On-going impact of the SARS-CoV-2 pandemic on the evolution of carbapenemase-producing Enterobacterales in Ontario, Canada

Background. The spread of carbapenemase-producing Enterobacterales (CPE) is global threat. Numerous outbreaks of CPE have been reported during the COVID-19 pandemic. We describe the impact of of the SARS-CoV-2 pandemic on the emergence of CPE in south-central Ontario, Canada. Incidence of clinical isolates of CPE and isolates with different CPE genes in Toronto/Peel region, 2017-2021. The upper panel shows the incidence of patients with clinical isolates of CPE by year and quarter from q4 2007 to q1 2022. The lower panel shows the incidence of patients with clinical isolates with different carbapenemase genes by fiscal year during the same period. Methods. TIBDN has performed population-based surveillance for CPE in Toronto/Peel region (pop 4.5M) from first identified isolate in 2007. All laboratories test/refer all carbapenem non-susceptible Enterobacterial isolates for identification of CPE. Hospital charts are reviewed and patients/physicians interviewed. Population data are obtained from Statistics Canada. Results. From 10/2007 to 3/31/2022, 1367 persons colonized or infected with CPE were identified. Theirmedian age was 68.7yrs (IQR 54-78yrs);761 (56%) weremale. 772 (56%) were colonized when first identified;115 (8.4%) were bacteremic at identification or subsequently developed bacteremia. The most common organisms were E. coli (651, 48%), K. pneumoniae (436, 32%), Enterobacter spp. (146, 11%), Citrobacter spp (62, 5%);the most common genes were NDM+/-OXA-48 (722, 53%), OXA-48-like (341, 25%), KPC (225, 16%), VIM(44, 3%). The incidence of CPE infections increased steadily until 3/2020 then declined by 61%and remained stable until 3/2022 (Figure, upper panel). The declinewas greater for E. coli (56%decrease), K. pneumoniae (62%) than for Enterobacter spp. (30%) and other species (19%). It occurred in all genes in 2020;however, KPC containing organisms increased again in 2021 (Figure, lower panel). Conclusion. The advent of the COVID-19 pandemic was associated with an immediate, substantial decline in the incidence of patients with CPE in our population area. This decline occurred in both isolates with genes usually occurring in cases imported from other countries, and in those usually occurring in cases associated with transmission within Canadian hospitals. Decreased travel and enhanced infection prevention and control in hospitals may both have contributed to reductions in CPE during the pandemic. (Figure Presented).

A review of patients’ thoughts, feelings and priorities as evidenced in their responses to the paediatric cystic fibrosis annual review questionnaires

Objective: To gain an insight into the thoughts, feelings and priorities of our paediatric CF patient cohort via a patient questionnaire completed at annual review. Method: A retrospective review of paediatric CF patients’ responses to an annual review questionnaire from July 2017 to December 2021. Our children are encouraged to enter free text responses to the following questions below at their annual review. - Things that make me happy - Things I don’t like - Important things -Worries - Future plans The data was analysed and organised into broad themes identified as: • Friend and Family (socialising) • Activities (electronics, sports/exercise, holidays, hobbies) • Education (homework, exams, grades) • MY CF (needles/blood test, medicine, health, death) • Other (food, pets, sleep, bad dreams, bullying, coronavirus) Results: We received 31 responses from primary school children and 18 from secondary school. Conclusion: Friends and family are important and have a positive impact on our patients. They seem to enjoy various indoor and outdoor activities, with only a small percentage not enjoying exercise;20% plan to improve this aspect of their care. A high percentage of secondary school children indicated they do not like school/homework and worry about exams/low grades. None of our patients were happy about their CF but felt it was important. Only 3 responses in total feared death from CF. “Noise” and “bad dreams” were the main other issues identified that younger patients did not like, and it was surprising that during the pandemic, only 3 respondents worried about coronavirus. The responses to the questionnaire allow the MDT to discuss what is going well and identify any areas that may need to be addressed. It allows us to support our patients in remaining upbeat with positive attitudes regarding their health and CF care and our ethos is reflected in one of the children’s responses: “Do everything, but better.”

