Pneumonia during pregnancy has been proven to be associated with increased maternal and fetal morbidity and mortality. The management of severe pneumonia in gravid patients is even more challenging. Thus, we summarized the characteristics and pregnancy outcomes of these patients and explored the probable risk factors and predictive factors for pneumonia during pregnancy and the appropriate timing of delivery in severe pneumonia patients. A retrospective cohort study was conducted with 12 patients who were diagnosed with severe pneumonia complicating pregnancy at Peking Union Medical College Hospital between January 2010 and June 2017. The clinical features, treatment strategies, and pregnancy outcomes were collected from medical records and telephone calls. All 12 patients were in their late second or third trimester. The patients had a higher prevalence of anemia (50%) and preeclampsia (25%) than ordinary pregnant women. Delayed diagnoses were not uncommon. Two mothers died in our series, resulting in a mortality rate of 17%. Two intrauterine deaths were observed. Elective delivery was not performed in any of the four patients in their second trimester. Six of the seven patients who presented after 28 weeks of gestation and had live fetuses underwent emergency deliveries. Preterm births (6/7) and cesarean sections (5/7) were the two leading adverse outcomes in newborns. Anemia, advanced gestational age, and preeclampsia might be associated with the severity of pneumonia. Chest radiographs should be taken as soon as pneumonia is highly suspected to facilitate an early diagnosis. High incidences of adverse fetal outcomes were observed; thus, termination of the pregnancy is recommended for patients in their third trimester when respiratory function deteriorates progressively. However, it might be reasonable to continue pregnancy for those in their first or second trimester.

Objective COVID-19 started spreading widely in China in January 2020. Outpatient fever clinics (FCs), instituted during the SARS epidemic in 2003, were upgraded to serve for COVID-19 screening and prevention of disease transmission in large tertiary hospitals in China. FCs were hoped to relieve some of the healthcare burden from emergency departments (EDs). We aimed to evaluate the effect of upgrading the FC system on rates of nosocomial COVID-19 infection and ED patient attendance at Peking Union Medical College Hospital (PUMCH). Design A retrospective cohort study. Participants A total of 6365 patients were screened in the FC. Methods The FC of PUMCH was upgraded on 20 January 2020. We performed a retrospective study of patients presenting to the FC between 12 December 2019 and 29 February 2020. The date when COVID-19 was declared an outbreak in Beijing was 20 January 2020. Two groups of data were collected and subsequently compared with each other: the first group of data was collected within 40 days before 20 January 2020; the second group of data was collected within 40 days after 20 January 2020. All necessary data, including patient baseline information, diagnosis, follow-up conditions and the transfer records between the FC and ED, were collected and analysed. Results 6365 patients were screened in the FC, among whom 2912 patients were screened before 21 January 2020, while 3453 were screened afterward. Screening results showed that upper respiratory infection was the major disease associated with fever. After the outbreak of COVID-19, the number of patients who were transferred from the FC to the ED decreased significantly (39.21% vs 15.75%, p<0.001), and patients generally spent more time in the FC (55 vs 203 min, p<0.001), compared with before the outbreak. For critically ill patients waiting for their screening results, the total length of stay in the FC was 22 min before the outbreak, compared with 442 min after the outbreak (p<0.001). The number of in-hospital deaths of critically ill patients in the FC was 9 out of 29 patients before the outbreak and 21 out of 38 after the outbreak (p<0.05). Nineteen cases of COVID-19 were confirmed in the FC during the period of this study. However, no other patients nor any healthcare providers were cross-infected. Conclusion The workload of the FC increased significantly after the COVID-19 outbreak. New protocols regarding the use of FC likely helped prevent the spread of COVID-19 within the hospital. The upgraded FC also reduced the burden on the ED.

Background: Chylopericardium is a rare condition characterized by the accumulation of chyle in the pericardial space. It is most commonly caused by thoracic duct injury. Chylopericardium following esophagectomy is extremely rare but can cause life-threatening complications. This report presents a case of chylopericardium post-esophagectomy, resulting in cardiac tamponade and cardiac arrest. A systematic literature review was also conducted to facilitate the understanding of this rare condition. Case presentation: A 41-year-old male was admitted to our hospital with intermediate to highly differentiated squamous cell carcinoma of the mid-thoracic esophagus (clinical T4NxM0). He underwent thoracoscopic-laparoscopic esophagectomy with cervical anastomosis. On postoperative day 1, patient had a cardiac arrest secondary to cardiac tamponade, requiring emergency ultrasound-guided drainage. The drained fluid was initially serous but became chylous after the administration of enteral nutritional emulsion. As a result of significant daily pericardial drainage, patient subsequently underwent thoracic duct ligation. The amount of drainage was substantially reduced post-thoracic duct ligation. Over a period of 2 years and 7 months, patient recovered well and tolerated full oral diet. A comprehensive literature review was conducted and 4 reported cases were identified. Among these cases, three patients developed pericardial tamponade secondary to chylopericardium post-esophagectomy. Conclusion: Chylopericardium is a rare but serious complication post-esophagectomy. Prompt echocardiography and thorough pericardial fluid analysis are crucial for diagnosis. Thoracic duct ligation has been shown to be an effective management approach for this condition.

