Coronavirus disease 2019 (COVID-19) is a heterogenous, predominantly pulmonary disease caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) that has resulted in catastrophic illness around the world. Thrombotic microangiopathy (TMA) is a triad of hemolytic anemia, thrombocytopenia, and end organ damage. This is present in severe cases of COVID-19 and in hemolytic uremic syndrome (HUS) commonly caused by Escherichia coli (E.coli) 0157:H7. We report a novel case of a toddler who presented with classic features suggestive of HUS characterized by bloody diarrhea followed by thrombocytopenia, hemolytic anemia, and acute kidney injury, in whom a polymerase chain reaction (PCR) test for SARS-CoV-2 was positive.

BACKGROUND Autologous Hematopoietic Stem Cell Transplant (AHSCT) remains an important treatment for multiple myeloma (MM) despite the continuous addition of novel agents into the therapeutic armamentarium. Since MM is predominantly a disease of the elderly, a significant proportion of patients do not undergo AHSCT due to 'a perceived lack of fitness'. This retrospective study evaluates the patterns of AHSCT in MM patients with regards to age and objective fitness assessment as per standardized indices. METHODS: Records of all MM patients treated at our institute from January 2017 till December 2019 were utilized to collect data regarding age, survival duration, risk scores as per the Revised-Myeloma Comorbidity Index (R-MCI) and fitness scores as per the Hematopoietic Stem Cell Transplant-Comorbidity Index (HSCT-CI). Patients with low and intermediate R-MCI risk scores were regarded as 'fit for AHSCT'. Patients with HSCT-CI categorizations of 'fit' and 'intermediate fit' were regarded as 'fit for AHSCT'. Proportions were compared using the Fisher-Exact-Test with a significance cut-off of p<0.05. Survival data were compared with the Log-Rank test. RESULTS: Out of the 81 patients, 54 (66.7%) were aged ≤65 years & 27 (33.3%) >65 years. The R-MCI classified 96.3% and 81.5% of patients aged ≤65 years and >65 years as AHSCT eligible, respectively (p 0.0381). The HSCT-CI classified a similar proportion of patients aged ≤65 years and >65 years as AHSCT eligible (79.6% vs. 77.8%, p 1). However, patients aged ≤65 years were offered AHSCT more frequently than those >65 years (57.4% vs. 29.6%, p 0.0207). Those aged ≤65 years underwent AHSCT more frequently than those >65 years (38.9% vs. 14.8%, p 0.0402). (Panel A, Figure-1). Those who underwent AHSCT had greater median survival (MS) compared to those who did not undergo AHSCT (MS not reached vs. 36 months, p 0.0023) (Panel B, Figure 1). Those who were offered AHSCT had greater MS compared to those who were not offered AHSCT (MS not reached vs. 36 months, p 0.033) (Panel C, Figure 1). The MS of patients classified as fit and intermediate fit as per the HSCT CI was significantly better than that of those classified as 'unfit' (p 0.0362) (Panel D, Figure 1). The MS of patients classified by the R-MCI as low risk was significantly better than that of those classified as 'intermediate and high risk' (p 0.0253) (Panel E, Figure 1). When the MS of overall patients aged ≤65 years was compared to that of those aged >65 years, there was no significant difference with the MS not reached in either group (p 0.0875) (Panel F, Figure 1). When the survival curves of four groups (aged >65 years who underwent AHSCT, aged >65 years who did not undergo AHSCT, aged ≤65 years who underwent AHSCT, and those aged ≤65 years who did not undergo AHSCT) were compared, there was a statistically significant difference favouring those who underwent AHSCT irrespective of the age group (p 0.0167) (Panel G, Figure 1). Conclusions: Both the R-MCI and HSCT-CI revealed that approximately four out of five patients aged >65 years were AHSCT eligible. This analysis of the patterns of AHSCT for MM in our institution revealed a bias against those aged >65 years, with fewer patients of this age group being offered AHSCT. It would hence be prudent to perform objective fitness assessments using validated indices so as to ensure that every patient fit enough to benefit from an AHSCT receives the same irrespective of his/her age. While it is well known that treatment availability and affordability are two major reasons for low rates of AHSCT in Low & Middle Income Countries (LMICs), it can be said from our data that physicians' bias against advanced age could be another factor. These results strongly suggest that use of AHSCT in fit elderly patients in LMICs may further improve outcomes. Figure Disclosures No relevant conflicts of interest to declare.

