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Introduction: Colorectal cancer (CRC) is the second leading cause of cancer-related deaths in the United States (US) and disproportionately impacts Black individuals. The US Preventive Services Taskforce began recommending CRC screening for individuals aged 45-49 in 2021, however effective strategies to increase screening participation in Black individuals in this age group are unknown. Thus, the National Colorectal RoundTable (NCCRT) used a mixed methods approach to identify barriers and facilitators to CRC screening in Black individuals, with specific focus on those age 45-49. Results informed the development of the 2022 NCCRT Messaging Guidebook for Black & African American People. Method(s): We conducted a mixed-methods study in a large, nationally representative sample of unscreened Black individuals. We first conducted semi-structured qualitative interviews with Black individuals over age 45, recruited from the Schlesinger Group qualitative research platform. Findings informed content for a subsequent survey to understand barriers and facilitators, administered broadly via the Prodege online research platform. Messages to encourage screening participation were developed based on learnings from prior ACS and NCCRT work. Message were tested using MaxDiff analytic methods and reviewed by a multidisciplinary advisory committee for inclusion in the Guidebook. Result(s): There were 10 qualitative interview and 490 survey participants. The average age of participants was 52.7 (s.d.56.1) for interviews and 55.3 (s.d.57.3) for surveys. 40.0% were female and 38.2% lived in the Southeast US (Table). The most frequently reported barrier to screening was procrastination (40.0% in age 45-49;42.8% in age 50-65;34.2% in age .55). Procrastination was often attributed to financial concerns (20.8% in age 45-49) and COVID-19 (27.0% in age 50-54;21.8% in age .55) (Figure). Of those age 45-49, the majority preferred to receive screening information from a health care provider (57.5%), however only 31.7% reported that a provider had initiated a screening conversation. Several messages rated as highly effective in encouraging screening were included in the NCCRT Guidebook. Conclusion(s): We identified several age-specific barriers to CRC screening and developed unique messaging to motivate screening among unscreened Black individuals age 45 and over. Messages that tested positively are publicly available as a resource for organizations and institutions that aim to increase screening rates.
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Background: A small Midwest cystic fibrosis (CF) center gained child life support in fall of 2016, but availability was limited due to sharing full-time equivalents (FTEs) between 31 outpatient subspecialty clinics. Child life involvementwas often restricted to immediate stressors (e.g., throat swabs, blood draws, first pulmonary function tests) in a reactive approach, but in the summer of 2020, the child life team added FTEs, increasing the ability for a primary child life specialist (CLS) to be more integrated into the clinic workflow. Partnering with the nurse care coordinators, a comprehensive, proactive approach to the integration of child life was formed, focusing on full scope of practice. Method(s): CFregistered nurse care coordinators collaborated with the CLSto discuss the goal of integration while understanding knownpatient stressors and optimal developmental and coping goals for patients younger than 19 and their siblings. We also determined ways to reduce disruption to clinic workflowwhile leveraging scheduling and increasing awareness of scope of practice of the interdisciplinary team, patients, and families. The CLS also obtained feedback from the family advisory committee engrained in clinic along with hosting a booth at the center's annual CF familyevent that targets caregivers of children with CF. Throughout each of these formative actions,(Figure Presented) Figure 1. : Child life integration protocol the primary focus was on collaboration with the interdisciplinary team, employing the full scope of practice of the CLS, mitigating logistical barriers, and optimizing patient experience and satisfaction. Result(s): The current plan (Figure 1) is based on identified time points where developmentally appropriate interventions and resources are implemented in a stepwise fashion, building upon itself. Interventions are individualized for each patient or family member based on coping and learning needs or developmental differences and are completed by the CLS based on professional judgment and after assessment and rapport is built. The scope of practice includes preparation for procedures or changes in the plan of care, procedural support, creation of coping plans for in-clinic and at-home care routines or events, educational activities and resources (e.g., making slime to learn about mucus, word searches about medications), therapeutic activities to support emotional processing of chronic illness, providing information on typical growth and development to caregivers, and facilitating developmentally appropriate transition-readiness goals through CF R.I.S.E. materials. During the COVID global pandemic, changes to outpatient clinic, including addition of virtual appointments, allowed the CLS to expand practice further. In these video appointments, teen patients appear to be more engaging and talkative, allowing the CLS to better assess coping, adherence, and transition readiness in a relaxed Table 1. Two-way table depicting concordance between substance use and mental health screening results at same encounter. General Anxiety Disorder (GAD7) and Patient Health Questionnaire (PHQ9) results were aggregated such that a positive screening result on either was compared with neither being positive.(Table Presented) environment more suited to their developmental needs. Based on the success of having video appointments with adolescent patients without caregivers present, the CLS and the registered nurse care coordinators agreed to include these moving forward. Conclusion(s): The integration of the CLS at full scope of practice benefits not only patients and families, but also the interdisciplinary team and clinic as a whole. By taking a proactive and preventative approach, coping and psychosocial concerns can be navigated throughout the developmental stages with greater stability and emotional safety for patients and their familiesCopyright © 2022, European Cystic Fibrosis Society. All rights reserved
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Purpose of Study: Individuals with neurodevelopmental disabilities (NDD) encounter the healthcare system more frequently than their neurotypical peers, but most systems have not adapted a patient-centered approach to train staff and design spaces that are optimized for individuals with NDD. Certified Child Life Specialists (CCLS), Developmental-Behavioral Pediatricians, and a board-certified behavioral analyst at the Center for Excellence in Developmental Disabilities (CEDD) at the UC Davis MIND Institute partnered with nursing teams from the UC Davis COVID Vaccine Program to develop a dedicated Vaccine Clinic that addresses common barriers to vaccination for individuals with NDD. The program included training for vaccine program staff, and COVID vaccination and vaccine education for individuals with NDD in a safe, inclusive setting. Methods Used: MIND Institute staff obtained input from CEDD Community Advisory Committee and community partners to develop clinic protocols and dissemination strategies. Vaccine program staff received training about NDD and a website and video describing the clinic were created. After patients scheduled an appointment, they were contacted by CCLS who completed a structured intake interview that addressed each patient's likes and dislikes, sensory sensitivities, preferred method of communication, and history of previous experiences with medical procedures. Prior to the vaccine appointment, Child Life staff shared a social story with the families that provided a visual description of each step of their visit to the MIND Vaccine Clinic. Team huddles were completed the morning of vaccine clinic. Summary of Results: 321 doses of the COVID-19 vaccine were scheduled to be administered to individuals with NDD ages 5 to 67 years (225 M, 91 F, gender nonconforming 5). 8 appointments were either canceled or the individual did not attend. We were able to safely administer 310 (99.3%) doses. Conclusion(s): Strategies were developed to address common barriers to vaccination, some of which are more common in individuals with NDD, including sensory dysregulation, history of medical trauma, and concerns about how a novel vaccine might impact a patient's specific medical condition. A structured intake, staff training, daily huddles and a quiet dedicated space, longer appointments and dedicated parking were key elements of clinic success.
