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1.
Frontiers in Oncology ; 12 (no pagination), 2022.
Article in English | EMBASE | ID: covidwho-2199072

ABSTRACT

Background and objectives: Patients with muscle-invasive bladder cancer (MIBC) often experience a waiting period before radical surgery for numerous reasons;however, the COVID-19 outbreak has exacerbated this problem. Therefore, it is necessary to discuss the impact of the unavoidable time of surgical delay on the outcome of patients with MIBC. Method(s): In all, 165 patients from high-volume centers with pT2-pT3 MIBC, who underwent radical surgery between January 2008 and November 2020, were retrospectively evaluated. Patients' demographic and pathological information was recorded. Based on the time of surgical delay endured, patients were divided into three groups: long waiting time (> 90 days), intermediate waiting time (30-90 days), and short waiting time (<= 30 days). Finally, each group's pathological characteristics and survival rates were compared. Result(s): The median time of surgical delay for all patients was 33 days (interquartile range, IQR: 16-67 days). Among the 165 patients, 32 (19.4%) were classified into the long waiting time group, 55 (33.3%) into the intermediate waiting time group, and 78 (47.3%) into the short waiting time group. The median follow-up period for all patients was 48 months (IQR: 23-84 months). The median times of surgical delay in the long, intermediate, and short waiting time groups were 188 days (IQR: 98-367 days), 39 days (IQR: 35-65 days), and 16 days (IQR: 12-22 days), respectively. The 5-year overall survival (OS) rate for all patients was 58.4%, and that in the long, intermediate, and short waiting time groups were 35.7%, 61.3%, and 64.1%, respectively (P = 0.035). The 5-year cancer-specific survival (CSS) rates in the long, intermediate, and short waiting time groups were 38.9%, 61.5%, and 65.0%, respectively (P = 0.042). The multivariate Cox regression analysis identified age, time of surgical delay, pT stage, and lymph node involvement as independent determinants of OS and CSS. Conclusion(s): In patients with pT2-pT3 MIBC, the time of surgical delay > 90 days can have a negative impact on survival. Copyright © 2022 Li, Chen, Raj, Xue, Zhao, Shen, Peng and Zhu.

2.
Neuro-Oncology ; 24(Supplement 7):vii129, 2022.
Article in English | EMBASE | ID: covidwho-2189425

ABSTRACT

Sex is an important factor that influences disease development, progression, and treatment. In multiple non-reproductive cancers, sex differences in incidence, progression, treatment response, survival, and other clinical outcomes are observed. Overall, males have a 20% higher chance of developing cancer over their lifetime, and experience worse clinical outcomes when compared with females. The NIH recognizes the importance of sex as a biologic variable and addressing sex as a biological variable is now required for all researchers submitting NIH grants. While more researchers are investigating the role of sex differences in cancer, a systematic review that examines the patterns of sex differences in incidence and survival across 15 non-reproductive cancers has not yet been published. We performed a systematic review by searching five databases using keywords and controlled vocabulary terms for each concept of interest and limited to English language. Records were included if it reported sex differences in human adults (18+), addressed incidence, mortality, or survival, at least one of the 15 cancers of interest, and were a cohort, cross-sectional, RCT, or case control study. Covidence was used for screening and two reviewers independently screened each record at title/ and then full text. Two reviewers independently completed data extraction using Microsoft Excel and the Cochrane RoB 2.0, and JBI tools were used for risk of bias assessment. The searches and pilot of the methods are underway. Understanding the role sex-differences play on incidence and survival are important for adding to our understanding of advances in diagnosis and treatment of individuals with cancer.

3.
International Journal of Radiation Oncology Biology Physics ; 115(1):252-253, 2023.
Article in English | EMBASE | ID: covidwho-2179654
4.
Aging and Cancer ; 3(3-4):161-168, 2022.
Article in English | ProQuest Central | ID: covidwho-2172311

ABSTRACT

BackgroundThe coronavirus disease 2019 (COVID‐19) pandemic resulted in enormous medical and economic burden worldwide during the past 3 years. The vaccination was deemed the effective option to prevent the severe symptoms, and especially recommended among cancer patients. Shanghai experienced the first lockdown during the recent Omicron pandemic since 2019. How patients with pancreatic adenocarcinoma (PAC) suffered from the pandemic and how vaccination influenced their oncological outcomes were unexplored yet.MethodThe retrospective study was carried out in a high‐volume referral center including 1157 consecutively enrolled patients with PAC experiencing the COVID‐19 pandemic. The primary outcome was the overall survival (OS).ResultsLimited postoperative patients (9.21%) received the vaccination. The lockdown in Shanghai (April to May, 2022) was not observed impacting the survival prognoses of patients with PAC. Though vaccination was not significantly associated with OS itself (adjusted hazard ratio (aHR): 2.032 [0.940–4.391], p = 0.071), it was discovered to synergistically improve the chemotherapy effect in the multivariate analyses (interaction p = 0.023).ConclusionThe vaccination itself did not influence the survival prognoses of patients with PAC. A potential positive interaction was observed between chemotherapy and vaccination despite the limited follow‐up time. The postoperative patients should consider the vaccination more. The patients with PAC did not suffer worse prognostic outcomes from the strict sanitary policy during the wave of COVID‐19 pandemic in Shanghai.

