Examining the frequency of endoscopic findings in patients with covid-19 with upper gastrointestinal bleeding referred to al-Zahra Hospital of Isfahan.

Background: Gastrointestinal bleeding is one of the consequences of COVID-19, which is associated with increased hospitalization and patient mortality. This study was conducted to determine the prevalence of endoscopic findings and the outcome of gastrointestinal bleeding in patients with COVID-19 who were hospitalized from September to December 2019 in Al-Zahra Hospital, Isfahan. Method(s): In this cross-sectional study, out of 5800 patients who were admitted to Al-Zahra Hospital in Isfahan from September to December 2019 due to COVID-19 (according to the positive PCR test result), 87 patients who underwent endoscopy due to upper gastrointestinal bleeding by a skilled gastroenterologist, were selected and studied. Demographic characteristics, underlying diseases, use of anticoagulants, and laboratory findings were studied and evaluated and finally, the disease was evaluated and compared based on endoscopic findings. Result(s): Based on the results obtained from this research, the patients with endoscopic lesions had higher average age (P=0.041), lower blood oxygen saturation percentage (P=0.028), and higher bleeding intensity (P=0.018). The frequency of using anticoagulant drugs in the group whose endoscopy results were abnormal was higher but insignificant. Hemoglobin, platelet, lymphocyte, and CRP levels were higher in the group whose endoscopy was normal, and NLR, LDH, and D-dimer levels were higher in the group whose endoscopy was abnormal (P<0.050). Three people (11.55%) from the group with normal endoscopy and 18 people (29.5%) from the group with abnormal endoscopy died, but the frequency of death was not significantly different between the two groups (P=0.070). Conclusion(s): The findings of the present study showed that the COVID patients with upper gastrointestinal bleeding who had endoscopic lesions had significant differences in some characteristics such as age, bleeding intensity, and blood oxygen saturation percentage with patients with normal endoscopy. Also, the frequency of death in patients with endoscopic lesions was relatively higher. Therefore, COVID patients with gastrointestinal bleeding should undergo endoscopy as soon as possible and necessary measures should be taken to control and prevent gastrointestinal bleeding.Copyright © 2022 Tabesh et al. Tehran University of Medical Sciences. Published by Tehran University of Medical Sciences.

The use of venovenous extracorporeal membrane oxygenation in COVID-19: An updated systematic review and meta-analysis of clinical outcomes

Objectives: The objective of this study is to assess the clinical benefits and potential risks of using venovenous extracorporeal membrane oxygenation (VV ECMO) as a treatment for COVID-19 patients with severe respiratory failure. Method(s): Relevant studies were identified through searches of electronic databases, including PubMed, EMBASE, and the Cochrane Library, from January 2020 to December 2022. We included observational studies on adult patients who received venovenous (VV) ECMO support for COVID-19-induced ARDS. The primary outcome was in-hospital mortality, 3-month mortality, and complications associated with VV ECMO. Statistical analysis was performed using R version 4.0.3 and the metafor and meta packages. Result(s): The final analysis included 39 studies comprising 10,702 patients. In-hospital mortality for adults receiving ECMO was 34.2% (95% CI: 28.5% - 40.3%;I2 = 93%), while the 3-month mortality rate was 50.2% (95% CI: 44.4% - 56.0%;I2 = 51%). Bleeding requiring transfusion occurred in 33.7% of patients (95% CI, 23.9 - 45.1;I2 = 96%). The pooled estimates for other complications were as follows: overall thromboembolic events 40.9% (95% CI, 24.8 - 59.3;I2 = 97%), stroke 8.7% (95% CI, 5.7 - 13.2;I2 = 72%), deep vein thrombosis 15.4% (95% CI, 9.7 - 23.6;I2 = 80%), pulmonary embolism 15.6% (95% CI, 9.3 - 25.1;I2 = 92%), gastrointestinal haemorrhage 8.1% (95% CI, 5.5 - 11.8;I2 = 56%), and the need for any renal replacement therapy in 38.0% of patients (95% CI, 31.6 - 44.8;I2 = 84%). Bacterial pneumonia occurred in 46.4% of patients (95% CI, 32.5 - 61.0;I2 = 96%). Conclusion(s): Venovenous extracorporeal membrane oxygenation (VV ECMO) may be an effective treatment option for COVID-19 patients with severe respiratory failure. The use of VV ECMO was associated with reduced in-hospital and 3-month mortality. However, bleeding is a common complication that should be closely monitored. Further research is needed to determine the optimal use of VV ECMO in this patient population and to identify factors that may predict a favourable response to treatment.

Prognostic Value of Elevated Lipase in Pancreatitis versus Non Pancreatitis Hyperlipasemia (NPHL) due to Non-Malignant Causes

Introduction: While elevated lipase is typically used to diagnose acute pancreatitis, it has also been associated with other critical disease states including sepsis, COVID-19, bowel obstruction, and trauma. In this study we compared outcomes of patients with elevated lipase who had pancreatitis and NPHL. Method(s): Retrospective analysis was performed on all patients who presented to the Emergency Department between February 2016 and August 2020 with lipase >= 3x the upper limit of normal. Patient demographics and past medical history, including active cancer, were noted. Patient outcomes were followed through November 2021. If applicable, dates of death were also documented. Result(s): 414 total patients were included in this study. Upon initial evaluation, 305/414 (74%) were diagnosed with acute pancreatitis (AP) and 109/414 had NPHL. The age (54 617 vs. 58 618, p=0.0220), Sex (male 164/305 vs. 49/109, p=0.1194), and BMI (28.9 67.4 vs. 25.8 64.6, p=0.0066) were compared between the AP and NPHL groups. The serum lipase in the AP and NPHL group were respectively 1471 61070 vs. 605 6555 (p< 0.0001). The most common causes of NPHL were sepsis (10/109;9%) renal failure (7/109;6%), GI bleed (5/109;4%), and bowel obstruction (5/109;4%). The NPHL group had higher rate of malignancy (29/105;28%) compared to those with AP (35/305;11%, p< 0.0001). NPHL patients without malignancy had a higher mortality rate (63/80;80%) compared to those without malignancy in the AP group (17/270;6.3%, p< 0.0001). The most common malignancy in patients with AP was breast (6/35;17%, vs. 3/29;10%, p=0.4943). In NPHL, the most common malignancies were pancreatic (4/29;14%, vs. 3/35;9%, p=0.6920) and bowel malignancies (4/29;14%, vs. 4/35, 11% p51.0000). Conclusion(s): Patients with NPHL without malignancy have higher mortality than those with pancreatitis despite lower serum lipase levels. A limitation of our study is the difference between age and BMI of AP versus NPHL patients. Whether this impacts the prognostic relevance of NPHL on survival need to be explored in future studies.

