Covid-19 and Women in the Tourism & Hospitality Workforce: A Thematic Analysis

The impact of COVID-19 on the tourism and hospitality industries is one of the most hotly debated studies in recent literature, but how women in the tourism and hospitality industries dealt with the pandemic has received insufficient attention. Therefore, the purpose of this research is to explore and investigate the impact of COVID-19 on women in the workforce, specifically in the hospitality and tourism industries in India. A qualitative study methodology was adopted, and in-depth interviews were conducted among 30 females, including employees, small-scale vendors, and entrepreneurs. A thematic analysis of the results was conducted using Nvivo-12. By using thematic analysis, twelve sub-themes were condensed into three main themes. The study addresses the main issues of women in the workforce in a time of uncertainty and crisis and highlights actions needed for the inclusive development of women in society.

African American Faith Communities and Public Health: Working at the Intersections of COVID-19

The unprecedented global disruption caused by COVID-19 has illuminated structural racism and systemic inequities in healthcare, public health, and socioeconomic status. How these inequities are addressed will influence whether we can control or stop the pandemic. Prioritizing collaboration and equity and investing financial and social capital into community leadership is essential to mitigating and addressing both the short- and long-term repercussions of COVID-19. Through analysis of, and evidence from, the lived experiences of a national network of African American pastors, the authors recommend four strategies to expedite recovery from the pandemic in the African American community and to promote enduring beneficial societal change: (1) public health and faith communities should initiate and maintain ongoing relationships that are based on trust;(2) recognition and acknowledgement by public and health care organizations that faith community leaders possess unique knowledge of their communities;(3) inclusion of faith community leaders as full partners when planning and strategizing, making decisions, solving problems, and developing policies that affect community wellbeing;and (4) use of an intersecting approach that recognizes the multifactorial realities of COVID-19 and uses remedies that effectively address existing and new problems in a comprehensive, long-term manner.

Leading through Disruption and Change

Join us for a conversation with three Chicago-based Chief Information Officers. Learn how each has navigated the disruptions and changes associated with COVID-19 pandemic at their institutions and how their IT departments are faring under new conditions of remote and hybrid work. We'll look at the biggest challenges facing their institutions today and how they approached possible solutions. Meet our CIOS below. © 2023 Owner/Author.

The rise of Endobronchial Ultrasound (EBUS) and fall of Mediastinoscopy

Introduction: For over 50 years mediastinoscopy was considered the gold-standard to sample the mediastinum. The introduction of EBUS-TBNA (endobronchial ultrasound - transbronchial needle aspiration) revolutionised the diagnosis and staging of lung cancer and the diagnosis of metastases and investigation of isolated mediastinal and hilar lymphadenopathy. Objective(s): We aim to examine the relation between the number of EBUS and mediastinoscopy procedures performed in a large regional Cancer Alliance. Methodology A retrospective observational study of the number of EBUS and Mediastinoscopy procedures performed in the Greater Manchester Cancer Alliance between 2011-2020. Result(s): The number of EBUS procedures performed increased annually, from 362 in 2013 to a peak of 1,660 in 2019. There was a decline in in 2020 owing to the COVID-19 pandemic but this has recovered again in 2021 (n=1565). The number of mediastinoscopies was inversely proportional and declined on an annual basis with 179 performed in 2011, reducing to 21 in 2020 Conclusion(s): EBUS is now a widely available and highly adopted procedure for sampling the mediastinum. The number of procedures performed has increased on an annual basis and led to a reduction in the need for undertaking mediastinoscopies. The less invasive nature of EBUS has likely lowered the threshold for sampling the mediastinum to investigate benign conditions such as tuberculosis and sarcoidosis.

Using Cross-Cultural Collaboration to Establish a Working Coalition for An Equitable COVID-19 Vaccine Program

Coalitions and collaborations with African Americans in the United States are often between people with equal humanity but unequal power. Endeavors between historically harmed communities and representatives of systems that continue to harm them frequently lead to intentional and unintentional miscommunication, mistrust, and distrust. The causes for health inequity are complex and should include consideration of systemic racism. In most standard public health models, departments typically take the lead and invite select members of the community to help. This article describes a collaboration that took place in Marin City, California, between African American churches, the department of public health, and community-based organizations during the COVID-19 pandemic. This example focuses on the value of African American history and cosmology as a foundation for respectful cross-cultural collaboration in implementing a COVID-19 vaccination effort. A cross-cultural collaborative model was developed for use by this coalition to guide the development and implementation of community response teams. Unique and shared responsibilities provided by the coalition partners are examined. Humanistic principles, including empathy, positive regard, trust, and grace, are held as central to the model when planning, implementing, and evaluating activities undertaken by cross-cultural coalitions. Sustainability issues are considered concerning staffing, funding, and public policy. © The Author(s) 2023.

