Requiring ICU Admission Research Articles

Group A Streptococcal Bacteremia: Ten Years' Experience from a Tertiary Care Center in South India.

ABSTRACTBackgroundBacteremia is an uncommon complication of group A streptococcal (GAS) infections. The data on GAS bacteremia is scarce from developing nations such as India.Patients and methodsWe performed a retrospective analysis of patients diagnosed with GAS bacteremia in a tertiary care hospital in Kerala, India over a 10-year period (2012–2021) by review of the electronic medical records (EMRs).ResultsA total of 58 cases of GAS bacteremia were identified in the study period. Skin/soft tissue infection was the most common source of bacteremia. A total of 34.4% of the patients required ICU admission and the in-hospital mortality was 22.4%. All the GAS isolates were sensitive to penicillin, ampicillin, and ceftriaxone. Erythromycin and clindamycin resistance was seen in 39.7% and 24.1% isolates, respectively.ConclusionThis study shows that despite advancement in medical sciences, GAS bacteremia remains as a disease with high morbidity and mortality. A higher rate of clindamycin resistance was observed compared to previous Indian studies.How to cite this articleJayakumar JS, Niyas VKM, Arjun R. Group A Streptococcal Bacteremia: Ten Years’ Experience from a Tertiary Care Center in South India. Indian J Crit Care Med 2022;26(9):1019–1021.

The use of ICU resources in CAR-T cell recipients: a hospital-wide study

BackgroundCAR-T cell (chimeric antigen receptor T) therapy has emerged as an effective treatment of refractory hematological malignancies. Intensive care management is intrinsic to CAR-T cell therapy. We aim to describe and to assess outcomes in critically ill CAR-T cell recipients.Study design and methodsHospital-wide retrospective study. Consecutive CAR-T cell recipients requiring ICU admission from July 2017 and December 2020 were included.Results71 patients (median age 60 years [37–68]) were admitted to the ICU 6 days [4–7] after CAR-T cell infusion. Underlying malignancies included diffuse large B cell lymphoma (n = 53, 75%), acute lymphoblastic leukemia (17 patients, 24%) and multiple myeloma (n = 1, 1.45%). Performance status (PS) was 1 [1–2]. Shock was the main reason for ICU admission (n = 40, 48%). Isolated cytokine release syndrome (CRS) was the most common complication (n = 33, 46%), while 21 patients (30%) had microbiologically documented bacterial infection (chiefly catheter-related infection). Immune effector cell-associated neurotoxicity syndrome was reported in 26 (37%) patients. At ICU admission, vasopressors were required in 18 patients (25%) and invasive mechanical ventilation in two. Overall, 49 (69%) and 40 patients (56%) received tocilizumab or steroids, respectively.Determinant of mortality were the reason for ICU admission (disease progression vs. sepsis or CRS (HR 4.02 [95%CI 1.10–14.65]), Performance status (HR 1.97/point [95%CI 1.14–3.41]) and SOFA score (HR 1.16/point [95%CI 1.01–1.33]).ConclusionsMeaningful survival could be achieved in up to half the CAR-T cell recipients. The severity of organ dysfunction is a major determinant of death, especially in patients with altered performance status or disease progression.

EP-577 Seasonal Variation of Presentation of Perforated Peptic Ulcer Disease: An Overview of Patient Demographics, Management and Outcomes in Northern Ireland

Abstract Background Perforated peptic ulcer disease is one of the most common causes of acute peritonitis. It carries significant mortality and morbidity. Several previous studies have reported a seasonal variation in presentation of patients with perforated ulcers. Here we present this study from a Northern Irish perspective on perforated peptic ulcers. Methods A retrospective cohort study was conducted on perforated peptic ulcer patients who presented to Altnagelvin Area Hospital emergency department between 2015 to 2020. Data on patient demographics, clinical presentation, investigations, management and outcomes were collected. Primary outcome was to investigate if seasonality was associated with incidence of perforated peptic ulcers. Followup data was also collected. Seasons were defined as per UK Met Office. Results A total of 50 patients presented with perforated PUD. Male:female ratio was approximately 3:2. Peaks were noted in spring and winter. April was the most common month for presentation followed by December. Smoking was the most common risk factor followed by alcohol abuse. 14 patients (28%) were either very frail or had contained perforations and were conservatively managed. 3 deaths were noted (6%). 13 patients (26%) required ICU admission at some stage in their management. Conclusions Slight seasonal variation was noted in presentation of perforated peptic ulcers in our study with more common incidence in winter and spring months. The month of April was noted to have the peak incidence of the disease in our study.

