A free-standing children's hospital helps a post-partum woman needing VV-ECMO during COVID-19 Pandemic when ECMO resources were limited

Our case is a 21 y/o pregnant female, 26weeks gestation who presented to OB triage with COVID-19. She was admitted to OB/GYN unit in acute hypoxic respiratory failure and started on steroids and remdesivir. On hospital day 6, she underwent an emergent c-section for fetal distress due to increasing hypoxia and severe ARDS. As her arterial blood gas being ph 7.17/81/40/29.6/-0.4, lactate 6.8nmol/L with escalating vasoactive medication and ventilator settings;ECMO was decided. However, all adult ECMO resources were limited, even within other adult facilities in Central Florida. Through multidisciplinary discussions amongst OB/GYN, adult ICU, and our pediatric ECMO activation team, it was decided to transfer the patient to our free-standing pediatric hospital. The patient was successfully transferred and cannulated for VV-ECMO. Total ECMO run was 413 hours. On ECMO day #12 patient underwent a tracheostomy. On ECMO day # 17, patient developed headaches and seizure activity in which CT revealed a subdural hemorrhage. She was taken off ECMO and underwent an emergent decompressive craniectomy with hematoma evacuation by our pediatric neurosurgical team. Once stable enough, she was discharged post ECMO day #15 (PICU day #32) to rehabilitation center. Two weeks later she had her bone flap replaced, trach removed, and she walked out of our unit home. This case exudes two key points for discussion. The first point of understanding ECMO physiology allows a team to treat many different patient populations. Although this patient was unusual to our pediatric bedside providers being post-partum, our team knew we could help. The second key point is excellent multidisciplinary teamwork and that communication is essential. At Orlando Health Arnold Palmer Hospital, our ECMO activation team consists of surgeons, pediatric intensivists, CT surgeons, perfusionists, nursing, and administration. We meet virtually to discuss how to execute initiation and daily ECMO treatment plans. There were some on the virtual call that were hesitant in accepting care of this adult due to variety of reasons, saying no would have been the easier answer, but not the right thing to do. What we learned from this case may seem so obvious and simple but very difficult to execute;multidisciplinary teamwork, humility, and open communication gave this patient the ability to walk out of the hospital with her baby. Other pediatric ECMO teams can learn from this case is they too can help in extraordinary times such as during a pandemic when adult recourses are limited.

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)

Was Covid Era a Blessing in Disguise for the Patient?

Background and Aims: In the Covid era, Continuous blood glucose monitoring(CGM) was used more frequently and it proved to be quite a helpful and accurate tool for glycemic regulation. Method(s): 75 yrs old Saudi gentleman, had Type 2 diabetes >30yrs, Hypertension, Primary Hypothyroidism, dyslipidemia, mixed polyneuropathy, Iron deficiency anemia, and benign prostatic hypertrophy. In March,2020 his BP and blood glucose readings were high at home. He had a past history of subdural hematoma with hydrocephalus(staus post-shunting). He was on Glargine, oral hypoglycemic agents, anti-hypertensives, Levothyroxine, Atorvastatin, Aspirin, iron fumarate, calcium carbonate and cholecalciferol. Fully conscious, and co-operative, of average built and height.BP 170/70 mmHg, pulse 93/m, RR 18/ m,O2sat 100%, afebrile, BMI 24.96 kg/m2. Fundoscopy normal. He had dry feet and impaired monofilament and vibration testing. Result(s): Hb% 13.1g/dl(12.6 before),MCV 93.8fl,S.Ferritin 10.5ug/l(30-400),Vit.B12 270 pmol/l(145-637),HbA1c 8%(6.4 in Feb.2020).The renal, liver and thyroid functions-intact. Albumin creatinine ratio 12.23mg/g(0-30). Nerve conduction study-mixed polyneuropathy. He continued to follow-up physically even during the Covid crisis due to the elevated SMBG and BP values. Gliclazide & antihypertensive doses were optimized and Glargine was started.On patient's follow-up in August, 2020, time in range had improved to 80%(33% in June,2020),average glucose was 147 mg/dl(200 before), glucose variability was 27.8%(28.9), hypoglycemia (54-79mg/dl) was 1%(0). On last follow-up on 27.06.2022 his HbA1c had climbed up to 8.3%(7.3 in September, 2021). He was compliant to the diabetes regime, but had stopped using the Libre sensor. Conclusion(s): The case signifies the advantage of a meticulous CGM usage during the Covid pandemic, that resulted in a reasonable glycemic control.

Randomized Evaluation of Surgery in Elderly with Traumatic Acute SubDural Hematoma (RESET-ASDH trial): study protocol for a pragmatic randomized controlled trial with multicenter parallel group design.