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Purpose of Study: Between September 2020 and November 2021, a survey was developed in partnership with children, youth, and community members experiencing vulnerabilities in a Vancouver Inner City Neighbourhood (ICN) to explore challenges encountered during the COVID-19 pandemic. In the survey, participants were asked questions about their financial status, housing security, food accessibility, and other social determinants of health. Other equity-seeking groups in Vancouver, including youth experiencing developmental and/or other medical diversity, wished to adapt the ICN COVID-19 survey to explore the impact of the pandemic in their community. These youth are active members of the province's pediatric tertiary care teaching hospital's Youth Advisory Committee (YAC), and in sharing their lived experience as patients, they strive to improve the quality of healthcare for children and youth throughout British Columbia. The objectives of this study were to: 1) adapt the COVID-19 survey to capture the views and needs of youth experiencing developmental and/or other medical diversity;and 2) identify how the COVID-19 pandemic impacted this group's social determinants of health. Methods Used: Ethics board approval was obtained for this observational, cross-sectional study (H20-00987). The research team and YAC co-constructed an adapted COVID-19 survey via Zoom dialogues. YAC members completed the survey online via Qualtrics from May 2022-August 2022. Demographic information and survey results were analyzed using descriptive statistics. Summary of Results: In total, 12 participants completed the survey, including 11 youth and 1 staff member. The median age of the youth participants was 23 years (n=11, min=14, max=29). During the COVID-19 pandemic, 82% (9/11) of youth reported changes in their ability to attend work or school, 36% (4/11) reported concern around reliable and affordable access to medications/medical treatment, and 46% (5/11) reported difficulty in caring for themselves. 46% (5/11) of youth also reported difficulty in caring for older adults or people in their families with disabilities. Many youth (6/11;55%) reported they had less than five people to turn to for support in times of stress, and 46% (5/11) of youth reported the pandemic changed their ability to connect with these people. Furthermore, 82% (9/11) of youth reported experiencing some level of distress related to the pandemic. 73% (8/11) of youth reported heightened anxiety, 82% (9/11) reported worsened mood, 55% (6/11) reported difficulty sleeping, and 64% (7/11) reported difficulty exercising. Conclusion(s): Youth with developmental and/or other complex medical diversity experienced difficulties accessing work and education, reliable and affordable medical care, and social support due to the COVID-19 pandemic. The pandemic negatively impacted the social, emotional, and physical wellbeing of these youth, indicating a need for future dialogue and advocacy to ensure the views and voices on rights of children and youth are honoured.
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Background: Breast cancer disparities between Black and White women have persisted in the US, with breast cancer death rates 40% higher in Black women compared to White women (American Cancer Society Cancer Facts & Figures for African American/Black People 2022-2024). Education and interventions at the community level can potentially reduce racial gaps, particularly in curbing late-stage diagnoses that disproportionately affect Black women with breast cancer. Together, the American Cancer Society (ACS) and Pfizer Global Medical Grants (Pfizer) developed a collaborative model to support health systems in engaging communities to reduce breast cancer disparities between Black and White women. This collaboration aimed to identify novel interventions and provide foundational support for these communities to advance their work in bridging the gap in breast cancer disparities. Method(s): This collaborative grant program divided project responsibilities, in which Pfizer provided funding and ACS provided project oversight and technical support. An advisory committee provided input on the areas of most need, impact and project direction. Funding applicants were required to partner with local organizations to implement evidence-based initiatives for education and/or quality improvement within the respected community. The grant award selection committee comprised of experts in the field, including breast cancer survivors and individuals from racial/ethnic minority groups. In response to a Request for Proposals, over 100 applications were systematically reviewed based on the National Cancer Institute grant selection process. The committee selected 9 grantees with innovative proposals addressing breast cancer disparities for Black women along the cancer-care continuum. Bi-annual progress reports were used to measure progress, with a final report to mark projects' impact and reach. The COVID-19 pandemic presented numerous obstacles during the project period and the ability to convene with partners virtually through web-based sessions helped to foster opportunities for collaboration and knowledge sharing among leaders in cancer disparities research. Result(s): The projects occurred from January 2020 to June 2022, with no-cost extensions given to accommodate COVID-19 pandemic delays. During this period grantees successfully completed project goals in one of three areas: screening, identifying areas of need and education. Approximately 10,000 patients and 200 healthcare professions were impacted among three projects focused on increasing mammography efforts in Black women during the project period. Three projects incorporated surveys and focus groups to identify novel areas for intervention/need and interviewed over 350 patients and over 60 health care professionals. The remaining three grantee projects that focused on education successfully implemented advertisement campaigns and lecture series to target patients and healthcare professionals. The projects selected under this model independently completed their goals within the project period while also laying a foundation to continue work in reducing disparities along the cancer care continuum with their enhanced community partner relations. Additionally, the project period also provided opportunities for external collaborations and discussion among all grantees through 8 ACS-coordinated online sessions and 3 summits. Conclusion(s): Projects selected by the public-private grant initiative model can enhance community relationships and provide infrastructure to continue work along the cancer care continuum. We believe this collaborative competitive grant program can be used for future efforts to address breast cancer and other health disparities at the community level. Similar collaborative funding projects related to prostate and pan-tumor disparities have been launched and are currently ongoing.