Clinical characteristics and outcomes of traumatic brain injury patients admitted to tertiary level surgical intensive care unit of Kashmir, India

Background: Traumatic brain injury (TBI) is a leading cause of mortality, morbidity, disability, and socioeconomic losses in the Indian subcontinent. For policy making, there is a lack of reliable and larger data regarding traumatic brain injuries in our setting. Aim: In our study an attempt was made to analyze and assess the clinical characteristics of patients with traumatic brain injuries admitted in Surgical Intensive Care Unit of SMHS hospital Srinagar. Materials and Methods: In this observational study, 89 patients of TBI admitted in SICU during study period were enrolled, after obtaining ethical clearance from institutional ethical clearancecommittee. All the study patients were followed up in SICU on daily basis. All thedata required for study was recorded from the patient’s clinical notes as per studyprotocol. Outcome of patients was assessed in terms of survival at discharge from SICU. Results: Majority of the TBI patients requiring ICU admission had Severe TBI (64%). Allthe patients required CT Brain on arrival to hospital and brain contusions (65.2%) were the most common findings on CT brain. Check CT brain was required in53.9% of patients. There was need for neurosurgical intervention in 49.4% ofpatients and 21.3% required blood transfusions.

Incidence and risk factors of COVID-19 associated pneumothorax.

Pneumothorax has been increasingly observed among patients with coronavirus disease-2019 (COVID-19) pneumonia, specifically in those patients who develop acute respiratory distress syndrome (ARDS). In this study, we sought to determine the incidence and potential risk factors of pneumothorax in critically ill adults with COVID-19. This retrospective cohort study included adult patients with laboratory-confirmed SARS-CoV-2 infection admitted to one of the adult intensive care units of a tertiary, academic teaching hospital from May 2020 through May 2021. Among 334 COVID-19 cases requiring ICU admission, the incidence of pneumothorax was 10% (33 patients). Patients who experienced pneumothorax more frequently required vasopressor support (28/33 [84%] vs. 191/301 [63%] P = 0.04), were more likely to be proned (25/33 [75%] vs. 111/301 [36%], P<0.001), and the presence of pneumothorax was associated with prolonged duration of mechanical ventilation; 21 (1-97) versus 7 (1-79) days, p<0.001 as well as prolonged hospital length of stay (29 [9-133] vs. 15 [1-90] days, P<0.001), but mortality was not significantly different between groups. Importantly, when we performed a Cox proportional hazard ratio (HR) model of multivariate parameters, we found that administration of tocilizumab significantly increased the risk of developing pneumothorax (HR = 10.7; CI [3.6-32], P<0.001). Among 334 critically ill patients with COVID-19, the incidence of pneumothorax was 10%. Presence of pneumothorax was associated with prolonged duration of mechanical ventilation and length of hospital stay. Strikingly, receipt of tocilizumab was associated with an increased risk of developing pneumothorax.

Adult hospitalizations from immigration detention in Louisiana and Texas, 2015-2018.

Poor health conditions within immigration detention facilities have attracted significant concerns from policymakers and activists alike. There is no systematic data on the causes of hospitalizations from immigration detention facilities or their relative morbidity. The objective of this study, therefore, was to analyze the causes of hospitalizations from immigration detention facilities, as well as the percentage of hospitalizations necessitating ICU or intermediate-ICU (i.e, "step-down") admission and the types of surgical and interventional procedures conducted during these hospitalizations. We conducted a cross-sectional study of statewide adult (age 18 and greater) hospitalization data, with hospitalizations attributed to immigration facilities via payor designations (from Immigration and Customs Enforcement) and geospatial data in Texas and Louisiana from 2015-2018. Our analysis identified 5,215 hospitalizations of which 887 met inclusion criteria for analysis. Average age was 36 (standard deviation, 13.7), and 23.6% were female. The most common causes of hospitalization were related to infectious diseases (207, 23.3%) and psychiatric illness (147, 16.6%). 340 (38.3%) hospitalizations required a surgical or interventional procedure. Seventy-two (8.1%) hospitalizations required ICU admission and 175 (19.5%) required intermediate ICU. In this relatively young cohort, hospitalizations from immigration detention were accompanied with significant morbidity. Policymakers should mitigate the medical risks of immigration detention by improving access to medical and psychiatric care in facilities.

