However, the data on the COVID-19 related outcomes in patients diagnosed with major gastrointestinal cancers is lacking. We aimed to investigate the patients' characteristics and outcomes of COVID-19 infection in patients with a preexisting diagnosis of GI cancer. Methods: A search query was performed to identify all adult patients (≥ 18 years) diagnosed with COVID-19 between January 15, 2020, and July 15, 2020, on TriNet Database. The search criteria to identify potential COVID-19 patients were based on specific COVID-19 diagnosis codes or positive laboratory confirmation of COVID-19. Patients with COVID-19 and a diagnosis of the malignant esophagus, gastric, pancreatobiliary, hepatocellular, and colorectal cancer ever were included in the GI cancer group. Patients with COVID-19 who never had a diagnosis of GI cancer were included in the control group. The main outcomes were the 30-day risk for mortality, mechanical ventilation, and hospitalization after adjusting for confounding factors with 1:1 propensity score matching. For each outcome, the risk ratio (RR) with a 95% confidence interval (CI) was calculated to compare the outcomes. Results: A total of 434,375 adult patients from 40 HCO’s diagnosed with major GI cancers were identified in the Research Network. We identified a total of 1043 patients in the cancer group and 111,373 patients in the control group. Baseline demographics are described in the Table. More than half of the patients (53%) had a preexisting diagnosis of colorectal cancer while 19% of the patients had liver & intrahepatic bile duct cancers, and 15% had pancreato-biliary and 13% of patients were diagnosed with esophageal or gastric cancers. In crude analysis, COVID-19 patients with pre-existing GI cancers had a significantly higher risk of hospitalization (RR 2.37, 95% CI 2.19-2.55), mechanical ventilation (RR 2.16, 95% CI 1.69-2.75) and mortality (RR 3.81, 95% 3.14-4.63) compared to the control group. After PSM, the risk of hospitalization (RR 1.25, 95% CI 1.11-1.41) and mortality (RR 1.43, 95% CI 1.06-1.93) was still higher in COVID-19 patients with pre-existing GI cancers. However, mechanical ventilation was not significantly different in the matched groups (RR 1.91, 95% CI 0.84-1.71). Conclusion: Our study found that outcomes in patients with pre-existing GI cancers who had COVID-19 infection were worse in regard to hospitalizations and mortality. This difference persisted even after robust propensity score matching. COVID-19 patients with pre-existing GI cancers should be aggressively managed with close monitoring and can be prioritized for COVID-19 vaccination programs.(table presented) Baseline patient characteristics and 30 day outcomes in patients diagnosed with major GI cancers infected with COVID-19.
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Introduction: The COVID-19 pandemic has caused an extraordinary burden on the healthcare system and has dramatically impacted the delivery of health care services including endoscopy procedures and routine gastroenterology inpatient and ambulatory care. This has led to significant concerns that major gastrointestinal cancer diagnosis can be delayed as a consequence of this pandemic. We aimed to quantify the impact of the COVID-19 pandemic on the diagnoses of major GI cancers. Methods: Search queries were performed on the TriNetX platform to estimate the number of patient encounters, procedures, and diagnoses of new GI cancers per 100,000 patients at participating HCOs in the US between March 15, 2020, and July 15, 2020, and March 15, 2019, to July 15, 2019. Differences in the number of encounters, procedure volume, and new diagnoses before and during the pandemic are compared and reported as a percentage increase or decrease. Results: During the pandemic, major declines were seen in both the inpatient (13,334.50 vs. 22,256.57;%change: -42.99% per HCO) and emergency department (21,933.06 vs.35,225.72;% change: -40.09% per HCO) in comparison to the same interval in 2019. A relatively smaller decline was seen in the ambulatory visits (130,245.84 vs. 159,996.81;% change -22.55% per HCO) during the pandemic compared to 2019. A large increase in virtual or telehealth visits (7,266 vs. 14,612.67;% change +4465.02%) was seen during the pandemic compared to 2019. The volume of the upper endoscopies per 100,000 patients had a decline of 71.84% (52.47 per 100,000 vs. 186.38 per 100,000) with 2019. Similarly, a decline of 84.66% (46.02 per 100,000 vs. 299.95 per 100,000) was seen in the volume of colonoscopies during the pandemic compared with 2019. The number of right upper quadrant abdominal ultrasounds (344.74 vs. 536.79;% change = -35.78%) decreased during the pandemic in comparison to the same duration in 2019. The new diagnoses of the liver and intrahepatic cancers declined to almost one-third (34.13%) during the pandemic while the diagnoses of colorectal cancers decreased by 30.91 % as compared to the similar duration in 2019. We also noticed a decline in the number of new diagnoses in the esophageal and gastric cancers (26.96%) followed by pancreato-biliary cancers (-22.81%). Conclusion: Our study showed that the health care encounters and major GI procedures declined during the pandemic leading to a reduction of new diagnoses GI cancer cases among the patients who had health care encounters during the pandemic that could have led to missed opportunities for a new diagnosis of cancers. Delay in diagnosis during the COVID-19 pandemic could lead to an increase in late-stage cancer cases and poor cancer outcomes. Urgent policy and practice interventions are needed to address the consequences of delays in the diagnosis of these can-cers.(Table Presented)Number of patient encounters, endoscopic procedures and new diagnoses of major GI cancers per 100,000 patients with a percentage change before and during the pandemic.