Prolonged Use of HFNC in Young Patients Increases Mortality in Covid+ Mechanically Ventilated Patients

Background: Management of acute respiratory distress in patients with COVID-19 has changed over the course of the pandemic. The impact of length of time on High Flow Nasal Cannula (HFNC) prior to mechanical ventilation is unknown. Methods: This is a multi-center retrospective chart review of COVID-positive hospitalized patients, who received mechanical ventilation from March 2020- October 2021. The primary outcome variable was survival to discharge, variables collated included patient demographics, vital signs, comorbidities, including the Charlson comorbidity index (CCI), as well as critical care therapeutic and diagnostic interventions. Results: All COVID-19 positive patients, with respiratory failure who underwent mechanical ventilation across study sites were included (N=709), of which 318 (45%) were accrued in March-May 2020. Patients had an average age of 62 (SD=15) years, majority male (67%), and an average CCI of 3.65 (SD=3.11). The unadjusted mortality for mechanically ventilated patients in our cohort was 56% (n=397). 169 (54%) of the remaining 312 were discharged home. Mortality varied over the study period, with the highest noted Nov 1st 2020 - Jan.31st 2021 (N=141, 69.8%) compared to other time periods (47-53%, p<0.0001). Notably at this time patients had the longest duration of pre-intubation high-flow oxygen support (mean 6.3 days vs. 4.2 days overall), the highest rate of Non-Invasiave Positive Pressure Ventilation (NIPPV) utilization (49% vs. 33% overall) and the lowest PaO2 to FiO2 ratio (mean 125 vs. 139 overall) (p<0.01). Duration of HFNC was independently associated with a higher risk of post-intubation mortality: OR (95% CI) = 3.1 (1.8-5.4) for 3-7 days, 7.2 (3.8-13.7) for ≥8 days (reference: 1-2 days) (p<0.0001) (accounting for age, gender, BMI and CCI). Furthermore, the magnitude of this association was found to vary between age groups: for 3-7 days duration (ref: 1-2 days), OR = 4.8 (1.9 - 12.1) in ≥65 years old vs. 2.1 (1.0 - 4.6) in <65 years old. Notably, at 8 days or more of HFNC, the association with age was reversed for ≥8 days duration (ref: 1-2 days): OR = 5.3 (2.0 - 13.9) in ≥65 years old vs. 8.6 (3.7 - 20.0) for <65 years old. Conclusion: The prolonged use of high flow oxygenation prior to mechanical intubation increased the risk of mortality, particularly in young patients use of HFNC for 8 days or more was associated with significantly higher mortality.

Evaluating the Ability to ID (COVID-19) NOW: a Large Real-World Prospective Evaluation of the Abbott ID NOW COVID-19 Assay.

The Abbott ID NOW COVID-19 assay is a rapid point-of-care molecular test for SARS-CoV-2 detection. In theory, it has the potential to decrease turnaround times (TATs) and rapidly facilitate patient flow and triage. Reports for its performance have been mixed, likely due to variations in patient cohorts, preanalytical considerations, and study design. We prospectively evaluated the ID NOW performance against reference reverse transcriptase PCR (RT-PCR) tests, using dual swabs. Patients presented at a large multisite academic hospital with the highest volumes of COVID-19 admissions in Canada. From 1,968 valid swabs, 186 were true positive, 1,760 were true negative, 21 were false negatives, and 1 was false positive. At 10.5% positivity rate, the positive and negative predictive values were 99.5% and 98.8%, respectively. This led to a modest increase in the pretest probability in this cohort of individuals presenting <7 days of symptom onset. The mean times from collection to laboratory receipt and receipt to reporting were 31 and 23 min, respectively. This reduced TAT observed in our study may assist with triage of admitted patients and breaking the chain of transmission through immediate notification of status. We also observed how test performance changed with prevalence, and thus, how the test is used to "rule in" or "rule out" disease must be considered. Although the ID NOW is regarded as a rapid test, it is not high throughput and requires rapid transportation times (<1 h) that may not be plausible in large centers. The utility of this test should be considered with the observed TAT and interpreted in the context of limitations discussed. IMPORTANCE Rapid testing for COVID-19 has been recognized as one potentially important measure in managing the pandemic. However, these rapid tests vary grossly in their performance and their applicability. There have been many studies evaluating the performance of rapid tests for SARS-CoV-2 detection. However, they are frequently not prospective, and patients are not simultaneously swabbed to compare the reference standard RT-PCR. Previous ID NOW study findings are mixed, which may be due to various factors, including patient, epidemiological, and preanalytical considerations. It is critical to consider how the pretest and posttest probabilities and epidemiological factors may affect the performance as the community prevalence of disease fluctuates during this highly dynamic pandemic. We consider how the ID NOW may be utilized in different settings, with considerations of public health and infection control and prevention risk tolerance.