Outcomes of patients admitted to the ICU for acute stroke: a retrospective cohort

BackgroundAlthough acute stroke is a leading cause of morbidity and mortality worldwide, data on outcomes of stroke patients requiring ICU admission are limited. We aimed to identify factors associated with a good neurological outcome (defined as a modified Rankin Scale score [mRS] of 0–2) 6 months after ICU admission.MethodsWe retrospectively studied consecutive patients who were admitted to the ICU of a French university-affiliated hospital between January 2014 and December 2018 and whose ICD-10 code indicated acute stroke. Patients with isolated subarachnoid hemorrhage or posttraumatic stroke were excluded.ResultsThe 323 identified patients had a median age of 67 [54.5–77] years; 173 (53.6%) were male. The main reasons for ICU admission were neurological failure (87%), hemodynamic instability (28.2%), acute respiratory failure (26%), and cardiac arrest (5.3%). At ICU admission, the Glasgow Coma Scale score was 6 [4–10] and the SAPSII was 54 [35–64]. The stroke was hemorrhagic in 248 (76.8%) patients and ischemic in 75 (23.2%). Mechanical ventilation was required in 257 patients (79.6%). Six months after ICU admission, 61 (19.5%) patients had a good neurological outcome (mRS, 0–2), 50 (16%) had significant disability (mRS, 3–5), and 202 (64.5%) had died; 10 were lost to follow-up. By multivariable analysis, factors independently associated with not having an mRS of 0–2 at 6 months were older age (odds ratio, 0.93/year; 95% confidence interval, 0.89–0.96; P < 0.01) and lower Glasgow Coma Scale score at ICU admission (odds ratio, 1.23/point; 95% confidence interval, 1.07–1.40; P < 0.01).ConclusionsAcute stroke requiring ICU admission carried a poor prognosis, with less than a fifth of patients having a good neurological outcome at 6 months. Age and depth of coma independently predicted the outcome.

Initial Chest X-ray scoring in the prediction of COVID-19 patients’ outcome in the United Arab Emirates

Background: The radiological scoring of severity and progression of lung abnormalities is of great value for clinicians to define the clinical management of COVID-19 patients. Objectives: The purpose of this study is to implement the Brixia scoring tool to assess the pattern of lung involvement in patients with COVID-19 to help predict the severity of their clinical outcome, where the clinical outcome correlates to outpatient, inpatient and/or ICU admission. Patients and Methods: We conducted a case series study at the Sheikh Khalifa Medical City Ajman (SKMCA), United Arab Emirates from 14 March to 30 October 2020. Patients’ medical records were reviewed and followed up from the time of diagnosis until discharge and/or death. The patients were included based on the following criteria: Confirmed COVID-19 infection via RT-PCR assay, symptoms of COVID-19 within one week prior to presenting at the hospital and an initial Chest X-ray at hospital presentation. Two independent and experienced radiologists implemented the Brixia scoring tool for the assessment of pulmonary involvement detected on CXR of patients with COVID-19. Results: We reported cut-off values of the CXR score to be 7 for ICU admission (sensitivity=84.1%) and a cut-off score of 9 to predict the outcome of death (sensitivity=70.4%); where both values were statistically significant with p-value &lt;0.001. Age and co-morbid conditions potentiate the CXR score. Conclusion: Patients with a Brixia score higher than the cut-off value would require ICU admission. In addition to the Brixia scoring tool, age and pre-existing co-morbid diseases are important predictors of the clinical outcome. CXR can serve as a valuable factor for risk stratification for clinical outcome in patients with COVID-19 pneumonia

Dexametasona frente a metilprednisolona ajustada al peso en pacientes con neumonía moderada-grave por SARS-CoV-2

ObjectivesTo compare the 30-day outcome (mortality and/or ICU admission) of patients admitted for moderate-severe SARS-CoV-2 pneumonia treated with dexamethasone after the Recovery study versus those treated with weight-adjusted methylprednisolone. MethodsRetrospective cohort study of 65 patients with moderate-severe pneumonia who received dexamethasone 6 mg/day (DXM group) versus 80 treated with weight-adjusted methylprednisolone (MTPN group). ResultsTwenty-one (32.3%) patients in the DXM group died vs. 8 (10%) in the MTPN group (p-value < 0.001) and 29 (44.6%) in the DXM group required ICU admission vs. 2 (2.5%) of the MTPN group (p-value < 0.001). There were no baseline differences regarding sociodemographic characteristics with a higher mean qSOFA in the MTPN group. The hazard ratio for mortality and ICU admission adjusted for age, sex, and admission CRP was 2.189 (1.082–4.426; 95% CI) and 10.589 (2.139–48.347; 95% CI) for the DXM group, respectively, vs. MTPN group. ConclusionsMortality and admission to the ICU were lower in patients treated with weight-adjusted methylprednisolone compared to those treated with dexamethasone.

