The sixth annual academic international medicine virtual congress and scientific forum, May 21–23, 2021: Best practices in shifting landscapes

Annelies De Wulf; Christina Bloem; Taryn Clark; Andrew C Miller; Michael S Firstenberg; Stanislaw P Stawicki; Bonnie Arquilla

doi:10.4103/IJAM.IJAM_154_21

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CONFERENCE ABSTRACTS AND REPORTS

Year : 2021 | Volume : 7 | Issue : 4 | Page : 252-306

The sixth annual academic international medicine virtual congress and scientific forum, May 21–23, 2021: Best practices in shifting landscapes

Annelies De Wulf, Christina Bloem, Taryn Clark, Andrew C Miller, Michael S Firstenberg, Stanislaw P Stawicki, Bonnie Arquilla
The Academic International Medicine 2021 Congress and Scientific Forum Planning Committee, The American College of Academic International Medicine, Bethlehem, PA, USA

Date of Submission	21-Nov-2021
Date of Acceptance	10-Dec-2021
Date of Web Publication	24-Dec-2021

Correspondence Address:
Dr. Annelies De Wulf
on behalf of ACAIM, Executive Leadership & AIM 2021 Planning Committee, Bethlehem, Pennsylvania
USA

Source of Support: None, Conflict of Interest: None

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DOI: 10.4103/IJAM.IJAM_154_21

Abstract

The COVID-19 pandemic continued to dominate the discourse within the Academic International Medicine (AIM) community during 2021. Although there were early signs of slow but steady pandemic recovery and the promise of “postpandemic world” was emerging, we were far from declaring victory in this healthcare battle of the century. What is certain is that our collective resilience and innovative spirit have never been more instrumental in alleviating the effects of a global calamity. With the goal of providing top-quality, highly relevant content for our membership, the American College of Academic International Medicine made a strategic decision in the late 2020 to move forward with Virtual 6th Annual Congress and Scientific Forum (AIM 2021). The theme of this year's meeting was “Best Practices in Shifting Landscapes” and reflected the rapidly changing environment we continue to operate in. Primary organization of the meeting was facilitated by the Louisiana State University Spirit of Charity Emergency Medicine Residency Program in New Orleans, with substantial contributions provided by the SUNY Downstate Medical Center team from Brooklyn, New York. The Scientific Forum was also transitioned to a virtual platform, enabling participants from around the globe to present their research. A summary of these efforts and outcomes is provided in this article.
The following core competencies are addressed in this article: Interpersonal and communication skills; Professionalism; Practice-based learning and improvement; Systems based practice.

Keywords: American College of Academic International Medicine, Academic International Medicine, annual meeting, scholarly output, scientific forum

How to cite this article:
De Wulf A, Bloem C, Clark T, Miller AC, Firstenberg MS, Stawicki SP, Arquilla B. The sixth annual academic international medicine virtual congress and scientific forum, May 21–23, 2021: Best practices in shifting landscapes. Int J Acad Med 2021;7:252-306

How to cite this URL:
De Wulf A, Bloem C, Clark T, Miller AC, Firstenberg MS, Stawicki SP, Arquilla B. The sixth annual academic international medicine virtual congress and scientific forum, May 21–23, 2021: Best practices in shifting landscapes. Int J Acad Med [serial online] 2021 [cited 2023 Jun 5];7:252-306. Available from: https://www.ijam-web.org/text.asp?2021/7/4/252/333406

Introduction

Entering its 6^th year of operations and growth, the American College of Academic International Medicine (ACAIM) continued to navigate the challenging landscape of the globally persistent novel coronavirus disease 2019 (COVID-19). Given the many waves of the pandemic, combined with the emergence of new, more infectious virus strains, as well as the lack of universally available vaccinations, the Academic International Medicine (AIM) 2021 Conference Planning Committee decided to pursue a fully Virtual Congress and Scientific Forum. Corresponding action plan was implemented, with the event subsequently taking place on May 21–23, 2021. The scientific program featured more than 30 speakers and 40 scientific presentations. In addition, a half-day pre-Conference workshop and a satellite consensus session took place on Friday, May 21. An overview of the pre-conference sessions, highlights from the main program, as well as published abstracts from the Scientific Forum will now follow.

The Academic International Medicine 2021 Congress Theme

With the goal of providing top-quality, highly relevant content for our membership, the ACAIM Conference Planning Committee (CPC) created a program relevant to both the current COVID-19 pandemic and the postpandemic future. Although it was recognized that the social distancing and restrictions associated with the novel coronavirus would significantly affect attendee experience, the availability of advanced virtual platforms provided an effective high-quality environment for learning and knowledge exchange.

Due to the ongoing pandemic and related challenges, especially for the AIM community, the theme for the 2021 Congress was “Best Practices in Shifting Landscapes.” Because the emergence of COVID-19 brought with it significant changes across virtually every domain of human society, topics discussed during the conference were diverse and reflected the “shifting landscapes” of our inherently multidisciplinary specialty as we adapt to the new realities and evolving global events.

Virtual Academic International Medicine 2021 Congress

The original ACAIM CPC plan called for an in-person meeting in the late May of 2021. However, due to the persistence of COVID-19 and ongoing travel and social distancing restrictions, the meeting was transitioned to a purely virtual experience. Arrangements for this transition were made in the late 2020, based on various projected trajectories of the pandemic, with the CPC assuming an “intermediate” scenario where some areas of the globe would simultaneously see easing of restrictions while other areas would see re-emergence of the pandemic.

In hindsight, this was an appropriate decision, especially given that international travel restrictions persisted around the world well past the planned Congress and many areas of the United States actively struggled to contain new COVID-19 outbreaks around the time of the conference. Logistically, we utilized a single-track approach, with breakout sessions for small-group discussion sessions.

Highlights of the Academic International Medicine 2021 Congress Program

May 21, 2021: Pre-Conference

The 2021 AIM Congress included Pre-Conference Workshop titled, “Leadership through Times of Crisis: Moral Injury and AIM Community Resilience.” The workshop, led by Dr. Wendy Dean and Dr. Simon Talbot, highlighted the phenomenon of moral injury, its role in adversely affecting professional accomplishment and job satisfaction, and approaches to address and remedy this potentially destructive phenomenon. Important aspects of leadership, teamwork, empathy, as well as institutional and group dynamics were discussed during the session.

This year's Pre-Conference activities concluded with the 2021 Consensus Session titled, “COVID-19 and Widening Health Disparities.” The Consensus Session was led and moderated by Dr. Rebecca Jeanmonod, member of the ACAIM Board of Governors and ACAIM Diversity and Inclusion Committee. The session created a robust framework for the planned Consensus Statement that will focus on health disparities across various socioeconomic factors, in the context of the ongoing COVID-19 pandemic.

May 22, 2021: Conference Day #1

The main Conference event started with Dr. Annelies De Wulf, President of ACAIM, and Dr. Lisa Moreno-Walton, President of American Academy of Emergency Medicine (AAEM), making joint Opening Remarks. Their Leadership Message acknowledged the sacrifices of the front-line healthcare workers while highlighting the hope of the post-COVID-19 world. Dr. De Wulf emphasized the main message of the conference – “Best Practices in Shifting Landscapes.” Dr. Moreno-Walton additionally discussed the importance of the ACAIM-AAEM alliance, now in its second year of active implementation.

The Past-President Keynote Address, titled “International Medicine Student and Resident Experiences: Lessons Learned from Pre-and Post-COVID-19 Eras,” was presented by Dr. Jessica Evert, the Executive Director of Child Family Health International (CFHI). Key aspects of graduate and postgraduate medical training in the context of international medicine were discussed. Important definitional and practical aspects of the topic were outlined, with focus on best current practices and evolving state-of-the-art approaches.

The Main Keynote Address then followed, given by Dr. Roger Glass, Fogarty Director at the National Institutes of Health (NIH). In addition to outlining the Fogarty International Center mission, the Keynote Address highlighted various strategic goals of the organization, including research capacity building, encouraging innovation, managing the dual burden of communicable and non-communicable disease, supporting implementation science, as well as creating and strengthening partnerships. Dr. Glass also discussed the impact of the COVID-19 pandemic on both the NIH's international efforts as well as on the Fogarty program. Finally, our 2021 Keynote Speaker offered pearls of wisdom to those pursuing a career in Academic International Medicine.

Following the Keynotes, a series of “Best Practices” panel sessions took place. The first session, moderated by Dr. Arun Kumar (Wayne State University, Detroit, Michigan, United States) and featuring Dr. Paul Kilgore (Wayne State University, Detroit), Dr. Prashant Mahajan (University of Michigan, Ann Arbor), Dr. Joseph Hanna (Rutgers New Jersey Medical School, Newark), and Dr. Bhakti Hansoti (Johns Hopkins University, Baltimore, Maryland), focused on “Best Practices in International Research.” Panelists summarized their experiences in this key area of AIM emphasizing some of the ways in which clinical research was able to be continued despite the pandemic. Collaborative aspects of international research were also discussed, including the importance of diversity, equity, and inclusion.

The second panel session, moderated by Dr. Taryn Clark (SUNY Downstate, Brooklyn, New York), focused on “Best Practices in Clinical International Medicine.” The panel consisted of Dr. Susan Moffatt-Bruce (Chief Executive Officer, Royal College of Physicians and Surgeons of Canada, Ottawa, Canada); Dr. Judith Lasker (Lehigh University, Bethlehem, Pennslyvania, USA); Ms. Tricia Todd (University of Minnesota, Minneapolis); Dr. Amanda Gosman (University of San Diego, California); Dr. Armila Ratnayake; and Dr. Sanjeewa Garusingh (ESARC, Easter Sunday Attack Consortium, Sri Lanka). Topics discussed ranged from patient safety to global health partnerships to capacity building in international settings, to mass casualty incident management.

The third session, moderated by Dr. Ijeoma Opara (Wayne State University, Detroit, Michigan) discussed “Best Practices in Decolonizing International Medicine and Establishing an Antiracist Praxis.” The panel consisted of Dr. Carlos Faerron (CISG, Interamerican Center for Global Health, Costa Rica and University of Maryland, Baltimore); Dr. Adrian Holloway (University of Maryland, Baltimore); Dr. Jamey Snell (Wayne State University, Detroit); and Dr. Franci Taylor (Director, American Indian Resource Center, Salt Lake City, Utah). During this session, experts discussed a variety of topics that are fundamental to operating modern bidirectional International Medical Programs (IMPs), as outlined in the 2017 ACAIM Comprehensive Framework for IMPs.

The fourth panel session, moderated by Dr. Nicole Kaban (Louisiana State University, New Orleans) and featuring Dr. Rebecca Jeanmonod (St. Luke's University Health Network, Bethlehem, Pennsylvania), Dr. Eric Gokcen (Temple University School of Medicine, Philadelphia, Pennsylvania), Dr. Ana Paula Freitas (Hospital de Pronto Socorro, Porto Alegre, Brazil), and Dr. Nicholas Comninellis (Institute for International Medicine, Kansas City, Missouri, USA), focused on “Best Practices in International Medicine Education.” Panelists outlined key aspects of international medical education, touching on topics such as utilization of Internet/digital tools to facilitate remote/online education, sustainable international residency training, and other aspects related to the COVID-19 pandemic.

The fifth session, moderated by Dr. Ziad Sifri and Dr. Harsh Sule (Rutgers New Jersey Medical School, Newark, New Jersey), was titled “COVID-19 Pandemic: International Experiences and Perspectives” and featured distinguished panelists from around the globe – Dr. Prachi Burke (New Zealand); Dr. Ian Maia (Brazil); Dr. Ben Nuertey (Ghana); Dr. Nino Butskhrikidze (Georgia); Dr. Daniel Fliterman Molinari (Israel); Dr. Carlos Garcia Rosas (Mexico); Dr. Hassan Al-Thani (Qatar); Dr. Vimal Krishnan (India); and Dr. Alwi Abdul Rahman (Malaysia). The panelists discussed local and regional COVID-19 responses around the globe, with many common elements emerging during the discussion, highlighting surprising degree of similarity despite geographic and socioeconomic differences.

Saturday sessions concluded with a “Virtual Happy Hour” session featuring AIM 2021 Speakers.

May 23, 2021: Conference Day #2

The second day of the Congress was primarily dedicated to AIM 2021 Scientific Forum, with abstract presentations. Researchers, students, residents, fellows and attendings from more than 30 academic institutions presented their abstracts, utilizing either short (e.g., 5 min presentation + 1 min questions) or long (e.g., 8 min presentation + 2 min questions) virtual formats. This year's forum was highly competitive, with winners in four different categories, as follows:

Best 2021 Medical Student Case Study: “Post-Traumatic Epigastric Swelling – Expect the Unexpected” by Mohammad Khalid (Kasturba Medical College and Hospital, Manipal, India)
Best 2021 Resident or Attending Case Study: “COVID-19 Associated Primary Spontaneous Tension Pneumothorax – Case Report and Systematic Review” by Dr. Fateen Ata (Hamad Medical Corporation, Doha, Qatar)
Best 2021 Medical Student Abstract: “Waxing in Productivity – Describing the Academic Output of the West African College of Surgeons” by Gary S. Hoffman (Rutgers New Jersey Medical School, Newark, New Jersey, United States)
Best Resident or Attending Abstract: “The Use of Point-of-Care Ultrasound (PoCUS) as Initial Diagnostic Tool in Patients with Acute-Onset Dyspnea” by Dr. Himanshi Baid (All India Institute of Medical Sciences, Rishikesh, India).

Other important sessions of the 2^nd day of the 2021 AIM Congress included “Ethics of International Medicine” by Dr. Lisa Moreno-Walton (Louisiana State University, New Orleans); “International Travel Post-Vaccination” by Dr. David Cennimo (Rutgers New Jersey Medical School, Newark); “Clinical Practice in Beirut's Crises: The Beirut Explosion and Economic Challenges” by Dr. Tharwat El Zahran (American University of Beirut, Lebanon); and “Social Isolation During the COVID-19 Pandemic” by Dr. Matthew Baker (Wright State University, Dayton, Ohio). More detailed information about these sessions is available on ACAIM Twitter (https://twitter. com/AcaimInfo).

Annual American College of Academic International Medicine Leadership Awards

This year, ACAIM continued the tradition of highly competitive Emerging Leader and Distinguished Leader Awards. Nomination cycle for the awards started several months before the Congress, with a dedicated Awards Committee convened to administer this process in an unbiased and confidential fashion. ACAIM is honored to present this year's awardees:

The 2021 ACAIM Emerging Leader Award: Dr. Andrew C. Miller, MD, FACEP, FAIM, Dip. ABIM
The 2021 ACAIM Distinguished Leader Award: Dr. Lisa Moreno-Walton, MD, FAAEM.

Annual American College of Academic International Medicine Leadership Elections

In accordance with ACAIM Bylaws, the 2021 election cycle was initiated in January, with an open and transparent self-nomination process for prospective organizational leaders. The self-nomination process closed in April and was followed by leadership elections, with results announced ahead of our 6^th Annual Virtual Congress and Scientific Forum. Dr. Michael S. Firstenberg was installed as ACAIM President, with Dr. Annelies De Wulf becoming our Past-President. Dr. Mayur Narayan begins his tenure as President Elect. Dr. Dianne McCallister became Vice President. Dr. Harry L. Anderson, III, continues as ACAIM Treasurer. Finally, Dr. Veronica Tucci was elected to become ACAIM Executive Secretary. In addition, a record number of 11 actively contributing members were inducted as Fellows of Academic International Medicine (FAIM, see www.acaim.org/fellowship for more information).

Conclusions

The COVID-19 pandemic has resulted in many challenges to the AIM community. The impact on the field of clinical medicine has been the most pronounced, particularly in the way that education is provided and academic medicine is pursued by clinicians. However, significant effects were felt across other domains, including research funding, staffing, and travel restrictions. In response, ACAIM sought to fill the void left by canceled educational activities and conferences by offering virtual education and various AIM-oriented expert platforms.

As we approach 2022, we look forward to increasing our membership, to projecting our positive influence, and to organizing and hosting an exciting meeting that will leave an indelible footprint in the AIM community. We will strive to improve our educational outreach to low- and middle-income countries (LMIC) to assist in the continual improvement of undergraduate and graduate medical pedagogy through teaching, research, and administrative support, with focus on bidirectionality, quality, and sustainability. We also hope that the COVID-19 pandemic will finally come under sufficient control to allow us to re-engage as global community and do what we do best – Academic International Medicine!

Financial support and sponsorship

The Academic International Medicine 2021 Congress and Scientific Forum was supported by the following benefactors: FPL Financial Strategies, IntechOpen, LifeAire Systems, Louisiana State University Spirit of Charity Emergency Medicine Residency Program, and Nova Science Publishers.

Conflicts of interest

All authors of this report are members of ACAIM Executive Leadership / Governing Boards, and were actively involved in the planning of AIM 2021 Congress and Scientific Forum.

Ethical conduct of research

All of the abstracts and case reports listed below were required to follow applicable EQUATOR Network (http://www.equator-network.org/) guidelines prior to acceptance for presentation at the AIM 2021 Scientific Forum. This includes approval by Institutional Review Board / Ethics Committee and patient consent declaration for case reports or series. Verification of the above pre-requisites was performed by the AIM 2021 Conference Planning Committee.

Abstract #1

Category: Quick Shot/Case Report

Global Health Disaster–Preparedness Workshop in Ecuador: A Hospital's Strategy to Respond to COVID-19

Maria Armas

Pontificia Unviversidad Catolica del Ecuador, Quito, Ecuador

Introduction: Northwell Health Surgical Service Line has established a long-term relationship with Hospital Padre Carollo in Quito, Ecuador. This vertical connection understands the educational needs of the community. In January 2020, hospital staff participated in the full-day training of the Disaster–Preparedness Workshop. The invitation included physicians, nurses, residents, medical students, paramedics, teachers, and hospital administrators.

Methods: The disaster workshop integrated highly-competent bilingual and board-certified physicians in emergency medicine, surgery, and critical care, joined by local surgery and emergency physicians, a specialist in emergency and critical care in nursing, and the Associate Medical Director of the New York City Fire Department.

The first part included teaching lectures and clinical reasoning in emergencies, as well as clinical cases and management methods in practice [Figure 1]. A section focused on emergency and critical care skills. The second part involved nonclinicians. Then, the audience was evenly mingled into groups to discuss disaster scenarios and practice priority assignation, in addition to hands-on training in lifesaving techniques. Afterward, feedback on important aspects to consider when categorizing each situation was provided. A final emphasis was given in a workshop on how to develop escalation and communication strategies, anticipating worst-case scenarios and massive casualty incidents.

Results: After the pandemic hit the country, the hospital elaborated strategies to contain the COVID-19 emergency. First, a multidisciplinary team was assembled to design a contingency plan. This management team then went on to define infrastructural and technical limitations of the hospital and to establish appropriate communication channels within the health system network. These steps were taken while ensuring that pertinent international management guidelines are followed. Next, dedicated spaces for COVID-19 patients were created in the emergency rooms, main hospital, and critical care units. Beyond this initial phase, many flexible modifications took place during the evolving pandemic.

Northwell Health was a few weeks ahead in the pandemic; thus, their experience was a fundamental guide throughout our strategy development process. In the Disaster–Preparedness–Workshop experience, we acknowledged that an effective crisis response has to be multidisciplinary and multisectoral. However, learning from global health policy interventions is still a permanent commitment.

Conclusion: The COVID-19 crisis clearly shows that the implementation of preparedness interventions is essential to support global health needs.

Abstract #2

Category: Quick Shot/Case Report

Handlebar Hernia due to Blunt Abdominal Trauma

Siddharth Dubhashi

All India Institute of Medical Sciences, Nagpur, Maharashtra, India

Introduction: Handlebar hernias are traumatic abdominal wall hernias (TAWH) caused due to injury by handlebar-like objects. Blunt TAWH usually present not only with disruption of the muscular and fascial layers but also with intact skin and no signs of previous hernia at the same site. This is a rare case of handlebar hernia with a skin defect.

Case Report: A 23-year-old man presented to the surgical emergency room with herniation of bowel loops through a traumatic defect in the left lower abdomen [Figure 1] and [Figure 2]. He had sustained the injury as a result of the blunt impact force of the handlebar of the motorcycle he was riding. The impact was so severe that the blunt injury caused disruption of skin, muscle, and fascial layers. The patient was hemodynamically stable. He was taken up for emergency laparotomy. The herniating congested small bowel loops were examined for viability. The bowel was traced in either direction for possibility of any associated injury. There was no evidence of free fluid in abdomen. The hernia defect measuring 5 cm × 4 cm was sutured in layers. Definitive surgical closure is shown in [Figure 3].

Discussion: The elastic properties of the skin prevent its disruption due to blunt forces in TAWH. The presenting features of TAWH include a history of blunt abdominal trauma, pain in abdomen, and a local swelling along with the presence of skin ecchymosis, tattoo, or imprints as London sign. An abdominal wall defect would be palpable. In an acute emergency presentation, as seen in our case, it is advisable to do an emergency open repair without any mesh placement. Early intervention will help in avoiding complications of bowel incarceration and subsequent morbidity.

Conclusion: Handlebar hernia is extremely rare. Loss of skin integrity is not usually seen in these cases. Diagnosis of this condition in cases of blunt abdominal wall trauma requires a high index of clinical suspicion. This is a rare presentation of a rare entity.

Abstract #3

Category: Quick Shot/Case Report

Establishing Health Strategies and Surgical Leadership: Facing the COVID-19 Pandemic in a Hospital in Ecuador

Maria Armas

Pontificia Universidad Catolica del Ecuador, Quito, Ecuador

Introduction: Every surgical mission provides an opportunity for innovation and improvement of the local health system. The impact of surgical missions relies on the continuous well-being of the people and communities visited. Therefore, meeting surgical and clinical needs and addressing education gaps will help strengthen the health system.

Methods: Northwell Health Surgical Service Line has established a long-term relationship with a local hospital, Hospital Padre Carollo, in Quito, Ecuador. A priority has always been training host country providers to master the skills and knowledge needed to maintain quality healthcare even after the mission volunteers leave the area. Intending to further meet educational needs, in January 2020, a disaster workshop took place in the hospital facilities. A complete day of didactics and practical training involved physicians, nurses, residents, medical students, and hospital administrators. Hence, the final lesson: Anticipate worst-case scenarios and plan strategies.

Results: In March 2020, the western world shut down in response to the ongoing pandemic. At the same time, COVID-19 cases reached high mortality rates at the coast of the country. An already fragile health system required the prompt implementation of appropriate emergency strategies. At Hospital Padre Carollo, an emergency response team led by a surgeon came together to design an emergency protocol and surgical workflow. The committee was integrated by physicians of different specialties, nurses, and hospital administrators. The hospital promptly adapted the infrastructure of the emergency department and hospitalization areas. In the operating rooms, personal protective equipment was reinforced, negative pressure rooms were designated, and regional anesthesia was preferred for the reduction of aerosol spread. These responses were designed to meet the needs of COVID-19 patients without leaving the other clinical and surgical needs unattended.

Conclusion: A full year after the pandemic first arrived in our region, the results achieved due to the implementation of the current plan included reduced postoperative complications and low morbidity and mortality rates in surgical procedures involving COVID-19 patients. An open international communication channel is still a priority. It enhances awareness of partnerships, promotes continuity of care, and cooperates in the development of health strategies. Hence, in settings with limited resources, a supportive global system is necessary to enable potential clinical leaders, develop autonomous strategies, set up clinical networks, and strengthen institutions.