Evaluating the reliability of goniometry for assessment of finger range of motion during video consultations

Keywords: Goniometry;Remote consultation/telemedicine;Hand therapy Purpose: Measurement of finger and hand joint range of motion is a core part of hand therapy assessment with protocols for reliable assessment, and well-established intra- and inter-rater reliability to guide appropriate interpretation. The rapid shift to adoption of video consultations in March 2020, due to COVID restrictions, necessitated a shift in assessment and treatment approaches across many branches of healthcare and brought the challenge of how to effectively deliver assessment and interventions remotely. While goniometry over video had been shown to be reliable for assessment of other joints, there was no literature testing the reliability of measurement of finger range using goniometry performed over video. We sought to evaluate the reliability of using on-screen goniometry for the measurement of finger range to determine the value of using this as an outcome measure and inform clinical practice. Methods: One hundred and thirty-three pairs of measurements (in-person, and over video) were collected, including measures of extension and flexion at each finger joint. Pairs of measurements were compared and Pearson's correlation coefficients (r) and Coefficient of Reproducibility (CR) were calculated on the difference between each pair. Results: Across all pairs of measurements r = 0.98 showing a very high degree of agreement between measurements taken face to face or over video. The reproducibility coefficient (CR), indicating a smallest accurately detectable change, was 11.8ʹ. Conclusion(s): These findings suggest that while measuring finger range over video introduces an additional element of variability compared to measuring face to face (likely due to additional difficulty of standardising orientation of the hand relative to the screen) it appears only marginally less consistent than the accepted inter-rater reliability for standard finger goniometry (7–9ʹ). We find that this data supports the use of goniometry as a standard part of hand therapy assessment in video consultations, but recommend that care is taken to reduce variability as far as possible (by maintaining therapist continuity, standardising position and measurement protocol), and interpret findings appropriately for the reliability of this measurement. Impact: Improved understanding of the reliability of goniometry during remote consultations allows effective assessment and interpretation of findings – strengthening reliability of assessment measures and improving remote assessment and treatment. Funding acknowledgements: None.

What effect does interaction with a physiotherapist have on self-rated confidence, capacity, and motivation to exercise?

Keywords: Exercise;Motivation;Confidence Purpose: The purpose of this study was to determine if seeing a physiotherapist affects self-rated confidence, capacity and motivation to exercise. Methods: The sample consisted of participants from the intervention arm of the AERO feasibility study, which tested an individually tailored exercise adherence intervention for older people with musculoskeletal problems. Participants were asked three questions prior to starting their first physiotherapy session. • Do you feel you have the necessary capacity (e.g. strength, flexibility, fitness, etc.) to undertake an exercise programme? Score on a scale 0–10 where 0 is ‘I definitely don’t have capacity’, to 10: ‘I definitely do have the capacity’ • How confident do you feel that you can undertake an exercise programme? (i.e. Do you feel you have the time, any equipment that you might need etc.) Score on a scale of 0–10, where 0 is ‘not confident at all’, and 10 is ‘totally confident’ • How motivated do you feel to undertake your exercise programme on a scale of 0–10? Where 0 is ‘completely unmotivated’ and 10 is ‘completely motivated’ Participants were then assessed and treated by a physiotherapist. After seeing the physiotherapist, the same questions were asked. The time frame between completing the questions for the first and second time was roughly 2 h. Mean scores and standard deviation for the two timepoints were calculated. Group differences were compared using Wilcoxon signed rank test and effect sizes were calculated with Cohen's D. All data were analysed using SPSS. Results: 21 participants were recruited to the intervention arm of the AERO feasibility RCT, with a mean age of 74.1 years (SD 6.2 years), 8 of the participants were male and 13 female. Self-reported confidence, capacity and motivation to exercise increased after seeing a physiotherapist – • self-rated confidence = pre-physio mean 6.63 (SD 2.59), post-physio mean 9.26 (SD 0.99) Z = −3.304, P = 0.001, d = 1.34 • Capability pre-physio mean 6.84 (SD 2.50), post-physio mean 8.21 (SD 2.50) Z = −2.684, P = 0.007, d = 0.53 • Motivation pre-physio mean 7.47 (SD 2.41) post physio mean 9.16 (SD 1.07) Z = −2.680, P = 0.007, d = 0.90 Conclusion(s): This study found that participants self-reported confidence, capability and motivation to exercise increased following an appointment with a physiotherapist. This is important given the challenge of adherence to exercise reported in the previous literature. If interaction with a physiotherapist has the ability to improve behavioural regulation related to exercise, it should continue to be seen as important, particularly as services emerge from COVID-19 restrictions. The results of this study need to be understood in the context of a small sample size that was recruited for a feasibility trial. However, the difference in group means and effect sizes indicate that this is an area that warrants further investigation. Future research should consider testing for this effect in an appropriately large sample size. Impact: The importance of seeing a physiotherapist to improve behavioural regulation in regard to exercise is underlined. Further research needs to confirm these findings in a large sample and across different populations. Funding acknowledgements: This work was funded by the Physiotherapy Research Unit, Nuffield Orthopaedic Centre, Oxford, UK and The Centre for Movement, Occupational and Rehabilitation Sciences (MOReS), Oxford Brookes University, Oxford, UK.

