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Objectives: To measure the prevalence of viral infections, length of stay (LOS), and outcome in children admitted to the pediatric intensive care unit (PICU) during the period preceding the COVID-19 pandemic in a MERS-CoV endemic country. Methods: A retrospective chart review of children 0–14 years old admitted to PICU with a viral infection. Results: Of 1736 patients, 164 patients (9.45%) had a positive viral infection. The annual prevalence trended downward over a three-year period, from 11.7% to 7.3%. The median PICU LOS was 11.6 days. Viral infections were responsible for 1904.4 (21.94%) PICU patient-days. Mechanical ventilation was used in 91.5% of patients, including noninvasive and invasive modes. Comorbidities were significantly associated with intubation (P-value = 0.025). Patients infected with multiple viruses had median pediatric index of mortality 2 (PIM 2) scores of 4, as compared to 1 for patients with single virus infections (p < 0.001), and a median PICU LOS of 12 days, compared to 4 in the single-virus group (p < 0.001). Overall, mortality associated with viral infections in PICU was 7 (4.3%). Patients with viral infections having multiple organ failure were significantly more likely to die in the PICU (p = 0.001). Conclusion: Viral infections are responsible for one-fifth of PICU patient-days, with a high demand for mechanical ventilation. Patients with multiple viral infections had longer LOS, and higher PIM 2 scores. The downward trend in the yearly rate of PICU admissions for viral infections between the end of the MERS-CoV outbreak and the start of the COVID-19 pandemic may suggest viral interference that warrants further investigations. © 2022 Japanese Society of Chemotherapy and The Japanese Association for Infectious Diseases
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Rationale: To seek optimal dosing regimens for Oral immunotherapy (OIT). Methods: A retrospective chart review of 93 patients undergoing "bite proof” nut OIT dosing was undertaken. Patients were escalated to doses of 250-500mg of nut protein for a 6-12 month period and then completed a 2gm nut challenge. Results: Among 93 patients, a total of 209 2g Nut Oral Food Challenges (OFCs) were conducted. 202 of the 209 administered 2g OFCs were passed (96.65%). Among the 6 patients who did not tolerate the initial 2gm OFC, there were no obvious differentiating characteristics identified including single vs multiple food OIT administration, age, concomitant omalizumab, or change in IgE levels from baseline. 12 of the 93 patients who successfully passed the 2gm challenge elected to reduce their dose to the bite proof dosing 3x weekly. 7 of these 12 patients completed a subsequent 2gm OFC 1 year after the initial OFC. All 7 patients successfully tolerated the second 2gm OFC. Conclusions: Patients undergoing a 6-12 month course of 250-500mg daily nut protein dosing exhibited robust success in passing a 2gm OFC. Defining characteristics of patients who failed initial 2gm OFCs could not be determined due to the small number of OFC failures. A subset of patients passing the 2gm OFC demonstrated continued success in tolerating a 2gm nut challenge following a decrease in dosing frequency. Unfortunately the COVID pandemic prohibited further OFCs study of such patients. Future studies of such patients will help elucidate ideal long term OIT dosing strategies.
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Case Report:We describe a case of a non-verbal 5-yearold patient with autism and global developmental delay who presented with headache, nausea, vomiting, and decreased oral intake and found to have acute cerebellar syndrome/cerebellitis secondary to COVID-19 infection. Method(s): Chart Review. Summary of Results: A 5-year-old male with autism spectrum disorder and global developmental delay presented with one week history of headache, nausea, and non-bilious, non-bloody emesis. Despite intravenous fluid resuscitation and anti-emetic treatment, the patient continued to have persistent emesis with decreased oral intake and urine output. Physical exam findings were notable for aniscoria with right pupil larger than left, fixed upward gaze deviation, horizontal nystagmus, and nuchal rigidity. Patient was able to move all extremities spontaneously with normal tone and without rigidity or hyperreflexia. A complete blood cell count was consistent with the following: WBC 17.29 K/uL, hemoglobin level 12.8 g/dL, hematocrit 38.9%, and platelet count 482 K/ uL. C-reactive protein <4.0 mg/L and procalcitonin 0.12 ng/mL. CT Head on hospital day one showed no acute intracranial abnormality. Due to the patient's acute neurological changes, MRI brain was obtained and revealed patchy areas of hyperintensity in both the cerebellar hemispheres with moderate swelling of the cerebellum causing narrowing of the posterior fossa extra-axial cerebrospinal fluid (CSF) spaces. In addition, there was obstruction of the cerebral aqueduct due to extrinsic mass effect by the swollen cerebellum. CSF studies were notable for the following: 148 total nucleated cells with 75% lymphocytes and 17% monocytes and 2 red blood cells, protein was elevated at 113 mg/dL, and glucose was normal at 52 mg/dL. Meningitis and encephalitis panel was without any acute findings. Other laboratory testing was negative for tuberculosis, syphilis, chlamydia, HIV, and EBV. The patient tested positive for COVID-19 virus about one month prior to the onset of symptoms. Imaging and laboratory results in the setting of obstructive hydrocephalus with associated symptoms of nausea, emesis, headache, and upward gaze deviation are consistent with acute cerebellar syndrome, or cerebellitis. Due to obstructive hydrocephalus and inflammation of the cerebellum, patient was started on high-dose steroids, and neurosurgery placed external ventricular drain (EVD). The patient worked closely with physical medicine and rehabilitation as well as speech therapy, physical therapy, and occupational therapy to make a full recovery following this illness. Conclusion(s): Headache, nausea, and vomiting are often seen as benign findings;however, it is important to obtain specific details regarding the timing of symptoms, especially in the setting of a non-verbal patient. Because inflammation of the cerebellum can lead to hydrocephalus and potential herniation, prompt diagnosis is crucial to prevent long term effects of cerebellitis. Copyright © 2023 Southern Society for Clinical Investigation.