Abstract #4

Category: Quick Shot/Case Report

START-ER: A Proposed Novel Interactive Platform to Teach Triage Principles in Indian Emergency Departments

Naman Agrawal, Ravi Yadav

All India Institute of Medical Sciences, Rishikesh, Uttarakhand, India

Introduction: The emergency department (ED) is a “room full of risk and uncertainty.” In addition to be able to diagnose medical conditions, the skill of efficient utilization of available resources is of paramount importance for a physician, more so in a developing country like India where EDs face various challenges related to documentation, data, triage efficacy, equipment, human resource management, and organization of care and training. Triage is an important concept and integral part of patient management in ED. It not only entails quick assessment and rapid sorting based on one patient's clinical condition but also demands the triage officer to have a situational awareness about the department and its various clinical processes. Teaching about triage principles is not a routine part of undergraduate curriculum in India. For residents in emergency medicine, teaching of triage principles has been largely been through didactic methods/interactive group discussions. However, these methods lack realism. There is no way to track the understanding and performance of the students in real-life ED triage scenarios. Moreover, sensitizing the students about time sensitivity of triage decisions and importance of queuing is less achievable by conventional teaching. We aim to determine the efficacy of “START-ER:”

Methods: A video game-based teaching of ED triage principles in the training of medical students, interns, and emergency medicine residents in India. An interactive video game shall be developed and pilot-tested. Final-year MBBS students, interns, and emergency medicine residents will be enrolled in the study and randomly assigned to either of the two limbs: START-ER game and card-sorting exercise. Triage training will be imparted by initial face-to-face didactic lectures. Those in START-ER limb will be given a brief introduction about the game, followed by game time of 60 min. Performance will be assessed by evaluating the correct assignment of triage tag and time taken to triage all cases in a scenario.

Conclusions: We plan to implement the above protocol at our institution and potentially recruit other participating centers. We hope that the START-ER approach will help provide important aspects of educational experience that will introduce added value to our current Emergency Medicine teaching paradigms. After all, accurate triage is one of the most difficult competencies to teach within our specialty curriculum.

Abstract #5

Category: Quick Shot/Case Report

Global Surgical Care for Native Amazons in Ecuador: Laparoscopic Hernia Repair in Bariatric Surgery Gastric Sleeve: A Case Report

Maria Armas

Pontificia Universidad Catolica del Ecuador, Quito, Ecuador

Introduction and case scenario: A 53-year-old woman was visited by a surgical brigade at her hometown Aguarico, situated in the deep of the Amazon Jungle of Ecuador. Her medical history was significant for obesity grade 3, with an elevated body mass index of 40.4 kg/m², weight of 200 pounds, and height of 4.9 feet, in addition to an umbilical hernia of approximately 6 cm.

The town of Aguarico is surrounded by the Yasuni Reserve. After a 10-h boat trip, the surgical team found an obese patient with constant intense pain in her lower abdomen that restricted her daily activities. The patient had not received surgical attention due to geographical reasons. After a clinical evaluation, the local surgical team sought international help.

Discussion: The complexity implied performing the surgery in a second-level hospital in the city of Quito with the support and guidance of the Northwell Health Surgical Service Line (SSL). The goal of SSL was to set up a bariatric program with the local surgery team, providing a full day of specialized training in skills for bariatric surgery and laparoscopic procedures. Together, they planned a simultaneous approach. For the operation, surgical and anesthesia supplies were provided, as well as step-by-step guidance during the intervention. A gastric sleeve and two ventral hernias repair were successfully performed. Postanesthesia care and postoperative recovery were covered by SSL.

On follow-up, the patient lost close to 25 kg. No complaints and short or long-term complications were reported. In a patient interview, she describes a transformation in her life, she returned to her daily activities, and her relationships have also improved. The patient considers that the care provided by the local surgical brigade had not been possible without international support.

Conclusion: The burden of untreated surgical conditions affects people living in areas with restricted access to surgical procedures. This case reflects a vulnerable health system with many unmet needs. Hence, establishing global health partnerships with the collaboration of national and international teams can expand widespread health coverage for those in remote areas.

Abstract #6

Category: Quick Shot/Case Report

Pacemaker Lead Migration and Ventricular Perforation in a Patient with Chest Pain

Jennifer A. Reyes, Ahmed K. Amer, Durotimi D. Ayodeji, Alwiya O. Saleh, Mauricio Danckers

SUNY Downstate Medical Center, Brooklyn, New York, United States

Introduction and case report: Pacemaker lead migration and ventricular perforation is a rare, potentially fatal event. This case study describes one of the rare presentations of chest pain in a middle-aged man. A 52-year-old gentleman with a medical history of second-degree atrioventricular (AV) block type II status-post pacemaker placement who presented a day after his pacemaker was placed complaining of sudden-onset constant localized chest pain, without respiratory distress or hemodynamic instability. Electrocardiography showed nonpaced ventricular rhythm. Chest X-ray showed the right ventricular (RV) lead overlying the distal RV. Serum troponins were slightly elevated above reference range. Device interrogation revealed atrial sensing with failure to capture and increasing the rate of fire exacerbated the patient's symptoms. A stat chest computed tomography showed perforation of the ventricular wall by the pacemaker lead, prompting emergent intervention by cardiothoracic surgery for lead removal and RV repair [Figure 1]. The patient underwent epicardial lead placement and was discharged home without suffering a negative outcome.

Discussion: The pathophysiology of perforation is attributed to continuous pressure of the thin lead per unit of the myocardial wall. Perforation of the RV apex is the most commonly affected area due to weakness of the wall. The most common presentations are chest pain, dyspnea, dizziness, syncope, and pacing or sensing failure. Chest X-ray may not reveal any abnormality; therefore, a noncontrast computed tomography (CT) scan is required to make the diagnosis.

Conclusion: This case elucidates the importance of maintaining a high index of suspicion for this rare diagnosis in patients with a pacemaker presenting with chest pain.

Abstract #7

Category: Quick Shot/Case Report

Profile and Outcomes of Adult Patients Receiving Cardiopulmonary Resuscitation in a Tertiary Care Academic Emergency Department of India: A Study Proposal

Naman Agrawal, Bharat Bhushan, V. Nagasubramanyam

All India Institute of Medical Sciences, Rishikesh, Uttarakhand, India

Introduction: Sudden cardiac death can occur either out of the hospital (out-of-hospital cardiac arrest) or in-hospital (in-hospital cardiac arrest). Survival after cardiopulmonary resuscitation is dependent on number of factors, including quality of prehospital services, likely cause for cardiac arrest, good teamwork, and competence of resuscitator.^[1],[2],[3] Most of the data regarding the outcomes and profile of patients undergoing cardiopulmonary resuscitation come from the western countries. There are only small studies from India describing the profile of cardiac arrest patients. This paucity of data can be ascribed to lack of surveillance system for cardiac arrests in India. Furthermore, emergency medicine is a young specialty in India. In addition, prehospital services are in their infancy and the level of training for paramedics is yet to be standardized nationwide. All these factors contribute to a huge gap in knowledge about patients developing cardiac arrest in emergency departments of India. Scientific enquiry into the nature of these patients is the need of the hour. Resuscitation science needs to be developed in India so that indigenous population may have improved survival after evidence-based patient-oriented resuscitative efforts.

Methods: We intend to assess the profile and outcomes of patients receiving cardiopulmonary resuscitation in the department of emergency medicine at the All India Institute of Medical Sciences (AIIMS), Rishikesh. The data from this study will set the bottom line for further research and efforts to influence the outcomes of this subset of patients. Forwarding the relevant data collected from the study, an institutional/regional registry for cardiac arrest patients may be developed. All adult patients presenting to the emergency department where cardiopulmonary resuscitation is performed will be included in the study. Details relating to patient demographics, etiology of cardiac arrest, duration and details of resuscitative attempts, immediate outcomes, etc., will be recorded in a predesigned pro forma. The patients shall be followed till emergency department disposition and short-term patient outcomes recorded and analyzed. All the data will be collected in the predesigned pro forma and entered into Microsoft excel spread sheet in a computer. All subjects will be included in the analysis. Descriptive statistics shall be applied. Data will be analyzed using SPSS software version 22 (IBM Corporation, Armonk, New York).

Conclusion: We hope to implement the above-outlined protocol in the near future, hopefully with other centers joining to strengthen the overall quality of the study. Our goal is to provide new insights into factors affecting outcomes in cardiopulmonary resuscitation, with subsequent efforts directed at addressing those specific factors.

Neumar RW, Shuster M, Callaway CW, Gent LM, Atkins DL, Bhanji F, et al. Part 1: Executive summary: 2015 American Heart Association guidelines update for cardiopulmonary resuscitation and emergency cardiovascular care. Circulation 2015;132:S315-67.
Krishna CK, Showkat HI, Taktani M, Khatri V. Out of hospital cardiac arrest resuscitation outcome in North India – CARO study. World J Emerg Med 2017;8:200-5.
Rajaram R, Rajagopalan RE, Pai M, Mahendran S. Survival after cardiopulmonary resuscitation in an urban Indian hospital. Natl Med J India 1999;12:51-5.

Abstract #8

Category: Quick Shot/Case Report

Phase-Zero Platform: New Electronic Data-Capture Solution

Ngoc Le

PhaseZero Ventures, Inc., Boston, Massachusetts, United States

Introduction: Over 50% of regulated and 80% of unregulated studies run still on paper due to a lack of universally acceptable electronic data-capture (EDC) solutions in the market. Phase-Zero is a new venture developing an EDC platform that was tested using a simulated exercise of its survey instrument by randomly invited researchers.

Methods: Researchers were invited via e-mail to use Phase-Zero platform to develop a predesigned survey instrument by following certain instructions. This simulated exercise used variables such as basic demographics, short and long text, radio buttons, drop-down, checkboxes, time, and date variables. Later, they completed a survey about their experience with this new platform.

Results: Eighteen participants completed the simulation and the survey. They included 8 students, 3 principal investigators, and 7 physicians who reported having prior experience with survey data (78%) and electronic health record data (72%). EDC was performed using Castor Clinical Trial Platform (44%), Google Forms (22%), RedCap (5%), and EpiCollect (5%) and paper (28%). Thirty-three percent had institutional subscription to some EDC tool and 44% were satisfied with their existing tools. Most important features reported in an EDC were ease of use (72%), affordability (44%), and functionality (44%). Lack of features in the existing solutions was observed by 50%. The users gave 4/5 rating for overall satisfaction with the Phase-Zero experience.

Conclusion: Phase-Zero is an upcoming EDC solution being tailored to the needs of researchers around the globe. Simulated-based evaluation of this software provided us realistic and valuable feedback to achieve better customer satisfaction.

Abstract #9

Category: Quick Shot/Case Report

Prevalence and Predictors of Burnout in Healthcare Workers during COVID-19 Pandemic: a Cross-Sectional Study Proposal

Naman Agrawal, Hannah Chawang Joyce, Bharat Bhushan, V. Nagasubramanyam

All India Institute of Medical Sciences, Rishikesh, Uttarakhand, India

Introduction: Burnout is a psychological syndrome characterized by chronic exhaustion, cynicism, and ineffectiveness. It emerges as a response to highly stressful conditions in the workplace.^{[1],[2],[3],[4],[5],[6]} It is disturbingly prevalent in healthcare. The COVID-19 pandemic has contributed to the stress leading to burnout of healthcare professionals globally. Increasing work hours, change in the working environment, and increased vulnerability to get infected have all contributed to the stress. Routine and frequent use of personal protective equipment (PPE) which may be uncomfortable ultimately leads to early physical fatigue. Social distancing from loved ones has posed a risk for later developing symptoms of posttraumatic stress disorder, loneliness, anxiety, and depression. There has been a strong impact on both physical and psychological health of healthcare workers.^{[7],[8],[9],[10],[11],[12],[13]} There are limited data available from India on the physician burnout during COVID-19 pandemic and none from Northern India. It is important to evaluate how the burnout rate has affected healthcare workers in this unique time of rising COVID-19 cases.

Methods: This study aims to assess the correlation of the work-related stress during the COVID-19 pandemic and burnout. We also intend to study the prevalence of burnout of all the working health care workers in the setting of a tertiary care teaching hospital. A three-part survey will be distributed to healthcare workers in a tertiary care teaching hospital. The first part of the survey will include the resident demographics, personal habits, and work-related conditions. The second part consists of self-perceived stressors using the self-perceived scoring system (PSS-4). Moreover, the third part will include the abbreviated Maslach burnout inventory and hospital anxiety and depression scale. The survey consists of 30 questions 9-item questionnaire of after taking informed written consent; an anonymous paper-based survey will be administered by the investigating team to assess the burnout, anxiety, and depression among doctors and nursing officers of AIIMS Rishikesh. Data will be analyzed using professional statistics package SPSS 23.0 version (IBM Corporation, Armonk, New York) for windows. Appropriate tests of significance will be used depending on nature of variables. Correlation between predictor and outcome variables will be determined.

Conclusions: It is our hope that the proposed study, if implemented and carried out successfully, will provide improved understanding of the concept of burnout. Such research performed in our geographic region is necessary as various socio-economic factors from various published studies may be different and not necessarily applicable in our local setting.

References

Maslach C, Goldberg J. Prevention of burnout: New perspectives. Appl Prev Psychol 1998;7:63-74.
Stehman CR, Testo Z, Gershaw RS, Kellogg AR. Burnout, drop out, suicide: Physician loss in emergency medicine, part I. West J Emerg Med 2019;20:485-94.
Ahola K, Toppinen-Tanner S, Seppänen J. Interventions to alleviate burnout symptoms and to support return to work among employees with burnout: Systematic review and meta-analysis. Burn Res 2017;4:1-11.
Langade D, Modi PD, Sidhwa YF, Hishikar NA, Gharpure AS, Wankhade K, et al. Burnout syndrome among medical practitioners across India: A questionnaire-based survey. Cureus 2016;8:e771.
Bradley M, Chahar P. Burnout of healthcare providers during COVID-19. Cleve Clin J Med 2020;7:1-3. [doi: 10.3949/ccjm.87a.ccc051].
Sultana A, Sharma R, Hossain MM, Bhattacharya S, Purohit N. Burnout among healthcare providers during COVID-19: Challenges and evidence-based interventions. Indian J Med Ethics 2020;V:1-6.
Moukarzel A, Michelet P, Durand AC, Sebbane M, Bourgeois S, Markarian T, et al. Burnout syndrome among emergency department staff: Prevalence and associated factors. Biomed Res Int 2019;2019:6462472.
Azoulay E, De Waele J, Ferrer R, Staudinger T, Borkowska M, Povoa P, et al. Symptoms of burnout in intensive care unit specialists facing the COVID-19 outbreak. Ann Intensive Care 2020;10:110.
Liu Q, Luo D, Haase JE, Guo Q, Wang XQ, Liu S, et al. The experiences of health-care providers during the COVID-19 crisis in China: A qualitative study. Lancet Glob Health 2020;8:e790-8.
Brooks SK, Webster RK, Smith LE, Woodland L, Wessely S, Greenberg N, et al. The psychological impact of quarantine and how to reduce it: Rapid review of the evidence. Lancet 2020;395:912-20.
Woo T, Ho R, Tang A, Tam W. Global prevalence of burnout symptoms among nurses: A systematic review and meta-analysis. J Psychiatr Res 2020;123:9-20.
Kim JS, Choi JS. Factors influencing emergency nurses' burnout during an outbreak of Middle East respiratory syndrome coronavirus in Korea. Asian Nurs Res (Korean Soc Nurs Sci) 2016;10:295-9.
West CP, Dyrbye LN, Shanafelt TD. Physician burnout: Contributors, consequences and solutions. J Intern Med 2018;283:516-29.

Abstract #10

Category: Quick Shot/Case Report

Disaster Planning During a Pandemic

Ayush Srivastava

Jai Prakash Narayan Apex Trauma Center, AIIMS, New Delhi, India

Introduction: India is home to large number religious mass gatherings such as Kumbh Mela and Rath Yatra. These events are usually conducted in a systematic manner with a disaster preparedness plan in place. India is also host to a number of other festivals that are celebrated as multiple small gatherings across cities. These festivals, though having the potential to overwhelm emergencies and healthcare systems, usually do not qualify as mass gatherings and hence attract little attention from Authorities.

Methods: Holi, one of the most vibrant festivals of India, is celebrated on the arrival of spring harvest season and end of winters in India. Holi marks the triumph of good over evil and usually celebrated by splashing colors and water over each other. However, for many, the enthusiasm of this festival is marred by unwanted health consequences.

Results: The Emergency Department of our Tertiary Care Trauma Center received 436 patients on Holi in 2020, which is three times the daily average footfall. Though being the pandemic year, the total number of COVID-19 cases on March 10, 2020, was less than 10 in the city. This year, with the daily new cases of COVID-19 reaching the 2000 mark again and a total of 8000 active cases in the city, the challenges were unique. The government had ruled out any possibility of a lockdown, though implemented certain restrictions on celebrations of Holi.

Conclusion: Our presentation discussed the disaster preparedness planning of a tertiary care hospital in view of Holi festivities during an ongoing pandemic. This involves identifying organizational resources, engaging stakeholders, enhancing capacity, and determining roles and responsibilities.

Abstract #11

Category: Quick Shot/Case Report

Diversity Efforts and Their Impact on One Residency from 2009 to 2019

Brianna Wapples, Taryn Clark, Julia Terle, Jennifer Avegno, Pierre Detiege

Louisiana State University Health Sciences Center, New Orleans, Louisiana, United States

Background: The American Medical System has historically demonstrated a lack of equitable healthcare for all patients across a variety of specialties. Although evidence demonstrating racial homogeneity is linked to higher levels of sickness, disability, and premature death, diversity in the United States physician workforce does not reflect national diversity.^[1],[2] Nine percent of emergency medicine (EM) physicians identify as under-represented minorities (Black, Hispanic/Latino, American Indian/Alaskan Native), even though this population makes up 33% of the United States population.^[3] In 2009, the Academic Assembly of the Council of Emergency Medicine Directors published best practice strategies to increase the number of URMs in EM residencies,^[4] Using these guidelines along with implementing original programing, The EM Program at Louisiana State University New Orleans (LSUNO) sought to improve diversity within the residency over several recruitment cycles.

Methods: A multifaceted diversification effort was put forth including recruitment, education/research, and pipeline/community initiatives to promote recruitment of diverse residents. Accreditation Counsel for Graduate Medical Education (ACGME) demographic data sheets of LSUNO Emergency Medicine categorical interns over 10 recruitment cycles (2009–2019) were reviewed to determine if diversity interventions were having an impact on recruitment of non-White and URM residents. The data review was IRB exempt.

Results: URM scholarships, pipeline/community programs, and novel educational/curriculum programs significantly improved recruitment of nonwhite and URM interns. This was reflected in our survey of LSUNO EM categorical interns over a 10-year period between 2009 and 2019 where interns identified as non-White increased threefold (from 14% to 46%) and URM interns increased almost sixfold (from 6% to 32%).

Conclusions: Purposeful multifaceted efforts can improve candidate diversity in residency recruitment with significant and rapid effect. After implementation of diversification efforts, the LSUNO EM residency was able to significantly improve diversity within the residency over several recruitment cycles and able to more closely resembled the national US population of URMs, which could have impacts on health outcomes. The methods detailed in this article can serve as a roadmap for other programs seeking to recruit and retain diverse residents.

References

Richardson LD, Babcock Irvin C, Tamayo-Sarver JH. Racial and ethnic disparities in the clinical practice of emergency medicine. Acad Emerg Med 2003;10:1184-8.
Section II: Current Status of the U.S. Physician Workforce: AAMC Interactive Report. Available from: http://www.aamcdiversityfactsandfigures.org/section-ii-current-status-of-us-physician-workforce/index.html#ref1. [Last accessed on 2020 Jan 12].
Landry AM, Stevens J, Kelly SP, Sanchez LD, Fisher J. Under-represented minorities in emergency medicine. J Emerg Med 2013;45:100-4.
Heron SL, Lovell EO, Wang E, Bowman SH. Promoting diversity in emergency medicine: Summary recommendations from the 2008 Council of Emergency Medicine Residency Directors (CORD) Academic Assembly Diversity Workgroup. Acad Emerg Med 2009;16:450-3.

Abstract #12

Category: Quick Shot/Case Report

Global Health Initiative: Emergency and Disaster Training

Jeffrey Rosa, Darío González, Gino Farina, Gustavo Leon, Augusto Maldonado, Rafael Barrera

Northwell Health, New Hyde Park, New York, United States

Introduction: Since 2018, Northwell Health has partnered with several hospitals in Ecuador to conduct emergency and disaster management training as part of its Global Health Initiative. One such hospital, Hospital Padre Carollo, located in the capital city of Quito, Ecuador, caters to the poor population offering low-cost medical services. The hospital is a 70-bedded facility with six operating rooms and a small intensive care unit.

Methods: In 2018, the inaugural year, 12 surgical and emergency medicine (EM) residents participated in the training workshops. The training that year consisted of tabletop exercises involving a mass casualty incident started by an accident with a truck carrying chemicals.

By 2019, the training had grown to 30 people including critical care residents, emergency department residents, trauma surgeons, and nursing staff. Hypothetical mass casualty incident (MCI) training involving a natural disaster was again carried out.

Results: In January, 2020, Northwell Global Health Initiative once again conducted a disaster management workshop. Training was expanded to include EM physicians and nursing staff from Hospital Padre Carollo; EM, general surgery, trauma surgery, and critical care medicine residents from Univerisidad Catolica del Ecuador School of Medicine; firefighters, ambulance drivers, and paramedics from Hospital Padre Carollo; as well as other professors of nursing and medicine from local schools in Quito totaling over 50 participants.

Hands-on training was expanded beyond the tabletop discussion modality previously used. The hypothetical MCI used as the basis for training was an explosion at the “El Tejar” tunnel. Lectures were also expanded to include:

Thoracic trauma by Dr. Augusto Maldonado
Abdominal trauma by Dr. Gustavo Leon
Mechanical ventilation and physiology of the respiratory system by Dr. Rafael Barrera
EKG interpretation by Dr. Gino Farina
Critical Care nursing and ventilator management for nursing by Nurse Jeffrey Rosa
Practical training in tourniquet application, Stop the Bleed and Basic Life Support by Nurse Jeffrey Rosa.

Conclusion: As a direct result of the challenges posed during these hypothetical trainings, local staff were able to create and/or update disaster protocols which better allowed them to have a more well-organized approach to the management of the COVID-19 pandemic.

Abstract #13

Category: Quick Shot/Case Report

Qualitative Study of Factors Critical to Implementation of Blockchain-Based Global Immunity Passports for COVID-19: Implications from Healthcare to International Travel

Sarah K. Hill, Julie M. Aultman, Dianne McCallister, Stanislaw P. Stawicki, Michael S. Firstenberg¹

Department of Research and Innovation, St. Luke's University Health Network, Bethlehem, Pennsylvania, ¹Department of Cardiothoracic Surgery, Ascension Medical Group, Appleton, Wisconsin, United States

Introduction: The coronavirus disease 2019 (COVID-19) pandemic created immense bio-socio-economic challenges. To address these challenges, applications of novel technologies have emerged, including blockchain technology (BCT). Distributed ledgers (or blockchains) facilitate the establishment of a validated, secure, and durable transaction network. BCT offers the opportunity to access a global, internally-validated, highly secure, trusted, and private dataset, including essential health information. Concomitantly, society faces the task of safely re-opening to previously accept social interactions. The evolving concept of COVID-19 immunity passports (IPs) remains a globally controversial means to track or allow “safe” passage. Here, we discuss our findings of a qualitative study on the potential application of BCT to compile immune status and its ethical and practical implications.

Methods: We conducted an in-depth literature search using the terms “blockchain,” “technology,” “pandemic,” “immunity,” and “passports.” Permutations of these terms along with secondary search results were also evaluated. 97 results were identified and subsequently analyzed for relevant content. Specifically, we examined the benefits and potential for BCT and evaluate its application to IP in public health and safety domains. Descriptive and qualitative reporting of our findings is provided, including relevant ethical challenges of maintaining and implementing such global tool.

Results: A comprehensive literature search resulted in 97 highly relevant articles. Upon detailed review of these sources, five major themes emerged, each of which was further analyzed for additional contextual subsets [Table 1]. In general, BCT appears highly suitable for IP implementations.

