Several studies have documented increased exercise capacity with supplemental oxygen therapy in patients with COPD and exertional hypoxemia, but a large trial failed to demonstrate a survival benefit in this population. Due to the heterogeneity observed in therapeutic responses, we sought to retrospectively evaluate survival in male COPD patients with exertional hypoxemia who had a clinically meaningful improvement in exercise capacity while using supplemental oxygen compared to their 6-minute walk test distance (6MWD) while walking on room air. We defined them as responders or non-responders based on a change in 6MWD of greater or less than 54m. We compared their clinical and physiologic characteristics, and their survival over time. From 817 COPD subjects who underwent an assessment for home oxygen during the study period, 140 met inclusion criteria, with 70 (50%) qualifying as responders. There were no significant differences in demographics, lung function, or baseline oxygenation between the groups. The only difference noted was in the baseline 6MWD on room air, with responders to oxygen therapy having significantly lower values (137 ± 74m, 27 ± 15% predicted) compared to non-responders (244 ± 108, 49 ± 23% predicted). Despite their poorer functional capacity, mortality was significantly lower in responders after adjusting for age, comorbidities, and FEV 1 (HR 0.51; CI 0.31–0.83; p = 0.007) compared to non-responders after a median follow-up time of 3 years. We conclude that assessing the immediate effects of oxygen on exercise capacity may be an important way to identify individuals with exertional hypoxemia who may benefit in the long-term from ambulatory oxygen. Prospective long-term studies in this subset of patients with exercise induced hypoxemia are warranted.

Rationale: Landmark studies of long-term oxygen therapy (LTOT) in patients with chronic obstructive pulmonary disease (COPD) used arterial oxygen pressure (PaO2) to define severe hypoxemia; however, oxygen saturation as measured by pulse oximetry (SpO(2)) is commonly used instead. The Global Initiative for Chronic Obstructive Lung Disease (GOLD) guidelines recommend evaluation with arterial blood gas (ABG) analysis if SpO(2) is <= 92%. This recommendation has not been evaluated in stable outpatients with COPD undergoing testing for LTOT. Objectives: To evaluate the performance of SpO(2) compared with ABG analysis of PaO2 and arterial oxygen saturation (SaO(2)) to detect severe resting hypoxemia in patients with COPD. Methods: Retrospective analysis of paired SpO(2) and ABG values from stable outpatients with COPD who underwent LTOT assessment in a single center. We calculated false negatives (FNs) as an SpO(2)>88% or>89% in the presence of pulmonary hypertension with a PaO2 <= 55mmHg or <59mmHg in the presence of pulmonary hypertension. Test performance was assessed using receiver operating characteristic (ROC) analysis, intraclass correlation coefficient (ICC), test bias, precision, and accuracy root-mean-square (Arms). An adjusted multivariate analysis was used to evaluate factors affecting SpO(2) bias. Results: Of 518 patients, the prevalence of severe resting hypoxemia was 74 (14.3%), with 52 missed by SpO(2) (FN, 10%), including 13 (2.5%) with an SpO(2).92% (occult hypoxemia). FNs and occult hypoxemia in Black patients were 9% and 1.5%, respectively, and were 13% and 5%, respectively, among active smokers. The correlation between SpO(2) and SaO(2) was acceptable (ICC= 0.78; 95% confidence interval, 0.74-0.81); and the bias of SpO(2) was 0.45%, with a precision of 2.6 (24.65 to 15.55%) and Arms of 2.59. These measurements were similar in Black patients, but in active smokers, correlation was lower and bias showed greater overestimation of SpO(2). ROC analysis suggests that the optimal SpO(2) cutoff to warrant LTOT evaluation by ABG analysis is <94%. Conclusions: SpO(2) as the only measure of oxygenation carries a high FN rate in detecting severe resting hypoxemia in patients with COPD undergoing evaluation for LTOT. Reflex measurement of PaO2 by ABG analysis should be used as recommended by GOLD, ideally at a cutoff higher than an SpO2 <92%, especially in active smokers.

