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55 Positivity Rates of CT Imaging for Pulmonary Embolism in COVID-19 Patients

Study Objectives: Early evidence has suggested a high prevalence of acute pulmonary embolism (PE) in Coronavirus 19 (COVID). However, the bulk of existing data evaluates the population of COVID patients admitted to an intensive care unit (ICU). There has been limited evidence in the emergency department (ED) population and as a result, there is variability in diagnostic evaluation for patients presenting with COVID. The objective of this study was to describe the diagnostic evaluation of both COVID positive and negative patients in the ED. Methods: Over a period of 13 months beginning March 2020, all patients presenting to the emergency department (ED) of a single, tertiary academic medical center in the United States and tested for COVID, who had contrast-enhanced computed tomography (CT) imaging of the chest performed were included in this retrospective cohort study. The primary outcome was CT positivity rate for PE and radiologist impressions were used to determine positivity rate for all patients. A subset of patients received D-dimer testing or received supplemental oxygen in the ED and CT positivity was evaluated in these strata. Results: After exclusion of CT chest studies without contrast, 5576 patient encounters were included in the final cohort with 367 patients considered to be COVID positive at the time of ED presentation. The positivity rate for PE in COVID positive patients was 9.8% compared to 7.1% for non-COVID patients. The rate of D-dimer testing prior to CT was higher (76% vs 25%) in COVID positive compared to negative patients. CT test positivity rate was close when comparing COVID positive and negative patients who did not receive oxygen (5.0% vs 6.3%) but in those that received supplemental oxygen in the ED, 12.7% of COVID positive patients were positive for PE compared to 8.3% for COVID negative. The d-dimer institutional cut-off of 0.5 mcg/mL was sensitive for PE on CT without false negative results. There was a significant age difference between hypoxic patients (median age of 63) and not-hypoxic patients (median age of 50). A Sankey diagram of COVID positive patients who had both contrast-enhanced CTs performed and D-dimers drawn is presented as a figure. Conclusion: Non-hypoxic COVID positive patients had a largely comparable positivity rate of PE on contrast enhanced CT imaging compared to non-hypoxic non-COVID patients, but in the subset of patients who received supplemental oxygen, COVID patients were at considerably increased risk of PE. Using the conventional cut-off value of D-dimers yielded no false negative results, however D-dimer values frequently were obtained as part of a routine COVID workup for risk stratification. Our study was limited by its single center design. Further research is needed to determine if COVID positive patients have an increased risk of pulmonary embolism. [Formula presented]

Study Objectives: Emergency departments (EDs) often serve vulnerable populations who may lack primary care and have suffered disproportionate COVID-19 pandemic effects. Comparing patients having and lacking a regular source of medical care and other ED patient characteristics, we assessed COVID-19 vaccine hesitancy, reasons for not wanting the vaccine, perceived access to vaccine sites and willingness to get the vaccine as part of ED care.
Results: Of 2575 patients approached, 2301 (89.4%) participated. Of the 18.4% of respondents who lacked a regular source of medical care, 65% used the ED as their usual source of health care. The overall rate of vaccine hesitancy was 39%; the range among the 15 sites was 28 to 58%. Respondents who lacked a regular source of medical care were more commonly vaccine hesitant than those who had a regular source of medical care (47 vs 38%, 9% difference, 95% CI 4 -14%). Other characteristics associated with greater vaccine hesitancy were younger age (median 40 vs 52, p < 0.0001), (female sex (45% vs 33%; difference 12%, 95% CI 8 to 16%), African-American race (54% vs 30%; difference 24%, 95% CI 19 to 29%), Latinx ethnicity (39% vs 30%; difference 9%, 95% CI 4 to 14%), and not having a prior influenza vaccine in the past five years (58% vs 31%; difference 27%, 95% CI 23 to 32%). Homelessness and uninsured status were not associated with greater vaccine hesitancy. Fewer vaccine hesitant respondents reported that some or all of their family members would accept the COVID-19 vaccine if it was offered to them (29% vs 75%, 46% difference, 95% CI 42 to 50%). Of the 61% COVID-19 vaccine acceptors, 21% stated that they lacked a primary doctor or clinic to receive it. The vast majority (95%) of these respondents lacking primary care would accept the COVID-19 vaccine as part of their care in the ED.
Conclusions: ED patients who lack a regular source of medical care are particularly hesitant to COVID-19 vaccination. Most COVID-19 vaccine acceptors would accept it as part of their care in the ED. EDs may have pivotal roles in COVID-19 vaccine messaging and delivery to highly vulnerable populations. Study Objectives: Early evidence has suggested a high prevalence of acute pulmonary embolism (PE) in Coronavirus 19 (COVID). However, the bulk of existing data evaluates the population of COVID patients admitted to an intensive care unit (ICU). There has been limited evidence in the emergency department (ED) population and as a result, there is variability in diagnostic evaluation for patients presenting with COVID. The objective of this study was to describe the diagnostic evaluation of both COVID positive and negative patients in the ED.
Methods: Over a period of 13 months beginning March 2020, all patients presenting to the emergency department (ED) of a single, tertiary academic medical center in the United States and tested for COVID, who had contrast-enhanced computed tomography (CT) imaging of the chest performed were included in this retrospective cohort study. The primary outcome was CT positivity rate for PE and radiologist impressions were used to determine positivity rate for all patients. A subset of patients received D-dimer testing or received supplemental oxygen in the ED and CT positivity was evaluated in these strata.
Results: After exclusion of CT chest studies without contrast, 5576 patient encounters were included in the final cohort with 367 patients considered to be COVID positive at the time of ED presentation. The positivity rate for PE in COVID positive patients was 9.8% compared to 7.1% for non-COVID patients. The rate of D-dimer testing prior to CT was higher (76% vs 25%) in COVID positive compared to negative patients. CT test positivity rate was close when comparing COVID positive and negative patients who did not receive oxygen (5.0% vs 6.3%) but in those that received supplemental oxygen in the ED, 12.7% of COVID positive patients were positive for PE compared to 8.3% for COVID negative. The d-dimer institutional cut-off of 0.5 mcg/ mL was sensitive for PE on CT without false negative results. There was a significant age difference between hypoxic patients (median age of 63) and not-hypoxic patients (median age of 50). A Sankey diagram of COVID positive patients who had both contrastenhanced CTs performed and D-dimers drawn is presented as a figure.
Conclusion: Non-hypoxic COVID positive patients had a largely comparable positivity rate of PE on contrast enhanced CT imaging compared to non-hypoxic non-COVID patients, but in the subset of patients who received supplemental oxygen, COVID patients were at considerably increased risk of PE. Using the conventional cutoff value of D-dimers yielded no false negative results, however D-dimer values frequently were obtained as part of a routine COVID workup for risk stratification. Our study was limited by its single center design. Further research is needed to determine if COVID positive patients have an increased risk of pulmonary embolism.

