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Journal of Clinical Outcomes Management ; 29(5):39-48, 2022.
Article in English | EMBASE | ID: covidwho-2067257


Objective: The COVID-19 pandemic has been a challenge for hospital medical staffs worldwide due to high volumes of patients acutely ill with novel syndromes and prevailing uncertainty regarding optimum supportive and therapeutic interventions. Additionally, the response to this crisis was driven by a plethora of nontraditional information sources, such as email chains, websites, non-peer-reviewed preprints, and press releases. Care patterns became idiosyncratic and often incorporated unproven interventions driven by these nontraditional information sources. This report evaluates the efforts of a health system to create and empower a multidisciplinary committee to develop, implement, and monitor evidence-based, standardized protocols for patients with COVID-19. Method(s): This report describes the composition of the committee, its scope, and its important interactions with the health system pharmacy and therapeutics committee, research teams, and other work groups planning other aspects of COVID-19 management. It illustrates how the committee was used to demonstrate for trainees the process and value of critically examining evidence, even in a chaotic environment. Result(s): Data show successful interventions in reducing excessive ordering of certain laboratory tests, reduction of nonrecommended therapies, and rapid uptake of evidence-based or guidelines-supported interventions. Conclusion(s): A multidisciplinary committee dedicated solely to planning, implementing, and monitoring standard approaches that eventually became evidence-based decision-making led to an improved focus on treatment options and outcomes for COVID-19 patients. Data presented illustrate the attainable success of a committee that is both adaptable and suitable for similar emergencies in the future. Copyright © 2022 Turner White Communications Inc.. All rights reserved.

American Journal of Respiratory and Critical Care Medicine ; 205:1, 2022.
Article in English | English Web of Science | ID: covidwho-1879926
American Journal of Respiratory and Critical Care Medicine ; 203(9):1, 2021.
Article in English | Web of Science | ID: covidwho-1407319
American Journal of Respiratory and Critical Care Medicine ; 203(9), 2021.
Article in English | EMBASE | ID: covidwho-1277253


Introduction: Coronavirus Disease 2019 (COVID-19) testing has grown exponentially in the United States since the dawn of the pandemic, with the vast majority of samples being obtained via nasopharyngeal swab. Although convenient and widely used, the test itself carries potential adverse effects, particularly those at high risk of bleeding. We present a patient who developed several arrays of complications after being tested for COVID-19 using the nasal swab sampling technique. Case Presentation: An 80-yo female presented from home with a complaint of hematuria. Her past medical history includes rheumatic heart disease status post repair on warfarin, atrial fibrillation and stroke. Vital signs were normal. She had benign head and neck exam, clear lung sounds, an irregular heart rhythm and a normal abdominal exam. Labs were at baseline with hemoglobin of 10.4. Chest x-ray and CT abdomen were unremarkable. She received a PCR nasopharyngeal swab in the emergency room and subsequently developed profuse epistaxis. Initial nasal packing and Afrin sprays failed to control the bleeding and she required emergent intubation for airway protection. She also needed vasopressors due to hypotension. Repeat hemoglobin was 7.5 and lactic acid was 10.4. Bleeding eventually stopped after continuous nasal packing, transfusional support and IV vitamin K. In the following days, she developed fever, leukocytosis and lung infiltrates. She received empiric antibiotic coverage, although no growth from cultures. Endoscopy findings were consistent with ischemic colitis. Later, she stabilized hemodynamically but was unable to be liberated from the ventilator. She was discharge to a long-term care facility after 43 days of stay. Discussion: Nasopharyngeal swabs are the mainstay of testing for COVID-19, however, little has been discussed regarding its procedural risks. Common adverse effects include headaches, nasal pain, ear discomfort and rhinorrhea. Recent studies have suggested that the incidence of epistaxis can be as high as 10% after the test. Alternatively, multiple research centers, including Yale and University of Illinois have released promising data on saliva-based testing. Their evidence supported high sensitivity comparable to the nasopharyngeal method with simpler and safer nature. Also, the saliva-based testing can be done at home, which is believed to reduce healthcare cost and lower the risk of cross infection. This case vividly demonstrates that even the most common procedure can result in devastating outcomes. As such, health care providers should be cognizant of these complications and consider alternative testing method when possible.

American Journal of Respiratory and Critical Care Medicine ; 203(9), 2021.
Article in English | EMBASE | ID: covidwho-1277181


INTRODUCTIONEsophagopulmonary fistula (EPF) is an improper communication between the esophagus and lung parenchyma. The the etiology of EPFs including esophageal malignancy with direct tumor invasion or post-radiation therapy (accounts for 50%), prolonged mechanical ventilation, infectious/inflammatory disease, caustic ingestion, trauma, or indwelling esophageal stent. Here we present a case of EPF complicated by parapneumonic effusion initially thought to be an empyema. CASE REPORTA 53-year-old male with past medical history of polysubstance abuse, HIV, perforated peptic ulcer s/p partial gastrectomy, and hypertension presented with productive cough, fever, unintentional weight loss, and non-bloody watery diarrhea for two days. He also reported difficulty swallowing liquids and occasionally solid foods for several months associated with cough during ingestion. Vital signs showed BP 116/74, HR 135, RR 29, temperature 102.1°F, and oxygen saturation 93% on room air. Physical exam revealed rales with decreased air entry of the right lung fields. Labs were significant for WBC 20,300, Hgb 7.9, Platelets 467,000, and procalcitonin 0.68. Urine drug screen and SARS-COV2 PCR were negative. ABG on room air with pH 7.369, pCO2 40.6, and pO2 65.1. Pleural fluid showed a WBC count 8375 and pH 7.0. CXR showed opacity in the right middle and lower lung. CT chest showed complex right pleural effusion with multiple areas of gas and atelectasis of right lower lobe with possible superimposed consolidation or areas of necrosis. Chest tube was placed with 600cc cloudy serous fluid determined to be exudative. Due to the clinical presentation, and signs of sepsis along with nature of pleural fluid, empyema was suspected. Pleural fluid culture was positive for gram negative rods, corynebacterium, and candida albicans. AFB culture and cytology were negative. However, due to nature of debris in esophagus and GI history, esophagram was performed which confirmed the presence of an EPF between the right distal esophagus and right lower lobe. The patient was initially treated with empiric antibiotics with de-escalation based on cultures. Unfortunately, after brief recovery, patient left the hospital against medical advice. DISCUSSIONThere are few cases reported involving a benign etiology being a cause of EPF as reported in this case. The patient had history of perforated peptic ulcer which is likely the underlying etiology. Due to this being a chronic issue, patient likely developed an infectious process which responded well to therapy. The relative uncertainty to the initial diagnosis and the underlying etiology behind this finding makes our case unique.