Five-year review of a tertiary paediatric sleep service for complex patients

Introduction Our paediatric sleep unit commenced service for children with complex medical problems in July 2015. Service capacity includes 12 inpatient level 1 studies (two neonates) and one home study per week. FTE includes senior scientists 2.6, sleep technologists 1.7, administration 1.0, nursing 0.7 and medical 1.2. The primary aim of this study was to evaluate activity during the first 5-years. The secondary aim was to document the impact of the COVID-19 pandemic. Methods Sleep unit operational & diagnostic data were collected from sleep booking sheets, sleep study reports, electronic medical records. Descriptive statistics are presented. Results A total of 2186 sleep studies were performed (July 2015 to June 2020) with a range of 368–472 studies per annum. Overall, 61.7% were diagnostic studies, 20.8% titration studies (CPAP, oxygen, bi-level or invasive ventilation), 10% neonatal and 7.5% home studies. Between 2016–2020, the average waiting time (days) for a neonatal study was 16, a titration study was 106, a diagnostic study was 110 and a home study was 76. Further delays were caused by the COVID19 pandemic. Mean waiting time rose 229% from 108 days (Feb 2020) to 355 days (Feb 2021). Referrals for sleep studies have exceeded bed capacity since the beginning of the pandemic. Discussion This audit describes activity in a tertiary complex paediatric sleep service during the first 5 years. The service has struggled on current FTE and bed capacity to manage waiting times, exacerbated further by the COVID-19 pandemic. A new business and clinical model are warranted.

Critical Environmental Justice and Pandemic Events: Florida Farm Work during COVID-19

Extant research has well established that exposure to infectious disease can be a significant problem for vulnerable populations that have been deemed "essential" during widespread health crises. We contribute to this growing body of literature by delineating the utility of the critical environmental justice (CEJ) framework for investigating infectious disease in the context of at-risk groups such as farmworker communities. Specifically, we highlight how the four pillars of CEJ are applicable to potential or real exposure to pathogens in farmworkers' living and working spaces, and how responses and support for these essential workers can be shaped by intersectional factors, the "expendability" of farmworkers, and broader state and corporate structural influences. We draw from a case study of Florida farmworker outreach professionals to center the perceptions and experiences of individuals working directly with farmworker communities during the COVID-19 pandemic. We conclude with a discussion of how our research contributes to the broader understanding of CEJ in the context of widespread health threats, as well as an overview of lessons learned for regulatory and health agencies.

Pulmonary Complications and Mortality in Patients with SARS-CoV-2 Undergoing Elective and Emergent Hand Surgery

Background Patients acutely infected with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) may have increased risk for postsurgical pulmonary complications and mortality, particularly with general anesthesia. Surgery is often delayed to mitigate risk;however, excessive delays may result in morbidity. Optimal criteria for delaying surgery in patients with or without symptoms are unknown. This study aimed to evaluate any complications following hand surgery in patients testing positive for SARS-CoV-2.Methods We retrospectively reviewed patients with a positive polymerase chain reaction test within 60 days before or after hand surgery between March 31, 2020 and March 31, 2021. Patients were telephoned also to supplement records. Type of surgery, type of anesthesia, comorbidities, timing of surgery, onset of symptoms, and complications were recorded.Results We identified 21 patients undergoing 26 procedures, of which 21 (81%) were emergency procedures and 5 (19%) were elective. Mean age was 37 years (range: 17-71). General anesthesia was used in 88% of cases, with mean duration of 110 minutes. SARS-CoV-2 was diagnosed on average 6 days preoperatively (range: 39 days preop-14 days postop). Positive tests were usually identified preoperatively (50%), versus day-of-surgery (25%) or postoperatively (25%). Patients were symptomatic in only 27% of cases, and completely asymptomatic in 73%. No asymptomatic patients developed complications. One patient suffered a fracture malunion after delayed surgery. Pulmonary complications were noted in 3 patients;all had prior pulmonary disease and underwent emergency surgeries under general anesthesia. Overall mortality rate was 0%.Conclusion Pulmonary complications and mortality are low following hand surgery in asymptomatic patients with a positive SARS-CoV-2 test.