Background: Studies have shown a decline in hospitalizations due to acute exacerbation of chronic obstructive pulmonary disease (AECOPD) during the coronavirus disease 2019 (COVID-19) pandemic. However, the impact of the pandemic on AECOPDs of all severities in longitudinal cohorts of patients is lacking. Methods: We conducted analysis of 123 individuals with COPD who have been followed since 2017. AECOPDs of mild (treatment at home), moderate (emergency department or urgent visit evaluation), and severe (hospitalization) type were assessed by chart review and patient interview. Compliance with preventive measures to avoid COVID-19 infection was assessed in 2020. Differences between the rate of AECOPD by year was analyzed as well as differences in preventive measures by COPD disease severity. Results: During the COVID-19 pandemic in 2020, there was a significant reduction in AECOPDs in our cohort with 26 participants (21%) having an exacerbation compared to 46 (37%) in 2019, 52 (42%) in 2018, and 44 (36%) in 2017. Mean exacerbation rates decreased 54% overall and 74% in frequent exacerbators compared with the prior 3-year average. The decrease was noted in AECOPDs of all severities. Overall, there was a high rate of reported compliance with social distancing and face mask use that was significantly higher in the group with more severe COPD based on symptoms and forced expiratory volume in 1 second. Conclusions: Individuals with COPD, including frequent exacerbators, showed a marked decrease in AECOPD during the COVID-19 pandemic and high adherence to recommended preventive measures. Evaluation of the impact of preventive strategies on AECOPD in a non-pandemic setting may be of value and requires further study.

METHODS: We created an order set in our electronic medical record that automatically ordered two sputum collections testing for AFB smear, culture, and NAAT using Xpert MTB/RIF 8 hours apart. We analyzed the results of those tests for the two years before and aft er implementation. We calculated the earliest possible time to clearance of AII based on two negative NAAT tests or three negative AFB smears. We measured the accuracy of NAAT compared to AFB smear, the time to obtain results for each component of the order set, length of stay, and time on AII. We used parametric and non-parametric independent sample tests to compare the differences between patients who used the order set versus those who did not.

SESSION TITLE: Tuesday Abstract Posters SESSION TYPE: Original Investigation Posters PRESENTED ON: 10/22/2019 01:00 PM - 02:00 PM PURPOSE: A potential benefit of statins in reducing the risk of acute respiratory distress syndrome (ARDS) was shown in a septic shock animal model, however, this effect hasn’t been replicated in patients after they have developed ARDS. We aimed to evaluate the effect of statin therapy prior to admission in patients with septic shock on the risk of developing ARDS METHODS: A retrospective cohort of patients with septic shock in a community hospital ICU from December 2013 to December 2014 was complied. Patients who met criteria for septic shock were included. ARDS was defined based on the Berlin Criteria. Statin use prior to admission was determined from the home medication list. Demographic, clinical and laboratory data were collected. ARDS, ICU and hospital length of stay, and ventilator days were defined as outcomes. A multivariate regression analysis was employed with statin prior to admission as the independent variable, and ARDS as the dependent variable RESULTS: Of the 128 included patients, 61% were female, 71% were white, and the mean age was 67 years.The most common causes of septic shock were: intra-abdominal infection 34%, pneumonia 31%, and urinary tract infection 20%. In our sample, 56% of patients required mechanical ventilation, and the overall mortality was 50%. A total of 22% met criteria for ARDS with a mean PaFiO2 ratio of 128 (SD 67). Prior to admission 33% of patients were taking a statin. Patients taking statins were more likely to be older (73.7 +/- 10 vs 64.4 +/- 18; p=0.002), have diabetes mellitus (59% vs 40%; p=0.033), take aspirin (50% vs 19%; p<0.001), take beta blockers (47.6% vs 26%; p=0.013), have higher serum albumin levels (2.6 g/dL +/- 0.76 vs 2.1 +/- 0.74), and less likely to have cirrhosis (0% vs 12%; p=0.021). Patients taking a statin were less likely to develop ARDS (7% vs 29%; p=0.005). In the subset of patients on statins prior to admission, there was no significant difference in incidence of ARDS based on continuation of statin upon admission to the ICU (4.2% vs 11%; p=0.387). When controlling for age, gender, race, diabetes, aspirin, beta blockers, cirrhosis, pneumonia, albumin level, and lactate level, statin use prior to admission was associated with a significantly decreased risk of ARDS (OR 0.18; p=0.03). Statin use prior to admission was not associated with a significant reduction in length of stay (12.8 +/- 13.2 vs 15.4 +/- 16.1; p=0.365), ICU length of stay (4.7 +/- 4.8 vs 6.0 +/- 6.3; p=0.244), or ventilator days (3.1 +/- 5.6 vs 3.8 +/- 5.7; p=0.528). CONCLUSIONS: Statin therapy prior to septic shock was associated with a significantly decreased risk of developing ARDS in this retrospective cohort of community hospital patients CLINICAL IMPLICATIONS: Statins appear to reduce the risk of ARDS when patients have been taking them prior to developing septic shock. Further research into the mechanism by which statins modulate the pathogenesis of ARDS is warranted DISCLOSURES: No relevant relationships by Andres Chacon, source=Web Response No relevant relationships by Elie Donath, source=Admin input No relevant relationships by Brian Garnet, source=Web Response No relevant relationships by Mehdi Mirsaeidi, source=Web Response No relevant relationships by Juan Teran Plasencia, source=Web Response no disclosure on file for Adam Wellikoff