The intersection of pandemic control, evolving global socioeconomic disparities, technologic advances, and the needs for the preservation of basic human rights and freedoms illustrate the concerns of the use of immunity passports. The evolution of 5 themes reflects the unification of key concepts that must be addressed before widespread implementation and social acceptance.

Conclusions: Although the major themes concerning implementation of IPs exist, BCT poses a potential practical solution to these political, economic, ethical, and scientific issues.

Abstract #14

Category: Quick Shot/Case Report

Facilitators and Barriers to E-learning in Indian Emergency Medicine residency programs during the COVID-19 Pandemic

Vimak Krishnan S, Sanjan A, Jayaraj M. Balakrishnan

Kasturba Medical College and Manipal Academy of Higher Education, Manipal, Karnataka, India

Introduction: COVID-19 pandemic led to an unprecedented crisis with close to 128 million cases worldwide with more than 2.8 million deaths as of March 2021. Educational intervention mediated via the internet would be categorized as E-learning, and it has been steadily increasing worldwide.^{[1],[2],[3],[4],[5],[6],[7]} E-Learning when compared to conventional learning strategies has shown only a small positive effect in the past. According to a review that focused on resource-limited settings from multiple countries, E-learning in medical education improves student engagement and increases the efficiency and effectiveness of faculty.^{[5],[6],[7],[8],[9],[10]} Most of the universities have a curriculum hinging on conventional teaching strategies with minimal utilization of online resources. With this study, we tried to evaluate the faculty and resident perspectives on facilitators and barriers to E-Learning during the COVID-19 pandemic from Emergency medicine residency programs in India.

Methods: The study is a multicenter national online survey conducted after IRB approval (IEC 396-2020) by the department of emergency medicine in a tertiary care teaching hospital in India. A predesigned pro forma was converted into a Google Form for dissemination via mail. A period of 8 weeks was given to complete the questionnaire with three reminders.

Results: The main facilitators for E-learning according to residents were flexible timings (79.4%), better faculty engagement (52.9%), and improved small group discussions (50%). In contrast, among faculty, 93% felt that flexible timings facilitated the online classes. Faculty also concluded that faculty engagement (50%), small group discussions (42%), and asynchronous assignments (35.2%) had a positive impact. The significant barriers to the use of online education encountered by both the students (84%) and faculty (76%) were internet connectivity and integration with devices such as smartphones or laptops.

Conclusion: There is a significant rise in the use of E-learning during the pandemic leading to a better understanding of the faculty and student perspectives on E-learning. This survey sheds light on the facilitators and barriers to E-learning in Indian emergency medicine residency programs during the COVID-19 pandemic.

Keywords: COVID-19 pandemic, E-learning, emergency medicine

References

Vaona A, Banzi R, Kwag KH, Rigon G, Cereda D, Pecoraro V, et al. E-learning for health professionals. Cochrane Database Syst Rev 2018;1:CD011736.
Barteit S, Jahn A, Banda SS, Bärnighausen T, Bowa A, Chileshe G, et al. E-learning for medical education in Sub-Saharan Africa and low-resource settings: Viewpoint. J Med Internet Res 2019;21:e12449.
Undergraduate Medical Education: Thoughts on Future Challenges | SpringerLink. Available form: https://link.springer.com/article/10.1186/1472-6920-2-8. [Last accessed on 2020 Jun 20].
Integrating an Open-Source Course Management System (Moodle) into the Teaching of a First-Year Medical Physiology Course: A Case Study | Advances in Physiology Education. Available from: https://journals.physiology.org/doi/full/10.1152/advan.00008.2011. [Last accessed on 2020 Jun 20].
Gaikwad N, Tankhiwale S. Interactive E-learning module in pharmacology: A pilot project at a rural medical college in India. Perspect Med Educ 2014;3:15-30.
Lall P, Rees R, Law GC, Dunleavy G, Cotič Ž, Car J. Influences on the implementation of mobile learning for medical and nursing education: Qualitative systematic review by the digital health education collaboration. J Med Internet Res 2019;21:e12895.
Full Article: New Directions in E-Learning Research in Health Professions Education: Report of Two Symposia. Available from: https://www.tandfonline.com/doi/full/10.3109/0142159X.2012.638010. [Last accessed on 2020 Jun 20].
What do we mean by Web-Based Learning? A Systematic Review of the Variability of Interventions – Cook – 2010 – Medical Education – Wiley Online Library. Available from: https://onlinelibrary.wiley.com/doi/full/10.1111/j.1365-2923.2010.03723.x. [Last accessed on 2020 Jun 20].
Frehywot S, Vovides Y, Talib Z, Mikhail N, Ross H, Wohltjen H, et al. E-learning in medical education in resource constrained low- and middle-income countries. Hum Resour Health 2013;11:4.
Regmi K, Jones L. A systematic review of the factors – Enablers and barriers – Affecting e-learning in health sciences education. BMC Med Educ 2020;20:91.

Abstract #15

Category: Quick Shot/Case Report

Epidemiological Profile and Risk Factors related to Intensive Care Unit Admission in Patients with COVID-19, Admitted by the Emergency Department of Hospital de Clínicas de Porto Alegre

Ana Paula Freitas, Silvana Teixeira Dal Ponte

Hospital de Clinicas de Porto Alegre, Porto Alegre, Rio Grande do Sul, Brazil

Introduction: COVID-19 infection is a disease with a wide spectrum of manifestations, from mild to severe cases with progression to severe acute respiratory syndrome and multiple organ dysfunction. Our objective was to identify characteristics and risk factors related to critical illness due to COVID-19 in patients admitted to the Hospital de Clínicas de Porto Alegre (HCPA). As a secondary objective, it will be evaluated by the general profile of the cohort.

Methods: In this retrospective, single-center study, we evaluated a cohort of inpatients with COVID-19 confirmed infection, from March 9, 2020, to July 27, 2020, admitted by the HCPA Emergency.

Results: Most of the 369 included patients were male (51.8%), with a mean age of 57 years, and had previous comorbidity (284 out of 352/80.7%), the most prevalent being hypertension (48, 2%) and obesity (35%). The most common symptoms were fatigue (47.2%), myalgia (42%), and diarrhea (29.8%). The average number of days between symptom onset and hospital admission was 7.19 ± 4.49 days and between symptom onset and mechanical ventilation was 10 days. 123 patients were admitted to the intensive care bed (33.3%), 88 required invasive mechanical ventilation (23.8%), and 33 developed acute kidney injury requiring renal replacement therapy (8.9%). The overall in-hospital mortality rate was 14.9% (55), and 32.5% among patients admitted to the intensive care unit (ICU). Compared with noncritical patients, the most critical patients were older (56 vs. 59, P = 0.065) and had a higher presence of comorbidities (83.3%× 79.3% P < 0.001). Upon admission, this group had a higher SOFA score (2.8 × 1.35, P < 0.001).

Conclusion: In the cohort of this study, the most severe disease by SARS-CoV-2, that is, which requires hospitalization, affects mostly men with previous comorbidities and older age. SOFA score on admission is related to risk for admission to the ICU.

Keywords: Coronavirus, COVID 19, hospitalization in an intensive care unit, risk factor

Abstract #16

Category: Quick Shot/Case Report

Sinus Bradyarrhythmia in Accidental Kodo Millet (Paspalum scrobiculatum) Poisoning – A Case Report

R. Surendar

Jawaharlal Institute of Postgraduate Medical Education and Research, Puducherry, India

Introduction: The Kodo Millet crop known by different names such as Varagu, Harka, and Arikelu in different regions is commonly consumed and grown predominantly in India. The toxic nature of the crop is due to the compound cyclopiazonic acid, which is due to the infection of crop by certain fungus species.

Case Report: In this article, we discuss a case of Kodo Millet [Figure 1] poisoning which presented with episodes of vomiting, sweating, giddiness, and dysphagia. On examination, sinus bradycardia and hypotension were the major findings. Electrocardiograph (ECG) showed sinus bradyarrhythmia which was a rare presentation of Kodo Millet poisoning [Figure 2]. We managed the patient symptomatically [Figure 3] and he was discharged after 24 h as the symptoms and the ECG findings were reverted.

Discussion: Kodo Millet poisoning often occurs due to accidental consumption of infected crops. Its occurrence is rare and the management involves only supportive care and monitoring. However, it is important to rule out it as a possible differential diagnosis in similar case scenarios due to other causes.

Conclusion: Sinus bradyarrhythmia is a rare condition to be associated with Kodo Millet poisoning. Thus, an emergency physician should be aware of this toxicity to possibly rule out all the differential diagnosis and early management.

Keywords: India, Kodo Millet, Varagu poisoning

Abstract #17

Category: Quick Shot/Case Report

Simulation Training Exercise of the Initial Assessment and Management of the Poisoning Patient in the Emergency Department of a Teaching Hospital in South India

Linu Sekhar, Roopasree Sivam¹

J Sree Gokulam Medical College, Trivandrum, Kerala, India, ¹GG Hospital, Trivandrum, Kerala, India

Introduction: Simulation training is in novice stages in most teaching hospitals in India. This exercise was aimed to develop knowledge, skill, and attitude about the initial assessment and management of poisoning patients among house surgeons (interns) in a tertiary care center in South India.

Methods: Four house surgeons (interns) were selected for the exercise and the simulation modality was standardized patient scenario. The entire exercise lasted for 190 min, which included 20 min for the scenario and debriefing for 20 min for each house surgeon. The learning objectives of the exercise were (1) to learn history-taking skills in poisoning patients, (2) to learn to identify vital sign abnormalities and initiate appropriate interventions, and (3) to learn soft skills to deal with the agitated bystanders of the patient. After prebriefing, each intern was assigned the role of treating doctor and the entire simulation scenario was run. After the scenario was over, knowledge, skill, and attitude acquired through the simulation exercise were assessed through a posttest questionnaire for each house surgeon. At the end of the scenario for all house surgeons, a common debriefing session was held.

Results: All four students (100%) looked for vital signs and identified abnormalities whereas only three students (75%) did intervention for the abnormalities. While all four students (100%) identified the toxidrome as cholinergic, only two students (50%) took proper history after stabilization of the patient. After vomiting, 4 of the students (100%) used suctioning, but only 1 student (25%) put the patient in left lateral position. Only 1 student (25%) could deal with the angry bystander (husband) properly

Conclusion: Knowledge levels of house surgeons can be significantly improved through standardized patient simulation exercises. Soft skill acquisition (attitude) is the most difficult element in the standardized patient simulation exercise done in my Department. Simulation should be incorporated in the curriculum of undergraduate students.

Keywords: House surgeons, poisoning, simulation

Abstract #18

Category: Quick Shot/Case Report

COVID-19 Innovations in Telemedicine: Telepsychiatric Service and Delivery through a Global Health Partnership

Maria Monserrate Vasconez, Shari J Jardine, Ivan T Palacios¹

Universidad San Francisco de Quito, Quito, Ecuador, ¹Center for Global Health, Northwell Health System, Long Island, New York

Introduction: During the COVID-19 pandemic, through an ongoing international collaboration between Northwell Health and Universidad San Francisco de Quito (USFQ), a telepsychiatry program (TSP) emerged in response to urgent mental health needs identified through rural health centers in Ecuador. Serving districts D1708 and D1709 of the Metropolitan District of Quito, the program supports neglected and underprivileged populations through integrated virtual mental health services for financially vulnerable individuals. Using telemedicine to deliver mental health services is an integral and innovative mechanism to improve access and reduce stigma. Average local income is less than $3 USD per day, and this program has expanded access for individuals who were not previously able to access mental health services.

Methods: At no cost to the individual patient, the intervention includes graduate medical students from USFQ, psychiatry residents from Northwell Health, and a psychologist from each health center. The TSP team collaborates to identify, refer and provide psychiatric consultation for patients.

Results: The TSP was instituted in January 2021 and has been providing consultations for at least four patients once a week using the internet to expand equity and access to mental health services. The program comprises four main strategies: the identification and screening of patients that require a psychiatric evaluation by the health center psychologists; initial contact with patients for consent, coordination, and explanation of the program by the graduate medical students from USFQ; TSP consultation performed by the psychiatry residents from Northwell Health; and lastly the creation of an ongoing treatment plan and medication referral (if required) with the local health center in collaboration with graduate medical students from USFQ and the psychologist of the health center. Each task is carried out by a particular team member, adhering to a treatment and referral protocol.

Conclusion: This multidisciplinary approach supports inclusion and equity in mental health services, reduction of stigma in the primary care setting, and baseline knowledge of the prevalence and distribution of mental health diseases. This work could lead to future interdisciplinary research, experiential education experiences for students and medical providers in mental health, and education in telemedicine.

Abstract #19

Category: Quick Shot/Case Report

Takayasu Arteritis Presenting as Young Stroke in Emergency Department – A Case Report

R. Surendar

Jawaharlal Institute of Postgraduate Medical Education and Research, Puducherry, India

Introduction: Young stroke can present due to various causes. Takayasu arteritis (TKA) as an underlying cause of young stroke is a rare scenario. We discuss a case of young stroke due to TKA presented to our emergency department.

Case report: The patient presented with right hemiparesis, with deviation of angle of mouth to left. Computed tomography angiograph showed wall thickening around left common carotid artery in the coronal view and left cervical internal carotid artery luminal narrowing in the axial view. The patient was treated with systemic steroids for 3 weeks followed by tapering of the dose. General condition of the patient improved after initiation of steroids, and the patient was discharged after 5 days with outpatient follow-up. The major mechanism of stroke in TKA could be due to embolization, inflammatory cause, or stenotic occlusion in extracranial vessels. Our case had occlusion of left internal carotid artery and presented with stroke findings.

Conclusion: With prompt history and investigations, early diagnosis and management of TKA can be done which reduces further morbidity and disability to the patient.

Abstract #20

Category: Quick Shot/Case Report

“Coronadengue” Disease: DENV/SARS-CoV-2 Coinfections in Ecuador

Ricardo Izurieta, Tatiana Gardellini, Leandro Tana¹, Enrique Teran¹

Department of Global Communicable Diseases, College of Public Health, University of South Florida, South Florida, USA, ¹ School of Medicine, Universidad San Francisco de Quito, Quito, Ecuador

Introduction: On April 26, 2021, it has been reported the first cases of DENV/SARS-CoV-2 coinfection in Ecuador. This coinfection, which is currently referred as “Coronadengue” disease, was confirmed by laboratory testing in two patients of the Instituto Ecuatoriano de Seguridad Social Hospital “Los Ceibos” in the port of Guayaquil. The possibility of an overlapping of dengue and COVID-19 pandemics was already adverted by epidemiology and tropical infectious diseases experts worldwide and locally.^{[1],[2],[3],[4]}

Discussion: There have been a continuous dengue epidemic in Ecuador with the report of 16,570 cases in 2020 and 6528 accumulated cases in 2021, reported by April 15.^[5] As of April 30, 2021, in Ecuador, 381,862 RT-PCR–confirmed cases and 18,631 deaths have been reported.^[6] Dengue and COVID-19 diseases both exhibit nonspecific signs and symptoms, including fever, headache, abdominal pain, malaise, and nausea. In addition, in both diseases, blood tests show leukopenia, thrombocytopenia, and elevated liver enzymes, which make difficult to discern the diagnosis.^[7] In tropical endemic areas where there is the transmission of arboviruses, SARS-CoV-2 has arrived to coexist with tropical infectious diseases; therefore, it is necessary that health practitioners make a clear clinical distinction between both diseases. Besides SARS-CoV-2 RT-PCR testing, it should be run a PCR and/or NS1 testing to differentiate between a true dengue infection, a false-positive infection and DENV/SARS-CoV-2 coinfection. In dengue endemic countries like Ecuador, it would be advised to screen for COVID-19 infection in all patients with suspected diagnosis of dengue fever, and start as soon as possible COVID-19 treatment, monitoring, and quarantine.^[8] Further, the monitoring of plasma dynamics in the event of a plasma leakage should be installed though an assessment of daily symptoms and evaluation of fluid balance. Considering dengue may trigger a hypersensitivity immune reaction, it is plausible to think that SARS-CoV-2 infection is likely to give more severe symptoms in the case of a coinfection.

Conclusion: This report of DENV/SARS-CoV-2 coinfection also calls for the reinforcing of the messages among the communities to maintain the rehydration and prescribe only acetaminophen as antipyretic until the patient is seen by a health professional.

References

Panda PK, Sharawat IK. COVID-19 and/with dengue infection: A curse in an overburdened healthcare system. Trop Doct 2021;51:106-8.
Ridwan R. COVID-19 and dengue: A deadly duo. Trop Doct 2020;50:270-2.
Navarro JC, Arrivillaga-Henríquez J, Salazar-Loor J, Rodriguez-Morales AJ. COVID-19 and dengue, co-epidemics in Ecuador and other countries in Latin America: Pushing strained health care systems over the edge. Travel Med Infect Dis 2020;37:101656.
Nacher M, Douine M, Gaillet M, Flamand C, Rousset D, Rousseau C, et al. Simultaneous dengue and COVID-19 epidemics: Difficult days ahead? PLoS Negl Trop Dis 2020;14:e0008426.
Ministerio de Salud Publica. Gaceta Epidemiologica Ecuador SIVE-ALERTA. Available online at: https://www.salud.gob.ec/gaceta-epidemiologica-ecuador-sive-alerta/. [Last accessed on 2021 Dec 10].
Informe emidemiologico de COVID-19, Ecuador 2021. Available at: https://www.salud.gob.ec/wp-content/uploads/2021/12/MSP_ecu_cvd19_datos_epi_20211207.pdf. [Last accessed 2021 Dec 14].
Centers for Disease Control and Prevention: Symptoms of Coronavirus. Available from: https://www.cdc.gov/coronavirus/2019-ncov/symptoms-testing/symptoms.html. [Last accessed on 2021 Apr 30].
Masyeni S, Santoso MS, Widyaningsih PD, Asmara DW, Nainu F, Harapan H, et al. Serological cross-reaction and coinfection of dengue and COVID-19 in Asia: Experience from Indonesia. Int J Infect Dis 2021;102:152-4.

Abstract #21

Category: Quick Shot/Case Report

Flecainide-Induced Agranulocytosis - A Rare Entity

Shobi Venkatachalam

Nazareth Hospital, Philadelphia, Pennsylvania, United States

Introduction: Agranulocytosis is acute leukopenia with absolute neutrophil count <0.5 × 10^3/uL and poses a high threat of serious infections.^{[1],[2],[3],[4]} Idiosyncratic drug-induced agranulocytosis should be suspected with unexplained agranulocytosis.

Case Description: A 63-year-old male was hospitalized for acute respiratory failure from hronic obstructive pulmonary disease (COPD) exacerbation. Past history was diabetes mellitus type 2, hypertension, COPD, and sleep apnea. He received intravenous and oral steroids for COPD exacerbation. He developed atrial fibrillation with rapid ventricular rate during hospitalization. He failed to convert to sinus rhythm even with direct cardioversion. Amiodarone and intravenous diltiazem infusions were started for rate control. Subsequently, flecainide was added for rhythm control. He converted to normal sinus rhythm with flecainide. Acute-onset agranulocytosis was evident within 1 week of starting flecainide (white blood cell [WBC] count was 0.8 10³/uL and absolute neutrophil count was 16/uL). His reticulocyte count was low at 0.1% suggesting bone marrow suppression. B12 level was 321 pg/mL (Ref: 211–911 pg/mL) and serum folate was 15.7 ng/mL (Ref: >4 ng/mL). His WBC count was previously in the normal range. Peripheral blood smear showed no evidence of primary hematological malignancy. He remained afebrile and asymptomatic while being neutropenic. Flecainide was discontinued and a steady improvement in WBC count to the normal range was noted in about 4 days. He was managed with rate control strategy for his atrial fibrillation with amiodarone and diltiazem.

Discussion: Mechanisms for drug-induced neutropenia include immune-mediated destruction of neutrophils or toxic suppression of the bone marrow precursors by the drug. The very few case reports of flecainide-associated agranulocytosis were presumed to be immune mediated through antineutrophil antibodies. However, our patient had a low reticulocyte count suggesting bone marrow myeloid progenitor cells suppression by flecainide, leading to decreased neutrophil production. Our patient responded to withdrawal of flecainide; however, in drug-induced agranulocytosis patients with a prolonged recovery time, granulocyte colony-stimulating factor therapy decreases the recovery time. Known drugs associated with this dangerous complication are listed in [Table 1]. Differential diagnosis is outlined in [Table 2].

Conclusion: Failure to recognize the association of neutropenia with flecainide and discontinuing it in a timely manner may result in serious infections and death. Awareness of this association by clinicians may help mitigate such risks.

References

Andrès E, Maloisel F. Idiosyncratic drug-induced agranulocytosis or acute neutropenia. Curr Opin Hematol 2008;15:15-21.
Tesfa D, Keisu M, Palmblad J. Idiosyncratic drug-induced agranulocytosis: Possible mechanisms and management. Am J Hematol 2009;84:428-34.
Andrès E, Villalba NL, Zulfiqar AA, Serraj K, Mourot-Cottet R, Gottenberg AJ. State of art of idiosyncratic drug-induced neutropenia or agranulocytosis, with a focus on biotherapies. J Clin Med 2019;8:1351.
Gibson C, Berliner N. How we evaluate and treat neutropenia in adults. Blood 2014;124:1251-8.

Abstract #22

Category: Quick Shot/Case Report

Gender Disparities in Delivering Surgical Care on Short-Term Surgical Missions to Sierra Leone

Giovanna Mele, Fatemeh Parvin-Nejad¹, Ariel Omiunu, Lauren Hutnik, Samba Jalloh², Ziad C. Sifri¹

Departments of Medical Education and ¹Surgery, Rutgers New Jersey Medical School, Newark, NJ, USA, ²College of Medicine and Allied Health Sciences, University of Sierra Leone, Freetown, Sierra Leone

Introduction: Women receive disproportionately less access to surgical care compared to men in low- and middle-income countries (LMICs). Short-term surgical missions (STSMs) aim to alleviate surgical burdens in LMICs, yet concerns remain about gender inequalities in allocation of free surgical care. We sought to determine if women received equitable access to surgical care on STSMs. We hypothesized that women receive a lower proportion of surgical procedures compared to men.

Methods: Chart review was performed on adults undergoing elective surgery during 4 STSMs to Kabala, Sierra Leone, between 2013 and 2019 by one American nongovernmental organization. Procedure type, gender distribution, mean age, and symptom duration were collected. As some surgical diseases were sex-specific, outcomes were also measured for the single most common procedure (inguinal hernia repair [IHR]). To control for gender differences in IHR, review of literature was completed to compare published gender distribution to that seen on STSMs.

Results: Of 234 patients, females had a statistically lower representation compared to males in all surgical procedures (84% vs. 16%; P < 0.001). Mean age was 42.8 ± 13.1 years in males and 44.0 ± 13.0 years in females (P = 0.59). Duration of symptoms was significantly different between males (6.0 ± 5.7 years) and females (3.9 ± 2.3 years) (P = 0.04).

One hundred and sixty-three IHRs were performed, representing 70% of all surgeries. Female representation among IHRs (21 subjects, 13%) was not significantly different compared to aggregate findings of 45 published studies (101,021 females out of 1051,633 total subjects, 10%) (P = 0.16). Mean age (males: 41.5 ± 12.6 years vs. females: 45.1 ± 9.5 years, P = 0.21) and duration of symptoms (males: 5.7 ± 5.0 years vs. females: 3.8 ± 1.6 years, P = 0.11) were not significantly different for males and females undergoing IHR.

Conclusion: Although men receive significantly more surgeries compared to women, women receive equitable access to similar surgeries on STSMs when compared to published literature. Women also experience no delay in access compared to men when receiving equivalent procedures. This study is important in raising awareness about potential gender biases in the allocation of surgical care on humanitarian missions. Other organizations should also examine gender distribution to ensure equitable access for women in the communities they serve.

