SARS-CoV2 infection after vaccination in patients requiring extracorporeal life support: An analysis from the EuroECMO-COVID study group

Objectives: At the beginning of the pandemic, it was believed that severe SARS-CoV2 infection would induce lifelong immunity and that reinfections would be unlikely. However, several cases of reinfection were documented in previously infected patient and the waning humoral immunity has raised significant concerns. Accordingly, long-term and durable vaccineinduce antibody protection against infection have also become a challenge, as several breakthroughs of COVID-19 have been identified in individuals partially or fully vaccinated. This study describes the incidence, the characteristics of severe COVID-19 infections requiring ECMO occurred after vaccination and the presence of side effects related to the vaccine. Method(s): EuroECMO COVID is a prospective, multicenter, observational study, developed by the EuroELSO, based on data from patients aged >=16 years who received ECMO support for refractory COVID-19 during the pandemic in 204 centers. The analysis investigates the survival of vaccinated patient, the associations between management-related variables, the incidence of vaccination during the different pandemic phases, the type of vaccines and the possible side effects. Result(s): Immunosuppressed patients are susceptible to reinfection even after being naturally infected or receiving a full vaccination. Ineffective antibody production, due to relatively ineffective vaccines, inadequate number of doses or the time after vaccination are involved in the pathogenesis of postvaccination infections. This population was found to have a partial immunity due to an inadequate number of doses and an overlapped time from vaccination and SARS-CoV2 incubation with PCR results after being vaccinated. Several manifestations of SARS-CoV2 infection are similar to vaccine-induce side effects and mild symptoms can be presented both as an adverse reaction after vaccination and a result of infection. In this subgroup no side effects were attributable to the vaccine. Conclusion(s): Vaccination does not entirely prevent SARS-CoV2 but will lead to less morbidity and mortality, as demonstrated by less need of ICU and ECMO care. In addition, the partial immunity for inadequate doses of vaccine or through the evolution of new variants demonstrated the importance of further analysis to differentiate the possible causes of waning humoral immunity.

Feasibility and acceptability of virtual career development workshop for pediatric endocrine trainees: A PedsENDO365 initiative

Objectives The identification of goals and development of skills that align with an individual's values provides a professional pathway for success and aids in preventing burnout. This process has been threatened by the COVID 19 pandemic, thus, we created a virtual professional development program for pediatric endocrine fellows training in the United States. Methods PedsENDO 365 is a Pediatric Endocrine Society initiative launched to address year-round learning needs of pediatric endocrine fellows. The workgroup engaged with fellowship program directors across the US as key stakeholders. Lack of resources and expertise, partly due to small program size, were noted as major barriers. Fellow participants completed a pre-workshop inventory to elucidate their personal values, skills and career interests, and to create short and long term learning and career goals. A two-hour session included a presentation about career trajectories, description of individual learning planning process and I-SMART (Important - Specific, Measurable, Actionable, Realistic, Time-limited) goal setting. Learners participated in small group discussions facilitated by program directors about the assessment and alignment of skills, interests, and values when developing goals. Results 39 fellows (1st to 4th year) participated in the workshop. 24 attendees (83% women, 13% men and 4% non-binary, 1st year=17%, 2nd year=54%, 3rd year=25%, 4th year=4%) completed an evaluation of the program. 96% fellows found the session relevant and would recommend it to other fellows. The three major takeaways were the importance of aligning values and skills with career goals, setting I-SMART goals, and the importance of time management and work-life balance. The fellows enjoyed the flexibility afforded by the remote session for connecting with participants and leaders across the country. Conclusions A virtual professional development for pediatric endocrine trainees is feasible and well received by participants. Professional societies can provide virtual career development programs to allow networking opportunities with individuals outside their institutions.

Charting the ‘new normal’ in Canadian community pharmacy practice: scoping review