5.
Cancer Control ; 29: 10732748221141233, 2022.
Article in English | MEDLINE | ID: covidwho-2138741

ABSTRACT

BACKGROUND: It is 1 of the standard treatment options for metastasis pancreatic cancer to receive nab-paclitaxel (125 mg/m2) plus gemcitabine (1000 mg/m2) on days 1, 8 and 15 every 28 days. Some patients showed intolerance and inconvenience to this therapeutic regimen. Thus, we conducted this retrospective real-world study to determine the efficacy and tolerability of a modified 21-day nab-paclitaxel plus gemcitabine (nab-P/Gem) regimen for the first-line treatment of locally advanced or metastatic pancreatic cancer. METHODS: Patients with locally advanced and metastatic pancreatic cancer treated with nab-paclitaxel (125 mg/m2) plus gemcitabine (1000 mg/m2) on days 1 and 8 every 21-day at West China Hospital and Shang Jin Hospital of Sichuan University from Mar 2018 to Dec 2021 were reviewed retrospectively. Clinical characteristics of patients were collected. The progression-free survival, overall survival, objective response rate, disease control rate, and toxicity were evaluated. RESULTS: A total of 113 patients who received the modified regimen of 21-day nab-P/Gem chemotherapy were included. The median overall survival was 9.3 months and the median progression-free survival was 4.4 months. The objective response rate and disease control rate were 18.6% and 56.7%, respectively. The median relative dose intensity for this modified regimen was 65%. The adverse events were mild to moderate, and the most common grade 3 or 4 treatment-related adverse events were neutropenia (21%) and leukopenia (16%). CONCLUSIONS: Our study showed that this modified regimen of 21-day nab-P/Gem for locally advanced and metastatic pancreatic cancer had comparable efficacy and tolerable toxicity. This treatment may provide a considerable option for pancreatic cancer patients who desire a modified schedule. The modified regimen of 21-day nab-P/Gem is also an option worth considering during the coronavirus disease 2019 pandemic for minimizing the number of visits and limiting the risk of exposure.


Subject(s)
Antimetabolites, Antineoplastic , Paclitaxel , Pancreatic Neoplasms , Humans , Antineoplastic Combined Chemotherapy Protocols , Pancreatic Neoplasms/drug therapy , Pancreatic Neoplasms/pathology , Retrospective Studies , Paclitaxel/administration & dosage , Paclitaxel/therapeutic use , Antimetabolites, Antineoplastic/administration & dosage , Antimetabolites, Antineoplastic/therapeutic use
6.
Cancer Discovery ; 12(4):878, 2022.
Article in English | EMBASE | ID: covidwho-2124911
7.
The Lancet Regional Health - Western Pacific ; 31:100624, 2023.
Article in English | ScienceDirect | ID: covidwho-2120119

ABSTRACT

Summary Overall survival (OS) is considered the standard clinical endpoint to support effectiveness claims in new drug applications globally, particularly for lethal conditions such as cancer. However, the source and reliability of OS in the setting of clinical trials have seldom been doubted and discussed. This study first raised the common issue that data integrity and reliability are doubtful when we collect OS information or other time-to-event endpoints based solely on simple follow-up records by investigators without supporting material, especially since the 2019 COVID-19 pandemic. Then, two rounds of discussions with 30 Chinese experts were held and 12 potential source scenarios of three methods for obtaining the time of death of participants, including death certificate, death record and follow-up record, were sorted out and analysed. With a comprehensive assessment of the 12 scenarios by legitimacy, data reliability, data acquisition efficiency, difficulty of data acquisition, and coverage of participants, both short-term and long-term recommended sources, overall strategies and detailed measures for improving the integrity and reliability of death date are presented. In the short term, we suggest integrated sources such as public security systems made available to drug inspection centres appropriately as soon as possible to strengthen supervision. Death certificates provided by participants’ family members and detailed standard follow-up records are recommended to investigators as the two channels of mutual compensation, and the acquisition of supporting materials is encouraged as long as it is not prohibited legally. Moreover, we expect that the sharing of electronic medical records and the legal disclosure of death records in established health registries can be realized with the joint efforts of the whole industry in the long-term. The above proposed solutions are mainly based on the context of China and can also provide reference for other countries in the world.