BACKGROUND: The rapidly increasing number of elderly (≥ 65 years old) with TBI is accompanied by substantial medical and economic consequences. An ASDH is the most common injury in elderly with TBI and the surgical versus conservative treatment of this patient group remains an important clinical dilemma. Current BTF guidelines are not based on high-quality evidence and compliance is low, allowing for large international treatment variation. The RESET-ASDH trial is an international multicenter RCT on the (cost-)effectiveness of early neurosurgical hematoma evacuation versus initial conservative treatment in elderly with a t-ASDH METHODS: In total, 300 patients will be recruited from 17 Belgian and Dutch trauma centers. Patients ≥ 65 years with at first presentation a GCS ≥ 9 and a t-ASDH > 10 mm or a t-ASDH < 10 mm and a midline shift > 5 mm, or a GCS < 9 with a traumatic ASDH < 10 mm and a midline shift < 5 mm without extracranial explanation for the comatose state, for whom clinical equipoise exists will be randomized to early surgical hematoma evacuation or initial conservative management with the possibility of delayed secondary surgery. When possible, patients or their legal representatives will be asked for consent before inclusion. When obtaining patient or proxy consent is impossible within the therapeutic time window, patients are enrolled using the deferred consent procedure. Medical-ethical approval was obtained in the Netherlands and Belgium. The choice of neurosurgical techniques will be left to the discretion of the neurosurgeon. Patients will be analyzed according to an intention-to-treat design. The primary endpoint will be functional outcome on the GOS-E after 1 year. Patient recruitment starts in 2022 with the exact timing depending on the current COVID-19 crisis and is expected to end in 2024. DISCUSSION: The study results will be implemented after publication and presented on international conferences. Depending on the trial results, the current Brain Trauma Foundation guidelines will either be substantiated by high-quality evidence or will have to be altered. TRIAL REGISTRATION: Nederlands Trial Register (NTR), Trial NL9012 . CLINICALTRIALS: gov, Trial NCT04648436 .

ALCOHOL WITHDRAWAL SYNDROME TREATMENT WITH PHENOBARBITAL VS BENZODIAZEPINE: SAFETY AND LENGTH OF STAY

SESSION TITLE: What's New in Critical Care? SESSION TYPE: Original Investigation Posters PRESENTED ON: 10/18/2022 01:30 pm - 02:30 pm PURPOSE: Alcohol withdrawal syndrome (AWS) is a common etiology of intensive care unit (ICU) admission(Vigouroux et al 2021). Emergency Department (ED) related alcohol visits have increased in incidence dramatically since the beginning of the SARS-CoV2 pandemic. A median ICU length of stay (LOS) of 8 days for severe AWS has been previously reported. The increase in substance abuse observed during the pandemic may prolong future patients’ LOS. Pandemic staffing and bed shortages have made it even more evident the need to research efficient and safe treatment options of common hospital admission diagnosis such as AWS. Current national guidelines recommend benzodiazepines as first-line therapy for inpatient management of AWS (American Society of Addiction Medicine Clinical Practice Guidelines). However, historically phenobarbital (PB) and other barbiturates have been utilized with varying success. Recent evidence has demonstrated phenobarbital loading followed by symptom-triggered benzodiazepines may reduce LOS and ICU admission (Rosenson et al 2012). We retrospectively evaluated ED and ICU data to further guide our future research on PB in AWS, specifically;LOS, location of admission, and high risk side effects frequently associated with PB such as intubation. METHODS: Patients admitted for AWS and who received PB from 8/1/2021 to 02/01/2022 were identified. Subsequently, these subjects were then matched to themselves for historical AWS admissions without receipt of PB. Exclusion criteria included: admission with concomitant diagnosis with expected admission LOS longer than AWS treatment course;no separate admission for AWS. Pertinent patient demographics were collected including cumulative dosing of benzodiazepines, disposition from the ED, hospital LOS, ICU LOS, relative hypotension, and intubation. Data was analyzed using descriptive statistics and one-sided Student T-test. RESULTS: Total of 16 patients received PB during the six month identification period. Six were excluded due to lack of previous admission for AWS. Three were excluded for previous admissions with concomitant disease states requiring prolonged admissions. These included endoscopy, long-bone fracture, and subdural hematoma. Seven patients (14 unique admissions) met inclusion criteria. Patients were all male with a mean age of 58. Compared to non-PB admissions a trend in mean reduction of hospital LOS was 39.3 hours shorter in the PB cohort (p-value=0.068). Mean benzodiazepine reduction (lorazepam equivalents) was 26.3mg less in the PB cohort (p-value = 0.064). No intubations or hypotensive events were observed in either cohort. CONCLUSIONS: When PB was utilized there was reduction in total hospital LOS with no increase in intubations. Preliminary patient matched data of PB in AWS appears efficacious and safe. CLINICAL IMPLICATIONS: PB may decrease overall hospital LOS in AWS. DISCLOSURES: No relevant relationships by Yara Albair No relevant relationships by Nicholas Barreras No relevant relationships by Jessica Kim No relevant relationships by Marc McDowell No relevant relationships by Joshua Posner No relevant relationships by Mariana Silva