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Purpose of Study: Vaccinations are an essential part of preventative medicine and provide for the improvement of public health by preventing the spread of infectious diseases. Patients with autoimmune rheumatic diseases have chronic illnesses that often require prolonged or lifelong immunosuppression or immunomodulation therapy to promote both quality-of-life and survival. Less than half of these patients receive the most common vaccinations despite having a higher risk of vaccine-preventable infections than the general population. The evaluation of immunization status and discussion of vaccines have remained under-prioritized in the medical community due to a wide variety of factors. The use of smart phrases has been shown in previous studies to positively affect clinical outcomes. Improvement in the documentation rate with this method can prompt discussion of immunizations and reduce the rate of suboptimal vaccination coverage in this high-risk patient population. We aimed to increase documentation of vaccinations by ten percent over four weeks using a novel vaccine smart phrase. This will prompt the provider to discuss patient-specific vaccination strategies and has the potential to improve vaccination rates in UMMC rheumatology patients. Methods Used: A baseline assessment through chart review was performed for four weeks immediately prior to implementation (March 14, 2022). Then, educational material on dot phrase implementation was provided electronically to four rheumatology fellows and a two week adjustment period was allowed. The impact of the smart phrase intervention was defined as the difference in the frequency of discussion (via documentation) of vaccinations (COVID, influenza, pneumococcal, and zoster) per clinical in-person encounter four weeks before and four weeks after implementation. Inclusion criteria were any patient with a rheumatology fellow provider seen in adult rheumatology clinic at UMMC. A total of 345 patient encounters were evaluated. Summary of Results: Results showed that implementation of the dot phrase was unable to meet our goal of increased vaccination documentation by 10%. In fact, a 5% overall decrease in the frequency of vaccine documentation was observed. [Figure presented] Conclusion(s): We suspect that an increased patient-to-provider ratio may have pressured the system and led to decreased discussion of vaccinations. Additionally, while we were careful to choose a time for assessment which avoided COVID-19 peaks, proximity to a recent spike may have artificially increased baseline vaccination discussion relative to post-implementation. Lastly, patient charts were not reviewed from prior to the pre-intervention assessment period in an effort to prioritize sample size. It is possible that a discussion on vaccination status was not repeated in subsequent clinic visits. Future studies seek to increase the length of time of the assessment in order to minimize these effects. Additionally, fellow education should be provided in person with the opportunity for further discussion and fellow input. Copyright © 2023 Southern Society for Clinical Investigation.
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Objectives: This study was conducted to describe the use of tofacitinib in severe and critical Coronavirus disease -2019 (COVID-19), and to explore the association of drug initiation time with survival. Method(s): This was a retrospective chart review of inpatients with severe or critical COVID-19 at a tertiary care hospital, who received generic tofacitinib for at least 48 hours. The baseline demographics, comorbidities, treatment, adverse effects and outcomes (i.e. mortality at day 28) were analysed. The severity of COVID-19 was categorised as per WHO classification. Patients were further grouped based on median duration of symptomatic illness prior to tofacitinib administration, as early or late initiation groups. Result(s): Forty-one patients [(85.4% males), mean age 52.9 +/- 12.5 years], were studied. 65.9% (n = 27) of patients had severe COVID-19, while 34.1% (n = 14) were critically ill. Death occurred in 36.6% patients (n = 15). The median time to prescription of tofacitinib was 13 (9.50, 16.0) days of symptom onset. Tofacitinib was initiated early (8-13 days) in 56.1% of patients (n = 23), while the remaining received it beyond day 14 of symptom onset (late initiation group). The proportion of survivors was significantly higher in the early initiation group (21/23, 91.3%) compared to the late group (5/18, 27.8%) (P < 0.0001). Among severe COVID-19 patients, 100% and 62.5% of the patients were survivors among early and late initiation groups respectively (P < 0.01). In the critical COVID-19 patients, 50% were alive on day 28 in the early group while all died in the hospital in the late initiation group (P = 0.06). Multivariate logistic regression adjusted for age, presence of diabetes mellitus (DM) and illness duration prior to hospitalisation demonstrated higher odds of survival (AOR-19.3, 95% C.I. 2.57, 145.2) in the early initiation group, compared to the late initiation group. Conclusion(s): Early initiation of tofacitinib in severe and critical COVID-19 has potential to improve survival odds. (Table Presented).
