Early nutritional screening, appropriate first line advice and prescribed oral nutrition support across organisational boundaries. New oral nutrition support pathway striving for seamless delivery of care from Hospital into Community Care

In the UK, approximately 3 million people are malnourished or at risk of malnutrition. Malnutrition is a major public health issue with costs the NHS over £19 billion per year in England alone. We know 93% of malnutrition happens in peoples own homes, 5% in care homes and 2% in hospital. It is also understood that 30% of inpatients are at higher risk of becoming malnourished in hospital. 1 As many departments, demand for dietetic services has outweighed capacity, in part due to improved rates of nutritional risk screening across the organisation. The Trust uses an internal validated nutritional screening tool but community partners largely use MUST (Malnutrition Universal Screening Tool). Within our Dietetic team, we identified a number of treatment strategies needed to ensure timely care, patient empowerment and patient safety with a focus on improved nutrition to help recovery across organisational boundaries from the acute admission and into primary care. Patients who are identified as malnourished or at very high risk of malnutrition, have specialist requirements should have immediate referral to a dietitian. Oral nutritional supplements are now prescribed appropriately whilst in hospital and post discharge in line with national and local guidelines. 4 Communication between different healthcare professionals and settings is essential for the seamless delivery of care2 and hospital teams discharging patients with an identified risk of malnutrition should communicate this in writing to primary care teams3. As a team, we decided to encompass nutrition and dysphagia scores as an inpatient on discharge letters. This was be achieved by working closely with the pharmacy, Speech and Language, catering, nursing and medical teams to develop and implement a clear process for all adult inpatients to improve ward based nutritional care and appropriate prescribing, based on their individual risk of malnutrition. We have developed and implemented a discharge process that provides patients with a nutrition pack (malnutrition pathway leaflets, cover letter +/- Care Homes information) +/- nutritional supplements on discharge. The process was developed with local CCGs, GPs, PCN Pharmacists and community dietetic services. Outcomes measured include;appropriate prescribing, access to snacks and supplements, clinical outcomes including length of stay (LOS), readmission rates and timely access to first line advice. Baseline audit information revealed only 8% of inpatients received the a first line nutrition leaflet, this has increased to 13% just 6 weeks post implementation, patient first line snacks has increased to 5 different categories as choice available has increased. Oral nutritional support (ONS) is now solely prescribed using the agreed ONS pathway. Early indications suggest a direct improvement in patient care and choice. References 1. Brothern A, Simmonds N, Stroud M.2010. Malnutrition Matters: Meeting Quality Standards in Nutritional Care. A report on behalf BAPEN Quality Group 2. ‘A Guide to Managing Adult Malnutrition in the Community’ Last accessed from: on 02.07.2021 3. ‘Pathway for using ONS in the Management of Malnutrition’ Last accessed from:https://www.malnutritionpathway.co.uk/library/ons_pathway.pdf on 29.06.2021 4. ‘Nutritional considerations for primary care teams managing patients with or recovering from COVID-19’ BDA and optimising nutritional prescribing last accessed :. 02.07.21