8.
Journal of Vascular Access ; 23(1 Supplement):1-2, 2022.
Article in English | EMBASE | ID: covidwho-2114535

ABSTRACT

Introduction: Dialysis access surgery, in the UK, is almost always performed in NHS healthboard-run hospitals. During the height of the COVID-19 pandemic, in which access to elective operating theatres became limited, arrangements were made in our vascular access service, to perform some dialysis access surgery in a local private hospital. Patients were selected such that those deemed suitable as day-case and unlikely to require in-patient stay were chosen. A scoring system, 'Medically Necessary Time-Sensitive' (MeNTS) criteria, was proposed recently to assist in such decision-making processes by considering procedural, disease, and patient factors (Prachand et al, J Am Coll Surg.2020). The cumulative MeNTS score ranges from 21 to 105, with a score >65 signifying a 'too high risk to be justified' procedure. The aim of this study was to use MeNTS scores retrospectively to determine whether correct decisions were made in performing dialysis-access operations in the usual NHS university healthboard (UHB) setting vs local private hospital (Spire). Method(s): MeNTS scores were calculated for all patients who underwent dialysis access surgery at both sites between March 2020 - March 2021. Outcomes assessed included patient survival and COVID-19 infection Results: 213 Patients underwent dialysis access surgery at UHB and 76 at Spire. Mean cumulative MeNTS scores were 40.03(+/-0.30) and 39.97(+/-0.46) for the UHB and Spire groups, respectively (P=.922). COVID-19 infection occurred in four patients at UHB, and none in Spire (P=.576). Successful dialysis access was achieved in 76.06% and 69.74% in UHB and Spire patients, respectively (P=.287). At 30 days, one UHB patient had died whilst all Spire patients were alive (P>.999). Discussion and conclusion: Dialysis access surgery can take place safely during the COVID-19 pandemic, with necessary precautions. A modified version of the MeNTS score to make it more renal-specific would allow maximum benefit to be achieved from it in this field.

9.
J Neurooncol ; 2022 Nov 10.
Article in English | MEDLINE | ID: covidwho-2116588

ABSTRACT

PURPOSE: Shorter hypofractionated radiation therapy (HF-RT) schedules may have radiobiological, patient convenience and healthcare resource advantages over conventionally fractionated radiation therapy (CF-RT) in glioblastoma (GBM). We report outcomes of young, fit GBM patients treated with HF-RT and CF-RT during the COVID-19 pandemic, and a meta-analysis of HF-RT literature in this patient subgroup. METHODS: Hospital records of patients with IDH-wildtype GBM treated with HF-RT (50 Gy/20 fractions) and CF-RT (60 Gy/30 fractions) between January 2020 and September 2021 were reviewed. Overall survival (OS) and progression-free survival (PFS) were estimated using the Kaplan-Meier method. Univariable analysis was performed using Cox regression analysis. A systematic search and meta-analysis of studies from January 2000 to January 2022 was performed. RESULTS: 41 patients were treated (HF-RT:15, CF-RT:26). For both HF-RT and CF-RT groups, median age was 58 years and 80-90% were ECOG 0-1. There were more methylated tumours in the HF-RT group. All patients received concurrent/adjuvant temozolomide. At 19.2 months median follow-up, median OS was 19.8 months and not-reached for HF-RT and CF-RT (p = 0.5), and median PFS was 7.7 and 5.8 months, respectively (p = 0.8). HF-RT or CF-RT did not influence OS/PFS on univariable analysis. Grade 3 radionecrosis rate was 6.7% and 7.7%, respectively. 15 of 1135 studies screened from a systematic search were eligible for meta-analysis. For studies involving temozolomide, pooled median OS and PFS with HF-RT were 17.5 and 9.9 months (927 and 862 patients). Studies using shortened HF-RT schedules reported 0-2% Grade 3 radionecrosis rates. CONCLUSION: HF-RT may offer equivalent outcomes and reduce treatment burden compared to CF-RT in young, fit GBM patients.