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Background In Stem Cell Transplants approximately two thirds of donors are identified and used from unrelated donor registries. In January 2020, we considered the impact that Covid19 infections and restrictions would have on donor availability. We identified that we needed to change our practice to ensure we could continue the SCT procedures which are critical for patients. Methods In January 2020, the Joint United Kingdom Blood Transfusion and Transplantation Service Professional Advisory committee (JPAC) changed the Tissue and cell donor selection guidelines. The risk and restrictions of Covid19 caused significant challenges including logistical issues for product delivery. Donor deferrals at medical assessments increased from 14% to 29% and overall activity in the UK was 75% of usual provision. Best practice was established and agreed with the donor registries. As per NICE guidelines, cryopreservation of all stem cell products was recommended with fresh donations considered according to patient condition. Back up donors were identified where possible. All donors were tested for Covid 19 on day of medical and harvest to ensure effective screening. We carried out 58 stem cell procedures from unrelated donors in 2020 and 56 in 2021. This activity is comparable to previous years. We secured stem cell products from Germany, USA, Korea, Poland, Turkey, Greece, Switzerland, the Netherlands and the UK. We analysed our data to assess if any delays occurred. Ethical approval was not required for this service evaluation. Results SCT activity was maintained throughout Covid19 with only postponement of elective SCT's which was assessed to be in the patient's best interest. Discussion We were able to adapt our practice to the benefit of our patients in unique and challenging circumstances. Conclusion We implemented measures which enabled BMT activity to continue throughout the acute Covid19 period despite challenges with new variants and further restrictions.
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Each year, the U.S. Centers for Disease Control and Prevention (CDC) releases the adult vaccine schedule. The 2022 adult vaccine schedule has several changes which will be discussed in the following manuscript. The Advisory Committee on Immunization Practices reviews the preliminary schedules usually at their October or November meetings. The following professional societies also approve the adult schedules prior to the 2022 publications: American College of Physicians (ACP), American Academy of Family Physicians (AAFP), American College of Obstetricians and Gynecologists (ACOG), American College of Nurse-Midwives (ACNM), American Academy of Physician Assistants (AAPA) and the Society for Healthcare Epidemiology of America (SHEA). Once the final draft is approved by the CDC, it is published in the Morbidity and Mortality Weekly Report (MMWR) and released to healthcare providers and the general public with a cover page, tables, notes and—new for the 2022 schedule—an appendix with contraindications and precautions for the different approved vaccines.
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Purpose: Transplant recipients are at increased risk of infectious complications from vaccine-preventable diseases. This study aimed to evaluate using a pharmacy technician to provide routine childhood immunizations during kidney transplant or heart transplant clinic to improve immunization rates. Method(s): Patients seen in our pediatric kidney or heart transplant clinics between August 2021 and November 2021 were included. Patient vaccine records were screened by the pharmacy technician, under transplant pharmacist supervision, prior to clinic visits to identify needed immunizations. Recommendations were based on the Advisory Committee on Immunization Practices (ACIP) and the American Society of Transplantation (AST) guidelines for vaccination of solid organ transplant candidates and recipients. The pharmacy technician contacted parents before clinic to discuss in clinic vaccination administration whenever possible. With verbal consent, the pharmacy technician submitted a vaccine prescription to the hospital's outpatient pharmacy, acquired the vaccine from the pharmacy, and administered the vaccine during clinic under the supervision of an immunization-certified pharmacist. All vaccines were entered into the Utah State Immunization Information System Registry. Result(s): Prior to initiation of this program, vaccines were rarely administered in clinic. During the 4-month study period, a total of 168 patients were screened (86 kidney transplant recipients, 82 heart transplant recipients), with 49 (29%) fully vaccinated. A total of 47 patients received vaccines during the study period (22 kidney transplant recipients, 25 heart transplant recipients) with 89 vaccine doses administered. The most frequently administered vaccines were SARS-CoV-2, influenza, and meningococcal (Table 1). No adverse events were recorded. Conclusion(s): Utilizing a pharmacy technician certified in immunization administration increased the number of vaccines administered to pediatric kidney and heart transplant recipients. Transplant programs who adopt a pharmacy technician immunization program in the clinic setting may benefit from close collaboration with an outpatient pharmacy.
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Purpose: The OPTN DTAC, a multidisciplinary group, evaluates potential donor derived transmission events (PDDTE) to assess the likelihood of disease transmission. Method(s): Retrospective study of PDDTE cases reported to the OPTN between 01/20 and 12/20. DTAC reviewed cases using a standardized classification algorithm. Result(s): During 2020, there were 18,318 donors and 37,583 unique recipients. DTAC reviewed 261/427 PDDTE from donor (111) or recipient (150) findings. 64/261 (25%) donors had proven/probable transmission (P/P Tr) of infection, malignancies or other to 84/206 (41%) exposed recipients [figure]. 12 involved living donors. Infection occurred with 44/64 P/P cases affecting 63 recipients. Viruses were most frequent P/P infections with 29 recipients having P/P Tr from 19 donors. COVID-19 PDDTE represented 11% (29/261) of all cases reviewed involving 29 donors and 15 lung and 76 non-lung recipients. One lung recipient had P/P Tr and died;none of the non-lung recipients developed P/P Tr. For bacteria, 20 recipients had P/P Tr from 14 donors. Deaths from infection (N=10) occurred at a median of 20 days (5-89 days). Attributable death was highest for fungal (4/12, 33%) and bacterial infections (6/20, 30%). 7 donors with malignancies were classified as P/P impacting 15 recipients with 1 attributable death. 53 non-infection, non-malignancy PDDTE were reported;13 resulted in P/P Tr to 14 recipients. Conclusion(s): Although P/P events remain rare, 1/4 reviewed cases resulted in unanticipated P/P Tr. This is a conservative estimate due to passive reporting and empiric interventions. In 29 COVID-19 PDDTE only 1 lung recipient had P/P Tr. The DTAC continues to evaluate PDDTE to maximize organ use and minimize the risk of transmission. (Table Presented).