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Introduction: Our institution cares for a largely underserved urban population, treating about 120 children annually with radiation therapy;roughly 10% are referred for proton therapy elsewhere. COVID-19 led to some decreases in medical care due to uncertainties regarding the state of public health. The purpose of this study is to evaluate existing socioeconomic disparities using the University of Wisconsin Area Deprivation Index (ADI) and whether the pandemic impacted this referral pattern. Method(s): Over the last twenty years, approximately 2,275 children have presented to our institution for radiation treatment. A retrospective chart review was conducted and a patient database of demographic and clinical information was created. We used demographic data to obtain the ADI, and compared relative disparity rankings between proton therapy recipients and a random sample of patients from the 25 most common zip codes (representative of over 20% of the total cohort). We compared the number of patients treated only at the closest proton facility before and after the onset of the pandemic. Result(s): The demographic make-up of our patient population is approximately 53.7% Latino, 22.6% White, 9.5% African American, 9.2% Asian, and 5% Other. Of these patients, about 500 had diagnoses typically referred for proton therapy (such as brain tumors, neuroblastoma, sarcomas, and Hodgkin lymphoma). At baseline, we found a statistically significant difference in the median state ADI decile of 3 and 7 for protons and photons, respectively, reflecting lower socioeconomic disadvantage in the proton group. There was a difference in the median household income (based on zip code) of $102,028 and $70,479 between the proton and photon groups (p < 0.0001). There was also a difference in median household income of $57,871 and $76,808 between Latino and Non-Latino patients (p < 0.0001). Demographic data for the proton therapy cohort showed that 46.2% of these patients were White, 15.4% were Latino, 15.4% were African American, 7.7% were Asian, and 15.4% were Other. At the closest proton facility, between 2014-2019, 16 of our patients received radiation therapy. Since the beginning of pandemic associated restrictions in March 2020, 19 patients have received proton therapy at this center. Conclusion(s): Disparities preventing patients from receiving proton therapy have been described. Our work adds granular census block data and uses the ADI which takes into account median family income, unemployment rate, households without access to a vehicle, English language proficiency and more. Those with lower ADI risk rankings were overrepresented in the proton therapy group. Despite the pandemic and added referral challenges, the number of patients able to receive proton therapy did not decrease which we hypothesize may be due to many factors, including the unanticipated flexibility of remote work amongst those with lower ADI rankings. Latinos were least likely to have proton therapy, and further research is needed to ameliorate the disparities and barriers to care which they face.
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Background: Both cancer and COVID-19 have been reported to be associated with an increased risk of VTE. Severe disease needing hospitalization is also associated with an increased risk of VTE. There is a paucity of data evaluating the effects of race on this risk, with the limited available data suggesting that such a correlation exists. Given the increased prevalence of comorbidities and risk factors for VTE in African Americans (AA), we sought to evaluate if there are racial disparities in the incidence of VTE in the hospitalized subset of COVID-19 patients with cancer. Method(s): This was a retrospective chart review of unvaccinated cancer patients hospitalized with COVID-19 at a major tertiary health facility. Only cancer patients who were on active systemic chemotherapy were included. The primary study outcomes were development of DVT or PE (VTE) within 30 days of COVID-19 diagnosis. Secondary outcomes included mortality, hospital length of stay, mechanical ventilation, ICU admission, and need for vasopressors. Mean and standard deviation were reported for continuous variables;proportions were reported for categorical variables. To compare between races, the Chi-square test was used for categorical variables and the t-test was used for continuous variables. Multivariable logistic regression was then conducted to assess the relationship between race and selected factors. All statistical tests were 2-sided with an alpha (significance) level of 0.05. Result(s): A total of 73 patients were included in our analysis. The median age of the cohort was 70 years (interquartile range [IQR] 64-79). Gender breakdown: 58.9% males, 41.1 females. 31.5% were Caucasian, 64.4% African American, 1.4% Hispanic, and 2.7% other races/ethnicities. There were 8 DVT/PE patients in the cohort. Of 23 Caucasians in our cohort, 3 (13.0%) had VTE. Of 47 African Americans, 5 (10.6%) had DVT/PE. There was no significant difference between the incidence of VTE and race (p > 0.05). Multivariable logistic regression did not show a significant relationship between race and VTE, controlling for age, ICU stay, intubation, vasopressor use, serum ferritin and serum IL-6 levels. Notably, all patients included in this study were on enoxaparin prophylaxis for VTE. The only variable associated with DVT/PE was age and the presence of hemoglobinopathy. Incidence of VTE was significantly associated with increasing age (p < 0.03) and the presence of hemoglobinopathy (p < 0.01). Hemoglobinopathy was only seen in AA cancer patients with VTE (n = 4), and none in Caucasian patients. Conclusion(s): Contrary to what has been reported in the literature, we did not detect racial disparity in the incidence of VTE in hospitalized cancer patients with COVID 19. Prophylactic anticoagulation likely had a protective effect. However, racial disparity was observed in AA cancer patients with hemoglobinopathy with increased VTE risk despite prophylactic anticoagulation. This warrants further evaluation in future studies.
