Evaluation of Bladder Cancer Patients' Utilization of Urologic Telehealth Services

INTRODUCTION AND OBJECTIVE: Infection control practices and public policy in response to the COVID-19 pandemic shifted healthcare practices towards a telemedicine format. Even two years after peak onset of the pandemic, many clinics, including our own institution, maintain a working telehealth option for patient visits, with some patients even preferring this modality of care delivery. Our objective was to evaluate patient utilization of telehealth visits versus inperson visits at our institution and whether this was impacted by demographics, medical history, and socioeconomic factors. METHOD(S): Medical Record Numbers for all patients with bladder cancer were pulled via accessible billing-level data from the period 7/1/2019-2/28/2022. Chart review was conducted to pull clinical data on patients including telehealth versus in person visits, demographic data, clinical stage, comorbidities (diabetes, smoking status, BMI), rural/urban status by zip code (>50,000, <50,000 individuals) and income levels by zip code (25K-49.9K, 50K-99.9K, <100K), payor status, patient distance, and gas savings/carbon footprint. RESULT(S): 430 patients completed in person visits while 268 completed telehealth visits. There was no statistically significant difference for in person visits vs. telehealth visits regarding patients' race (p=0.541), ethnicity (p=0.394) age (p=0.862), urban/rural status (p=0.507), payor status (p=0.127), mean zip code income (p=0.175), and comorbidities (p=0.626 for diabetes, p=0.706 for smoking, p=0.459 for BMI), and clinical stage (p=0.07). There was a statistically significant difference in mean distance (14.85 miles versus 26.86 miles, p<0.01). CONCLUSION(S): Post-pandemic, telehealth usage and acceptability among patients with bladder cancer remains high. Patients' with bladder cancer receive care from their urologist via in person visits versus telehealth at similar rates irrespective of their urban/rural status, demographics, payor status, relevant comorbidities, or relative income. Patients are more likely to engage in care with their urologist via telehealth if they live farther from a large urban academic center, which produces an economical and environmental impact via gas/time savings and reduced carbon footprint.

Content Validation of Patient-Reported Sleep Measures and Development of a Conceptual Model of Sleep Disturbance in Patients with Moderate-to-Severe, Uncontrolled Asthma.

Purpose: Sleep disturbance is common in patients with asthma and can lead to subsequent impacts on health-related quality of life (HRQOL). Fit-for-purpose patient-reported outcome measures (PROMs) assessing asthma-related sleep disturbance and next-day HRQOL impact (next-day impact) are needed to evaluate disease burden and treatment effects. Patients and Methods: Adults (18-65 years) from three US clinics were recruited for semistructured interviews. Concept elicitation (CE) identified how asthma affects participants' sleep and how asthma-related sleep disturbances impact their daily lives, which informed conceptual model development. Cognitive debriefing (CD) of the Asthma Sleep Disturbance Questionnaire (ASDQ), Sleep Diary, and Patient-Reported Outcomes Measurement Information System Sleep-Related Impairment Short Form 8a (PROMIS SRI SF8a) was completed to assess each measure's content validity. Results: Twelve individuals participated in two interview rounds (6 individuals per round). Participants most frequently reported asthma-related nighttime awakening and decreased sleep quality and duration. Negative impacts of a poor night's sleep due to asthma symptoms included feeling tired/fatigue/lack of energy and subsequent negative impacts on physical functioning, emotions and mood, mental functioning, work or volunteerism, and social functioning. Across both rounds of CD interviews, participants generally found the Sleep Diary and PROMIS SRI SF8a items relevant and easy to complete with no modifications. The ASDQ was modified for clarity and consistency. Conclusion: As described in the conceptual model, asthma affects multiple aspects of sleep that can cause next-day fatigue and other subsequent negative HRQOL impacts. This study demonstrates that the ASDQ, Sleep Diary, and PROMIS SRI SF8a items are comprehensive, relevant, and appropriate for patients with moderate-to-severe, uncontrolled asthma. Evaluation of psychometric properties for the ASDQ, Sleep Diary, and PROMIS SRI SF8a based on clinical trial data in patients with moderate-to-severe, uncontrolled asthma will further support their use.