Abstract #23

Category: Quick Shot/Case Report

Global Educational Experience of a Surgical Mission Trip

Miguel Ardrade, Maria Del Los Angeles Cardenas Sanchez, Rafael Barrera

Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Long Island, New York, United States

Introduction: The main objective of medical and surgical practice is the reduction of physical and mental human suffering as a result of any disease or injury.^{[1],[2],[3],[4],[5],[6],[7]} The Northwell-UIO 2020 medical mission to Ecuador was envisioned and successfully executed to help achieve Northwell Health's goal of becoming a globally-recognized leader in high-quality and socially conscious healthcare and health education.

Methods: A Northwell-sponsored team of about thirty employees and community volunteers [Table 1] partnered with Hospital Padre Carollo, Fundación Tierra Nueva, and the Ecuadorian Ministry of Public Health, to provide surgical services to the indigent and underserved of Quito, Ecuador, from January 19 to January 24, 2020. There is usually a second visit scheduled for late October but due to the COVID-19 pandemic, it has been delayed.

Results: A total of 127 patients were evaluated, some of which were being seen in postoperative follow-up after surgical intervention during prior missions. Fifty-six patients were initially scheduled for surgery. Ultimately, 53 operations were performed, including 30 adult and 23 pediatric procedures [Table 2]. No major complications occurred, and all patients were recovering appropriately at postoperative evaluation on January 24, 2020.

Discussion and Conclusions: In addition to the above-outlined services, participating team members also provided didactic and practical training for Ecuadorian healthcare providers, residents, and students to fulfill our educational mission and further strengthen our relationship with partnering institutions. In addition, and for the first time, Northwell's Center for Global Health partnered with Universidad de San Francisco in Quito to organize a Global Health Week focused on the development of research, education, and mental health outreach and partnerships.

References

Caldron PH, Impens A, Pavlova M, Groot W. A systematic review of social, economic and diplomatic aspects of short-term medical missions. BMC Health Serv Res 2015;15:380.
Martiniuk AL, Manouchehrian M, Negin JA, Zwi AB. Brain Gains: A literature review of medical missions to low and middle-income countries. BMC Health Serv Res 2012;12:134.
Barrera R, Aronowitz D, Badauoi C, Jarrin P, Santoriello LM, Palacios I, et al. Global clinical experience of a long-term surgical mission trip. Int J Surg Glob Health 2020;3:e13.
Ologunde R, Maruthappu M, Shanmugarajah K, Shalhoul J. Surgical care in low and middle-income countries: Burden and barriers. Int J Surg 2014;12:858-63.
Debas HT, Gosselin R, McCord C, Thind A, Jamison DT, Breman JG, et al., editors. Disease Control Priorities in Developing Countries. 2^nd ed. New York: Oxford University Press; 2006. p. 1245-59.
Montgomery LM. Short-term medical missions: Enhancing or eroding health? Missiology 1993;21:333-41.
Berry N. Did we do good? NGOs, conflicts of interest and the evaluation of short-term medical missions in Sololá, Guatemala. Soc Sci Med 2014;120:344-51.

Abstract #24

Category: Quick Shot/Case Report

Levofloxacin-Induced Supraventricular Arrhythmias - A Savior Can Be Satan!

Shambhavi Sharma, Manpreet Singh, Jeet Ram Kashyap¹, Dheeraj Kapoor, Lakesh Anand, Jasveer Singh

Departments of Anaesthesia and Intensive Care and ¹Cardiology, Government Medical College and Hospital, Chandigarh, India

Introduction:Levofloxacin, the purified S-isomer, causes QTc prolongation and ventricular tachycardia in a patient with structural heart disease and rarely atrial fibrillation with prolongation of the QT interval.

Case report: We hereby, present a case of an 82-year-old male, who was admitted at hospital with mild cough and high grade fever 3 days. He had tachycardia and irregular pulse. Rest all investigations were within normal limits. Detailed history revealed that he had history of off and on discomfort after walking for 800 m. Chest examination had bilateral crepts on basal regions. Pneumonia was diagnosed and X-ray revealed left-sided mild consolidation, and electrocardiography (ECG) showed ST depression significantly. The patient was admitted in critical care unit (CCU). Oxygen, antibiotics, and other supportive therapy were administered. There was fall in SpO₂ from 94% to 88%, and he developed breathlessness. Immediately, emergency angioplasty in (left anterior descending) LAD and left circumflex arteries was done. Right posterior coronary artery was also blocked but anomalous and thus could not be stented. The patient was transitioned to postoperative CCU and noninvasive ventilation was administered. Oxygenation was maintained. The patient was advised intravenous (IV) levofloxacin BD, IV ceftriaxone 1.5 g BD + supportive treatment. On close monitoring, it was noticed that as soon as 50% of levofloxacin was administered, the patient developed atrial arrhythmias (AF). 12-Lead ECG revealed atrial ectopics although stable haemodynamically. When levofloxacin was infused, then the patient developed AF for the next 5 h, and later, heart rate became sinus rhythm. After 12 h, again, a similar event occurred after start of infusion of levofloxacin. After 3 such sequential events, it was diagnosed that levofloxacin might have led to these events. After the third event, injection levofloxacin was stopped and injection cefoperazone plus sulbactam (+antiarrythmic) was started in view of pneumonia. There was no such similar event later. The patient was discharged after 4 days.

Conclusion: Levofloxacin, a fairly popular “savior” drug, often used for pneumonia, can lead to cardiac catastrophe at any moment by inducing supraventricular arrhythmias and thus better be avoided.

Abstract #25

Category: Quick Shot/Case Report

Spontaneous Pneumomediastinum Mimicking Acute Pericarditis

Haseeb Chaudhary, Zohaib Yousaf¹, Khezar Syed

Department of Internal Medicine, Reading Hospital, Tower Health System, PA, USA, ¹Department of Internal Medicine, Hamad Medical Corporation, Doha, Qatar

Introduction: ST elevations on electrocardiogram (EKG) have can be caused by early repolarization, coronary vasospasm, acute pericarditis, ST-elevation myocardial infarction, ventricular aneurysms, and dissecting aneurysm of the aorta reaching the pericardium.^{[1],[2],[3],[4],[5]} The clinical presentation of these diseases closely resembles that of spontaneous pneumomediastinum (SPM), with sudden-onset chest pain and shortness of breath. ST-T changes on EKG mimic acute coronary syndrome posing a diagnostic challenge.^[6],[7],[8] We describe two such cases of SPM with concomitant pneumopericardium.

Case Presentations: Patient characteristics are summarized in [Table 1]

Case 1: A 19-year-old gentleman with a history of occasional marijuana use presented with acute-onset progressive central and sharp pleuritic chest pain followed by a brief syncopal episode. The vitals were normal. Examination showed crepitus around the left lower neck and Hamman's crunch on precordial auscultation. EKG showed ST segment elevations in the precordial leads. Serial troponins were negative. Chest X-ray and computed tomography (CT) chest confirmed spontaneous pneumomediastinum and pneumopericardium. The echocardiogram was unremarkable. The patient was successfully managed with analgesia, oxygen therapy, and clinical observation, with gradual resolution of EKG changes as the pneumopericardium resolved.

Case 2: A 19-year-old gentleman with a history of smoking and marijuana use, presented with left-sided chest pain radiating to the base of neck back and shoulders. His blood pressure was 162/91 mmHg, otherwise unremarkable vitals. He had supraclavicular crepitus but otherwise normal systemic examination. EKG showed diffuse ST segment elevation, PR segment depression, and evidence of left ventricular hypertrophy. Chest X-ray and subsequent CT chest showed air in the anterior mediastinum, pneumopericardium, and subcutaneous emphysema. The patient was initially started on ibuprofen and colchicine given the EKG changes highly suggestive of acute pericarditis, but later therapy was tailored to mild analgesia with clinical observation. EKG changes subsided upon resolution of pneumopericardium.

Discussion: We postulate that the EKG changes associated with pneumopericardium could be related to the direct inflammatory effect from air leakage between the pericardium and the chest wall.

Conclusion: ST-T changes may give an initial diagnostic clue of the presence of pneumopericardium accompanying SPM.

References

Bhardwaj R, Berzingi C, Miller C, Hobbs G, Gharib W, Beto RJ, et al. Differential diagnosis of acute pericarditis from normal variant early repolarization and left ventricular hypertrophy with early repolarization: An electrocardiographic study. Am J Med Sci 2013;345:28-32.
Engelmann MD, Hasbak P. Early repolarization. Differential diagnosis of electrocardiographic ST segment elevation. Ugeskr Laeger 2000;162:5914-7.
de Bliek EC. ST elevation: Differential diagnosis and caveats. A comprehensive review to help distinguish ST elevation myocardial infarction from nonischemic etiologies of ST elevation. Turk J Emerg Med 2018;18:1-10.
Brady W. ST-segment elevation in ED adult chest pain patients: Etiology and diagnostic accuracy for AMI. J Emerg Med 1998;16:797-8.
Chenkin J. Diagnosis of aortic dissection presenting as ST-elevation myocardial infarction using point-of-care ultrasound. J Emerg Med 2017;53:880-4.
Brearley WD Jr., Taylor L 3^rd, Haley MW, Littmann L. Pneumomediastinum mimicking acute ST-segment elevation myocardial infarction. Int J Cardiol 2007;117:e73-5.
Lolay GA, Burchett A, Ziada KM. Pneumomediastinum and ST-segment elevation. Am J Cardiol 2016;118:1603-4.
Skaug B, Taylor KR, Chandrasekaran S. Oesophageal rupture masquerading as STEMI. BMJ Case Rep 2016;2016:10.1136/bcr-2016-214906.

Abstract #26

Category: Quick Shot/Case Report

Posttraumatic Epigastric Swelling: Expect the Unexpected

Mohammad Khalid, Sanjan A., Vimal Krishnan S

Department of Emergency Medicine, Karturba Medical College, Manipal Academy of Higher Education, Manipal, Karnataka, India

Introduction: Trauma to pancreas constitutes 2% of all abdominal injuries. The pancreatic injury can range from simple bruising to complete transection. Pancreatic pseudocyst (PPC) is a late complication. Pancreatic injuries are often overlooked. Use of point-of-care ultrasound (POCUS) in emergency department has increased the suspicion of traumatic PPC.

Case study: Here, we report two cases of traumatic PPC.

A 23-year-old male presented after 12 days following blunt abdominal trauma via the bike handle. He complained of abdominal discomfort radiating to back with grazed abrasion over epigastric region. Initial evaluation from other hospital revealed no trauma-related injury and discharged uneventfully. Abdominal photograph is shown in [Figure 1].

POCUS revealed hypoechoic lesion in epigastric region [Figure 2]. Contrast-enhanced computed tomography (CECT) abdomen revealed pseudocyst pancreas with superior mesenteric vein thrombosis. Initially, he was managed conservatively. Pig tail catheter insertion done following increase in size. After another 10 days, he had severe abdominal pain. CECT abdomen revealed a closed loop obstruction and an emergency laparotomy was done [Figure 3].

The second case was a 15-year-old boy with blunt abdominal trauma with a football 30 days back, following which he developed pain abdomen radiating to the back for the past 2 days.

CECT abdomen was followed by an Magnetic Resonance Cholangiopancreatography (MRCP) which showed a large well-circumscribed fluid collection-pseudocyst in the lesser sac extending through gastrohepatic and hepatoduodenal ligament. Endoscopic ultrasound-guided pseudocyst drainage was done.

Discussion: Pancreatic pseudocyst formation (PPC) secondary to trauma has late presentation and is difficult to diagnose. Mortality rate is as high as 20%–40%, warranting meticulous management. Conservative management consists of bowel rest, nasogastric tube suction, somatostatin or octreotide, total parenteral nutrition, and analgesia. Failure of conservative management warrants endoscopic/percutaneous drainage methods.

Abstract #27

Category: Podium Presentation

Volumetric Densities of Emergency Medicine-Focused Meta-Analytical Research in Clinical Medicine

Ankit K. Sahu, Thomas Cox¹, Sagar Galwankar¹, Sanjeev Bhoi

Department of Emergency Medicine, All India Institute of Medical Sciences, New Delhi, India, ¹Department of Emergency Medicine, Sarasota Memorial Hospital, Florida State University, Florida, USA

Introduction: Systematic review with meta-analysis (MA) is the highest level of evidence in the evidence-based medicine pyramid, and this type of study is being conducted in the emergency medicine (EM) research more frequently nowadays, than earlier. The purpose of this systematic review was to conduct the bibliographic analysis of the published meta-analysis in topmost emergency medicine journals.

Methods: This systematic review was performed according to the Preferred Reporting Items for Systematic review and Meta-analysis. Top ten journals of the emergency medicine field (according to the Clarivate Analytics, 2020 impact factor) were searched for all published MAs in January 1, 2018, to December 31, 2020. Databases including PubMed, EMBASE, and Web of Science were also searched. The reviews without MAs, systematic review snapshots, letters, editorials, commentaries, and retracted papers were excluded. Bibliographic data of the published articles were extracted and qualitatively synthesized.

Results: A total of 127 MAs was finally included in the qualitative synthesis. Most of the MAs were published in the resuscitation (n = 46, 36.2%), followed by academic emergency medicine (n = 20, 15.7%). Pairwise MA (n = 117, 92.1%) was the most common type of MA published whereas network MA (n = 7, 5.5%), individual patient data MA (n = 2, 1.6%), and qualitative MA (n = 1, 0.8%) were less common. Median number of authors in the MA was six (interquartile range: 4–8). The majority of first authors belonged to the United States (n = 40, 31.5%) and were of EM specialty (n = 68, 53.5%). Among all the included MAs, 66 out of 127 (46.4%) articles had a biostatistician or epidemiologist as a coauthor. The number of studies in the MA varied from 2 to 84 (median: 12 studies) and the number of patients varied from 115 to 1,029,978 (median: 2080). In the EM journals, published MA mostly belonged to the clinical domains like cardiac arrest resuscitation (n = 42, 33.1%), followed by trauma (n = 13, 10.2%), cardiovascular system (n = 13, 10.2%), bedside ultrasonography (n = 10, 7.9%), etc. In cardiac arrest resuscitation, most MAs were related to prognostication after cardiac arrest, followed by chest compression technique. In trauma studies, most commonly studied subdomain was burns.

Conclusion: This study aimed at qualitatively synthesizing data on published MAs in EM literature and found that resuscitation science was the most common domain where MA were conducted.

Abstract #28

Category: Podium Presentation

Comparing Ultrasound-Guided Estimation of Internal Jugular Vein Collapsibility Index with Inferior Vena Cava Collapsibility Index and Invasively Monitored Central Venous Pressure in Patients with Shock in Emergency Medicine Department

Hannah Chawang, Nidhi Kaeley, Bharat Bhushan, Udit Chauhan, Himanshi Baid

All India Institute of Medical Sciences, Rishikesh, Uttarkhand, India

Introduction: Hemodynamic monitoring of patients in shock is very important and can be challenging in the emergency department (ED). Invasive methods such as measuring the central venous pressure (CVP) have been used in the past as an estimation of preload and right atrial pressure mainly in intensive care units. However, this is time-consuming and requires expertise in the placement of the catheter. Noninvasive techniques such as inferior vena cava parameters (diameter and collapsibility index) as an indirect measure of CVP were then extensively studied as an alternative by using portable ultrasonography. However, it poses a limitation in obesity, postabdominal surgeries, excessive abdominal gas, or intrathoracic air. Hence, recently, the use of internal jugular vein parameters has been on the rise. However, there are not many studies to prove its efficacy. The objective of this study was to compare the internal jugular vein collapsibility index (IJV-CI) and inferior vena cava collapsibility index (IVC-CI) with invasively monitored CVP in patients with shock in ED.

Methods: This was a prospective observational study in the emergency medicine department of All India Institute of medical Sciences, Rishikesh, India. Patients with a central venous catheter in the ED were included in the study. The IVC diameter and IJV parameters such as A-P diameter and cross-sectional area of the right IJV were measured in the inspiratory and expiratory phase using bedside USG. This was done at 0° and 30° position. The collapsibility indexes were calculated and compared with the invasively monitored CVP value.

Results: 73 patients were included in the study. The mean age was 49 years. The percentage of female was 36%. The correlations between CVP and IJV-CI at 0° for cross-sectional area (CSA) and diameter were r = −0.374 (P = 0.011) and r = −0.389 (P = 0.015), respectively. However, the correlations at 30° for CSA and diameter were r = −0.453 (P = 0.001) and r = −0.412 (P = 0.008), respectively.

Conclusion: The IJV-CI showed a moderate correlation between IJV parameters and CVP at 30°. The correlation was more at 30° than at 0°. Hence, it can be used as an adjunct in the assessment of fluid status in critical patients in the ED when measuring the IVC is difficult.

Abstract #29

Category: Podium Presentation

Portable Decontamination Unit for Chemical Exposure/Injuries during Festival of Colors (Holi) at a Tertiary Care Trauma Center (AIIMS, New Delhi) in India

A. Anuj, Tej Prakash Sinha

Department of Emergency Medicine, All India Institute of Medical Sciences, New Delhi, India

Introduction: Mass decontamination procedures are usually required for exposure to a variety of chemical, biological, and radiation weapons (collectively known as HAZMAT) as a part of warfare or mass casualties. India, being a land of festivals, has similar scenarios as a part of large-scale exposure to various HAZMAT, one of them being the exposure to artificial colors during Holi (festival of colors). At our trauma center, we created portable decontamination unit as a rapid and efficient procedure to decontaminate individuals or large numbers of people in a short time, especially the ones without immediate life-threatening injuries.

Methods: We demarcated the presenting area of our ED into primary and secondary decontamination corridors, observation area, and medical triage area. The medical triage area identified patients with life-threatening injuries requiring immediate clinical attention, and the rest of the patients were sent to a designated decontamination triage to rapidly identify patients who require decontamination. This allowed us to significantly reduce the time and resources needed for decontamination. If they had no signs of exposure to contaminant, they were directed to observation area; if not, they were sent to decontamination corridor.

The decontamination corridor consisted of high-volume, low-pressure water deluges to remove contaminants. We had designated personnel with adequate PPE working in the decontamination zone. They in turn required decontamination due to their proximity to release, contact with patients, and clean-up of the contaminated area. The patients being decontaminated were adequately spaced apart to reduce further secondary contamination and exposure to off-gassing. Adequate wash time was provided to ensure adequate soaking. After primary decontamination, patients were directed to secondary decontamination if required, tagged to identify their decontamination status, and directed to observation or further medical triage depending on presence of symptoms.

Conclusion: During the current pandemic, large-scale chemical exposures could be managed in resource-poor settings catering to a large population with the use of systematically designed decontamination units ready to cater to such scenarios.

Abstract #30

Category: Podium Presentation

COVID-19–Associated Primary Spontaneous Tension Pneumothorax – Case Report and Systematic Review

Fateen Ata, Zohaib Yousaf, Maya Omran¹, Adeel Ahmed Khan, Dore Chikkahanasoge Ananthegowda¹, Mohamad Khatib¹, Talat Saeed Chughtai²

Departments of Internal Medicine and ²Trauma Surgery and Thoracic Surgery, Hamad General Hospital, Hamad Medical Corporation, ¹Medical Intensive Care Unit, Hazm Mebaireek Hospital, Hamad Medical Corporation, Doha, Qatar

Introduction: Pulmonary complications of COVID-19 can include pneumonia, pulmonary embolism, and pneumothorax. Primary spontaneous tension pneumothorax (PSTP) is a rare and life-threatening complication that may lead to significant morbidity and potentially death.

Methods: We report a case of COVID-19 pneumonia in a patient with no known underlying lung disease, or risk factors for pneumothorax or barotrauma, who developed a delayed primary PSTP. A systematic literature search was performed to include eligible studies (N = 6) reporting the presence of PSTP in the setting of COVID-19 infection.^{[1],[2],[3],[4],[5],[6]}

Case Presentation: A 40-year-old Filipino gentleman, previously healthy, presented with 2 days of sore throat and progressive shortness of breath. A SARS-CoV-2 RT PCR was positive. He was tachypneic and required 10 l of oxygen to maintain adequate O₂ saturation. He was managed with antimicrobials, remdesevir, IVIG, tocilizumab, and convalescent plasma for severe COVID-19 pneumonia during his hospital stay. On day 22, his tachypnea suddenly increased (41/min), and workup revealed PSTP. An emergent chest drain was placed, and the PTX eventually resolved. The patient was discharged home asymptomatic.

Results: The mean age of 6 patients reported in the literature with COVID-19 pneumonia-associated PSTP was 47.2 ± 14.8 years. 83.3% were males. Diabetes and hypertension were the most found comorbidities (33.3% each). Among the risk factors of PSTP, smoking, noninvasive ventilation, and mechanical ventilation were present in 33% each. Dyspnea was the commonest complaint (100%), followed by cough and fever (83.3% each). 66.7% had left-sided PSTP, and 66.7% had a mediastinal shift. Chest drain (CD) was inserted in 100% cases, with VATS, pleurectomy, and pleurodesis in 16.7% each. Death was reported in one patient. Our patient presented with dyspnea and fever. He developed PSTP during on 22^nd postadmission day. A chest tube was inserted with subsequent resolution of PSTP, and the patient was discharged asymptomatic. Key summary results are presented in [Table 1].

Conclusion: PSTP is rarely associated with COVID-19 infection. Although serious, it is treatable, if diagnosed early, with a recovery rate of 85.7%. In the absence of other risk factors, it can be concluded that COVID-19 can be an independent risk factor for the development of PSTP.

References

Flower L, Carter JL, Rosales Lopez J, Henry AM. Tension pneumothorax in a patient with COVID-19. BMJ Case Rep 2020;13:e235861.
Al-Shokri SD, Ahmed AO, Saleh AO, AbouKamar M, Ahmed K, Mohamed MF. Case report: COVID-19-related pneumothorax-case series highlighting a significant complication. Am J Trop Med Hyg 2020;103:1166-9.
Umar Shahzad M, Han J, Ramtoola MI, Lamprou V, Gupta U. Spontaneous tension pneumothorax as a complication of COVID-19. Case Rep Med 2021;2021:4126861.
Khurram R, Johnson FT, Naran R, Hare S. Spontaneous tension pneumothorax and acute pulmonary emboli in a patient with COVID-19 infection. BMJ Case Rep 2020;13:e237475.
Rehnberg L, Chambers R, Lam S, Chamberlain M, Dushianthan A. Recurrent pneumothorax in a critically ill ventilated COVID-19 patient. Case Rep Crit Care 2020;2020:8896923.
Kasturi S, Muthirevula A, Chinthareddy RR, Lingaraju VC. Delayed COVID-19 sequel – A challenging case of recurrent spontaneous pneumothorax. Research Square; 2020;11:1-9.

Abstract #31

Category: Podium Presentation

Incremental Benefit in Adding Thrombo-Elastography to Routine Management of Acute Trauma Patients in Emergency Department at Tertiary Care Trauma Center in India: An Interim Study Update

A. Anuj, Tej Prakash Sinha, Sanjeev Bhoi

Department of Emergency Medicine, All India Institute of Medical Sciences, New Delhi, India

Introduction: The use of thrombo-elastography (TEG) has become routine clinical practice in the management of acute trauma patients in higher-level centers across the world. However, in resource-poor settings, the availability of the same in a timely fashion for incorporation into routine clinical management is still difficult. We tried to compare the incremental benefit that TEG provides to guide transfusion requirements using various outcome parameters and transfusions avoided as compared to management based on clinical parameters and blood gas analysis which is routinely available

Methods and Discussion: We are conducting a randomized control trial involving patients triaged to the red area of our trauma emergency department. Transfusion requirements in the interventional group were guided by TEG in addition to clinical parameters and blood gas analyses. In the control group, the transfusion was guided solely based on clinical and blood gas parameters. The primary end point was difference in the transfusion requirements of two groups. Secondary end points included outcome parameters including mortality, duration of stay in the red area (requiring critical clinical monitoring), total duration of hospital stay, requirement of emergency laparotomy, development of hospital-acquired infection, and improvement in coagulation parameters.