IntroductionTo identify the Canada-wide changes in community pharmacy practice in response to the COVID-19 pandemic and to assess what is currently being practiced.What are the emerging practices and regulations that keep community pharmacies safe (customers and professionals) during the COVID-19 pandemic and what are the implications of these changes?MethodsReview includes primary studies (i.e., experimental, quasi-experimental, observational, and qualitative study designs) and grey literature that broadly focused on policies, regulations, and recommendations developed for Canadian community pharmacies during the COVID-19 pandemic. Study s and full texts were screened for eligibility by two reviewers, independently. Data extraction of relevant studies were also done independently by two reviewers. All discrepancies were addressed through further discussion or adjudicated by a third reviewer. Presentation of the extracted data focuses on descriptive frequencies and thematic analysis and the results are presented in diagrammatic or tabular form, with a narrative summary of the findings.ResultsTeam members screened fifty-five citations and considered five to meet the inclusion criteria, with an additional 449 grey literature items. Pharmacists rely on regulatory and professional associations as their primary information source, yet corporate employers were found to offer better resources for communicating policies to pharmacists.1 In the pan-Canadian context, Health Canada granted pharmacists new permissions for prescribing, including extending and renewing prescriptions2 3 while simultaneously recommending that pharmacists should limit patient medication supplies.2 4 Although COVID-19 updates were regularly being sent by regulatory bodies and national associations, pharmacists were either unaware of where to find or did not understand available information.1 2 4 5DiscussionAs Canada emerges from the COVID-19 pandemic, there is a ‘new normal’ for community pharmacy practice, or an expanded role in the overall healthcare system. This review adds to the understanding of how pharmacies faced challenges of incorporating rapidly evolving information into practice, while maintaining client care and worker safety.ReferencesAustin Z, Gregory P. Resilience in the time of pandemic: the experience of community pharmacists during COVID-19. Research in Social and Administrative Pharmacy 2021;17(1):1867–75.Elbeddini A, Hooda N, Yang L. Role of Canadian pharmacists in managing drug shortage concerns amid the COVID-19 pandemic. Canadian Pharmacists Journal/Revue des Pharmaciens du Canada 2020;153(4):198–203.Merks P, Jakubowska M, Drelich E, Świeczkowski D, Bogusz J, Bilmin K, et al. The legal extension of the role of pharmacists in light of the COVID-19 global pandemic. Research in Social and Administrative Pharmacy 2021;17(1):1807–12.Elbeddini A, Botross A, Gerochi R, Gazarin M, Elshahawi A. Pharmacy response to COVID-19: lessons learnt from Canada. Journal of Pharmaceutical Policy and Practice 2020;13(1):1–8.Gregory PAM, Austin Z. COVID-19: how did community pharmacies get through the first wave? Canadian Pharmacists Journal/Revue des Pharmaciens du Canada 2020;153(5):243–51.

CHARACTERISTICS ASSOCIATED with POOR COVID-19 OUTCOMES in PEOPLE with PSORIASIS and SPONDYLOARTHRITIS: DATA from the COVID-19 PSOPROTECT and GLOBAL RHEUMATOLOGY ALLIANCE PHYSICIAN-REPORTED REGISTRIES