Occupational therapy treatment time during inpatient traumatic spinal cord injury rehabilitation: A retrospective study from a tertiary center in Riyadh

Background: Occupational therapy (OT) is a part of the rehabilitation process which facilitates and enables individuals with spinal cord injuries (SCI) to be as independent as possible in their activities of daily living (ADLs). Little is known about the OT treatment plan and the duration of the selected treatment intervention during SCI rehabilitation. This study aims to describe the duration of OT treatment that patients with SCI Received during their inpatient rehabilitation stay.&#x0D; Materials and Methods: A chart review of patients with SCI who attended inpatient rehabilitation at King Abdulaziz Medical City between 2016 and 2020 was conducted. The documented rehabilitation session, including the treatment duration and the type of therapeutic intervention, were extracted from each patient’s electronic medical file.&#x0D; Results: A total of 50 eligible patients have been included in this analysis. The median age of the study population was 28, and the majority were male patients (82%). The most common reason for the SCI was a motor vehicle accident (94%), in which 56% required ICU admission. The median total time spent over the patient’s stay was 1785 min, approximately 43.7 hr of OT rehabilitation.&#x0D; Conclusion: Differentiation between and within traumatic SCI patient level in the length of stay (LOS). Differentiation in time intensity was explained by patient and injury characteristics. Also, we identified a significant variation in time spent among traumatic SCI for all OT interventions when examining the median of the total number of hours. Specifically, we found that lower body dressing training was the most time-consuming ADL.

Identifying endotypes of individuals after an attack of pancreatitis based on unsupervised machine learning of multiplex cytokine profiles

After an attack of pancreatitis, individuals may develop metabolic sequelae (eg, new-onset diabetes) and/or pancreatic cancer. These new-onset morbidities are, at least in part, driven by low-grade inflammation. The aim was to study the profiles of cytokines/chemokines in individuals after an attack of pancreatitis. A commercially available panel including 31 cytokines/chemokines was investigated. Random forest classifier and unsupervised hierarchical clustering were applied to study participants (who had no persistent organ failure and did not require ICU admission) according to their cytokine/chemokine profiles. Pancreatitis-related characteristics, detailed body composition (determined using 3.0 T magnetic resonance imaging), markers of glucose, lipid, and iron metabolism, gut and pancreatic hormones, as well as liver and pancreatic enzymes, were compared between clusters. Bootstrap validation was employed. A total of 160 participants, including 107 postpancreatitis individuals (investigated at a median of 18 months after the last attack of pancreatitis) and 53 healthy volunteers, were studied. Twenty-two cytokines/chemokines were significantly different between postpancreatitis and health. Two distinct endotypes of individuals after an attack of pancreatitis were identified–‟inflammatory” and ‟noninflammatory.” Sixteen cytokines/chemokines were significantly higher in the inflammatory endotype compared with the noninflammatory endotype. No cytokine/chemokine was significantly higher in the noninflammatory endotype. The inflammatory endotype was characterized by significantly elevated insulin (P= 0.001), glucose-dependent insulinotropic peptide (P = 0.001), peptide YY (P = 0.017), and ghrelin (P = 0.014). The noninflammatory endotype was characterized by significantly elevated hepcidin (P= 0.016). Pancreatitis-related factors, body composition, and other studied parameters did not differ significantly between the 2 endotypes. Individuals with a similar phenotype and clinical course of pancreatitis have differing cytokine/chemokine profiles after clinical resolution of the disease. People with the inflammatory endotype have distinct changes in the pancreatic and gut hormones known to be involved in the pathogenesis of new-onset morbidities after an attack of pancreatitis.

Epidemiology and Outcomes of Bacterial Coinfection in Hospitalized Children With Respiratory Viral Infections: A Single Center Retrospective Chart Review.

Children with viral respiratory illness are often suspected of having bacterial coinfection. This study was designed to determine the impact of bacterial coinfection on hospital course and outcomes and the rate of antimicrobial misuse. Single-center retrospective chart review, including all hospitalized children who had a respiratory viral panel sent within 48 hours of admission from January 2015 to December 2019. Patients who had a positive respiratory, urine, blood culture within 24 hours of admission were identified. Demographics, resource utilization, and outcomes were compared between the 2 groups. This study included 2192 patients. Of those, 269 patients had positive bacterial cultures. Out of these cultures from 192 patients were identified as contaminants. True bacterial coinfection was 3.5% (77/2192). Almost 1/3 of admitted patients were prescribed empiric antimicrobials. Children with bacterial coinfection tended to be younger (median age 8.4 months vs 16.3 months, p < 0.01) and had higher proportion of prematurity (23.3% vs 12.1%, p < 0.01). Children with bacterial coinfection were more likely to require ICU admission (37.6% vs 23.9%, p < 0.01) and intubation (28.5% vs 5.3 %, p < 0.01). They had higher ICU (5.7 days vs 1.9 days, p < 0.01) and hospital length of stay (4.0 days vs 2.0 days, p < 0.01), higher mortality (2.6% vs 0.2%, p = 0.02), and a higher median cost of hospital care ($3774.44 vs $2424.49.90, p < 0.01). The rate of bacterial coinfection in hospitalized children with viral infections is very low, which contradicts the routine administration of empiric antimicrobials. Patients with coinfection require more hospital resources and have worse clinical outcomes.