A Diagnostically Challenging Case of Primary Pancreatic Lymphoma

Introduction: Primary Pancreatic Lymphoma (PPL) is the exceedingly rare instance of extranodal Non-Hodgkin's Lymphoma developing mainly in the pancreas.We report a diagnostically challenging case of a patient presenting with a rapidly growing pancreatic mass, found to have PPL. Case Description/Methods: A 48-year-old female with past history of tobacco use presented with several months of cramping abdominal pain following COVID-19 infection. She denied weight loss, fevers, or night sweats. Her physical exam, CBC, CMP, lipase, LDH, and CA 19-9 were unremarkable. An abdominal ultrasound revealed a 2.8 x 1.9 x 3 cm cystic mass of the pancreatic head, most congruent with a pseudocyst. Worsening abdominal pain prompted repeat ultrasound one month later, which showed a doubling in size. Endoscopic ultrasound (EUS) with fine needle aspiration of the cystic mass and surrounding lymph nodes yielded cystic contents and reactive lymphadenopathy. Two months later, her abdominal pain worsened and repeat imaging showed further doubling in size with encasement of the celiac plexus. A second FNA performed via EUS redemonstrated cystic contents. An ultrasound-guided core needle biopsy of the mass revealed necrotic CD301 diffuse large B cell lymphoma (DLBCL). PET scan was suggestive of stage IV PPL (Figure). Imaging also identified an inguinal lymph node that returned as CD101 BCL61 high grade follicular lymphoma, which was thought to be a distinct lesion. She was started on R-CHOP. Her clinical course was complicated by the formation and subsequent rupture of a splenic artery pseudoaneurysm, gastrointestinal bleeding, anuric kidney injury, and intestinal ischemia. She ultimately transitioned to comfort care. Discussion(s): Primary pancreatic lymphoma comprises 0.6% of extranodal lymphomas and 0.2% of primary pancreatic tumors. The clinical presentation is often vague and includes abdominal pain, B symptoms, jaundice, or bowel obstruction. The diagnostic criteria according to the WHO requires that the (1) majority of tumor burden be localized to the pancreas and (2) existing nearby and distant lymph node involvement should be secondary to pancreatic presentation. A biopsy is required to diagnose PPL, which is histologically most often DLBCL. Our case highlights the challenges associated with diagnosing PPL despite two EUS with FNA. Although rare, one should proceed with a high index of suspicion for PPL in any patient presenting with a rapidly enlarging pancreatic mass.

Marginal Artery of Drummond Pseudoaneurysm Masquerading as Fistulous Tract Resulting in Recurrent Lower Gastrointestinal Bleeding

Introduction: The mortality rate of patients hospitalized with a lower gastrointestinal bleed has been reported at 1.1% in the United States from 2005 to 2014. Pseudoaneurysms, typically associated with pancreatitis, have been described in case reports as a rare condition with a small subset presenting as gastrointestinal bleeding. Our study describes a rare case of recurrent lower gastrointestinal bleeding diagnosed as a pseudoaneurysm by endoscopy and angiography. Case Description/Methods: A 38-year-old male presented to our facility from a long-term care facility with hematochezia and blood clots per gastrostomy-jejunostomy. He had recently been hospitalized for severe coronavirus disease 2019 with a complicated hospital course in the intensive care unit including necrotizing pancreatitis with an abdominal drain, multiple secondary infections, tracheostomy, and percutaneous endoscopic gastrostomy-jejunostomy. On previous hospitalization, he was found to have a small pseudoaneurysm of the gastroduodenal artery and received embolization of the gastroduodenal and gastroepiploic arteries at that time. During transport to our hospital, he was noted to have tachycardia, hypotension requiring norepinephrine, and was transfused one unit of red blood cells. Hemoglobin at this time was 7.5 g/dl after transfusion. Esophagogastroduodenoscopy was completed and showed a gastrojejunostomy tube in the expected location but was noted to be tight to the mucosa, which was pale in appearance. Flexible sigmoidoscopy revealed localized areas of edematous and erythematous mucosa with some associated oozing throughout the sigmoid colon. Repeat evaluation was completed one week later due to recurrent hematochezia. Colonoscopy was performed with identification of an apparent fistulous tract in the sigmoid colon located at 35 cm. Computed tomography angiography localized a pseudoaneurysm arising from the marginal artery of Drummond just proximal to its anastomosis with the ascending branch of the left colic artery and was successfully embolized. Discussion(s): Pseudoaneurysms, such as the one described in this case, have been shown to be associated with pancreatitis and can result if a pseudocyst involves adjacent vasculature. Gastrointestinal bleeding is a rare presentation of this condition. However, this case highlights the importance of repeat colonoscopy and angiography in the setting of a lower gastrointestinal bleed of unknown etiology.