Retroclival hematomas in adult patients: A systematic review of a rare intracranial hematoma

Objective: Adulthood retroclival hematomas (RCHs) are a rare condition characterized by intracranial bleeding along the posterior aspect of the clivus. There are few reports in the literature that describe these hematomas. There is no agreement on how to treat these hematomas. Methods: An extensive literature review was performed, and the data was classified and analyzed on this topic from January 2000 to January 2022. A systematic review was carried out in accordance with the PRISMA and CARE Guidelines. Results were analyzed and potential clinical links were extracted. Results: Twenty-seven RCHs in adulthood were reported in twenty high-quality articles. 12/27 RCHs in adults were spontaneous. Epidural retroclival hematomas were present in 12/27 patients, while subdural hematomas were present in 13/27 patients. 15 of 22 adult RCHs observed were small in size. Epidural hematomas are typically associated with trauma (9/15 traumatic RCHs), whereas subdural hematomas are more frequently associated with spontaneous bleeding (8/12 spontaneous RCHs). There was one case of hydrocephalus, six cases of cranial nerve palsies (five of which were traumatic), and thirteen cases of intraspinal extension of the hematoma. Seven individuals exhibited craniovertebral instability (100 percent traumatic). Most hematomas were conservatively treated (77.8 percent). 21 hematomas had favorable clinical outcomes. Conclusions: There is a lack of agreement on management protocols for RCHs in adulthood. These hematomas occur almost equally in both the extradural and the subdural spaces, and they are typically small in size. When an RCH occurs in the epidural space, it is more likely to result in cranial nerve palsies and craniospinal instability. Associated craniovertebral anomalies must be thoroughly analyzed in trauma patients. Only patients with a significant mass effect on the brainstem are candidates for surgical hematoma evacuation. It is imperative that future studies on this rare entity adhere to strict publication guidelines.

Spontaneous spinal subdural hematoma in COVID-19 patient: Croatian national COVID hospital experience.

Background: Spontaneous spinal subdural hematoma (SSDH) is a rare condition and causes of acute spinal cord compression, with symptoms varying from mild to severe neurological deficit. SSDH could occur as a consequence of posttraumatic, iatrogenic, or spontaneous causes, including underlying arteriovenous malformations, tumors, or coagulation disorder. Due to its rarity, it is difficult to establish standardized treatment. We present a rare case of SSDH in COVID-19 patient and course of treatment in COVID hospital. Case Description: A 71-year-old female patient was admitted due to instability, weakness of the left leg, and intensive pain in the upper part of thoracic spine as well as mild respiratory symptoms of COVID-19. She was not on pronounced anticoagulant therapy and her coagulogram at admission was within normal range. MRI revealed acute subdural hematoma at the level C VII to Th III compressing the spinal cord. The patient underwent a decompressive Th I and Th II laminectomy and hematoma evacuation. Post-operative MRI revealed a satisfactory decompression and re-expansion of the spinal cord. COVID-19 symptoms remained mild. Conclusion: SSDH represents a neurological emergency, possibly leading to significant deficit and requires urgent recognition and treatment. One of the main difficulties when diagnosing is to consider such condition when there is no history of anticoagulant treatment or previous trauma. Since high incidence of coagulation abnormalities and thromboembolic events was described COVID-19 patients, when considering the pathology of the central nervous system, the bleeding within it due to COVID-19 should be taken into account, in both brain and spine.