Is there a learning effect on 1-min sit-to-stand test in post-COVID-19 patients?

The 1-min sit-to-stand test is a repeatable field test without differences between the first and second tests. Hence, conducting one attempt of the 1-min STST would be enough to evaluate functional capacity in patients recovered from #COVID19. https://bit.ly/3y3ycAP

PNEUMONIA SEVERITY INDEX COMPARED TO CURB-65 IN PREDICTING THE OUTCOME OF COMMUNITY ACQUIRED PNEUMONIA -A PROSPECTIVE STUDY

Introduction: Community-acquired pneumonia (CAP) is a leading cause of morbidity and mortality worldwide. Several severity scores have been proposed to guide initial decision making on hospitalization and to predict the outcome. Pneumonia Severity Index (PSI) and CURB 65 are the two most widely used scoring systems to prognosticate pneumonia. Objectives: Tocompare the efficacy of PSI and CURB 65 scoring systems in prognosticating the outcome in cases of CAP. Methods: This is a prospective study conducted over a period of one year on 150 patients who presented with community acquired pneumonia on the grounds of their clinical and paraclinical findings in our institution under the Department of respiratory Medicine, and fulfilling the inclusion and exclusion criteria. The patients were classified as per CURB 65 and PSI system and their outcome compared. Results: We studied 150 patients with community-acquired pneumonia (114 men, 36 women). In our study 100 % of patients in CURB 65 class 4 and 5 required ICU admission and death was 84.6% and 100% respectively. Majority of patients of PSI class 4 and 5 needed ICU admission 67% and 96% respectively and death was 16% and 58% respectively. The sensitivity and specificity of CURB-65 class ≥3 in predicting mortality were 79% and 89%, respectively (AUC 0.92). As for pneumonia severity index class ≥4, the rates were 79% and 84%, respectively (AUC 0.86). The mortality rate and need for ICU admission increased progressively with increasing scores. Conclusion: CURB-65 seems to be the preferred method to predict mortality and need for ICU admission in patients with community-acquired pneumonia.

CLINICAL CHARACTERISTICS, MANAGEMENT PRACTICES AND IN-HOSPITAL OUTCOMES OF SCRUB TYPHUS PATIENTS IN A TERTIARY CARE CENTER IN THE NORTH EASTERN STATE, TRIPURA

Background- With the changing epidemiology, scrub typhus is now among the commonest causes of AFI in India and a high suspicion should be maintained, and an early diagnosis and promt management is warranted to prevent complications. Objective - Clinical characteristics, management practices and in-hospital outcomes of scrub typhus patients. Methods- a Cross-sectional retrospective study was conducted among 110 scrub typhus patients attending Agartala Government Medical College and GB Pant Hospital, a tertiary care centre of Tripura in last one year period. Their clinical profile, laboratory studies and management has been recorded and data has been evaluated with SPSS 21.0 for windows with p- value &lt;0.05. Results- the commonest presenting symptoms of scrub typhus are high-grade fever with chills , headache and it most commonly effects farmers. Most commonly effected age group was 40-50 years of age. Most of the patients were from West Tripura followed by Khowai Tripura and least patients were from North Tripura. Predominately it occured in September, October and November i.e. in post monsoon period. The pathognomonic eschar was present in 43% patients and rarest presentation was paraparesis (0.9%). Lymphadenopathy (9%), neck rigidity (6%), hepatomegaly (10%), splenomegaly (4%), acute respiratory distress syndrome was seen in 14% patients. Hepatic involvement was the most common complication seen in our study (42%). Anemia was present in 25% and thrombocytopenia was present in 22% patients. Subside of fever to doxycycline injection seen in 73% on day1 and 84% on day2. 19% Patient required icu admission. 9% developed ARDS and 6% required ET tube intubation and mechanical ventilation. 6% developed hypotension requiring inotropic support. 4% developed severe thrombocytopenia(&lt;10,000) required platelet transfusion. 11% developed acute kidney injury requiring haemodialysis. Survival rate were 93% and mortality 7%. In conclusion, scrub typhus became the leading infectious cause of acute febrile illness in North eastern state, Tripura. A high suspicion should be maintained, and an early diagnosis and promt management is warranted to prevent mortality and morbidity of patients.