The Effect of Patient Opioid Education on Opioid Use, Storage, and Disposal Patterns.

We evaluated the impact of patient education over opioid use, storage, and disposal on opioid handling patterns of palliative and chronic nonmalignant pain patients. We compared patient surveys before and after education and conducted further analysis for individual clinics due to group differences found prior to education. A total of 100 patients were included. After education, more patients reported never sharing their prescription opioid (95% vs. 66%; P < 0.01), and all reported awareness that one dose could be harmful to someone else (100% vs. 31%; P < 0.01). In addition, more patients reported locking their opioid for storage (85% vs. 13%; P < 0.01). Lastly, less patients reported leftover opioids (2% vs. 40%; P < 0.01), not always disposing (1% vs. 44%; P < 0.01), or purposefully saving (0% vs. 15%; P < 0.01), and all reported knowing the right way to dispose (100% vs. 14%; P < 0.01). Proper methods of disposal increased, including mixing with unpalatable substances (96% vs. 13%; P < 0.01) and utilizing drug-take-back programs (78% vs. 24%; P < 0.01). This project found that patient education improves knowledge and behavior related to opioid handling patterns. Further initiatives should help to identify higher-risk patients and develop educational tools.

COVID-19 Vaccination Uptake Among Health Care Workers (HCW) Requesting Medical Exemptions to Vaccination

Background. New York State adopted a COVID-19 vaccination requirement for all healthcare workers in September 2021, but they allowed medical exemptions. We examined reasons and frequency of medical exemption requests in an academic medical center. Methods. We conducted active surveillance of all medical exemption requests in a tertiary care academic center in Central NY. Age, gender, reason for request, prior acceptance of other required vaccines, letter of support from employee provider, adjudication of the request, and impact of the decision on COVID-19 vaccine acceptance were collected prospectively since the mandate became effective. Results. Among 8,776 HCWs, 108 requested medical exemptions, among those 57 (53%) were denied, 39 (36%) were granted temporary exemption, and 12 (11%) were permanent (Table). Females were more likely to request medical exemptions compared to males, 92 (85%) versus 16 (15%), respectively. Overall, 94 (87%) of the HCWs had a letter from their provider in support of their exemption. Nevertheless, only 47%of those qualified for permanent or temporary exemption usingCDCguidelines. The most common reasons for requesting exemption included: having natural immunity, receiving monoclonal antibodies, experiencing a common reaction to previous COVID-19 vaccination, and having an underlying medical condition (Figure 1). The majority of individuals who had a request denied or who received a temporary medical exemption were subsequently vaccinated, 63% and 79%, respectively (Figure 2). Demographic and other characteristics among health care workers (HCW) requesting medical exemptions. Conclusion. Females were more likely to request a medical exemption to vaccination and their requests were often supported by their providers. Future efforts should focus on educating both health care providers and the public about actual medical contraindications or precautions to vaccination to improve overall vaccination rates.

Inter-Rater Reliability of a Novel Objective Outcome Measure for the Study of Benign Central Airway Stenosis: Segmentation-Based Volume Rendering of Ct Scans