Co-locating public mental health services in communities: a realist evaluation : Shamini Gnani

Background Public mental health (PMH) services address social determinants of mental health, such as poverty, poor housing, and job insecurity. Austerity and welfare reform in the UK has led to cuts to social and welfare support, increasing poor mental health and widening inequalities, exacerbated by COVID-19. State health services lack capacity to tackle social issues that contribute to a large proportion of expressed mental health need. Co-locating PMH services within community spaces is a potential solution to increase early access and improve quality of services. Using a realist evaluation, we sought to develop the theory on how community co-location affects PMH outcomes, who this works best for, and how this is impacted by the context of delivery. Methods We collected data from service-users and service-providers at six case study sites across England, UK, using interviews (n = 62), four focus groups (n = 40) and two stakeholder workshops (n = 19). Results We identified four overarching theories. First, community providers do not operate under the same limits as state services allowing them the flexibility and time to build trust and ongoing relationships with service users. Second, the ethos and culture of services is to empower users to access help and be independent. Third, accessing support from a shared local space allows a coordinated and holistic response reducing barriers such as distance, cost, and anxiety. Four, as they are recreational services and spaces for access by all with no predefined/required level of need they are better at promoting wellbeing and primary prevention. Conclusions Community co-location of PMH services can strengthen the overall mental health system by widening reach to people vulnerable to poor mental health and enabling earlier intervention on associated social determinants. This has potential to reduce mental health inequalities and demand on the state health system. Key messages Community co-location of PMH services can provide early and holistic support for complex social issues. There is potential to support the state health system by alleviating demand for help with ‘non-health’ issues.

No Diving! National Estimates and Characteristics of Diving-related Injuries in Children and Adolescents from 2008-2020

Background: Recreational swimming/diving is the most common physical activity among US children and a significant cause of preventable morbidity across the United States. There are an estimated 50 million Americans that participate in swimming per year, 16 million of whom are children. Despite the popularity of swimming and diving, there are few up-to-date national divingrelated injury analyses, and no comprehensive injury analysis has been performed since the institution of International Swimming Pool •Spa Code (ISPSC) in 2012, which regulate diving equipment and design. This study offers a much-needed update on the national epidemiology of diving-related orthopedic injuries. Methods: The Consumer Product Safety Commission's National Electronic Injury Surveillance System (NEISS) database was queried for patients aged 0-18 from 2008- 2020 who presented to any of the approximately 100 NEISSparticipating emergency departments (EDs) for a diving-related injury. The patient cohort was identified using a search for consumer product code-1278 (diving). Injuries involving diving accessories, running, hitting, or tripping over the diving board, and injuries resulting from contact between two or more divers, were excluded. Infections were excluded. Dive characteristics such as dive height, dive skill, dive direction, and dive sequence were determined from case narratives. Descriptive statistical analysis was performed using Stata 16. Results: From 2008-2020 there were 1,157 cases of diving-related injury corresponding to a national estimate of 35,648 injuries (CI=28,067 - 43,230;Table 1). Children aged 10-14 accounted for 42% of all injuries, while adolescents aged 15-19 accounted for 38%. Nearly twice as many injuries occurred in boys compared to girls (64.2% vs 35.8% of total injuries, respectively). From 2008-2012, there were an average estimated 3,191 injuries per year. From 2013-2019, the yearly average decreased to 2,633 injuries (Figure 1). Due to the COVID-19 pandemic, there were relatively few (1,261) injuries in 2020. Compared to 2012, there were an estimated 1,081 fewer diving injuries in 2013, the first year the ISPSC codes were widely adopted. Lacerations were the most reported diagnosis for all years (24.9% of injuries). The head and neck were the mostinjured body parts (46.4% of injuries), followed by the face (17.4% of injuries), and lower extremities (16.6% of injuries). Concussions and nerve injury accounted for 6.7% and 0.1% of injuries, respectively. When the mechanism of injury was reported, unintentional contact with the diving board or platform was the most common cause (27.2% of injuries). Conclusion: Diving injuries are common in children and adolescents, especially in boys aged 10-19. Since the 2012 adoption of international safety standards for swimming pool design and operation, the average number of yearly divingrelated injuries has fallen by nearly 600 injuries/year. There was a significant reduction in diving-related injury corresponding with the COVID-19 pandemic.

