Faculty Bibliography

BACKGROUND:Ileal pouch-anal anastomosis (IPAA) is the mainstay of surgical treatment for patients with ulcerative colitis (UC) but is associated with an increased risk of infertility. We developed a simulation model examining the impact of initial surgical procedure on quality-adjusted life-years (QALYs) and fertility end points. METHODS:A patient-level state transition model was used to analyze outcomes by surgical approach strategy for females of childbearing age. Initial surgical options included IPAA, rectal-sparing colectomy with end ileostomy (RCEI), and ileorectal anastomosis (IRA). The primary outcome examined was QALYs, whereas secondary outcomes included UC and fertility-associated end points. RESULTS:IPAA resulted in higher QALYs for patients aged 20-30 years, as compared with RCEI. For patients aged 35 years, RCEI resulted in higher QALYs (7.54 RCEI vs 7.53 IPAA) and was associated with a 28% higher rate of childbirth, a 14-month decrease in time to childbirth, and a 77% reduction in in vitro fertilization utilization. When accounting for the decreased infertility risk associated with laparoscopic IPAA, IPAA resulted in higher QALYs (7.57) even for patients aged 35 years. CONCLUSIONS:Despite an increased risk of infertility, our model results suggest that IPAA may be the optimal surgical strategy for female UC patients aged 20-30 years who desire children. For patients aged 35 years, RCEI should additionally be considered, as QALYs for RCEI and IPAA were similar. These quantitative data can be used by patients and providers to help develop an individualized approach to surgical management choice.

BACKGROUND:Little is known about long-term recovery from severe COVID-19 disease. Here, we characterize overall health, physical health and mental health of patients one month after discharge for severe COVID-19. METHODS:This was a prospective single health system observational cohort study of patients ≥18 years hospitalized with laboratory-confirmed COVID-19 disease who required at least 6 liters of oxygen during admission, had intact baseline cognitive and functional status and were discharged alive. Participants were enrolled between 30 and 40 days after discharge. Outcomes were elicited through validated survey instruments: the PROMIS Dyspnea Characteristics and PROMIS Global Health-10. RESULTS:A total of 161 patients (40.6% of eligible) were enrolled; 152 (38.3%) completed the survey. Median age was 62 years (interquartile range [IQR], 50-67); 57 (37%) were female. Overall, 113/152 (74%) participants reported shortness of breath within the prior week (median score 3 out of 10 [IQR 0-5]), vs. 47/152 (31%) pre-COVID-19 infection (0, IQR 0-1), p<0.001. Participants also rated their physical health and mental health as worse in their post-COVID state (43.8, standard deviation 9.3; mental health 47.3, SD 9.3) compared to their pre-COVID state, (54.3, SD 9.3; 54.3, SD 7.8, respectively), both p <0.001. A total of 52/148 (35.1%) patients without pre-COVID oxygen requirements needed home oxygen after hospital discharge; 20/148 (13.5%) reported still using oxygen at time of survey. CONCLUSIONS:Patients with severe COVID-19 disease typically experience sequelae affecting their respiratory status, physical health and mental health for at least several weeks after hospital discharge.

Background/UNASSIGNED:The coronavirus disease 2019 pandemic has or threatens to overwhelm health care systems. Many institutions are developing ventilator triage policies. Objective/UNASSIGNED:To characterize the development of ventilator triage policies and compare policy content. Design/UNASSIGNED:Survey and mixed-methods content analysis. Setting/UNASSIGNED:North American hospitals associated with members of the Association of Bioethics Program Directors. Participants/UNASSIGNED:Program directors. Measurements/UNASSIGNED:Characteristics of institutions and policies, including triage criteria and triage committee membership. Results/UNASSIGNED:Sixty-seven program directors responded (response rate, 91.8%); 36 (53.7%) hospitals did not yet have a policy, and 7 (10.4%) hospitals' policies could not be shared. The 29 institutions providing policies were relatively evenly distributed among the 4 U.S. geographic regions (range, 5 to 9 policies per region). Among the 26 unique policies analyzed, 3 (11.3%) were produced by state health departments. The most frequently cited triage criteria were benefit (25 policies [96.2%]), need (14 [53.8%]), age (13 [50.0%]), conservation of resources (10 [38.5%]), and lottery (9 [34.6%]). Twenty-one (80.8%) policies use scoring systems, and 20 of these (95.2%) use a version of the Sequential Organ Failure Assessment score. Among the policies that specify the triage team's composition (23 [88.5%]), all require or recommend a physician member, 20 (87.0%) a nurse, 16 (69.6%) an ethicist, 8 (34.8%) a chaplain, and 8 (34.8%) a respiratory therapist. Thirteen (50.0% of all policies) require or recommend those making triage decisions not be involved in direct patient care, but only 2 (7.7%) require that their decisions be blinded to ethically irrelevant considerations. Limitation/UNASSIGNED:The results may not be generalizable to institutions without academic bioethics programs. Conclusion/UNASSIGNED:Over one half of respondents did not have ventilator triage policies. Policies have substantial heterogeneity, and many omit guidance on fair implementation.