Conclusion: This study attempts to quantify the incremental benefit of TEG in routine clinical management of acute trauma patients. This could potentially guide the process of allocation of resources in resource-poor settings in developing countries without necessarily hampering the best clinical care that can be provided in such settings

Abstract #32

Category: Podium Presentation

The Demographics of Tolosa-Hunt Syndrome in Qatar

Zohaib Yousaf, Fateen Ata, Suresh Nalaka Menik Arachchige, Saman Rose, Awni Alshurafa, Bassam Muthanna, Muhammad Zahid

Hamad Medical Corporation, Doha, Qatar

Introduction: Tolosa-Hunt syndrome (THS) is an extremely rare disease that manifests mainly as painful ophthalmoplegia. There is no single confirmatory test to diagnose THS; hence, a careful exclusion of other possibilities and applying validated diagnostic criteria such as the International Classification of Headache Disorders (ICH) – 3 diagnostic criteria aid in diagnosis. There is limited literature with regard to varied presentations, diagnosis, and management of THS. Steroids have some evidence in the management of THS, including both benign and inflammatory subtypes.

Methods: We conducted a single-center, retrospective study in Hamad General Hospital, the tertiary care hospital under Weill Cornell Medicine affiliated-Hamad Medical Corporation, Qatar. We included patients who were admitted with a diagnosis of THS from January 2015 to December 2020.

Results: Our cohort included 31 THS patients with different ethnic backgrounds, mainly Asians and Arabs (18 and 9, respectively). Visual disturbance was the most frequent presenting complaint (96.8%) followed by headaches (80.6%) [Figure 1]. Third nerve paralysis (partial or complete) was seen in 70.9% of cases. THS involved the left side in 61.3%, whereas the right side was involved in 38.7% of patients. Cerebrospinal fluid (CSF) analysis was abnormal in only 9.7% of cases. Magnetic resonance imaging (MRI) was abnormal in 64.5% of cases, with granulomatous lesions seen in 67.7% and high-intensity ring appearance along the optic nerve seen in 22.6% of cases. Biopsy of the affected tissue was carried out in 5 patients, and none was found abnormal. 100% of patients received steroids, with a response rate of 70.9% and a recurrence rate of 9.7%. The ICHD–3 diagnostic criteria were applicable on 54.8% of our patients. When divided among benign and inflammatory THS, the criteria were applicable in 85% of inflammatory THS patients.

Conclusions: THS is a rare disease with some possible ethnic variation in presentation and response to treatment. Our patient population had a higher rate of benign THS and a better response rate to steroids than international trends. ICHD-3 diagnostic criteria had a good validity in the inflammatory subtype of our patients. ICHD-3 criteria are not applicable on benign THS, and a strong clinical judgment is required to diagnose it.

Abstract #33

Category: Podium Presentation

Efficacy and Safety of Rituximab as Second-Line Therapy in Immune Thrombocytopenia Purpura Based on Ethnicity, A Study among the Arab Population

Fateen Ata, Zohaib Yousaf, Fathima Z. Zahir, Anas Mohamed Babiker, Amer Ali Farooqi, Mousa Ahmad AlHiyari, Adel Issam Al Bozom, Ahmed Hatim Mohamed, Abdulqadir J. Nashwan¹, Mohamed A. Yassin²

Department of Internal Medicine, Hamad General Hospital, Hamad Medical Corporation, ¹Department of Nursing for Education and Practice Development, Hamad Medical Corporation, ²Department of Medical Oncology/Hematology, National Centre for Cancer Care and Research, Hamad Medical Corporation, Doha, Qatar

Introduction: Rituximab is an anti-CD-20 monoclonal antibody used as the second-line therapy in immune thrombocytopenia purpura (ITP) patients who do not respond to or cannot tolerate first-line management, including steroids or splenectomy. The response rate for rituximab is variable in different populations ranging from around 30%–90%. Adverse effects of rituximab in ITP patients range from infusion site reactions to reactivation of hepatitis B virus and development of progressive multifocal leukoencephalopathy. The frequency of adverse effects also carries an interpopulation variation.

Methods: We conducted a single-center, retrospective study in the National Center for Cancer Care and Research, Qatar. We included chronic refractory ITP patients who received rituximab as a second-line therapy from January 2015 to December 2020. The data were analyzed based on ethnicities to ascertain the response rates in the Arab population. The response criteria were described based on the platelet levels: Complete response (CR) (>100 × 10⁹/L), partial response (PR) (51–100 × 10⁹/L), minor response (31–50 × 10⁹/L), and no response (1–30 × 10⁹/L).

Results: Out of 41 chronic ITP patients, most of the patients were Arabs (N = 26), followed by Asians (N = 12) and other ethnicities (N = 3). Rituximab was associated with an overall response rate of 80.4%, with CR in 58.5% and PR in 22%. Among the ethnicities, Arabs had the highest clinical response (84.6%) with the lowest adverse effects (11.5%). Asians had a response rate of 66.6%, with adverse effects seen in 16.7% of patients [Table 1].

Conclusions: In chronic refractory ITP, rituximab as a second-line agent has a very good clinical response in the Arab population with minimal toxicity compared to other ethnicities. More extensive trials are required to validate our results to enhance the safe use of rituximab in refractory ITP.

Abstract #34

Category: Podium Presentation

Quality Improvement Project to Improve Documentation of Smoking Status and Referral to Smoking Cessation Clinic in Patients Admitted to Medical Floor with Cerebrovascular Diseases

Zohaib Yousaf, Adeel Ahmad Khan, Rohit Sharma, Muhammad Bilal Jamshaid, Aamir Shahzad, Rashid Kazman, Fateen Ata, Muhammad Zahid

Hamad Medical Corporation, Doha, Qatar

Introduction: Smoking is a major risk factor for cardiovascular and cerebrovascular diseases. According to the World Health Organization, smoking is directly responsible for nearly 7 million deaths/year worldwide. The European Society of Cardiology recommends use of 5A's (Ask, Advise, Assess, Assist, and Arrange) approach for assessing smoking status of patients.

Methods: Baseline data of 100 patients for assessing documentation of smoking status and referral to smoking cessation clinic upon discharge for patients admitted with diagnosis of cerebrovascular accident (CVA) to acute medical assessment unit, Hamad General Hospital, Doha, Qatar, were collected. Smoking status was assessed in 74% of patients, 28% of patients were advised to quit smoking, and 28% were referred to a smoking cessation clinic. Problem statement: A significant number of our patients have cerebrovascular diseases. Lack of proper assessment of smoking status and referral to smoking cessation clinic prevents addressing a preventable cause of morbidity.

Aim Statement: The aim of this project was to improve smoking status documentation from 74% to 85%, advice to quit smoking from 28% to 45%, and smoking cessation clinic referrals from 28% to 45% in patients with cerebrovascular disease admitted to acute medical assessment unit (6 North 1), Hamad General Hospital, Qatar, from May 2019 to July 2019.

Process Measure: Documentation of the patient's smoking status, advice to quit smoking, and referring patients to smoking cessation clinic.

Outcome Measure: Improvement in smoking status documentation from 74% to 85%, advice to quit smoking from 28% to 45%, and smoking cessation clinic referrals from 28% to 45%.

Balancing Measure: More workload on medical personnel and more time requirement Interventions for change: After analysis of contributory factors via fishbone, following interventions for change were carried out: Cycle 1–2:-Conduct of educational sessions for residents about 5 A's approach to smoking assessment.-Orientation sessions for medical residents about smoking cessation clinic's availability at Hamad Medical Corporation, Qatar. Cycle 3–6: Distribution of handouts to medical trainees outlining importance of smoking cessation on patient outcome and role of 5 A's approach in achieving smoking cessation.-Regular reminders/feedback to residents in the form of E-mails.

Results: Six PDSA cycles were conducted. A total of 38 patients were included in 6 PDSA cycles, with a minimum of 5 patients in each PDSA cycle. Results were plotted on run charts. Target of 85% documentation of smoking status was achieved within four consecutive PDSA cycles (3–6). Documentation of advice to quit smoking reached the target of 45% within three consecutive PDSA cycles (4–6). Referrals to smoking cessation clinic improved to 45% within three consecutive PDSA cycles (4–6).

Conclusion: Documentation of smoking assessment using 5 A's approach can help appropriate assessment of smoking status and aid in assisting patients quit smoking, thereby decreasing the risk of mortality from cerebrovascular and cardiovascular diseases. Conduct of educational sessions for medical residents about importance of smoking cessation, 5 A's approach of smoking cessation, and orientation about the resources available and regular reminders are some strategies that can help in improving documentation of smoking status of patients. This, in turn, can improve referral to smoking cessation clinics, which increases the rate of smoking cessation among patients.

Abstract #35

Category: Podium Presentation

The Impact of COVID-19 on the Resident Well-Being in a Single US Healthcare System

Haseeb Chaudhary, Zohaib Yousaf^1,2, Anthony Donato

Department of Medicine, Tower Health, West Reading, Pennsylvania, United States, ¹Department of Medicine, Hamad Medical Corporation, Doha, Qatar, ²Dresden International University, Dresden, Germany

Introduction: Coronavirus disease 2019 (COVID-19) is an ongoing pandemic that has resulted in unprecedented physical and mental stress on the frontline healthcare worker. Resident physicians are the most vulnerable physician population in the healthcare system; hence, assessing their well-being during the pandemic is critical. The objective of this study was to assess the resident physicians' well-being during the COVID-19 pandemic and analyzing factors affecting it.

Methods: We measured physician well-being using the 7-question Mayo physician well-being index (WBI) in resident physicians in one six-hospital system in July and August 2020, at the nadir of the first COVID-19 pandemic, comparing our scores to last year's as well as national resident benchmarks.

Results: The response rate was 30%. The mean WBI score for all participants was 2.42 (standard deviation [SD] 1.83) versus 3.37 (SD 2.14) for the US national average for medical residents, with higher scores indicating higher levels of distress. Incidence of high stress (defined as WBI score >5) was 15.8% in the surveyed population, lower than both last year's survey (20.4%) and lower than the rate in the 2020 national resident survey (19.4%). Ninety-two percent of surveyed participants reported adequate training in donning and doffing PPE, and 81% reported PPE availability. Third-year residents and males had the highest overall scores and were both higher than the 2019 survey. Key study results are summarized in [Table 1], [Table 2], [Table 3].

Conclusions: Resident well-being in a US healthcare system as measured by Mayo WBI was not worse at the nadir of the first wave of the COVID-19 pandemic. When facing novel healthcare threats, adequate equipment availability, adequate training, and a well-managed patient care burden can positively impact resident physicians' well-being.

Abstract #36

Category: Podium Presentation

The Use of Point-of-care Ultrasound as Initial Diagnostic Tool in Patients with Acute-Onset Dyspnea in the Emergency Department of a Tertiary Care Center: a Diagnostic Accuracy Study

Himanshi Baid, Vempalli Nagasubramanyam¹, Subodh Kumar, Poonam Arora, Rohit Walia, Udit Chauhan, Krishna Shukla, Aakash Verma, Hannah Chawang, Disha Agarwal, Nidhi Kaeley, Bharat Bhushan Bharadwaj, Ankita Kabi, Naman Agrawal

All India Institute of Medical Sciences, Rishikesh, Uttarakhand, ¹All India Institute of Medical Sciences, Gorakhpur, Uttar Pradesh, India

Background: Dyspnea is one of the common symptoms patients present to the emergency department (ED). The broad spectrum of differentials often requires laboratory and radiological testing in addition to clinical evaluation, which may cause unnecessary delay. Point-of-care ultrasound (PoCUS) has shown promising results in accurately diagnosing patients with dyspnea, thus becoming a popular tool in ED settings while saving time and maintaining acceptable safety standards.

The purpose of this study was to study the utilization of PoCUS in patients with acute dyspnea as an initial diagnostic tool in the ED.

Methods: Adult patients presenting to the ED with acute dyspnea were prospectively enrolled. They were clinically evaluated, and the treating emergency physician (EP) ordered necessary investigations. A provisional diagnosis was made, initial treatment started. Another EP, trained in PoCUS, performed the scan, blinded to the laboratory investigations but not to the clinical evaluation parameters, and made a PoCUS diagnosis. The gold standard was the final composite diagnosis made by two emergency medicine consultants, who had access to all the investigations. Accuracy and concordance of the ultrasound diagnosis to the final composite diagnosis were calculated. The time to formulate a PoCUS diagnosis and final composite diagnosis was recorded and compared.

Results: A total of 237 patients were enrolled. The PoCUS and final composite diagnosis showed a good concordance (κ = 0.668). PoCUS showed a high sensitivity for acute pulmonary edema, pleural effusion, pneumothorax, pneumonia, pericardial effusion, and low sensitivity for AECOPD (acute exacerbations of chronic obstructive pulmonary disease) and ARDS/ALI (acute respiratory distress syndrome / acute lung injury). High overall specificity was seen.A high positive predictive value for all the diagnoses except left ventricular dysfunction, pericardial effusion, noncardiopulmonary causes of dyspnea, and a high negative predictive value for all except pneumonia was also seen. The median time taken to make PoCUS diagnosis was 15.6 min, while the median time taken for formulating the final composite diagnosis was 169.8 min. Thus, the time was significantly lower for PoCUS diagnosis with a P < 0.001.

Conclusion: PoCUS shows promise as a bedside initial diagnostic modality that may expedite the decision-making in ED for patients' prompt management and disposition with reliable accuracy.

Abstract #37

Category: Podium Presentation

Characterizing Breast Disease Literature Produced by Fellows of the West African College of Surgeons: Quantity, Content, and Local Impact

Fatemeh P. Parvin-Nejad, Gary S. Hoffman¹, Adriana I. Suarez-Ligon, Benedict C. Nwomeh², Philip M. Mshelbwala³, Ziad C. Sifri

Department of Surgery and ¹Rutgers New Jersey Medical School, Newark, NJ, ²Division of Pediatric Surgery, Nationwide Children's Hospital, Columbus, OH USA, ³Division of Pediatric Surgery, Department of Surgery, University of Abuja Teaching Hospital, Gwagwalada, FCT, Nigeria

Introduction: Breast cancer is the most common malignancy diagnosed in West African women and represents a rising disease burden with approximately 8% of the region's known surgical DALYs.^{[1],[2],[3],[4]} Understanding the insights of surgical providers is vital to improving local breast cancer care.^[5] However, the contribution of surgeons in the West African College of Surgeons (WACS) to breast cancer research, especially that dedicated to local populations, is unknown. This study aims to quantify research efforts by West African surgeons studying breast diseases and to evaluate the local relevance and impact of these authors' work.

Methods: Surgeons from 17 West African countries were identified from the WACS fellows roster. A bibliometric Scopus database search was completed to collect all articles published by WACS authors. Titles related to breast diseases were identified and further categorized by publication date, author order, research type, loco-regional relevance, and journal location.

Results: Of 7142 articles, 307 articles (4%) related to breast disease; 237 examined breast malignancies specifically. One hundred and fifty-two WACS surgeons were contributing authors, representing 32% of first authors. Publication dates ranged from 1964 to 2020, with 49% of articles published after 2010. One hundred and seventy-three titles (56%) included keywords specific to West Africa; another 48 (16%) related to general African populations or people of African descent [Figure 1]. One hundred and twenty-one articles (39%) were published in African journals, with an additional 168 articles (55%) in US or Western European journals. All but 45 articles (15%) either included Africa-related keywords or were published in African journals.

Conclusion: Breast disease is an underrepresented topic in West African surgical research, constituting 4% of publications by WACS surgeons but 8% of the region's surgical burden. However, most of this literature describes African populations or is disseminated in African journals, and nearly half was published within the last 10 years. These findings indicate that research efforts by West African surgeons are locally-focused but must continue to expand to match the region's rising burden of breast disease. Further studies may examine the content of publications on diagnostic and management strategies to identify areas for growth in clinical care.

References

Bray F, Ferlay J, Soerjomataram I, Siegel RL, Torre LA, Jemal A. Global cancer statistics 2018: GLOBOCAN estimates of incidence and mortality worldwide for 36 cancers in 185 countries. CA Cancer J Clin 2018;68:394-424.
Adeloye D, Sowunmi OY, Jacobs W, David RA, Adeosun AA, Amuta AO, et al. Estimating the incidence of breast cancer in Africa: A systematic review and meta-analysis. J Glob Health 2018;8:010419.
Azubuike SO, Muirhead C, Hayes L, McNally R. Rising global burden of breast cancer: The case of sub-Saharan Africa (with emphasis on Nigeria) and implications for regional development: A review. World J Surg Oncol 2018;16:63.
Ji P, Gong Y, Jin ML, Hu X, Di GH, Shao ZM. The burden and trends of breast cancer from 1990 to 2017 at the global, regional, and national levels: Results from the global burden of disease study 2017. Front Oncol 2020;10:650.
Carter I. Creating locally relevant health information. PLoS Med 2005;2:e46.

Abstract #38

Category: Podium Presentation

Economic Effects of Air Purification Technology on Healthcare-Acquired Infection Costs: A Study of Simulated Implementation across Low-and-Middle-Income Regions of the Globe

Kathryn C. Kelley, Susan D. Schlener¹, Lee Levicoff, Stanislaw P. Stawicki

St. Luke's University Health Network, ¹Phoebe Ministries, Allentown Campus, 1925 Turner Street, Allentown, PA, USA

Introduction: Many pathogens responsible for healthcare-acquired infections (HAIs) exhibit airborne transmission. HAIs carry an estimated cost up to 3.8% of the annual global GDP, with rates reaching 15%–19% hospitalizations in low-and-middle-income countries (LMICs). Mitigation of HAIs should be promoted beyond high-income countries (HIC). This is a two-part study investigating the use of an advanced air purification technology (AAPT) on HAIs in two HIC care settings, followed by a simulated economic scenario for sustainably extending such paradigm to LMICs.

Methods: An IRB-approved study of AAPT was conducted in an acute care hospital's medical/surgical floor (ACH-MSF) and in a long-term care facility (LTCF) memory support floor. In ACH-MSF setting, three zones were studied: control floor with high efficiency particulate air (HEPA) filtration; mixed HEPA and AAPT remediation; and AAPT remediation. In LTCF, two study zones were control floor with HEPA and AAPT remediation. Statistical comparisons of HAI rates between each study zone in both settings were conducted. Furthermore, an economic study of observed effect sizes was superimposed on existing LMIC data simulating potential health system savings associated with AAPT implementation.

Results: In total, 8345 patients were studied across both settings. The ACH-MSF data demonstrated a nonstatistically significant decrease (30.2%) in HAIs in the AAPT zones (0.40% and 0.48%) compared to the control zone (0.63%). The LTCF data showed a significant decrease (39.8%) in HAIs postinstallation (1.0 vs. 1.66 HAIs/month preinstallation). Due to paucity of international data, primary economic calculations were based on the estimated HAI-related costs associated with hospital length of stay (HLOS) using 2 additional patient-days per HAI event. When extrapolated to LMIC data, savings exceeded $2.66 billion globally [Table 1].

Conclusions: When extrapolated across all LMICs, AAPT has the potential to reduce global healthcare expenditures by a total of $2.66 billion. This estimate assumes “best case” scenario with lowest reported/estimated HAI rates and lowest associated excess HLOS, along with the initial investment cost of approximately 10% of the overall estimated benefit. Based on our simulation, a strong case can be made for AAPT implementation across LMICs, with significant anticipated health system savings.

Abstract #39

Category: Podium Presentation

Waxing in Productivity: Describing the Academic Output of the West African College of Surgeons and Assessing the Contributions of Outside Collaboration

Gary S. Hoffman, Fatemeh P. Parvin-Nejad¹, Matthew Linz, Giovanna Mele, Elizabeth Akbulut², Sarah Elina Salter, Christopher Goydos, Dina Saba, Arnold Oparanozie, Edwige Dossou-Kitti, Benedict C. Nwomeh³, Philip M. Mshelbwala⁴, Ziad C. Sifri¹

Departments of Medical Education and ¹Surgery, Rutgers New Jersey Medical School, ²Rutgers University, Newark, NJ, ³Division of Pediatric Surgery, Nationwide Children's Hospital, Columbus, OH, ⁴Division of Pediatric Surgery, Department of Surgery, University of Abuja Teaching Hospital, Gwagwalada, FCT, Nigeria

Introduction: General surgeons in West Africa face a high burden of disease and wide scope of practice, including a large amount of subspecialty work. Despite these challenges, the West African College of Surgeons (WACS) maintains a significant research output. Though previous work has quantified this body of literature, its content has not yet been examined. This study aims to describe WACS academic output to identify areas of particular strength and potential gaps for further research. In addition, we sought to investigate if content varies upon collaboration with high-income countries (HICs).

Methods: A roster of WACS general surgery fellows was used to query Scopus for articles published by each member. Content categories were assigned after reviewing article abstracts. HIC collaborators were identified based on the World Bank income category of their institution's country. A two-proportion Z-test was used to compare content in articles with and without HIC collaboration.

Results: The 7142 articles encompassed 36 content tags. The most frequent content categories were pediatric surgery (1335, 18.7%), surgical oncology (1279, 17.9%), and urology (1034, 14.5%) [Table 1]. Of all 13,916 tags, 6591 (47.4%) encompassed general surgery topics, 3326 (23.9%) involved surgical subspecialties, and 1716 (12.3%) described nonsurgical fields. HIC collaboration was observed in 942 articles (13.2%), whereas 6200 (86.8%) were published solely by West African institutions. Articles concerning access, academia, breast surgery, demographics, and surgical oncology demonstrated higher HIC collaboration, while articles studying pediatric surgery, orthopedics, gastroenterology, otolaryngology, and abdominal surgery had more independent work from West African institutions.

Conclusion: General surgeons in West Africa conduct research in a wide array of surgical and nonsurgical specialties. Scarcity of research in some areas, such as transplant and endocrine, highlights the potential for further study. A small percentage of abstracts featured HIC collaboration, reinforcing the independent nature of WACS academic output. In addition, there were significant differences in content when HIC institutions were involved. Although this may represent differing research interests, it also highlights areas such as breast surgery in which HICs have more exposure, revealing opportunities for HICs to provide potentially valuable input in West African surgical research.

Abstract #40

Category: Podium Presentation

Adequacy of Advance Directives in Patients Admitted to the Intensive Care Unit

Logan Hochwald, Maya Roth¹, Fontenot Bailli¹, Darian Harris¹, Stacey Rhodes¹, Evrim Oral², Lisa Moreno-Walton^1,3

Concordia University, ¹Louisiana State University Health Sciences Center New Orleans, ²Louisiana State University Health Sciences Center, New Orleans School of Public Health, ³University Medical Center New Orleans, New Orleans, Louisiana, USA

Introduction: Advance directives (ADs) state patient wishes regarding medical care when they are unable using a living will and/or power of attorney (POA). Recent studies found that intensive care unit (ICU) patients with a do not resuscitate (DNR) status have higher mortality rates. Another study found 11% of healthcare providers use chest compressions if DNR patients sustain cardiopulmonary arrest, indicating in-depth analysis of frequency and efficacy of ICU admissions for DNR patients could improve ADs. Our objectives were to determine the number of ICU patients admitted with an AD, if they outlined specific wishes, and life support measures aligned with ADs, if ADs limit futile procedures.

Methods: We conducted a chart review of 1134 patients ≥18 years admitted to University Medical Center, New Orleans ICU, from August 2015 to March 2019. We recorded demographic information and specific wishes of patients with an AD and/or POA. Data were analyzed using SAS 9.4 (SAS Institute, Cary, North Carolina). Associations between categorical variables were assessed with Fisher's exact and Pearson's Chi-square tests. Associations between presence of ADs and sociodemographic factors such as gender and race were assessed.