Background: Some factors associated with severe COVID-19 outcomes have been identifed in patients with psoriasis (PsO) and infammatory/autoimmune rheumatic diseases, namely older age, male sex, comorbidity burden, higher disease activity, and certain medications such as rituximab. However, information about specifcities of patients with PsO, psoriatic arthritis (PsA) and axial spondyloarthritis (axSpA), including disease modifying anti-rheumatic drugs (DMARDs) specifcally licensed for these conditions, such as IL-17 inhibitors (IL-17i), IL-23/IL-12 + 23 inhibitors (IL-23/IL-12 + 23i), and apremilast, is lacking. Objectives: To determine characteristics associated with severe COVID-19 outcomes in people with PsO, PsA and axSpA. Methods: This study was a pooled analysis of data from two physician-reported registries: the Psoriasis Patient Registry for Outcomes, Therapy and Epidemiology of COVID-19 Infection (PsoProtect), comprising patients with PsO/PsA, and the COVID-19 Global Rheumatology Alliance (GRA) registry, comprising patients with PsA/axSpA. Data from the beginning of the pandemic up to 25 October, 2021 were included. An ordinal severity outcome was defned as: 1) not hospitalised, 2) hospitalised without death, and 3) death. A multivariable ordinal logistic regression model was constructed to assess the relationship between COVID-19 severity and demographic characteristics (age, sex, time period of infection), comorbidities (hypertension, other cardiovascular disease [CVD], chronic obstructive lung disease [COPD], asthma, other chronic lung disease, chronic kidney disease, cancer, smoking, obesity, diabetes mellitus [DM]), rheumatic/skin disease (PsO, PsA, axSpA), physician-reported disease activity, and medication exposure (methotrexate, lefunomide, sulfasalazine, TNFi, IL17i, IL-23/IL-12 + 23i, Janus kinase inhibitors (JAKi), apremilast, glucocorticoids [GC] and NSAIDs). Age-adjustment was performed employing four-knot restricted cubic splines. Country-adjustment was performed using random effects. Results: A total of 5008 individuals with PsO (n=921), PsA (n=2263) and axSpA (n=1824) were included. Mean age was 50 years (SD 13.5) and 51.8% were male. Hospitalisation (without death) was observed in 14.6% of cases and 1.8% died. In the multivariable model, the following variables were associated with severe COVID-19 outcomes: older age (Figure 1), male sex (OR 1.53, 95%CI 1.29-1.82), CVD (hypertension alone: 1.26, 1.02-1.56;other CVD alone: 1.89, 1.22-2.94;vs no hypertension and no other CVD), COPD or asthma (1.75, 1.32-2.32), other lung disease (2.56, 1.66-3.97), chronic kidney disease (2.32, 1.50-3.59), obesity and DM (obesity alone: 1.36, 1.07-1.71;DM alone: 1.85, 1.39-2.47;obesity and DM: 1.89, 1.34-2.67;vs no obesity and no DM), higher disease activity and GC intake (remission/low disease activity and GC intake: 1.96, 1.36-2.82;moderate/severe disease activity and no GC intake: 1.35, 1.05-1.72;moderate/severe disease activity and GC intake 2.30, 1.41-3.74;vs remission/low disease activity and no GC intake). Conversely, the following variables were associated with less severe COVID-19 outcomes: time period after 15 June 2020 (16 June 2020-31 December 2020: 0.42, 0.34-0.51;1 January 2021 onwards: 0.52, 0.41-0.67;vs time period until 15 June 2020), a diagnosis of PsO (without arthritis) (0.49, 0.37-0.65;vs PsA), and exposure to TNFi (0.58, 0.45-0.75;vs no DMARDs), IL17i (0.63, 0.45-0.88;vs no DMARDs), IL-23/IL-12 + 23i (0.68, 0.46-0.997;vs no DMARDs) and NSAIDs (0.77, 0.60-0.98;vs no NSAIDs). Conclusion: More severe COVID-19 outcomes in PsO, PsA and axSpA are largely driven by demographic factors (age, sex), comorbidities, and active disease. None of the DMARDs typically used in PsO, PsA and axSpA, were associated with severe COVID-19 outcomes, including IL-17i, IL-23/IL-12 + 23i, JAKi and apremilast.

Use of Patients Know Best as a tool to improve patient engagement and deliver a digital dietetics service to kidney patients

Patient initiated follow up is being supported by NHS England and NHS Improvement1 to offer flexibility with follow up care and promote self-management and enable shared decision making. As a means of undertaking this, citizen held health records via web passed portals have become a new feature within clinical services, especially during the Covid-19 pandemic. It has been discussed elsewhere2 what benefits may be gained from using digital web based portals to improve patient engagement and self-management by patients with kidney disease. As a team of kidney dietitians, the citizen health held record known as Patients Know Best (PKB) was adopted as the portal of choice for use with patients as a means of patient initiated follow up and service improvement. A six month pilot phase was undertaken between September 2020 - March 2021 in which willing and interested patients had the opportunity to register on to the Kidney Dietitians’ PKB page. Upon registering the patients were able to use a two way message function which means direct access to their kidney dietitian, a full library of information ranging from YouTube tutorials, departmental information leaflets, links to charity websites, free cook books available on the internet and links to other platforms such as Humber Health Apps and Patient View. Dietitians had the ability to electronically undertake nutritional screening, bowel assessment questionnaires using PKB and could also send 24hr food recalls and 5 day food diaries (known as consultations) for completion ahead of booked appointments via telephone or video. PKB is also being used as a teaching aide during face to face and remote consultations to promote patient empowerment and self-care3. Data from the pilot phase showed that 49 patients had registered with the platform. In terms of instant messaging, 43% of messages had been instigated by the patient. Approximately 90% of messages received by the dietitians were read and responded to with 24 hours. Data also revealed that 100% of consultations initiated by the dietitian had also been completed within 24 hours enabling timely intervention. Due to the success of the pilot phase, a mail shot has now been sent to all dialysis patients (circa 400) offering them the opportunity to register with the Kidney Dietitians PKB site and a further consultation has been designed and added to PKB for audit data collection purposes. References 1. ‘Patient initiated follow up: Giving patients greater control over their hospital follow up care’ Last accessed fromhttps://www.england.nhs.uk/outpatient-transformation-programme/patient-initiated-follow-up-giving-patients-greater-control-over-their-hospital-follow-up-care/ 02.07.2021 2. The role of patient portals in enhancing self-care in patients with renal conditions (2020) Hazara, A. M., Durrans, K., Bhandari, S. Clinical Kidney Journal;Vol 13;1-7. 3. ‘The ‘future is bright’ for patients of the kidney dietetics service’ Patients Know Best last accessed from on 02.07.2021