10.
American Journal of Transplantation ; 22(Supplement 3):948, 2022.
Article in English | EMBASE | ID: covidwho-2063503

ABSTRACT

Purpose: Currently there are no UNOS guidelines regarding the selection criteria required for simultaneous heart-kidney transplant recipients (SHKT). As of 2018 our center has begun performing these dual transplants for appropriate candidates. We report on the criteria devised to guide SHKT candidate selection at our institution and the subsequent clinical outcomes. Method(s): This is a single center, retrospective study of 26 patients who received SHKT at our institution from Dec 2018 to Oct 2021. A multidisciplinary team composed of heart and kidney transplant medical and surgical members determined appropriate recipient-donor SHKT candidate pairs. Selection criteria for SHKT was established by our kidney transplant group and included an evaluation for chronic kidney disease (CKD) or evidence of acute kidney injury (AKI) with a prolonged course or requiring renal replacement therapy (RRT). The surgery was conducted according to our institution's standardized protocols. The majority of patients received IL2-RA and methylprednisolone induction therapy, and all patients received triple immunosuppression therapy with prednisone, mycophenolate mofetil and tacrolimus. Adjustments in long term therapy were made in collaboration between the heart and kidney transplant teams. Result(s): From Dec 2018 to Oct 2021, 26 patients underwent SHKT at our institution. 24 patients (92%) carried a diagnosis of chronic kidney disease (CKD) as defined as an eGFR <60 ml/min/1.73m2 for at least 90 days on at least two separate tests. Clinical risk factors for CKD, the presence of proteinuria, and renal imaging data were also taken into consideration when determining a diagnosis of CKD. Two patients (8%) carried a diagnosis of stage III AKI for at least 4 weeks and required renal replacement therapy during their hospital course. Of our 26 patients, one patient received a DCD donor and 12 patients (46%) received hepatitis C donors. 25 patients (96%) received induction therapy with IL2-RA. During the first 3 months post-transplant, the only patient who received ATG had 7 severe infections;11 patients (44%) and 13 patients (52%) who received IL2 -RA had no infections and <= 4 mild infections, respectively. One patient died due to COVID 19 pneumonia complicated by multisystem organ failure. For a median follow up period of 410 (187-707) days, 8% patients in the IL2-RA induction cohort experienced a 2R/3A heart rejection, 8% patients remained on HD due to primary kidney graft nonfunction, and the survival rate was 96%. Conclusion(s): UNOS guidelines regarding selection criteria for SHKT are an important next step in the care of heart transplant candidates with kidney disease, particularly as the number of SHKT performed yearly increase. Compared to the literature, our data supports the use of standardized criteria for SHKT selection and the use of IL2- RA as an induction strategy with excellent patient survival.

11.
American Journal of Transplantation ; 22(Supplement 3):720, 2022.
Article in English | EMBASE | ID: covidwho-2063497

ABSTRACT

Purpose: Liver transplant recipients have a high risk of developing postoperative pulmonary complications. Pulmonary function tests (PFTs) are expensive and often incapable of predicting patients at risk or improving patient outcomes, thus a single-center implemented specific criteria to determine when a PFT is administered for the evaluation of patients for liver transplantation. The protocol recommends a PFT for patients with a history of chronic lung disease, recurrent pneumonia prior to transplant, symptomatic COVID-19 requiring hospitalization, tobacco abuse, alpha-1 antitrypsin positivity, or oxygen dependency. Method(s): We conducted a retrospective cohort study of consecutive adult patients (age greater than 18 years) who underwent deceased donor liver transplantation from January 1, 2020, to June 30, 2021. We analyzed results from pre-protocol (PRE) and post-protocol (POST) implementation. Result(s): There were a total of 215 patients in the study, 186 PRE and 29 POST protocol implementation. In the PRE group, 168 (90%) patients received PFTs compared to 12 (41%) in the POST group, p<0.001). There was no difference between the PRE and POST groups based on age in years (56 vs 55, p=0.713), male gender (65% vs 662%, p=0.83), White race (80% vs 86%, p=0.15), BMI (34 vs 28, p=0.107), or cold ischemic time in hours (5.7 vs 6, p=0.252). There was no difference in FVC (3.3 vs 3.0, p=0.84), FEV1 (2.6 vs 2.2, p=0.87), FEV1/FVC% (76.9 vs 74.4, p=0.47) and DLCO (16.4 vs 13.8, p=0.11). The postoperative variables were the same for both groups with time to extubation hours (25 vs 31, p=0.26), ICU length of stay days (8 vs 10, p=0.12), and transplant admission length of stay days (14.4 vs 17.4, p=0.36). Lastly, there was no difference between PRE and POST graft survival (p=0.69) or patient survival (p=0.08). Conclusion(s): This study demonstrates the successful implementation of a PFT protocol with a cost savings of roughly $38,000 in just three months with no impact on patient outcomes. Further research is indicated for broad-scale implementation.

12.
American Journal of Transplantation ; 22(Supplement 3):1069, 2022.
Article in English | EMBASE | ID: covidwho-2063450

ABSTRACT

Purpose: Increasing mismatch between kidneys available for transplant and the number of patients on the transplant wait list has led to research into novel sources of organs. One such source is kidneys from hepatitis C NAT positive deceased donors. This was previously deemed unforbidden territory due to the risk of disease transmission;however, with the development of direct-acting antiviral agents for effective treatment of Hepatitis C, this organ pool is now usable. Method(s): A retrospective analysis of outcomes of Hepatitis C NAT positive kidney transplants into Hepatitis C seronegative recipients was conducted at newly opened Appalachian transplant center. Due to insurance constraints, the criteria to initiate hepatitis C therapy was seroconversion to positive Hepatitis C PCR. Outcomes examined include median creatinine, glomerular filtration rate (GFR), liver function tests, recipient Hepatitis C seroconversion, concomitant Ebstein Barr virus (EBV), Cytomegalovirus (CMV) or polyoma hominis (BK) activation, morbidities and mortality. Result(s): Six transplants (of 15 total kidney transplants) from Hepatitis C NAT positive donors were performed in the first year of establishment. Male to female ratio was 2:1 and median patient age was 55.7 years (Range 42-73 years). Median follow-up was 10 months (Range 2-12 months). Diabetes and hypertensive nephrosclerosis were the most common causes of end stage renal disease at 40%. The average time on dialysis was 2.9 years (Range 1-6 years), the most common type being hemodialysis (67%) followed by peritoneal dialysis (33%). Average time on transplant waitlist was 5.57 months (Range 1.2-13.2 months). All patients seroconverted but with treatment, by 24 weeks all patients maintained undetectable viral loads. Patient survival rate was 83% with a death censored graft survival rate of 100%. One patient died due to respiratory failure from COVID-19 infection. Median creatinine and GFr were 1.96 mg/dL (Range 1.8 - 2.6 mg/dL) and 41.3 (Range 35.3 - 50) respectively. One case each of acute antibody and T cell mediated rejection was seen (6.7%), which were treated successfully. CMV, BK and EBV virus reactivation were seen in one patient each (6.7%). The most common complication was COVID-19 infection (50%) followed by neutropenia (33%). Conclusion(s): With the development of direct-acting antiviral agents offering complete cure of Hepatitis C, kidneys from Hepatitis C positive donors can be used for transplantation with excellent outcomes.

