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1.
Journal of Urology ; 207(SUPPL 5):e169, 2022.
Article in English | EMBASE | ID: covidwho-1886483

ABSTRACT

INTRODUCTION AND OBJECTIVE: Nephrectomy and venous thrombectomy is a challenging procedure with potential morbidity and mortality. Despite the increasing use of immune checkpoint inhibitors (ICI) in the management of advanced renal cell carcinoma (RCC), data regarding the outcomes of venous thrombectomy following ICI is limited. We evaluated the feasibility and perioperative outcomes of nephrectomy and venous thrombectomy following ICIs. METHODS: Patients with locally advanced or metastatic RCC with venous thrombus undergoing nephrectomy following ICI therapy were evaluated in four high-volume US academic centers between June 2017 and June 2021. Clinical data, perioperative outcomes, and 90-day complications were recorded. RESULTS: Out of 79 patients who received post-ICI nephrectomy, 27 had venous thrombus. Median (IQR) age was 64 (55-71) years. ICI regimens were Nivolumab ± Ipilimumab (n=19), and Pembrolizumab± Axitinib (n=8). Nephrectomy was indicated following either a good clinical response to ICI (n=24) or as a palliative surgery (n=3). Venous thrombi levels are shown in Table-1. Among all patients, 26 (96%) underwent radical and 1 (4%) partial nephrectomy;12 (44.5%) open, 12 (44.5%) robotic and 3 (11%) laparoscopic. One robotic case converted electively to open. Vascular procedures included renal vein thrombectomy (n=6), IVC thrombectomy and primary repair (n=19), IVC patch repair (n=1), and suprarenal cavectomy (n=1). No intraoperative complications were reported. Nine patients showed no viable tumor in the thrombus, of whom 2 had complete response in the primary tumor as well (ypT0N0). 90-day complication rate was 33% (n=9), with 8 patients (30%) requiring readmission (Table-2). One death was reported within 90 days due to COVID-19 infection. CONCLUSIONS: Nephrectomy and venous thrombectomy following systemic immune checkpoint inhibitor therapy is feasible. One third of patients show no viable tumor in the thrombus. Larger studies are needed to predict pathological response.

2.
Gastroenterology ; 160(6):S-291-S-292, 2021.
Article in English | EMBASE | ID: covidwho-1594295

ABSTRACT

Background Gastrointestinal manifestations and hyperlipasemia commonly occur as part of novel coronavirus infection (COVID-19), while data on acute pancreatitis is limited to case reports. We aimed to study the prevalence of hyperlipasemia and acute pancreatitis in a large inpatient cohort of COVID-19 patients and their impact on clinical outcomes. Methods Retrospective chart review of all hospitalized patients with confirmed COVID-19 at an 8-hospital health system in Michigan, USA was performed between February 1,2020 through April 1,2020 with inclusion of patients with obtained lipase levels. Univariate analyses were performed to evaluate associations between hyperlipasemia and degree of hyperlipasemia and clinical outcomes of mechanical ventilation, intensive care unit (ICU) admission, and mortality. COVID-19 attributed pancreatitis was defined as an episode fulfilling criteria for acute pancreatitis defined earlier, a temporally associated diagnosis of COVID-19 and an exclusion of the most common etiologies of acute pancreatitis (gallstones, alcohol use, class IA/IB/II medication (by Badalov classification) use, endoscopic retrograde pancreatography, or metabolic etiologies (hypercalcemia, hypertriglyceridemia (>1000mg/ dl)). Results Prevalence of hyperlipasemia was 26.6% and of acute pancreatitis 0.33% in 301 patients with COVID-19. Patients with hyperlipasemia were older (p=0.044) and more likely to have chronic kidney disease (p=0.002) (Table 1). A total of 158 (52.5%) of patients reported at least one gastrointestinal symptom (abdominal pain, nausea, vomiting or diarrhea), and the presence of any gastrointestinal symptoms was not associated with the presence of hyperlipasemia (p=0.790). Neither presence of hyperlipasemia or its severity stratified into mild (60-120 U/L), moderate (120-180 U/L), and severe (>180 U/L) categories were associated with increased rates of mechanical ventilation, ICU admission or increased mortality (Table 2). Acute pancreatitis occurred in two patients of which one case was biliary in origin. Prevalence of COVID-19 acute pancreatitis in the reported cohort was 0.33%. Of the other patients with hyperlipasemia, 18 underwent computed tomography of the abdomen and an intra-abdominal process was identified in only two patients, with colitis identified in one patient, and ileus in another. Discussion and Conclusions Acute pancreatitis in COVID-19 patients is rare while hyperlipasemia is common. Hyperlipasemia in patients with COVID-19 is likely attributed to several non-pancreatic etiologies. Both hyperlipasemia in this population, and COVID-19 attributed acute pancreatitis do not appear to have significant impact on patients’ clinical outcomes.(Table presented) (Table presented)

