COVID-19 screening indications and characteristics for acute paediatric admissions in a single centre: A retrospective chart review

Background: Whilst the Irish Health Service Executive (HSE) currently recommends COVID-19 screening for all adult hospital admissions, current guidelines state that the screening of asymptomatic paediatric admissions is not necessarily required. However, clinically determining who requires testing can be difficult and subject to inter-carer variability. We sought to audit our acute admissions and swab results to determine rates of testing, characteristics of those being tested, and rates of positivity in a busy Irish tertiary paediatric unit. Methods: We reviewed the charts of 122 patients admitted acutely to our unit over the course of July 2021 to determine whether or not they had undergone COVID-19 screening using a nasopharyngeal PCR test and the clinical indication for testing. The clinical presentation of these admissions was analysed to try to determine positive predictive factors for COVID-19 screening and better streamline surveillance criteria. Results: A total of 122 admissions were analysed, with 74 (60.7%) having had a COVID-19 PCR test performed at the point of admission. Of these, 1 patient was found to be COVID-19 positive, giving an overall positivity rate of 0.8% amongst admissions analysed and 1.4% for admissions screened. The patient who returned a positive result was febrile at presentation but did not have any respiratory symptoms. Respiratory symptoms were documented for 45 of the 122 admissions (36.9%), and 42 of these underwent COVID-19 screening (93.3%). All swabs were negative. A total of 59 out of 122 were febrile at presentation, 55 (93.2%) of whom underwent screening. As above, 1 case tested positive. Of the afebrile patients, 19 out of 64 underwent COVID-19 screening. COVID-19 screening was performed in 12 patients who did not have a fever or respiratory symptoms at the time of presentation. In terms of non-respiratory presentations, screening was performed in 12 out of 14 (85.7%) presenting with gastritis/gastroenteritis, and 9 out of 12 (75%) presenting with a history and examination consistent with a UTI/pyelonephritis. Of 18 patients who were admitted with primarily psychiatric presentations, none had either a fever or respiratory symptoms at presentation, and none underwent COVID-19 screening. Conclusion: Our results reflect the existing data that COVID-19 appears to be less pathogenic in paediatric populations than in adult ones. Our low positivity rate compared to a high swab rate has repercussions in terms of bed allocation and isolation status. There is variation in terms of clinical criteria being viewed as sufficient to justify screening. Further study is required to determine consensus guidelines for COVID-19 surveillance in acute paediatric hospital admissions.

BUILT ENVIRONMENT OF NURSING HOMES AND INFECTION CONTROL AND PANDEMIC PREPAREDNESS

Background The disproportionately high death rate of nursing home (NH) residents from COVID-19 in many countries, including Ireland, has focussed attention on infection prevention and control, including the built environment, in nursing homes. This has been a poorly researched topic to date, and we undertook a systematic review of evidence for architectural design measures which support infection control and pandemic preparedness. Methods Databases were screened for keywords related to NHs, built environment, infection prevention and control, and COVID-19;relevant papers were uploaded onto Covidence and screened for relevance. Data extracted from included articles was tabulated under 8 specific aspects of the built environment. Results Of 17 papers included in the final analysis, four studies found that larger nursing homes carried an increased risk of COVID-19 infection. Crowding in NHs was also a risk factor for infection, with a high crowding index associated with COVID-19 infection in five studies. Green House care homes, which are based on small clusters of domestic dwellings, fared better than traditional NHs. Two papers found an association between the location of NHs and the risk of COVID-19 infection, with urban NHs and those in areas of high prevalence being more at risk. Two papers identified internal fittings as a target for infection prevention and control. Seven papers highlighted the role of adequate ventilation in NHs in the prevention of spread of COVID-19. Only one paper described easy access to the outdoors as beneficial to infection control. Conclusion Residents of NHs are amongst the most vulnerable to COVID-19 infection. When designing and building NHs, the role of the built environment in controlling the spread of the virus should not be underestimated. This research supported by Science Foundation Ireland.

The impact of COVID-19 on people ageing with an intellectual disability in Ireland: Protocol for a follow-up survey

Background:  The COVID-19 pandemic and associated lockdowns have had a dramatic impact on many people, but individuals with an intellectual disability, given the prevalence of congregate living and high levels of co-morbid conditions, may be particularly vulnerable at this time. A prior initial survey of participants of the Intellectual Disability Supplement to the Irish Longitudinal Study on Ageing (IDS-TILDA) found that, despite a majority of participants being tested, only a small proportion had tested positive for COVID-19. Furthermore, despite some reporting positive aspects to the lockdown, a similar proportion were experiencing stress or anxiety during the pandemic. The pandemic and lockdowns have continued, and it is possible that experiences and consequences have changed over time. Aim: To explore over time and in greater depth the impact of COVID-19 and associated lockdowns and to further establish rates of infection, rates of vaccination and participants' experiences. Methods: A structured questionnaire for people with intellectual disability participating in the IDS-TILDA longitudinal study, to be administered by telephone/video in summer 2021. Where participants are unable to respond independently, a proxy respondent will be invited to either assist the participant or answer questions on their behalf. This questionnaire will include questions from the first COVID-19 questionnaire, with extra questions assessing "long COVID" (i.e. COVID-19 lasting for 12 weeks or longer), infection control behaviours, changes in mental health, social contacts and loneliness, frailty, healthcare, and incidence of vaccination. Impact: The results of this survey will be used to inform healthcare provision for people with intellectual disability during the latter stages of the lockdown and into the future.