13.
American Journal of Transplantation ; 22(Supplement 3):992, 2022.
Article in English | EMBASE | ID: covidwho-2063425

ABSTRACT

Purpose: Lung transplant is the last resort for COVID-19 refractory ARDS. Dual organ transplant is seen as a relative contraindication at many institutions. We describe a case of simultaneous Lung-Kidney transplant (SLK) in a patient with COVID-19 ARDS. Method(s): A 24-year-old patient with no PMH presented to an outside hospital with a week of shortness of breath, cough, and fever. Despite treatment with Remdesivir and dexamethasone, the patient developed hypoxemic respiratory failure with acute renal injury requiring ICU care and intubation, V-V ECMO, and dialysis. Additionally, Intravenous and inhaled Aviptadil were given under emergency use authorization. While oxygenation improved, the patient could not be weaned off ECMO. With a LAS score of 90.29, the patient underwent an SLK transplant on HD 53, requiring standard induction and maintenance immunosuppression therapy. The patient was treated post-operatively for PGD as well as for subclinical AMR. After successful inpatient rehabilitation, the patient was discharged home after four months and had a one-month follow-up on room air and normal creatinine clearance. Result(s): Patients with pre-existing renal dysfunction who have undergone lung transplants have a significantly higher one- and three-year mortality than patients with normal GFR. The patient's survival after SLK was similar to isolated lung transplants at one and five years, according to an analysis of the UNOS/OPTN database. Still, dual organ transplant in the COVID-19 ARDS population is considered a contraindication at many centers, given these patients' critical illness and frailty. However, the frailty in this population is reversible due to the rapid onset of disease in an otherwise previously healthy younger population with minimal comorbidities. Thus, multiorgan transplantation should be considered in such a patient population. Our patient received Aviptadil as part of an EIND to stabilize patients and improve oxygenation while waiting on the transplant list. Conclusion(s): We propose that SLK transplantation should be considered for carefully selected patients with COVID-19 ARDS.

14.
American Journal of Transplantation ; 22(Supplement 3):1110, 2022.
Article in English | EMBASE | ID: covidwho-2063405

ABSTRACT

Purpose: Kidney transplantation has become the optimal treatment for end stage renal disease (ESRD), allowing dialysis free survival. Despite widespread availability of transplant programs;rural patients have limited access to transplantation due to several barriers including increased travel time and financial burden. We report outcomes after establishment of a kidney transplant program serving rural West Virginia. Method(s): A retrospective review of the first 15 kidney transplants performed at a newly established Appalachian transplant program was conducted. Primary outcomes measured were graft survival and function. Other outcomes included graft rejection, patient survival and complications. Data related to patient demographics, etiology of ESRD, type of renal replacement therapy, time on transplant waitlist and average travel to transplant center were also collected. Result(s): The first 15 kidneys transplanted had an overall death censored graft survival rate of 100%. Median patient age was 53 (Range 31- 73 years) and a median follow-up of 6 months (Range 1-13 months). The average time on dialysis for this cohort was 4 years (n=13, Range 1-6 years) and average time on waitlist was 4.06 months (Range 0.4-13.2 months). The most common type of dialysis was hemodialysis (77%) followed by peritoneal dialysis (15%). Two patients were predialysis. Diabetes with hypertension (20%), IgA nephropathy (13%) and diabetes without hypertension (13%) were the most common causes of ESRD. Median graft creatinine was 1.51 mg/dL (Range 1.26 - 1.83 mg/dL) with a glomerular filtration rate (GFR) at 51.38 (Range 41.86-70) at one year. One patient developed acute antibody mediated rejection and one developed borderline T cell mediated rejection (13.3%), which were successfully treated with steroids, plasmapheresis and immune globulin therapy. Two patients died (13.3 %);one from acute respiratory failure following coronavirus (COVID-19) infection and one from cardiac arrest secondary to myocarditis (possible COVID-19). Patients experienced COVID-19 infection at a rate of 13.3 %. The average distance patients had to travel was 94 miles (Range 12 - 164 miles) with a travel time of 1 hour and 52 minutes on average (Range 20 minutes - 2.5 hours) to reach the transplant center. Conclusion(s): We report comparable outcomes from our new rural transplant program despite several barriers to delivery of quality care to our population.