DELAYED PRESENTATION OF MYOCARDIAL INFARCTION IN THE SETTING OF A GLOBAL PANDEMIC

CASE: A 52-yo male with hypertension and former smoker was transferred from outside hospital with dyspnea and hemoptysis. He had presented with chest pain and abnormal ECG to an urgent care 2 days earlier but declined to visit the emergency room in fear of the pandemic. This time, he had respiratory distress requiring intubation and transfer to a higher level of care. He developed cardiogenic shock and profound refractory hypoxia. ECG showed sinus tachycardia, Q waves V1-V3. Chest X-ray had right-side pulmonary edema. An urgent transthoracic echocardiogram (TTE) revealed evidence of papillary muscle rupture (PMR) and LVEF of 65%. An emergent coronary angiogram showed multivessel disease, and a simultaneous transesophageal echocardiogram confirmed torrential mitral regurgitation and PMR. An intra-aortic balloon pump was placed. Patient then underwent urgent CABG/valve replacement and was discharged 10 days later. At 4-month follow-up patient was asymptomatic in clinic. IMPACT/DISCUSSION: Here we present a case of Non-ST-segment elevation myocardial infarction (NSTEMI) whose presentation was delayed due to fear on contracting COVID-19, resulting in papillary muscle rupture (PMR). Acute mitral regurgitation (MR) due to PMR is a life-threatening mechanical complication occurring in 3/1000 patients with myocardial infarction (MI) per year. Prepandemic studies showed that mechanical complications had decreased their incidence over time given the numerous advances in reperfusion therapies. The mortality of such complications remained elevated in numerous studies (4-fold higher than patients without mechanical complications), especially for patients presenting with late-STEMI. Mechanical complications are significantly less common in patients with NSTEMI, such as our patient. The COVID-19 pandemic marked a surge in delayed presentations of MI, resulting in rising incidence of complications worldwide. Certain studies have demonstrated that the pandemic itself is an independent risk factor for delayed presentations of acute coronary syndrome. Echocardiogram remains the diagnostic modality of choice with sensitivity of 65-85% to detect complications from MI, however high clinical suspicion is key to prompt early use of this imaging modality. Our case illustrates that awareness of delayed presentations amongst clinicians may grant early diagnosis and good outcomes. CONCLUSION: Mechanical complications with catastrophic presentations had decreased after the reperfusion treatment era, however the advent of the COVID-19 pandemic has raised concerns for an increasing incidence of delayed presentations of acute coronary events resulting in lethal complications. High clinical suspicion is paramount in diagnosis and outcomes associated to patients suffering from papillary muscle rupture as well as other mechanical complications of MI.

A Case of Suspected Covid-19 Booster-Induced Thromboembolism in a Nonagenarian

Background: mRNA vaccines have been instrumental in fighting the Covid- 19 pandemic. Due to waning immunity, booster doses have received emergency use authorization.1 While awaiting FDA approval, physicians should continue to report adverse effects. Here, we present a 90 year old incidentally found to have bilateral pulmonary emboli 6 days after receiving a Covid-19 booster vaccine. Case: WR is a 90 year old male with HTN, HLD, T2DM, CKD, CVA, osteoporosis, and prostate cancer in remission who presented to the ED after falling. He complained only of left hip pain. He denied chest pain, cough, or shortness of breath. X-ray revealed left hip fracture. CTA head and neck demonstrated concern for acute PE. Follow-up CTA chest showed large central pulmonary emboli extending into every lobe bilaterally and right heart strain. Notably, he received a mRNA Covid-19 booster vaccine 6 days prior. His first 2 vaccinations were uncomplicated. He had no personal or family history of blood clots. Vitals in ED: temp 36.8°C, HR 87, RR 24, BP 126/61, SaO2 87% on room air with improvement to 91% on 4L via nasal cannula. Physical exam was unremarkable except for tenderness and deformity of the left leg. Labs were significant for Cr 2.18 (baseline 1.7), troponin-HS 1990, and CPK 1514. Heparin was started, and he was admitted to the hospital. Discussion: We report the case of a nonagenarian incidentally found after a fall to have severe, yet asymptomatic, thromboembolism in the setting of a recent mRNA Covid-19 booster vaccine. The CDC recommends booster doses for people older than 50 and for those living in long-term care2, which is common among the elderly. Although there is evidence that some Covid-19 vaccines are associated with higher risk of blood clots than placebo, the absolute risk is substantially smaller compared to a similar event occurring after Covid-19 infection.3 There is not enough data right now to determine if booster doses affect these risks. However, it is reasonable to closely monitor those at higher risk for blood clots, such as geriatric patients who are prone to falling or prolonged periods of limited mobility.