SESSION TITLE: Technological Innovations in Imaging SESSION TYPE: Original Investigations PRESENTED ON: 10/17/22 1:30 PM - 2:30 PM PURPOSE: Central airway stenosis (CAS) is an important cause of pulmonary morbidity and mortality. Current grading and classification systems include subjective qualitative components, with limited data on reproducibility. We propose a novel radiographic segmentation approach to more objectively quantify CAS. Inter-rater reliability of this novel outcome, which is used in an ongoing randomized controlled trial (NCT04996173), has not been previously assessed. METHOD(S): Computed tomography (CT) scans demonstrating tracheal stenoses were identified in the Vanderbilt University Medical Center Benign Tracheal Stenosis registry. CTs were analyzed in OsiriX (Geneva, Switzerland) after upload via a secured cloud transfer service. Four independent readers with variable experience in CT interpretation were chosen (one chest radiologist, one pulmonary fellow, two internal medicine residents). Readers identified the point of nadir airway lumen, measured 1.5 cm above and below that point, then manually segmented visible tracheal lumen area on the soft tissue window of each axial CT slice within that 3 cm length. Missing ROI's were then generated in-between manual segmented areas. The Repulsor function was used to manually adjust the boundaries of the ROI to achieve fit. Intraclass correlation (ICC) was used to calculate the inter-rater reliability of the tracheal lumen volume of between readers. Other data collection variables included the type of CT scan, axial slice interval, the suspected underlying cause of CAS, and average stenotic volume. RESULT(S): Fifty CT scans from 38 individual patients identified in the registry from 2011-2021 were randomly chosen for inclusion. Most (22 of 38, 57.9%) had iatrogenic BCAS (either post-intubation or post-tracheostomy) and 10 (26.3%) had idiopathic subglottic stenosis. Half of the scans (n=25, 50%) were contrasted neck CT and half were non contrasted chest CTs. Scan slice thickness ranged 1 to 5 mm, median 2 mm (1.25-2.875). The median stenotic volume across all readers was 3.375 cm3 (2.52-4.51). The average ICC across all four readers was 0.969 (95% CI 0.944 - 0.982). CONCLUSION(S): Our proposed volume rendering and segmentation approach to BCAS proves to have substantial precision and agreement amongst readers of different skill levels. CLINICAL IMPLICATIONS: A NOVEL METHOD TO ASSESS SEVERITY OF BENIGN CENTRAL AIRWAY STENOSIS DISCLOSURES: No relevant relationships by Leah Brown No relevant relationships by Alexander Gelbard no disclosure on file for Robert Lentz;PI ofan investigator-initiated study relationship with Medtronic Please note: >$100000 by Fabien Maldonado, value=Grant/Research Support PI on investigator-initiated relationship with Erbe Please note: $5001 - $20000 by Fabien Maldonado, value=Grant/Research Support Consulting relationship with Medtronic Please note: $5001 - $20000 by Fabien Maldonado, value=Honoraria co-I industry-sponsored trial relationship with Lung Therapeutics Please note: $5001 - $20000 by Fabien Maldonado, value=Grant/Research Support Board of director member relationship with AABIP Please note: $1-$1000 by Fabien Maldonado, value=Travel No relevant relationships by Khushbu Patel No relevant relationships by Ankush Ratwani Consultant relationship with Medtronic/Covidien Please note: $1001 - $5000 by Otis Rickman, value=Consulting fee No relevant relationships by Evan Schwartz Copyright © 2022 American College of Chest Physicians

Comparison of abiraterone acetate and prednisolone (AAP) or combination enzalutamide (ENZ) + AAP for metastatic hormone sensitive prostate cancer (mHSPC) starting androgen deprivation therapy (ADT): Overall survival (OS) results of 2 randomised phase III trials from the STAMPEDE protocol