The prognostic value of biomarker levels and chest imaging in patients with COVID-19 presenting to the emergency department

IntroductionWe aimed to compare the prognostic value of a quantitative CT severity score with several laboratory parameters, particularly C-reactive protein, Procalcitonin, Neutrophil to lymphocyte ratio, D-dimer, ferritin, lactate dehydrogenase, lactate, troponin and B-type Natriuretic Peptide in predicting in-hospital mortality. MethodsThis was a retrospective chart review study of COVID-19 patients who presented to the Emergency Department of a tertiary care center between February and December 2020. All patients ≥18 years old who tested positive for the COVID-19 real-time reverse transcriptase polymerase chain reaction and underwent CT imaging at presentation were included. The primary outcome was the prognostic ability of CT severity score versus biomarkers in predicting in-hospital mortality. ResultsThe AUCs were: D-dimer (AUC: 0.67 95% CI = 0.57–0.77), CT severity score (0.66, 95% CI = 0.55–0.77), LDH (0.66, 95% CI = 0.55–0.77), Pro-BNP (0.65, 95% CI = 0.55–0.76), NLR (0.64, 95% CI = 0.53–0.75) and troponin (0.64, 95% CI = 0.52–0.75). In the stepwise logistic regression, age (OR = 1.07 95% CI = 1.05–1.09), obesity (OR = 2.02 95% CI = 1.25–3.26), neutrophil/lymphocyte ratio (OR = 1.02 95% CI = 1.01–1.04), CRP (OR = 1.01 95% CI = 1.004–1.01), lactate dehydrogenase (OR = 1.003 95% CI = 1.001–1.004) and CT severity score (OR = 1.17 95% CI = 1.12–1.23) were significantly associated with in-hospital mortality. ConclusionIn summary, CT severity score outperformed several biomarkers as a prognostic tool for covid related mortality. In COVID-19 patients requiring lung imaging, such as patients requiring ICU admission, patients with abnormal vital signs and those requiring mechanical ventilation, the results suggest obtaining and calculating the CT severity score to use it as a prognostic tool. If a CT was not performed, the results suggest using LDH, CRP or NLR if already done as prognostic tools in COVID-19 as these biomarkers were also found to be prognostic in COVID-19 patients.

Complications of second trimester induction for abortion or fetal demise for patients with and without prior cesarean delivery

ObjectiveCompare complication rates of second trimester induction for abortion or fetal demise for patients with and without prior cesarean delivery. Study designRetrospective cohort study examining induction for abortion or fetal demise for pregnancies from 14w0d to 23w6d gestation at 2 urban academic medical centers from 2009 to 2019. Exclusion criteria included preterm labor or cervical insufficiency, neonatal interventions, or if misoprostol was not the primary induction method. Complication rates were compared between those with no prior, 1 prior, and 2 or more (2+) prior cesarean deliveries. Complications analyzed were retained placenta, failed induction, infection, hemorrhage, blood transfusion, uterine rupture, intensive care unit admission, death, and readmission. Secondary analysis included cumulative misoprostol dosages and complete abortion rate within 24 hours. ResultsOf 520 patients, 411 patients had no prior cesarean delivery, 77 had 1 prior cesarean delivery, and 32 had 2+ prior cesarean deliveries. Eleven patients had a prior vertical uterine incision. About 26.5% of all patients received mifepristone. The 2+ prior cesarean delivery group was significantly older (35 vs 32 vs 32, p < 0.001) and more likely to be induced for fetal demise (62.5 vs 41.56 vs 39.17%, p = 0.04). Both cesarean groups were more likely to be obese (58.62 vs 49.35 vs 34.26%, p = 0.003). Patients with 2+ prior cesarean deliveries were more likely to experience uterine rupture (6.25 vs 0 vs 0%, p = 0.004), and require ICU admission (6.45 vs 1.3 vs 0.49%, p = 0.02). Secondary analysis outcomes were similar. Logistic regression showed patients with 2+ prior cesarean deliveries were more likely to experience a complication than those with 1 prior (adjusted odds ratio [aOR] 2.71, confidence interval [CI] 1.09–6.86, p = 0.03) or 0 prior cesarean deliveries (aOR 3.00, CI 1.30–7.02, p = 0.01). Patients with 1 prior or no prior cesarean deliveries had a similar risk of experiencing a complication (aOR 1.11, CI 0.64–1.89, p = 0.7). ConclusionsMost patients with prior cesarean deliveries can safely undergo induction in the second trimester for abortion or fetal demise. Patients with 2+ prior cesarean deliveries had a higher rate of at least 1 complication when compared to those with one or no prior cesarean delivery, despite similar misoprostol dosages and rates of complete abortion. ImplicationsThis large 10-year retrospective study examines the impact of prior cesarean delivery on the safety of second trimester induction. While second trimester labor induction abortion remains an option for all patients, specialized counseling for patients with 2 or more prior cesarean deliveries may be warranted.