Young Adults With COVID-19
Dhillon RS, Weise M, Wrotniak B, Cross K/University at Buffalo, Buffalo, New York Study Objectives: Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) and COVID-19-its associated disease in humans-appears to cause more severe morbidity and mortality in older adults and geriatric patients than in children and young adults. There is growing recognition of the association between both race and obesity and disease severity in hospitalized patients with COVID-19.However, the impact of age, race, and other major comorbidities on COVID-19 course in children and younger adults is not as well understood.
Methods: We conducted a retrospective analysis of 2656 patients under the age of 36 years with COVID-19 between March 1, 2020 and August 6, 2020 as reported to HEALTHeLINK, a regional health information system for western New York State. Subjects were split into pediatric (0-19 years) and young adult (20-36 years) datasets. We evaluated the association between candidate risk factors (age, sex, race, calculated BMI/BMI percentile, smoking status, diabetes, pre-existing respiratory disease, hypertension, and sickle cell disease) using recursive partitioning and linear regression. The primary outcome was hospital admission, with length of stay being the secondary outcome Results: There were 2129 young adults and 527 pediatric patients who tested positive for COVID-19 during our study period. In our young adult population, race was the most significant predictor of admission, followed by BMI. African Americans with a BMI > 23 had the highest rate of admission (66%, p<0.001). Interestingly, Asian race was a strong predictor of outpatient management, regardless of BMI. Smoking status and hypertension were less significant predictors of admission, whereas sex, diabetes, preexisting respiratory conditions, and sickle cell disease were not significant. For our pediatric population, race was also the most significant predictor of admission, with African Americans being admitted at higher rates than Whites and Asians. In the pediatric population, however, BMI percentile for age was not a predictor of admission. In regards to the secondary outcome, admitted young adult with COVID-19 had an average length of stay of 1.4 days (SD AE2) while the admitted pediatric COVID-19 patients had an average length of stay of 1 day (SD AE1.1). African American race was associated with longer length of stay in both populations however, BMI was only significant in the young adult population.
Conclusions: In a regional population of young adult and pediatric patients with COVID-19, race was strongly predictive of admission and length of stay. African American patients were most likely to be admitted, while Asian race was a strong predictor of outpatient management. For African American young adults, a BMI > 23 was the strongest additional predictor of admission. For younger patients with COVID-19 a simple decision tree that incorporates age, race, and BMI can help identify those patients least likely to need inpatient management.

Effect of COVID-19 Surge Mitigation on
Emergency Department Visits for Patients at High Risk for Opioid Overdose