Comparing the effect of strict versus routine awake prone positioning among patients hospitalized with COVID-19

Background: In patients with moderate to severe coronavirus disease 2019 (COVID-19), awake prone positioning improves oxygenation and clinical outcome. Despite prone positioning incorporated in the protocol, it's not followed in true letter and spirit. Aims and objectives: The objective of this study was to compare the effect of strict versus routine awake proning among patients hospitalized with Covid-19. Method(s): PCR positive COVID-19 patients admitted to the Khyber Teaching Hospital Peshawar's isolation unit were randomly allocated to 2 groups, Group A prone positioning (PP) was ensured for at least 12 hours by helping proning during rounds by the respiratory therapists and nurses. Further, prone positioning was ensured by the use of telemedicine, whereas Group B just followed the standard care in which awake proning was emphasized on a routine basis without doing any intervention. Their biochemical and clinical parameters, outcomes related to oxygen requirement, intubation, and mortality were followed weekly for two weeks or till discharge. Result(s): Out of the 58 patients, 29 patients with PP had a better outcome in terms of oxygenation (p<0.01), respiratory rate (P<0.05), and inflammatory markers such as serum ferritin (p<0.02) and C reactive protein (p<0.03). Additionally, ventilatory support (18% VS 42%, p<0.05) and mortality rate 21.4% Vs 64.3%) were significantly lower in the PP group. Conclusion(s): Strict compliance of awake prone positioning improved oxygenation in COVID-19 patients, resulting in a clinically better outcome.

Colchicine anti-inflammatory therapy for non-intensive care unit hospitalized COVID-19 patients: results from a pilot open-label, randomized controlled clinical trial.

Systemic inflammation is a hallmark of severe coronavirus disease-19 (COVID-19). Anti-inflammatory therapy is considered crucial to modulate the hyperinflammatory response (cytokine storm) in hospitalized COVID-19 patients. There is currently no specific, conclusively proven, cost-efficient, and worldwide available anti-inflammatory therapy available to treat COVID-19 patients with cytokine storm. The present study aimed to investigate the treatment benefit of oral colchicine for hospitalized COVID-19 patients with suspected cytokine storm. Colchicine is an approved drug and possesses multiple anti-inflammatory mechanisms. This was a pilot, open-label randomized controlled clinical trial comparing standard of care (SOC) plus oral colchicine (colchicine arm) vs. SOC alone (control arm) in non-ICU hospitalized COVID-19 patients with suspected cytokine storm. Colchicine treatment was initiated within first 48 hours of admission delivered at 1.5 mg loading dose, followed by 0.5 mg b.i.d. for next 6 days and 0.5 mg q.d. for the second week. A total of 96 patients were randomly allocated to the colchicine (n=48) and control groups (n=48). Both colchicine and control group patients experienced similar clinical outcomes by day 14 of hospitalization. Treatment outcome by day 14 in colchicine vs control arm: recovered and discharged alive: 36 (75.0%) vs. 37 (77.1%), remain admitted after 14-days: 4 (8.3%) vs. 5 (10.4%), ICU transferred: 4 (8.3%) vs. 3 (6.3%), and mortality: 4 (8.3%) vs. 3 (6.3%). The speed of improvement of COVID-19 acute symptoms including shortness of breath, fever, cough, the need of supplementary oxygen, and oxygen saturation level, was almost identical in the two groups. Length of hospitalization was on average 1.5 day shorter in the colchicine group. There was no evidence for a difference between the two groups in the follow-up serum levels of inflammatory biomarkers including C-reactive protein (CRP), D-dimer, lactate dehydrogenase (LDH), ferritin, interleukin-6 (IL-6), high-sensitivity troponin T (hs-TnT) and N-terminal pro b-type natriuretic peptide (NT pro-BNP). According to the results of our study, oral colchicine does not appear to show clinical benefits in non-ICU hospitalized COVID-19 patients with suspected cytokine storm. It is possible that the anti-inflammatory pathways of colchicine are not crucially involved in the pathogenesis of COVID-19.