A Case of Primary Biliary Cirrhosis With New Onset Hyperthyroidism and Supratherapeutic INR

Introduction: Hyperthyroidism is known to increase catabolism of vitamin-K-dependent clotting factors (II, VII, IX, X) and increase the response of vitamin K antagonists, usually warfarin. Primary biliary cirrhosis (PBC) has been associated with thyroid dysfunction (TD), especially with autoimmune thyroid disease. In the below case, a patient with known PBC on warfarin is found to have severely elevated INR related to new-onset hyperthyroidism with clinical consequences of hemorrhage including upper GI bleed. Case Description/Methods: A 64-year-old female with PBC and antiphospholipid antibody syndrome on warfarin was admitted for hemorrhagic epiglottitis requiring emergency intubation and supratherapeutic INR. Her PBC was diagnosed as stage II on biopsy 23 years ago and has remained clinically stable on ursodiol therapy. On presentation, the patient was tachycardic, tachypneic, and had O2 saturations <90% on HFNC prior to intubation. Physical exam significant for larger goiter with diffuse upper airway swelling. She was admitted and found to have COVID-19 infection, INR .16.0 and PT>200.0 (limit of lab), WBC of 22.8, and lactate of 2.5. LFTs WNL aside from albumin of 2.0. TSH was <0.0017 (limit of lab) and free T4 of 3.4, free T3 of 5.3. TSH receptor antibody (TRAB) and thyroid stimulating immunoglobulin (TSI) levels were normal. Her last TSH was normal a year ago. CTA chest found a 5.7cm heterogeneous, partially calcified superior mediastinal mass consistent with multinodular thyroid goiter. Patient was initially given prothrombin complex concentrate and vitamin K with correction of INR over the following few days. She was extubated and started on methimazole. During the hospital course, she was found to have coffee ground emesis for which an EGD was done with findings of non-bleeding gastric ulcer (Forrest Class IIc) and LA Grade D esophagitis with adherent clot and bleeding for which hemostatic spray was applied. Patient was discharged a few days later following resumption of warfarin and on pantoprazole and methimazole. Discussion(s): The above case demonstrates a rare case of PBC and new-onset hyperthyroidism due to multinodular thyroid goiter causing significantly elevated INR in the setting of warfarin use with hospital course complicated by GI bleed. PBC is associated with TD - hyperthyroidism, hypothyroidism, and thyroid cancer. Hyperthyroidism is less commonly associated with PBC compared to other TDs but should be considered especially with a finding of elevated INR.

Frequency and Predictors of Emergency Department Visits Following Colonoscopy: An Assessment of Procedure Safety

Introduction: Colonoscopy is the most commonly performed colorectal cancer screening test in the US, and is associated with known adverse events (AE), including gastrointestinal bleeding (GIB), bowel perforation, abdominal pain, and others. Despite this, post-colonoscopy AEs are rarely monitored by current colonoscopy quality programs. This study investigated the frequency of ED visits in the two weeks following an outpatient colonoscopy at a multi-site academic center. Method(s): We conducted a retrospective cohort study including all adults aged >= 40 who underwent an outpatient colonoscopy at a single academic center between 2016-2019. Data from 2020 were excluded given unpredicTable effects of the COVID-19 pandemic on healthcare utilization. Patients were identified using procedural codes and administrative claims records were used to identify persons who had a subsequent ED visit up to 14 days after their procedure date. For those with ED visits, patient charts were reviewed to data including details of ED presentation. Descriptive statistics were used to characterize the sample. Result(s): There were 187 patients who had an ED visit within two weeks of their colonoscopy, among 34,222 total colonoscopies during the same 4 year time period (0.44%). 46.1% of the ED visits reviewed were either definitely or possibly related to post-colonoscopy AEs. The mean age of the population sample was 61 years. The most common presenting symptoms to the ED post-colonoscopy included abdominal pain (47%), GI bleeding (27.7%), and nausea/vomiting (20.6%). The most common ED diagnosis included GI bleed (26.2%), dehydration (6.4%), and obstruction (3.6%). Nearly half of patients presenting to the ED were admitted (47.2%). In terms of clinical details of the colonoscopies of those who presented to the ED, polypectomy was performed in 67.4% of patients and polypectomy of a large (>=10mm) polyp was performed in 22.7% of patients. Hot snare/biopsy was used in 36.9% of patients and periprocedural use of anti-thrombotics occurred in 36.9% of patients. (Table) Conclusion(s): ED visits occurred in roughly 4 out of 1000 patients within two weeks of a colonoscopy at our center, and nearly half of these patients were admitted. A high proportion of ED visits were for GI symptoms. Furthermore, over 1/3rd of patients with ED visits following a colonoscopy had polyps removed with electrosurgical techniques. These data suggest that regular monitoring of post-colonoscopy ED visits may be valuable for quality improvement purposes.

Long-Term Efficacy and Safety of Zanubrutinib in Patients with Relapsed/Refractory (R/R) Marginal Zone Lymphoma (MZL): Final Analysis of the Magnolia (BGB-3111-214) Trial