COVID-19 PROTECTIVE BEHAVIORS AND CONSCIENTIOUSNESS IN OLDER ADULTS

Conscientiousness has been defined as a relatively stable personality trait that influences one's tendency to follow norms and rules, to be goal-directed and planful, and to engage in impulse control. Higher conscientiousness has been associated with decreased engagement in health-degrading behaviors (e.g., physical inactivity, unhealthy eating, smoking). Conscientiousness is correlated with use of protective health behaviors that could impact others (e.g., social distancing, quarantining) during the COVID-19 pandemic for adolescent and working adult age ranges and certain occupational fields (e.g. nursing) within the American and global population. However, these studies were generally cross-sectional, which does not allow for investigation of maintenance of these protective health behaviors, and generally not performed with high-risk populations, such as older adults. The present study will examine the longitudinal relationship between conscientiousness and protective health behaviors among older adults during the COVID-19 pandemic (N = 98). Participants completed measures of personality (NEO-FFI) before the pandemic and pandemic-specific protective health behaviors (Pandemic Stress Index) in March - May of 2020 and March - May of 2021.We hypothesize that higher conscientiousness will be associated with more protective health behaviors. We also hypothesize that higher conscientiousness will be associated with continued engagement in protective health behaviors and more adherence to CDC guidelines for COVID-19. Models will regress (1) baseline behavior on conscientiousness and (2) later behavior on baseline behavior and conscientiousness, testing whether behavior is maintained over time. Exploratory analyses will test interactions between conscientiousness and demographics (age, gender, and education). Examining the impact of conscientiousness among older adults in the context of a novel global pandemic may help to predict reactions to large-scale public health situations.

Sleep quality in children with primary ciliary dyskinesia (PCD)

Introduction: PCD is a rare, progressive disease resulting in upper and lower respiratory tract manifestations that increase the risk of sleep disordered breathing. This study is the first to characterize sleep quality in Australian children with PCD and examine it is relationship to mood and health-related quality of life (HrQOL). Methods: Clinically stable children with PCD (1-18 years of age) were recruited. Subjective sleep quality was assessed with the SDSC, PDSS and OSA-18 questionnaires. HrQOL and depressive symptoms were assessed via age-appropriate QOL-PCD and CDI questionnaires. Demographic data including passive smoke exposure was recorded. Pulmonary function testing and ENT assessments were performed. Children underwent overnight polysomnography including transcutaneous CO2 and video monitoring (50% studies complete due to Covid restrictions). Results: Twenty-two participants (10 female) aged 8.1 ± 5.1 (mean ± SD) years were recruited. Mean(±SD) FEV1 was 78.2 ± 21.2%. Ninety-two percent of children assessed were diagnosed with chronic rhinosinusitis and 35% exposed to regular passive cigarette smoke. Polysomnography identified sleep fragmentation in 90% of studies and one case of mild obstructive sleep apnoea. Subjective sleep questionnaires revealed 76% of parents and 50% of children reported clinically significant scores indicating sleep disturbance and excessive daytime somnolence respectively. Twenty-seven percent of parents reported a moderate-severe impact of sleep disturbance on QOL. Forty-six percent of children had elevated depression scores. HrQOL and mood scores were correlated with poor subjective sleep quality. Children exposed to passive cigarette smoke had poorer subjective sleep quality and lower HrQOL and mood. Conclusion: Even in periods of clinical stability, children with PCD exhibit poor sleep quality and excessive daytime sleepiness and this is associated with lower mood and HrQOL. Based on these findings, we recommend routine screening for mental health and symptoms of sleep disturbance in children and adolescents with PCD. The continued education of children and families regarding the effects of cigarette smoke is advised.