PB2268: IMPACT OF HEMATOLOGICAL DISORDERS ON MORTALITY AND SERIOUS OUTCOMES IN SARS-COV-2 INFECTION: A MULTICENTER COHORT STUDY

Background: Presence of hematologic diseases has been associated with worse outcomes in patients with SARS-CoV2 virus infection, including higher mortality rates than patients without these comorbidities. This cohort study included patients with and without prevalent hematologic diseases. Aims: To determine the impact of hematologic disorders on 30-day mortality and other severe outcomes in patients with SARS-COV-2 infection. Methods: A prospective cohort study was conducted in 6 COVID-19 reference centers in Mexico between March 1, 2020 and January 31, 2021. The main objective of our study was to determine the impact of hematologic disease status on 30-day mortality and on a composite outcome of severe complications(AKI, ARDS, and liver failure). Using data from patients treated in the largest center, those with COVID-19 and hematologic diseases were compared to non-hematologic COVID-19 controls. Pairing was performed according to COVID-19 treatment, age, sex, BMI, and CDC-defined variables of high mortality risk. As a secondary objective, a multi-center analysis was performed to determine risk factors for 30-day mortality in hematologic disease patients, determined by univariate and multivariate analysis. Results: For the main objective, 59 patients were recruited(matched 1:1). In the 30-day mortality analysis, we found no differences between the two groups: HR 1.08 (95% CI 0.52-2.24)p=0.833, OR 1.08 (95% CI 0.46-2.48)p=0.872. Regarding the composite outcome of severe complications, we found a HR 1.03, (95% CI 0.59-1.80)p=0.896. There was no difference in the 30-days survival between the two groups(p=0.832)(Figure 1). For our secondary objective, 158 patients were recruited: 46.6% women, median age 45 years, BMI 26.3 (IQR 23.2-29.7), 19.0% diabetes, 14.6% hypertension and 18% smokers, and 83.5% with hematologic malignancies. Supplementary oxygen was used in 81.6%, in hospital-treatment was necessary in 84.1%, and 41.4% required ICU admission. 30-day mortality was 42.4%. Complications during hospitalization included respiratory failure in 84.5%, of which only 48% received VMI; reasons for not receiving VMI included a non-intubation order issued by the patient or family members and lack of infrastructure. Regarding COVID-19 treatment, 30% received dexamethasone 6 mg/day and 30% received thromboprophylaxis. In the univariate analysis, the following were predictive factors of mortality: all types of malignancy HR 2.64 (95% CI 1.06-6.59)p=0.030, lymphoid malignancy HR 2.52 (95% CI 1.06-6.95)p=0.035, last treatment <3months HR 2.3 (95% CI 1.15-4.61)p=0.018, and palliative treatment HR 3.01 (95% CI I.35–7.72)p=0.007. Complete response was a protective factor HR 0.229 (95% CI 0.093–0.53)p=0.001. The use of dexamethasone was not a protective factor in this population HR 1.32 (95% CI 0.80-2.18)p=0.273. In the multivariate analysis, palliative status HR 4.8 (95% CI 1.07-22.18)p=0.040 and complete response HR 0.22 (95% CI 0.062-0.815)p=0.023 were risk and protective factors, respectively. Image:Summary/Conclusion: After careful pairing according to clinical characteristics, including CDC variables predictive of high mortality risk, we observed survival didn’t differ between groups, concluding hematologic disease did not impact 30-day mortality in COVID-19 patients. This is striking, since previous reports have described a higher mortality risk among patients with hematologic diseases, although the pairing process hadn’t been as thorough as ours. Also of note, use of dexamethasone was not associated with lower 30-day mortality in patients with hematologic diseases.

P1155: BREXUCABTAGENE AUTOLEUCEL FOR RELAPSED/REFRACTORY MANTLE CELL LYMPHOMA IN ROUTINE PRACTICE: UPDATED REPORT FROM THE US LYMPHOMA CAR T CONSORTIUM