SESSION TITLE: Shock SESSION TYPE: Affiliate Case Report Poster PRESENTED ON: Tuesday, October 31, 2017 at 01:30 PM - 02:30 PM INTRODUCTION: Carcinoid crisis is a potentially life-threatening complication of carcinoid tumors due to massive release of vasoactive peptides including serotonin, bradykinin, tachykinins, prostaglandins and histamine. The syndrome is characterized by profound flushing, bronchospasm, tachycardia and fluctuating blood pressure. While this complication is rare, prophylactic octreotide is given prior to surgery for known carcinoid tumors. CASE PRESENTATION: A 70-year-old man with coronary artery disease and HFrEF had two recent hospital admissions for partial small bowel obstructions over three months. He presented to the emergency room with acute nausea, vomiting and severe abdominal pain and was found to have a perforated viscous on CT of the abdomen requiring emergent exploratory laparotomy. Immediately after induction with etomidate and rocuronium, the anesthesiologist noted that he lost his blood pressure and pulse and ACLS protocol was initiated for pulseless electrical activity (PEA) with ROSC after 10 minutes. He was transferred to the ICU where he was stabilized, but remained in septic shock requiring moderate dose levophed. After 24 hours, he underwent surgery with small bowel resection and diverting ileostomy and noted to have multiple small bowel lesions that were sent for pathology. He was able to be weaned off inotropes following surgery and was clinically improving with good mental status when he had a second PEA arrest. During this second arrest his blood pressure was noted to precipitously drop around 20 minutes after stopping levophed. This time he again obtained ROSC after 40 minutes of CPR. Once stabilized there was no acidosis, no acute blood loss, EKG and serial troponins ruled out ACS, his AICD was interrogated and there were no arrhythmias noted and there were no electrolyte abnormalities. The patient passed away after his 4th PEA arrest after he had been weaned off inotropes again and extubated. An autopsy was performed per family request revealing clean coronaries, absence of PE and grossly appearing normal liver. Final small bowel pathology revealed carcinoid tumor. DISCUSSION: With the post-mortem diagnosis of carcinoid tumor, this was the likely cause of recurrent PEA arrest. Known cases are pre-treated with octreotide and phenylephrine is preferred to B1 agonists to avoid inducing distributive shock. CONCLUSIONS: While rare, carcinoid crisis must be considered in a patient with small bowel obstruction and recurrent episodes of distributive shock or PEA arrest without other identifiable cause. Special attention needs to be given to carcinoid syndrome as adrenergic medications given in the ICU can lead to this potentially fatal phenomenon and knowledge of the complex pharmacologic treatments may prove to be life saving. Reference #1: Kent, Margaret. Anesthesia for the carcinoid syndrome. AANA Journal. 51:150-153. Reference #2: Kaufman L and Summer E. 1979. Medical Problems for the Anesthetist. Vol. 4. Chicago: Year Book Medical Publishers, Inc. pp. 134-138. DISCLOSURE: The following authors have nothing to disclose: Imran Chishti, Tatyana Aliyeva, Brian Garnet, Mohammad Elballat No Product/Research Disclosure Information