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Purpose: Decision to transplant organs from SARS-CoV-2 NAT+ donors(N+D) balances risk of donor-derived infection with the scarcity of available organs to meet the needs of waitlisted candidates. Method(s): OPTN Ad Hoc Disease Transmission Advisory Committee (DTAC) reports on the use of organs from N+D from the onset of required SARS-CoV-2 lower respiratory tract(LRT) testing for lung donors (May 27, 2021) through August 31, 2021. OPTN data were analyzed for donors with a positive LRT or upper respiratory tract (URT) test reported in DonorNet discrete data fields (N+D), compared with donors who did not have positive LRT or URT in the discrete data fields (N-D). Result(s): Organs were recovered from 120 N+D (all OPTN Regions and 40/57 OPOs (70%)). Median donor age was 42 (IQR: 32-52) for N+D and 43 (30-56) for N-D. There was a greater proportion of DCD N+D than N-D (37.5% vs 28.3%, p=0.04). Underlying COD of anoxia and other were different (N+D 31.7%, 16.7% vs N-D 48%, 2.7%, respectively). Transplanted N+D and N-D did not differ by KDPI, LDRI or LVEF for kidney(KT), liver(LT) or heart(HT), respectively (Table 1). Median time from donor admission to first reported test (any result) was 0 and 4 days for URT and LRT, respectively. N+D recovery occurred a median of 2 (IQR: 1-6) days from last positive test. 246 organs (152KT, 50LT, 22HT, 22other) were transplanted from 107 N+D compared to 8969 organs from 3348 N-D. Recipients from N+D and N-D were similar in age, MELD/PELD (LT) and medical urgency status (HT). Median time from listing to transplant similar for N+D for all organs. The match run sequence number for final acceptor was higher for N+D for all organ types (Table 2). Median length of stay was similar for N+D and N-D for KT and LT (5d and 12-13d, respectively). For HT, median stay was shorter for N+D (30 vs 34d). For N+D, 3 of 50 LT died within 30d of transplant. During this timeframe, no PDDTEs were reported for any N+D at the time of transplant. Conclusion(s): N+D and N-D were similar in terms organ quality characteristics. Recipients receiving organs from N+D had higher match run sequence numbers, suggesting use of organs from N+D is not widespread across centers;however, with small numbers, this data will need to be verified. We cannot assess the relatedness of the three early mortality events in N+D recipients to donor or recipient characteristics. However, these data highlight the importance of ongoing outcome review of N+D recipients. (Figure Presented).
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SESSION TITLE: Rare Pulmonary Infections SESSION TYPE: Rapid Fire Case Reports PRESENTED ON: 10/18/2022 01:35 pm - 02:35 pm INTRODUCTION: Aspergillus is a group of opportunistic endemic fungal species that causes pathology within the respiratory tract and sinuses of individuals with predisposing factors, such as immunosuppression. While less frequently discussed, aspergillosis thyroiditis represents the most common fungal thyroiditis. We present a case of this condition that was misdiagnosed as amiodarone induced thyrotoxicosis. CASE PRESENTATION: A 54-year-old male was evaluated in outpatient pulmonary clinic after a chest CT revealed new upper lobe mass-like pleural based infiltrates with accompanying symptoms of dyspnea on exertion and fevers. His medical history was significant for orthotopic heart transplant 6 months ago due to a combination of non-ischemic cardiomyopathy with further decompensation from COVID-19 infection. After transplant, he was diagnosed with thyrotoxicosis secondary to amiodarone that was being treated with prednisone and methimazole. Given the concern for infection on imaging, he was admitted to the hospital and underwent urgent bronchoscopic evaluation. During the procedure, he was noted to have severe extrinsic tracheal compression. His neck imaging was consistent with a nodular goiter. The BAL revealed Aspergillosis fumigatus and he was subsequently treated with isavuconazium. Given the compression on the trachea and persistent dyspnea, the decision was to pursue total thyroidectomy. Surgery occurred 2 months after treatment was initiated for the Aspergillosis and with improvement on serial chest CTs. Pathologic examination of the thyroid tissue revealed extensive invasive aspergillus with abscesses involving both lobes. DISCUSSION: Aspergillus infection leading to disseminated disease typically occurs in individuals that have a compromised immune system such as seen in malignancy, solid organ transplant, chronic steroid use, and poorly controlled diabetes mellitus. Recently, it has been cited that up to 15% of hospitalized COVID-19 patients requiring intensive care develop aspergillus infection. After initial aspergillosis infection has been established, the thyroid gland is a site for dissemination due to its rich vascular supply. In addition, due to the angioinvasive properties of the pathogen, the fungus can breakdown tissue planes and easily travel from its site of origin. Thereby a primary infection in the respiratory tract can lead to dissemination to the neck structures due to its proximity. When thyroid invasion occurs, the common complaints are neck pain and swelling. Thyroid laboratory findings encompass the full spectrum including hyperthyroidism, hypothyroidism, and euthyroid. Given these non-specific findings, clinicians need to be conscious of this disease entity. CONCLUSIONS: In patients with immunocompromising conditions, findings of neck pain, swelling, and abnormal thyroid laboratory values should broaden the differential for clinicians to include aspergillosis thyroiditis. Reference #1: Alvi, Madiha M et al. "Aspergillus thyroiditis: a complication of respiratory tract infection in an immunocompromised patient.” Case reports in endocrinology vol. 2013 (2013): 741041. doi:10.1155/2013/741041 Reference #2: Marui, Suemi, et al. "Suppurative thyroiditis due to aspergillosis: a case report.” Journal of Medical Case Reports 8.1 (2014): 1-3. Reference #3: Kuehn, Bridget M. "Aspergillosis Is Common Among COVID-19 Patients in the ICU.” JAMA 326.16 (2021): 1573-1573. DISCLOSURES: No relevant relationships by A. Whitney Brown, value=Honoraria Removed 04/03/2022 by A. Whitney Brown No relevant relationships by A. Whitney Brown, value=Honoraria Removed 04/03/2022 by A. Whitney Brown No relevant relationships by A. Whitney Brown, value=Consulting fee Removed 04/03/2022 by A. Whitney Brown No relevant relationships by Kristen Bussa Advisory Committee Member relationship with Boehringer Ingelheim Please note: 2019-2021 Added 04/03/2022 by Christopher King, value=Consulting f e Advisory Committee Member relationship with Actelion Please note: 2019-2022 Added 04/03/2022 by Christopher King, value=Consulting fee Advisory Committee Member relationship with United Therapeutics Please note: 2019-2022 Added 04/03/2022 by Christopher King, value=Consulting fee Speaker/Speaker's Bureau relationship with Actelion Please note: 2019-2022 Added 04/03/2022 by Christopher King, value=Consulting fee Speaker/Speaker's Bureau relationship with United Therapeutics Please note: 2020-22 Added 04/03/2022 by Christopher King, value=Consulting fee No relevant relationships by Haresh Mani No relevant relationships by Mary Beth Maydosz No relevant relationships by Alan Nyquist No relevant relationships by Anju Singhal No relevant relationships by Amy Thatcher
