Impact of COVID-19 Pandemic on Ambulatory and Operating Room Rhinology Practice in the US

INTRODUCTION

The pandemic caused by the novel coronavirus virus has altered all facets of clinical practice in the United States. The goal of this study is to better understand the impact of COVID-19 on rhinologic ambulatory and operative practice.

METHODS

A 27-item survey to assess these objectives was created and approved by the Division of Rhinology faculty at Rush University Medical Center in April 2020. The survey was then distributed to rhinologists in a web based format via www.surveymonkey.com from April 10 through April 23, 2020.

RESULTS

A total of 277 U.S based rhinologists responded to the survey (23.04%). The most common practice types were single specialty private (44.9%) and academic (24.6%). 90.2% practice in a state under a shelter in place order. Comparing pre-COVID baseline to during-COVID, there was statistically significant reduction in the number of patients of seen daily in clinic (p < 0.001). The number of nasal endoscopies in the office and surgical procedures fell dramatically. Overall, 5 respondent rhinologists have been infected with COVID-19 and 27 have been furloughed.

CONCLUSION

COVID-19 has drastically affected rhinologic practice. There is a dramatic reduction of in person care in the office setting and surgical management of sinonasal and skull base disease. Enhanced PPE is being used in only half of potentially aerosolizing procedures which represents an area of further education. Novel approaches such as use of virtual encounters and point of care testing should be considered as options to facilitate care.

Increased Prevalence of Psychosis in Patients Who Get Admitted with Acute Myocardial Infarction with Worse Outcomes

Objective

To determine trends and impact on outcomes of acute myocardial infarction (AMI) in patients with pre-existing psychosis.

Background

While post-AMI psychosis has been extensively studied, contemporary studies including temporal trends on impact of pre-AMI Psychosis on AMI and post-AMI outcomes are lacking.

Methods

We used Nationwide Inpatient Sample (NIS) from Healthcare Cost and Utilization Project(HCUP) from 2002 to 2012. We identified AMI and psychosis as primary and secondary diagnosis respectively using validated International Classification of Diseases, 9th Revision, and Clinical Modification (ICD9CM) codes, and Cochrane-Armitage trend test and multivariate regression to generate adjusted odds ratios (aOR).

Results

We analyzed total of 7,174,274 AMI hospital admissions from 2002 to 2012 of which 1.77% had psychosis. Proportion of hospitalizations with psychosis increased from 6.94% to 11.85% (P-trend < 0.001). Utilization of percutaneous coronary intervention (PCI) was lower in patients with psychosis (29.98% vs. 40.36%, P < 0.001). Utilization of coronary artery bypass grafting (CABG) was lower in patients with psychosis (8.01% vs. 9.18%, P < 0.001). In-hospital mortality was significantly lower in patients with psychosis (aOR 0.677; 95% CI 0.630–0.727; P < 0.001) but discharge to specialty care higher (aOR 1.870; 95%CI 1.786–1.958; P < 0.001). In addition, median length of hospitalization (3.77 vs. 2.90 days; P < 0.001) was higher in hospitalizations with psychosis.

Conclusions

Our study displayed increasing proportion of patients with psychosis admitted due to AMI in last decade with lower mortality but higher morbidity post-infarction, and significantly less utilization of PCI and CABG. There was also increased length of stay patients with MDD. There is need to explore reasons behind this disparity in outcomes and PCI and CABG utilization to improve post-AMI outcomes in this vulnerable population.

Disclosure of interest

The authors have not supplied their declaration of competing interest.

Increased Prevalence of Major Depressive Disorder in Patients who Get Admitted with Atrial Fibrillation with Worse Outcomes

Objective

To determine trends and impact on outcomes of atrial fibrillation (AF) in patients with pre-existing major depressive disorder(MDD).

Background

While post-AF MDD has been extensively studied, contemporary studies including temporal trends on impact of pre-AF MDD on AF and post-AF outcomes are lacking.

Methods

We used Nationwide Inpatient Sample (NIS) from Healthcare Cost and Utilization Project (HCUP) from 2002 to 2012. We identified AF and MDD as primary and secondary diagnosis respectively using validated International Classification of Diseases, 9th Revision, and Clinical Modification (ICD9CM) codes, and used Cochrane-Armitage trend test and multivariate regression to generate adjusted odds ratios (aOR).