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Background: As COVID-19 vaccines continue to be administered worldwide, there are an increasing number of studies documenting cutaneous reactions following vaccination. Systemic reactions, such as urticarial diseases, occur. Purpose(s): The main objective of this study was to investigate the association between urticaria and recent vaccination for COVID-19. Method(s): A retrospective chart review examining the association of urticaria and COVID vaccination was conducted. Result(s): We report 17 patients who developed an urticarial reaction following vaccination against COVID and one patient who developed an urticarial reaction following a COVID infection. The vast majority of the patients were women with a mean age of 42.8 years. Conclusion(s): Cutaneous manifestations often follow COVID vaccination and infection. It may be helpful to inquire about recent infections and vaccinations in patients presenting with urticarial diseases. Copyright © 2022 Journal of Dermatology and Dermatologic Surgery.
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Background/Purpose: Covid-19 vaccine is one of the most effective strategies to control coronavirus disease 2019 (COVID-19) pandemic. However, safety data of these vaccines among patients with autoimmune diseases is limited. We report case series of patients who developed new-onset or flares of autoimmune disease after COVID-19 vaccination. Method(s): We conducted a retrospective chart review of patients treated by rheumatologists for new-onset or flares of autoimmune diseases after COVID-19 vaccination between March 2021-July 2022. Patients who had COVID-19 infection or other explainable causes were excluded. According to World Health Organization's Adverse Event Following Immunization causality assessment, we use 30-day cut off. Patients were divided into 2 groups. The first group had symptom onset within 30 days after vaccination whereas the second group had symptom onset 31-90 days post-vaccination. Patient's demographics, clinical manifestations and laboratory data were collected. Result(s): We identified 18 (46%) patients with new-onset autoimmune diseases, and 21 (54%) patients with autoimmune disease flares after COVID-19 vaccination. Four patients had recurrent flares following subsequent vaccination. The median age was 45 years and 66.7% were females. The median duration from last vaccination to symptom onset was 16 days. Twenty-two (56.4%) of patients developed symptoms within 30 days post-vaccination. Symptoms occurred mostly after the 2nd (44.2%) dose. The most common diagnosis was systemic lupus erythematosus (SLE) (32.6%) with modified Systemic Lupus Erythematosus Disease Activity Index-2000 ranging from 1-21 at diagnosis. Among patients with disease flares, 4 patients had undiagnosed autoimmune diseases before vaccination, 4 patients stopped immunosuppressive medications months prior to disease flares, 5 patients stopped immunosuppressive medications 1 week after vaccination, and 7 patients continued immunosuppressive medications. Fourteen (35.8%) cases required hospitalization, four of which were treated in intensive care units. The remaining patients were treated at outpatient clinic. Seven patients required initiation or adjustment of biologic disease modifying anti-rheumatic drugs, 19 patients received intravenous cyclophosphamide and/or intravenous methylprednisolone, 3 patients received intravenous immunoglobulin, and 5 patients underwent plasmapheresis. One patient improved without intervention. Three (7.9%) patients with new-onset autoimmune diseases died: 2 patients with SLE, and 1 patient with Hemophagocytic lymphohistiocytosis. Conclusion(s): There are cases of patients with new-onset or flare of autoimmune diseases occurring after COVID-19 vaccination. Although previously undiagnosed autoimmune disease or prior discontinuation of immunosuppressive medications partly contributed to disease flares, some cases occurred without other precipitating factors and were severe. Disease awareness and early detection are needed to improve patient outcomes. (Figure Presented).
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Background: As COVID-19 vaccines continue to be administered worldwide, there are an increasing number of studies documenting cutaneous reactions following vaccination. Systemic reactions, such as urticarial diseases, occur. Purpose(s): The main objective of this study was to investigate the association between urticaria and recent vaccination for COVID-19. Method(s): A retrospective chart review examining the association of urticaria and COVID vaccination was conducted. Result(s): We report 17 patients who developed an urticarial reaction following vaccination against COVID and one patient who developed an urticarial reaction following a COVID infection. The vast majority of the patients were women with a mean age of 42.8 years. Conclusion(s): Cutaneous manifestations often follow COVID vaccination and infection. It may be helpful to inquire about recent infections and vaccinations in patients presenting with urticarial diseases. Copyright © 2022 Journal of Dermatology and Dermatologic Surgery.