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SESSION TITLE: COVID-19 Infections: Issues During and After Hospitalization SESSION TYPE: Original Investigations PRESENTED ON: 10/17/2022 01:30 pm - 02:30 pm PURPOSE: It has been established that recipients of solid organ transplants have worse outcomes compared to the general population from COVID-19 infections. We sought to determine the course and outcomes of lung transplant recipients (LTR) with COVID-19 infections based on vaccination status and treatments. METHODS: We performed a retrospective study of all LTR from Inova Fairfax Hospital with COVID-19 infections. Infection was confirmed based on symptoms and testing from an urgent care, hospital, or home kit. Patients with presumed but unconfirmed COVID-19 infections were excluded. The study timeframe was the two-year period: 3/1/2020 - 2/28/2022. Data collected included patient demographics, transplant type, immunosuppression, immunization status, episodes of rejection, donor derived cell-free DNA (dd-cfDNA) values (where available), spirometric data, outpatient/inpatient treatments, hospitalization data, and outcomes including death, infections, and other complications. The severity of illness was based on the 8-point ordinal scale. RESULTS: There were 45 LTR who tested positive during the study period;22 male and 23 female, average age of 57 and mean time from transplant of 4 years. 11 of the patients were unvaccinated (UV), 2 partially vaccinated (PV), 11 vaccinated non-boosted (VNB), and 21 vaccinated and boosted (VB). In total, 34 (76%) LTR required hospitalization. Of those hospitalized: 7 UV, 1 PV, 11 VNB, and 15 FV. In addition, 7 of those hospitalized required intubation with only 1/7 surviving to discharge. Overall, 8/45 (17.8%) patients died from COVID-19: 3 UV, 1PV, 1 VNB, 3VB. Infectious complications included 3 cases of PCP, 1 empyema, and 1 reactivation of CMV. For individuals who had spirometry at least 2 weeks after diagnosis (n =25), FVC decreased in 17 LTR by an average of 0.17 L, the FEV1 decreased in 14 LTR by an average of 0.14 L. On repeat spirometry testing (n=14), FVC further decreased in 9 LTR by 0.25 L and the FEV1 further decreased in 7 LTR by 0.13 L. CONCLUSIONS: A large proportion of LTR with COVID-19 infections require hospitalization (76%) with a high associated mortality rate and a sustained lung function decline seen in many who survive. The high mortality was independent of vaccination status, likely reflecting the inability of LTR to mount an immune response. A high index of suspicion and monitoring for superimposed infections, especially PCP, appears prudent. The sustained decline in lung function raises the notion of COVID-19 as a precipitating factor for chronic lung allograft dysfunction (CLAD). CLINICAL IMPLICATIONS: LTR who contract COVID-19 infection represent a high-risk population, even in those fully vaccinated, with potential for hospitalization, death, loss of lung function, and infectious complications. In this population, new algorithms for immunosuppression, monitoring and treatments may help to improve outcomes. DISCLOSURES: No relevant relationships by Shambhu Aryal No relevant relationships by A. Whitney Brown, value=Honoraria Removed 04/03/2022 by A. Whitney Brown No relevant relationships by A. Whitney Brown, value=Honoraria Removed 04/03/2022 by A. Whitney Brown No relevant relationships by A. Whitney Brown, value=Consulting fee Removed 04/03/2022 by A. Whitney Brown No relevant relationships by Jessica Chun No relevant relationships by Meg Fregoso No relevant relationships by Vikramjit Khangoora Advisory Committee Member relationship with Boehringer Ingelheim Please note: 2019-2021 Added 04/03/2022 by Christopher King, value=Consulting fee Advisory Committee Member relationship with Actelion Please note: 2019-2022 Added 04/03/2022 by Christopher King, value=Consulting fee Advisory Committee Member relationship with United Therapeutics Please note: 2019-2022 Added 04/03/2022 by Christopher King, value=Consulting fee Speaker/Speaker's Bureau relationship with Actelion Please note: 2019-2022 Added 04/0 /2022 by Christopher King, value=Consulting fee Speaker/Speaker's Bureau relationship with United Therapeutics Please note: 2020-22 Added 04/03/2022 by Christopher King, value=Consulting fee Consultant relationship with Veracyte Please note: $1001 - $5000 by Steven Nathan, value=Honoraria Removed 03/29/2022 by Steven Nathan Consultant relationship with United Therapeutics Please note: $5001 - $20000 by Steven Nathan, value=Consulting fee Consultant relationship with Bellerophon Please note: $5001 - $20000 by Steven Nathan, value=Consulting fee Speaker/Speaker's Bureau relationship with Roche-Genentech Please note: $5001 - $20000 by Steven Nathan, value=Honoraria Speaker/Speaker's Bureau relationship with Boerhinger-Ingelheim Please note: $20001 - $100000 by Steven Nathan, value=Honoraria No relevant relationships by Alan Nyquist No relevant relationships by Michelle Schreffler Speaker/Speaker's Bureau relationship with United Therapeutics Please note: 2020-2022 Added 04/01/2022 by Oksana Shlobin, value=Consulting fee Speaker/Speaker's Bureau relationship with Bayer Please note: 2020-2022 Added 04/01/2022 by Oksana Shlobin, value=Honoraria Speaker/Speaker's Bureau relationship with Janssen&Janssen Please note: 2020-2022 Added 04/01/2022 by Oksana Shlobin, value=Honoraria Consultant relationship with Altavant Please note: 2020-2022 Added 04/01/2022 by Oksana Shlobin, value=Consulting fee Consultant relationship with Acceleron Please note: 2020-2022 Added 04/01/2022 by Oksana Shlobin, value=Honoraria Consultant relationship with United Therapeutics Please note: 2020-2022 Added 04/01/2022 by Oksana Shlobin, value=Honoraria No relevant relationships by Anju Singhal No relevant relationships by Christopher Thomas