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Background: The COVID 19 pandemic has caused a major disruption in healthcare delivery as lockdown orders and other restrictions have limited the ability to seek care and receive medical care and procedures. This investigation aimed to assess the pandemic impact on the incidence of gastrointestinal bleeds (GIB) related diseases and procedures compared to the pre-pandemic period. Methods: TrinetX, a national federated healthcare database comprised of 61 million patient records, was used to identify the incidence of new GIB related diseases and procedures (variables) performed each month for two periods of the pandemic. The first period was from April 2020-July 2020 (early pandemic), and the second was from August 2020-November 2020 (late pandemic). The mean for each variable was then compared with the pooled monthly incidence from similar periods between 2018-2019 before the pandemic. Descriptive analyses were performed, and comparisons were made using a student's t-test. Diseases and procedures were identified by ICD-10 and CPT codes, respectively. Results: A total of 20 variables were analyzed in both periods (Table 1). In the April 2020-July 2020 period, all 20 GIB related variables showed a statistically significant decrease in the average incidence compared to a similar pre-pandemic period. The top 5 variables were colonoscopy (-44% change, p=0.003), sigmoidoscopy (-40.7% change, p=0.002), polyps (- 38.5%, p=0.007), esophagogastroduodenoscopy (-38% change, p=0.005), and hemorrhoids (-35.8% change, p=0.005). In the Aug 2020-Nov 2020 period, only 8 GIB related variables showed a statistically significant decrease in the average incidence compared to a similar pre-pandemic period. The top 5 variables were colonoscopy (-38.2% change, p=0.01), sigmoidoscopy (-37.8% change, p=0.02), esophagogastroduodenoscopy (-34.8%, p=0.019), diverticulosis (-30.9% change, p=0.03), hemorrhoids (-30.8%, p=0.043). Discussion: The early pandemic period showed statistically significant decreases in all 20 GIB related diseases and procedures variables, while the late pandemic period showed statistically significant decreases in only 8 GIB related variables. This shows that while the healthcare field is improving its handle on the pandemic, patients with GIB have started seeking healthcare. Further research is warranted to examine the future implications of this disruption in the care of patients with GIB during the COVID-19 pandemic.(Table Presented) Pooled mean monthly incidence of Gastrointestinal Bleed related diagnosis and procedure variables related between April 2020-July 2020 (early pandemic), and August 2020-November 2020 (late pandemic) compared to similar periods between 2018-2019 (pre-pandemic).
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Introduction: Previous data has pointed towards worse outcomes with COVID-19 disease in the presence of obesity. Through sustained weight loss and improvement in metabolic co-morbids, a history of bariatric surgery may be hypothesized to reduce the risk of severe COVID-19 disease. However, the outcomes of COVID-19 disease in patients with obesity have not been explored. Methods: We conducted a retrospective cohort study on the multi-institutional research network TriNETX. Patients with COVID-19 were identified and divided into cohorts based on history of bariatric surgery (BS cohort and non-BS cohort). Clinical outcomes were compared in unmatched and propensity score matched analyses with patients matched 1:1 based on known risk factors of severe COVID-19 disease. Patients with no history of bariatric surgery but with clinical attributes qualifying for these procedures were identified and included in a 'bariatric procedure qualifying' group for sensitivity analysis. Results: Unmatched analysis revealed lower risk of mechanical ventilation or mortality at 30 days after COVID-19 diagnosis in the BS cohort compared to the non-BS cohort (1.07% vs 2.58%, Risk Ratio 0.41, 95% CI: 0.26 - 0.65). Lower risk of need for mechanical ventilation and lower mortality was noted in the bariatric surgery cohort. In the propensity score matched analysis, there was lower risk of reaching primary endpoint of mechanical ventilation or mortality in the BS cohort compared to the non-BS cohort (1.07% vs 3.09%, RR 0.35, 95% CI: 0.21 - 0.58). Mortality rate was lower in the BS cohort, and patients in the BS group were less likely to require critical care, mechanical ventilation, or develop acute kidney injury after COVID-19 diagnosis Log Rank tests revealed worse survival in both matched and unmatched analysis in the non-BS cohort when compared to the BS group (Log rank p values , 0.01 for all analyses). Subgroup analysis was performed comparing the RYGB and sleeve gastrectomy subgroups. No difference was noted in any clinical outcome on unmatched or matched analysis. On sensitivity analysis comparing BS group with BS qualifying cohort, lower rate of mortality, mechanical ventilation, need for critical care was noted in BS cohort (Table 1). Conclusion: In CONCLUSION:, our propensity matched analysis of a large cohort, we have found that a history of bariatric surgery is associated with a reduced risk of poor outcomes of COVID-19 disease compared to a cohort of obese patients as well as the general population..