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INTRODUCTION: ARDS net trial recommends keeping low tidal volumes (6-8 cc/IBW) and plateau pressures less than 30 cm H20. However, it is not well studied if sporadic elevation or continuous elevation of plateau pressures results in poor outcomes. We hypothesize that persistent elevation of p plat for >24 hrs. or > 6 times (measured 4 hrs. apart) continuously is associated with increased mortality. METHOD(S): Retrospective chart review of patients admitted with COVID-19 during the surge of August to September 2021 at Houston Methodist Baytown hospital. Inclusion Criteria- COVID-19 patients with respiratory failure, ards and intubated. Plateau pressures are recorded every 4 hrs. Data obtained from EPIC ICU flowsheet. Persistent elevation was defined as all the plateau pressures measured for > 24 hrs. and are continuously elevated. Exclusion criteria - patients admitted to ICU with cardiac arrest, patients who are covid negative and covid positive, but no ARDS are excluded. Tidal volume recorded is when the first highest p plateau pressure was documented. Descriptive statistics and t-tests were used to interpret the results. RESULT(S): Out of a total of 48 patients, only 12 patients survived, and 36 patients died. Mortality rate- 75%. Survivors vs. non survivors average Age(y) 42 vs.55 (p< 0.05), Tidal volume 5.98 ml/PBW vs.6.03 ml/PBW (p=0.105), Normal elastance 4.06 vs. 4.07(p=0.44), Delta P 22 vs.23(p=0.27) and ventilatory ratio 84 vs. 98(p< 0.05) were calculated during maximum plateau pressures. In patients with continuous p plat >30, 29 (85%) patients died and 5 (15%) survived. OR- 5.8 (P< 0.05). Out of the 5 patients that survived 2 went on ECMO. Intermittent p plat elevation was noted in 11 out of 14 patients who did not have continuous p plat elevation. CONCLUSION(S): Ventilatory ratio, a simple index of impaired ventilation and physiological dead space was higher in nonsurvivors compared with survivors. Continuous p plat elevation for more than 24 hrs. that is resistant to intervention might be an indirect indicator of worsening lung ventilation and increasing mortality. Rather than a single-time daily measurement of variables like delta P or p plateau pressure multiple measurements and trends might be helpful to prognosticate patients that might have poor outcomes and indicate worsening lung function.
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INTRODUCTION: As an infection control measure for COVID-19, our PICU transitioned to near universal video laryngoscopy (VL). In 2019, 24% of intubations used VL;this increased to 96% in 2021. Comparing these two cohorts elucidates the effect of transitioning from direct laryngoscopy (DL) to VL on first time success rate (FTSR), Cormack-Lehane (C-L) grade view and successful trainee intubation. First time intubation success is associated with fewer complications and is therefore an important marker of intubation safety. METHOD(S): Single Center retrospective case control. Data for 2019 were identified via chart review. Data from 2021 were obtained through a dedicated form introduced in the Fall of 2020. Each comparison group was limited to a full calendar year (Jan-Dec) to account for progression in trainee skill. A comparison was made between all patients in cohort groups with additional stratification of patients above and below the age of one. Included intubations were those in the PICU as well as those in the pediatric floor or ED performed by PICU staff. Statistics via Fischer Exact test. RESULT(S): 75 patients met criteria for 2019 and 73 in 2021. The age range in both groups was 2 days to 23 years. C-L view was documented in 72 of 75 patients in 2019 and all patients in 2021. 2019 had a 69.4% grade 1 C-L view rate, while 2021 had a 79.5% grade 1 C-L view rate (p=0.19). The overall FTSR in 2019 was 57.3% vs 65.7% in 2021 (p=0.31). 26 children under the age of one were intubated in both years, with a FTSR of 53.8% and 50% respectively. The FTSR in children above one year was 59.2% and 74.5% respectively (p=0.13). Additionally, an airway provider was documented in all but two cases in 2019. Of these, 75.3% were managed successfully by pediatric subspecialty fellows (PICU or rotating PEM). In 2021 this number increased to 84.9% (p=0.21). CONCLUSION(S): FTSR did not improve with transition to VL. In the 2021 cohort, children above age one had a 15.3% increased FTSR and trainees had a 9.6% increase in completed intubations. While not significant, these findings would benefit from reanalysis with a larger sample. First time success is an important marker for safe intubation practice, however there may be other benefits to either approach such as set up time and assistance from a second viewer.
