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We reported the results of our multicenter cohort study in all patients who presented for endoscopy between March 1 and May 17 and were evaluated before their endoscopy for SARS-CoV2 and were followed after their endoscopy for COVID-19 status. This cohort enabled us to calculate the conversion rate from COVID-19 negative to positive during the study period and evaluate the change in conversion rate with the implementation of social distancing and masking at the population level in New York City. Data were retrieved from electronic medical records systems of six tertiary care centers in New York City. We identified all adult patients who had endoscopy between March 1, and May 17, 2020. Conversion was defined as having a negative COVID-19 status before endoscopy and a positive status afterwards. Participants COVID-19 status was defined based on SARS-CoV2 PCR test or a combination of symptoms (Fever plus at least one of: dyspnea, cough, dysgeusia, or anosmia). Patients were evaluated before endoscopy and then by phone or telehealth visit afterwards. Spline regression was used to evaluate the conversion rate before and after adoption of social distancing (March 20, 2020) and mandatory masks (April 15, 2020) in New York City. Of the 1467 patients presenting for endoscopy during the study period, we had follow-up data on 1222 patients (51% outpatient and 49% inpatient endoscopies). Overall, 78 participants (6.38 %) converted after endoscopy (74 with a positive PCR, and 4 with symptoms as defined above), at a median of 23 days after endoscopy (IQR 11 to 42 days). Patients had a mean age of 62±15 years, and were 62% male (n=48). Multivariable analysis demonstrated that date of endoscopy, institution, and presence of cardiovascular disease were the independent predictors of conversion after endoscopy, with cardiovascular disease associated with a more than 2 fold increase in the risk of conversion (OR=2.1, 95%CI 1.2-3.6, p=0.009). The range of conversion from the six institutions varied widely (1 to 11%, p=0.035). Overall, participants whose endoscopies were performed later during the study period had a lower risk of conversion (OR for one week=0.87, 95%CI 0.80-0.94, p=0.001). Before social distancing, conversion rate was 8.4% on average and was increasing by 2.3% per week (p<0.001). After social distancing, the conversion rate was 6.7% on average, and started to decrease by 4.2% per week (p<0.001). After mandatory masks, the conversion rate was 2.2% on average but has started to increase slowly by 0.9% per week (p<0.001;see figure 1). These findings do support decrease in conversion rate amongst New Yorkers who presented for endoscopy with the implementation of social distancing and mandatory masking. We believe the slow but significant increase in conversion rates by the end of May reflects the relative loosening in social distancing in New York City.(Figure Presented)
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Introduction The risk of 2019 novel coronavirus (COVID-19) infection among patients and health care workers (HCWs) following endoscopy remains unclear. Methods We prospectively evaluated the incidence of COVID-19 infection among patients undergoing outpatient endoscopy and endoscopy unit staff between March and October 2020 at one tertiary care center in New York City. The primary outcome was COVID-19 infection within two weeks post-procedure. The clinical history, demographics, laboratory data, treatment, procedural data, and outcome measures were obtained from patients’ medical records. All patients had undergone nasopharyngeal nucleic-acid amplification testing swabs for COVID-19 prior to their procedures. Patients were then contacted 2 weeks after the procedure, via phone by research teams and nurses, with a specific list of questions (adapted from Repici et al.) to assess who had either tested positive for COVID-19 or developed symptoms ofCOVID-19 within 2 weeks after endoscopic procedures.1 Patients who screened positive for symptoms were directed for testing. Results A total of 850 endoscopic procedures were performed at our center between March and October of 2020. 131 were inpatients and were excluded from the analysis. Among the 719 outpatients, 231 were ERCPs, 111 were EUS, 207 were colonoscopies, and 170 were upper endoscopies. Post-procedure follow-up was obtained in 73% (n=524) of the patients. Of 719, 2 patients (0.38%) tested positive for COVID-19 within 2 weeks following endoscopy. Both patients had interval chemotherapy and were admitted to the hospital, so it is unclear when or where they converted. No advanced endoscopy attending or their associated nurses or technologists were subsequently infected with COVID-19 during the study period.Discussion Endoscopy procedures with appropriate PPE and preoperative testing appears to be associated with a low risk of periprocedural COVID-19 infection for outpatients and endoscopy unit staff. Diligence should continue with appropriate universal precaution and preoperative patient testing during this pandemic. References 1. Repici A, Aragona G, Cengia G, et al. Low risk of COVID-19 transmission in GI endoscopy. Gut. 2020;69(11):1925-1927. doi:10.1136/gutjnl-2020-321341