MIDDLE MENINGEAL ARTERY EMBOLIZATION AS A SAME-DAY DISCHARGE PROCEDURE

Introduction Middle meningeal artery embolization (MMAE) is a fundamental piece in the management of Chronic Subdural Hematoma (cSDH) that prevents recurrence and can serve as primary treatment for nonoperative candidates. MMAE offers time-effectiveness, since it may be performed in less than one hour under minimal sedation. As the COVID-19 pandemic makes inpatient beds scarce, MMAE could potentially become a same-day procedure which poses a potential economic benefit for both patients and health institutions alike. We reviewed MMAEs performed at our institution and measured the complication rates in an effort to determine if hospital admission after the procedure is necessary. Methods A retrospective analysis of patients who underwent MMAE for cSDH at the University of California, San Diego was performed. Data collected included post-procedural complications such as focal neurologic deficit, cognitive decline, and groin access-point hemorrhage identified within the first 4 hours, 24 hours, and delayed manner respectively. Success of treatment was defined as patient stability and return to baseline following the post-procedure assessment protocol performed routinely at our institution. We further characterized patients with the Charlson Comorbidity Index (CCI) to identify higher risk populations that would require increased observation. The CCI was also used to determine a cut-off point for same-day discharge eligibility. Results We analyzed data from 95 patients that had 143 subdural hematomas treated at our institution. Of the 95 patients, 93 patients (98%) had no complications following our institution's standardized assessments after MMAE or at discharge the following day. Average SDH size was 12.9mm. Twenty-one patients underwent surgical drainage after MMAE. Following MMAE, two patients presented complications;one patient, an 83-year-old female, developed transient headache and blurry vision one day after MMAE and was discharged uneventfully;this patient had a CCI of 4 points. The other patient was a 77-year-old male with metastatic prostate carcinoma and had an SDH volume expansion one day after the procedure which required operative intervention with burr-hole craniotomy and drainage;this patient had a CCI of 9 points (0% estimated 10-year survival). The remaining 93 patients suffered no complications after MMAE. Conclusion Time-effectiveness and low complication rates make MMAE an ideal same-day procedure for patients with cSDH and a low CCI score. The grand majority of patients had no complications following MMAE, suggesting a large patient population that may benefit from the same-day procedure aspect of intervention. Although some patients underwent planned surgical drainage, the embolization component of management was uneventful. Our analysis provides evidence that MMAE could develop into an ambulatory procedure in patients with cSDH and a low comorbidity profile;this could have economic benefits for both the patients requiring and the institutions offering the procedure. Further prospective studies are needed to strengthen these findings.

Decline in the Incidence of Chronic Subdural Hematoma During the Coronavirus Disease 2019 Pandemic: A Retrospective Single-Center Descriptive Study.

The coronavirus disease 2019 (COVID-19) pandemic has forced restrictions on social activities in some areas. There has also been a decrease in the number of trauma patients in the United States during the COVID-19 pandemic. Chronic subdural hematoma (CSDH) is a traumatic disorder that often develops following head injury. We therefore investigated the impact of the COVID-19 pandemic on CSDH. In this retrospective single-center descriptive study from April 2018 through September 2021, there were 5,282 head trauma patients and 196 patients with CSDH in the pre-pandemic group compared to 4,459 head trauma patients and 140 patients with CSDH in the intra-pandemic group. Significant decreases in the incidence rate (IR) of head trauma (951/100,000 vs. 795/100,000 person-years; IR ratio (IRR): 0.836, 95% confidence interval (CI): 0.803-0.870, p < 0.001) and also in the IR of CSDH (35.0/100,000 vs. 24.8/100,000 person-years, IRR: 0.708, 95% CI: 0.570-0.879, p = 0.002) were seen in the intra-pandemic group compared to the pre-pandemic group. In this study, the COVID-19 pandemic was associated with significant decreases in the IRs of head trauma and CSDH due to forced restrictions on social activities. Besides, the IR of mild cases of CSDH was significantly lower in the intra-pandemic group than in the pre-pandemic group (IRR: 0.68, 95% CI: 0.51-0.89, p = 0.006). Fewer people being out in communities should result in fewer chances for head trauma and CSDH. On the other hand, forced restrictions on social activities due to the COVID-19 pandemic should aggravate CSDH.

Adherence to the NICE traumatic brain injury management guidelines in a trauma centre during the covid pandemic

Objectives: The National Institute of Health and Care Excellence (NICE) has set standards for TBI patients' initial assessment and management. This study assessed respect for NICE TBI guidelines in patients referred to an English trauma centre during the Covid-19 pandemic. Design: A cross-sectional study. Subjects: TBI patients who presented to a District General Hospital between 1st December 2020 and 12th August 2021 and were referred to the tertiary neurosurgical centre. Methods: Data were collected from the electronic medical records of our subjects. Descriptive statistical analysis of the time between patients presenting to the emergency department, being reviewed by a trained member of staff, request for cranial CT imaging, and response to neurosurgical referral was done with SPSS version 27.0. Results: We collected data on 115 patients, and the TBI frequency peaked in the 60-99 age range. Most patients were men (55.9%, n = 65), and 77% had a frailty score of 5 or less, with 90% presenting with a GCS range of 13-15. At the referring hospital, twenty-eight percent (n = 32) of the patients were evaluated by a trained member of staff within 15 min of admission, and only 30% (n = 35) had cranial CT imaging within an hour of the assessment. Only half of the referrals (n = 58) were reviewed by Neurosurgeons within an hour. The most common lesion on cranial CT imaging was a subdural haemorrhage (34%, n = 40).

