COVID-19 in patients with Pulmonary Alveolar Proteinosis A European multicenter study

Background: Interruption of GM-CSF signaling leads to Pulmonary Alveolar Proteinosis (PAP), occasionally to lung infections and relates to the impaired ability of lung macrophages to catabolize phagocytized surfactant and handle microbes. COVID-19 is associated with worse prognosis in lung disorders. We hypothesized that PAP patients would be at increased risk for COVID-19 and poor outcome. Aim and objectives: This multi-center, retrospective, European study aimed to investigate prevalence and clinical consequences of COVID-19 in PAP and the impact of iGM-CSF treatment on hospitalization or death. Method(s): All patients with PAP and COVID-19 diagnosed and followed-up in 11 referral European centers from January 24th 2020 to August 31st 2021 were included. Prevalence, clinical course and outcome were investigated. Result(s): COVID-19 developed in 34/255 (13.3%) of patients, mostly adults (91.2%), all with autoimmune (a)PAP;all patients were infected before the preventive option of vaccination was available;11 (35.5%) were hospitalized, of whom almost half were in the ICU;3 (27%) of hospitalized patients either died or underwent lung-transplant;these three patients had worse DLCO% predicted (p=0.019) and had more often arterial hypertension (AH) (p=0.012), and a smoking history (p=0.002). All patients with mild disease treated at home survived. Among children, 3 developed COVID-19 with good outcome. Conclusion(s): PAP patients experienced similar rates of COVID-19 with the general population but increased rates of hospitalizations and deaths, underscoring the vulnerability of this population and the necessity of preventive measures to avoid infection. If infected, secondary prophylaxis with monoclonal antibodies and the impact of iGM-CSF must be considered.

Time to forge ahead: The Internet of Things for healthcare

Situated at the intersection of technology and medicine, the Internet of Things (IoT) holds the promise of addressing some of healthcare's most pressing challenges, from medical error, to chronic drug shortages, to overburdened hospital systems, to dealing with the COVID-19 pandemic. However, despite considerable recent technological advances, the pace of successful implementation of promising IoT healthcare initiatives has been slow. To inspire more productive collaboration, we present here a simple—but surprisingly underrated—problem-oriented approach to developing healthcare technologies. To further assist in this effort, we reviewed the various commercial, regulatory, social/cultural, and technological factors in the development of the IoT. We propose that fog computing—a technological paradigm wherein the burden of computing is shifted from a centralized cloud server closer to the data source—offers the greatest promise for building a robust and scalable healthcare IoT ecosystem. To this end, we explore the key enabling technologies that underpin the fog architecture, from the sensing layer all the way up to the cloud. It is our hope that ongoing advances in sensing, communications, cryptography, storage, machine learning, and artificial intelligence will be leveraged in meaningful ways to generate unprecedented medical intelligence and thus drive improvements in the health of many people. © 2022 Chongqing University of Posts and Telecommunications

Acceptability and feasibility pilot of co-designed telehealth physiotherapy interventions for children with asthma and dysfunctional breathing

IntroductionRespiratory physiotherapists aim to identify and treat contributory causes of poor asthma control, including dysfunctional breathing which impacts quality-of-life and symptoms. In the post-COVID-19 era new technologies are needed to deliver telemedicine. Before embedding health delivery transformations, it is essential to involve children and young people (CYP) and their carers to gain insight into their priorities in engaging with healthcare.ObjectivesTo co-design tele-physiotherapy services and online resources in partnership with CYP with asthma;to pilot the acceptability and feasibility of these interventions.MethodsCYP were recruited from a severe asthma clinic. Phase I: Co-design online resources and hybrid physiotherapy clinics. Phase II: Pilot tele-physiotherapy clinics via Attend Anywhere video platform and novel resources. Acceptability was assessed using electronic questionnaires and semi-structured interviews to service users and providers. Operational feasibility was analysed using website traffic data and hybrid clinic attendance.ResultsPhase I: Eight CYP and their families and 11 team members were recruited to co-design prototype solutions including seven educational online videos and downloadable resources (https://bit.ly/3udKqFU), the development of a new webpage, ‘Asthma Kids’ on the platform www.beamfeelgood.com including patient and parent blogs, and a live online 12-week program.Phase II: 25 CYP aged 7–16 were recruited into the pilot. All completed the course with no adverse events. 18/25 (72%) created profiles on Asthma Kids to join live group classes, watch on-demand videos or pre-set physiotherapy programmes. RBHT website videos had 296 views.Across 32 clinics, 94 physiotherapy consultations took place – 27 in-hospital and 67 virtual. 42% of CYP were not brought to virtual appointments compared to 20% for in-hospital ones. Of those who attended virtually, half experienced technical difficulties on the Attend Anywhere platform. Problems included poor signal, difficulties logging in and difficulty seeing patients using mobiles. Questionnaires showed service users and providers all recommended Asthma Kids and RBHT website resources, found hybrid tele-physiotherapy clinics accessible and flexible, however wanted the choice of in-hospital appointments.ConclusionCo-designed novel telehealth physiotherapy resources are easy for service users and providers to use. Hybrid tele-physiotherapy clinics offer choice, but experiences frequent technical issues and in-hospital appointments remain better attended.Please refer to page A214 for declarations of interest related to this .