Results

We analyzed total of 3,887,827 AF hospital admissions from 2002 to 2012 of which 6.78% had MDD. Proportion of hospitalizations with MDD increased from 4.93% to 14.19% (P-trend < 0.001). Utilization of atrial cardioversion was lower in patients with MDD (34.37% vs. 40.52%, P < 0.001). In-hospital mortality was significantly lower in patients with MDD (aOR0.749; 95% CI 0.664–0.846; P < 0.001) but discharge to specialty care was higher (aOR 1.695; 95%CI 1.650–1.741; P < 0.001). In addition, median length of hospitalization (2.5 vs. 2.13 days; P < 0.001) and median cost of hospitalization (28,246 vs. 22,663; P < 0.001) was higher in hospitalizations with MDD.

Conclusions

Our study displayed an increasing proportion of patients with MDD admitted due to AF in the last decade with lower mortality but higher morbidity post-AF. In addition, there was significantly less utilization of atrial cardioversion in this population along with higher median length and cost of hospitalization. There is a need to explore the reasons behind this disparity in outcomes and atrial cardioversion utilization in order to improve post-AF outcomes in this vulnerable population.

Disclosure of interest

The authors have not supplied their declaration of competing interest.

Temporal Trends in Drug Abuse in Adults with Acute Myocardial Infarction Show Worse Outcomes

Objective

To determine temporal trends, invasive treatment utilization and impact on outcomes of pre-infarction drug abuse (DA) on acute myocardial infarction (AMI) in adults.

Background

DA is important risk factor for AMI. However, temporal trends in drug abuse on AMI hospitalization outcomes in adults are lacking.

Methods

We used Nationwide Inpatient Sample (NIS) from Healthcare Cost and Utilization Project (HCUP) from 2002 to 2012. We identified AMI and DA as primary and secondary diagnosis respectively using validated International Classification of Diseases, 9th Revision, and Clinical Modification (ICD9CM) codes, and used the CochraneArmitage trend test and multivariate regression to generate adjusted odds ratios (aOR).

Results

We analyzed total of 7,174,274 AMI hospital admissions from 2002 to 2012 of which 1.67% had DA. Proportion of hospitalizations with DA increased from 5.63% to 12.08% (P trend < 0.001). Utilization of coronary artery bypass grafting (CABG) was lower in patients with DA (7.83% vs. 9.18%, P < 0.001). In-hospital mortality was significantly lower in patients with DA (aOR 0.811; 95% CI 0.693–0.735; P < 0.001) but discharge to specialty care was higher (aOR 1.076; 95% CI 1.025–1.128; P < 0.001). The median cost of hospitalization (40,834 vs. 37,253; P < 0.001) was higher in hospitalizations with DA.

Conclusions

We demonstrate an increasing proportion of adults admitted with AMI have DA over the decade. However, DA has paradoxical association with mortality in adults. DA is associated with lower CABG utilization and higher discharge to specialty care, with a higher mean cost of hospitalization. The reasons for the paradoxical association of DA with mortality and worse morbidity outcomes need to be explored in greater detail.

Disclosure of interest

The authors have not supplied their declaration of competing interest.

Primary signet ring cell carcinoma of colon: Retrospective analysis of VACCR database

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Background: Signet ring cell carcinoma accounts for less than 1% of all colon cancers. We examined the clinical pathological features and prognosis of signet ring cell carcinoma of colon and compare it with mucinous and non-mucinous adenocarcinoma of colon.

Methods: A total of 206 patients diagnosed with signet ring cell carcinoma from 1995 to 2009 were identified from the VA Central Cancer Registry (VACCR) database. Age, race, histology, grade, lymph node status, stage and type of treatment received data were collected.

Results: Out of 206 patients, 173 (83.9%) were white, 31 (15%) were black, and 2 patients were listed as unknown. Median age of diagnosis was 67 years as compared to 70 years for both mucinous and non-mucinous adenocarcinoma of colon. Pathological T-stages were as follows: T1 = 2.9%, T2=5.3%, T3=33.9%, T4= 25.7%, and unknown 32%. Of the total, 22.3% were located in caecum, 21.8% in ascending colon, 15.5% in sigmoid colon, 7.7% in appendix and hepatic flexure of colon, 11.1% in transverse colon, 2.9% in splenic flexure and 4.4% in descending colon. 33.5% were lymph node positive, 34.6% were lymph node negative, and 31.8% were unknown. Histologically grade 3 (55.4%) was most commonly reported followed by grade 2 (7.3%), grade 1 (2.5%), grade 4 (1.9%)and in 33% grade was unknown. 41.3% patients received only surgery while 34% received surgery with adjuvant chemotherapy, 7.3% received chemotherapy alone and 7.8% patients received either chemotherapy, radiation or hormonal therapy alone, 9% did not receive any therapy. 1 year, 3 year and 5 year survivals for signet ring cell cancer compared to adeno carcinoma was 60% vs 80%, 33% vs 60%, and 24% vs 47% respectively. Median survival of signet ring cell carcinoma compared to mucinous and non mucinous adenocarcinoma was 19 months, 48 months and 62 months respectively.