Background: AAP or ENZ added to ADT improves outcomes for mHSPC. Any benefit of combining ENZ & AAP in this disease setting is uncertain. Methods: STAMPEDE is a multi-arm, multi-stage (MAMS), platform protocol conducted at 117 sites in the UK & Switzerland. 2 trials with no overlapping controls randomised mHSPC patients (pts) 1:1 to ADT +/- AAP (1000mg od AA + 5mg od P) or AAP + ENZ (160mg od). Treatment was continued to progression. From Jan 2016 docetaxel 75mg/m2 3-weekly with P 10mg od was permitted + ADT. Using meta-analysis methods, we tested for evidence of a difference in OS and secondary outcomes (as described previously: failure-free, metastatic progression-free, progression-free & prostate cancer specific survival) across the 2 trials using data frozen 3 Jul 2022. All confidence intervals (CI) 95%. Restricted mean survival times (RMST) restricted to 84 months (m). Results: Between Nov 2011 & Jan 2014, 1003 pts were randomised ADT +/- AAP & between Jul 2014 & Mar 2016, 916 pts were randomised ADT +/- AAP + ENZ. Randomised groups were well balanced across both trials. Pt cohort: age, median 68 years (yr), IQR 63, 72;PSA prior to ADT, median 95.7 ng/ml, IQR 26.5, 346;de novo 94%, relapsed after radical treatment, 6%. In AAP + ENZ trial, 9% had docetaxel + ADT. OS benefit in AAP + ENZ trial, HR 0.65 (CI 0.55‒0.77) p = 1.4×10-6;in AAP trial, HR 0.62 (0.53, 0.73) p = 1.6×10-9. No evidence of a difference in treatment effect (interaction HR 1.05 CI 0.83‒1.32, p = 0.71) or between-trial heterogeneity (I2 p = 0.70). Same for secondary end-points. % (CI) of pts reporting grade 3-5 toxicity in 1st 5 yr: AAP trial, ADT: 38.5 (34.2-42.8), + AAP: 54.4 (50.0-58.8);AAP + ENZ trial, ADT: 45.2 (40.6 – 49.8), + AAP + ENZ: 67.9 (63.5 – 72.2);most frequently increased with AAP or AAP + ENZ = liver derangement, hypertension. At 7 yr in AAP trial (median follow-up: 95.8m), % (CI) pts alive with ADT: 30 (26, 34) versus with ADT + AAP: 48 (43, 52);RMST: ADT: 50.4m, ADT + AAP: 60.6m, p = 6.6 x 10-9. Conclusions: ENZ + AAP need not be combined for mHSPC. Clinically important improvements in OS when adding AAP to ADT are maintained at 7 yr. Clinical trial identification: NCT00268476. Legal entity responsible for the study: Medical Research Council Clinical Trials Unit at University College London. Funding: Cancer Research UK, Medical Research Council, Janssen, Astellas. Disclosure: G. Attard: Financial Interests, Personal, Invited Speaker: Janssen, Astellas, AstraZeneca;Financial Interests, Personal, Advisory Board: Janssen, Astellas, Novartis, Bayer, AstraZeneca, Pfizer, Sanofi, Sapience, Orion;Financial Interests, Personal, Royalties, Included in list of rewards to discoverers of abiraterone: Institute of Cancer Research;Financial Interests, Institutional, Research Grant: Janssen, Astellas;Non-Financial Interests, Principal Investigator: Janssen, Astellas;Non-Financial Interests, Advisory Role: Janssen, AstraZeneca. W.R. Cross: Financial Interests, Personal, Invited Speaker, Speaker fee: Myriad Genetics, Janssen, Astellas;Financial Interests, Personal, Advisory Board, Advisory Board fee: Bayer;Financial Interests, Institutional, Research Grant, Research grant: Myriad Genetics. S. Gillessen: Financial Interests, Personal, Advisory Board, 2018: Sanofi, Roche;Financial Interests, Personal, Advisory Board, 2018, 2019: Orion;Financial Interests, Personal, Invited Speaker, 2019 Speaker's Bureau: Janssen Cilag;Financial Interests, Personal, Advisory Board, 2020: Amgen;Financial Interests, Personal, Invited Speaker, 2020: ESMO;Financial Interests, Personal, Other, Travel Grant 2020: ProteoMEdiX;Financial Interests, Institutional, Advisory Board, 2018, 2019, 2022: Bayer;Financial Interests, Institutional, Advisory Board, 2020: Janssen Cilag, Roche, MSD Merck Sharp & Dohme, Pfizer;Financial Interests, Institutional, Advisory Board, 2018: AAA International, Menarini Silicon Biosystems;Financial Interests, Institutional, Advisory Board, 2019, 2020: Astellas Pharma;Financial Interests, Institutional, Advisory B ard, 2019: Tolero Pharmaceuticals;Financial Interests, Personal, Invited Speaker, 2021, 2022: SAKK, DESO;Financial Interests, Institutional, Advisory Board, 2021: Telixpharma, BMS, AAA International, Novartis, Modra Pharmaceuticas Holding B.V.;Financial Interests, Institutional, Other, Steering Committee 2021: Amgen;Financial Interests, Institutional, Advisory Board, 2021, 2022: Orion, Bayer;Financial Interests, Personal, Invited Speaker, 2021: SAKK, SAKK, SAMO - IBCSG (Swiss Academy of Multidisciplinary oncology);Financial Interests, Personal, Advisory Board, 2021: MSD Merck Sharp & Dhome;Financial Interests, Personal, 2021: RSI (Televisione Svizzera Italiana);Financial Interests, Institutional, Invited Speaker, 2021: Silvio Grasso Consulting;Financial Interests, Institutional, Other, Faculty activity 2022: WebMD-Medscape;Financial Interests, Institutional, Advisory Board, 2022: Myriad genetics, AstraZeneca;Financial Interests, Institutional, Invited Speaker, 2022: TOLREMO;Financial Interests, Personal, Other, Travel support 2022: AstraZeneca;Financial Interests, Institutional, Funding, 2021, Unrestricted grant for a Covid related study as co-investigator: Astellas;Non-Financial Interests, Advisory Role, 2019: Menarini Silicon Biosystems, Aranda;Non-Financial Interests, Advisory Role, Continuing: ProteoMediX. C. Pezaro: Financial Interests, Personal, Advisory Board, Ad board Dec 2020: Advanced Accelerator Applications;Financial Interests, Personal, Advisory Board, Aug 2021: Astellas;Financial Interests, Personal, Advisory Board, Oct 2021: Bayer;Financial Interests, Personal, Invited Speaker, Sept-Oct 2020: AstraZeneca;Financial Interests, Personal, Invited Speaker, Oct 2020: Janssen;Financial Interests, Personal, Advisory Board, July-Sept 2022: Pfizer. Z. Malik: Financial Interests, Personal, Advisory Board, advisry board for new hormonal therapy for breast cancer: sanofi;Financial Interests, Institutional, Invited Speaker, research grant for CHROME study: sanofi;Other, Other, support to attend meetings or advisory boards in the past: Astellas,Jaansen,Bayer;Other, Other, Sponsorship to attend ASCO meeting 2022: Bayer. M.R. Sydes: Financial Interests, Personal, Invited Speaker, Speaker fees at clinical trial statistics training sessions for clinicians (no discussion of particular drugs): Janssen;Financial Interests, Personal, Invited Speaker, Speaker fees at clinical trial statistics training session for clinicians (no discussion of particular drugs): Eli Lilly;Financial Interests, Institutional, Research Grant, Educational grant and drug for STAMPEDE trial: Astellas, Janssen, Novartis, Pfizer, Sanofi;Financial Interests, Institutional, Research Grant, Educational grant and biomarker costs for STAMPEDE trial: Clovis Oncology. L.C. brown: Financial Interests, Institutional, Research Grant, £170k educational grant for the FOCUS4-C Trial from June 2017 to Dec 2021: AstraZeneca;Financial Interests, Institutional, Funding, Various grants awarded to my institution for work undertaken as part of the STAMPEDE Trial: janssen pharmaceuticals;Non-Financial Interests, Other, I am a member of the CRUK CERP funding advisory panel and my Institution also receive grant funding from CRUK for the STAMPEDE and FOCUS4 trials: Cancer Research UK. M.K. Parmar: Financial Interests, Institutional, Full or part-time Employment, Director at MRC Clinical Trials Unit at UCL: Medical Research Council Clinical Trials Unit at UCL;Financial Interests, Institutional, Research Grant: AstraZeneca, Astellas, Janssen, Clovis;Non-Financial Interests, Advisory Role, Euro Ewing Consortium: University College London;Non-Financial Interests, Advisory Role, rEECur: University of Birmingham;Non-Financial Interests, Advisory Role, CompARE Trial: University of Birmingham. N.D. James: Financial Interests, Personal, Advisory Board, Advice around PARP inhibitors: AstraZeneca;Financial Interests, Personal, Advisory Board, Prostate cancer therapies: Janssen, Clovis, Novartis;Financial Interests, Institutional, Expert Testimony, Assisted with submissions regarding licencing for abiraterone: Janssen;Financial Interests, Personal, Advisory Board, Docetaxel: Sanofi;Financial Interests, Institutional, Expert Testimony, Providing STAMPEDE trial data to facilitate licence extensions internationally for docetaxel: Sanofi;Financial Interests, Personal, Advisory Board, Bladder cancer therapy: Merck;Financial Interests, Personal, Advisory Board, Advice around novel hormone therapies for prostate cancer: Bayer;Financial Interests, Personal, Invited Speaker, Lecture tour in Brazil August 2022 - speaking on therapy for advanced prostate cancer: Merck Sharp & Dohme (UK) Limited;Financial Interests, Institutional, Invited Speaker, Funding for STAMPEDE trial: Janssen, Astellas;Financial Interests, Institutional, Invited Speaker, Funding for RADIO trial bladder cancer: AstraZeneca. All other authors have declared no conflicts of interest.