15.
American Journal of Transplantation ; 22(Supplement 3):472-473, 2022.
Article in English | EMBASE | ID: covidwho-2063355

ABSTRACT

Purpose: Acuity circles (AC) allocation was implemented on 2/4/2020 with a goal of removing DSA and region from liver allocation and broadening the distribution of livers, particularly for highly medically urgent candidates. Method(s): OPTN waitlist and transplant data was analyzed 18 months pre- (8/6/2018- 2/3/2020) and post- (2/4/2020-8/3/2021) AC implementation. Result(s): Post-policy, there were 448 more adult (age 18+ at listing) and 83 less pediatric (<18 at listing) waitlist additions, 570 more adult (age 18+ at transplant) and 4 less pediatric (<18 at transplant) deceased donor liver-alone transplants, and 121 less adult and 12 less pediatric removals for death or too sick. Transplant rates significantly increased overall post-policy, notably in the most medically urgent groups (Figure 1). The national median transplant score for adults remained unchanged at 28 and decreased from 35 to 30 for pediatric transplant recipients, likely due to the increased number of adolescents (age 12-17) transplanted at MELD scores under 29. There was a noticeable shift in the distribution of distance between donor hospital and transplant program, particularly for the most medically urgent groups where larger proportions of livers are coming from 250-500 NMs (Figure 2). Despite this change, median cold ischemia time increased only 11 minutes for adult recipients and 33 minutes for pediatric recipients post-policy. One year post transplant patient survival decreased from 94% pre-policy to 93% post-policy (p=0.02). Conclusion(s): Broader allocation increased transplant rates and livers are traveling longer distances for candidates with greater medical urgency with little effect on cold ischemia time and post-transplant survival. Unfortunately, AC implementation was followed shortly by COVID-19 making it difficult to parse out COVID-19 from potential policy effects. Metrics will continue to be monitored as more data become available. (Figure Presented).

16.
Chest ; 162(4):A925, 2022.
Article in English | EMBASE | ID: covidwho-2060729

ABSTRACT

SESSION TITLE: ECMO and ARDS in COVID-19 Infections SESSION TYPE: Rapid Fire Original Inv PRESENTED ON: 10/17/2022 12:15 pm - 1:15 pm PURPOSE: To compare characteristics and outcomes of COVID-19 patients with respiratory failure meeting ECMO eligibility criteria who received ECMO vs. conventional therapy (CT) alone. METHODS: Retrospective analysis of COVID-19 patients (admitted April 2020 -December 2021) meeting ECMO eligibility criteria (PaO2/FiO2 <50 for more than 3 hours, PaO2/FiO2 < 80 for more than 6 hours, or pH < 7.25 with a pCO2 of at least 60 mm Hg for more than 6 hours within the first 7 days of mechanical ventilation (MV)) was performed. All patients received optimal therapies according to current guidelines. Due to the criteria evolution over the course of the pandemic, two intensivists confirmed eligibility by independent chart review. Differences between CT and ECMO groups were analyzed using Chi-square, Fisher’s exact, and Wilcoxon rank-sum tests as appropriate. RESULTS: 62 patients met ECMO eligibility criteria, and 20 of them received CT alone. Reasons for not receiving ECMO included high BMI, comorbid conditions, improving gas exchange, or treatment team preference. CT patients had higher BMI (39.0 vs. 32.5, p=0.01), higher incidence of acute kidney injury (70% vs. 42.9%, p=0.05), and lower prevalence of current smoking (10% vs. 33%) compared to ECMO patients. In-hospital mortality for CT was 60% vs. 47.6% for ECMO (p= 0.36). Overall, CT patients had a significantly shorter duration of MV, ICU and hospital length of stay (LOS) than ECMO patients (18.0 vs. 41.0, 19.0 vs. 44.5, and 18.0 vs. 49 days respectively, p< 0.001). CT survivors had a shorter duration of MV, and shorter ICU and hospital LOS than ECMO survivors (23.5 vs. 44.5, 25.0 vs. 52.0, 31.5 vs. 56.0 days respectively, p <0.05). Among CT patients, survivors were younger (38.5 vs. 55, p=0.01), had higher P/F ratio (66.0 vs. 53.5, p=0.05), and lower pCO2 (71.5 vs. 86.0, p= 0.02) during the first week of MV than non-survivors. Respiratory acidosis was the principal ECMO eligibility criteria in 50% of CT survivors and 8.3% of non-survivors. CONCLUSIONS: The difference in mortality between ECMO-eligible patients treated with ECMO vs. CT alone didn’t reach statistical significance, possibly due to small sample size. ECMO was associated with a longer duration of MV, and ICU and hospital LOS. In CT patients, younger age and less severe oxygenation and ventilation abnormalities were associated with survival. Observed survival differences in relation to respiratory acidosis vs. hypoxemia as the main ECMO indication require confirmation. CLINICAL IMPLICATIONS: A significant number of patients meeting ECMO eligibility criteria survived with CT alone. ECMO is resource-intensive and is not universally available, especially at the peaks of the pandemic. We demonstrate characteristics of survivors receiving CT alone which may help further refine ECMO indications in COVID-19 patients. DISCLOSURES: No relevant relationships by Roman Melamed No relevant relationships by Ramiro Saavedra Romero No relevant relationships by Lynn Sipsey No relevant relationships by Ashley Stenzel No relevant relationships by David Tierney

