Clinical Pearls Covid 19 for ER practitioners

331,844 Views | 254 Replies | Last: 2 yr ago by plain_o_llama
Enviroag02
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AG
Ag_of_08 said:

What I'm able to print is face shield holders and masks that can take filter inserts. The ones I've been seeing used in emergency situations are cutting up filters and using them as inserts. I doubt they meet full n95 standards, but most of the people using them are taking what they can get.

I know the PLA plastic has been questioned because it can be porous, but it will hold pressure with stripping around the mouth and nose.

The face shield frames are great if I could find clear lexan, I could make them by the dozen, but I dont have a source for the guard materials.

I will print anything that could be helpful at this point with the supplies I have *shrug*

Couldn't you cut up some HEPA vacuum bags or HEPA air filter to size for the inserts? Wouldn't that be similar to a P100 which is better than N95 anyway?
JB99
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AG
Any use of the Malaria drug? Hydroxychloroquine?
Win At Life
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AG
Thanks guys. Keep doing God's work.
doctorAg13
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AG
Pulling for you OP. God bless you and your staff.
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gdw4ab
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AG
How are your PPE supplies?

What is your group's contingency plan if a critical number of you are unable to work from illness?
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doctorAg13
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AG
What is the age distribution of your patients?
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ThatOneGuy
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AG
Thanks for posting this. I'm working at a rural Texas ER currently, but I trained EM in Baton Rouge so I have been following the South Louisiana situation. It hasn't hit here yet but I am sure it's coming. It's in every county around us. We have no ICU at my hospital so we will be tubing and attempting transfers. This may prove difficult once all the ICU beds in Houston and Austin are filled to capacity before it even hits out here. Do you have any experience with how rural ED that are critical access without ICU care are handling things in your area? As a typically transfer accepting hospital what is your situation regarding transfers for higher level care?
VaultingChemist
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AG
JB99 said:

Any use of the Malaria drug? Hydroxychloroquine?
He stated that Plaquenil was used. Prescription brand name for hydroxychloroquine.
Ranger222
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AG
Thank you are all you are doing in this fight.
gdw4ab
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AG
Previous ER medical director at a rural Texas site here. IMO, got to hope that social distancing plus differences in population density allow for recovery in metro areas before rural areas get hit hard. Otherwise, I think you're going to be managing those intubated patients in your ER indefinitely. Hope to be wrong of course.
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PikesPeakAg
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AG
Thanks for posting. Blunt, honest assessment of experienced doc that provides insight on so many levels. Forced me to reassess where we are operationally and with regard to clinical protocols. I pray for all the ED docs in all of this.
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Dr. Not Yet Dr. Ag
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I've got several doc friends in NOLA that are giving identical stories. The kind of stuff you and they are talking about are things I'd never have expected to see as a physician. I went from seeing none of these patients, to 10 of them in the last 2 days. All of them so far mild. I'm sure that this will change in the next day or two. As i told some of my colleagues, based on the number of mild cases I'm seeing, **** is about to hit the fan.
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bay fan
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S
Thank you Doctor. You and your associates are in my prayers.
CT75
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AG
First of all.... GOD BLESS YOU AG!!! Prayers to you and your family.

Questions....
Quote:

A ratio of absolute neutrophil count to absolute lymphocyte count greater than 3.5 may be the highest predictor of poor outcome. the UK is automatically intubating these patients for expected outcomes regardless of their clinical presentation.
Children (young folks?) generally have higher lymphocyte counts...does this explain why it is thought that younger people have 'on average' less deadly cases?


Quote:

Clinical course is predictable.
2-11 days after exposure (day 5 on average) flu like symptoms start. Common are fever, headache, dry cough, myalgias(back pain), nausea without vomiting, abdominal discomfort with some diarrhea, loss of smell, anorexia, fatigue.

Day 5 of symptoms- increased SOB, and bilateral viral pneumonia from direct viral damage to lung parenchyma.

Day 10- Cytokine storm leading to acute ARDS and multiorgan failure. You can literally watch it happen in a matter of hours.

81% mild symptoms, 14% severe symptoms requiring hospitalization, 5% critical.

I assume that the 'mild symptom' cases do not experience the cytokine storm? Am I interpreting that correctly?