No abstract

Background Multiple myeloma (MM) predominantly affects older patients; many of whom do not undergo autologous hematopoietic stem cell transplant (AHSCT) despite the associated survival benefits. This study was conceived to investigate the patterns of AHSCT among MM patients with due regard to their age and standardized fitness assessments. Methods Fitness scores as per the hematopoietic stem cell transplant-comorbidity index (HSCT-CI) and risk scores as per the revised-myeloma comorbidity index (R-MCI) of MM patients treated between January 2017 and December 2019 were analyzed to assess fitness for AHSCT. Proportions of patients who underwent AHSCT were calculated with regard to age and fitness for AHSCT. Results Of the 81 eligible patient records with a median age of 62 years, the HSCT-CI classified 79.6% and 77.8% of patients aged ≤65 years and >65 years as AHSCT eligible (p 1). Using the R-MCI, 96.3% and 81.5% of patients aged ≤65 years and >65 years, respectively, were classified as eligible for AHSCT (p 0.0381). Overall, patients aged ≤65 years underwent AHSCT with a greater frequency compared to those aged >65years (38.9 vs. 14.8%, p 0.0402). Irrespective of the age group, there was a statistically significant difference (p 0.0167) in terms of survival which favored those who underwent AHSCT. Conclusions Both the HSCT-CI and the R-MCI revealed that nearly 80% of patients aged >65 years were fit enough to receive AHSCT. However, far fewer patients of this age group underwent AHSCT. We propose that the routine inclusion of objective fitness assessment could ensure that fit older patients undergo AHSCT and thus do not miss out on the benefits of the same.

Background: Diabetes is an immunocompromising condition, and diabetic children should receive the 23-valent pneumococcal polysaccharide (PPSV23) vaccine as part of their preventive care because of their increased risk for invasive pneumococcal disease. This recommendation is often not followed, however, and at our institution, we discovered that a factor limiting vaccine administration was lack of knowledge about the recommendation among residents. Methods: Our objective with this quality improvement initiative was to improve pneumococcal vaccination rates among the inpatient pediatric diabetic population to 70% in 6 months. Three education and awareness initiatives were conducted during the postintervention period of March 2021 to August 2021 at St. Mary Medical Center in Shreveport, Louisiana. All pediatric diabetic patients from age 2 to 18 years who were admitted to the inpatient general pediatrics or critical care services were included. The primary outcome was vaccination with PPSV23. Results: We studied 63 pediatric patients with a mean age of 12.7 years. The vaccination ordering rate during the 6 months prior to the implementation of the quality improvement initiatives was 41%. In the 6 months postintervention, the overall vaccination ordering rate improved to 81%. During data collection, however, we discovered that even though the residents were assessing for vaccine eligibility and ordering the vaccines, not all vaccines were administered prior to discharge. In the preintervention period, the overall vaccine administration rate was 27%, improving to 42% in the postintervention period. Conclusion: Simple interventions that included resident education, development of a smart phrase in the electronic medical record, and liaison with pharmacy led to an increase in the pneumococcal vaccination ordering rate for pediatric patients with diabetes. However, we did not anticipate that the vaccination ordering and administration rates would be different when we initiated the project and had therefore focused our interventions on resident education only. Our discovery of the difference between vaccination ordering and vaccination administration helped identify 2 other areas for improvement: nursing education and additional improvement of the electronic medical record.