Science communication during COVID-19: when theory meets practice and best practices meet reality

This paper synthesizes the efforts of an interdisciplinary, University-convened communication task force in the U.S. that used science communication theory to develop an effective strategy during the early stages of the COVID-19 pandemic. We outline recommendations for researchers and practitioners who are, or are interested in, implementing theory-based communication practices while describing how we dealt with the unforeseen realities we faced. Overall, we recommend that effective public health and science communication should be based on theory and formative evaluation while relying on established infrastructure, real-time data, a deep understanding of intended target audiences, and intentional coordination with community partners.

Parsing Immune Correlates of Protection Against SARS-CoV-2 from Biomedical Literature

After the emergence of severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) in 2019, identification of immune correlates of protection (CoPs) have become increasingly important to understand the immune response to SARS-CoV-2. The vast amount of preprint and published literature related to COVID-19 makes it challenging for researchers to stay up to date on research results regarding CoPs against SARS-CoV-2. To address this problem, we developed a machine learning classifier to identify papers relevant to CoPs and a customized named entity recognition (NER) model to extract terms of interest, including CoPs, vaccines, assays, and animal models. A user-friendly visualization tool was populated with the extracted and normalized NER results and associated publication information including links to full-text articles and clinical trial information where available. The goal of this pilot project is to provide a basis for developing real-time informatics platforms that can inform researchers with scientific insights from emerging research.

Association Between Urban Greenspace and Mental Wellbeing During the COVID-19 Pandemic in a US Cohort

The Coronavirus Disease 2019 (COVID-19) pandemic brought unprecedented socially isolating measures to mitigate the spread of disease, heightening the importance of public outdoor urban greenspace. Here, we investigated the association between tree-rich greenspace and mental health in a large opportunity sample surveyed using a crowdsourcing research website (www.covid19resilience.org) between April 6th and October 12th, 2020 during the pandemic in the United States. Participants living in the U.S. (N = 2,089, 83.1% females, mean age 42 years, age range 18-90 years) were mapped to 1,080 unique ZIP Codes and mean tree canopy density was calculated with a 250m buffer around each ZIP Code grouped by quartile as a proxy for nearby greenspace. Four mental health parameters were assessed: (1) COVID-19-related worries;(2) anxiety symptoms;(3) depression symptoms;and (4) a standardized and weighted composite mental health score of all three parameters. Multivariate regression analyses with multilevel models were used to study the association between nearby greenspace and the four mental health outcomes, controlling for participant demographics and ZIP Code urbanicity. In the entire cohort, increased nearby greenspace showed a significant protective effect for depression (Coef. = -0.27;p = 0.0499), and composite mental health scores (Coef. = -0.19;p = 0.038) when comparing ZIP Codes with the most greenspace to ZIP Codes with the least, with no observed effects on COVID-19 related worries or anxiety individually. Stratifying by age suggested protective trends of greenspace on mental health in older subsets of the population (top age quartile, over 51 years old) experiencing less depression (Coef. = -0.45;p = 0.048) and lower composite mental health scores (Coef. = -0.34;- = 0.032) as a function of nearby greenspace. Additionally, younger subsets of the population (second youngest age quartile, 31-38 years) experienced lower COVID-19 related worries (Coef. = -1.34;p = 0.022) as a function of greenspace. These findings may indicate that tree-rich greenspace plays a protective role on mental health during the COVID-19 pandemic, specifically in certain age groups, supporting the use of greenspace-related strategies to help mitigate mental health burden during this challenging and isolating time.