Introduction: Advanced MZL is generally incurable, with periods of remission and relapse. Zanubrutinib (BGB-3111), a potent and highly specific next-generation Bruton tyrosine kinase (BTK) inhibitor, was approved in the US and Canada for R/R MZL based on the MAGNOLIA primary analysis (BGB- 3111-214;NCT03846427);here, the final MAGNOLIA analysis is presented. Method(s): This was a phase 2, multicenter, single-arm study of adult patients (pts) with R/R MZL (>=1 prior CD20-directed therapy). Zanubrutinib (160 mg twice daily) was given until disease progression or unacceptable toxicity. The primary endpoint was overall response rate (ORR) by independent review committee (IRC) per Lugano classification. Secondary endpoints were investigator-assessed ORR, duration of response (DOR), progression-free survival (PFS), overall survival (OS), and safety. Efficacy was assessed by positron emission tomography (PET)-based Lugano criteria for IRC-confirmed fluorodeoxyglucose (FDG)-avid disease at baseline;non-avid disease was assessed by computed tomography (CT)-based criteria. Result(s): As of May 4, 2022, 68 pts were treated (median age=70 y [range 37-95];>=75 y=27.9%). MZL subtypes included extranodal (38.2%), nodal (38.2%), splenic (17.6%), and unknown (5.9%). The median number of prior therapies was 2 (range 1-6);32.4% of pts had disease refractory to last therapy, most (89.7%) had prior chemoimmunotherapy, and 7 (10.3%) had rituximab monotherapy as their only prior treatment. Sixty-one pts (89.7%) had FDG-avid disease. After a median follow-up of 28.0 mos (range 1.6-32.9) and a median treatment duration of 24.2 mos (range 0.9-32.9), 66 pts were efficacy- evaluable. IRC-assessed ORR (complete response [CR]+partial response [PR]) was 68.2% (CR=25.8%). By subtype, (Figure Presented)(Figure Presented)ORR/CR rates were 64.0%/40.0% (extranodal), 76.0%/20.0% (nodal), 66.7%/8.3% (splenic), and 50.0%/25.0% (unknown). Median DOR, PFS, and OS were not reached. Over 70.0% of pts were alive or progression-free after 2 years (Figure). Sensitivity analysis using only CT-based criteria (n=66) showed an ORR of 66.7% and CR of 24.2%. The most common treatment-emergent AEs were bruising (23.5%), diarrhea (22.1%), and constipation (17.6%). Neutropenia (8.8%) and COVID-19 pneumonia (5.9%) were the most common Grade >=3 AEs. Five pts (7.4%) died due to unrelated AEs: COVID-19 pneumonia=2, acute myeloid leukemia=1, myocardial infarction=1, septic encephalopathy=1. Hypertension occurred in 3 pts (4.4%), atrial fibrillation and atrial flutter in 1 pt (1.5%) each;none led to treatment withdrawal. One pt (1.5%) had a Grade 3 gastrointestinal hemorrhage while receiving rivaroxaban. None of the pts required dose reduction. Conclusion(s): In this final analysis with over 2 years of median follow-up, zanubrutinib continues to demonstrate durable disease control and was generally well tolerated, with no new safety signals observedCopyright © 2023 American Society for Transplantation and Cellular Therapy

In-hospital outcomes of ST elevation myocardial infarction in post-COVID-19 patients.

Aim. To study clinical and anamnestic data, as well as inhospital outcomes in patients with ST elevation myocardial infarction (STEMI) with prior coronavirus disease 2019 (COVID-19) compared with previously uninfected STEMI patients. Material and methods. This prospective study included 181 patients treated for STEMI. The patients were divided into 2 groups, depending on the anti-SARS-CoV-2 IgG titer as follows: the main group included 62 seropositive patients, while the control group - 119 seronegative patients without prior COVID-19. Anamnesis, clinical and paraclinical examination, including electrocardiography, echocardiography, coronary angiography, were performed. Mortality and incidence of STEMI complications at the hospital stage were analyzed. Results. The mean age of the patients was 62,6+/-12,3 years. The vast majority were men (69,1% (n=125)). The median time from the onset of COVID-19 manifestations to STEMI was 60,00 [45,00;83,00] days. According to, the patients of both groups were comparable the severity of circulatory failure (p>0,05). Coronary angiography found that in patients of the main group, Thrombolysis In Myocardial Infarction (TIMI) score of 0-1 in the infarct-related artery was recorded much less frequently (62,9% (n=39) vs, 77,3% (n=92), p=0,0397). Patients of the main group demonstrated a lower concentration of leukocytes (9,30*109/l [7,80;11,40] vs 10,70*109/l [8,40;14,00], p=0,0065), higher levels of C-reactive protein (21,5 mg/L [9,1;55,8] vs 10,2 mg/L [5,1;20,5], p=0,0002) and troponin I (9,6 ng/mL [2,2;26,0] vs 7,6 ng/mL [2,2;11,5], p=0,0486). Lethal outcome was recorded in 6,5% (n=4) of cases in the main group and 8,4% (n=10) in the control group (p=0,6409). Both groups were comparable in terms of the incidence of complications (recurrent myocardial infarction, ventricular fibrillation, complete atrioventricular block, stroke, gastrointestinal bleeding) during hospitalization (p>0,05). Conclusion. Patients with STEMI after COVID-19, despite a more burdened history and higher levels of C-reactive protein and troponin I, compared with STEMI patients without COVID-19, did not differ significantly in clinical status, morbidity, and inhospital mortality.Copyright © 2023, Silicea-Poligraf. All rights reserved.

Prevalence of adverse drug reactions associated with emergency department visits and risk factors for hospitalization

