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Troponins have close to 100% sensitivity when drawn 6 to 12 hours after the start of chest pain in acute coronary syndrome (ACS). Length of hospital stay (LOS) is a marker of efficient hospital management. Since troponin measurements at 3 (Q3H) and 6-hour (Q6H) intervals have comparable efficacy for ACS, we suggest considering Q3H troponins as opposed to Q6H in chest pain admissions to shorten LOS. A retrospective review of 389 patients who presented to Stony Brook Southampton Hospital in 2020 and 2021 with chest pain was conducted. Two patient care strategies were examined, one involved collecting troponins Q6H and the other Q3H. 319 patients with the Q6H strategy were analyzed and 61.1% were ruled in for ACS. For the Q3H strategy, 70 patients were analyzed in which 42.9% were ruled in for ACS. LOS was defined as hours between triage and submission of discharge instructions. A two-sample t-test was performed to find correlation between frequency of troponins and LOS. A two-sample t-test assuming unequal variance was conducted to compare LOS in hours between Q6H and Q3H strategies. There was a significant difference in LOS for Q6H (M = 123, SD = 201) and Q3H (M = 66, SD = 135) troponins; t = 2.91, p = 0.002. These results suggest that LOS is lessened when troponin intervals are shorter. The variance was elevated (40249,18343), possibly due to patients who stayed longer for other needs, but mean LOS and standard deviation remained decreased both when excluding patients that stayed longer than one week, and when including all patients in the analysis. Optimizing LOS has a variety of benefits. In patients with chest pain, shortening the interval of troponin collection can lessen LOS. Studies of comparable efficacy of shorter troponin intervals in evaluation of ACS have led to the practice of trending at Q3H intervals in Europe. Our study demonstrates that trending troponins Q3H is viable in a community hospital in the United States and should be further investigated and considered in the future.

Length of stay (LOS) in the hospital for patients presenting with chest pain can be influenced by several factors. In patients evaluated for acute coronary syndrome (ACS), admission to a cardiology service may allow patients to have a shorter LOS, while admission to a non-specialty service has been shown to potentially cause worse outcomes. In this analysis, we evaluate whether specialized care decreases LOS in patients who present with chest pain. A retrospective review of 389 patients who presented to Stony Brook Southampton Hospital in 2020 and 2021 with chest pain and underwent ACS evaluation was conducted. The two strategies involved admissions to the cardiology service or to other hospital services. We analyzed 95 cardiology admissions, 56.8% of which ruled in for ACS, and 294 admissions to other hospital services, 58.2% of which ruled in for ACS. LOS was defined as hours between triage and submission of discharge instructions. A two-sample t-test was performed to find correlations between admission service and length of hospital stay. A two-sample t-test assuming unequal variance was conducted to compare LOS in hours between patients admitted to the cardiology and non-cardiology services. There was a significant difference in LOS for the cardiology service (M = 48, SD = 55) and non-cardiology service (M = 134, SD = 214) conditions; t = 6.30, p < 0.001. These results suggest that LOS is lessened when chest pain patients are admitted to the cardiology service. The variance was elevated (2985, 45849), possibly due to patients who stayed longer for other needs, but mean LOS and SD remained decreased when excluding patients that stayed longer than one week, and when including all patients in the analysis. When admitting a patient, there are many ways to optimize LOS. Admission of patients who present with chest pain to a specialty cardiology service may allow patients to have a more efficient LOS and should be further investigated and considered in the future.