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SESSION TITLE: All About the CLOT: VTE SESSION TYPE: Original Investigations PRESENTED ON: 10/16/2022 10:30 am - 11:30 am PURPOSE: Patients diagnosed with intermediate high-risk pulmonary embolism (IHRPE) may develop early clinical decompensation requiring advanced reperfusion therapy. The clinical parameters and biomarkers which may prognosticate this progression to high risk acute PE are not clearly defined in the current clinical practice guidelines. There remains a critical knowledge gap regarding identifying the 5-17% of patients who will demonstrate decompensation within the first 72 hours after initial presentation. We measured serial acute PE biomarkers to better understand their patterns of evolution. METHODS: Single arm prospective observational pilot study measuring serial biomarkers in newly diagnosed and hospitalized IHRPE patients (age >18 years) meeting ESC 2019 criteria. Vital signs (HR, SBP, SI, SPO2/FiO2 index) were recorded at seven pre-specified times to assess clinical course during the first 72 hours. Blood biomarkers were evaluated during the same pre-specified time blocks. Cardiac biomarkers (NT Pro BNP, troponin) were measured every 8 hours for first 24 hours and then every 12 hours. Non-cardiac biomarkers (uric acid, lactate) were measured once every 24 hours. RESULTS: Total of 20 subjects (16M) were diagnosed via CT angiogram and enrolled after informed consent. Median age was 61.5 years (IQR 53, 72.5). Comorbidities included underlying malignancy (5), prior history of VTE (3) and Covid-19 (1). Radiographic embolus patterns included saddle (9), distal main PA/lobar (9) and segmental/sub-segmental (2). Lower extremity DVT were found in 14 subjects. Median admission vital signs (IQR) at time of presentation were: Heart rate 110 BPM (101,118), SBP 116 mmHg (100, 132);RR 21 per min (16, 23);Shock index 0.9 (0.8, 1.1);SPO2 85% (85, 96);and SPO2/FiO2 ratio 289 (246, 454). Subjects were admitted to the medical ward (13) and ICU (7). 16 remained clinically stable and 4 had clinical decompensation (2 respiratory failure, 2 shock) of whom 2 expired. At enrollment, troponin (TNT) was elevated in 20/20 subjects, NT proBNP in 18/20subjects, lactate in 8/20 subjects, and uric acid in 9/20 subjects;biomarkers normalized at different rates, with marked inter-individual variation. The median (IQR) peak values were: TNT, 0.05 (0.025, 0.078) ng/ml;NTproBNP, 2458 (1147, 5599) pg/ml;lactate, 1.8 (1.4, 3.4) mmol/L;and, uric acid, 6.2 (5.0, 7.4) mg/dl. 1/16 (6.3%) stable patients showed an 8-16 hr increase in TNT, compared with 2/4 (50%) of the decompensated patients, who required subsequent advanced PE interventions (p=0.088). CONCLUSIONS: Biomarkers in IHRPE patients evolve with variable time-courses. The potential of rising troponin at 16 hours to identify risk for circulatory or respiratory decompensation deserves further investigation. CLINICAL IMPLICATIONS: Abnormal biomarkers may aid clinical decision-making regarding advanced therapies in IHRPE patients. DISCLOSURES: No relevant relationships by Wendy Craig No relevant relationships by Ariel McKenna No relevant relationships by Victoria Molina No relevant relationships by Alexander Smith No relevant relationships by Hilamber Subba Advisory Committee Member relationship with ACI Clinical Please note: 2020-2022 Added 04/04/2022 by Joel Wirth, value=Salary
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SESSION TITLE: Pathology Under the Microscope SESSION TYPE: Case Reports PRESENTED ON: 10/19/2022 11:15 am - 12:15 pm INTRODUCTION: Rosai-Dorfman disease (RDD) is a rare, idiopathic, nonmalignant lymphohistiocytic proliferative disorder that presents with lymphadenopathy and less commonly with extranodal involvement (1). This is a case of a patient found to have a pulmonary artery mass and bone lesions consistent with RDD. CASE PRESENTATION: A 33-year-old female with COVID pneumonia presented with one week of dyspnea, myalgias, and chills. She developed hypoxia requiring 2L of supplemental oxygen. Physical exam was benign and without lymphadenopathy. CT angiography demonstrated a well circumscribed 2.3cm x 2.1cm eccentric filling defect concerning for a pulmonary embolism versus vascular mass. She had a normal troponin and brain natriuretic peptide. Echocardiogram showed normal left ventricular ejection fraction and right ventricular size and function. Lower extremity dopplers were negative for acute deep venous thrombosis. Cardiac MRI demonstrated a mass in the posterior aspect of the proximal main pulmonary artery superior to the pulmonic valve measuring 1.9cm x 1.6cm that was consistent with a benign cardiac tumor. Patient was discharged and underwent sternotomy and excision of the mass one week later. Pathology showed histiocytosis consistent with RDD. Post-operatively she developed recurrent fevers and imaging showed bony lesions in her lumbar spine, maxilla, and skull base. Pathology from an IR guided biopsy of the lumbar lesion was suggestive of RDD. DISCUSSION: RDD is a rare, nonmalignant lymphohistiocytic proliferative disorder that usually involves lymph nodes. Concurrent nodal and extranodal involvement has been reported in 43% of cases while isolated extranodal involvement has been reported in 23% of cases. Common extranodal sites include cutaneous, soft tissue, upper respiratory tract, bone, and central nervous system (1). There are only a few cases reported of pulmonary artery involvement. These cases include a patient with RDD invading the pulmonary trunk and aorta who required surgical resection and reconstruction due to impending right ventricular failure (2) and a young woman with RDD causing nearly complete obstruction of the main pulmonary artery resulting in severe pulmonary hypertension and heart failure who required debulking (3). This case demonstrates RDD involving the main pulmonary artery and bones which was incidentally discovered when the patient was hospitalized for COVID pneumonia. RDD has a benign course but when the pulmonary artery is involved, patients often require surgical excision. CONCLUSIONS: RDD is a benign proliferation of histiocytes that most commonly presents with cervical lymphadenopathy. Extranodal involvement has been reported but pulmonary artery involvement is rare. RDD has a benign course, but pulmonary arterial involvement often requires surgical excision. Reference #1: Gaitonde, S. (2007). Multifocal, extranodal sinus histiocytosis with massive lymphadenopathy: an overview. Archives of pathology & laboratory medicine, 131(7), 1117-1121. Reference #2: Prendes, B. L., Brinkman, W. T., Sengupta, A. L., & Bavaria, J. E. (2009). Atypical presentation of extranodal Rosai-Dorfman disease. The Annals of thoracic surgery, 87(2), 616-618. Reference #3: Walters, D. M., Dunnington, G. H., Dustin, S. M., Frierson, H. F., Peeler, B. B., Kozower, B. D., … & Lau, C. L. (2010). Rosai-Dorfman disease presenting as a pulmonary artery mass. The Annals of thoracic surgery, 89(1), 300-302. DISCLOSURES: No relevant relationships by Veena Dronamraju Advisory Committee Member relationship with Nabriva Please note: 1 day Added 03/14/2022 by Rohit Gupta, value=Consulting fee No relevant relationships by MARUTI KUMARAN no disclosure on file for Bilal Lashari;No relevant relationships by Parth Rali No relevant relationships by Stephanie Tittaferrante No relevant relationships by Yoshiya Toyoda