Objective: Adverse drug reactions increase morbidity and mortality, prolong hospital stay and increase healthcare costs. The primary objective of this study was to determine the prevalence of emergency department visits for adverse drug reactions and to describe their characteristics. The secondary objective was to determine the predictor variables of hospitalization for adverse drug reactions associated with emergency department visits. Method(s): Observational and retrospective study of adverse drug reactions registered in an emergency department, carried out from November 15th to December 15th, 2021. The demographic and clinical characteristics of the patients, the drugs involved and the adverse drug reactions were described. Logistic regression was performed to identify factors related to hospitalization for adverse drug reactions. Result(s): 10,799 patients visited the emergency department and 216 (2%) patients with adverse drug reactions were included. The mean age was 70 +/- 17.5 (18-98) years and 47.7% of the patients were male. A total of 54.6% of patients required hospitalization and 1.6% died from adverse drug reactions. The total number of drugs involved was 315 with 149 different drugs. The pharmacological group corresponding to the nervous system constituted the most representative group (n = 81). High-risk medications, such as antithrombotic agents (n = 53), were the subgroup of medications that caused the most emergency department visits and hospitalization. Acenocumarol (n = 20) was the main drug involved. Gastrointestinal (n = 62) disorders were the most common. Diarrhea (n = 16) was the most frequent adverse drug reaction, while gastrointestinal bleeding (n = 13) caused the highest number of hospitalizations. Charlson comorbidity index behaved as an independent risk factor for hospitalization (aOR 3.24, 95% CI: 1.47-7.13, p = 0.003, in Charlson comorbidity index 4-6;and aOR 20.07, 95% CI: 6.87-58.64, p = 0.000, in Charlson comorbidity index >= 10). Conclusion(s): The prevalence of emergency department visits for adverse drug reactions continues to be a non-negligible health problem. High-risk drugs such as antithrombotic agents were the main therapeutic subgroup involved. Charlson comorbidity index was an independent factor in hospitalization, while gastrointestinal bleeding was the adverse drug reaction with the highest number of hospital admissions.Copyright © 2022 Sociedad Espanola de Farmacia Hospitalaria (S.E.F.H)

Mortality And Morbidity Burden Of Covid-19 Infection In Left Ventricular Assist Device Patients

Introduction: COVID-19 pandemic has resulted in more than 6.1 million deaths and more than 480 million infections worldwide (1). Left ventricular assist device patients (LVAD) with their multiple co-morbidities are at high risk for morbidity and mortality from the COVID-19 infection. Few studies and case reports demonstrating the outcomes of COVID-19 infection in LVAD patients have been published, with the most recent study in 2021 (2-4). However, none of these studies spanned the entire stretch of the pandemic. Hypothesis: : COVID-19 infection would result in significant mortality and multi-system complications among patients with an LVAD. Method(s): IRB approval was obtained for our retrospective cohort study. 225 LVAD patients across two large centers in Texas, USA were screened for COVID-19 infection from December 1, 2019 to February 28, 2022. 68 events of COVID-19 infection were identified among 64 patients. One patient was excluded due to false positive test and 3 patients were infected twice and counted as separate events. Outcomes including mortality, respiratory failure, bleeding, and thromboembolic complications were assessed. Result(s): Baseline characteristics and results are summarized in Table 1. 51% of the patients needed hospitalization or emergency department visit for COVID infection. Five patients were intubated (7.4%). 6 patients developed chronic hypoxic respiratory failure requiring outpatient supplemental oxygen. 4 patients suffered from ventricular tachycardias while three other patients had Implantable cardioverter Defibrillator (ICD) shocks during COVID infection. 9 patients had epistaxis or gastrointestinal bleeding within 1 month of testing COVID positive. One HM2 patient had confirmed LVAD outflow cannula thrombus on CT heart and another patient with HeartWare had confirmed inflow cannula thrombus requiring emergent exchange to HM3 due to pump stoppage. Three patients suffered a stroke (5%). No events of pulmonary emboli or DVTs were noted. The mortality rate among this cohort was 14% (9 out of 64 patients). Four patients died during the same hospitalization. 33% had HM2 and 67% had HM3 LVADs, making a mortality rate of 37% (3 out of 8) for HM2 patients and 9% for HM3 (6 out of 55). 88% were males, 56% were African Americans, 67% had NICM, and 78% had at least moderate RV dysfunction at baseline. Conclusion(s): COVID-19 infection resulted in significant mortality and complications including stroke, pump thrombus, arrhythmias, respiratory failure, and bleeding events among LVAD patients.Copyright © 2022

Kaiser Permanent (Kp) Mid-Atlantic States (Mas) Experience with Covid Related Hospital Admissions in Adult Patients with Myositis

Background. Myositis is a group of rare systemic disease and may be treated with immunosuppressives which increase the risk for poor outcome with the COVID19 pandemic. Patients with this condition may have higher rates of admission to the hospital. Methods. KP is a health insurance plan and provides care to about 800 thousand people (including Medicare and Medicaid population) in Maryland, District of Columbia and Northern Virginia. As part of quality improvements, we randomly looked at 40 patients from our larger cohort with myositis who are diagnosed and followed by a board-certified rheumatologist. We noted hospitalizations and Covid infection from March 1, 2020 to December 31, 2021. Results. Of the 40 patients, 29 (72%) were female and 11 were male. 19 (47%) were Blacks, 18 whites (including 6 Latino), and 3 Asians. Age ranged from 25 to 80 years with a mean age of 59.6 years. 25 (62%) patients had Dermatomyositis, 14 had polymyositis and 1 was IBM. The mean age at diagnosis was 55.9 years (range 23-80 years). 12 (30%) had myositis specific antibodies (4 Jo-1, 4 Mi-2, 1 PL 7, 1 PL 12, 1 PL7 plus PL12, 1 TIF Gamma). 22 (55%) were negative. Six did not have antibody testing. During this time, 11 (27.5%) were admitted to the hospital, 2 patients tested positive for COVID 19. One tested positive in the hospital and was asymptomatic. The other person was admitted for symptomatic COVID 19 infection. Other reasons for admission were cardiac, pulmonary (noncovid 19 related), infections, Gastrointestinal issues (including GI bleeding). One admission was for accidental bleach ingestion, and one for psychiatric admission. Of these 40 patients, 38 (95%) patients have received the COVID vaccinations, one patient refused, and for one person we do not have any record of vaccination. Conclusion. The admission rates to the hospital do appear to be higher for this group of patients with myositis, as is generally postulated. However, the reasons for admission were largely related to reasons other than COVID 19 infection and were related to general medical conditions.