COVID-19 COMPLICATED BY THE INVASION OF ASPERGILLUS TERREUS

TOPIC: Chest Infections TYPE: Medical Student/Resident Case Reports INTRODUCTION: Coronavirus associated pulmonary aspergillosis (CAPA) appears to be emerging on a global scale. Studies have consistently indicated that CAPA is associated with significantly higher mortality rates, when compared to patients with COVID-19 alone [1]. Unfortunately, definitive guidelines regarding the surveillance, diagnosis, & treatment of CAPA are currently lacking. CASE PRESENTATION: A 59 year old male with hypertension & diabetes presented with dyspnea & cough. On arrival, he was initially afebrile, though hypoxic & tachycardic. He tested positive for COVID-19 & influenza B on admission. Dexamethasone & remdesivir were initiated, along with oseltamivir & empiric antibiotics. CT of the chest was notable for bilateral ground glass opacities. On hospital day 11, he developed respiratory failure on BiPAP therapy, prompting intubation & ICU transfer. He subsequently succumbed to septic shock requiring hemodynamic support. Given concern for bacterial superinfection, antibiotic therapies were escalated. Despite the initial defervescence, he continued to have persistent febrile recrudescence. Blood & sputum cultures remained negative. He ultimately required tracheostomy and PEG tube placement. On day 38, his lower respiratory culture revealed growth of Aspergillus terreus. Voriconazole was initiated. On day 43, his fever returned again. Repeat CT of the chest revealed progressive fibrosis, with a cavitation in the right lower lung. He remained ventilator dependent, given his persistently high FiO2 requirements. On day 52, he became markedly hypoxemic with copious mucoid secretions, prompting emergent bronchoscopy. Despite clearance, he eventually became bradycardic & developed PEA arrest. The patient ultimately expired. DISCUSSION: CAPA remains a diagnostic challenge, fraught by logistical burdens & a variety of crudely defined criteria. Cases may currently be underreported, undertreated, or clinically overlooked. Obscure species such as A. terreus are of particular concern, given the proposed lethality of this strain & it's widely reported resistance to amphotericin B [3]. Unfortunately, guidelines for the surveillance of superinfections are currently insufficient. This is troublesome, considering the well documented risk of invasive pulmonary aspergillosis with the use of immunosuppressive agents, such as tocilizumab & corticosteroids [2]. Co-infection with influenza may augment this risk further. CONCLUSIONS: CAPA presents clinicians with a multitude of clinical uncertainties, which necessitate further analysis & investigation. Given the heightened risk of mortality, we propose a lower threshold for the suspicion, diagnosis & treatment of CAPA in patients with refractory respiratory distress, and/or febrile recrudescence despite the appropriate therapies. Surveillance should be particularly stringent, in those treated with immunosuppressive agents, or concomitantly diagnosed with influenza. REFERENCE #1: Apostolopoulou A, Esquer Garrigos Z, et al. Invasive Pulmonary Aspergillosis in Patients with SARS-CoV-2 Infection: A Systematic Review of the Literature. Diagnostics. 2020;10(10):807. REFERENCE #2: Koehler, P., Bassetti, M, et al. Defining and managing COVID-19-associated pulmonary aspergillosis: the 2020 ECMM/ISHAM consensus criteria for research and clinical guidance. The Lancet. Infectious diseases. 2020, Dec 20 REFERENCE #3: Steinbach, W, Benjamin, D, et al. Infections Due to Aspergillus terreus: A Multicenter Retrospective Analysis of 83 Cases, Clinical Infectious Diseases, Volume 39, Issue 2, 15 July 2004, Pages 192–198 DISCLOSURES: No relevant relationships by Huda Asif, source=Web Response No relevant relationships by Sunil Bali, source=Web Response No relevant relationships by Christopher Siriphand, source=Web Response No relevant relationships by Christopher Wood, source=Web Response

SARS-CoV-2 associated submassive pulmonary embolism even with the use of dabigatran

Introduction: The SARS-CoV-2 infection has been associated with a hypercoagulable state with a higher incidence of venous thromboembolic complications including deep venous thrombosis (DVT) and pulmonary embolisms (PE). The use of anticoagulation therapy has been suggested to prevent these complications with SARS-CoV-2 Infection. We present a case of submassive PE in the setting of SARS-CoV-2 infection while using, a direct thrombin inhibitor, dabigatran. Case Presentation: 69 y/o male with a history of DVT, on lifelong dabigatran (PRADAXA), presented with a worsening dry cough, dyspnea, chest pain, headache, nausea, and diarrhea for the past 3 days. The patient denied fever or known sick contact. He endorsed medication compliance with dabigatran 150 mg twice-daily dose. The social history was negative for smoking or illicit drug use. Initial blood work noted for high D-dimer, inflammatory markers like CRP and ferritin as well as high troponin, and pro-BNP with positive SARS-CoV-2 RT-PCR. CTA Chest showed right lower lobe patchy ground-glass opacities as well as large filling defects within the bilateral main pulmonary arteries representing acute bilateral PEs with CT evidence of right-sided cardiac strain (Figure-1). Lower extremities doppler ultrasound also showed acute DVT involving the right popliteal vein as well as partially occlusive DVT in the left superficial femoral vein and left popliteal vein. He was started on UF-heparin infusion for submissive PE. Given increased clot burden and evidence of right heart strain, he underwent successful catheter-directed thrombolysis by IR without complications. He also completed a course of Remdesivir and steroids (Decadron) for COVID-19 pneumonia. His respiratory status remained stable with minimal oxygen requirement and subsequently had negative SARS-CoV-2 RT-PCR. The patient was discharged home on long-term Apixaban anticoagulation therapy. Discussion: Dabigatran, a direct inhibitor of free and fibrin-bound thrombin, has been frequently used as an anticoagulation therapy for its good tolerance, predictable pharmacokinetics, and lack of necessity for coagulation monitoring. Dabigatran has been associated with a 92% reduction in the incidence of VTE in the general population. The SARS-CoV-2 infection has been reported for a higher incidence of 23% of VTE compared to non-SARS-CoV-2 critically ill patients. Our patient presented with submassive PE and DVT even with the use of a therapeutic dose of dabigatran in the setting of SARS-CoV-2 infection. This raises the concern about the anticoagulation effect of direct thrombin inhibitors like dabigatran with SARS-CoV-2 infection.