3.
American Journal of Gastroenterology ; 116(SUPPL):S1478, 2021.
Article in English | EMBASE | ID: covidwho-1534900

ABSTRACT

Introduction: A Dieulafoy's lesion is a large tortuous arteriole that can cause life-threatening hemorrhagic shock, occurring in 1-2% of cases of upper gastrointestinal bleeding. It is an underdiagnosed cause of obscure massive hematemesis because its small size and location makes it difficult to visualize. Case Description/Methods: An 84-year-old white male with atrial fibrillation, on apixaban, presented for large-volume hematemesis. Physical examination revealed blood pressure of 80/60 mmHg, pulse of 110 beats/minute, orthostasis, temperature of 36.9°C, and an ill-appearing individual with a diffusely tender abdomen. Laboratory examination revealed leukocytes of 19.9 bil/L (normal: 3.5-10.1 bil/L), hemoglobin of 11.2 g/dL (normal: 13.5-17 g/dL) which dropped to 7.5 g/dL in 2 hours. Computed tomography of the abdomen and pelvis without contrast demonstrated diffusely distended stomach with internal debris concerning for blood products. He was intubated for airway protection and transfused 1-unit of packed-erythrocytes. Intravenous pantoprazole and norepinephrine were administered, and he was transferred to the medical intensive care unit. He was also incidentally found to have coronavirus disease (COVID-19). With precautions taken for COVID-19 infection, he underwent emergent esophogastroduodenoscopy revealing a bleeding vessel, Dieulafoy's lesion, proximal to the gastroesophageal (GE) junction (Figure 1) with a huge amount of clotted blood at the gastric fundus and body. The vessel was injected with 3 mL of epinephrine and two clips were placed achieving hemostasis. The next day, the patient's blood pressures improved, his hemoglobin stabilized to 9.2 g/dL and he was extubated. Discussion: A Dieulafoy's lesion is commonly located in the stomach, with majority found proximal to the GE junction however it can be hidden in the gastric mucosal folds. Treatment includes heat probe coagulation, epinephrine injection or banding. Our case demonstrates that rare diagnoses such as a Dieulafoy's lesion should be considered in the differential diagnosis in patients presenting with hematemesis as timely endoscopic treatment can often result in immediate cessation of bleeding. When the bleeding vessel cannot be located, these patients are often referred for angiography.