17.
Chest ; 162(4):A319, 2022.
Article in English | EMBASE | ID: covidwho-2060563

ABSTRACT

SESSION TITLE: Critical Care in Chest Infections Case Report Posters 2 SESSION TYPE: Case Report Posters PRESENTED ON: 10/17/2022 12:15 pm - 01:15 pm INTRODUCTION: During the COVID-19 pandemic, acute respiratory distress syndrome (ARDS) was a very common presentation. Many clinicians sought to rule out COVID-19 in those presenting with hypoxia and shortness of breath due to the importance of triage and quarantining infected individuals and those under investigation. As a result, delay in diagnosis of other viral and bacterial pathogens occurred. There is a known but rare overlapping of disease processes and sometimes even co-infections with COVID-19 and Pneumocystis jirovecii pneumonia (PJP) which made narrowing the differential challenging [1,2]. We present a case of a patient with known HIV who presented with typical features of COVID-19 and clinically worsened. Further investigation revealed PJP and AIDS. CASE PRESENTATION: A 55-year-old female with a past medical history of human immunodeficiency virus (HIV), previously controlled on highly active antiretroviral therapy (HAART), presented with shortness of breath, cough, and syncope. She required sedation and mechanical ventilation following significant hypoxia on admission. Chest radiograph and computed tomography (CT) were concerning for acute respiratory distress syndrome (ARDS) with diffuse bilateral ground glass opacities (Figure 1 and Figure 2) and she was found to be in septic shock requiring vasopressors. She presented during the COVID-19 pandemic and it was initially thought to be the cause of her condition, however she repeatedly tested negative via polymerase chain reaction (PCR). Through further investigation, it was found that her total cluster of differentiation 4 (CD4) cell count was 184/??L, posing a risk for opportunistic infections. Prior records indicated her last CD4 count was greater than 250/??L. Bronchoscopy showed progressively darker-tinged aliquots significant for diffuse alveolar hemorrhage that stained positive for Pneumocystis jirovecii pneumonia (PJP). She was treated with appropriate antimicrobial therapy, eventually weaned from ventilation, and transferred to the floor despite her high risk of morbidity and mortality [3]. DISCUSSION: This clinical case demonstrates PJP infection in an individual with features on imaging nearly identical to those of COVID-19 during the pandemic. There is a strong role in verifying CD4 count and HIV viral level in those affected with HIV with reported medication adherence who present with critical illness. There should be a low threshold to perform bronchoscopy in patients with ARDS and negative COVID-19 if no known source is identified. CONCLUSIONS: It is important to consider all causes of ARDS in patients who are immunocompromised with a low threshold to test for and treat uncommon causes, such as opportunistic infections, because the treatment should be directed at the underlying cause. Reference #1: Coleman, H., Snell, L., Simons, R., Douthwaite, S. and Lee, M., 2020. Coronavirus disease 2019 and Pneumocystis jirovecii pneumonia: a diagnostic dilemma in HIV. AIDS, 34(8), pp.1258-1260. Reference #2: Menon, A., Berg, D., Brea, E., Deutsch, A., Kidia, K., Thurber, E., Polsky, S., Yeh, T., Duskin, J., Holliday, A., Gay, E. and Fredenburgh, L., 2020. A Case of COVID-19 and Pneumocystis jirovecii Coinfection. American Journal of Respiratory and Critical Care Medicine, 202(1), pp.136-138. Reference #3: Dworkin, M., Hanson, D. and Navin, T., 2001. Survival of Patients with AIDS, after Diagnosis of Pneumocystis carinii Pneumonia, in the United States. The Journal of Infectious Diseases, 183(9), pp.1409-1412. DISCLOSURES: No relevant relationships by salah alandary No relevant relationships by Joella Lambert No relevant relationships by Joshua Lung