Environmental impact of volatile anaesthetic use in Scotland over a 3-year period

Volatile anaesthetic agents are potent greenhouse gases (GHGs), representing approximately 5% of the carbon footprint of acute NHS services [1]. Desflurane is an especially potent GHG, with a global warming potential of 1620 CO2 equivalents (CO2e), compared with 210 CO2e for sevoflurane [2]. Efforts to promote environmentally responsible anaesthesia continue, mostly through education and spreading the message through the Scottish Environmental Anaesthesia Group. We aimed to measure changing patterns of volatile anaesthetic use over 3 years, and snapshot nitrous oxide use, within NHS Scotland. Methods The project was registered with clinical governance in NHS Tayside. We quantified volatile use in Scotland from 2018 to 2021 using purchasing data for each territorial health board on a quarterly basis, from point of peak use to the third quarter (Q3) of the 2020/2021 financial year. This was calculated per head of catchment population, with CO2e calculated using the data published by Sulbaek Andersen et al. [1]. Additionally, a survey of anaesthetists within Scotland was carried out to determine patterns of fresh gas flow rates and nitrous oxide use nationally. Results Desflurane fell from a mean of 17.2% to 9.6% of volatile use across larger Scottish hospitals from 2018 to 2021. Between health boards, desflurane use varied from 64.7 to 0 ml per 1000 catchment population, per quarter, at the end of the study period (Fig. 1). A sustained downward trend in desflurane was noted in most health boards, and overall consumption steeply declined, even outwith the COVID-19 pandemic. One hundred and sixty-six anaesthetists responded to the survey. The most common flow rate during maintenance was 0.5-1.9 min-1. Of the anaesthetists, 86% 'rarely' or 'never' used nitrous oxide, with only two anaesthetists out of 166 using it 'always' or 'often'. Default fresh gas flow on anaesthetic machines varied between hospitals and sometimes within hospitals. Figure 1 Desflurane use per quarter per health board. Discussion Even once the effects of COVID-19 are considered, we demonstrate a sustained reduction in desflurane use over 3 years, across an NHS catchment population of 5.5 million. This represents substantial reductions in CO2e emissions. Further reductions in desflurane and nitrous oxide purchasing could offer large environmental and financial benefits. At least one major hospital in Scotland is now decommissioning its nitrous oxide manifold and switching to cylinders for occasional use. Reducing default fresh gas flow rates on anaesthetic machines may offer a means of further reducing unnecessary volatile expenditure.

Late Breaking Abstract - Telerehabilitation compared to centre-based pulmonary rehabilitation: a randomised controlled equivalence trial

Background: Pulmonary rehabilitation is an effective treatment for people with chronic respiratory disease, but is delivered to <5% of eligible individuals. Due to COVID-19 remote rehabilitation models may be critical for future delivery of services. Aims: To compare the efficacy of home-based telerehabilitation (TR) and centre-based pulmonary rehabilitation (PR) in people with chronic respiratory disease. Methods: Assessor blinded, multi-centre RCT, powered for equivalence. Participants were randomised to centre-based PR or home-based TR. Both programs were 2 sessions/week for 8 weeks. Telerehabilitation used a stationary cycle and group videoconferencing to enable social interaction and real time monitoring. The primary outcome was change in chronic respiratory disease questionnaire dyspnea domain (CRQ-D) at end rehabilitation, with a pre-specified equivalence margin of 2.5 points. Results: We randomised 142 participants to PR (n=72) orTR (n=72). Both groups had clinically important improvements in CRQ-D following rehabilitation (TR mean (95%CI) 4 (2 to 5) vs PR 5 (3 to 7)), however equivalence of TR was not confirmed (mean difference between groups (MD) -1 point (-3 to 1)), with similar findings at 12 month followup (MD -1 point (-4 to 1)). The 6-minute walk distance (6MWD) was equivalent at end rehabilitation (MD -6 metres (-26 to 15) and at 12 months superiority of TR could not be excluded (MD 14 metres (-10 to 38). The proportion of participants who completed >70% of prescribed sessions was high (84% TR vs 79% PR). Conclusions: Home-based TR achieved clinically important gains in health-related quality of life, but equivalence to centre-based PR was not confirmed.