From hospital to home: Virtually observed Administration of biologics in children with Severe asthma during covid-19

Introduction and Objectives Children with severe asthma receiving biologic injections, require 2-4 weekly hospital visits. Omalizumab and mepolizumab are licensed for home use, however data on the safety of home administration in children is lacking. In March 2020 due to Covid-19, services urgently needed to be redesigned to reduce footfall within the hospital and protect shielding patients and we trialled home administration. Methods Families suitable for home-administration were identified by the multidisciplinary team (MDT). If they accepted, they were then consented and attended hospital for a face to face, two-hour training session with the Clinical Nurse Specialist (CNS). Subsequent injections were supervised by video call with the CNS. Spirometry, measured using a home spirometer (Nuvoair®), Asthma Control Test (ACT), Paediatric Asthma Quality of Life Questionnaire (PAQLQ), oral corticosteroid (OCS) requirement and unscheduled healthcare visits were documented 4 weekly. Results Of 23 patients, 16 (70%) were identified by the MDT as suitable for home-administration;14 families agreed to this recommendation and 2 patients agreed to local services administering it. All were trained within four weeks. 7 patients were unsuitable (dose not licensed for home administration n=1;parent not wanting to administer n=2;safeguarding concerns n=2, previous mild reaction n=1;not fully established on biologic, n=1). We initially encountered some problems including parents not giving a full dose (1) and breaking the syringe (1). However, video call supervision ensured issues were addressed in real time and appropriate action taken. There were no adverse effects. Forced expiratory volume in one second (FEV1) remained unchanged, unscheduled healthcare visits and OCS courses did not increase with virtually observed home-administration of biologics. ACT and PAQLQ scores improved during the first 4 months of home-administration. Conclusions Virtually observed home-administration of omalizumab and mepolizumab is a feasible and safe option. To our knowledge we were the first UK paediatric centre to implement this model, with home spirometry and video calls supporting home-administration. Consequently, this has changed our practice and once established, virtually observed home-administration can be offered to suitable families, being mindful of the financial and time implications this high level service requires.

Monitoring lung function of young people with CF at home: Is it reliable? Results from the climb-CF study