Thank you again for your service.
KidDoc
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AG
Damn. Thanks for sharing. Terrible virus.
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BCO07
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AG
Im in a smaller city in Texas and we're just starting to ramp up with cases. We've only had a couple actually be admitted and no mortality thus far, though I expect that will change. Hopefully the procedures we have put in place from lessons learned on the coasts and NOLA will help. Right now we are looking at starting HCQ and azithro on anybody who's hypoxic and COVID presumed/positive.

What scares me is the cardiomyopathy that seems to present after ARDS. I haven't seen a ton on the subject, but I wonder how quickly people are going to dobutamine after levo in a shock situation.
DifferenceMaker Ag
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ttu_85 said:

I'm but a lowly tard with a CS background. We too have our own unique terminology, acronym etc. I understand the OP was rushed and had to use his instinctive terminology to get this out to the masses with the time available to him.

This document critically important and the best I have heard anywhere regarding this crisis. If any medical professional could edit it for the medical layman that would be so helpful.

God bless the OP for taking the time to share this critical information and for their work in the trenches.

Notes added in parenthesis for the layperson. Please let me know if I misinterpreted anything.


I just spent an hour typing a long post that erased when I went to change the title so I apologize to the grammar and spelling police. This one will not be proofread and much shorter.

I am an ER MD in New Orleans. Class of 98. Every one of my colleagues have now seen several hundred Covid 19 patients and this is what I think I know.

Clinical course is predictable.
2-11 days after exposure (day 5 on average) flu like symptoms start. Common are fever, headache, dry cough, myalgias (general muscular pain; back pain indicated as common), nausea without vomiting, abdominal discomfort with some diarrhea, loss of smell, anorexia, fatigue.

Day 5 of symptoms- increased SOB (shortness of breath), and bilateral viral pneumonia (double pneumonia) from direct viral damage to lung parenchyma (the portion of the lung involved in gas transfer - the alveoli, alveolar ducts and respiratory bronchioles.)

Day 10- Cytokine storm (overproduction of immune cells and their activating compounds (cytokines), signaling an inflammatory response flaring out of control) leading to acute ARDS (Acute respiratory distress syndrome) and multiorgan failure. You can literally watch it happen in a matter of hours.

81% mild symptoms, 14% severe symptoms requiring hospitalization, 5% critical.

Patient presentation is varied. Patients are coming in hypoxic (poor oxygen saturation; below 90%) even 75% without dyspnea (labored breathing). I have seen Covid patients present with encephalopathy (brain injury, headache), renal (kidney) failure from dehydration, DKA (Diabetic ketoacidosis: occurs when the body starts breaking down fat at a rate that is much too fast. The liver processes the fat into a fuel called ketones, which causes the blood to become acidic). I have seen the bilateral interstitial pneumonia on the xray of the asymptomatic shoulder dislocation or on the CT's of the (respiratory) asymptomatic polytrauma patient. Essentially if they are in my ER, they have it. Seen three positive flu swabs in 2 weeks and all three had Covid 19 as well. Somehow this ***** has told all other disease processes to get out of town.

China reported 15% cardiac involvement. I have seen covid 19 patients present with myocarditis, pericarditis, new onset CHF (Congestive heart failure) and new onset atrial fibrillation. I still order a troponin, but no cardiologist will treat no matter what the number in a suspected Covid 19 patient. Even our non covid 19 STEMIs (ST-Elevation Myocardial Infarction; serious heart attack) at all of our facilities are getting TPA (Tissue plasminogen activator used to dissolve blood clots) in the ED (Emergency Department) and rescue PCI (Percutaneous Coronary Intervention; aka angioplasty with stint) at 60 minutes only if TPA fails.

Diagnostic
CXR (Chest X-Ray)- bilateral interstitial pneumonia (anecdotally starts most often in the RLL (lower lobe of the right lung) so bilateral on CXR is not required). The hypoxia does not correlate with the CXR findings. Their lungs do not sound bad. Keep your stethoscope in your pocket and evaluate with your eyes and pulse ox.