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Background: COVID-19 patients are at increased risk of venous thromboembolism (VTE) requiring the use of anticoagulation. Gastrointestinal bleeding (GIB) is increasingly being reported, complicating the decision to initiate or resume anticoagulation as providers balance the risk of thrombotic disease with the risk of bleeding. Aim: Our primary aim is to assess rebleeding rates in COVID-19 patients with GIB and determine whether endoscopic evaluation and anticoagulation use affects these rates. Our secondary aim is to determine the 30-day VTE and mortality rates in this cohort. Methods: This is a retrospective study that reviewed 56 cases of COVID-19 patients with GIB admitted to the hospital between March 4th – May 25th. All patients tested positive for COVID 19 with reverse transcriptase polymerase chain reaction nasopharyngeal swabs. The cases were reviewed for the following outcomes: rates of therapeutic intervention, 30-day rebleeding, 30-day VTE events and 30-day mortality. Results: 23/56 (41%) of COVID-19 patients with GIB rebled within 30 days. There was no reduction in rebleeding rate with endoscopic therapy compared to medical management alone (39% vs. 42%, p=0.81). There was no difference in 30 day rebleeding rate among patients restarted on anticoagulation after endoscopy compared to those that were restarted on anticoagulation after medical management alone (41% vs 29%, p = 0.47). 15/56 (27%) of the cohort had VTE during their hospitalization, 53% of which were diagnosed after anticoagulation was held due to GIB. Patients that undergone endoscopy were more likely to be initiated or resumed on anticoagulation after bleed then those that did not (87% vs 55%, p=0.02). The all-cause 30-day mortality and GI-bleeding related deaths were 32% and 9% respectively. There was no difference in 30 day mortality rate among patients that were restarted on anticoagulation after endoscopic management compared to those restarted on anticoagulation after conservative management alone (24% vs 29%, p=0.70). Conclusions: In this cohort, while there was no difference in rebleeding rate when comparing endoscopic therapy to conservative management, patients who underwent endoscopy were more likely to be restarted on anticoagulation. Given that there was no difference in rebleeding or mortality rates among those restarted on anticoagulation after endoscopy compared to patients that were restarted on anticoagulation after conservative management, it seems reasonable to re-challenge COVID-19 patients who have stopped bleeding with anticoagulation even if endoscopy cannot be performed. However, larger studies are needed to guide management of these complex patients.(Table Presented) (Table Presented)
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Background: Rhabdomyolysis (RM) is a potentially devastating breakdown of skeletal muscle leading to complications including renal failure. It has been associated previously with COVID-19, but there is a paucity of studies outside of case reports. Our study aims to quantify the rates of RM in hospitalized COVID-19 patients and assess its relationship with liver enzyme abnormalities and various outcomes. Methods: This study was a retrospective, observational study of the first 1,107 patients admitted at two academic hospitals in New York with a diagnosis of COVID-19 confirmed by nasopharyngeal PCR. RM was defined as a peak CK>5000 U/L or a CK>1500 U/L with a urine analysis (UA) within 7 days of peak CK with moderate to large blood on dipstick and the presence of either granular casts or <20 RBC/HPF. Patients without a CK and/or UA collected were presumed to have no RM. The primary outcome was prevalence of RM among those presenting with abnormal liver enzymes (defined as ALT and AST >40 U/L). Secondary outcomes analyzed in multivariable logistic regression controlling for age, gender, race, BMI and comorbidities (diabetes, HTN, CKD, cardiovascular disease, OSA, previous thromboembolism or cancer) included kidney injury, need for dialysis, ICU stay and death. Results: Of the 1,107 patients, 44 (4.0%) were found to have RM (Figure 1A). On admission, 591 patients (60%) of those with liver enzymes drawn had elevated levels. 69% of these had AST:ALT>1;patients presenting with this finding were much more likely to already have RM or develop it during their hospitalization (8.3% vs 1.6%, OR 5.67, 95% CI 2.69-11.95). 79% of patients with RM presented with elevated AST and AST:ALT>1. Mortality was much higher in those with RM (43.2% vs 16.6%, p<0.001). While admission serum creatinine was similar, those with RM had much higher peak creatinine (4.5 vs 2.1, p<0.01). All patients with elevated AST had higher prevalence of RM, new dialysis and death (Figure 1B). In multivariable logistic regression controlling for age, gender, race, BMI and preexisting comorbidities, RM was independently associated with need for ICU stay (OR 7.08, 95% CI 2.92-17.18, p<0.001), new dialysis (OR 6.90, 95% CI 2.73-17.47, p<0.001) and death (OR 3.35, 95% CI 1.38-8.13, p<0.001). Conclusion: RM is common in COVID-19 and is often associated with elevations in AST and AST:ALT ratio. While direct liver injury has been reported in RM, our findings are likely related to the presence of AST in skeletal muscle, leading to a rise in serum levels on breakdown. In our study, RM is independently associated with poor outcomes;thus early recognition in COVID patients is key, and presentation with elevated liver enzymes, especially AST>ALT should increase clinical suspicion.