SESSION TITLE: Sepsis I SESSION TYPE: Original Investigation Poster PRESENTED ON: Wednesday, October 26, 2016 at 01:30 PM - 02:30 PM PURPOSE: Recent research has revealed that early lactate clearance is associated with a reduction in inflammatory markers and improved clinical outcomes in septic shock. Acute respiratory distress syndrome (ARDS) is a well-established complication of septic shock, yet little is known about the relationship between ARDS and lactate clearance. The aim here was to evaluate whether improved lactate clearance is associated with improved outcomes in patients with septic shock complicated by ARDS. METHODS: A retrospective cohort of all patients diagnosed with septic shock in an ICU at a community hospital during a three-month period of time was compiled. Patients were excluded if they did not meet criteria for septic shock on manual review, or if they had heart disease that would preclude the diagnosis of ARDS such as severe valvular heart disease or heart failure with reduced ejection fraction measured by echocardiogram. ARDS was defined based on the Berlin Criteria using review of arterial blood gas, x-ray and/or CT chest imaging and radiologist interpretation. Lactate clearance was calculated as a repeat lactate level (4-24 hours after initial) divided by lactate level at the time of septic shock diagnosis. Additional variables were collected including demographics, source of infection, and possible confounders (medications, cirrhosis, and transfusion). A multivariate logistic regression analysis was employed where in-hospital mortality was the dependent variable, and lactate level as well as lactate clearance (along with other covariates of interest) were the independent variables, to identify whether any relationship was present. RESULTS: Of the 268 patients reviewed, 135 were excluded (47 did not meet criteria for septic shock, 88 had significant heart disease, and 15 had missing data). Of the included patients, 61% were female, 29% were non-white, mean age was 67 years. Ultimately, 117 septic shock patients were included in this analysis and 57 died in hospital. Mean lactate level was 4.24 mmol/L (SD 3.63), and lactate clearance of at least 10% from baseline was observed in 45/63 cases (71%). As expected, baseline lactate levels were a strong predictor of mortality - an increase of 1 mmol/L was associated with a 15% increased risk of death (HR 1.15, 95% CI 1.07-1.23, p<0.001). Additionally, in patients with septic shock complicated by ARDS, lactate clearance of at least 10% from baseline was associated with a reduced mortality risk of 97% (HR=0.03, 95% CI 0.002-0.44, p=0.01). CONCLUSIONS: Lactate clearance is associated with decreased mortality in patients with septic shock complicated by ARDS. CLINICAL IMPLICATIONS: Lactate clearance in addition to lactate levels should be futher examined to risk stratify patients with septic shock complicated by ARDS. DISCLOSURE: The following authors have nothing to disclose: Mohammad Elballat, Martin Aldana-Campos, Brian Garnet, Varun Shah, Atif Shah, Elie Donath, Samer Fahmy No Product/Research Disclosure Information