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The banking industry is important to a country's economic growth. With a large network of branches and a diverse range of financial services, India's banking system is large. The aim of this research is to study the financial results of India's two largest private and two public banks. The financial performance of banks was analyzed using net profit, assets, liabilities, income, expense, margin ratio, and return on equity ratio. After evaluating financial data from 2015 to 2019, the study concluded that the private banks performed better than public banks. The results of this study will benefit bank, shareholders and customers, as well as bank management.
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Rationale: Coronavirus disease 2019 (COVID-19) can cause severe respiratory failure that worsens despite maximal medical management. When to initiate extracorporeal membrane oxygenation (ECMO) and how to manage these patients on ECMO is not clear. Here, we present our experience with venovenous ECMO to support patients with COVID-19 and compare it to historic patients supported with VV-ECMO for other causes of respiratory failure. Methods: Patients admitted to our tertiary academic medical center in 2019 and 2020 who received VV ECMO support were included in this retrospective chart review. We examined patients with and without COVID-19 infection. We placed COVID-19 patients on ECMO who failed supportive care with mechanical ventilation using a high PEEP low tidal volume strategy, prone positioning, and neuromuscular blockade. Data analysis were done in Excel and Prism. Non-parametric data were compared with unpaired, two-tailed Mann-Whitney tests. Results: ECMO was provided to 26 COVID-19 patients and 38 patients without COVID-19. Median (interquartile range) age of COVID-19 patients was 49.5 (40.5-56.25), compared with non-COVID-19 patients: 53.5 (30.5-60.25), p=0.28. COVID-19 patients had a significantly higher BMI: 32 (30.1-35.9) vs. 26.4 (23.6-29.4), p<0.001. There were 27% female COVID-19 patients compared with 37% female non-COVID patients (p=0.43). COVID-19 patients had similar PaO2:FiO2 ratios as non-COVID patients on day of cannulation: 74 (69-112) vs 78 (60-205), p=0.65. COVID-19 patients had longer ventilator duration pre-cannulation (not including time spent intubated at outside hospitals prior to transfer to our center)-1.9 (1.4-7.0) days vs 0.7 (-.2-1.0) days, p<0.001. COVID patients spent more days on ECMO compared with non-COVID patients: 20.7 (7.3-36.5) vs. 11.5 (3.8-26.8), p=0.14. Twelve (46%) of the COVID-19 ECMO patients died, compared with 9 (25%) of the non-COVID ECMO patients, p=0.10. Conclusions: In patients with severe SARS-CoV-2 pneumonia induced ARDS who fail maximal supportive therapy with mechanical ventilation, outcomes are similar or worse than patients historically receiving VV ECMO support for respiratory failure. These findings highlight the need to determine the optimal timing of ECMO initiation and management in patients with severe SARS-CoV-2 pneumonia.
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Introduction Veno-venous extracorporeal membrane oxygenation (VV-ECMO) as bridge to recovery in critically ill COVID-19 continues to be commonly utilized strategy in cases with persistent respiratory failure refractory to traditional ventilation support Case Report We report 5 cases of severe acute respiratory syndrome coronavirus-2 infection (SARS-CoV-2) who were treated with ECMO (Table 1). All 5 cases presented with fever, cough and shortness of breath and a positive nasopharyngeal swab for SARS-CoV-2 on admission. Case 1, 2, 3 and 5 patients were hypoxemic with saturation less than 90% on admission and decompensated rapidly, whereas Case 4 decompensated after day 14. Mechanical ventilation failed to provide adequate oxygenation in all 5 cases;case 2,3 and 5 were started on recruitment measures with proning while it was not possible for case 1 owing to morbid obesity. Proning was not possible in the case 4 as patient became severely hypoxemic while patient was undergoing mechanical thrombectomy. The case 1-4 remained on ECMO for 19, 17, 17 and 2 days respectively. All except case 2 had improvement in APACHEII and SOFA score after ECMO initiation. All 5 patients had elevated inflammatory markers of serum ferritin, D-dimer, Lactate dehydrogenase (LDH), C-reactive protein (CRP) which trended down after a few days of ECMO initiation All 5 patients received high dose steroids during their stay in the ICU. Case 4 and 5 passed away after compassionate extubation. Case 1-3 had prolonged hospital course with complication of hospital acquired pneumonia requiring multiple courses of broad-spectrum antibiotics. Summary Our observational report of 5 patients reports the use of ECMO in critically ill SARS-CoV-2 with ARDS and difficult to maintain saturation despite mechanical ventilation and proning with recovery for 3 patients. However, given the lack of ECMO centers;this is not a readily available option. Further studies are warranted to investigate the role of ECMO in SARRS-CoV-2 and careful identification of appropriate candidates.