Learning from acute COVID-19in a patient with potential immune dysregulation

Case report-IntroductionThroughout the COVID-19 pandemic, children and adolescents have been at minimal risk of admission to hospital and intensive care from SARS-COV2 and exhibited a different phenotype of critical illness to adults. We present a 9-year-old Caucasian boy who, early in the pandemic, became PCR positive and was admitted to paediatric intensive care (PICU) with an adult phenotype of hyperinflammation and acute respiratory distress syndrome (ARDS). He has trisomy 21 and last year was admitted to PICU with ARDS and macrophage activation syndrome. We share how this early case influenced our thinking and subsequent management of cases thought to have PIMS-TS.Case report-Case descriptionHe presented to a district hospital on March 31st with fever and persistent cough without respiratory or other compromise. Discharged home with oral antibiotics, he obtunded within 18 h and returned as an emergency with persistent fever, cough, and haemoptysis with Sa02 77% in 15litres oxygen. Following intubation, a large pulmonary haemorrhage made ventilation difficult and three cardiac arrests occurred prior to transfer on inotropic support.On arrival, results showed Lymphocytes 1.2, Hb 104, Platelets 365, Ferritin 2059, INR 1.2, Procalcitonin (PCT) 43.84, CRP 219, CK 296, LDH 2035, Albumin 35, D-dimer 37.55. SARS-COV2 was confirmed in endotracheal secretions. All other microbiology investigations remained negative other than a scanty growth of Candida. Radiology demonstrated bilateral opacifications and pleural effusions. Blood film was consistent with the clinical picture with no signs of malignancy. Subsequent key results included cytopenia with troughs of Hb 86, Lymphocytes 0.2, Platelets 84;peak Ferritin 6283, d-dimer 50.60 and PCT >100, plateauing by day 7.He was ventilated for 23 days requiring high pressures (PIP consistently >30), nitric oxide and inotropes. There was no clinical improvement despite optimal supportive treatment, but immunomodulation was held during repeat microbiology investigation and concern for losing a fine care balance. However, when formally considering ECMO, a trial of Anakinra 4 mg/kg increasing to 8 mg/kg twice daily over 4 days (day 5-9) was commenced. The inflammatory markers had already plateaued then started to fall and there was no meaningful respiratory improvement with anakinra. Intravenous immunoglobulin (IVIG) was administered day 9-10, but improvement in respiratory function only occurred with IV methylprednisolone 10 mg/kg/dose when (days 16-18) the team felt immunomodulation was safe and data from adult intensive care was supportive. He transferred to the ward on day 30 and discharged to his local hospital on day 83. PCR remained positive until day 32.Case report-DiscussionAs in other children with evidence of SARS-COV2, this child showed a rapid and unpredictable decline in condition, but he presented with an opportunity for prevention of the ensuing hyperinflammation. There is a need for research to identify a fingerprint of inflammation that predicts subsequent decline and the value of prompt, safe immunomodulation to distract from critical cytokine cascades.It is unclear why this boy was one of very few children to develop an adult phenotype but given an altered immune state associated with trisomy 21 and a previous episode of ARDS with hyperinflammation it would suggest that inherent Trisomy 21 genetic risk factors may be involved. He also had previously been identified to features of chronic lung disease that was a contributing factor.Successful management of this child resulted from rigorous organ support and close collaboration between consultants and junior staff in PICU, infectious diseases and rheumatology.This was the beginning of a critical relationship that allowed rapid sharing of information and concerns to maintain safety and explore differentials and treatment strategies. A decision to commence immunomodulation had to consider the fragile state of support and risk;for instance, from fluid overload, the background risk of infection and neoplasia and profe sionals understanding of drug safety. Anakinra was used first due to a short half-life, extensive safety data in toxic shock and routine use in rheumatology. IVIG was delayed due to fluid volume, but neither this nor anakinra had a meaningful clinical effect. The key response to steroids is like that reported in adults including the RECOVERY trial.Other learning points showed unexpected patterns and limited utility of blood investigations, as seen later in PIMS-TS. This included incongruence in peaks of ferritin and LDH and delayed recovery of cell lines except Hb which was an early signal of improvement.Case report-Key learning pointsA collaborative approach across teams during the care of this patient was critical and primed relationships prior to the surge of PIMS-TS cases. The role of rheumatology has been clearly defined by its familiarity with the benefit and safety of immunomodulatory agents, which has enabled support of intensive care and infectious disease teams in their use.This patient may also have highlighted a predisposition in some cohorts to states of hyperinflammation given his previous episode last year. Is this due to his trisomy 21 and suspected immune dysregulation or other factors, as we know these patients are at an increased risk of infections and autoimmune conditions?Clinical course in children is unpredictable and frequently associated with rapid decline. Teams must remain flexible and able to respond with different treatment strategies as cases continue to evolve. Here there was an adult phenotype and supportive treatment remained key. As in adult care the benefit of steroids in ventilated patients was clear. However, ongoing research is required to examine the safety (and benefit) of early immunomodulation use when other differentials (including sepsis and malignancy) have not been fully or reliably excluded.There is an argument to use immunomodulation early in the presentation of similar patients in the future. Further molecular biological studies such as the DIAMOND study may help us identify key inflammatory pathways and subsequently screening tools to inform such initial treatment and avoid the rapid decline and hospital or PICU admission. Each immunomodulator has distinct characteristics and response to treatment is not predictable. Does this inform treatment algorithms in the absence of evidence from trials? In the absence of trials for this phenotype should treatment follow an adult based algorithm.We hope that by sharing this case it will stimulate further discussion and research to help us treat future similar patients.