4.
Journal of Urology ; 206(SUPPL 3):e342-e343, 2021.
Article in English | EMBASE | ID: covidwho-1483603

ABSTRACT

INTRODUCTION AND OBJECTIVE: COVID-19 has drastically changed didactic residency education. The urologic community displayed its resilience and adaptability by swiftly converting in-person education to webinar events in response to the pandemic. The goal of this study was to analyze the trends of urology webinars since the declaration of the COVID-19 pandemic. METHODS: The official social media accounts for all AUAregistered urology residency and urologic-oncology fellowship programs were systematically searched for webinar listings. All of the free webinars available to the greater urologic community posted between January 1, 2020 and June 1, 2020 were included in this study. Data was abstracted from each webinar including the date of delivery, topic of discussion, and number of speakers. Temporal trends were analyzed via join-point regression modelling. RESULTS: A total of 450 webinars were offered in the initial 18 weeks following the pandemic declaration. A total of 629 speakers from 96 academic institutions were involved in at least one webinar. The mean webinar duration was 58.7 minutes. At the peak of the “webinar frenzy,” a mean of 7.1 webinars/day were offered with 12.7 speakers/day involved. Urologic webinars increased in availability significantly from weeks 1 to 9 and decreased in availability non-significantly from weeks 10 to 18. Urologic-oncology was the most commonly discussed sub-specialty, representing 113 (25.1%) separate lectures with 151 speakers. Urologic-oncology increased in interest significantly over weeks 1 to 9 (AWPC: 110.7%;p<0.001) with a stable trend (AWPC -5.5, p=0.3) from weeks 10 to 18. Prostate cancer (33.9%) was the most discussed subject, followed by bladder cancer (29.5%), kidney cancer (12.5%), testis cancer (8%), upper urinary tract cancer (7.2%) and penile cancer (3.5%). CONCLUSIONS: In conclusion, our analysis demonstrates impressive and immediate reaction of the academic urologic community and specifically, the urologic-oncologic community, to continuing medical education amidst a pandemic. While webinars have some limitations, they have the opportunity to increase educational access across geographical and financial barriers. Time will show if webinars have a permanent role in the future of medical education or if we have witnessed the rise and fall of a “webin-era.”. (Table Presented).

5.
Journal of Urology ; 206:E342-E343, 2021.
Article in English | Web of Science | ID: covidwho-1411287
6.
European Urology ; 79:S1357-S1358, 2021.
Article in English | Web of Science | ID: covidwho-1357815
7.
Journal of General Internal Medicine ; 36(SUPPL 1):S94-S94, 2021.
Article in English | Web of Science | ID: covidwho-1349069
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10.
J Intern Med ; 288(4): 469-476, 2020 10.
Article in English | MEDLINE | ID: covidwho-810836

ABSTRACT

INTRODUCTION: Higher comorbidity and older age have been reported as correlates of poor outcomes in COVID-19 patients worldwide; however, US data are scarce. We evaluated mortality predictors of COVID-19 in a large cohort of hospitalized patients in the United States. DESIGN: Retrospective, multicenter cohort of inpatients diagnosed with COVID-19 by RT-PCR from 1 March to 17 April 2020 was performed, and outcome data evaluated from 1 March to 17 April 2020. Measures included demographics, comorbidities, clinical presentation, laboratory values and imaging on admission. Primary outcome was mortality. Secondary outcomes included length of stay, time to death and development of acute kidney injury in the first 48-h. RESULTS: The 1305 patients were hospitalized during the evaluation period. Mean age was 61.0 ± 16.3, 53.8% were male and 66.1% African American. Mean BMI was 33.2 ± 8.8 kg m-2 . Median Charlson Comorbidity Index (CCI) was 2 (1-4), and 72.6% of patients had at least one comorbidity, with hypertension (56.2%) and diabetes mellitus (30.1%) being the most prevalent. ACE-I/ARB use and NSAIDs use were widely prevalent (43.3% and 35.7%, respectively). Mortality occurred in 200 (15.3%) of patients with median time of 10 (6-14) days. Age > 60 (aOR: 1.93, 95% CI: 1.26-2.94) and CCI > 3 (aOR: 2.71, 95% CI: 1.85-3.97) were independently associated with mortality by multivariate analyses. NSAIDs and ACE-I/ARB use had no significant effects on renal failure in the first 48 h. CONCLUSION: Advanced age and an increasing number of comorbidities are independent predictors of in-hospital mortality for COVID-19 patients. NSAIDs and ACE-I/ARB use prior to admission is not associated with renal failure or increased mortality.


Subject(s)
Betacoronavirus/genetics , Coronavirus Infections/epidemiology , Diabetes Mellitus/epidemiology , Disease Management , Hypertension/epidemiology , Pneumonia, Viral/epidemiology , Age Factors , COVID-19 , Comorbidity , Coronavirus Infections/therapy , Diabetes Mellitus/therapy , Female , Follow-Up Studies , Hospital Mortality/trends , Humans , Hypertension/therapy , Inpatients , Male , Michigan/epidemiology , Middle Aged , Pandemics , Pneumonia, Viral/therapy , Prevalence , Prognosis , RNA, Viral/analysis , Retrospective Studies , Risk Factors , SARS-CoV-2 , Survival Rate/trends
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