Background: The ZUMA-2 trial and real-world studies showed high efficacy of brexucabtagene autoleucel (brexu-cel) in relapsed/refractory mantle cell lymphoma (MCL). We previously reported an objective response rate (ORR) of 89% in 95 patients receiving standard-of-care brexu-cel in the US Lymphoma CAR T Consortium (Wang et al, ASH 2021). Aims: To update the safety and efficacy results of the Consortium study with more patients and longer follow-up. Methods: Patients who underwent leukapheresis for standard-of-care brexu-cel manufacture at one of the 16 Consortium centers between 8/1/2020 and 12/31/2021 were included. Baseline characteristics, bridging therapy, cytokine release syndrome (CRS), immune effector cell-associated neurotoxicity syndrome (ICANS), and treatment outcome data were collected. Eligibility for ZUMA-2 was retrospectively determined based on characteristics at leukapheresis. Time-to-event data were analyzed using the Kaplan-Meier method. Results: At the data cut-off date of 1/31/2022, 189 patients underwent leukapheresis; 167 (88%) completed infusion and 22 (12%) did not (manufacture failure n=7, death n=6, disease progression n=5, organ dysfunction n=2, complete response [CR] to bridging therapy n=1, patient decline n=1). The median age of the 167 infused patients was 67 years (range 34-89) and 76% were male. 16% had high risk simplified MIPI, 57% had Ki-67 ≥50%, 41% had blastoid or pleomorphic variant, 49% had TP53 alteration, 31% had complex karyotype, 14% had bulky disease (≥10 cm), and 10% had CNS involvement. The median prior lines of therapy was 3 (range 1-10), and 86% were BTKi-exposed (89% of which were refractory). 130 (78%) patients would not have met ZUMA-2 eligibility criteria, and the most common reasons were prior therapies (eg, anthracycline- or bendamustine-naïve [16%], BTKi-naïve [14%], >5 lines of prior therapy [11%]), renal dysfunction (21%), cardiac comorbidities (14%), cytopenias (11%), ECOG PS ≥2 (11%), and CNS involvement (10%). 113 (68%) patients received bridging therapy, which included immunochemotherapy (n=45), BTKi (n=45), venetoclax (n=24), radiotherapy (n=23), corticosteroid (n=18), and lenalidomide (n=6). The median time from leukapheresis to lymphodepletion chemotherapy was 28 days (range 17-140). The rate of CRS was 90% (8% grade ≥3, 1 grade 5), and the rate of ICANS was 61% (32% grade ≥3, 0 grade 5). Medications used to manage CRS and/or ICANS included tocilizumab (76%), corticosteroid (68%), anakinra (16%), and siltuximab (3%). 20% of patients required ICU admission, with a median stay of 3 days (range 1-12); 18% required vasopressors, 3% required mechanical ventilation, and 3% required dialysis. Among 159 evaluable patients, the day 30 ORR was 89%, with 70% CR and 19% partial response (PR). With continued follow-up, the best ORR was 89%, with 80% CR and 9% PR. The best ORR/CR rate were 89%/77% for high Ki-67% (≥50%), 88%/79% for blastoid or pleomorphic variant, 88%/73% for complex karyotype, 90%/72% for TP53 altered, 81%/75% for CNS involved, 89%/79% for BTKi-exposed, 91%/83% for BTKi-naïve, and 89%/78% for ZUMA-2 ineligible. With a median follow-up of 5.6 months (range 0.2-15.3), the 6-month estimates for duration of response, progression-free survival, and overall survival were 67% (95% CI 57-75), 63% (95% CI 54-71) and 85% (95% CI 77-90), respectively. Summary/Conclusion: This updated analysis demonstrated favorable safety and efficacy results of brexu-cel in R/R MCL that are consistent with the initial report. Despite 78% of patients being ineligible for ZUMA-2, the responses, CRS, ICANS and survival outcomes were comparable to ZUMA-2 data.

Cryptococcosis among hospitalised patients with COVID-19: Amulticentre research network study.

It is unclear if there is an association between COVID‐19 and cryptococcosis. Therefore, this study aimed to describe the clinical features, risk factors, and outcomes associated with cryptococcosis in hospitalised patients with COVID‐19. The objectives of this study were to determine the incidence of and examine factors associated with cryptococcosis after a diagnosis of COVID‐19. We used TriNetX to identify and sort patients 18 years and older hospitalised with COVID‐19 into two cohorts based on the presence or absence of a diagnosis of cryptococcosis following diagnosis of COVID‐19. Outcomes of interest included the incidence of cryptococcosis following the diagnosis of COVID‐19 as well as the proportion of patients in each group who had underlying comorbidities, received immunomodulatory therapy, required ICU admission or mechanical ventilation (MV), or died. Propensity score matching was used to adjust for confounding. Among 212,479 hospitalised patients with COVID‐19, 65 developed cryptococcosis. The incidence of cryptococcosis following COVID‐19 was 0.022%. Patients with cryptococcosis were more likely to be male and have underlying comorbidities. Among cases, 32% were people with HIV. Patients with cryptococcosis were more likely to have received tocilizumab (p < .0001) or baricitinib (p < .0001), but not dexamethasone (p = .0840). ICU admission (38% vs 29%), MV (23% vs 11%), and mortality (36% vs 14%) were significantly higher among patients with cryptococcosis. Mortality remained elevated after adjusted propensity score matching. Cryptococcosis occurred most often in hospitalised patients with COVID‐19 who had traditional risk factors, comparable to findings in patients without COVID‐19. Cryptococcosis was associated with increased ICU admission, MV, and mortality.