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SESSION TITLE: Actionable Improvements in Safety and Quality SESSION TYPE: Rapid Fire Original Inv PRESENTED ON: 10/17/2022 12:15 pm - 1:15 pm PURPOSE: The overall mortality rate for patients ‘transfered’ to the medical intensive care units is thought to be significantly higher than the mortality rate amongst those admitted directly. (1) It has also been suggested that uninsured critically ill patients have a higher probability of being ‘transferred’ to other hospitals as well as a higher mortality rate. (2, 3) We aim to determine whether insurance coverage impacts the transfer of critically ill patients. METHODS: This study was conducted at a quaternary care hospital which is also a regional transfer center. We accessed the public data for the year 2020 through our institutions Transfer Center Dashboard, System Analytics. The two aspects of transferred patients we focused upon were: 1) Hospital service (subspecialty care required) and 2) Financial class. Major subspecialties included in the study were: Pulmonology, Internal Medicine, Neurosurgery, Cardiology, and Neurology. Our study was a patient safety project, hence it qualified for IRB exemption. We classified the percentage of transfers as ‘Accepted’, ‘Declined’, or ‘Canceled’;and determined the insurance status of the patient. RESULTS: We found a total of 3552 patients transfers were initiated. 31.9% (1136) transfer patients were accepted, 46.79% (1662) transfers were declined, and 21.23% (754) were canceled due to reasons including unsafe transfer, acceptance at other institutions, or death prior to transfer. Major categories for transfers were Pulmonology (16.1%), other Internal Medicine related diseases (15.3%), and Neurosurgery (11.8%) were the subspecialties with the highest rate of transfers. In terms of financial class, we determined that 44.81% (n=509) of the ICU transfers had no insurance, 27.81% (n=316) had Medicare support, and 17.81% (n=202) had managed care through a health maintenance organization (HMO);the remaining 9.59% had other insurance plans. We used a binomial test to determine the probability of a transfer under no insurance (p) with the formula p + q=1, across the total number of transfer requests (n). K was the number of actual transfers that occurred. Total transfer requests were n=3552, actual transfers were k=1136 and transfers without insurance were 509/44.8%, converted into p=0.45 with a resulting q of 0.55.For z-test, we used the formula z = ((K - np) +- 0.5) / √npq = 15.58. Our one-tailed probability of exactly, or fewer than, 1136(K) out of 3552(n) was p <.000001. Our study was limited because of the COVID-19 pandemic occurring in the same year. CONCLUSIONS: Based on our results, we conclude that the ‘uninsured’ patients are more susceptible to getting transferred to other institutions. CLINICAL IMPLICATIONS: Critically ill ‘uninsured’ patients are selctively subjected to be transfered to other hospitals for higher level of care. These transfers may have significant health implications thereby resulting in higher morbidity and mortality in unisured populations. DISCLOSURES: No relevant relationships by Joodi Akhtar No relevant relationships by Sahar Fatima Advisory Committee Member relationship with Astra Zeneca Please note: 24 months Added 03/16/2022 by FAISAL MASUD, value=Honoraria Advisory Committee Member relationship with Teleflex Please note: 12 months Added 03/16/2022 by FAISAL MASUD, value=Consulting fee Advisory Committee Member relationship with La Jolla Please note: 12 months Added 03/16/2022 by FAISAL MASUD, value=Consulting fee No relevant relationships by Iqbal Ratnani No relevant relationships by Salim Surani No relevant relationships by Anza Zahid
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SESSION TITLE: COVID-19 Case Report Posters 2 SESSION TYPE: Case Report Posters PRESENTED ON: 10/19/2022 12:45 pm - 01:45 pm INTRODUCTION: Much has been learned about the immune dysregulation and release of pro-inflammatory cytokines since the emergence of the COVID-19 pandemic.1 Patients with interstitial lung disease are often on immunosuppressive agents, such as rituximab, which is a B-cell depleting agent. There has been a large retrospective cohort study showing that rituximab therapy was the only immunosuppressive medication with a trend towards in-hospital death.2 We present a case of COVID-19 in a patient on rituximab with ANCA vasculitis. CASE PRESENTATION: A 51-year-old male, never smoker, with ANCA positive vasculitis (positive MPO and PR3) and interstitial lung disease (on 4-5L of oxygen) presented to the hospital with nausea and fever for 2 days and was found to have a positive SARS-CoV-2 PCR. At the time of presentation, he was on rituximab 1000 mg x 2 doses every 6 months with last infusion one month prior to presentation, azathioprine 150 mg daily, prednisone 15 mg daily, nintedanib 100 mg BID, and IVIG monthly. Spirometry showed FVC of 1.60L/37% predicted and an FEV1 1.28L/39% predicted. Patient had 2 COVID vaccinations and one booster (all Pfizer mRNA), the latter 3 months prior to presentation. On admission, he was saturating at 55% on 4L and placed on 15L non-rebreather;he was afebrile, normotensive, and with a pulse of 110 BPM. Exam was notable for a cough, wheezing, and tachypnea. Lab work was notable for positive SARS-COV-2 PCR, a total white blood cell count of 5.3x103 uL, and a normal hemoglobin and platelet count. He had a CO2 of 34, normal creatinine, and no transaminitis. Lactate dehydrogenase (LDH) was elevated at 318 U/L, and lactate was elevated at 3.5 mmol/L. His chest x-ray on admission demonstrated patchy filling opacities and low lung volumes. He received dexamethasone, remdesivir, and the monoclonal antibodies casirivimab and imdevimab (REGEN-COV) on the first day of admission. Patient also received his monthly IVIG dose inpatient. After a week, he was weaned back to his home oxygen and symptomatically back to baseline. Most recent PFTs on the same outpatient immunosuppressive regimen as prior to admission are unchanged. Patient received two doses of preventative monoclonal antibodies (EVUSHELD) 3 months after admission. DISCUSSION: Here we discuss a case of a patient with severe COVID-19 pneumonia requiring inpatient hospitalization despite three COVID mRNA vaccinations, likely secondary to difficulty in mounting an immune response to the vaccinations given his use of immunosuppressive medications. This is also an example of the early use of monoclonal antibodies in an inpatient with long term preservation of his underlying lung function.3 CONCLUSIONS: We recommend counseling and close observation of patients on rituximab due to risk of severe COVID-19 infection as well the use of preventative monoclonal antibodies (EVUSHELD). Reference #1: Jamal M, Bangash HI, Habiba M, Lei Y, Xie T, Sun J, Wei Z, Hong Z, Shao L, Zhang Q. Immune dysregulation and system pathology in COVID-19. Virulence. 