Application of a Novel Swallowable Telemetric Device for Real Time Luminal Blood Detection to Guide Timing of Enteroscopy in a Patient with Obscure-Occult Gastrointestinal Bleeding: A Case Report

Background and aim: Gastrointestinal (GI) bleeding is deemed "obscure" when upper and lower GI endoscopy reveal no bleeding site. While the term "overt" is used in cases where visible blood passage is observed or reported, cases without macroscopic bleeding stigmata are defined "occult". Although small bowel origin accounts for only about 5% of all GI bleedings, it makes up the majority of obscure GI bleedings. Diagnostic work-up and treatment of small bowel GI bleedings can be challenging, especially when overt bleeding symptoms are absent. Material(s) and Method(s): We report the case of a frail patient with multiple comorbidities and evidence of bleeding small bowel angiodysplastic lesions on videocapsule assisted enteroscopy (VCE). Device assisted enteroscopy (DAE), planned in order to treat the bleeding lesions, was delayed after the patient contracted SARSCoV- 2 infection. Eight weeks after, in the absence of clinical signs of bleeding, a device for real time luminal blood detection (HemoPillR acute, Ovesco) was applied to guide timing of enteroscopy. Result(s): The 71 year old male patient was on dual anti platelet therapy and had persistent clinical features of iron deficiency anemia (Hemoglobin 8,0g/dl). Upper and lower GI endoscopy were negative for potential bleeding sources. VCE showed three small lesions suspect for angiodysplasia within 1 to 13 minutes after pylorus passage. Upon recovery from SARS-CoV-2 infection and congestive heart failure with respiratory insufficiency, we administered HemoPillRacute orally, without previous bowel preparation. The measurement showed a peak HemoPillR-Index (HI max) at 1h 47min after capsule administration (Fig. 1) and was therefore indicative of a small bowel bleeding site, best approachable by antegrade oral route, in keeping with the prior VCE findings. On subsequent DAE, performed through spiral enteroscopy, the small bowel angiodysplastic lesions were successfully treated. [Figure presented] Conclusion(s): Our case report illustrates how a novel telemetric blood detection measurement was able to confirm luminal blood presence and successfully guide timing of therapeutic DAE in a patient with obscure-occult GI bleeding, without the need for repetition of VCE.Copyright © 2023. Editrice Gastroenterologica Italiana S.r.l.

Impact of Covid-19 on Endoscopic Demography: A Cross Sectional Study

Background: Pandemics are never easy to deal with, especially this new covid pandemic which has exposed the vulnerability and multiple lacunae in our existing health care. In this midst of chaos and uncertainty delivering endoscopic services had become a nightmare, as endoscopy is a procedure done in the aero digestive tract and also an aerosol generating procedure. This led to a lot of enigma and skepticism in selection of patients and precautions to be taken while performing procedures. Objective(s): To Know the Feasibility and Utility of endoscopy as diagnostic and therapeutic services in Covid pandemic in the midst of chaos and uncertainties. Material(s) and Method(s): It is a retrospective study conducted from May 2020 to December 2020 in a Tertiary care Gastro hospital. Patients were screened clinically by Questionnaire highlighting the travel history, contact history, and residing history (hot spots for covid). X-Ray, HRCT and RT-PCR was done to exclude high risk cases. Clinical screening for symptoms, Vitals, Spo2 was done on all the patients. The procedures were performed using standard endoscopy equipment with appropriate COVID 19 protocols. Result(s): One thousand two hundred and eighty (1280) patients aged between 20 years to > 70 years were referred and undertake upper and lower GI endoscopy in a Tertiary Care gastro hospital. Majority of the cases who underwent endoscopy were in the age group 31-40 years 317 (24.8%). They comprised of 59.9% males and 40.1% females. Common endoscopic diagnoses were Gastric erosions 31.4% followed by Normal Upper gastrointestinal endoscopy (UGIE) / Lax Gastroesophageal (GE) Junction 17.4%. The most common symptom was dyspepsia seen in 725 (56.6%) of the patients, followed by dysphagia in 92 (7.2%), abdominal discomfort 64 (5%). Conclusion(s): This study highlights, with proper history and clinical screening and appropriate precautions it was possible to provide endoscopy service to the needy without a strict protocol and expensive pre-endoscopy work up like HRCT and RT-PCR for all patients, without compromising patient or staff safety. Patients with alarm symptoms like Dysphagia and GI Bleed benefited the most, many patients with functional GI Disorders also were reassured with negative endoscopy and counseling. As during these times, people were in panic mode with all negative things happening around;many of these functional patients with overlap anxiety disorders were scared to death. A positive diagnosis is very important while managing most of these GI disorders.Copyright © 2022 Dr. Yashwant Research Labs Pvt. Ltd.. All rights reserved.

Prevalence, causes, medical interventions, and mortality outcome of acute gastrointestinal bleeding among COVID-19 inpatients.