E14579 Background: We retrospectively analysed the cases of immune checkpoint inhibitor(ICI) -associated myocarditis managed in PUMCH. We aim to investigate the clinical characteristics of myocarditis and the risk factors affecting the prognosis. Methods: Medical records of all checkpoint inhibitor-related myocarditis were reviewed retrospectively. Descriptive statistics were used for the report of clinical outcomes. Univariate and multivariate Logistic analyses were performed to establish a prognostic model. Results: The median age of 19 patients was 64 years old (range 39̃80 years). The median time of onset from the iniatial of ICIs was 21 days (ranging from 2 to 375 days). Seven cases were grade 4 (36.8%), 2 cases were grade 3 (10.5%), 8 cases were grade 2 (42.1%), and 2 cases were grade 1 (10.5%). Clinical symptoms included dyspnea (13/19, 68.4%), fatigue (11/19, 57.9%), myalgia/myasthenia (9/19, 47.4%), sweating (6/19, 31.6%) and palpitation (6/19, 31.6%) et al. 47.4% (9/19) of the patients showed cardiac insufficiency/hemodynamic instability at first, and 52.6% (10/19) of the patients showed symptoms related to myositis first. cTnI and CK increased in all patients. The level of cTnI was significantly higher in grade 3̃4 than that in grade 1-2. NTproBNP was elevated in all grade 4 cases and one grade 3 case. The LVEF decreased only in 4 patients with grade 4 myocarditis (4/19, 22.2%). The electrocardiogram showed ventricular arrhythmia in 4 cases and complete atrioventricular block (3°AVB) in 3 cases. All patients were treated with corticosteroids (GCS). Grade 4 (6 cases), grade 3 (1 case) and grade 2 (2 cases) were given GCS pulse dose. The median total duration of GCS treatment was 42 days (range: 14-60 days). Three patients were treated with tocilizumab and one patient with infliximab. All patients with grade 3-4 and 2 patients with grade 2 were also treated with IVIG. Pacemakers were implanted in 3 patients with 3°AVB. The mortality rate of 19 cases was 21.1% (4/19), and the mortality rate of grade 4 myocarditis was 42.9%(3/7). The longer course before GCS therapy (p = 0.023), the higher NTproBNP (p = 0.030) and the lower LVEF value (p = 0.014) were found in the death group compared to the survival group. Logistic regression analysis showed that LVEF is an independent risk factor. The myocarditis prognostic model was condstructed as follows: Y = 8.794-18.002*LVEF, the prognostic critical value of LVEF was 57.5%, the area under the ROC curve of the prognostic model was 0.894 (95%CI: 0.735̃1.000), the sensitivity was 0.769, and the specificity was 1.000. Conclusions: We describe the largest single-center immune myocarditis cohort to date. Paying attention to the symptoms related to myositis is helpful to find more grade 1-2 myocarditis. cTnI is sensitive to myocarditis, and NTproBNP is of great significance to grade 3 ̃ 4 cases. LVEF < 57% may be an independent risk factor for poor prognosis.

Acquired von Willebrand syndrome (AVWS) is caused by an acquired deficiency of von Willebrand factor (VWF), a multimeric protein required for primary hemostasis. For patients with heart valve diseases, high gradient across the malfunctioning valves could cause elevated shear stress and damage the most effective large VWF, eventually resulting in AVWS. However, AVWS has not been reported in association with normally functioning mechanical valves. Herein, we reported a 74-year-old female who suffered from recurrent gastrointestinal bleeding with a history of mechanical aortic and mitral valve replacement. This patient’s function/antigen ratio of VWF was decreased and gel electrophoresis revealed the loss of large VWF, which confirmed the diagnosis of AVWS. Echocardiogram showed that the function of the prostheses was normal. However, the gradient across aortic valve was increased due to a high cardiac state which is secondary to chronic anemia, resulting in the disruption of large VWF multimers and exacerbation of gastrointestinal (GI) bleeding. After managing the patient’s anemia with transfusion, the gradient across the aortic valve had improved, with the resolution of GI bleeding. This is the first case report of AVWS that is associated with a normally functioning mechanical valve. AVWS should be considered one of the differential diagnoses if patients present with unexplained GI bleeding on the background of having prosthetic heart valves. The management of the underlying condition is essential.

Objectives: COVID-19 began spreading widely in China in January 2020. Outpatient “Fever Clinics” (FCs), instituted during the SARS epidemic in 2003 were upgraded to provide COVID-19 screening and prevention attached to large tertiary hospitals. We sought to analyze the effect of upgraded FCs to detecting COVID-19 at our institution. Design: A population-based cross-sectional study. Participants: A total of 6,365 patients were screened in the FC. Methods: The FC of Peking Union Medical College Hospital (PUMCH) was upgraded on January 20, 2020. We performed a retrospective study of patients presenting to the FC between December 12, 2019 to February 29, 2020, covering a period of 40 days before and after upgrading the FC. All necessary data, including baseline patient information, diagnoses, follow-up conditions for critical patients, transfer information between the FC and emergency department (ED) were collected and analyzed. Results: 6,365 patients were screened in the FC, among whom 2,192 patients were screened before January 21, 2020, while 3,453 were screened afterwards. Screening results showed that upper respiratory infection was the major disease associated with fever. Compared to before the outbreak, patients transferred from the FC to ED decreased significantly [39.21% vs 15.75%, p<0.001] and tended to spend more time in the FC [55 vs 203mins, p<0.001]. For critically-ill patients waiting for a screening result, the total length of stay in the FC was 22mins before the outbreak, compared to 442mins after the outbreak (p< 0.001). The number of in-hospital deaths of critical-care patients seen first in the FC was 9 of 29 patients before the outbreak and 21 of 38 after (p<0.050). Nineteen COVID-19 cases were confirmed in the FC, but no other patients or medical care providers were cross-infected. Conclusion: The work-load of the FC increased after the COVID-19 outbreak and effectively prevented COVID-19 from spreading in the hospital,as well as offload ED resources.