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Introduction We present a case of COVID-19 causing hypercoagulability and inflammatory stress leading to STEMI in a patient who went on to develop persistent cardiogenic shock requiring LVA) implantation. Case Report 57-year-old lady developed COVID-19 infection in May 2020. In June 2020, she presented with chest pain, was noted to have STEMI on EKG, complicated by cardiac arrest with ROSC in 14 minutes. She was in cardiogenic shock as well and was started on veno-arterial ECMO. She underwent left anterior descending artery stent placement. Further hospitalization was complicated by persistent cardiogenic shock and complete heart block and underwent pacemaker and cardiac-defibrillator implantation. She developed pulmonary edema, acute kidney injury requiring hemodialysis, shock liver, and persistent cardiogenic shock. She was weaned off VA-ECMO after 4 days but continued to have severely reduced cardiac function. RHC revealed severe volume overload, pulmonary venous hypertension, low cardiac output, and right heart dysfunction. Echo showed severe LV dysfunction with an EF of 15%. A femoral intra-aortic balloon pump(IABP) was placed on July 7, 2020. An attempt was made to wean her off of IABP on July 10th,however, it was unsuccessful and she was transitioned to axillary intra-aortic balloon pump. She remained IABP dependent thereafter and on July 15th, given persistent cardiogenic shock, decision was made to pursue advanced heart failure therapies. After multi-disciplinary discussion, the decision to pursue LVAD implantation was made. She underwent a successful LVAD implantation on July 20th . She failed an extubation trial and underwent tracheostomy on July 23rd . Post LVAD, she developed atrial fibrillation and was started on digoxin and amiodarone. Her symptoms improved and she was subsequently discharged to rehabilitation in late August on amiodarone, digoxin, metoprolol, prasugrel, warfarin, spironolactone and lisinopril. The detailed timeline is shown in figure 1. Summary Hypercoagulability and severe inflammatory stress leading to life-threatening illness is a significant complication of COVID-19 infection. A low threshold for suspecting and treating hypercoagulability and inflammatory induced myocardial ischemia and injury and cardiogenic shock is a reasonable strategy to decrease acute as well as chronic morbidity and mortality.
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INTRODUCTION: Roughly 1.2M feeding tubes are placed annually in the US, most of which are placed without direct visualization. The current state within our Network is blind bedside placement with x-ray confirmation. The cost of blind placement is $1.46M annually, with potential additional cost due to complications (airway placement, pneumothorax, death), delayed nutrition/administration of medications, and cost of x-ray. We identified 3 adverse events which occurred over a 3-year time period with blind placement, resulting in 2 deaths and 1 lung placement. Sub-specialty departments have expressed frustration for lack of a "tubes service" in an effort to provide more timely nutrition in a safe manner as well as avoid need for x-rays. METHODS: In an effort to improve quality of care to patients, optimize time to tube placement, and ensure accurate placement eliminating need for x-rays, an enteral nutrition platform was implemented with GI fellow training and placement of NG and post-pyloric tubes under direct visualization without the use of endoscopy. The inpatient service received consults for failed bedside NG placements via a specific EPIC order set. Each fellow was required to participate in a demo on proper device use and per form 2 live placements with industry and lead physician providing atelbow assistance. The Program Director developed an instruction sheet which was made a part of the curriculum, Figure 1. with the first 50 placements to be confirmed by x-ray. RESULTS: The service began in February 2020 and 10 consults had been received thus far. The GI fellows achieved a 100% success using tube with direct visualization. X-ray confirmed proper placement with no adverse events. Average time from consult to placement was 10 hours and time from consult to use was less than 24 hours, Figure 2. Xinying et al reported time from consult to blind placement was an average of ;21 hours. Given the COVID-19 pandemic, fellow training was halted and 2 competent fellows continued to place tubes eliminating the need for transport and x-ray during that critical time. CONCLUSION: The tube service was well accepted in our hospital. An initial cost/benefit analysis shows a potential $840.20 in savings per patient (Table 1) with decreased need for x-rays, elimination of adverse events as direct visual capability, earlier time to feeding and decreased length of stay. Further cost/benefit will be analyzed as we expand throughout our very large health system.