Making every operation count - using an instructional design model to maximise the learning experience in neurosurgery

Objectives: Recent reforms to postgraduate medical education, the 'Shape of Training (SoT)' and 'Excellence by Design: standard for postgraduate curricula' mandate a re-evaluation of the way in which surgical education is delivered, particularly in the teaching of surgical techniques. More so, as we continue to train with the restrictions imposed by the COVID pandemic, emphasis must be placed on maximising every training opportunity. Design: In this article, we demonstrate the utility of an instructional design method to enhance the teaching of neurosurgical procedures. Specifically, we utilise the instructional design method of teaching first described by Robert Gagne in the 1960s. Subjects: The framework we provide can be used to equip all neurosurgical trainees with the necessary capabilities to achieve the high-level outcomes expected from the new curriculum. Methods: We design a lesson plan using Gagne's nine events of instruction, in this case using burr hole evacuation of chronic subdural haematomas as an example. The ordered nature of Gagne's nine-step model allows a complete picture to be formed and structures teaching for a comparable learning experience. Conclusions: One particular strength of this teaching method is placing the learned skill in the wider context of patient care includes perioperative management. By empowering trainees to consider all aspects of the underlying reasoning for a procedure, well-rounded clinicians can be developed who are comfortable in the real-world application of procedural skills. The creative lesson plan optimises the learning process and ensures that the objectives are comprehensively fulfilled. The structured approach fortifies a good basis for understanding the operation and ensures that progression to independence is a safe approach.

Chronic Subdural Hematoma, Caused by Disseminated Intravascular Coagulation and/or Anticoagulation Therapy, after COVID-19.

Chronic subdural hematoma (CSDH) typically develops in the supratentorial region in elderly patients. We treated a case of unilateral supratentorial and bilateral infratentorial CSDH, whereby the patient had a coronavirus disease 2019 (COVID-19) infection combined with disseminated intravascular coagulation 2 months earlier. The patient had not experienced any head trauma before the onset of the CSDH. The postoperative course was uneventful, and the patient experienced no neurological deficit. We propose that we should be aware not only of acute ischemic or hemorrhagic diseases after COVID-19 infection but also of chronic subdural hematoma caused by coagulopathy after a COVID-19 infection.

Parvovirus (B19) Infection during Pregnancy: Possible Effect on the Course of Pregnancy and Rare Fetal Outcomes. A Case Report and Literature Review.

Infection caused by human parvovirus B19 (B19) often has mild yet wide-ranging clinical signs, with the course of disease usually defined as benign. Particularly prevalent in the population of young children, the virus is commonly transmitted to the parents, especially to susceptible mothers. During pregnancy, particularly the first and second trimesters, parvovirus infection can lead to pathology of the fetus: anemia, heart failure, hydrops, and disorders of physical and neurological development. In severe cases, the disease can result in fetal demise. This article presents a rare case of manifestation of B19 infection during pregnancy. At the 27th week of gestation, a sudden change in fetal movement occurred in a previously healthy pregnancy. The examination of both fetus and the mother revealed newly formed fetal subdural hematoma of unknown etiology and ventriculomegaly. Following extensive examination to ascertain the origin of fetal pathology, a maternal B19 infection was detected. Due to worsening fetal condition, a planned cesarean section was performed to terminate the pregnancy at 31 weeks of gestation. A preterm male newborn was delivered in a critical condition with congenital B19 infection, hydrocephalus, and severe progressive encephalopathy. The manifestation and the origin of the fetal condition remain partially unclear. The transplacental transmission of maternal B19 infection to the fetus occurs in approximately 30% of cases. The main method for diagnosing B19 infection is Polymerase Chain Reaction (PCR) performed on blood serum. In the absence of clinical manifestations, the early diagnosis of B19 infection is rarely achieved. As a result, the disease left untreated can progress inconspicuously and cause serious complications. Treatment strategies are limited and depend on the condition of the pregnant woman and the fetus. When applicable, intrauterine blood transfusion reduces the risk of fetal mortality. It is crucial to assess the predisposing factors of the infection and evaluate signs of early manifestation, as this may help prevent the progression and poor outcomes of the disease.