Outcomes of renal replacement therapy in the critically ill with COVID-19.

OBJECTIVE: To describe outcomes of critically ill patients with COVID-19, particularly the association of renal replacement therapy to mortality. DESIGN: A single-center prospective observational study was carried out. SETTING: ICU of a tertiary care center. PATIENTS: Consecutive adults with COVID-19 admitted to the ICU. INTERVENTION: Renal replacement therapy. MAIN VARIABLES OF INTEREST: Demographic data, medical history, illness severity, type of oxygen therapy, laboratory data and use of renal replacement therapy to generate a logistic regression model describing independent risk factors for mortality. RESULTS: Of the total of 166 patients, 51% were mechanically ventilated and 26% required renal replacement therapy. The overall hospital mortality rate was 36%, versus 56% for those requiring renal replacement therapy, and 68% for those with both mechanical ventilation and renal replacement therapy. The logistic regression model identified four independent risk factors for mortality: age (adjusted OR 2.8 [95% CI 1.8-4.4] for every 10-year increase), mechanical ventilation (4.2 [1.7-10.6]), need for continuous venovenous hemofiltration (2.3 [1.3-4.0]) and C-reactive protein (1.1 [1.0-1.2] for every 10mg/L increase). CONCLUSIONS: In our cohort, acute kidney injury requiring renal replacement therapy was associated to a high mortality rate similar to that associated to the need for mechanical ventilation, while multiorgan failure necessitating both techniques implied an extremely high mortality risk.

Mesenchymal stromal cell therapy for acute respiratory distress syndrome due to COVID-19

INTRODUCTION: The acute respiratory distress syndrome (ARDS) resulting from coronavirus disease 2019 (COVID-19) is associated with a massive release of inflammatory cytokines and high mortality. Preliminary mortality rates of those who require mechanical ventilation ranges from 31-66%. Mesenchymal stromal cells (MSCs) have anti-inflammatory properties and are being studied as a potential treatment for steroid-resistant graft-vs-host disease, which is characterized by excessive immune activation and tissue damage. Furthermore, MSCs have shown activity in pre-clinical studies in treating acute lung injury. We aimed to determine the safety and feasibility of MSC in mechanically ventilated patients with COVID-19 moderate to severe ARDS. METHODS: Eleven patients were treated with remestemcel-L, an allogeneic cryopreserved MSC product, under individual patient emergency investigational new drug (eIND) applications. Patients were eligible if they had COVID-19 disease with moderate to severe ARDS and had been receiving mechanical ventilation for less than 72 hours prior to the first infusion. Patients with pre-existing lung disease requiring supplemental oxygen or severe liver or kidney injury were excluded. Each patient received two infusions of remestemcel-L at a dose of 2 million cells/kg/ infusion, 48-120 hours apart. RESULTS: Remestemcel-L infusions were well-tolerated in all eleven patients. After 28 days of follow-up, ten patients (91%) were extubated, nine (82%) remained liberated from mechanical ventilation and were discharged from the ICU and two (18%) died. The median time to extubation was ten days. Eight patients (73%) were discharged from the hospital. C reactive protein levels significantly declined within five days of MSC infusion. Five patients developed secondary infections and one patient experienced pulmonary embolism, which were thought to be attributable to their underlying disease. CONCLUSIONS: Remestemcel-L infusions to treat COVID-19 associated moderate to severe ARDS were safe and associated with substantial clinical and laboratory improvement. A randomized controlled trial based on these results is underway.

Study protocol for the COvid-19 Toolbox for All IslaNd (CONTAIN) project: A cross-border analysis in Ireland to disentangle psychological, behavioural, media and governmental responses to COVID-19

COVID-19 represents a serious challenge to governments and healthcare systems. In addition to testing/contact tracing, behavioural and social responses such as handwashing and social distancing or cocooning are effective tools for mitigating the spread of the disease. Psychological (e.g., risk perceptions, self-efficacy) and contextual factors (government, public health messaging, etc.) are likely to drive these behaviours. Collated real-time information of these indicators strengthens local, national and international public health advice and messaging. Further, understanding how well public health and government messages and measures are understood, communicated via (social) media and adhered to is vital. There are two governments and public health jurisdictions on the island of Ireland, the Republic of Ireland (ROI) and Northern Ireland (NI). This represents an opportunity to explore implications of differing measures and messaging across these two jurisdictions as they relate to COVID-19 on two similar populations. The expert research team are drawn from a range of disciplines in the two countries. This project has four nested studies: Assessment of key behavioural, social and psychological factors through a large, prospective representative telephone survey of individuals aged over-18 on a weekly basis over eight weeks (n=3072);and conduct qualitative focus groups over the same period. Interrogation of social media messaging and formal media responses in both jurisdictions to investigate the spread of (mis)information.Modelling data from Studies 1 and 2, plotting the psychosocial/behavioural and media messaging information with international, ROI and NI incidence and mortality data. Conducting an assessment of health policy transfer in an attempt to incorporate the most significant public health and political insights from each jurisdiction. The CONTAIN project will develop an evidence-based toolbox for targeting public health messaging and political leadership and will be created for use for the anticipated second wave of COVID-19, and subsequently for future epidemics/pandemics.