Labs- WBC (white blood cell count) low, Lymphocytes low, platelets lower than their normal, Procalcitonin (substance produced in response to bacterial infections but also in response to tissue injury) normal in 95%.
CRP (C-Reactive Protein Test: A plasma protein that rises in the blood with the inflammation from certain conditions) and Ferritin (blood protein that indicates iron level) elevated most often. CPK (creatine phosphokinase: elevated levels indicate muscle trauma, including heart), D-Dimer (a small protein fragment present in the blood after a blood clot is degraded by fibrinolysis), LDH (Lactate dehydrogenase: plays an important role in cellular respiration, the process by which glucose (sugar) from food is converted into usable energy for our cells.), Alk (Anaplastic lymphoma kinase: plays a pivotal role in cellular communication and in the normal development and function of the nervous system), Phos (Phosphorus level: key to kidney function)/AST (Aspartate aminotransferase: released into blood when the liver or heart is damaged)/ALT (alanine transaminase: high levels can indicate a liver problem) commonly elevated.
Notice D-Dimer- I would be very careful about CT PE (CT pulmonary angiography used to detect pulmonary embolisms) these patients for their hypoxia. The patients receiving IV contrast are going into renal (kidney) failure and on the vent sooner.

Basically, if you have a bilateral pneumonia with normal to low WBC, lymphopenia, normal procalcitonin, elevated CRP and ferritin- you have covid-19 and do not need a nasal swab to tell you that.

A ratio of absolute neutrophil (type of white blood cell) count to absolute lymphocyte (type of white blood cell) count greater than 3.5 may be the highest predictor of poor outcome. the UK is automatically intubating these patients for expected outcomes regardless of their clinical presentation.

An elevated Interleukin-6 (IL6: stimulates the inflammatory and auto-immune processes in many diseases) is an indicator of their cytokine storm. If this is elevated watch these patients closely with both eyes.

Other factors that appear to be predictive of poor outcomes are thrombocytopenia (low blood platelet count) and LFTs (liver function test) 5x upper limit of normal.

Disposition
I had never discharged multifocal pneumonia before. Now I personally do it 12-15 times a shift. 2 weeks ago we were admitting anyone who needed supplemental oxygen. Now we are discharging with oxygen if the patient is comfortable and oxygenating above 92% on nasal cannula. We have contracted with a company that sends a paramedic to their home twice daily to check on them and record a pulse ox. We know many of these patients will bounce back but if it saves a bed for a day we have accomplished something. Obviously we are fearful some won't make it back.

We are a small community hospital. Our 22 bed ICU and now a 4 bed Endoscopy suite are all Covid 19. All of these patients are intubated except one. 75% of our floor beds have been cohorted into covid 19 wards and are full. We are averaging 4 rescue intubations a day on the floor. We now have 9 vented patients in our ER transferred down from the floor after intubation.

Luckily we are part of a larger hospital group. Our main teaching hospital repurposed space to open 50 new Covid 19 ICU beds this past Sunday so these numbers are with significant decompression. Today those 50 beds are full. They are opening 30 more by Friday. But even with the "lockdown", our AI models are expecting a 200-400% increase in covid 19 patients by 4/4/2020.


Treatment
Supportive

worldwide 86% of covid 19 patients that go on a vent die. Seattle reporting 70%. Our hospital has had 5 deaths and one patient who was extubated. Extubation happens on day 10 per the Chinese and day 11 per Seattle.

Plaquenil which has weak ACE2 (angiotensin-converting enzyme) blockade doesn't appear to be a savior of any kind in our patient population. Theoretically, it may have some prophylactic properties but so far it is difficult to see the benefit to our hospitalized patients, but we are using it and the studies will tell. With Plaquenil's potential QT prolongation (refers to an interval seen in an electrocardiogram (EKG) test of heart function) and liver toxic effects (both particularly problematic in covid 19 patients), I am not longer selectively prescribing this medication as I stated on a previous post.

We are also using Azithromycin, but are intermittently running out of IV.

Do not give these patient's standard sepsis fluid resuscitation. Be very judicious with the fluids as it hastens their respiratory decompensation. Outside the DKA and renal failure dehydration, leave them dry.

Proning vented patients significantly helps oxygenation. Even self proning the ones on nasal cannula helps.

Vent settings- Usual ARDS stuff, low volume, permissive hypercapnia, etc. Except for Peep of 5 will not do. Start at 14 and you may go up to 25 if needed.

Do not use Bipap (Bilevel Positive Airway Pressure, and is very similar in function and design to a CPAP machine )- it does not work well and is a significant exposure risk with high levels of aerosolized virus to you and your staff. Even after a cough or sneeze this virus can aerosolize up to 3 hours.