Sustained Control and Prevention of COVID-19 Outbreaks in Detroit Skilled Nursing Facilities

Background. Nursing home residents, a vulnerable population, experienced an extraordinary surge of COVID-19 cases and deaths at the beginning of the pandemic. Multidisciplinary collaboration from the Detroit Health Department (DHD), academic centers, along with interim guidance from the CDC provided a structured approach to control SARS-CoV-2 in Detroit skilled nursing facilities (SNF). We aim to describe this model. Methods. There were 26 SNF prioritized by the DHD over a 13-month period from 3/2020 - 4/2021. Testing for SARS-CoV-2 occurred biweekly, on average, at each facility for staff and residents. Any staff or resident cases were investigated by a specialized investigations team to determine outbreak status. Any resident that was identified as positive for SARS-CoV-2 was moved to a designated in-house quarantine unit or specific COVID-19 designated nursing homes within the City of Detroit, and cohorting guidance was provided. Facilities were evaluated for environmental controls, PPE provided as needed and infection prevention guidance was provided. COVID-19 vaccination was conducted by pharmaceutical chains or the DHD and vaccine education sessions were conducted for nursing home staff and residents. Results. On average, SNF facilities served a total of 2,262 residents (2031-2367 range) and employed a total of 2,965 staff (1034-3124 range) during the period from 7/2020 - 4/2021. SARS-CoV-2 cases overall for Michigan and Detroit are shown in Figure 1. In SNF facilities, cases ranged from zero to 279 cases in residents and zero to 115 cases per week in staff (Figure 1). Beginning 3/2020, the majority of cases were residents, whereas after 10/2020, staff cases exceeded resident cases. Immunization rates were 63% (partial) and 58% (complete) for residents, and 26% and 23% for staff, respectively. Measures to reduce vaccine hesitancy included organized education sessions, messaging from trusted leaders and organized mass vaccination schedules. Conclusion. We describe the effectiveness of multidisciplinary interventions to control dissemination, morbidity and mortality of SARS-CoV-2 amongst SNF residents in Detroit. We emphasize the continued need to address vaccine hesitancy and importance of this model as successful interventions to decrease infection rates.

Up to 6 years follow-up of people with MS (n=250) receiving cladribine

Introduction: Oral cladribine is a licensed disease-modifying treatment (DMT) for highly active relapsing multiple sclerosis (RMS). We report clinical and paraclinical data collected as part of ongoing follow-up of our cohort of people with MS (pwMS) treated with subcutaneous (s.c.) cladribine personalised dosing (CPD). Objectives and Aims: To report follow-up data in pwMS treated using CPD (adjusted for weight and total lymphocyte count, TLC). Methods: CPD was offered to pwMS with signs of disease activity irrespective of their disease course. Cladribine 10 mg s.c. was given on three consecutive days (four in pwMS & gt;90kg) during week 1. Based on TLC at week 4, patients were given another 0-3 doses at week 5. A second cycle of CPD was administered 11 months later. Follow-up included recording of adverse events, relapses, annual EDSS, 9-hole peg, timed 25-foot walking, and symbol digit modalities tests. MRI (gadolinium enhancing T1 and T2 lesions), cerebrospinal fluid (CSF) neurofilament light chain (NfL) measurements and full blood counts were obtained. Results: 250 pwMS (113 RMS, 137 PMS) received CPD. 211/250 completed a second cycle. Baseline age 45 (17-72) years and baseline EDSS 0-8.5. The safety and tolerability profile of CPD was generally very good. Six severely disabled pwMS died (one each from influenza, encephalitis, hypoxic brain injury due to choking, COVID19 pneumonia, haemopericardium and dissecting aortic aneurysm and unknown [prior EDSS 9.5]). One myocardial infarction, two breast cancers, one pulmonary embolism occurred, and three severe allergic skin reactions without long term sequelae. Severe lymphopenia (WHO grade 3-4) occurred in 7% despite personalised dosing. In 74/155 pwMS (47.7% of those with EDSS data available), EDSS remained stable or improved at follow up (median 2.9 years). In n=37, mean pre- and post-treatment CSF-NfL measurements at -4.4 and 11.3 months, respectively, were 1079pg/ml (CI 557, 1601) and 508pg/ml (CI 330, 686). Conclusions: Our ongoing observations of this uncontrolled real world cohort suggests CPD is a safe, well tolerated treatment for pwMS with disease activity. Efficacy of cladribine in preserving upper limb function in advanced MS (EDSS 6.5-8.5) will be tested in the ChariotMS trial.