18.
ASAIO Journal ; 68(Supplement 3):61, 2022.
Article in English | EMBASE | ID: covidwho-2058514

ABSTRACT

Objective: The motto Cannulate, Extubate, Ambulate reflects the care ECMO patients receive at West Virginia University Medicine. Early mobility, crucial in our outcomes, especially with the COVID-19 population, is started with a Physical Therapist. This is followed by all team members participating in ECMO mobilization. This project examined the impact of mobilization for our COVID+ population placed on VV ECMO. Method(s): A WVU retrospective review was completed of COVID-19+ patients on ECMO between 3/2020 and 12/2021, determining survival to decannulation and discharge location. Mobility was examined for ECMOday of first active participation, first active transfer out of bed, and first ambulation. Further, PT sessions during cannulation, total PT, staff assist mobility while cannulated, and total number of sessions during admission. All patients who survived to discharge were included in survival rate, but those transferred to outside facilities for ECMO management were excluded from mobility and discharge location analyses. Result(s): Out of 91 patients, 70% successfully decannulated, and 98.4% survived to discharge. Mobilization began day 1 of ECMO, averaging 7.6 sessions/patient during their hospitalization. 88% performed their first active transfers with PT assist. Mobility sessions were also performed by Nursing/ECMO Specialists (3.6 times vs. 2.8 times). Total active mobilizations ranged 2-69 sessions, averaging 13.9 mobilizations during hospitalization. 60% of COVID-19 ECMO survivors were discharged home. Conclusion(s): Physical therapists lead mobility efforts, however, active involvement of nursing and ECMO Specialists is vital to provide continuity and repetition of mobility. Our results suggest teamwork improves patient survival and other important outcomes.

19.
ASAIO Journal ; 68(Supplement 3):66, 2022.
Article in English | EMBASE | ID: covidwho-2058241

ABSTRACT

Purpose: We report the clinical outcomes of an Adult Respiratory ECMO (VV-ECMO) program that was rapidly established in a community hospital within a 4-week period. The program was launched in response to increasing patients presenting with acute respiratory failure due to COVID-19. Method(s): Our institution supported urgent preparedness to add VVECMO therapy to our established, nurse-run Adult VA-ECMO program. ICU nurses were trained to run VV-ECMO through interdisciplinary collaboration with neonatal-pediatric ECMO nurses, cardiac perfusionists, providers (NP, PA), respiratory therapists, and physicians. Retrospective data of VV-ECMO therapy was collected between November 2020 and June 2022. Result(s): 29 patients with ARDS due to COVID-19 received VV-ECMO. Of the 29 patients were 23 males and 6 females, of median age 48 (31-59) years and median body mass index (BMI) 31.4 kg/m2 (20.5-49.2). The mean duration of VV-ECMO was 970 hours (44.1 days) and the longest run time was 2752 hours (114.6 days). Patient survival rate to VV-ECMO explant was 66%. Patient survival to discharge with a return to pre-ECMO functional capacity was 55%, defined as supplemental oxygen requirements less than 3L nasal cannula and rehabilitating to activities of daily living. Conclusion(s): In the setting of the COVID-19 pandemic, an Adult VV-ECMO program was rapidly developed and executed in an advanced community hospital system. Our VV-ECMO program results are comparable to programs at major academic centers, with survival rates on par with statistics reported by the ELSO registry. Additionally, our outcomes demonstrate that a nurse-run VV-ECMO program can be both feasible and successful.

20.
ASAIO Journal ; 68(Supplement 3):26, 2022.
Article in English | EMBASE | ID: covidwho-2058110

ABSTRACT

Background: Mortality for patients receiving extracorporeal membrane oxygenation (ECMO) for COVID-19 has increased over time. We investigated the association between immunomodulators and mortality for patients receiving ECMO for COVID-19. Method(s): We analysed the Extracorporeal Life Support Organisation Registry from Jan 1, 2020 through Dec 31, 2021, comparing in-hospital mortality and the overall survival since ECMO initiation of patients who did and did not receive immunomodulators (selective interleukin blockers, corticosteroids, janus-kinase inhibitors, convalescent plasma, and intravenous immunoglobulins) before or during ECMO, by using logistic regression and Cox regression. We calculated the propensity scores, and applied the overlap-weightage method to account for confounding factors. We conducted sensitivity analyses including regression models using inverse propensity score weightage method, models adjusted by propensity score, and unadjusted models to ensure robustness of results. A subgroup analysis on patients receiving corticosteroids was conducted. Result(s): 7180 patients were included in the final analysis. Immunomodulators were associated with increased mortality (OR: 1.168, 95%CI: 1.059-1.289, p=0.0020) and shorter survival since ECMO (HR: 1.05, 95%- CI: 1.078, 95%CI: 1.007-1.154, p=0.031). Similarly, corticosteroids were associated with a significant increase in mortality (OR: 1.302, 95%-CI: 1.180-1.437, p<0.0001) and shorter survival (HR: 1.221, 95%-CI: 1.139- 1.308, p<0.0001). Sensitivity analyses did not significantly change the overall results. Conclusion(s): Immunomodulators and corticosteroids, in particular, were associated with a significant increase in mortality amongst patients receiving ECMO for COVID-19, even after adjusting for potential confounding variables. Further studies are required to evaluate the timing of immunomodulators and understand the possible mechanisms behind this association.

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