Safety and Efficacy of Apixaban as Thromboprophylaxis in Multiple Myeloma Patients Receiving Chemotherapy: A Prospective Cohort Study

Apixaban 2.5 mg twice-daily replaced low-molecular-weight-heparin as thromboprophylaxis (TP) for multiple myeloma (MM) patients receiving outpatientbased chemotherapy considered to be high-risk of venous thromboembolism (VTE) on 1st November 2019 in our regional centre. This prospective cohort study aimed to assess the safety and efficacy of apixaban as thromboprophylaxis in highthrombotic risk patients with MM. Data were systematically collected from the electronic noting system for service evaluation, retrospectively for the historic cohort (1st Nov 2018-1st Nov 2019) prior to the introduction of the novel thromboprophylactic strategy, and prospectively (1st Nov 2019-1st Nov 2020) following the change of local guidelines to include apixaban as TP in high-thrombotic risk patients with MM. Exclusion criteria included antithrombotic treatment other than thromboprophylaxis or contraindication to thromboprophylaxis such as thrombocytopenia or doxorubicin use (due to possible drug-drug interaction with apixaban leading to reduced levels). Data collected included previous VTE history, thromboprophylactic agent, thrombosis and bleeding events while on chemotherapy. Primary outcomes included thrombotic and bleeding events. Table 1 demonstrates patient characteristics and results. There were 102 MM patients in the historic and 147 in the prospective cohort. VTE prophylaxis was prescribed in 82 out of 102 (80%) of the historic cohort and 114 out of 147 (78%) of the prospective cohort. In patients not prescribed thromboprophylaxis, the chemotherapy regimen contained Daratumumab in 65% in the historic and 76% in the prospective cohort. After the introduction of the amended thromboprophylactic strategy, prescriptions of apixaban increased from 22out of 82 (27%) to 60 out of 114 (53%), while aspirin prescriptions fell from 51out of 82 (62%) to 47 out of 114 (41%). After the introduction of apixaban as recommended thromboprophylaxis for high thrombotic risk patients, thrombotic events reduced from 3% (3/102) to 1.4% (2/147). All thrombotic events (two deep vein thrombosis [DVT], one pulmonary embolism) in the historic cohort occurred despite aspirin as thromboprophylaxis and on a pomalidomidecontaining regimen. In the prospective cohort, the thrombotic events were a proximal DVT while on aspirin TP and a peripherally inserted central catheter (PICC)-associated thrombosis occurring on no TP. There were no thrombotic events in patients receiving prophylactic apixaban in either cohort. There were five bleeding events in the historic cohort. This included one major bleeding event of a traumatic subdural haematoma (on apixaban TP). There were two clinically relevant non-major bleeding (CRNMB): an episode of frank haematuria and a per rectum bleed secondary to haemorrhoids (aspirin as TP), and two minor bleeds. In the prospective cohort, there was one major bleeding event which was a gastrointestinal bleed requiring a two-unit blood transfusion (aspirin as TP). One CRNMB event included haemoptysis secondary to COVID-19 (apixaban as TP) and eight minor bleeding events, two of which occurred on no TP. Overall, major bleeding occurred in 1.2% (1/82) and CRNMB in 1.2% (1/82) patients on prophylactic apixaban across both cohorts. These data add further support to the use of apixaban rather than LMWH as thromboprophylaxis for myeloma patients is considered to be at high thrombotic risk, with very low rates of thrombosis and acceptably low rates of major and CRNMB..

Neuro-trauma and COVID-19 Pandemic in New York City. Influence of Viral Spread Prevention Policies

INTRODUCTION: New York City (NYC) is the epicenter of the novel coronavirus disease 2019 (COVID-19) pandemic in the United States. Cancellation of non-essential activities and social distancing policies are implemented during this crisis to avoid spread of the infection. METHODS: Retrospective and prospective reviews were performed from a Level-II trauma-center from November 2019 (one month before the outbreak started in China) to April 2020. General demographics, mechanism of trauma, diagnosis, and treatment were recorded. We dichotomized the data between pre-COVID-19 (before March 1st) and COVID-19 period, and compared differences between the two groups. RESULTS: A total of 150 patients composed our cohort, with a mean age of 66.2 years (SD+/-: 18.9), and 66% male. An average of 25 neuro-traumas/month was observed, with the highest average cases per day in March (1 case/day), and the lowest in April (0.6 cases/day). We noticed a progressive decrease of neuro-traumas since the beginning of March (from 11 cases to 2 cases a week), with the lowest point in the first week of April. This tendency was evident after March 16th, simultaneously with the cancellation of all non-essential activities in NYC during COVID-19 era, the most common mechanism of trauma was mechanical fall, but it was less frequent compared to the pre-COVID-19 period (61.4% vs 40.8;P = .04). Subdural hematomas were the most common pathology in both periods. Non-operative management was selected for most patients (79.2 vs 87.8%, P = .201) in both periods, but the tendency to convert code status to Do-Not-Intubate/Do-Not-Resuscitate (DNI/DNR) increased during the COVID-19 crisis (5.9% to 12.2%, P = .041). CONCLUSION: A temporary decrease of neuro-traumas was observed during the initial phase and peak of the crisis. This tendency was observed simultaneously with the implementation of social-distancing policies as the number of total infected patients was rising in NYC. Mechanical falls were the most frequent cause of neuro-trauma in both periods. More neuro-trauma patients were converted to DNI/DNR code during the crisis and this was not necessarily related to patient's COVID-19 status.