Results: Study population consisted of 1134 patients, 697 males, 68% Black, 25% White, 4% Hispanic, 2.7% other, and 1.6% declined. 383 had an AD and 90 had a POA; only 24 ADs and 46 POA stated specific wishes; 47 received care aligned with their wishes and 2 did not. Comparing ADs among males versus females, odds of having an AD were 0.742 (confidence interval 0.584–1.454), and Blacks versus Whites had odds of 1.742 (confidence level 1.272–2.386). Life support measures were given to 153 patients with an AD and 188 without an AD. Chi-square analysis produced a Chi-square value of 26.6859; P = 2.394e-7.

Conclusion: Out of 1134 patients, 383 had an AD, 90 had a POA, while 24 AD and 46 POA stated exact wants. 40 ADs were followed correctly when requiring a more intense level of care. Blacks were more likely to have an AD than Whites, males were less likely to have an AD than females, and patients with an AD were more likely to not receive life support measures.

Abstract #41

Category: Podium Presentation

The Efforts to Diversify Faculty within Their Departments: A National Survey of Emergency Medicine Department Heads

Alexis Jones, Darian Harris¹, Stacey Rhodes¹, Jessica Fox², Evrim Oral², Lisa Moreno − Walton^1,3

Xavier University, ¹Louisiana State University Health Science Center New Orleans, ²Louisiana State University Health Science Center New Orleans School of Public Health, ³University Medical Center New Orleans, New Orleans, Louisiana, USA

Introduction: There is growing evidence that clinician bias, racism, inequality, stereotyping, and discrimination have indeed contributed to health inequities. These variables are proven to have negative effects on patient care and health outcomes. Studies have shown that diversifying the physician workforce can produce better patient outcomes and decrease health disparities. Patients are more likely to communicate higher levels of care satisfaction when treated by health professionals who share their racial, ethnic, or cultural background. Although many health centers, hospitals, and divisions are determined to promote diversity among their faculty and staff, there has been little progress in minority representation. This study aims to assess diversity in emergency medicine departments nationwide, diversity efforts, and the effectiveness of those methods.

Methods: This is a national convenience sampling of 263 emergency medicine department heads including medical directors, section chiefs, and department chairs. A REDCap questionnaire was developed and distributed. Participation was tracked and weekly follow-up reminders were sent to participants. Interim analysis was conducted on participants. Statistical analysis was carried out in SAS 9.4 (SAS Institute, Cary, North Carolina). Fisher's exact tests were conducted to assess the associations between variables.

Results: Our interim analysis consisted of the first 24 responses, 17 males (70.8%) and 7 (29.2%) females, with aligning gender identity. Participants self-identified as follows: White (91.7%), Blacks (8.3%), and Hispanics/Latinos (4.2%). Looking at suburban versus urban programs where 3–5, 6–10, and >10 physicians of color were hired, we found the following for suburban (0, 0, 0) versus urban (4, 3, 3), respectively (P < 0.0483).

Conclusion: Based on this interim analysis, we conclude that 66.7% of the participants classify as white males. While 66% of the non-White leaders hired 6–10 physicians of color, only 5% of white leaders hired 6–10 physicians of color. When asked how successful their efforts were to diversify their staff, 3 respondents reported their efforts were very successful versus 20 respondents reported either partially or not very successful. Looking at programs that hired 3 or more physicians of color, we found an association between the type of location (suburban versus urban) and the number of physicians of color hired by leaders.

Abstract #42

Category: Podium Presentation

Assessment of Posttraumatic Stress Disorder among Emergency Medical Services: A Survey Study within an Urban Emergency Medical Service

Corinne Martin, Kasha Bornstein¹, Lauren Rodriguez², Darian Harris², Stacey Rhodes², Jeffery Elder³, Emily Nichols⁴, Evrim Oral⁵, Lisa Moreno-Walton³

Louisiana State University, Baton Rouge, ¹University of Miami School of Medicine, FL, ²Louisiana State University Health Science Center New Orleans; ³City of New Orleans Emergency Medical Services, ⁴Louisiana State University Health Sciences Center School of Public Health, ⁵Department of Emergency Medicine, Louisiana State University Health Sciences Center, New Orleans, USA

Introduction: Emergency medical service (EMS) workers are usually the first medical providers during emergencies and disaster scenarios and often face dangerous and traumatic events. Workplace stress and exposure are strongly associated with greater rates of posttraumatic stress disorder (PTSD) and depression than the general population. Research has identified increased psychological distress in a population following natural disasters. Few studies have assessed the effects of these events on EMS workers. The severity of psychological trauma from working through Hurricane Katrina and the subsequent recovery has mental health implications for first responders. New Orleans was hit by Hurricane Katrina 15 years ago and is currently an epicenter of COVID-19. This study aims to identify the prevalence of PTSD in New Orleans EMS (NOEMS) workers who participated during Hurricane Katrina and/or the COVID-19 crisis as compared to the general population and assess if exposure to such events builds resiliency.

Methods: NOEMS workers fitting study criteria were given an anonymous questionnaire including a validated PTSD DSM-IV assessment tool and demographic questions. Responses, specific covariates, and PTSD scores were determined by symptom severity and a severity threshold of 30. PCL_C score comparisons were made with respect to demographics using Kruskal–Wallis, Wilcoxon rank-sum, or Student's t-tests depending on statistical assumptions. We modeled PTSD using multivariable logistic regression.

Results: Of the 85 respondents, PTSD point prevalence was 55.3%. 60% were male, 69.41% White, 91.43% non-Hispanic, and 51.76% had no children. 82.93% lived with children. 69.05% were paramedics, averaging 11.5 years of experience; 57.14% lived in New Orleans post-Katrina, 21.74% sought therapy, 72.94% worked only during COVID-19, and 27.06% worked both Hurricane Katrina and the pandemic. Females had higher severity scores versus males (P = 0.0352). Black EMS workers working during COVID-19 were 4.4 times more likely to have PTSD versus their White counterparts (P = 0.0395).

Conclusion: 33.7% met PTSD diagnostic criteria. Of those, the majority were White, male, lived in NOLA post-Katrina, and trained paramedics. Respondents who worked during Hurricane Katrina and COVID-19 showed a lower percentage of PTSD versus those who only worked during COVID. Respondents who worked Katrina and COVID-19 had a lower average of severity scores.

Abstract #43

Category: Podium Presentation

Hepatitis C among Incarcerated Population in an Urban Emergency Department

Alina Mohiuddin, Jackson Mierl¹, Stacey Rhodes¹, Jessica Fox², Evrim Oral², Lisa Moreno^1,3

Loyola University New Orleans, ¹Louisiana State University Health Science Center New Orleans, ²Louisiana State University Health Science Center New Orleans School of Public Health, ³University Medical Center New Orleans, New Orleans, Louisiana, USA

Introduction: Louisiana has one of the highest incarceration rates and a high prevalence of hepatitis C virus (HCV). One-third of all US HCV cases are among the incarcerated. Barriers to care impair proper treatment. The Centers for Disease Control and Prevention states 90% of HCV cases are curable if treated. Despite a cure, high rates of HCV morbidity and mortality exist among the incarcerated in Louisiana. At University Medical Center New Orleans (UMCNO), one of the first emergency department (ED)-based HCV testing programs was initiated in 2015. We averaged >200 in-custody visits per month in our ED. This study aimed to estimate follow-up rates, demographics, and HCV prevalence among the incarcerated at UMCNO.

Methods: This was a retrospective chart review of 285 in custody patients screening positive for HCV in our ED, March 1, 2013, to October 1, 2017. We reviewed charts to determine if referral orders were placed, appointments given, and if appointments were attended. Those linked to care were assessed regarding treatment. Demographics were collected. Statistical analysis was carried out using SAS 9.4 (SAS Institute, Cary, North Carolina). Basic descriptives were calculated. Associations were assess by Fisher's exact or Pearson's Chi-square tests.

Results: Our study population consisted of 285 subjects, 249 (87%) male. Patients self-identified as Black (172), White (97), and others (15); others included NULL, the patient declined, or other. 87 (30.53%) were referred for follow-up, 184 (64.56%) were not, and 14 lost to follow-up (4.91%). 38 (13.33%) patients attended an appointment: 16 (42.11%) UMC, 18 (47.37%) a prison facility, and 4 (10.53%) outside facilities. 17 (30.36%) attendees completed treatment. Referral rates 30.53% compared to 70% for the general population at UMCNO.

Conclusion: While data were limited, we can still make observations. This study shows the disproportionate burden of HCV among incarcerated patients. Although there were no significant differences in HCV treatment by gender and race, infection rates were higher among Blacks. A large majority of incarcerated patients were diagnosed with HCV, a small percentage (30.53%) were referred, an even smaller percentage attended appointments. This illuminates the disparity in HCV infection rates and treatment rates among the incarcerated.

Abstract #44

Category: Podium Presentation

Delays in Hepatitis C Fibrosis Staging on Liver Function

Sierra Sossamon, Austin Jones¹, Kanayo Okeke-Eweni², Lisa Moreno-Walton^2,3

Louisiana State University Health Science Center New Orleans, ¹Tulane University, ²University Medical Center New Orleans, ³Louisiana State University Health Sciences Center Department of Emergency Medicine, New Orleans, New Orleans, Louisiana, USA

Introduction: Hepatitis C virus (HCV) claims more American lives than the next 60 reportable infectious diseases combined.^[1] Our study objective was to assess delays in hepatic fibrosis staging on decline in liver function.

Methods: We undertook a retrospective cohort study of all individuals diagnosed with HCV by UMCNO ED between March 1, 2015, and August 1, 2017, and who received subsequent hepatic fibrosis staging. Data were collected by electronic chart review. Exposure was defined as time from chronic HCV diagnosis to fibrosis staging. Our primary outcome was change in liver function measured by AST to platelet ratio index (APRI) and fibrosis-4 (FIB4) index. Measures of hepatic function were collected at time of HCV screening, time of fibrosis staging, and start of HCV therapy (if achieved). A secondary analysis was conducted among patients who initiated treatment, assessing time from HCV diagnosis to treatment start on change in liver function. Analysis was performed using multivariable linear regression models producing risk differences, adjusting for history intravenous drug use (IVDU) and insurance status.

Results: In total, 904 patients were included. On average, patients were 55.0 years old (interquartile range [IQR] = 10.0), while a majority were Black/African American (70.1%), male (78.2%), insured through Medicaid (60.1%), and did not report a history of IVDU (52.3%). Following HCV diagnosis, hepatitis ultrasound occurred a median of 120 days later (IQR = 345), FibroScan occurred a median of 251 days later (IQR = 383), FibroSure occurred a median of 232 days later (IQR = 507). Among FibroSure and FibroScan staging methods, the first fibrosis staging following HCV diagnosis was median of 248 days (IQR = 506), while a median of 216 (IQR = 495) days when including hepatic ultrasound. APRI was 0.44 (IQR = 0.67) at screening, 0.41 (IQR = 0.52) at first fibrosis staging, and 0.36 (IQR = 0.44) at treatment. FIB4 was 1.68 (IQR = 1.74) at screening, 1.67 (IQR = 1.61) at first fibrosis staging, and 1.67 (IQR = 1.16) at treatment. For each 180-day delay in fibrosis staging following HCV diagnosis, patients had a 13% (P = 0.03) and 20% (P < 0.001) increase in hepatic dysfunction, as measured by APRI and FIB4, respectively. For each 180-day delay in initiating treatment following HCV diagnosis, patients had both an 11% increase in hepatic dysfunction by APRI (P = 0.28) and FIB4 (P = 0.17).

Conclusion: There was a statistically significant relationship on increase in hepatic dysfunction with increasing delay from HCV antibody screening to fibrosis staging. Patients who receive RUQ ultrasound may receive fibrosis staging earlier than those staged by FibroScan or FibroSure tests. Relationships between delays in care on hepatic dysfunction indicate a potential area necessitating further study to better understand whether the requirement for fibrosis staging negatively affects treatment outcomes for patients with HCV.

Abstract #45

Category: Podium Presentation

Demographic, Epidemiological, and Clinical Factors of Presumptive Positive COVID-19 Patients Evaluated in an Urban Emergency Department

Mima Fondong, Ada Tusa, Stacey Rhodes¹, Darian Harris¹, Austin Jones², David Janz¹, Peter DeBlieux¹, Lauren Rodriguez, Sarah O'Brien², Fiona Sylvies², Lisa Moreno-Walton

LSUHSC School of Medicine New Orleans, ¹University Medical Center New Orleans, ²Tulane University School of Medicine, New Orleans, Louisiana, USA

Introduction: On March 9, 2020, the novel coronavirus (COVID-19) breached Louisiana state lines, spreading to all 64 parishes within a month and New Orleans as the epicenter. Data from the Louisiana Department of Health (LDH) revealed Black and elderly patients are disproportionately affected by the virus. Objectives of this study are: to identify demographics, chief complaints, and comorbidities among patients who tested positive for COVID-19 at University Medical Center New Orleans (UMCNO) ED, to identify the treatments utilized in these patients, and to correlate these variables with patient outcomes.

Methods: A retrospective chart review of the first 160 patients ≥18 years old testing positive for COVID-19 at UMCNO-ED was conducted. We queried patient characteristics, clinical care practices, and hospital courses. Data were stored in RedCap. Descriptive analyses were conducted using de-identified patient data in SAS 9.4 (SAS Institute, Cary, North Carolina) and Microsoft Excel (Microsoft Corporation, Redmond, Washington).

Results: Interim analysis shows that the most commonly affected demographics were females (54%), Black patients (89%), those with a body mass index >35 (34%), and those 40–50 years old (27%) with a mean age of 49.5 (95% confidence interval 47.3–51.7). Common preexisting health conditions include obesity, hypertension, and diabetes. Common chief complaints included flu-like symptoms, cough, fever, and shortness of breath. 55 patients (34%) were admitted, and 12 patients (7.5%) expired. 15% of hospitalized patients were admitted directly to the intensive care unit. 29% of patients were treated with azithromycin alone, and 12.5% were treated with azithromycin and hydroxychloroquine. Most admitted patients received oxygen therapy by nasal cannula (69%), and 14 patients (9%) were intubated. Of the intubated patients, 50% were proned, and 43% required renal replacement therapy. Patients who expired at UMC had longer hospital stays than those who recovered (6.9 vs. 5.2 days, P = 0.042).

Conclusion: The demographic findings of this study partially mirror those published by the LDH. While the common comorbidities, chief complaints, and applied treatments of this sample were identified, future directions must include multivariate analyses to explore the relationships between clinical factors and their contributions to COVID-19 infectivity and mortality. There will also be an expansion of sample size and further investigation of patient occupation, zip code, and insurance coverage.

Abstract #46

Category: Podium Presentation

Racial Disparities in Associations of Stress with Increased Risk of Coronary Heart Disease: A Survey Study within an Urban Emergency Department

Tori Wiley, Darian Harris¹, Evrim Oral¹, Lisa Moreno-Walton^1,2

Xavier University, ¹Louisiana State University Health Sciences Center, ²University Medical Center New Orleans, New Orleans, Louisiana, USA

Introduction: Coronary heart disease (CHD) is worsened by co-existing health conditions and other risk factors. Stress is a risk factor for CHD. Psychosocial stress, perceived stress, work-related stress, and other social factors play a role in predisposing individuals to developing CHD, especially minorities. In the United States, African-Americans are often exposed to these stressors due to their socioeconomic background. While studies have assessed work-related or occupational stress during emergency care, empirical data linking stress and increased CHD risks among patients and medical staff in the emergency department (ED) are limited. This study aims to identify associations between stress and CHD and determine if race and other risk factors are modifiers of stress-related increases in CHD risk reported in the ED.

Methods: This is a cross-sectional survey study administered to patients, their families, ancillary staff, nurses, medical students, residents, and physicians in the ED at University Medical Center New Orleans assessing stress and its impact on cardiovascular health. A 75–80-question survey constructed from validated surveys was administered via RedCap or by pen and paper. Data points included demographics, personal and family medical history, experiences of stress, and discrimination. Statistical analysis conducted by SAS 9.4 (SAS Institute, Cary, North Carolina). Fisher's exact test was used to assess associations between CHD and discrimination and also perceived stress and discrimination. Linear regression was used to assess potential risk factors, including age gender, race, and perceived stress affecting CHD scores.

Results: Our study population consisted of 73 subjects, females (56.2%), Whites (63.0%), Blacks (30.1%), multiracial (1.4%), Asian (2.7%), and unknown (2.7%). Of all participants, 35% were patients. 61.5% reported moderate perceived stress and 52% high scores for risk of CHD in reference to discrimination, neither statistically significant. Perceived Stress Scale scores were not statistically significant. Linear regression showed being black as risk factor for CHD (P = 0.0214) and age (P = 0.0031) were both statistically significant.

Conclusion: Lack of significance may be due to sample size. This is an interim analysis. Further exploration is necessary to determine if validated tools fully reflect overall stress. Furthermore, we need to assess what role resilience plays in self-reported levels of perceived stress.

Abstract #47

Category: Podium Presentation

Emergency Medicine Analytics of Big Data from Research on Burnout in Medicine

Ankit K. Sahu, Sagar Galwankar¹, Praveen Aggarwal

Department of Emergency Medicine, All India Institute of Medical Sciences, New Delhi, India, ¹Department of Emergency Medicine, Sarasota Memorial Hospital, Florida State University, Florida, USA

Introduction: The objective of this meta-analysis was to find the updated prevalence of burnout among the emergency medicine residents and physicians.

Methods: This systematic review and meta-analysis (SR-MA) was performed according to the PRISMA guidelines. Databases including PubMed, EMBASE, and Web of Science were searched from the inception to March 4, 2020. The search was limited to the studies that reported the prevalence of burnout among emergency physicians (PHY) and emergency residents (RES). To avoid the clinical heterogeneity, only studies that had utilized the Maslach Burnout Inventory questionnaire to evaluate the presence of burnout in any of the three subscales (emotional exhaustion, depersonalization, and sense of personal accomplishment) were included in this SR-MA. Meta-analysis of proportions was done using a random-effects model.

Results: A total of 360 studies were identified by search criteria. As per inclusion criteria, only 35 studies were finally included in the meta-analysis. A total of 8248 emergency doctors were included with a mean age of 34.4 years and 57% male. Sample size of the studies ranged from 20 to 1522. Fifteen out of 35 studies were from USA. Only PHY were included in 25 studies, only RES were included in 7 studies, and rest of the studies included both. The overall prevalence of burnout among ED doctors was 0.51 (95% confidence interval [CI]: 0.39–0.62, I² - 99%). The RES (0.56, 95% CI: 0.33–0.78, I² - 91.5%) reported to have more burnout proportion as compared to that of the PHY (0.52, 95% CI: 0.41–0.63, I² - 97.8%). While assessing the prevalence of burnout in different domains, higher depersonalization was found in 0.48 (95% CI: 0.34–0.62, I² - 98.8%), higher emotional exhaustion in 0.45 (95% CI: 0.35–0.55, I² - 97.8%), and lower sense of personal accomplishment in 0.39 (95% CI: 0.30–0.49, I² - 96.3%). Higher statistical heterogeneity persisted after extensive subgroup analysis.

Conclusion: Burnout among the doctors in ED is a major health issue that has to be recognized. Furthermore, the identification of the potential risk factors for this disorder is crucial so that high-risk groups could be early identified and properly addressed.

Abstract #48

Category: Podium Presentation

Informing the Colombian Decennial Plan through a Granular Mortality Analysis

Andres Fernando Gomez Samper, David Tulloch, Daniela Blanco, Linda Lucia Cardoso, Ricardo Elias, Nunez Rocha, Roshni Thayagrajan, Gabriel E. Herrera-Almario, Joseph S. Hanna

Department of Surgery, Rutgers - Robert Wood Johnson School of Medicine, New Brunswick, New Jersey, USA

Introduction: The Lancet Commission on Global Surgery core surgical indicators has given the surgical community metrics and methodology for objectively characterizing the disparity in access to surgery when needed. Much effort has been invested in understanding the access gap vis-à -vis physical and geographic access and provider availability. Benchmarking the safety of care delivered using Indicator 4 is fundamental to ensuring equitable access. However, aggregate national statistics without risk-adjusted, service line-specific data are insufficient to inform robust surgical health system strengthening plans. Herein, we characterize Colombian surgical mortality by urgency, service line, and age to better inform the Ministry of Health's deliberations and development of the next revision of the Decennial Plan.

Methods: Data to inform total operative volume and mortality were abstracted from the Colombian National Health Information System (SISPRO, DANE). Clasificación Única de Procedimientos en Salud (CUPS) codes of procedures performed in an operating theater were used to query SISPRO to calculate total operative volume for 2016. These data were cross-referenced with the Department Administrativo Nacional de Estadística mortality database to determine whether a death was preceded by a surgical procedure within 30 days. Performance of elective versus emergency procedures was determined using admission ICD10 codes defined by the Iowa Department of Human Services. Deaths were further subcategorized by service line by CUPS code.

Results: In 2016, aggregate national mortality was 0.86%, while mortality attributable to elective and emergency surgery was 0.68% and 1.41%, respectively. Observed mortality is 7.8 times higher for elderly as compared to young patients (2.97% vs. 0.38%, respectively). Elders underwent an average of 1.4 procedures in the 30 days preceding death. Patients undergoing foregut, neurosurgical, thoracic, lower gastrointestinal, and cardiac surgical procedures experienced the highest mortality rates (16.4%, 8.2%, 5.9%, 5.4%, and 5.4% respectively).

Conclusions: Lancet Commission on Global Surgery Indicator 4 can be contextualized by surgical urgency, age, and service line to inform the development of a national surgical obstetric and anesthesia plan within the Decennial Plan for National Health Service Quality and value improvement.

Abstract #49

Category: Podium Presentation

The Relationship between Cardiac Injury and Mortality in COVID-19 Patients in a Predominantly Black/African-American/Afro-Caribbean Population in Brooklyn, NY

Emmanuel C Adomfeh, Johnathan Francios, Harshith Priyan, Anoop V. Pushkoor, Clara Wilson, Brandon Dasilva, Patrick Geraghty, Pia Daniels, Louis Salciccioli

SUNY Downstate Medical Center, Brooklyn, New York, United States

Introduction: Although an increased disease burden of COVID-19 and related deaths is evident in predominantly Black/African-American/Afro-Caribbean populations, not many studies have examined cardiovascular comorbidities and associated cardiac injury contributions to morbidity and mortality of COVID-19 in this population.

Through this study, we investigate the contributions of cardiovascular comorbidities and cardiac injury to morbidity and mortality of COVID-19 in a predominantly Black/African-American/Afro-Caribbean population.

Methods: This is a retrospective cohort study of 572 laboratory-confirmed COVID-19 patients admitted to SUNY Downstate Health Science University between March 12 and May 12, 2020, who met inclusion criteria. Patients with a documented troponin level on admission to hospital or peak troponin level during hospital course above 0.15 μg/L were denoted as having cardiac injury. Of this group, 110 patients were in the cardiac injury group and 462 patients were in the no cardiac injury group.

The main outcomes assessed in this study were length of stay, requirement of high-flow nasal cannula, noninvasive ventilation, intensive care unit admission rate, and mortality within 60 days after admission. Patient demographics and clinical data, such as presenting symptoms, laboratory and radiologic findings, and kidney failure during admission, were also collected.