OBJECTIVE: This study aimed to evaluate the prevalence, causes, medical interventions, and mortality outcome of acute gastrointestinal bleeding (AGIB) among COVID-19 patients hospitalized during the delta pandemic in Vietnam. METHODS: The medical records of COVID-19 patients hospitalized in a tertiary hospital in Vietnam from July to October 2021 were retrospectively collected. Data regarding age, sex, comorbidities, COVID-19 severity, onset time of AGIB, therapeutic interventions for AGIB, and mortality outcome were analyzed. RESULTS: Of 1567 COVID-19 inpatients, 56 (3.6%) had AGIB. The independent risk factors for AGIB in COVID-19 inpatients included age (OR = 1.03, 95% CI: 1.01-1.04, p = .003), male sex (OR = 1.86, 95% CI: 1.06-3.26, p = .03), chronic liver disease (OR = 6.21, 95% CI: 2.97-13.00, p < .001), and chronic kidney disease (OR = 2.17, 95% CI: 1.01-4.65, p = .047). Among 34 AGIB patients undergoing endoscopy, upper AGIB was determined in 24 (70.6%) patients. Peptic ulcer disease and hemorrhagic erosive gastritis were the most common causes (64.7%, 22/34). The therapeutic interventions for AGIB included blood transfusion (76.8%, 43/56), endoscopic hemostasis (23.5%, 8/34), and surgery (1.8%, 1/56). The mortality rate in the AGIB group was significantly higher than that in the non-AGIB group (46.4% vs. 27.7%, OR = 2.26, 95% CI: 1.32-3.87, p = .002). However, the majority (76.9%) of deaths in COVID-19 inpatients with AGIB were not bleeding-related. CONCLUSIONS: Age, male sex, chronic liver disease, and chronic kidney disease are risk factors for AGIB among COVID-19 inpatients. Peptic ulcer disease is the most common cause. COVID-19 inpatients with AGIB have a higher risk of mortality, but a large percentage of deaths are not bleeding-related.

Since there is not enough information of sudden digestive tract bleeding among Asian populations with COVID-19, this study aimed to measure the proportion of existing cases, causes, medical treatments and deaths of sudden digestive tract bleeding in COVID-19 patients who were hospitalized during the Delta-variant pandemic in Vietnam. We collected medical records of 1567 COVID-19 patients from a specialty hospital in Vietnam from July to October 2021. Sudden digestive tract bleeding was present in 3.6% of COVID-19 inpatients. The risk of sudden digestive tract bleeding was higher in COVID-19 patients who were old, male, or had long-term liver or kidney disease. The most common cause of sudden digestive tract bleeding among COVID-19 inpatients were stomach ulcers. In addition, COVID-19 inpatients with sudden digestive tract bleeding had a higher risk of death, but a large proportion of deaths were not bleeding-related.

Final results of a phase 1b/2 study of tivozanib in combination with durvalumab in patients with advanced hepatocellular carcinoma in both previously untreated patients and patients progressing on atezolizumab and bevacizumab

Background: The approval of atezolizumab + bevacizumab for untreated advanced HCC was a significant benefit for patients, but with an increased risk of potentially severe bleeding complications. Tivozanib (a selective VEGFR 1, 2, & 3 tyrosine kinase inhibitor [TKI]) has been combined with durvalumab in the DEDUCTIVE study;preliminary results presented in January 2022 showed that this combination was well tolerated with comparable efficacy to other immune checkpoint and VEGF containing regimens in patients with previously untreated HCC (J Clin Oncol 40, no. 4 suppl 462-462). We now report the final results of this cohort (cohort A) of patients as well as those with previously treated HCC, including safety results for all the patients. Method(s): Major eligibility criteria included age .18 yrs with documented advanced HCC, Child-Pugh Class A, ECOG 0 or 1, and creatinine clearance .40 ml/min. Major exclusion criteria included co-infection with HBV and HCV and significant organ dysfunction. Patients were treated with 0.89 mg tivozanib p.o., 21 days on followed by 7 days off and 1500 mg durvalumab i.v. every 28 days. The primary objective was to determine the safety and tolerability of this combination in patients with advanced HCC;secondary objectives included assessing objective response rate (ORR), progression free survival, and overall survival (OS). The study was amended in 2021 to include a cohort of patients previously treated with atezolizumab and bevacizumab (cohort B). Result(s): 21 patients were enrolled in cohort A and 6 in cohort B;the median age was 67, 88% of patients were male, and 24% were Asian. The median followup time was 13.2 mos and 3.4 mos for cohorts A and B, respectively. Data were available for 25 of the 27 patients enrolled. For cohort A, the ORR was 25% (5/20) and 1-year OS was 76%. For safety analysis, 24 (96%) patients had at least 1 treatment-emergent adverse event (TEAE);92% were attributed possibly to either tivozanib or durvalumab;32% were serious TEAEs and there was 1 TEAE leading to death (unrelated). Of the 8 (32%) serious TEAE, 2 were coronavirus infection. 2 patients had serious (grade 3) treatment-related AEs: 1 pneumonitis and 1 with gastrointestinal hemorrhage and anemia. There were no grade 4 or 5 treatment-related AEs. Conclusion(s): Treatment with the combination of tivozanib and durvalumab in patients with either untreated advanced HCC or those previously treated with atezolizumab and bevacizumab was well tolerated;no severe bleeding events occurred in this study. Efficacy outcomes were comparable to other IO-TKI combinations in HCC. Data for PDL1 status, HBV/HCV status was collected and will be presented along with final safety and efficacy results for both cohorts.

The perspective of clinical pharmacologist: what is the safety of complex polypharmacy in hospitalized COVID-19 patients?

Introduction: For today, in order to improve the prognosis of COVID-19 treatment outcome, the most urgent task is the rational and safe use of medicines in case of required polypharmacy. Aim(s): To assess the safety of provided complex pharmacotherapy in hospitalized COVID-19 patients. Method(s): Single-center retrospective study of medical records of 590 COVID-19 patients hospitalized during 08.2021-10.2021. The information concerning drug prescriptions from patients' medication's charts was collected and processed using descriptive statistics. Result(s): The frequency of different medication groups' prescriptions with certain drugs is presented in Figure 1. The median number of concurrent prescribed drugs stood at 6(3;9). Notably, coadministration of glucocorticoids and anticoagulants along with antibiotics and antifungals increases the risks of hepatonephrotoxicity and GI bleeding. Conclusion(s): Analysis showed that complex pharmacotherapy of COVID-19 patients was provided according to the protocols. Nevertheless, from the point of view of clinical pharmacology, the combination of the above-mentioned drugs groups may increase the risk of side effects. Therefore, even standard treatment requires monitoring of the patient's clinical condition and laboratory parameters to increase the medication safety of personalized complex polypharmacy. (Figure Presented).