High social vulnerability affects survival of pediatric patients with abusive head trauma: Comparison during COVID-19

Background: Abusive Head Trauma (AHT) is a syndrome of life-threatening intracranial injuries. The COVID-19 pandemic imposed new stresses upon socially vulnerable populations, but the relationships between social vulnerability, COVID-19 and AHT outcomes are not known. We investigated whether patient or social factors predicted survival after AHT and whether these factors and outcomes were modified during COVID-19. Methods: A single-institution database was queried for all admissions of children with a confirmed diagnosis of AHT from 2018-2021. Clinical information, radiographs and clinic follow-up data were reviewed. Social vulnerability index (SVI) was calculated based on published methods (atsdr.cdc.gov). Univariate and multivariate analyses were performed. Results: One hundred and three cases of AHT were reviewed. Median age at presentation was 4 months (IQR 2-10) in the overall cohort, males outnumbered females overall (76 males, 27 females). 18 patients died (17.5%), higher than previously reported rates. Nonsurvivors had higher social vulnerability index (.867 vs .719, p=0.004);71% had high social vulnerability compared to 39% of survivors. There was no difference in fatality rate before (19%) or during (15%) COVID-19. All nonsurvivors were intubated on admission, compared to 36% of survivors (p<0.001) and all nonsurvivors were comatose compared to 29% of survivors (p<0.001);61% of nonsurvivors had cardiac arrest on admission compared to 3% of survivors (p<0.001). The injury severity score of nonsurvivors was higher than that of survivors (27 vs 17, p=0.02 in univariate analysis). Nonsurvivors were less likely to have multiple fractures (11% vs. 43%, p=0.01). Nonsurvivors were more likely to have bilateral hypoxic ischemic injury (HII, 89% vs 29%, p< 0.001, Crude OR for survival 0.33, p<0.001, p=0.017 in multivariate analysis). There was no difference in rates or types of neurosurgical intervention, intracranial hemorrhage location, or presence of spinal hemorrhage between nonsurvivors and survivors. Discussion: Mortality from AHT in our series was higher than previously reported: more than one out of six children in our series did not survive. Although nonsurvivors were more likely to live in highly vulnerable social settings, COVID-19 did not change survival rate. Nonsurvivors are more likely to present in coma requiring intubation and in cardiac arrest. Subdural hematomas are seen in survivors and non-survivors but surgical mass lesions are rare and surgery does not improve survival. We identify a strong association between completed bilateral HII on admission and fatality in AHT. The high mortality of AHT in association with HII, and the low efficacy of intervention after completed HII supports a public health effort towards treatment and prevention focusing on socially vulnerable communities.

SAFETY OF SONOTHROMBOLYSIS AFTER PERCUTANEOUS CORONARY INTERVENTION FOR PATIENTS WITH ST-ELEVATION MYOCARDIAL INFARCTION

Background Sonothrombolysis using diagnostic ultrasound and microbubbles has been proposed as a potential adjunctive treatment that could reduce microvascular obstruction (MVO) in patients with ST-elevation myocardial infarction (STEMI). In this preliminary analysis of an ongoing randomized controlled trial on the efficacy of sonothrombolysis after percutaneous coronary intervention (PCI) in STEMI patients with MVO, we sought to assess whether a difference could be observed between the treatment and control group with respect to the occurrence of early and late serious adverse events (SAE). Methods Patients with STEMI and persistent ST-elevation on the electrocardiogram (ECG) after PCI were randomized to sonothrombolysis (> 60 high mechanical index pulses in the apical 4-, 2- and 3-chamber view during an infusion of commercially available microbubbles) or sham (low mechanical index imaging with < 6 HMI pulses for perfusion imaging). All SAEs, defined according to the International guidelines for Good Clinical Practice (ICH-GCP), were recorded and divided in early (<1 month) and late (<6 months) SAEs. Results Forty-five patients were included in the trial. In total, 12 SAEs occurred: 4 in the sonothrombolysis group (2 early, 2 late), 8 in the control group (6 early, 2 late). In the sonothrombolysis group, the SAEs consisted of out-of-hospital cardiac arrest, gastrointestinal bleeding, collapse with subdural hematoma and endocarditis. In the control group, the listed SAEs were all-cause death (2x), hospitalization for heart failure, pneumonia, COVID-infection, diabetes mellitus, non ST-elevation myocardial infarction and aspecific chest paint. Conclusion Sonothrombolysis after PCI in patients with high-risk STEMI and MVO is not associated with an increased occurrence of early or late SAEs. Further clinical trials are needed to comment on the efficacy of sonothrombolysis in this patient population.