2021 Dec;12(1):918-936. doi: 10.1080/21505594.2021.1898790. PMID: 33757410;PMCID: PMC7993139. Reference #2: Andersen, K. M., Bates, B. A., Rashidi, E. S., Olex, A. L., Mannon, R. B., Patel, R. C., Singh, J., Sun, J., Auwaerter, P. G., Ng, D. K., Segal, J. B., Garibaldi, B. T., Mehta, H. B., Alexander, G. C., Haendel, M. A., & Chute, C. G. (2022). Long-term use of immunosuppressive medicines and in-hospital COVID-19 outcomes: A retrospective cohort study using data from the National COVID Cohort Collaborative. The Lancet Rheumatology, 4(1), e33–e41. https://doi.org/10.1016/S2665-9913(21)00325-8 Reference #3: Weinreich, D. M., Sivapalasingam, S., Norton, T., Ali, S., Gao, H., Bhore, R., Xiao, J., Hooper, A. T., Hamilton, J. D., Musser, B. J., Rofail, D., Hussein, M., Im, J., Atmodjo, D. Y., Perry, C., Pan, C., Mahmood, A., Hosain, R., Davis, J. D., Yancopoulos, G. D. (2021). Regen-cov antibody combination and outcomes in outpatients with covid-19. New England Journal of Medicine, 385(23), e81. https://doi.org/10.1056/NEJMoa2108163 DISCLOSURES: Advisory Committee Member relationship with Genentech Please note: 2019-2022 Added 06/06/2022 by Ayodeji Adegunsoye, value=Consulting fee Advisory Committee Member relationship with Boehringer Ingelheim Please note: 2018-2022 Added 06/06/2022 by Ayodeji Adegunsoye, value=Consulting fee Speaker/Speaker's Bureau relationship with Boehringer Ingelheim Please note: 2018-2022 Added 06/06/2022 by Ayodeji Adegunsoye, value=Honoraria Consultant relationship with Genentech Please note: 2018-2020 by Ayodeji Adegunsoye, value=Consulting fee Removed 06/06/2022 by Ayodeji Adegunsoye No relevant relationships by Cathryn Lee No relevant relationships by Kavitha Selvan PI relationship with Boehringer-Ingelheim Please note: >$100000 by Mary Strek, value=Grant/Research Support PI relationship with Galapagos Please note: $70,000-100,00 by Mary Strek, value=Grant/Research Support Endpoint Adjudication Committee Member relationship with Fibrogen Please note: $1-$1000 by Mary Strek, value=Honoraria No relevant relationships by Rachel Strykowski
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SESSION TITLE: Studies on COVID-19 Infections Posters SESSION TYPE: Original Investigation Posters PRESENTED ON: 10/18/2022 01:30 pm - 02:30 pm PURPOSE: To evaluate factors associated with early versus late mortality in hospitalized patient with COVID-19. METHODS: This observational study analyzed data of patients who died from COVID-19 at Ben Taub Hospital, a tertiary care County teaching hospital, between from March 2020 to February 2022. Demographic, comorbidities, laboratory values as well as COVID-19 treatments were examined. Patients were divided into two groups: those who had early mortality and those with late mortality (death ≤7 days or >7 days of admission, respectively). RESULTS: 212 patients with COVID-19 died during that period. Of these, 46 patients had early mortality and 166 patients had late mortality. 19/46 (41.3%) of the patients in early mortality group died within 72 hours of presentation. There were no differences between the two groups with regards to age, gender, ethnicity, or body mass index. Both groups were similar with regards to history of tobacco use, hypertension, diabetes mellitus, coronary artery disease, congestive heart failure, cerebrovascular accident, atrial fibrillation, obstructive airway disease, cancer, liver cirrhosis and human immunodeficiency virus infection. There were no differences with regards to COVID vaccination status between the two groups. Peak D dimer, peak C-reactive protein, peak ferritin, peak lactate dehydrogenase and lymphocyte nadir during the hospital course were also similar between the two groups. Patients in the early mortality group had shorter time from symptom onset to admission {3.91 days (SD 5.63) in early vs 6.85 days (SD 8.01) in late}. There were no differences between the two groups regarding use of mechanical ventilation. Patients with late mortality were more likely to have received systemic steroids (90.9% vs 60.9%), anticoagulation (94.6% vs 65.2%), remdesivir (75.3% vs 32.6%), inhaled epoprostenol (50.6% vs 19.6%) compared to early mortality, respectively. In addition to severity of symptoms and clinical condition at the outset of the disease, early death may have been related to not receiving some of these medications.1 CONCLUSIONS: Early mortality in patients with COVID-19 is associated with shorter time to symptoms onset and the lower likelihood to have received systemic steroids, systemic anticoagulation, remdesivir and inhaled epoprostenol. CLINICAL IMPLICATIONS: Early recognition and intervention may prevent early mortality in COVID-19 patients. Reference: Sun, Q., Qiu, H., Huang, M. et al. Lower mortality of COVID-19 by early recognition and intervention: experience from Jiangsu Province. Ann. Intensive Care 10, 33 (2020). https://doi.org/10.1186/s13613-020-00650-2 DISCLOSURES: No relevant relationships by Muhammad Adrish Advisory Committee Member relationship with AstraZeneca, Genentech, GSK, Mylan, Sanofi Please note: 2020-2021 by Nicola Hanania, value=Consulting fee Consultant relationship with AstraZeneca, Genentech, GSK, Mylan, Sanofi Please note: 2020-2021 by Nicola Hanania, value=Consulting fee Advisory Committee Member relationship with Regeneron, Amgen, and Teva Please note: 2020-2021 by Nicola Hanania, value=Consulting fee Consultant relationship with Regeneron, Amgen, and Teva Please note: 2020-2021 by Nicola Hanania, value=Consulting fee Removed 08/02/2022 by Nicola Hanania Research support relationship with Boehringer Ingelheim, GSK, Novartis Please note: 2020-2021 by Nicola Hanania, value=Grant/Research Support Research support relationship with Sanofi Genzyme and Genentech Please note: 2020-2021 by Nicola Hanania, value=Grant/Research Support No relevant relationships by Stephanie Stalcup