The same goes for nebulizer treatments. Use MDI. you can give 8-10 puffs at one time of an albuterol MDI (Metered-dose inhaler). Use only if wheezing which isn't often with covid 19. If you have to give a nebulizer must be in a negative pressure room; and if you can, instruct the patient on how to start it after you leave the room.

Do not use steroids, it makes this worse. Push out to your urgent cares to stop their usual practice of steroid shots for their URI (upper respiratory infection)/bronchitis.

We are currently out of Versed, Fentanyl, and intermittently Propofol. Get the dosing of Precedex and Nimbex back in your heads.

One of my colleagues who is a 31 yo old female who graduated residency last may with no health problems and normal BMI is out with the symptoms and an SaO2 (saturated O2 level in the blood) of 92%. She will be the first of many.

I PPE best I have. I do wear a MaxAir PAPR the entire shift. I do not take it off to eat or drink during the shift. I undress in the garage and go straight to the shower. My wife and kids fled to her parents outside Hattiesburg. The stress and exposure at work coupled with the isolation at home is trying. But everyone is going through something right now. Everyone is scared; patients and employees. But we are the leaders of that emergency room. Be nice to your nurses and staff. Show by example how to tackle this crisis head on. Good luck to us all.





bloom
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Thank you for taking the time to share information-it is much appreciated. The Plaquenil combo seems to be working well on some patients in other locations. Is there a chance that there are 2 strains (it seems like this was a topic) and the drug combo is only effective against the milder strain? Not a medical professional could the strain a patient has be determined easily?
Mmaltby98
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Wonderful write up. Could not of written it better my self. That's what we're seeing in DFW as well.
Pelayo
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AG
pre and post exposure recommendation for what they are worth





We'll follow the post-exposure, considering the pre

even if ineffective harm is all but nil

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TelcoAg
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McInnis 03
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AG
For those with the elevated levels of IL6, are any of the IL-6 receptor blockers being administered? If so, any results to speak of?


This editorial written yesterday has some inisghts....
https://www.sitcancer.org/research/covid-19-resources/il-6-editorial

Quote:

Emerging evidence suggests that high levels of CRP and IL-6 are observed in patients infected with COVID-19 [1, 8]. Anecdotal experience on the use of tocilizumab at doses comparable to those used for the management of CRS from investigators in Italy [9] and from China [10] has reported rapid improvement in both intubated and non-intubated patients. In these reports, expeditious administration of anti-IL-6R therapy for patients in acute respiratory distress has been critical. A recent study protocol to evaluate the efficacy of tocilizumab in COVID-19 induced pneumonitis accrued over 300 patients worldwide in less than 24 hours. Additionally, Genentech will also provide 10,000 vials of tocilizumab to the U.S. Strategic National Stockpile [11]. Tocilizumab was also approved in China in March 2020, for the treatment of patients with COVID-19 with serious lung damage and elevated IL-6. Sponsors, investigators, and regulators have moved with unprecedented speed and collaboration to initiate protocols to formally study the safety and efficacy of antiviral agents and vaccines, as well as various anti-IL-6 antibodies in patients with COVID-19. In the US, a trial of sarilumab in the COVID-19 setting is ongoing [12].

dermdoc
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AG
Thank you sir and prayers sent. I feel so inadequate as a Derm when I read this stuff. Hang tough army.
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HunterAggie
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Incredible info.

It reads right out of a movie. I hope this one ends well.

(Thank you for being on the front lines).
OnlyANobody
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Thank you. For the information, for what you do, and for persevering while enduring the absence of your family.
Tabasco
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AG
Thank you OP. Sucks that your initial write up got deleted. And thanks for rewriting
BCO07
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AG
dermdoc said:

Thank you sir and prayers sent. I feel so inadequate as a Derm when I read this stuff. Hang tough army.
Then you know how I feel when my answer is "I dunno, its a rash. Oh, hyrodcortizone didn't work...try antifungal."
Mordred
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AG
Dr. Not Yet Dr. Ag said:

I've got several doc friends in NOLA that are giving identical stories. The kind of stuff you and they are talking about are things I'd never have expected to see as a physician. I went from seeing none of these patients, to 10 of them in the last 2 days. All of them so far mild. I'm sure that this will change in the next day or two. As i told some of my colleagues, based on the number of mild cases I'm seeing, **** is about to hit the fan.
Where are you practicing?
Dr. Not Yet Dr. Ag
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San Antonio. I think they state that we reportedly have only 67 confirmed cases currently, however, I can tell you that the large majority of patients that likely have it are being sent home without testing. I have seen 2 confirmed cases myself. Another 8 that either have a confirmed close contact with a +individual, labs and imaging results that are classic for the CV, or a very concerning travel history and symptoms that are consistent with it.
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ttu_85
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DifferenceMaker Ag said:

ttu_85 said:

I'm but a lowly tard with a CS background. We too have our own unique terminology, acronym etc. I understand the OP was rushed and had to use his instinctive terminology to get this out to the masses with the time available to him.

This document critically important and the best I have heard anywhere regarding this crisis. If any medical professional could edit it for the medical layman that would be so helpful.

God bless the OP for taking the time to share this critical information and for their work in the trenches.

Notes added in parenthesis for the layperson. Please let me know if I misinterpreted anything.

...
...
...

Many thanks to the OP and DifferenceMaker Ag !!
Mordred
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AG
Dr. Not Yet Dr. Ag said:

San Antonio. I think they state that we reportedly have only 67 confirmed cases currently, however, I can tell you that the large majority of patients that likely have it are being sent home without testing. I have seen 2 confirmed cases myself. Another 8 that either have a confirmed close contact with a +individual, labs and imaging results that are classic for the CV, or a very concerning travel history and symptoms that are consistent with it.
Thanks. I suspected you were in Texas, but was hoping you weren't. Very clear that still almost nobody is being tested here.

Best of luck to you, doc.
McInnis
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AG
Dr. Not Yet Dr. Ag said:

San Antonio. I think they state that we reportedly have only 67 confirmed cases currently, however, I can tell you that the large majority of patients that likely have it are being sent home without testing.
Even though a lot of this is over my head, it's sobering to say the least. But we all need to keep this statement in mind when we look at fatality rates that are based on the number of confirmed cases.
docaggie
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AG
Ag_of_08 said:

What I'm able to print is face shield holders and masks that can take filter inserts. The ones I've been seeing used in emergency situations are cutting up filters and using them as inserts. I doubt they meet full n95 standards, but most of the people using them are taking what they can get.

I know the PLA plastic has been questioned because it can be porous, but it will hold pressure with stripping around the mouth and nose.

The face shield frames are great if I could find clear lexan, I could make them by the dozen, but I dont have a source for the guard materials.

I will print anything that could be helpful at this point with the supplies I have *shrug*
I've got our residents making makeshift face shields using transparency film meant for overhead projectors.
They were in stock at Amazon yesterday
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Infection_Ag11
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AG
McInnis 03 said:

For those with the elevated levels of IL6, are any of the IL-6 receptor blockers being administered? If so, any results to speak of?


This editorial written yesterday has some inisghts....
https://www.sitcancer.org/research/covid-19-resources/il-6-editorial

Quote:

Emerging evidence suggests that high levels of CRP and IL-6 are observed in patients infected with COVID-19 [1, 8]. Anecdotal experience on the use of tocilizumab at doses comparable to those used for the management of CRS from investigators in Italy [9] and from China [10] has reported rapid improvement in both intubated and non-intubated patients. In these reports, expeditious administration of anti-IL-6R therapy for patients in acute respiratory distress has been critical. A recent study protocol to evaluate the efficacy of tocilizumab in COVID-19 induced pneumonitis accrued over 300 patients worldwide in less than 24 hours. Additionally, Genentech will also provide 10,000 vials of tocilizumab to the U.S. Strategic National Stockpile [11]. Tocilizumab was also approved in China in March 2020, for the treatment of patients with COVID-19 with serious lung damage and elevated IL-6. Sponsors, investigators, and regulators have moved with unprecedented speed and collaboration to initiate protocols to formally study the safety and efficacy of antiviral agents and vaccines, as well as various anti-IL-6 antibodies in patients with COVID-19. In the US, a trial of sarilumab in the COVID-19 setting is ongoing [12].




Yes, we're conducting trials with multiple IL-6 inhibitors. At my facility we're enrolling patients in a sirolumab.
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BCO07
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AG
where did that come from?
 
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