Introduction: Conventionally, young people with CF are reviewed in clinic in person every 2-3 months;home monitoring is not standard. At each visit, depending on age, they perform spirometry supervised by a CF team member to guide clinical decisions. Previous studies have suggested that short-term variation of 6.3% FEV1% predicted (FEV1%pred) is “normal” and a change >13% is likely to represent disease progression (Taylor-Robinson, et al. Thorax. 2012). Handheld turbine spirometers are readily available, and the COVID-19 pandemic has catalysed major changes in practice, with centres reducing clinic visits in favour of home monitoring. The recent completion of our home monitoring feasibility study (CLIMBCF) allowed us to test the hypothesis that home and clinic spirometers give equivalent results. Methods: We designed a study-specific mobile phone app incorporating integrated Bluetooth no-touch data capture from a Vitalograph BT spirometer. We recruited participants aged 2 to 17 years from 8 sites in 2 countries. Suitably aged children were provided with a spirometer, trained in its use and asked to record values at least twice weekly. Clinic visits continued every 8-12 weeks for the 6 months of the study. Here, we compare FEV1 from clinic visits with those obtained unsupervised at home on the same (±1) day. Raw data were converted to GLI FEV1%pred. Where multiple episodes were available for an individual, the first was included in this analysis. We also calculated coefficient of variation (CoV) on all home measurements obtained during diary-defined periods of clinical stability. Results: Paired readings were available from 67 participants (37 female). Median (IQR) age was 10 (7;14) years. Median (IQR) FEV1% values were significantly different between clinic (90.4 [80.4;100.6]%) and home (85.4 [70.7;93.8]%) (p<0.0001). Values from the 2 devices correlated (r2=0.85;p <0.001) but there was substantial bias with higher clinic values from 51 (77.6%) participants. Mean±SD difference between clinic and home FEV1 was 6.5% ± 8.2% with limits of agreement (LoA) of -9.6% to + 22.7%. This bias remained but was less marked in the subgroup ≥12 years (3.8% ± 8.9%;LoA -13.6% to +21%). Median (IQR) CoV in stable children (n=74;age 7 [7;12] years;20 [8;35] measurements per participant) was 9.9% (5.8;14.2%). Discussion: Home spirometers tend to under-read compared to supervised measurements in the clinic. This is similar to previous comparisons of clinic spirometry with handheld devices carried out simultaneously, both supervised by a physiologist (Avdimiretz, et al. Pediatr Pulmonol. 2020). The greater bias in our study shows this may be even more marked when the manoeuvre is carried out unsupervised. While the bias is lower in older participants the limits of agreement are still wide. CoV of repeated measures is higher than reported from clinics, making the home technique less sensitive to deterioration. Unsupervised remote and supervised clinic spirometry are not equivalent. Uncritically giving patients spirometers to use at home may mislead and better strategies are needed.

What is feasible when it comes to monitoring young people with cystic fibrosis at home? The results of the climb CF study

Introduction: There are >350,000 health apps available on app stores across the world however CF is usually assessed at hospital visits. It is unclear whether monitoring children with CF at home is feasible or useful. With the advent of COVID-19 home monitoring has become more necessary. Here we report the results of the CLIMB-CF study which explored the feasibility of home monitoring and potential obstacles. Methods: We designed a study-specific application with input from the CF Trust Youth Advisor Group, and enrolled participants aged 2 to 17 years of age across mulitple sites in the UK and Canada for 6 months. They were asked to complete measures either daily (wellness, cough severity, appetite, sputum volume, breathlessness and tiredness scores, heart rate, oxygen saturations, temperature, respiratory rate, activity and sleep disturbances) or twice a week (weight, and lung function if >5 years of age). After 2 months participants were also given the option to collect samples at home (urine, nasal secretions, sputum, throat swabs and dried blood spots [DBS]). At the end of the study parents and participants over 12 completed feasibility questionnaires. Results: Of 148 (aim was 160), 2 withdrew prior to starting due to social issues, 2 failed to achieve clinical stability and 8 withdrew during the study. Median age of the participants was 7.9 years and 82 (57%) were female. Over the 6 months the median completion of all measures was 40.1% (13.6-69.9%). 2 to 5 year olds completed 54.4% (20.5-77%), 6 to 11 year olds 45.8% (27.0-71.6%) and young people over 12 completed only 15.6% (9.8-30.0%). 77.5% of all participants contacted the study team for technical help at least once. One participant withdrew due to frustration with a piece of equipment. Parents who felt home monitoring did not, or only slightly interfered with their usual activities completed 52% (28.3- 77.6%) of measures compared with those perceiving a heavier burden, 29.9% (9.2-74.5%). Participants over 12 who felt home monitoring did not interfere with their usual activities completed 37.8% (14.5-73.2%) of measures compared to only 9.6% (5.6-22.3%) of measures if they felt it moderately interfered. 73.5% of parents found the ability to monitor their child's health very helpful or helpful. Teenagers felt that sputum collection, nasal secretion collection and DBS collection and spirometry were least acceptable. Discussion: The majority of participants and parents felt home monitoring did not negatively impact their lives. When designing future home monitoring applications those participants who felt home monitoring did not impact their daily lives completed more measures. Teenagers entered less data than younger children;even if they perceived home monitoring was not having a significant impact on their daily lives, completion rates were poor. Interestingly, spirometry was one of the measures teenagers found least acceptable. A significant proportion of our participants required technical help during the study. Our findings should impact on future home monitoring strategies.