TOPIC: Biotechnology TYPE: Medical Student/Resident Case Reports INTRODUCTION: Recent case reports have called attention to cerebral venous thrombosis after receiving the Johnson & Johnson vaccine for the novel Coronavirus 2019 (COVID-19), which resulted in the temporary suspension of the single-dose viral vector option. However, as of April 13th, 2020, CDC states that there are no reports of the clotting in the approximately 180 million doses of the Pfizer and Moderna vaccines administered in the United States. Here we present a case of a healthy male who developed pulmonary embolisms after receiving the Moderna vaccine. CASE PRESENTATION: A 55-year-old healthy, physically active male of Ashkenazi Jewish descent presents with multiple bilateral segmental and sub-segmental pulmonary embolisms. Twenty-four hours prior to onset of symptoms, the two-vaccine series of Moderna was completed. The patient was both COVID-19 PCR and COVID-19 IgG antibody negative, but positive for COVID IgM antibody. There was no evidence of deep vein thrombosis. In addition, his hypercoagulable work-up was negative. DISCUSSION: COVID-19 dramatically increases the risk of pulmonary embolism through a proposed mechanism of thrombo-inflammation triggered by viral infection, which originates in the pulmonary vasculature. Initially it was theorized that the etiology of this patient's pulmonary embolisms were an acute COVID-19 infection but two PCR tests from two different laboratories resulted as negative. Increased clotting has not yet been reported in the Pfizer and Moderna mRNA vaccine cohorts. In fact, the preliminary data from the Moderna vaccine trial stated that risk of pulmonary embolism is less than 0.03%, which was lower than the placebo group.It is also unknown if the Moderna vaccine trial included patients of Ashkenazi Jewish descent. It is theorized that as more patients worldwide become vaccinated, major side effects could increase as those patients who were not originally represented in the preliminary studies. CONCLUSIONS: Although the Moderna vaccine has shown to theoretically decrease the risk of clotting by decreasing risk of COVID-19 infection, as more of the world becomes vaccinated, the incidence of side effects could increase, despite preliminary data. REFERENCE #1: Abou-Ismail MY, Diamond A, Kapoor S, Arafah Y, Nayak L. The hypercoagulable state in COVID-19: Incidence, pathophysiology, and management [published correction appears in Thromb Res. 2020 Nov 26;:]. Thromb Res. 2020;194:101-115. doi:10.1016/j.thromres.2020.06.029 REFERENCE #2: Oliver SE, Gargano JW, Marin M, Wallace M, Curran KG, Chamberland M, McClung N, Campos-Outcalt D, Morgan RL, Mbaeyi S, Romero JR, Talbot HK, Lee GM, Bell BP, Dooling K. The Advisory Committee on Immunization Practices' Interim Recommendation for Use of Moderna COVID-19 Vaccine - United States, December 2020. MMWR Morb Mortal Wkly Rep. 2021 Jan 1;69(5152):1653-1656. doi: 10.15585/mmwr.mm695152e1. PMID: 33382675. REFERENCE #3: VRBPAC December 17, 2020 Meeting Announcement. U.S. Food and Drug Administration. https://www.fda.gov/advisory-committees/advisory-committee-calendar/vaccines-and-related-biological-products-advisory-committee-december-17-2020-meeting-announcement. Published December 17, 2020. Accessed April 27, 2021. DISCLOSURES: No relevant relationships by David Capone, source=Web Response No relevant relationships by Brett Kingsborough, source=Web Response No relevant relationships by Kathryn Saxby, source=Web Response No relevant relationships by Daisy Young, source=Web Response

TOPIC: Chest Infections TYPE: Medical Student/Resident Case Reports INTRODUCTION: Vaccinations against Novel Coronavirus 2019 (COVID-19) for immunocompromised individuals have been increasingly prioritized to avoid severe infection. Here is a case of severe COVID-19 infection in a patient with malignant lymphoma who completed the vaccination course. CASE PRESENTATION: A 79-year-old male with malignant lymphoma on active Rituximab was diagnosed with COVID-19 two months after completing the Pfizer vaccination course. He presented with a worsening cough despite receiving monoclonal antibodies outpatient. On evaluation, his vitals were stable. Chest x-ray revealed bilateral pleural effusions with bibasilar opacities. During his hospitalization, he received a full course of dexamethasone, ivermectin, remdesivir and baricitinib. However, his cough and oxygenation progressively worsened, with eventual intubation and vasopressor support. Computed Tomography (CT) Chest showed progressive worsening of COVID-19 Pneumonia. Originally on admission he had tested negative for the IgM and IgG antibodies against the Nucleocapsid (N) Protein which raised the suspicion that he had not mounted an immune response to the vaccine. On further evaluation, he was found to have positive antibody titers against Spike (S) proteins which confirmed that he had mounted a response to the vaccine despite his immunocompromised status. DISCUSSION: Anti-CD20 therapy is one of the primary therapies for hematological malignancies. Despite T cell function being the primary role against COVID-19, there is increasing evidence that B-cell depletion may inhibit protective immunity following infection and vaccination. A two-dose regimen of BNT162b2 (Pfizer) conferred 95% protection against COVID-19 in persons 16 years of age or older, and decreased the rate of severe infection. However, only 4% of the vaccinated patients suffered from any malignancy;0.2% of them had metastatic solid tumors, leukemia, lymphoma and none were on chemotherapy. The efficacy of the vaccine was extrapolated to include the subset of individuals on active chemotherapy. Interestingly, despite having an active immunological response to the vaccine and normal T-cell function, the patient suffered from severe COVID pneumonia. CONCLUSIONS: Though widespread immunization against COVID-19 is underway, patients with hematological malignancies still remain a vulnerable population. The decision to halt immunomodulatory therapy to improve efficacy of the vaccine needs further investigation. REFERENCE #1: Baker D et al. (2020). COVID-19 vaccine-readiness for anti-CD20-depleting therapy in autoimmune diseases. Clinical & Experimental Immunology, 202(2), 149–161. https://doi.org/10.1111/cei.13495 DISCLOSURES: No relevant relationships by Luke Alessi, source=Web Response No relevant relationships by Louis Avvento, source=Web Response No relevant relationships by Abdul Qadeer, source=Web Response No relevant relationships by Kathryn Saxby, source=Web Response No relevant relationships by Howard Sklarek, source=Web Response No relevant relationships by LAKSHMI SUBRAMANIAN, source=Web Response No relevant relationships by Daisy Young, source=Web Response