Catastrophe, Care, and All That Remains

During 2020, a menacing sense of doom and anxiety proliferated by the Trump administration's shock-and-awe tactics compounded the brutally uneven distribution of exposure, social atomization, precarity, abandonment, and premature death under the COVID-19 pandemic. The pandemic has had especially lethal consequences for those who are impoverished, racially abjected, and deemed violable or disposable within economies of dispossession. For Indigenous peoples under US occupation, the mainstream news coverage of the pandemic's death toll in the Navajo Nation, Standing Rock, and other Indigenous nations came and went with little sustained inquiry into the conditions of colonization, critical for understanding the current moment. The obstinate negligence of the CARES Act toward peoples and communities most impacted by the pandemic is only one example of this intensified necropolitics. We focus here on conceptions and mobilizations of care and uncaring, and the catastrophe of the settler-capitalist state this time. With all the talk about the need for self-care and community care in this period of concentrated epic crises, we ask: How does the discourse of care operate within an imperial social formation? Is an otherwise possible? What are our obligations in kinship and reciprocity? And how do we attend to these obligations in times of imposed distance?. © 2021 Duke University Press. All Rights Reserved.

The impact of methotrexate and targeted immunosuppression on cellular and humoral immune responses to COVID-19 vaccine BNT162b2: a cohort study

Individuals on immunosuppression were excluded from COVID-19 vaccine trials. We evaluated immune responses to COVID-19 vaccine BNT162b2 (Pfizer-BioNTech) in people taking methotrexate and biologics. Given the roll out of extended interval vaccination programmes to maximise population coverage, we present findings following the first dose. We recruited individuals with psoriasis (n=84) established on methotrexate or biologic monotherapy (TNF, IL-17 or IL-23 inhibitors) and healthy controls (n=17). Immunogenicity was evaluated pre and post (day 28) vaccine. Seroconversion rates were lower in patients taking immunosuppression (78%, 95%CI 67-87%) compared to controls (100%, 95%CI 79-100%), with the lowest rate in those on methotrexate (50%, 95%CI 26-74%). Neutralising activity to wild-type SARS-CoV-2 was lower in patients receiving methotrexate (median ID50 152, IQR 47-257) compared to controls (median ID50 316, IQR 212-481, p<0.01), but preserved in those receiving biologics (median ID50 280, IQR 137-428). Neutralising titres against B.1.1.7 were comparably low in all participants. Spike-specific T cell responses (including IFNγ, IL-2, IL-21) were induced in all groups, and were equivalent among individuals receiving methotrexate, biologics and controls. Functional humoral immunity to a single dose of BNT162b2 is impaired by methotrexate but not by biologics, while cellular responses are unaffected. Seroconversion alone may not adequately reflect vaccine immunogenicity in individuals with immune-mediated disease receiving immunosuppression. Real-world pharmacovigilance studies will determine whether these findings translate to clinical effectiveness.

Incidence of candidaemia in prolonged venovenous extracorporeal membrane oxygenation.

This single-centre retrospective study reports the dynamics of the incidence of candida bloodstream infection (CBSI) in 145 patients receiving venovenous extracorporeal membrane oxygenation (ECMO) for respiratory support between January 2014 and December 2018. The incidence rate and odds ratio (OR) of CBSI were calculated, stratified by week of ECMO exposure. Weekly incidence increased throughout the ECMO run, with an increasing trend in OR (P=0.005), and a window of continued risk after decannulation was observed. Of the 13 patients who developed CBSI, five (38%) received empirical micafungin treatment before positive culture due to clinical suspicion. There is a need for prospective studies aiming to improve ECMO diagnostic stewardship practices and discourage unnecessary antifungal prophylaxis or empiric management.