Results: In describing the general study population, the median age was 69 years, 303 (52.97%) patients were male and 269 (47.03%) patients were female, and 515 (90.03%) patients described themselves as Black/African American. When compared to patients without cardiac injury, patients with cardiac injury were older (median age, 72 years vs. 66 years; P < 0.001) and more likely to have the following comorbidities: congestive heart failure (23 [20.91%] vs. 49 [10.61%]; P < 0.05), chronic obstructive pulmonary disease (14.71 [12.73%] vs. 31 [6.71%]; P < 0.05), and end-stage renal disease (21 [19.09%] vs. 51 [11.04%]; P < 0.05). Patients with cardiac injury were also more likely to be smokers (24 [21.82%] vs. 57 [12.34%]; P < 0.05). For presenting symptoms, patients with cardiac injury were less likely to report symptoms of fever (50 [45.45%] vs. 291 [62.99%]; P < 0.05), and myalgia (8 [7.27%] vs. 84 [18.18%]; P < 0.05). Labs showed higher white blood cell count (8.46 [6.46–11.75] vs. 7.74 [5.59–10.3] cells/μL, P < 0.05), blood urea nitrogen (39.50 [22.00–59.00] vs. 25.00 [15.00–43.00] mg/dL, P < 0.001), creatinine (2.00 [1.00–4.00] vs. 1.00 [1.00–3.00] mg/dL, P < 0.001), and procalcitonin (1.71 [0.41–1.85] vs. 0.45 [0.15–1.34] ng/mL, P < 0.001). The median (IQR) troponin level was higher (0.29 [0.19–0.82] μg/L vs. 0.02 [0.02–0.06] μg/L), and peak median troponin level was higher (0.44 [0.25–1.67] μg/L vs. 0.03 [0.02–0.0.07] μg/L, P < 0.001). In terms of hospital course, patients with cardiac injury have higher proportion of renal failure (60 [54.55%] vs. 154 [33.33%], P < 0.001), more likely to require intubation (41 [37.27%] vs. 93 [20.13%], P < 0.001), and more likely to be transferred to ICU (30 [27.27%] vs. 80 [17.32%], P < 0.05). No significant differences were seen in radiologic findings or in the proportion of those requiring noninvasive ventilation. 60-day mortality rate was higher (69 [62.73%] patients vs. 152 [32.90%], P < 0.001). Multivariable adjusted Cox proportional hazard regression model demonstrated a notably higher risk of death (hazards ratio 1.528 [95% CI, 1.125–2.075], P < 0.05) and reduced mean survival time, per log rank test (33.547 [95% CI, 23.857–43.237] vs. 52.692 [95% CI, 45.328–60.057] days, P < 0.001).

Conclusions: The study results exhibit a statistically significant association between cardiac injury and morbidity and mortality amongst COVID-19–positive individuals from a predominantly Black, African-American, and Afro-Caribbean population.

Abstract #50

Category: Podium Presentation

Quantifying Obstetricians and Gynecologists and the Distribution of Accredited Postgraduate Training Programs of the West African College of Surgeons

Angela M. DaCosta, Fatemeh P. Parvin-Nejad¹, Marlee R. Hirsch, Adam R. Taylor, Claudine Sylvester², Benedict C. Nwomeh³, Philip M. Mshelbwala⁴, Ziad Sifri¹

Departments of Medical Education and ¹Surgery, Rutgers New Jersey Medical School, Newark, ²Department of Obstetrics and Gynecology, St. Barnabas Medical Center, Livingston, NJ, ³Division of Pediatric Surgery, Nationwide Children's Hospital, Columbus, OH, USA, ⁴Division of Pediatric Surgery, Department of Surgery, University of Abuja Teaching Hospital, Gwagwalada, FCT, Nigeria

Introduction: Physician shortages are a known contributor to high rates of maternal mortality in West Africa.^[1] In Ghana, the availability of obstetrics/gynecology (OB/GYN) training programs accredited by the West African College of Surgeons (WACS) has been identified as the most salient factor in retaining providers in the country.^[2] However, the distribution of OB/GYN providers and training opportunities across other West African countries is unknown. The goal of this study is to quantify disparities in the number of OB/GYNs and OB/GYN training programs across West Africa.

Methods: OB/GYNs were identified from the WACS roster of Fellows. Accredited OB/GYN training programs were identified from the WACS website. Population data were obtained from The World Bank catalog. Statistical analyses were completed in Microsoft Excel.

Results: Of 4911 total WACS fellows, 1665 (33.9%) were OB/GYNs. The mean number of WACS OB/GYNs per country was 98 (±14), with fewer than 20 OB/GYNs in 13 (76.5%) of the 17 member countries. Nigeria had the most OB/GYNs with 1257 or 75.5% of the total number of WACS OB/GYNs, followed by Ghana with 121 OB/GYNs (7.26%). Nigeria also had the highest density of OB/GYNs with 0.625 providers per 100,000 population [Figure 1]. Seventy of the 76 WACS-accredited OB/GYN programs (92.1%) were located in Nigeria.

Of the remaining programs, 3 (3.9%) were located in Ghana and one each in Sierra Leone, Gambia, and Liberia. Twelve of the 17 WACS member countries (70.6%) contained no programs. The density of OB/GYNs was significantly correlated with the number of WACS-accredited OB/GYN training programs per country (Pearson's R = 0.6292, P < 0.01).

Conclusions: OB/GYNs represent over one-third of WACS fellows yet are primarily located in countries with available training programs. Most training programs are concentrated in Nigeria and Ghana, two countries with historical efforts of expanding programs and nearly two-thirds of the West African population. The density of WACS-accredited OB/GYN training programs is correlated with the number of providers in each country. These findings highlight significant disparities in the OB/GYN workforce across West Africa and the need to expand training programs to reduce the critical provider shortage and decrease the region's maternal mortality rate.

References

Gunawardena N, Bishwajit G, Yaya S. Facility-based maternal death in Western Africa: A systematic review. Front Public Health 2018;6:48.
Anderson FW, Mutchnick I, Kwawukume EY, Danso KA, Klufio CA, Clinton Y, et al. Who will be there when women deliver? Assuring retention of obstetric providers. Obstet Gynecol 2007;110:1012-6.

Abstract #51

Category: Podium Presentation

Resident Confidence and Educational Perceptions regarding Methods of Learning Pediatric Intubation

Rebecca Jeanmonod, Guhan Rammohan, Michael Grimaldi, Jonathan Pester, Holly Stankewicz, Rachel Patterson, Megan Minor, Keith Baker, Scott Melanson, Donald Jeanmonod

Department of Emergency Medicine, St. Luke's University Health Network, Bethlehem, Pennsylvania, United States

Introduction: In the age of readily accessible free medical education, many learners use the internet or other independent means as a primary way to learn how to perform procedures. There are also numerous described methods by which to teach procedures using simulation. The optimal method for teaching procedures is not known. In this study, we compare residents' confidence with their pediatric intubation skill set and their confidence in being able to teach this skill set to others after training using (1) standard simulation, (2) the Peyton method, or (3) self-directed learning with free access to simulation mannikins.

Methods: Emergency medicine residents at a single residency training program were randomized to one of the three above listed training groups. Before training, each resident underwent a standard airway simulation session with two blinded observers to provide a skills assessment as well as to give the residents an opportunity to ask questions about the procedure and gain exposure to the mannikins. Residents in the standard simulation group then underwent training using standard simulation with postprocedure debriefing. Residents in the Peyton method group (described elsewhere) underwent simulation through a highly structured technique which includes teacher demonstration, teacher deconstruction, learner comprehension, and learner execution. The residents in the independent learning group were encouraged to master the skill set through any means they saw fit, including questioning faculty, using the simulation mannikins (which are available to them 24 h a day in the emergency department), and using online resources. All residents filled out a survey regarding their prior experience, knowledge base, confidence in performing pediatric intubations, and confidence in teaching pediatric intubation skills after their training.

Results: 28 residents were randomized into the three learner groups. There were no differences in groups in terms of prior pediatric intubations performed or observed (P = 0.63 and 0.12, respectively), familiarity with indications/contraindications/complications and procedural steps (P = 0.25 and 0.20, respectively), or level of training (P = 0.72). After training, there were no differences in resident comfort with performing the procedure unsupervised (median of 2 on a 5 point Likert scale, intraquartile range 2–3, P = 0.50), but residents in the independent study were significantly less comfortable with their ability to teach the skill to others as compared to either simulation group (median of 2 on 5-point Likert scale as compared to median of 3.5 [standard simulation] and 4.0 [Peyton method], P = 0.04).

Conclusions: Residents using self-directed learning to master pediatric intubation are less comfortable teaching the procedure than their peers who are taught using simulation.

Abstract #52

Category: Long Abstract

A Rare case of Double Superior Vena Cava, Diagnosed after Central Line Placement, in a Polytrauma Patient

Temur Baykuziyev, Fatima Emam¹, Ismail Mahmood², Syed Nabir³, Zahoor Ahmed³, Hassan Al-Thani⁴, Talat Chughtai⁵

Trauma and Critical Care Medicine Fellowship, Hamad Medical Corporation, ¹Qatar University College of Medicine, Departments of ²Trauma Surgery, ³Trauma Radiology, ⁴Department of Trauma and Vascular Surgery and ⁵Trauma and Thoracic Surgery, Hamad Medical Corporation, Doha, Qatar

Introduction: Duplication of the superior vena cava (SVC), involving a persistent left SVC, is a rare anomaly, estimated to exist in 0.3%–0.5% of the general population^[1],[2] and 3%–10% of patients with other forms of congenital heart disease.^[2] The majority of cases are asymptomatic and diagnosed incidentally. However, this anomaly may present difficulties during cardiac pacemaker implantation, radiofrequency catheter ablation, and internal jugular or subclavian vein catheter insertion, including diagnostic dilemmas^[3],[4],[5] as to perceived access or positioning of catheters. Moreover, double SVC is surgically important in the presence of congenital heart disease. In this article, we present the case of an adult poly-trauma patient in whom a double SVC with persistent left SVC (PLSVC) was incidentally diagnosed during central venous catheter (CVC) placement.

Case Presentation: A 24-year-old male patient, with no medical history, sustained multiple injuries due to a fall from an unknown height. He was hypotensive and tachycardic at the scene and a right-sided needle decompression of the chest was performed by EMS for suspected tension pneumothorax. In the trauma room (TRU), the patient was intubated, a right-sided chest tube was inserted, and a FAST study was performed, revealing free intra-abdominal fluid.

The patient was taken to operative theater, where a damage control laparotomy was performed to control bleeding and contamination. A small bowel resection (distal jejunum, for mesenteric injury with bowel ischemia) without anastomosis, and liver packing (for multiple lacerations) was performed. The abdomen was kept open, and he was admitted to the trauma intensive care unit (TICU) postoperatively. He subsequently underwent a second look laparotomy for removal of the packs and bowel anastomosis, and the abdomen was closed.

In the TICU, central venous access was required for inotropic support, and the right subclavian vein was cannulated with a 7.5 French triple-lumen catheter under ultrasound guidance. The procedure was uneventful, and a Chest X-Ray was performed to confirm the position of the CVC [Figure 1]a.

On day 17, the patient became febrile and showed laboratory signs of sepsis. Because of CVC-related sepsis as a potential cause, the decision was made to remove the right CVC and insert a new central line, this time using the left subclavian vein as access.

The left subclavian vein was cannulated with a 7.5 French triple lumen catheter under landmark approach. The procedure was uneventful; the vein was found on the first pass, and there was no resistance to guidewire or catheter advancement. There was also good forward and back flow from the catheter. A post-procedure chest X-Ray was performed to verify the position of the CVC [Figure 1]b.

Because of uncertainty of the position of the CVC, a paired blood sample was obtained from the both the most distal port of the triple-lumen catheter, as well as a peripheral vein. Blood gas analysis of these samples found that both samples had identical PO₂, indicating venous location of the CVC (i.e., not arterial). The waveform was also suggestive of central venous position.

The initial admission CT scan of the chest done (including 3D reconstructions) were then re-reviewed, focusing on the upper thoracic venous anatomy, and it revealed the presence of a double SVC, with the left CVC in a persistent left SVC [Figure 2] and [Figure 3].

The vascular surgeon and radiologist were consulted. Double SVC was confirmed both, and no other cardiac or extra-cardiac anomalies were identified by the radiologist.

It was decided not to remove the CVC and continue to use it (for inotropes and TPN) given its position in a left SVC that was draining into the right venous return system. The CVC was removed after 8 days postinsertion. No complications occurred during removal of the CVC.

Over the course of the remainder of his TICU stay, the patient developed complications of abdominal and pelvic collections, as well as a wound infection. These were managed with antibiotics, drainage, and a vacuum-assisted wound closure dressing. He was transferred to the trauma ward in stable condition and eventually discharged home. The patient has been seen in outpatient follow-up for 8 months and is asymptomatic from a cardiovascular point of view and free from complications from the CVC insertion.

Discussion: One of the uncommon, yet important, complications of CVC placement is mal-positioning of the tip of the CVC in a vessel other than the (normally right-sided) SVC. Mal-positioning has been described in approximately 7% of cases of neck/thoracic CVC placement in the literature.^[1] Mal-positioning of a CVC can usually be attributed to variations in thoracic venous anatomy. Although very rare, these variations include vein tributaries with low-resistance routes that lead to “misdirection” of the catheter tip. Congenital variations are usually discovered incidentally on imaging after CVC placement.^[1],[2] Although these variations are usually asymptomatic, they can make the radiologic location of the CVC tip difficult to discriminate.

Among congenital variation, the most common is the presence of an isolated persistent left-sided SVC, or PLSVC.^[1] Double SVC, with a normal right and abnormal PLSVC, is rarely encountered. The incidence in general population has been documented by many authors to be less than 0.5%.^[3] The incidence may reach up to 12% in patients with other forms of congenital heart disease.^[2] The true incidence of PLSVC may be underestimated because of failure to identify the anomaly in asymptomatic patients and those with no associated cardiac abnormalities.

A PLSVC results from the failure of regression of the left anterior cardinal vein. This may occur with or without a rudimentary left innominate vein as a communication between the two SVCs. There are four variants of SVC: single right-sided SVC draining into the right atrium (normal), double SVC with right and left SVC emptying into the right atrium (as was the case in our patient), double SVC with each emptying into the ipsilateral atria, and single PLSVC emptying into the left atrium (the latter two being extremely rare but are more prone to complications). 92% of left-sided SVCs drain into the right atrium (usually via the coronary sinus), with the remainder draining into directly into the left atrium. The left atrium drainage pattern represents a right-to-left shunt. They are usually asymptomatic; however, they may lead to cyanosis and right heart failure, or paradoxical systemic embolization.^{[2],[3],[4],[5]}

In patients who have suspected anomalies (based on clinical or chest X-ray suspicion), diagnosis can be confirmed with CT of the chest with contrast or transthoracic echocardiography.^[2],[4]

Double SVC (draining into the right atrium) is usually discovered incidentally and the patient will usually have no clinical signs, as was seen in our patient. Apart from causing diagnostic dilemmas during CVC insertions, double SVC may impact (challenges and complications) on procedures which require upper body central venous access, such as cardiac pacemaker implantation (temporary or permanent), implantable defibrillator placement, and radio-frequency catheter ablation. CVC insertion may result in unusual catheter positions, with subsequent inadvertent cardiac perforation. Ineffective retrograde cardioplegia may occur during cannulation of the heart for cardiopulmonary bypass and thus may demand modification of surgical technique for cardiac surgery with extracorporeal circulation, during which the PLSVC should be cannulated separately.

Isolated left SVC has been associated with an increased risk of arrhythmias, most commonly atrial fibrillation because of abnormalities to the atrioventricular node and the bundle of His. When left SVC is encountered, there should be an investigation of other possible associated congenital defects. Cardiac anomalies include atrial and ventricular septal defects, endocardial cushion defects, tetralogy of Fallot, and cor triatriatum. The most frequently associated extra-cardiac anomaly is esophageal atresia.^[2],[3] In our patient, investigations revealed neither cardiac nor extracardiac anomalies.

Conclusion: Anomalies of the superior vena cava are rare but, when present, are frequently identified as incidental findings during/after CVC insertions, cross-sectional imaging, and echocardiography and are occasionally associated with important clinical sequalae. When encountered, there should be an investigation of other possible congenital defects. A double SVC may make it difficult for internal jugular or subclavian venous catheterization, radiofrequency ablation, pacemaker and defibrillator insertion, or coronary artery bypass graft surgery. Drainage of PLSVC into left atrium also results in a right-to-left shunt. It is critical to fully characterize the pattern of cardiac venous return in any patient suspected of PLSVC before initiation of use of their central venous access device. Physicians should consider presence of PLSVC whenever a catheter or guide wire inserted via left subclavian vein takes an unusual left-sided downward course.

References

Roldan CJ, Paniagua L. Central venous catheter intravascular malpositioning: Causes, prevention, diagnosis, and correction. West J Emerg Med 2015;16:658-64.
Povoski SP, Khabiri H. Persistent left superior vena cava: Review of the literature, clinical implications, and relevance of alterations in thoracic central venous anatomy as pertaining to the general principles of central venous access device placement and venography in cancer patients. World J Surg Oncol 2011;9:173.
Iimura A, Oguchi T, Shibata M, Matsuo M, Takahashi T. Double superior vena cava and anomaly of cardiovascular system with a review of the literature. Okajimas Folia Anat Jpn 2011;88:37-42.
Oliveira JD, Martins I. Congenital systemic venous return anomalies to the right atrium review. Insights Imaging 2019;10:115.
Irwin RB, Greaves M, Schmitt M. Left superior vena cava: Revisited. Eur Heart J Cardiovasc Imaging 2012;13:284-91

Abstract #53

Category: Long Abstract

Association of Neutrophil Lymphocyte, Platelet Lymphocyte, and Lymphocyte Monocyte Ratios with Severity of COVID-19 Pneumonia

Takshak Shankar, Nidhi Kaeley, Rohit Walia

All India Institute of Medical Sciences, Rishikesh, Uttarkhand, India

Introduction: COVID-19 infection has emerged as a global pandemic. It was detected at Wuhan, China, in December 2019. Since then, it has rapidly spread to almost all the countries of the world, taking a heavy toll on human life.^[1],[2] As per the world meter, on March 2, 2021, there were around 11.12 million cases, with 157,385 reported deaths due to COVID-19 infection in India. Kerala and Maharashtra, which are the two worst-hit Indian states, continue to report a high daily positivity rate.^[3] The common signs and symptoms of the disease include fever, breathlessness, cough, loose stools, headache, and fever. The presentation of the patients span from mild to severe form of the disease and a more catastrophic form as acute respiratory distress syndrome. Besides respiratory system involvement, neurological, cardiovascular, renal, and hepatic complications of severe acute respiratory syndrome (SARS)-CoV-2 infection have also been reported. The gold standard diagnostic modality of COVID-19 infection is real-time–polymerase chain reaction (RT-PCR). However, it is time-consuming. Thus, there is an urgent need to analyze serum biomarkers of inflammation, which can have both diagnostic and prognostic implications. Hematological biomarkers such as total leukocyte count (TLC), neutrophil lymphocyte ratio (NLR), and lymphocyte monocyte ratio (LMR) have been individually studied as prognostic markers and to predict severity in patients with COVID-19 infection.^[4],[5] As in patients with SARS and Middle East respiratory syndrome (MERS), there is dysregulated host response, leading to cytokine storm in patients with COVID-19 infection. Robust inflammatory response coupled with weak adaptive immunity contributes to multi-organ involvement in COVID-19 infection. Further, NLR has been assessed in patients with COPD, pancreatitis, and cardiovascular disease.^[6],[7] A number of case series have observed a significant relationship between NLR and mortality in patients with COVID-19 infection.^[8] In addition to NLR ratio, platelet lymphocyte ratio (PLR) and LMR have been assessed as inflammatory markers.^[9] In this study, we assessed the association of all the three markers NLR, LMR, and PLR, with severity of COVID-19 patients.

Materials and Methods: The retrospective study was carried out at emergency medicine department of a tertiary care hospital of Uttrakhand over a period of 6 months. 350 RT-PCR–confirmed cases of COVID-19 infection were enrolled in the study. Detailed demographic (age, sex), clinical, hematological and biochemical parameters, comorbidity history (diabetes, hypertension, asthma, COPD, ischemic heart disease), CT findings, and CT score were noted in each patient from the hospital record section. All the patients were subdivided in two groups, one with oxygen saturation more than 94% (mild group) and the other with oxygen saturation less than 94% (moderate–severe group). NLR, PLR, and LMR were calculated in all the patients and were compared in both the groups. The clinico-demographic, biochemical, hematological, and outcomes of all the patients were compared for both the groups. Clinical and hematological parameters of alive and expired patients were also compared

Statistical Analysis: Statistical analysis was performed by the SPSS program for Windows, version 17.0 (SPSS, Chicago, Illinois, USA). Continuous variables are presented as mean ± standard deviation, and categorical variables are presented as absolute numbers and percentage.

Data were checked for normality before statistical analysis. Normally distributed continuous variables were compared using the unpaired t-test, whereas the Mann–Whitney U-test was used for those variables that were not normally distributed. Categorical variables were analysd using either the Chi-square test or Fisher's exact test. Kaplan–Meier survival analysis was used to estimate mortality of study patients since admission based on SpO2 (>94% or ≤94%). For all statistical tests, a P < 0.05 was taken to indicate a significant difference.

Results: As shown in [Table 1], retrospective analysis of 350 patients with COVID-19 pneumonia was done in this study. They were subdivided into two groups - one with oxygen saturation less than equal to 94% (80, 22.8%) and the other with oxygen saturation more than 94% (270, 77.1%). 263 (75.1%) were males and 87 (24.8%) were females. There was no statistically significant difference in gender and age in both the groups. The mean of age of the patients with oxygen saturation less than equal to 94% was 54.91 ± 13.2 years, which was almost similar to the mean age in the other group. Mean diastolic blood pressure (72.6 ± 11.58 mm of Hg) was significantly lower in the group of patients with SpO₂ ≤94%. Similarly, Glassgow coma scale (GCS) was significantly lower in this group. Mean heart rate (100.31 ± 16.5 beats per minute) and respiratory rate (25.4 ± 2.48 per minute) were higher in the group with SpO₂ ≤94%. Among the comorbidities, hypertension (99, 28.2%) and diabetes mellitus (125, 35.7%) were the most common. Hypertension was significantly more common in the group with oxygen saturation less than, equal to 94%. The other comorbidities were ischemic heart disease (54, 15.4%), asthma (11, 3.1%), and COPD (17, 4.8%). Mortality (36, 45%) was higher in the group with SpO₂ ≤94%. Length of stay was not significantly longer in the group with SpO₂ ≤94%. In the mild group, significantly more number of patients were discharged as compared to the severe group. Among the hematological parameters, total leukocyte count (12.71 ± 17.8/cumm) was significantly higher in the group with SpO₂ ≤94%. NLR was significantly higher in the group with SpO₂ ≤94% [Table 2]. LMR (1.48 ± 0.9) and PLR (406.13 ± 251.1) were significantly lower in the group with SpO₂ ≤94%. No significant association was observed with the other biochemical parameters [Table 3]. [Table 4] shows various parameters association with mortality in COVID-19 pneumonia. Age (65.23 ± 13.7 years), respiratory rate (33.7 ± 2.3 per minute), absolute neutrophil count (14,618.2), and NLR (14.29) were significantly higher in the group who succumbed to death.