SESSION TITLE: Sepsis II SESSION TYPE: Original Investigation Poster PRESENTED ON: Wednesday, October 26, 2016 at 01:30 PM - 02:30 PM PURPOSE: Recent research has demonstrated an association between hypoalbuminemia and mortality in patients with septic shock. Multiple randomized controlled trials have found no benefit of albumin transfusion as compared to crystalloid transfusion for fluid resuscitation in patients with septic shock. Our aim was to confirm the association of hypoalbuminemia with mortality in septic shock and explore a possible association of albumin transfusion with mortality. METHODS: A retrospective cohort of all patients diagnosed with septic shock in a community hospital ICU during a three-month period of time was compiled. Patients were excluded if they did not meet criteria for septic shock on manual review, or if they had heart disease that would preclude the diagnosis of acute respiratory distress syndrome since this was used as an outcome in another analysis of this dataset. Baseline albumin levels were recorded at admission, and medication administration records were reviewed for transfusion of albumin. Additional variables were collected including demographics, source of infection, and possible confounders. A multivariate logistic regression analysis with in-hospital mortality as the dependent variable, and albumin as well as albumin transfusion (along with other covariates of interest) as the independent variables, was used to identify whether any relationship was present. RESULTS: Of 268 patients reviewed, 150 were excluded (47 did not meet criteria for septic shock, 88 had significant heart disease, and 15 were missing data). Of the included patients, 63% were female, 29% were non-white, mean age was 67 years. In hospital mortality was 50%, mean baseline albumin level was 2.29 g/dl (SD 0.76), and 31% of these patients received an albumin transfusion with doses ranging from a single dose of 25g of 25% albumin to nine doses of 50g of 25% albumin. Baseline albumin levels were strongly associated with mortality, and after controlling for age, sex, and baseline lactate level, odds of mortality decreased by 56.5% (OR 0.435, CI 0.24-0.78, p=0.005) for each increase of 1g/dl of baseline albumin. Albumin transfusion was strongly associated with mortality as well - increasing odds of mortality by 238% (OR 3.38, CI 1.25-9.17, p=0.017). This association remained highly significant and was amplified among those patients with baseline albumin >1.8 g/dl (OR 4.96, CI 1.38-17.9, p=0.014) particularly when compared to patients with baseline albumin <1.8 g/dl (OR 1.54, CI 0.23-10.19, p=0.44). CONCLUSIONS: Hypoalbuminemia in patients with septic shock is strongly associated with increased mortality. Albumin transfusion is also strongly associated with increased mortality particularly in patients with higher baseline albumin levels. CLINICAL IMPLICATIONS: Future studies should consider including baseline albumin in the risk stratification of patients with septic shock, and further research is warranted to evaluate the association observed between albumin and mortality in septic shock patients. DISCLOSURE: The following authors have nothing to disclose: Brian Garnet, Martin Aldana-Campos, Varun Shah, Mohammad Elballat, Atif Shah, Elie Donath, Samer Fahmy No Product/Research Disclosure Information

SESSION TITLE: Pulmonary Arterial Hypertension Posters II SESSION TYPE: Original Investigation Poster PRESENTED ON: Wednesday, October 28, 2015 at 01:30 PM - 02:30 PM PURPOSE: Several recent clinical trials have showed that Riociguat, a member of a novel class of medications, soluble guanylate cyclase activators, has beneficial effects in both clinical and hemodynamic outcomes patients with differing etiologies of pulmonary artery hypertension (PAH). We sought to determine whether these outcomes were generalizable across groups. METHODS: We searched Pubmed, Medline, Embase and Cochrane for prospective RCTs that compared Riociguat to placebo in patients with PAH. Trials that included patients with PAH regardless of etiology randomized to Riociguat or placebo were included. Mantel Haenszel relative risk and mean difference were calculated using the fixed or random effect model based on heterogeneity. RESULTS: Data from 3 randomized, placebo controlled trials of Riociguat in patients with PAH resulted in 283 patients. For the primary outcome, 6 minute walk distance, Riociguat was associated with a significant increase compared to placebo (mean difference 37.2 m; 95% CI 24.5-49.9 m; p<0.001). A quality of life score, the EQ-SD also had a significant increase compared to placebo (mean difference 0.08; 95% CI 0.04-0.13; p<0.001). Analysis of hemodynamic variables revealed a significant decrease in pulmonary artery pressure in the Riociguat group (mean difference -3.95 mm Hg; 95% CI -5.26- -2.64 mm Hg; p<0.001), while pulmonary capillary wedge pressure was not significantly different (mean difference 0.35 mm Hg; 95% CI 0.38-1.08 mm Hg; p=0.35). Our analysis also showed a significant decrease in dyspnea in the Riociguat group (OR 0.46; 95% CI 0.26-0.81; p=0.007), but no difference in adverse events (OR 1.02; 95% CI 0.93-1.12; p=0.67), or mortality (OR 0.65; 95% CI 0.20-2.11; p=0.47). CONCLUSIONS: Riociguat significantly improves exercise tolerance in patients with both primary and secondary PAH through an apparent direct effect on pulmonary artery pressure. CLINICAL IMPLICATIONS: Guanylate cyclase activators may benefit patients who continue to have symptoms from PAH on standard medical therapy regardless of the etiology of PAH. DISCLOSURE: The following authors have nothing to disclose: Abdulah Alrifai, Brian Garnet, Varun Shah, Louis Lit No Product/Research Disclosure Information