Effect of Bamlanivimab vs Placebo on Incidence of COVID-19 Among Residents and Staff of Skilled Nursing and Assisted Living Facilities A Randomized Clinical Trial

Importance Preventive interventions are needed to protect residents and staff of skilled nursing and assisted living facilities from COVID-19 during outbreaks in their facilities. Bamlanivimab, a neutralizing monoclonal antibody against SARS-CoV-2, may confer rapid protection from SARS-CoV-2 infection and COVID-19. Objective To determine the effect of bamlanivimab on the incidence of COVID-19 among residents and staff of skilled nursing and assisted living facilities. Design, Setting, and Participants Randomized, double-blind, single-dose, phase 3 trial that enrolled residents and staff of 74 skilled nursing and assisted living facilities in the United States with at least 1 confirmed SARS-CoV-2 index case. A total of 1175 participants enrolled in the study from August 2 to November 20, 2020. Database lock was triggered on January 13, 2021, when all participants reached study day 57. Interventions Participants were randomized to receive a single intravenous infusion of bamlanivimab, 4200 mg (n = 588), or placebo (n = 587). Main Outcomes and Measures The primary outcome was incidence of COVID-19, defined as the detection of SARS-CoV-2 by reverse transcriptase-polymerase chain reaction and mild or worse disease severity within 21 days of detection, within 8 weeks of randomization. Key secondary outcomes included incidence of moderate or worse COVID-19 severity and incidence of SARS-CoV-2 infection. Results The prevention population comprised a total of 966 participants (666 staff and 300 residents) who were negative at baseline for SARS-CoV-2 infection and serology (mean age, 53.0 [range, 18-104] years;722 [74.7%] women). Bamlanivimab significantly reduced the incidence of COVID-19 in the prevention population compared with placebo (8.5% vs 15.2%;odds ratio, 0.43 [95% CI, 0.28-0.68];P < .001;absolute risk difference, -6.6 [95% CI, -10.7 to -2.6] percentage points). Five deaths attributed to COVID-19 were reported by day 57;all occurred in the placebo group. Among 1175 participants who received study product (safety population), the rate of participants with adverse events was 20.1% in the bamlanivimab group and 18.9% in the placebo group. The most common adverse events were urinary tract infection (reported by 12 participants [2%] who received bamlanivimab and 14 [2.4%] who received placebo) and hypertension (reported by 7 participants [1.2%] who received bamlanivimab and 10 [1.7%] who received placebo). Conclusions and Relevance Among residents and staff in skilled nursing and assisted living facilities, treatment during August-November 2020 with bamlanivimab monotherapy reduced the incidence of COVID-19 infection. Further research is needed to assess preventive efficacy with current patterns of viral strains with combination monoclonal antibody therapy. This randomized clinical trial assesses the effect of a single intravenous infusion of bamlanivimab vs placebo on incidence of COVID-19 among residents and staff of skilled nursing and assisted living facilities. Question Among residents and staff of skilled nursing and assisted living facilities with high risk of SARS-CoV-2 exposure, what is the effect of bamlanivimab on the incidence of COVID-19? Findings This randomized phase 3 clinical trial included 966 participants who were residents and staff at US skilled nursing and assisted living facilities with at least 1 confirmed SARS-CoV-2 index case and who were negative at baseline for SARS-CoV-2 infection and serology, enrolled from August to November 2020. The incidence of COVID-19 infection among those treated with bamlanivimab vs placebo was 8.5% vs 15.2%, respectively, a difference that was statistically significant. Meaning Bamlanivimab monotherapy compared with placebo reduced the risk of COVID-19 in residents and staff of skilled nursing and assisted living facilities.