Discussion: The COVID-19 pandemic, first detected in December 2019, has spread exponentially all over the world. Although the mortality of COVID-19 infection is only 2.5%, it poses a humongous challenge to identify and initiate timely management in these patients. The common clinical characteristics of the infection are fever, cough, and breathlessness.^[10] The gold standard diagnostic modality of COVID-19 infection is reverse-transcriptase polymerase chain reaction.^[11] In our study, majority of the patients were more than 50 years of age. However, there was no statistically significant difference in age group of the two subgroups. As per the previous studies, age is found to be significantly associated with mortality in patients with COVID-19 pneumonia. The geriatric population is are more vulnerable to severe form of the disease due to co-existent comorbidities as well as weak immune system.^[12] In our study, patients with COVID-19 pneumonia who succumbed to death belonged to higher age group as compared to patients who were discharged in stable condition. In this study, diastolic blood pressure was significantly lover in the group with SPO₂ ≤94%. Clearly, both heart rate and respiratory rate were significantly higher in the moderate–severe group. Both the parameters have been identified by previous studies as prognostic and mortality markers in COVID-19 pneumonia patients.^[13] Hypertension followed by diabetes mellitus were found to be the most common comorbidities in patients with severe COVID-19 infection. However, hypertension was significantly more common in patients with SPO₂ ≤94%. Similar results were observed by studies conducted by Mertz et al.^[14] Chronic conditions such as cardiovascular diseases hypertension, diabetes mellitus, and chronic obstructive pulmonary diseases can have significant impact on mortality and prognostic parameters of viral infection such as SARS-COV-2, MERS, and SARS.^[15] Lately, researchers have highlighted the significant role of multiple ratios such as NLR, LMR, and PLR in many chronic inflammatory conditions. These ratios can be used as diagnostic and prognostic predictors of severity in patients with COVID-19 pneumonia. The NLR, PLR, and LMR can provide a low-cost diagnostic and prognostic substitute to RT-PLR (platelet-to-lymphocyte ratio) test in COVID-19 patients.^[16] In the present study, the absolute neutrophil count and NLR were significantly higher in the group with oxygen saturation less than equal to 94% and also, in the patients who expired. Thus, NLR should be integrated in the prognostic norm graph in patients with COVID-19 pneumonia. Shang et al. studied the role of NLR, CRP, and platelets as predictors of disease serenity and emphasized NLR as the determinant of COVID-19 pneumonia severity.^[17] A Chinese study has highlighted that NLR cut off value more than 3.3 in COVID-19 pneumonia is associated with poor prognosis and lower survival rate. NLR has also been studied as a marker of endothelial dysfunction and is significantly associated with cardiovascular mortality.^[18]The endothelial dysfunction leads to viral alveolar damage in patients with COVID-19 infection. SARS-CoV-2 utilizes angiotensin converting enzyme-2 (ACE-2) receptor to enter the cells. This ACE-2 is expressed in multiple organs including endothelial cells.^[19] The patients with multiple comorbidities such as hypertension and diabetes have preexisting endothelial dysfunction. Thus, these patients are more vulnerable to severe form of disease. Endothelial damage triggers the inflammatory cascade stimulating activation of complement and increasing endothelial permeability, resulting in cytokine storm. There is increase in NLR in severe form of disease. The values of both baseline NLR and peak values of NLR can be compared to assess the severity of the disease.^[20] Hence; NLR can be used as a cost-effective and easily measurable biomarker of COVID-19 disease severity. In this study, the LMR was significantly lower in-patients with severe COVID-19 group (SpO₂ ≤94%). This is in accordance with the previous studies. Neutrophils account for more than 60% of leukocyte count. They release oxygen free radicals and trigger DNA damage and release of virus from the cells, resulting in stimulation of humoral immune response. Neutrophils stimulate the production of various cytokines such as vascular endothelial growth factor, granulocyte-colony stimulating factor, granulocyte-monocyte colony-stimulating factor, IL-1, and TNF-alpha. This proinflammatory cascade leads to enhanced expression of CD8+ T-lymphocytes and increase NLR.^[21],[22] NLR ratio has been assessed as useful marker in various oncological diseases, autoimmune disorders, and bacterial pneumonias.^{[23],[24],[25]} However, the ratio has been reported rarely in viral pneumonia. Elevated NLR and leukopenia have been reported as independent risk factors in patients with COVID-19 pneumonia. Some studies have also reported eosinophilia leukopenia as prognostic variables in patients with COVID-19 pneumonia.^{[26],[27],[28]} Clearly, these biomarkers can aid in ruling out other causes of respiratory infections and undifferentiated fevers.

Conclusion: NLR, LMR, and PLR can be used as cheap and readily available biomarkers to assess severity in patients with COVID-19 infection. The focus of this study is early detection of COVID-19 infection and stratifying it as severe and nonsevere utilizing these ratios.

References

Li Q, Guan X, Wu P, Wang X, Zhou L, Tong Y, et al. Early transmission dynamics in Wuhan, China, of novel coronavirus-infected pneumonia. N Engl J Med 2020;382:1199-207.
Hui DS, I Azhar E, Madani TA, Ntoumi F, Kock R, Dar O, et al. The continuing 2019-nCoV epidemic threat of novel coronaviruses to global health – The latest 2019 novel coronavirus outbreak in Wuhan, China. Int J Infect Dis 2020;91:264-6.
Government of India. Ministry of Health and Family Welfare. Available from: https://www.mohfw.gov.in/. [Last accessed 2021 Dec 01].
Wu C, Chen X, Cai Y, Xia J, Zhou X, Xu S, et al. Risk factors associated with acute respiratory distress syndrome and death in patients with coronavirus disease 2019 pneumonia in Wuhan, China. JAMA Intern Med 2020;180:934-43.
Ferrando C, Suarez-Sipmann F, Mellado-Artigas R, Hernández M, Gea A, Arruti E, et al. Clinical features, ventilatory management, and outcome of ARDS caused by COVID-19 are similar to other causes of ARDS. Intensive Care Med 2020;46:2200-11.
Azkur AK, Akdis M, Azkur D, Sokolowska M, van de Veen W, Brüggen MC, et al. Immune response to SARS-CoV-2 and mechanisms of immunopathological changes in COVID-19. Allergy 2020;75:1564-81.
Kong W, He Y, Bao H, Zhang W, Wang X. Diagnostic value of neutrophil-lymphocyte ratio for predicting the severity of acute pancreatitis: A meta-analysis. Dis Markers 2020;2020:9731854.
Liao D, Zhou F, Luo L, Xu M, Wang H, Xia J, et al. Haematological characteristics and risk factors in the classification and prognosis evaluation of COVID-19: A retrospective cohort study. Lancet Haematol 2020;7:e671-8.
Ying HQ, Deng QW, He BS, Pan YQ, Wang F, Sun HL, et al. The prognostic value of preoperative NLR, d-NLR, PLR and LMR for predicting clinical outcome in surgical colorectal cancer patients. Med Oncol 2014;31:305.
Li Q, Guan X, Wu P, Wang X, Zhou L, Tong Y, et al. Early transmission dynamics in Wuhan, China, of novel coronavirus-infected pneumonia. N Engl J Med 2020;382:1199-207.
Zhu N, Zhang D, Wang W, Li X, Yang B, Song J, et al. A novel coronavirus from patients with pneumonia in China, 2019. N Engl J Med 2020;382:727-33.
Xie J, Covassin N, Fan Z, Singh P, Gao W, Li G, et al. Association between hypoxemia and mortality in patients with COVID-19. Mayo Clin Proc 2020;95:1138-47.
Wong CK, Wong JY, Tang EH, Au CH, Wai AK. Clinical presentations, laboratory and radiological findings, and treatments for 11,028 COVID-19 patients: A systematic review and meta-analysis. Sci Rep 2020;10:19765.
Mertz D, Kim TH, Johnstone J, Lam PP, Science M, Kuster SP, et al. Populations at risk for severe or complicated influenza illness: Systematic review and meta-analysis. BMJ 2013;347:f5061.
Badawi A, Ryoo SG. Prevalence of comorbidities in the Middle East respiratory syndrome coronavirus (MERS-CoV): A systematic review and meta-analysis. Int J Infect Dis 2016;49:129-33.
Yang AP, Liu JP, Tao WQ, Li HM. The diagnostic and predictive role of NLR, d-NLR and PLR in COVID-19 patients. Int Immunopharmacol 2020;84:106504.
Epidemiology Working Group for NCIP Epidemic Response; Chinese Center for Disease Control and Prevention. The epidemiological characteristics of an outbreak of 2019 novel coronavirus diseases (COVID-19) in China. Zhonghua Liu Xing Bing Xue Za Zhi 2020;41:145-51.
Martínez-Urbistondo D, Beltrán A, Beloqui O, Huerta A. The neutrophil-to-lymphocyte ratio as a marker of systemic endothelial dysfunction in asymptomatic subjects. Nefrologia 2016;36:397-403.
Mehra MR, Desai SS, Kuy S, Henry TD, Patel AN. Cardiovascular disease, drug therapy, and mortality in COVID-19. N Engl J Med 2020;382:e102.
Gasparyan AY, Ayvazyan L, Mukanova U, Yessirkepov M, Kitas GD. The platelet-to-lymphocyte ratio as an inflammatory marker in rheumatic diseases. Ann Lab Med 2019;39:345-57.
Kusumanto YH, Dam WA, Hospers GA, Meijer C, Mulder NH. Platelets and granulocytes, in particular the neutrophils, form important compartments for circulating vascular endothelial growth factor. Angiogenesis 2003;6:283-7.
Rabinowich H, Cohen R, Bruderman I, Steiner Z, Klajman A. Functional analysis of mononuclear cells infiltrating into tumors: Lysis of autologous human tumor cells by cultured infiltrating lymphocytes. Cancer Res 1987;47:173-7.
Ying HQ, Deng QW, He BS, Pan YQ, Wang F, Sun HL, et al. The prognostic value of preoperative NLR, d-NLR, PLR and LMR for predicting clinical outcome in surgical colorectal cancer patients. Med Oncol 2014;31:305.
Saeed AM, Rosati LM, Narang A, Moningi S, Hacker-Prietz A, Le DT, et al. Elevated absolute monocyte count, absolute neutrophil count, and neutrophil-to-lymphocyte ratio as prognostic factors in locally advanced pancreatic cancer patients treated with stereotactic body radiation therapy. Int J Radiat Oncol Biol Phys 2015;93:E157.
Nam KW, Kim TJ, Lee JS, Kwon HM, Lee YS, Ko SB, et al. High neutrophil-to-lymphocyte ratio predicts stroke-associated pneumonia. Stroke 2018;49:1886-92.
Liu J, Liu Y, Xiang P, Pu L, Xiong H, Li C, et al. Neutrophil-to-lymphocyte ratio predicts critical illness patients with 2019 coronavirus disease in the early stage. J Transl Med 2020;18:206.
Henry BM, de Oliveira MHS, Benoit S, Plebani M, Lippi G. Hematologic, biochemical and immune biomarker abnormalities associated with severe illness and mortality in coronavirus disease 2019 (COVID-19): A meta-analysis. Clin Chem Lab Med 2020;58:1021-8.
Gómez-Rial J, Rivero-Calle I, Salas A, Martinón-Torres F. Role of monocytes/macrophages in COVID-19 pathogenesis: Implications for THERAPY. Infect Drug Resist 2020;13:2485-93.

Abstract #54

Category: Long Abstract

Takayasu Arteritis Presenting as Young Stroke in Emergency Department

R. Surendar

Jawaharlal Institute of Postgraduate Medical Education and Research, Puducherry, India

Introduction: Young stroke incidence is increasing in both developed and developing countries.^[1] Among the conventional risk factors and causes, the incidence of young stroke as initial presentation in Takayasu arteritis (TKA) is being reported nowadays.^[2] TKA, a large-vessel vasculitis, is a chronic granulomatous inflammatory condition of unknown etiology that predominantly affects the women of younger age group.^[3] The aorta and its branches the coronary and pulmonary arteries are primarily affected arteries in TKA.^[4] TKA can present both with intracranial and extracranial manifestations. Here, we present a case of TKA with young stroke as an initial presentation diagnosed and managed in our emergency department (ED) of tertiary care institute.

Case Description: A 25-year-old woman presented to our ED with complaints of weakness in right upper limb and lower limb and deviation of angle of mouth to the left side, following an episode of unconsciousness. There was no history of similar episodes in the past. There was no relevant history of early-onset stroke or any ischemic events in the family. The patient was having no comorbidities. History of intake of oral contraceptive pills 1 year back was present. No other relevant positive history was present.

On examination in ED, the patient was conscious, oriented, and afebrile. Pulse rate was 82/min, SpO₂ 98% in room air, respiratory rate 14/min, no pallor, cyanosis, or icterus. Blood pressure was 60/40 in the left upper limb in the supine position [Table 1].

Neurological examination revealed muscle strength of the right upper and lower limbs as grade 2+ and 3+ over 5, respectively. On the left side, the muscle strength was 4+ over 5 in both upper and lower limbs. Facial deviation to the left with drooling of saliva was present. There was right hemiparesis, with generalized hyperreflexia and extensor plantar on the right side. Cardiac examination showed normal heart sounds, no murmurs, and no added sounds. Carotid bruit was present. Other systemic examination was normal. Optic fundi examination was normal.

Laboratory Investigations: The white blood cell count was 7430 per cubic milliliter, with normal differential count. Hemoglobin levels were 9 g per deciliter. Platelet count was 4.8 lakh per cubic milliliter. The erythrocyte sedimentation rate and C-reactive protein levels were elevated which were 42 mm/h and 33 mg/l, respectively. Prothrombin and activated partial thromboplastin levels were within normal limits. All other serum biochemical parameters were within normal limits. Human immunodeficiency virus antibodies, hepatitis antibodies, and rapid antigen test were negative. Chest X-ray and electrocardiograph also showed normal findings. Computed tomography (CT) brain showed left middle cerebral artery infract [Figure 1]. Contrast-enhanced CT showed wall thickening around the origin of left common carotid artery in coronal plane [Figure 2] and left cervical internal carotid artery luminal narrowing in the axial view [Figure 3].

The diagnoses of TKA was made based on the American College of Rheumatology criteria of 1990^[5],[6] [Table 2]. Age of the patient, decreased brachial pulse on the left side, and difference in blood pressure between right and the left arm, along with CT arteriogram findings, were all present in our patient, thus satisfying the criteria for diagnosis of TKA.

Management: The patient was started on oral prednisolone 1 mg/kg/day once daily for 3 weeks along with aspirin, clopidogrel, and atorvastatin. The general condition of the patient improved following the administration of systemic steroids. The patient was monitored and discharged after 5 days with outpatient follow-up. The dosage of steroids was tapered and discontinued after 3 weeks.

Discussion: Stroke in younger adult population will cause significant morbidity and disability in their life. The causes for young stroke are diverse, and it is different from that of the stroke in elderly age group.^[7] TKA, a chronic inflammatory condition, predominantly affecting the female gender, presents commonly as headache, hypertension, claudication, bruits, absent pulses, and sometimes as fever.^[8] Although neurological symptoms are the common presentation, stroke as an initial presenting complaint is rare in TKA. The mechanism of stroke in TKA could be either due to embolization of the vessel, inflammatory cause, stenotic occlusion in extracranial vessels; other causes include young hypertension and premature atherosclerosis.^[3] In our case, there was occlusion of left internal carotid artery and thus presented with stroke findings.

Although TKA diagnosis as a cause of stroke could be identified after a series of investigations and imaging studies, after ruling out other possible causes, the diagnosis of the same in ED is challenging. Early diagnosis and timely management play a significant role in prognosis of the cerebrovascular event due to TKA. The permanent neurological deficit could be avoided or reduced by early administration of steroids. Thus, it is of utmost importance to consider TKA as a differential diagnosis for young stroke in ED. Our patient improved and was discharged after 5 days with follow-up advice.

Conclusion: The neurological manifestations are common in chronic presentation of TKA; however, stroke as an acute initial symptom of TKA is a rare situation. As an emergency physician, it is quite challenging and important to think and diagnose TKA as underlying cause for young stroke presentation. The problem with diagnosing TKA is due to rarity and the complexity of the disease. However, if identified the earliest, better management could be provided to the patient, which is very much possible in ED with prompt history, examination and appropriate imaging studies. This will greatly reduce the disability and morbidity of the patient.

Grant or Other Financial Support: Nil.

Conflicts of Interest: None declared.

Authors' Contribution: All the authors have equally contributed to data collection and writing and preparation of this manuscript.

References

Edwards JD, Kapral MK, Lindsay MP, Fang J, Swartz RH. Young stroke survivors with no early recurrence at high long-term risk of adverse outcomes. J Am Heart Assoc 2019;8:e010370.
Hwang J, Kim SJ, Bang OY, Chung CS, Lee KH, Kim DK, et al. Ischemic stroke in Takayasu's arteritis: Lesion patterns and possible mechanisms. J Clin Neurol 2012;8:109-15.
Vidhate M, Garg RK, Yadav R, Kohli N, Naphade P, Anuradha HK. An unusual case of Takayasu's arteritis: Evaluation by CT angiography. Ann Indian Acad Neurol 2011;14:304-6.
Gao S, Wang R. Takayasu arteritis presenting with massive cerebral ischemic infarction in a 35-year-old woman: A case report. J Med Case Rep 2013;7:179.
de Souza AW, de Carvalho JF. Diagnostic and classification criteria of Takayasu arteritis. J Autoimmun 2014;48-49:79-83.
Arend WP, Michel BA, Bloch DA, Hunder GG, Calabrese LH, Edworthy SM, et al. The American College of Rheumatology 1990 criteria for the classification of Takayasu arteritis. Arthritis Rheum 1990;33:1129-34.
Rashid MH, Kashem MA, Biswas S, Hoque MM. Risk factors in young stroke. J Med 2020;21:26-30.
Cheo SW, Mohd Zamin H, Low QJ, Tan YA, Chia YK. A case of Takayasu Arteritis presenting with young stroke. Med J Malaysia 2020;75:745-7.

Abstract #55

Category: Long Abstract

Pneumomediastinum and Pneumopericardium in COVID-19 – A Case Report

R. Surendar

Jawaharlal Institute of Postgraduate Medical Education and Research, Puducherry, India

Introduction: Severe acute respiratory syndrome caused by the novel coronavirus (SARS-CoV-2) is a widespread pandemic affecting the world, with the first case being reported in Wuhan, China, in 2019. The pathophysiology of COVID-19 disease and its varied clinical presentations are still being studied. The disease is known to cause pneumonia, acute respiratory distress syndrome, myocarditis, pericarditis, cardiomyopathy, acute renal failure, hypercoagulable state, thromboembolic events, and disseminated intravascular coagulation.^[1] Dysregulated immune response of the host has been postulated to be the cause of most of its manifestations. The typical radiological findings in SARS-CoV-2 are bilateral, multifocal, subpleural/peripheral, patchy ground-glass opacities though atypical findings are not uncommon. Pneumomediastinum and pneumopericardium are reported in cases of severe acute respiratory syndrome caused by coronavirus.^[2] We present a case of COVID-19 disease associated with pneumomediastinum and pneumopericardium.

Case Details: A 51-year-old male, known diabetic and hypertensive, nonsmoker, nonasthmatic, presented to our emergency department (ED) during COVID-19 pandemic with complaints of fever and cough for 7 days and chest tightness and progressive dyspnea for 3 days. At the time of presentation to our ED, the patient was conscious, oriented, febrile, and tachypneic. Vital signs were respiratory rate of 36/min, oxygen saturation of 62% in room air, pulse rate of 120/min, blood pressure of 120/70 mmHg, and temperature of 102.4°F. On examination, crepitus felt in the neck limited inferiorly by the clavicles. On auscultation, bilateral coarse crackles heard. The patient required incremental supportive oxygen and he saturated 92% with 15 L/min of oxygen delivered by high-flow nasal cannula (HFNC). The reverse transcriptase polymerase chain reaction (RT-PCR) for SARS-CoV-2 turned out to be positive for the patient. He was started on steroids and anticoagulants. The patient's lab reports were: random blood glucose : 416 mg/dL, serum urea: 50 mg/dL, serum creatinine: 0.70 mg/dL, serum sodium: 139 mEq/L, serum potassium: 5.44 mEq/L, serum calcium: 8.8 mg/dL, serum magnesium: 2.35 mEq/L, serum protein: 7.5 g/dL, serum albumin: 3.7 g/dL, hemoglobin: 13.2 g/dL, total leukocyte count: 13,170 cells/μL, platelet count: 4.15 × 10⁵ μL, d-dimer: 1.440 μg/mL, serum ferritin: 150.2 ng/mL, CRP: 14.4 mg/dL, and serum lactate dehydrogenase (LDH): 730 IU/L.

Chest X-ray [[Figure 1], previous page] taken in admission showed subcutaneous emphysema with pneumomediastinum and pneumopericardium extending along the neck. On day 2 [[Figure 2] on previous page], the chest X-ray revealed diffuse pneumothoraxes and subcutaneous emphysema along with pneumomediastinum and pneumopericardium. The high-resolution computed tomography (HRCT) demonstrated air in the pericardial space, mediastinum, pleural space, and subcutaneous planes [[Figure 3] and [Figure 4], see previous page].

Discussion: Pneumomediastinum and pneumopericardium are rare findings seen in cases of coronavirus infection. There are few reported cases of the same during COVID-19 pandemic as well as during SARS outbreak due to coronavirus which occurred in 2002–2003. Chu et al. reported 13 cases of spontaneous pneumomediastinum in a hospital in Hong Kong, China, out of 123 virologically confirmed SARS-CoV patients who got admitted during 2002 outbreak.^[1]

Pneumomediastinum is the accumulation of free air or gas in the mediastinal space. Pneumomediastinum can result due to trauma, esophageal rupture, tear along the tracheobronchial tree, or due to intrathoracic infections. The pathogenesis of pneumomediastinum in infectious disease is controversial whether it is spontaneous or secondary. Pneumomediastinum may occur due to dysregulated immune response occurring in coronavirus infection which can result in diffuse alveolar damage and rupture of alveoli. This can lead on to leakage of air in the interstitial space which can track along the tracheobronchial tree and the vasculatures to spread toward the hilum, resulting in pneumomediastinum, the so-called Macklin effect.^[2],[3] Secondary pneumomediastinum may occur due to positive pressure ventilation and high intrathoracic pressures.

Pneumopericardium is the air accumulated in the pericardial space. This may occur in cases of myocarditis and pericarditis in corona virus infection which occurs as a result of dysregulated immune response again. The air in the mediastinum may enter the pericardial space along the roots of large vessels covered by pericardium. Air in the mediastinum may enter the pleural space as well, resulting in pneumothoraxes. Since the deep layer of cervical fascia is continuous with the mediastinum, the air in the mediastinum can track along the cervical fascia and spread as subcutaneous emphysema in the neck which in later stages may track along diffusely and involve the subcutaneous plane of whole of chest. The air can track along the bronchovascular sheath along the pressure gradient. Pneumoperitoneum has also been reported in a case of COVID-19 infection.^[4]

In our case, the subsequent chest X-rays taken make evident the clinical course which has progressed from pneumomediastinum and pneumopericardium with minimal subcutaneous emphysema in the neck to involve the subcutaneous plane extensively in the chest and pneumothoraxes.

The risk factors for development of spontaneous pneumomediastinum and pneumopericardium are yet to be studied in detail. Some of the risk factors postulated are severe cough, asthma exacerbation, raised serum LDH levels, and steroid use. Coughing can cause sudden momentary increase in intra-alveolar pressure resulting in rupture of the alveolar wall which is already weakened due to the inflammatory process. Cases of spontaneous pneumomediastinum have been reported in severe acute asthma exacerbation.^[5],[6] Raised serum LDH levels is a marker for cellular damage and has been found to be associated with pneumomediastinum and pneumopericardium.^[1] Steroid use may cause weakening of the pulmonary interstitium and serve as a risk factor for development of pneumomediastinum.^[7]

The diagnosis of pneumopericardium and pneumomediastinum in early stages is critical as the worsening clinical status of the patient may be correlated with these findings and can be managed accordingly. Spontaneous pneumomediastinum is mostly benign and can be managed conservatively, whereas in rare cases, it can result in malignant or tension pneumomediastinum.^[8] The tension pneumomediastinum causes compression of the tracheobronchial tree and major intrathoracic vessels which results in hemodynamic instability and it might require mediastinotomy and decompression.

Conclusion: A patient presenting with signs of pneumothorax or pneumopericardium should be suspected for COVID-19 infection, irrespective of the absence of classical signs of COVID-19 infection. Although the pathogenesis and risk factors for development of pneumomediastinum and pneumopericardium in coronavirus infection are yet to be studied in detail, the recognition of this entity in COVID-19 is important in terms of diagnosis and management. Presenting with simple breathlessness, patients can progress to life-threatening pneumothoraxes within few days without any intervention. Thus, it is vital as an emergency physician to suspect and exclude all possible differential diagnoses especially when we are challenged with this pandemic situation of COVID-19.

References

Chu CM, Leung YY, Hui JY, Hung IF, Chan VL, Leung WS, et al. Spontaneous pneumomediastinum in patients with severe acute respiratory syndrome. Eur Respir J 2004;23:802-4.
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