Conclusions: Signet ring cell carcinoma of colon has poor survival rates than the other histological subtypes. Signet ring cell carcinoma presents at an earlier age, higher tumor grade and advanced stage at diagnosis when compared to mucinous and non-mucinous adenocarcinoma of colon. Due to rarity of this disease further multi-institute studies are required for in-depth understanding and analysis of this disease.

No significant financial relationships to disclose.

Primary non-Hodgkin lymphoma of the colon among patients in the Veterans Affairs Health System

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Background: Primary non-Hodgkin lymphoma (NHL) of the colon is rare. There are no randomized controlled trials describing treatment outcomes for this tumor. We provide the largest descriptive study of this tumor to date.

Methods: Retrospective analysis of 109 patients diagnosed with primary non-Hodgkin lymphoma of the colon from 1995 to 2008 was done via the Veteran's Affairs Central Cancer Registry. By definition, all cases presented with a lymphomatous involvement of the colon as the first manifestation of their disease with no previous diagnosis of NHL of any type or site. Demographic, staging, histology, treatment, and outcome data was recorded. Lymphomas were classified as aggressive versus indolent based on their histology.

Results: There were 36,260 colon cancers diagnosed in 1995-2008 of which 109 (0.3%) were primary non-Hodgkin colon lymphomas. The median age of diagnosis was 67 years. 55 pts had aggressive disease, 27 pts had indolent disease, and 27 pts had inadequate histological data. Diffuse large B cell lymphoma (73%) was the most common aggressive lymphoma whereas it was marginal zone (56%) in the indolent group. The indolent group had 5- year survival rate of 76.9% compared to 48.6% for the aggressive group. Both groups had received different treatment regimens as seen in the Table with variable mean survival outcomes.

Conclusions: Our data suggests addition of postoperative adjuvant chemotherapy appears superior to surgery alone in the treatment of aggressive disease whereas it does not appear to provide any benefit in the treatment of indolent disease. However, patient numbers are too small to draw definite conclusions and warrant future investigation in multinational randomized fashion.

[Table: see text]

No significant financial relationships to disclose.

Phase I study of imatinib in combination with gemcitabine and capecitabine

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Background: Imatinib-mediated inhibition of platelet-derived growth factor receptor lowers tumor interstitial pressure allowing for improved intratumoral antineoplastic drug concentration. A phase I study of imatinib (Im) with the synergistic combination of gemcitabine (Gem) and capecitabine (Cape) was undertaken. Methods: Eligibility requirements included refractory solid tumors, ECOG 0/1 and adequate organ function. A 3-week treatment cycle was used with the dose levels (DL) 0 and -1 as outlined in the table. Dose limiting toxicity (DLT) was defined as occurring within the first 2 cycles of therapy. Patients remained on therapy unless DLT occurred or disease progression. Results: Twelve patients with a median age of 59.5 (range 44 - 77) were evaluable. Baseline characteristics included ECOG PS 0/1: 6/6; prior systemic therapies: median 3 (range 1–6); tumor types: renal (4), melanoma (2), prostate, esophageal, pancreatic, small cell lung, breast, unknown primary. At DL 0, 2 of 6 patients experienced DLT (gr. 3 thrombocytopenia; gr. 4 leucopenia). At DL -1, 1 of 6 patients experienced DLT (gr. 3 thrombocytopenia). No patient missed a dose; one patient in DL -1 completed only 1 cycle. Median cycles administered was 2 (range, 1 - 19). At cycle 2 evaluation, 7 pts had stable disease, 4 had progressive disease and 1 was not evaluable. Grade 3 or 4 toxicity included thrombocytopenia, leucopenia, hyperglycemia and weakness. All hematologic grade 3/4 toxicity was seen in patients having received ≥3 cytotoxic regimens previously. Most common grade 1/2 toxicities included anemia, nausea/emesis and fatigue. One patient with renal cell had stable disease (SD) for 15 cycles and one patient with melanoma had SD for 19 cycles. Conclusions: Im in combination with Gem and Cape is well tolerated in patients without extensive exposure to cytotoxic therapy. Activity is seen in various tumor types particularly melanoma and renal cell. The suggested dose for phase II studies is Im 400 mg/d, Gem 400 mg/m2 and Cape 400 mg/m2 in the dose schedule as described above.