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INTRODUCTION: Neurological prognostication is an important part of caring for critically ill patients and can help guide goals of care. This has become a challenge when caring for patients with severe COVID-19 pneumonia, as they have been shown to often have prolonged periods of coma followed by meaningful neurological recovery. However, this has not been studied in patients who require venovenous extracorporeal membrane oxygenation (VV-ECMO) support. We hypothesize that patients with COVID-19 pneumonia on VV-ECMO will have a more prolonged period of unconsciousness when compared to their COVID-negative counterparts. METHOD(S): We conducted a retrospective chart review of all patients who received VV-ECMO support at our institution from March 2020 to January 2022. This timeframe was selected to limit the effect of any changes in sedation practices that were brought about by the COVID-19 pandemic. We compared the daily Glascow Coma Scale (GCS) of patients with COVID-19 pneumonia to those who were cannulated for other etiologies. Our outcomes were duration of unconsciousness, which was defined as time from intubation to GCS motor score=6 for 48 hours, as well as changes in GCS over time. RESULT(S): Our preliminary analysis included 84 patients, 57 (68%) of whom were COVID-19 positive. There were no significant differences in the baseline characteristics of the groups, including initial Sequential Organ Failure Assessment score and need for renal replacement therapy. Patients with COVID-19 pneumonia had a significantly longer duration on ECMO in hours (952 vs 312, p< 0.001) and hospital length of stay in days (42 vs 30, p=0.01). There was no significant difference in the duration of unconsciousness (days) between the two groups (11 vs 9, p=0.21). However, the trend in GCS over time was notable as we found that patients with COVID-19 spent more days unresponsive, defined as a GCS=3 (8 vs 5, p=0.04). CONCLUSION(S): Our preliminary analysis found that in patients on VV-ECMO, those with COVID-19 pneumonia spent a longer time on ECMO and in the hospital. While there was no difference in the duration of unconsciousness, patients with COVID-19 spent more of that period unresponsive prior to recovery. While additional analysis is needed, this finding may assist providers when prognosticating neurological recovery.
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INTRODUCTION: Although Staphylococcus aureus is known to be a poor prognostic factor in coronavirus disease of 2019 (SARS-CoV-2 or COVID-19), it is unclear if COVID-19 increases the risk of S. aureus infections. The purpose of this study is to give healthcare providers a better understanding of the pharmacological risk factors that may predispose patients to a S. aureus co-infection in COVID-19 positive patients. METHOD(S): This retrospective chart review included adult patients treated at a Spectrum Health medical or cardiothoracic ICU between October 2020 and November 2021. To be included in the exposure arm of the analysis, patients had to have a positive culture for S. aureus. A chi-square analysis was utilized for the primary outcome while a logistic regression was used to uncover possible risk factors for S. aureus in COVID-19 patients. Overall, S. aureus infections were compared between patients with and without COVID-19 with a secondary analysis that was done for patients who had been treated with tocilizumab or dexamethasone. RESULT(S): A total of 406 patients were included;96 patients were positive for S. aureus, and 310 patients remained negative throughout their admission. COVID-19 patients were more likely to acquire a S. aureus infection than their COVID-19 negative counterparts (p < 0.0001). Neither tocilizumab nor dexamethasone use were statistically significant in increasing risk of S. aureus co-infection. CONCLUSION(S): COVID-19 patients are more likely to acquire S. aureus infections than their COVID-19 negative counterparts. Dexamethasone and tocilizumab use were not associated with increased incidence of S. aureus infections in COVID-19 patients.
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INTRODUCTION: Patients with COVID-19 in the intensive care unit (ICU) often require prolonged use of intravenous (IV) vasopressors which become a barrier to intensive care unit (ICU) discharge. The goal of this study is to describe the effect of midodrine, an alpha-1 agonist, on time to IV vasopressor discontinuation in COVID-19 patients in the ICU. METHOD(S): This study was an IRB-approved retrospective chart review conducted at a community, tertiary care hospital between January 2020 until November 2021. Eligible participants included hypotensive patients aged 18 years or older who were admitted to an ICU on at least 0.1 mcg/kg/ min of norepinephrine for 24hrs with a diagnosis of septic shock and COVID-19. Pearson Chi-Square and Independent- Samples Mann-Whitney U Test were used to analyze baseline characteristics, ICU length of stay, and time to IV vasopressor discontinuation in patients that received at least one dose of midodrine and patients on comparable IV vasopressors not started on midodrine. RESULT(S): 70 patients were included in the study with 35 patients in the midodrine group and 35 patients in the control group. The median time to IV vasopressor discontinuation was 13 days for the midodrine group and 8 days for the control group (p < 0.001), but there were less patients started on a second IV vasopressor in the midodrine group. Median time of initiation of midodrine was 9 days and IV vasopressors were discontinued at a median of 4 days after starting midodrine. The mean ICU length of stay and Hospital length of stay were 26 days & 32 days in the midodrine group and 15 days & 21 days in the control group (p < 0.001). The average dose of midodrine was 10 mg per day. CONCLUSION(S): The initiation of midodrine in COVID-19 patients with septic shock was not found to decrease total time to IV vasopressor discontinuation. Although, there were less patients started on a second IV vasopressor in the midodrine group.