Neurological complications of COVID-19 are not well described. We report two patients who were diagnosed with COVID-19 after presenting with diplopia and ophthalmoparesis.

OBJECTIVE:We postulated that cerebral amyloid angiopathy (CAA) is associated with white matter atrophy (WMA) and that WMA can be related to cognitive changes in CAA. METHODS:White matter volume expressed as percent of intracranial volume (pWMV) of prospectively enrolled patients without dementia diagnosed with probable CAA was compared to age-matched healthy controls (HC) and patients with Alzheimer disease (AD). Cognitive scores were also sought to understand the potential effects of WMA on cognitive function. RESULTS:= 0.003, respectively). All associations remained independent in multivariable analyses. Within the CAA cohort, higher pWMV independently correlated with better scores of executive function. CONCLUSIONS:Patients with CAA show WMA when compared to age-matched HC and patients with AD. WMA independently correlates with the number of lobar microbleeds, a marker of CAA severity. Consistent spatial patterns of WMA especially in posterior regions might be related to CAA. The association between WMA and measures of executive function suggests that WMA might represent an important mediator of CAA-related neurologic dysfunction.

Delirium is a common symptom in patients admitted to our hospital with COVID-19, and in cases of hyperactive delirium we have frequently observed behaviors that pose a significant risk of disease transmission to health care providers. Managing this symptom has emerged as an important challenge, as our local health care system has been strained by providers becoming sick or quarantined. Preventative and non-pharmacologic interventions remain critical for managing delirium in such patients, though occasionally pharmacologic treatment is required. When use of an antipsychotic medication is indicated, we recommend that providers consider foregoing the lowest common dose and instead start with the next incrementally higher dose to more quickly and reliably ensure the safety of both patients and providers. We do not recommend initiating prophylactic treatment or escalating doses in a manner that conflicts with currently accepted guidelines without carefully considering the risks and benefits.

Autologous stem cell transplantation (ASCT) remains the standard-of-care for transplant-eligible multiple myeloma (MM) patients. Bortezomib with lenalidomide and dexamethasone (VRD) is the most common triplet regimen for newly diagnosed MM in the US. Carfilzomib with lenalidomide and dexamethasone (KRD) has promising efficacy and may supplant VRD. We compared stem cell yields and autograft minimal residual disease (MRD)-negativity after VRD and KRD induction. Deeper responses (very good partial response or better) were more common with KRD. Pre-collection bone marrow cellularity, interval from the end of induction therapy to start of stem cell collection, and method of stem cell obilization were similar for the two cohorts. Days to complete collection was greater with KRD (VRD 1.81 vs. KRD 2.2 days), which more often required ≥3 days of apheresis. Pre-collection viable CD34+ cell content was greater with VRD, as was collection yield (VRD 11.11 × 106 vs. KRD 9.19 × 106). Collection failure (<2 × 106 CD34+ cells/kg) was more frequent with KRD (5.4%) than VRD (0.7%). The differences in stem cell yields between VRD and KRD associate with degree of lenalidomide exposure. Age ≥70 predicted poorer collection for both cohorts. Stem cell autograft purity/MRD-negativity was higher with KRD (81.4%) than VRD (57.1%). For both cohorts, MRD-negativity was attained in a larger fraction of autografts than pre-collection bone marrows. For patients proceeding to ASCT, time to neutrophil/platelet engraftment was comparable. In summary, KRD induces deeper clinical responses and greater autograft purity than VRD without compromising stem cell yield or post-transplant engraftment kinetics.