Immunocompromised patients with B-cell deficiencies are at risk for prolonged symptomatic SARS-CoV-2 infection. We describe 4 patients treated for B-cell malignancies with B-cell depleting therapies who developed persistent SARS-COV-2 infection and had resolution of symptoms following an extended course of nirmatrelvir/ritonavir.

RATIONALE: We sought to identify geographic disparities and existing barriers to receiving life-saving epinephrine in Kansas schools. METHODS: A survey of school nurses was conducted at the 2015 Kansas School Nurse Association conference. Excel was used to analyze the descriptive data, which was compared to demographics published by the U.S. federal government. RESULTS: In 2009, the Kansas legislature authorized accredited schools to stock emergency epinephrine, pre-dating federal legislation in 2013. Unfortunately, stock epinephrine remains limited to only a few Kansas communities. Our survey revealed significant disparities in implementing stock epinephrine, with 59 of 105 counties reporting. Only 20 counties stocked epinephrine in at least 1 school. When stratifying by household income, 60% of schools that stocked epinephrine were in the top 10% of wealthy counties, whereas 41% that did not were in the bottom 50%. Of schools stocking epinephrine, 35% were in the wealthiest county. Further, 70% of schools with stock epinephrine were associated with the largest urban cores in Kansas. Nurses cited cost, legal liability, having a prescribing physician, lack of staff knowledge or training, and lack of administrator support as reasons why injectable epinephrine was not stocked in their schools. CONCLUSIONS: Our study reveals unequal access to life-saving epinephrine across Kansas, despite state and federal legislation. Further investigation is necessary to resolve this inequality, which disproportionately affects Kansas communities.

We thank Siyan Chen, MS, a paid biostatistician at the Richard A. and Susan F. Smith Center for Outcomes Research in Cardiology, for her help with graphics creation.

Background: Between 2016 and 2021, the average length of stay for congestive heart failure (CHF) patients at our Veterans Affairs (VA) Hospital has ranged from 0.8 to 1.9 days longer than comparable VA hospitals. This extended length of stay (LOS) results in increased healthcare costs and is an institutional focus to increase quality of care. Current cardiology guidelines for patients admitted with an acute CHF exacerbation recommend aggressive diuresis, defined as high-dose loop diuretics at least twice a day. We sought to analyze our institution’s compliance with this guideline-directed care. Methods: We performed a retrospective chart review of Veterans admitted between July and September 2021 with a primary diagnosis of CHF exacerbation. We tabulated the average LOS, days IV diuretics were administered, time(s) of administration, and the number of IV diuretic doses per day. Results: 44 patients were identified. The average LOS and number of days of IV diuretics a Veteran received was 7.5 (SD 3.5) and 4.5 (SD 1.4) days, respectively. The average number of IV diuretics given during days of IV diuresis was 1.4 (SD 0.5). We noted that 11.5% of IV diuretic doses were given before 8AM. Conclusions: Our results demonstrate that the diuresing patterns at our VA hospital fall short of the recommended guidelines. Receiving an average of 1.4 doses of IV diuretic, rather than at least 2, likely contributes to extended length of stay and cost. Additionally, we note that very few doses of diuretics are administered prior to 8AM, which may delay or prevent subsequent dosing. This project identifies clear targets for future quality improvement projects at our institution aimed at improving length of stay and Veteran care by increasing the number of IV diuretic doses per day.

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