P95 From hospital to home: virtually observed administration of biologics in children with severe asthma during COVID-19

Introduction and ObjectivesChildren with severe asthma receiving biologic injections, require 2–4 weekly hospital visits. Omalizumab and mepolizumab are licensed for home use, however data on the safety of home administration in children is lacking. In March 2020 due to Covid-19, services urgently needed to be redesigned to reduce footfall within the hospital and protect shielding patients and we trialled home administration.MethodsFamilies suitable for home-administration were identified by the multidisciplinary team (MDT). If they accepted, they were then consented and attended hospital for a face to face, two-hour training session with the Clinical Nurse Specialist (CNS). Subsequent injections were supervised by video call with the CNS. Spirometry, measured using a home spirometer (Nuvoair®), Asthma Control Test (ACT), Paediatric Asthma Quality of Life Questionnaire (PAQLQ), oral corticosteroid (OCS) requirement and unscheduled healthcare visits were documented 4 weekly.ResultsOf 23 patients, 16 (70%) were identified by the MDT as suitable for home-administration;14 families agreed to this recommendation and 2 patients agreed to local services administering it. All were trained within four weeks. 7 patients were unsuitable (dose not licensed for home administration n=1;parent not wanting to administer n=2;safeguarding concerns n=2, previous mild reaction n=1;not fully established on biologic, n=1).We initially encountered some problems including parents not giving a full dose (1) and breaking the syringe (1). However, video call supervision ensured issues were addressed in real time and appropriate action taken. There were no adverse effects.Forced expiratory volume in one second (FEV1) remained unchanged, unscheduled healthcare visits and OCS courses did not increase with virtually observed home-administration of biologics. ACT and PAQLQ scores improved during the first 4 months of home-administration.ConclusionsVirtually observed home-administration of omalizumab and mepolizumab is a feasible and safe option.To our knowledge we were the first UK paediatric centre to implement this model, with home spirometry and video calls supporting home-administration. Consequently, this has changed our practice and once established, virtually observed home-administration can be offered to suitable families, being mindful of the financial and time implications this high level service requires.

Utilization of fecal immunochemical testing in open access screening during pandemic endoscopy restrictions

INTRODUCTION: At our institution we utilize an Open Access Colonoscopy (OAC) program that allows patients to self-refer for colorectal cancer (CRC) screening and polyp surveillance. Patients are offered the choice of optical colonoscopy or CT colonography (CTC) and the submission is the reviewed for appropriateness. Open access procedures account for approximately 20% of the endoscopic procedures performed at our institution. Following the directive to postpone elective procedures due to the COVID-19 pandemic, our department had 202 OAC patientswhose CRC screening would be delayed. We utilized fecal immunochemical testing (FIT) to provide timely CRC screening to appropriate patients. FIT is a top tier, stool based, CRCscreening test for average risk patients. METHODS: This was an observational study which assessed all patients previously scheduled for CRC screening through a pre-existing OAC program. The rates of FIT eligibility, patient acceptance, patient completion, and results were tracked. RESULTS: A physician reviewed the 202 OAC patient request forms for FIT eligibility. We found 143 patients that were eligible for FIT with the primary exclusions being a personal history of polyps or a significant family history. Our eligibleOAC patients were proactively notified of delays and offered FIT by a nurse. Of the eligible patients, 100 (70%) accepted, 41 (29%) declined and 2 (1%) were unable to be reached. Nine weeks into our initiative, 64 eligible patients (64%) hadcompleted screening with 8 positive and 56 negative tests. Patients with positive FITs received scheduling precedence. Two advanced adenomas were detected in the first six weeks. CONCLUSION: FIT has been used for programmatic CRC screeningby healthcare systems due to low cost and ease of participation.Still, FIT is not widely utilized in many medical systems where patients are often screened opportunistically after presenting forcare via self-referral or referral from their primary care provider. Our findings suggest that the majority of our patients prioritizedtimely CRC screening over a specific modality of screening in a self-referral system. We propose that the utilization of FIT in OAC programs can decrease wait times for screening, particularly during periods of limited resources. This highlightsthe feasibility of FIT in a self-referral OAC program forproviders and health systems working to maintain access to care through streamlining of CRC screening. (Figure Presented) .