Challenges of Singapore's First Acute Geriatric Isolation Facility During the COVID-19 Pandemic

Aim: The COVID-19 pandemic has seen hospitals isolating suspect cases. Geriatric populations are at a risk of severe COVID-19 disease and often present with concomitant geriatric syndromes requiring holistic interdisciplinary care. However, isolation of older people poses challenges to care delivery. This study shares the experience of Singapore's first acute geriatric isolation facility geriatric PARI (Pneumonia-Acute Respiratory Infection) ward and describes the geriatric-related outcomes and pitfalls in care delivery. Method(s): This is a retrospective cross-sectional study performed in 7 negative pressure isolation rooms in an acute care public hospital in Singapore. 100 patients admitted consecutively to the geriatric PARI ward were included. Patient demographics, presenting symptoms and geriatric-related adverse outcomes associated with hospitalisation were collected and analysed. Result(s): Patients' mean age was 86.4 years (standard deviation [SD]: 6.8) with significant comorbidities being hypertension (81%), hyperlipidaemia (74%) and renal disease (70%). 51% of patients had dementia and 24% had behaviour and psychological symptoms of dementia (BPSD). 27% of patients presented atypically with delirium and 15% presented with a fall. Delirium was associated with restraint use (OR: 3.88;p-value 0.01). Falls rate was 1.64 per 1000 occupied bed. 1 patient screened positive for COVID-19. Conclusion(s): The geriatric PARI ward is essential for curbing nosocomial transmission of COVID-19. This is important in the older people with comorbidities who are more likely to develop morbidity and mortality. Our study reveals challenges in delivering person-centred care to the older patients in isolation rooms, especially in the management of delirium and falls prevention. Innovative strategies should be developed to minimise isolation-related adverse outcome.Copyright © The Author(s) 2022.

Deep Venous Thrombosis in Elderly Inpatients with Pneumonia

Background: The occurrence of deep vein thrombosis (DVT) in COVID-19 pneumonia has raised wide concern recently, but few studies have reported the incidence of DVT in other types of pneumonia. We evaluate the prevalence, risk factors and treatment of DVT in the elderly inpatients with pneumonia. Method(s): A cohort of 550 elderly inpatients (>= 75 years old) with pneumonia between 2017 and 2021 were reviewed. They were divided into DVT group and non-DVT groups on the basis of whether pneumonia was combined with new-found DVT. Clinical data were collected retrospectively. Patients with DVT were divided into anticoagulant group and non-anticoagulant groups on the basis of whether they received anticoagulant therapy. Result(s): Ninety-seven patients were included in the DVT group;453 in the non-DVT group. The incidence of DVT was 17.64%. Hospital stays were significantly longer for DVT patients than for non-DVT counterparts (p = 0.005). Coronary heart disease, heart failure, hyperlipidemia, bed rest, and elevated D-dimer were independent risk factors for DVT (p < 0.05). The rate of anticoagulant therapy in DVT group was 63.92% (62/97 cases). Follow-up showed that the continuous anticoagulant treatment rate was 48.39% (30/62 cases) at 3 months and 30.65% (19/62 cases) at 6 months. Conclusion(s): Elderly inpatients with pneumonia are at high risk of DVT. The combination of DVT and pneumonia may lead to prolonged hospitalization. Coronary heart disease, heart failure, hyperlipidemia, bed rest and elevated D-dimer are independent risk factors for DVT in these patients. The rate of regular anticoagulant treatment is low because of the high risk of bleeding.Copyright © 2022, Taiwan Society of Geriatric Emergency & Critical Care Medicine.

Evaluating Outcomes of Extracorporeal Life Support Use in Peripartum Patients: A Single Institution Experience

Background Indications and practice of extracorporeal membrane oxygenation (ECMO) use in pregnant patients are known;however, there is minimal evidence outside of meta-analysis and case series that comprehensively documents the outcomes. This study systematically evaluates the outcomes of ECMO utilization for peripartum patients in the setting of respiratory and/or cardiovascular failure. Methods All peripartum patients from 2018 to 2021 from a single center were screened to see if ECMO was initiated in the setting of cardiac, pulmonary, or combined failure. 15 patients met inclusion criteria of requiring ECMO while pregnant or up until 6 weeks postpartum. The patient demographics;operative details;ECMO registry data;critical care characteristics;adverse events per the codes for extracorporeal life support complications;and adverse outcome for maternal, fetus, and neonates were all collected. Results The cohort studied had a mean age of 30.3 years old, was racially diverse, and had few preexisting medical conditions before pregnancy. ECMO was indicated in 10/15 patients due to COVID-19 and 4/15 patients due to cardiac disease. ECMO was intended to be a bridge to recovery for 14/15 patients of which 11/14 patients recovered to discharge. The temporary ventricular decompression therapies used in VA ECMO patients were limited to the Protek Duo Right Ventricular Assist Device and TandemHeart device. No patients required transplantation or a durable mechanical device. Notable complications: 1 intrauterine fetal demise from placental malperfusion before ECMO was started;4 maternal deaths, of which 3 were related to ECMO;4 cardiac arrest events;1 limb ischemia event after ECMO cannulation;4 cannulation site hematomas;0 cannulation site hemorrhage;1 cardiac arrhythmia event;2 patients comprised all the intracranial hemorrhage events;and 2 patients comprised all the Gastrointestinal hemorrhage events. Conclusion To our knowledge;this is the first comprehensive documentation of adverse events in peripartum patients describing maternal, fetal, neonatal, and ECMO related outcomes. This data provides a standard format to evaluate risks of ECMO use in peripartum patients.Copyright © 2023 American College of Cardiology Foundation