Multifaceted approaches to engaging Black and Latinx populations: From bed to bedside

INTRODUCTION The Cancer Research Education and Engagement (CaRE2) Health Equity Center seeks to eliminate cancer disparities within Black and Latinx communities through research, training, education, and community engagement. The goal of this presentation is to share the unique model of community engagement that was implemented by the CaRE2 Center's Community Outreach Core (COC) during the COVID-19 pandemic. METHODS During the COVID-19 pandemic, the COC hosted community outreach events to address prostate and pancreatic cancer disparities. We overcame the challenges of COVID-19 by hosting these programs over Zoom, Facebook, and Twitter and allowing participants to interact and ask questions. The use of these platforms allowed us to develop and implement the innovative “bed to bedside” model, which allowed participants to gain a well-rounded understanding of the cancer process from cancer survivors, physicians, and researchers of color. The goal of these events were to 1) increase awareness of the importance of prostate and pancreatic cancer screening, 2) educate patients and community members about potential prostate and pancreatic cancer treatments, 3) raise awareness on prostate and pancreatic cancer research, and 4) address the causes and solutions to prostate and pancreatic cancer disparities in the Black and Latinx community. RESULT A total of 4 events were conducted between September and November of 2021, reaching a total of 30 persons directly and about 30 more through social media. At each event, evidence-based prostate cancer and pancreatic cancer education was disseminated. Of the attendees, 48% identified as Black or African American and 14% as Latino(x). Attendees were given the option to provide feedback and 90% of attendees agreed or strongly agreed that the presentations met their expectations. One benefit of conducting outreach activities via these platforms was the ability for more individuals to attend and the elimination of transportation barriers. Participants reported that attending virtually was easy to navigate and provided a suitable environment given the ongoing pandemic. Participants also reported that they enjoyed the “bed to bedside” model and shared that hearing from a survivor of color led to them feeling more comfortable in considering cancer screening. CONCLUSION The Care COC, in partnership with the community, is addressing disparities in the Black and Latinx population. One of the barriers that we had to overcome was continuing community outreach during the COVID-19 pandemic. The decision to provide health education outreach over social platforms, was essential to maintain our reach and impact. This allowed for the implementation of the “bed to bedside” model that included the different perspectives of care. We concluded that this model was effective and helped normalize the treatment process. We also concluded that outreach to the community should continue to provide cancer information via virtual formats especially as the COVID-19 related incidence and mortality begins to increase.

The outcomes of evolving treatment regimens among COVID-19 Confirmed severe and critical cases admitted at the lung center of the Philippines

Background and Aims: This study aims to describe the outcomes of evolving treatment regimens among COVID-19 confirmed severe and critical cases admitted at The Lung Center of the Philippines. Methods: A retrospective, cohort study conducted at The Lung Center of the Philippines from March 2020 to August 2020 that included 219 COVID-19 confirmed severe and critical patients. Results: Eleven out of 68 combinations of treatment regimens have significant difference in the proportion of survivors and non-survivors. Number of survivors is greatest for age group 50-59 (p= 0.106). Severe COVID-19 was associated with chronic kidney disease (p= 0.009). Most number of survivors is recorded for regimens with LCP standard of care 2 (antibiotic therapy, multivitamins + zinc, 02 therapy, IV fluid, and management of comorbidities + Anticoagulant + Dexamethasone) and high flow nasal cannula (HFNC). Combinations that included invasive ventilation showed an increased likelihood of death. Regression analysis showed that an increased Apache II score increased the likelihood of death and an increased PF ratio score lessened the probability of death. Median length of hospital stay is 11 days. Conclusions: Treatment regimens that included HFNC and LCP Standard of care 2 in combination with either interferon, tocilizumab, hemoperfusion, proning, or remdesivir decreases the likelihood of death. Invasive ventilation simultaneously given with any of the regimens increases the likelihood of death. Patients with higher Apache II scores and lower Pa02/Fi02 were non-survivors and in a more critical condition.