A 52-year-old woman presented with frontal headaches, panhypopituitarism, and right cranial nerve VI palsy. MRI of the brain with gadolinium revealed a destructive process involving the clivus and bilateral petrous apices, and extending into bilateral cavernous sinuses with encasement and narrowing of the bilateral cavernous carotids. There was soft tissue enhancement of the pre-pontine cistern with extension into the sella and enlargement of the pituitary gland. CT scan showed bony erosion of the skull base. Transnasal transsphenoidal biopsy showed friable bone in the rostrum of the sphenoid sinus. Pathology revealed connective and adipose tissue with acute and chronic inflammation and granulation tissue. Cultures were negative. Patient was also diagnosed with HIV during her hospital stay. She responded well clinically and radiographically to steroids. A 3-month follow-up MRI revealed persistent erosive lesion in the base of the occiput and clivus with decreased extension into the cavernous sinus, sella, and suprasellar region.

A range of innovative computer-based interventions for psychiatric disorders have been developed and are promising for drug use disorders due to reduced cost and greater availability compared to traditional treatment. Electronic searches were conducted from 1966 to November 19, 2009, using MEDLINE, Psychlit, and EMBASE. Four hundred sixty-eight nonduplicate records were identified. Two reviewers classified abstracts for study inclusion, resulting in 12 studies of moderate quality. Eleven studies were pilot or full-scale trials compared to a control condition. Interventions showed high acceptability despite substantial variation in type and amount of treatment. Compared to treatment-as-usual, computer-based interventions led to less substance use and higher motivation to change, better retention, and greater knowledge of presented information. Computer-based interventions for drug use disorders have the potential to dramatically expand and alter the landscape of treatment. Evaluation of Internet- and telephone-based delivery that allows for treatment-on-demand in patients' own environment is needed.

Objective. The aim of this study was to examine the association of pain catastrophizing and pain coping strategies with characteristic pain intensity (an average of worst, least, and typical pain intensity in the past week) and recent pain-related disability (an average of three measures of past week pain interference) in opioid-dependent patients enrolled in a methadone maintenance treatment program (MMTP) who reported recent pain. Design. Cross-sectional survey. Patients. One hundred and eight MMTP patients who reported recent pain. Measures. Participants completed measures of demographics, pain status (i.e., "chronic severe pain"[pain lasting at least 6 months with at least moderate pain intensity or significant pain interference in the past week] vs "some pain"[pain in the past week not meeting the threshold of chronic severe pain]), characteristic pain intensity, recent pain-related disability, somatization, depression, catastrophizing, and pain coping strategies. Results. Catastrophizing explained a significant proportion of the variance in characteristic pain intensity (14%) and recent pain-related disability (11%) after controlling for demographics, pain status, somatization, and depression. Mirroring the findings of studies of non-opioid-dependent chronic pain patients, greater catastrophizing was associated with greater pain intensity and increases in recent pain-related disability. On average, the chronic severe pain group reported higher levels of catastrophizing than the some pain group. Conclusion. Consistent with studies of patients with chronic pain who are not opioid dependent, our findings emphasize the importance of assessing and addressing catastrophizing in MMTP patients with pain.