Role of immunoglobulin g (igg) against n-protein of severe acute respiratory syndrome coronavirus 2 (sars-cov2) in coronavirus disease 2019 (COVID19) clinical outcomes

RATIONALE: The Nucleocapsid Protein (N Protein) of severe acute respiratory syndrome Coronavirus 2 (SARSCoV2) is located in the viral core. Immunoglobulin G (IgG) targeting N protein is detectable in the serum of infected patients. The effect of high titers of IgG against N-protein on clinical outcomes of SARS-CoV2 disease has not been described. METHODS: We studied 400 RT-PCR confirmed SARS-CoV2 patients to determine independent factors associated with poor outcomes, including MICU admission, prolonged MICU stay, and hospital admissions, and in-hospital mortality. We also measured serum IgG against the N protein and correlated its concentrations with clinical outcomes. RESULTS: We found that several factors, including Charlson comorbidity Index (CCI), high levels of IL6, and presentation with dyspnea were associated with poor clinical outcomes. It was shown that higher CCI and higher IL6 levels were independently associated with in-hospital mortality. Anti-N protein IgG was detected in the serum of 55 (55%) patients at the time of admission. A high concentration of antibodies, defined as signal to cut off ratio (S/Co)> 1.5 (75 percentile of all measurements), was found in 25 (25%) patients. The multivariable logistic regression models showed that between being an African American, higher CCI, lymphocyte counts, and S/Co ratio> 1.5, only S/Co ratio were independently associated with MICU admission and longer length of stay in hospital. (Figure 1) CONCLUSION: This study recommends that titers of IgG targeting N-protein of SARS-CoV2 at admission is a prognostic factor for the clinical course of disease and should be measured in all patients with SARS-CoV2 infection.

Reactivation mycobacterium tuberculosis associated acute respiratory distress syndrome following COVID-19 infection

Introduction: Acute respiratory distress syndrome (ARDS) is rare sequela of Mycobacterium tuberculosis (MTb) associated with miliary MTb in setting of immunosuppression. To date, five cases have been reported with MTbassociated ARDS in absence of miliary type of disease. We present a case of reactivation MTb ARDS following recent self-limited COVID-19 infection in otherwise immunocompetent patient. Case presentation: Patient is an 18-year-old male immigrant from Guatemala with past medical history only for confirmed COVID-19 infection one month before initial presentation, not requiring hospital admission. He presented at outside hospital with 5-day history of dyspnea, fever, and cough productive of sputum. Blood cultures, COVID-19 PCR, HIV, and respiratory viral panel were negative;broad-spectrum empiric antibiotics were started. Initial CT chest revealed bilateral consolidation with necrotizing pneumonia and right upper lobe cavitation. He was subsequently intubated for worsening hypoxemic, hypercapnic respiratory failure. Despite paralysis and prone ventilation with lungprotective strategy, he continued to worsen clinically with refractory hypoxemia and hypercapnia;APACHE-II and SOFA scores were 22 and 11, respectively. Patient was transferred to our facility 4 days after initial presentation for consideration of extracorporeal membrane oxygenation (ECMO) support and was immediately placed on venovenous ECMO. Sputum AFB smear was positive, later confirmed to be pan-sensitive MTb by culture;bronchoalveolar lavage (BAL) was positive MTb by PCR and culture. Patient was started on rifampin, isoniazid, pyrazinamide, ethambutol within 48 hours of transfer. He was continued on vasopressor and inotrope support for shock, likely cardiogenic, with left ventricle ejection fraction of 35% and global hypokinesis. Hospital course was complicated by massive hemoptysis requiring bronchial artery embolization. On CT chest angiography, bilateral extensive near-complete airspace opacification with progressive cavitation was seen (see Figure 1). After 35 days on ECMO, patient continued to have no significant clinical improvement with persistent severe shock and multi-organ dysfunction syndrome. Palliative care was consulted. After discussion with family, ECMO support was withdrawn, and patient expired. Discussion: MTb-associated ARDS has a mortality of 60-80%. Early detection and initiation of antitubercular therapy are crucial in successful management. The presence of shock unrelated to sepsis is a poor prognostic factor, as seen in our patient. This case is unique given it is one of few reported cases of reactivated latent MTb after recovery from COVID-19 pneumonia. We postulate that the aggressive nature and rapidity of clinical decompensation of this patient's MTb ARDS may be related to altered immune host mechanisms following COVID-19 infection.