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BACKGROUND: During Wave 3 of the COVID-19 pandemic, 15 community hospital paediatric inpatient units (comprising 167 beds) in Toronto were directed to close by the Greater Toronto Area (GTA) Hospital Incident Management System (IMS) Command Centre to increase adult inpatient bed capacity. All paediatric patients from closed inpatient units were redirected to a single tertiary care paediatric hospital, which increased capacity to accommodate these additional patients through activation of surge plans, while community hospitals redeployed resources to fill much needed gaps in adult care. OBJECTIVE(S): The objective was to describe patient characteristics of all transfers during the closure to explore the impact of community paediatric inpatient unit closures on transfers to the tertiary hospital. DESIGN/METHODS: A chart review of all transferred patients was conducted during the mandated closure and subsequent reopening. Transfers excluded ICU-level transfers as these were not impacted by IMS mandated closures. All transfers were categorized as requiring tertiary care (i.e. would typically be transferred) or not requiring tertiary care (i.e. only transferred due to the closure). Variables collected included sending hospital, admitting diagnosis, patient age, hospital disposition, and length of stay. Data was collected until the last paediatric unit reopened. Quality improvement project approval was granted by the institution. RESULT(S): A total of 858 patients were transferred to the tertiary hospital during the 67 day closure;of those, 530 were transferred solely to increase adult bed capacity (i.e. were categorized as patients requiring non-tertiary care). The majority of patients were admitted to general paediatrics (52%), and 39% went to a surgical inpatient unit. Most patients (68%) admitted had a length of stay between 24 and 72 hours. A third of patients admitted were under 2 years old, and a third were over 12 years old. The top three diagnoses for admission were infections, gastrointestinal issues, and general surgery. Two-thirds (60%) of transfers from closed sites came from three sites. CONCLUSION(S): More than half of the transfers occurred solely due to the mandated closures, and transfers returned to a stable volume once all sites re-opened. The GTA hospital system was able to respond to the mandated closure effectively through clear high-level communication, escalation processes and structures as well as responsive, real-time problem solving. Closures increased potential adult inpatient capacity by 6740 bed days and demonstrated an unprecedented system-wide approach to the provision of integrated paediatric care across the region.
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Background. Pregnant people and fetuses are uniquely vulnerable to SARS-CoV-2, a driver of inflammation and immune dysregulation. Prior investigations have shown that pregnant people with SARS-CoV-2 are at higher risk of severe illness, mortality, and obstetric complications. We investigated the impact of SARS-CoV-2 infection severity and latency on maternal and infant cytokine levels. Methods. We collected maternal blood and cord blood at delivery from motherinfant dyads (Chicago, IL;3/2020-1/2022). A multiplex cytokine panel (IsoPlexis) was run on plasma from 93 SARS-CoV-2 infected dyads and 32 matched controls. Clinical data was ed by chart review, including latency (acute being <=14 days and distant >14 days from SARS-CoV-2 infection to delivery) and severity (NIH criteria: asymptomatic, mild, moderate, severe/critical). Kruskal-Wallis tests with post-hoc pairwise Dunn Tests were used (alpha=0.05). Results. SARS-CoV-2 exposed infants had lower levels of MIP-1b (p=0.037) and PDGF (p=0.008) than controls [Fig 1]. There were no differences in maternal blood cytokines at time of delivery following SARS-CoV-2 infection during pregnancy (pooled analysis of all SARS-CoV-2). Stratifying by latency, acutely exposed infants showed higher levels of MCP-1 than controls or those with distant maternal SARS-CoV-2 (p=0.016). There were no significant differences in maternal cytokines between control, acute, and distant SARS-CoV-2. In mothers with acute SARS-CoV-2, differences in levels of IL-1B (p=0.011) and IL-10 (p=0.046) were observed across severity groups, with a significant linear trend for each among severity groups (p for trend < 0.001, respectively). Severe/critical acute infection resulted in higher maternal granzyme and IL-8 than mild infection (p=0.037 and 0.047) [Fig 2]. There were no differences across severity groups in 1) mothers with distant infection, 2) infants with acute maternal infection, or 3) infants with distant maternal infection. Conclusion. Cytokine levels in SARS-CoV-2 positive dyads were altered only in the setting of acute or more severe infection and demonstrated anti-inflammatory, anti-viral, and anti-angiogenic responses. In acute infection, greater severity drives higher levels of both a pro- and anti-inflammatory cytokine in pregnant people.