Distrust in Institutions: Reference and Library Instruction during an Infodemic

Librarians strive to educate patrons and curb the spread of disinformation by providing reference services, research consultations, and instruction in information literacy. The Covid-19 pandemic has brought into stark relief deceptive information practices used to further political agendas. We focus on the dissemination of Covid-19 disinformation by the United States government, particularly the Trump White House where the federal pandemic response was centered. The consequences of Covid-19 disinformation produced at the federal level continue, such as Covid-19 denial, distrust in government institutions, distrust in science, and over 570,000 deaths in the U.S. so far. We identify different kinds of deceptive information practices deployed by the executive branch that contributed to an already fraught information ecosystem. We discuss how this affects academic librarians, students, and researchers who work with government information, as well as potential solutions found in information literacy and scholarly communication. © 2021 Owner/Author.

Variant selection, characterization, and impact on antibody SARS-CoV-2 neutralization

Background: Monitoring genomic variation of SARS-CoV-2 is crucial in mitigating adaptation to the human host and developing effective treatments that safeguard global health. Bamlanivimab and etesevimab are monoclonal antibodies (mAbs) that have demonstrated potent SARS-CoV-2 neutralizing activity in both pre-clinical and clinical settings and have distinct but overlapping binding sites. Here, the selection and characterization of variants in a pre-clinical setting is presented alongside the impact of emerging variants on antibody binding affinity and viral neutralization potency. Methods: Variant selection was carried out via directed evolution of the receptor binding domain (RBD) and serial passage of authentic SARS-CoV-2 in the presence of bamlanivimab and etesevimab individually or in combination. Sequence confirmed, putative-resistance variants identified in both selection methodologies were incorporated into different assessment platforms (VSV-based SARS-CoV-2 pseudovirus neutralization, a yeast RBD display hACE2 competition, and binding affinity to mAb and hACE2) to evaluate potency loss of the selecting mAb and test activity against the mAb combination. Results: Serial passage of SARS-CoV-2 and directed evolution of the RBD protein were unable to select for resistant viral variants under the pressure of mAb combination therapy. In the same experimental paradigm, variants were identified when each mAb was evaluated alone (E484D/K/Q, F490S, Q493R, and S494P for bamlanivimab and K417N, D420N and N460K/S/T/Y for etesevimab). Neutralization and binding assessments confirmed reduced susceptibility of the variants to the single selecting mAb with 50-fold or greater reductions in potency. Importantly, aside from the Q493R variant, all other resistant viruses were neutralized by the mAb combination therapy. Conclusion: In vitro selection studies using single mAbs, bamlanivimab or etesevimab, identified key positions within the SARS-CoV-2 S-protein that have potential for viral resistance in the clinic, whereas similar studies with the mAb combination therapy were unable to select variants. Binding and competition assays confirmed the neutralization phenotyping data and indicates the mechanism of resistance is due to a reduction in binding affinity. The preclinical selection and functional characterization of resistant viral variants directly supports the observation that mAb combination therapy results in a lower frequency of treatment-emergent resistance in clinical treatment studies.