Cerebrovascular injury associated with COVID-19 and non-COVID-19 acute respiratory distress syndrome

Background: Neurologic complications of Coronavirus Disease 2019 (COVID-19) may be associated with neurotropism of the virus or secondary brain injury from systemic inflammation. Acute respiratory distress syndrome (ARDS) is associated with cerebrovascular injury, including both ischemia and hemorrhage. We aimed to compare brain MRI findings of COVID-19 associated ARDS with non-COVID-19 ARDS. Methods: A registry of patients with COVID-19 from March 2020 through July 2021 from a hospital network was reviewed. Patients who met criteria for ARDS by Berlin definition and underwent MRI during their hospitalization were included. These patients were matched 1:1 by age and sex with patients who underwent MRI from another registry of patients of ARDS in the same hospital between 2010 and 2018. Cerebrovascular injury was classified as either acute cerebral ischemia (ischemic infarct or hypoxic ischemic brain injury) or intracranial hemorrhage (ICH) including intraparenchymal hemorrhage, subarachnoid hemorrhage, subdural hematoma, and cerebral microbleeds (CMBs). Results: Of 13,319 patients with COVID-19 infection, 26 patients had ARDS and MRI. Sixty-six of 678 non-COVID-19 ARDS patients had an MRI and were matched 1:1 by age and sex resulting in 23 matched pairs. The median age was 66 and 59% of patients were male. Patients with COVID-19 ARDS were more likely to have hypertension and chronic kidney disease but otherwise baseline medical characteristics were similar. ARDS severity as determined by PaO2/FiO2 ratio at ICU admission was similar between both groups. No difference was seen in the prevalence of cerebrovascular injury (52% vs 61%, p=0.8), cerebral ischemia (35% vs 43%, p=0.8), ICH (43% vs 48%, p=1.0), or CMBs (43% vs 39% p=1.0) on MRI between the COVID-19 and non-COVID-19 cohorts. However, two unique patterns of injury were seen only among COVID-19 patients: hemorrhagic leukoencephalitis (3 patients, 12%) and bilateral cerebral peduncular ischemia with microhemorrhage (2 patients, 8%). Conclusion: Cerebrovascular injury was common in both COVID-19 and non-COVID-19 ARDS without significant frequency difference. However, COVID-19 ARDS had unique neuroimaging patterns that may indicate distinct patterns of brain injury of COVID-19.

Middle meningeal artery (MMA) embolization for chronic subdural haematoma: A prospective UK study

Objectives: MMA embolization has emerged in recent years as a safe and minimally invasive treatment for a chronic subdural haematoma. We report the first UK series of endovascular treatments of chronic subdural haematomas. Design: Prospective case series. Subjects: All adult patients referred with minimal midline shift (≤8 mm) and GCS ≥14/15 were considered. Patients had to be mobile with a standard origin of Middle Meningeal and Ophthalmic arteries. Patients with GCS ≤13 or profound weakness (MRC grade ≤3) were treated with Burr hole drainage and placement of subdural drains. Methods: Patients were recruited over a 7-month period from 25/10/2020 to 25/05/2021 through our electronic referral system. Patients' demographics, pre-morbid modified Rankin Score (mRS), symptoms, anticoagulation, and co-morbidities were prospectively collected. Suitability for endovascular treatment was discussed with the Neurovascular radiologist and neurosurgeon. SQUID-12 embolic material was used for all MMA embolizations which were performed under General Anaesthetic. Baseline CT/MRI characteristics were collected. Further imaging was obtained at 7, 21, 90, and 180 days. Clinical assessment and mRS were completed at three months. Results: Ten patients underwent endovascular embolization of MMA in the study period. Of these eight were male, the median age was 79 years. The median length of stay was 3 days. Follow-up CT at 3 weeks, obtained for 6/10 patients, has demonstrated significant reduction in both midline shift (μ = 3.3 mm, p = 0.0019) and maximum thickness of haematoma (μ = 5.8 mm, p = 0.0055). At the time of submission, five patients had reached the three months' follow-up period, of which, three had a complete radiological resolution, with a further patient observed to have >50% improvement in CT parameters. We report one mortality due to COVID-19. Conclusions: For select patients, MMA embolization is a safe, minimally invasive, and effective treatment for a chronic subdural haematoma. As we gain more experience, the procedure could be performed under local anaesthetic.