Outcomes of renal replacement therapy in the critically ill with COVID-19.

OBJECTIVE: To describe outcomes of critically ill patients with COVID-19, particularly the association of renal replacement therapy to mortality. DESIGN: A single-center prospective observational study was carried out. SETTING: ICU of a tertiary care center. PATIENTS: Consecutive adults with COVID-19 admitted to the ICU. INTERVENTION: Renal replacement therapy. MAIN VARIABLES OF INTEREST: Demographic data, medical history, illness severity, type of oxygen therapy, laboratory data and use of renal replacement therapy to generate a logistic regression model describing independent risk factors for mortality. RESULTS: Of the total of 166 patients, 51% were mechanically ventilated and 26% required renal replacement therapy. The overall hospital mortality rate was 36%, versus 56% for those requiring renal replacement therapy, and 68% for those with both mechanical ventilation and renal replacement therapy. The logistic regression model identified four independent risk factors for mortality: age (adjusted OR 2.8 [95% CI 1.8-4.4] for every 10-year increase), mechanical ventilation (4.2 [1.7-10.6]), need for continuous venovenous hemofiltration (2.3 [1.3-4.0]) and C-reactive protein (1.1 [1.0-1.2] for every 10 mg/L increase). CONCLUSIONS: In our cohort, acute kidney injury requiring renal replacement therapy was associated to a high mortality rate similar to that associated to the need for mechanical ventilation, while multiorgan failure necessitating both techniques implied an extremely high mortality risk.

OBJETIVO: Describir los resultados de pacientes críticamente enfermos con COVID-19, especialmente la asociación de la terapia de reemplazo renal con la mortalidad. DISEÑO: Estudio observacional, prospectivo y unicéntrico. ÁMBITO: En la unidad de cuidados intensivos (UCI) de un centro de atención terciaria. PACIENTES: Pacientes adultos con COVID-19 ingresados de forma consecutiva en la UCI. INTERVENCIÓN: Administración de terapia de reemplazo renal. VARIABLES DE INTERÉS PRINCIPALES: Datos demográficos, antecedentes médicos, gravedad de la enfermedad, tipo de oxigenoterapia, datos analíticos y uso de terapia de reemplazo renal para generar un modelo de regresión logística que describa factores de riesgo independientes de la mortalidad. RESULTADOS: De los 166 pacientes, el 51% recibieron ventilación mecánica (VM) y el 26% requirió terapia de reemplazo renal (TRR). La mortalidad hospitalaria global fue del 36%, frente al 56% en el caso de los pacientes que requirieron TRR y el 68% en el subconjunto de pacientes que necesitó tanto VM como RTT. Un modelo de regresión logística señala cuatro factores de riesgo independientes de la mortalidad: edad (OR ajustada: 2,8 [IC del 95%: 1,8-4,4] por cada incremento de 10 años), ventilación mecánica (4,2 [1,7-10,6]), necesidad de hemofiltración venovenosa continua (HVVC) (2,3 [1,3-4,0]), y proteína C reactiva (1,1 [1,0-1,2] por cada incremento de 10 mg/L). CONCLUSIONES: En nuestra cohorte, la lesión renal aguda que necesita TRR se asocia con una mortalidad similarmente elevada a la de los pacientes que requieren VM, y la insuficiencia multiorgánica que hace necesarias ambas intervenciones se asocia con un riesgo de mortalidad extremadamente alta.

Repositioning gastroenterology services during covid-19 pandemic

BACKGROUND: In COVID-19 pandemic, hospitals become overwhelmed with acute admissions leading to the suspension of outpatient clinics including gastroenterology and endoscopic services. Similarly available resources are channeled to combat the scourge. These diversions of resources coupled with lockdowns and fear of getting infected prevent patients from accessing routine and lifesaving gastroenterology services leading to increased gastrointestinal-related morbidity and mortality in at-risk populations. Often, there are delays in the diagnosis and early treatment of gastrointestinal cancers, and high risks of death from gastrointestinal bleeding. SUMMARY: This review discusses COVID-19 risk factors and ways and means of ensuring safe essential gastroenterology services in the setting of COVID-19 pandemic based on available evidence. Telemedicine avoids physical contacts, maximizes safety by reducing the risk of infection to both clinicians and patients, and is conducive to a lockdown, quarantine, or self-isolation environment of COVID-19. It can be used to triage critical cases requiring life-saving endoscopic procedures. The review also explores measures at derisking endoscopies being high-risk aerosol generating procedures. The emerging technology of non-contact endoscopy in the form of robotic endoscopy raises hope in this direction.