Factors associated with hospitalization due to COVID-19 in patients with psoriasis: Insights from a global registry

Psoriasis is a common immune-mediated inflammatory skin disease with frequent multimorbidity, and immunosuppressants are the mainstay of treatment in moderate-to-severe disease. An understanding of the impact of COVID-19 on individuals with psoriasis and the effect of psoriasis therapies on the course of COVID-19 is urgently required to inform clinical decision-making. This study sought to characterize the clinical course of COVID-19 in patients with psoriasis and to identify factors associated with hospitalization. Clinicianreported cases of confirmed or suspected COVID-19 in psoriasis were collected via an international online registry. Multivariable-adjusted logistic regression identified factors associated with hospitalization. Patient risk-mitigating behaviours were characterized using an independent global selfreport registry. In total, 334 clinician-reported cases (median age 50 years, 62% male, median body mass index 28 kg m-2, 85% white) from 22 countries [most frequently, the U.K. (35%), Italy (22%) and Spain (16%)] were available between 27 March and 20 June 2020. Altogether, 245 (73.3%) patients were receiving a biologic, 54 (16.2%) a nonbiologic and 31 (9.3%) no systemic treatment. Overall, 311 (93.1%) achieved a full recovery, 71 (21.2%) were hospitalized and nine (2.7%) died. Risk factors associated with hospitalization were older age [adjusted odds ratio (aOR) 1.71, 95% confidence interval (CI) 1.26-2.32], male sex (aOR 2.37, 95% CI 1.11-5.04) and nonwhite ethnicity (aOR 3.40, 95% CI 1.27-9.11), in addition to chronic lung disease (aOR 4.37, 95% CI 1.62-11.74) and hypertension (aOR 2.23, 95% CI 1.05-4.74). Reduced risk of hospitalization was associated with use of a biologic (aOR 0.42, 95% CI 0.18-0.98) vs. nonbiological systemic therapy. There was no difference in risk of hospitalization between classes of biologics. An independent selfreport psoriasis registry (1167 patients from 39 countries) suggested increased social isolation (76% vs. 66%;P < 0.05) but similar nonadherence to medication (18% vs 22%) in patients receiving biologics vs. nonbiological systemic treatments. In this international moderate-to-severe psoriasis case series, most patients fully recovered from COVID-19;older age, being male and being of nonwhite ethnicity increased risk of hospitalization. Use of biologics, when compared with nonbiological systemic therapies, was associated with reduced risk of hospitalization;however, this requires further study owing to potential selection bias and unmeasured confounding such as a difference in risk-mitigating behaviours.

Risk-mitigating behaviours in people with inflammatory skin and joint disease during the COVID-19 pandemic differ by treatment type: a cross-sectional patient survey.

BACKGROUND: Registry data suggest that people with immune-mediated inflammatory diseases (IMIDs) receiving targeted systemic therapies have fewer adverse coronavirus disease 2019 (COVID-19) outcomes compared with patients receiving no systemic treatments. OBJECTIVES: We used international patient survey data to explore the hypothesis that greater risk-mitigating behaviour in those receiving targeted therapies may account, at least in part, for this observation. METHODS: Online surveys were completed by individuals with psoriasis (globally) or rheumatic and musculoskeletal diseases (RMDs) (UK only) between 4 May and 7 September 2020. We used multiple logistic regression to assess the association between treatment type and risk-mitigating behaviour, adjusting for clinical and demographic characteristics. We characterized international variation in a mixed-effects model. RESULTS: Of 3720 participants (2869 psoriasis, 851 RMDs) from 74 countries, 2262 (60·8%) reported the most stringent risk-mitigating behaviour (classified here under the umbrella term 'shielding'). A greater proportion of those receiving targeted therapies (biologics and Janus Kinase inhibitors) reported shielding compared with those receiving no systemic therapy [adjusted odds ratio (OR) 1·63, 95% confidence interval (CI) 1·35-1·97]. The association between targeted therapy and shielding was preserved when standard systemic therapy was used as the reference group (OR 1·39, 95% CI 1·23-1·56). Shielding was associated with established risk factors for severe COVID-19 [male sex (OR 1·14, 95% CI 1·05-1·24), obesity (OR 1·37, 95% CI 1·23-1·54), comorbidity burden (OR 1·43, 95% CI 1·15-1·78)], a primary indication of RMDs (OR 1·37, 95% CI 1·27-1·48) and a positive anxiety or depression screen (OR 1·57, 95% CI 1·36-1·80). Modest differences in the proportion shielding were observed across nations. CONCLUSIONS: Greater risk-mitigating behaviour among people with IMIDs receiving targeted therapies may contribute to the reported lower risk of adverse COVID-19 outcomes. The behaviour variation across treatment groups, IMIDs and nations reinforces the need for clear evidence-based patient communication on risk-mitigation strategies and may help inform updated public health guidelines as the pandemic continues.