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Background. The Omicron surge caused a significant strain on the healthcare system, particularly as it relates to healthcare worker (HCW) infections. Occult infection transmission from HCWs to patients is an important area upon which infection control programs can continue to improve. Methods. We conducted a retrospective chart review of 9 patients on the immunocompromised solid organ transplant service who were exposed to a highly infectious vaccinated and boosted healthcare worker across 2 days during the Omicron surge in January 2022. Results. The index healthcare worker began to show symptoms shortly after rounds on the second day of clinical service. Nasopharyngeal rtPCR testing for SARS CoV 2 was positive, Ct value 15.9;a routine screening Covid19 test the day prior using an anterior nares swab had been negative. All 9 patients who were exposed and received follow-up testing on days 3-5 since exposure were negative for SARS CoV 2. One additional healthcare worker who was also exposed tested negative on followup testing despite several hours of close contact across 2 days. Both HCWs wore N95 respirators during all patient care and in breakrooms. Patient exposures were less than 15 minutes in duration, but also less than 6 feet in distance. Conclusion. The index healthcare worker did not transmit SARS CoV 2 to a cohort of immunocompromised patients or to a fellow HCW despite being very infectious. The index HCW wore an N95 respirator during all patient encounters which could have reduced the chance for transmission.
ABSTRACT
Background. Studies show that past SARS-CoV-2 infection provides a protective immune response against subsequent COVID-19, but the degree of protection from prior infection has not been determined. History of previous SARS-COV-2 Infection and Current SARS-COV-2 Infection Status at Admission. *Adjusted for chronic respiratory disease and prior COVID-19 vaccination Methods. From May 2021 through Feb 2022, adults (>= 18 years of age) hospitalized at Emory University Hospital and Emory University Hospital Midtown with acute respiratory infection (ARI) symptoms, who were PCR tested for SARS-CoV-2 were enrolled. A prior history of SARS-CoV-2 infection was obtained from patient interview and medical record review. Previous infection was defined as a self-reported prior SARS-CoV-2 infection or previous evidence of a positive SARS-CoV-2 PCR test >= 90 days before ARI hospital admission. We performed a test negative design to evaluate the protection provided by prior SARS-CoV-2 infection against subsequent COVID-19-related hospitalization. Effectiveness was determined using logistic regression analysis adjusted for patient sociodemographic and clinical characteristics and COVID-19 vaccination status. Results. Of 1152 adults hospitalized for ARI, 704/1152 (61%) were SARS-CoV-2 positive. 96/1152 (8%) had a prior SARS-CoV-2 infection before hospital admission. Patients with a previous history of SARS-CoV-2 infection were less likely to test positive for SARS-CoV-2 upon admission for ARI compared to those who did not have evidence of prior infection (31/96 [32%] vs 673/1056 [64%];adjustedOR: 0.25 [0.15, 0.41] (Table). Conclusion. Reinfections represented a small proportion (< 10%) of COVID-19-related hospitalizations. Prior SARS-CoV-2 infection provided meaningful protection against subsequent COVID-19-related hospitalization. The durability of this infection-induced immunity, variant-specific estimates, and the additive impact of vaccination are needed to further elucidate these findings.
ABSTRACT
Background. Hospitals have been experiencing an increasing number of acutely ill patients as well as those requiring prolonged hospitalizations, further worsened by the COVID-19 pandemic. This has resulted in increased orders for blood cultures. Once collected, the culture bottles require an incubation period, typically 5 days. The BD BACTEC Fx, a blood culture incubation automated system, holds blood culture bottles until growth is demonstrated or for 5 days, whichever occurs first. New bottles are placed in the apparatus along with older bottles awaiting growth. Capacity is reached when the machine cannot accommodate new bottles due to limited space.When this occurs,manual plating of blood cultures on agar plates is required. Manual plating adds additional responsibility to already overwhelmed microbiology labs. Methods. Following the institutional review board (IRB) approval, data were collected retrospectively at a 765-bed tertiary care center. Data was obtained from positive blood cultures from July 2017 to June 2020. We stratified positive blood cultures based on the day of positivity, from day one to day five. The charts were reviewed for positive blood culture results on day four and day five to evaluate for clinical significance. Clinical significance was determined by an Infectious Disease subspecialty team. Blood culture bottles that were positive on day 4 and day 5 in 1 bottle out of 2 bottles with coagulase-negative species of Staphylococcus, Corynebacterium spp, or Propionibacterium acnes were considered a contaminant and did not warrant further chart review. Results. On a retrospective review of data from July 2017 to June 2020, the total number of blood cultures obtained was 120,320. Among them, 7,558 blood cultures were positive. 94% were positive on day 1, 4% positive on day 2, 2% positive on day 3, 1% positive on day 4 and < 1% positive on day 5. Positive blood cultures on day 5 did not have any clinical significance, according to the chart review. Conclusion. Our study demonstrated that four days of incubation is sufficient for the BD BACTEC Fx automated blood culture incubation system without compromising clinical significance. Implementation of a 4-day incubation period will help with reducing saturation of slots and will improve readiness to accommodate more blood culture bottles.