[Table: see text]

[Table: see text]

Effect of family history on lung cancer outcomes

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Background: Risk factors for development of lung cancer includes a family history of the disease, especially if younger and multiple family members are affected. The effect of family history on lung cancer outcomes is unknown. A study was conducted to investigate this question. Methods: The following data were abstracted from the medical records of patients with lung cancer seen in the Medical Oncology clinic by one of the authors (AK, AG) between 1999 and 2006: age, gender, smoking history, family history, stage, treatment and survival. χ2 test and Wilcoxon test were used for univariate comparisons based on family history of lung cancer. Cox Proportional Hazards regression analysis was used to evaluate the adjusted risk of death by family history. Univariate probability of survival was computed using Kaplan Meier estimate and compared using the log rank test. Results: Two hundred and eighty-nine of the 560 patients studied (51%) were male and 519 (93%) had a smoking history. Median age at diagnosis was 63 years (range: 16 - 89 yrs). Of the 148 patients (26%) with a family history of lung cancer, 115 had an affected first degree relative. The histology of the patients’ malignancy was: adenocarcinoma - 227 (41%), squamous cell - 103 (18%), small cell - 93 (17%) and other non-small cell carcinoma - 137 (24%). There was no effect of family history on histology or stage at diagnosis. Median survival in patients with a family history was 53 months compared to 58 months in patients without such a history (p = 0.06). On multivariate analysis, after adjusting for age, histology, stage at diagnosis, and smoking history, patients with a family history of lung cancer had a relative risk of death of 1.65 (95% CI: 1.07 - 2.56) (p = 0.02) compared to those without a family history ( Table ). This risk was especially increased in those who had an affected first degree relative (RR: 1.72; 95% CI: 1.08 - 2.75, p = 0.02). Conclusions: Lung cancer patients who have a first degree relative with lung cancer appear to have a worse outcome than those without a family history of lung cancer.

No significant financial relationships to disclose.

[Table: see text]

Long-term effect of COPD on patients with lung cancer

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Background: Despite the association between chronic obstructive pulmonary disease (COPD) and lung cancer, their inter-relationship has not been studied. Their pathogenesis suggests that they may be a continuum of a single disease. The effect of COPD on outcomes in lung cancer has been primarily studied in surgical candidates in the peri-operative period, however long-term effects are unclear. We proposed to study the influence of COPD on overall survival in this patient population. Methods: After IRB approval a retrospective chart review was performed on patients with stage I and II, non-small cell lung carcinoma (NSCLC) diagnosed from 1994 through 2005. Data including demographics, smoking, treatment given, pulmonary function tests (PFTs) and survival were collected. Patients were classified as having COPD based on FEV1/FVC ratio of < 70%, and further graded by the percentage of predicted FEV1 value. Overall survival was computed by multiple linear regression and the p-value was calculated using the chi-square test. Results: Of the 399 patients with early stage NSCLC, 107 had PFTs evaluated before treatment of the cancer. Of these 42 (39%) did not have COPD, while 65 (61%) had COPD. Patients with COPD presented with a later stage (IB or II) as compared to those without COPD. After adjusting for age, stage, histology, treatment or smoking history, there was no difference in the overall survival among the two groups. The probability of 2-year overall survival for patients with mild, moderate, severe and very severe COPD was 100%, 79%, 77% and 62% respectively, compared with 72% for those without COPD. (p = 0.64). Conclusions: Patients with COPD presented with a later stage (IB or II) as compared to those without COPD. Despite this there was a trend toward an improvement in overall survival in patients with mild to moderate COPD that underwent surgical resection. This may be related, in part, to the beneficial effects of volume reduction of the diseased lung. The data are limited by low power that may have led to insignificant results. Further larger studies are required to better assess the relationship between COPD and lung cancer and its long term effects.

No significant financial relationships to disclose.