Angiotensin Converting Enzyme (Ace) Levels in Irish Population after Covid

Background ACE is a potent pro-inflammatory modulator that controls chemokines and adhesion molecules, and elevated ACE activity associated with immunoinflammatory conditions, including cardiovascular diseases (CVD) and diabetes. The ACE inhibitors are recommended as primary treatment for these illnesses. ACE is a peptidyl-dipeptidase that catalyses Angiotensin I to Angiotensin II, whilst inactivating bradykinin during blood pressure regulation via the Renin-Angiotensin System. The purpose of this study is to establish a reference interval (RI) for ACE in the Irish population after COVID, and to examine if there is an underlying correlation between ACE concentrations and a range of biomarkers. Methods Serum samples of 200 randomly selected patients were obtained from several Irish hospitals in March 2022 (in compliance withGuidance on Anonymisation and Pseudonymisation, June 2019). We analysed for ACE (Buhlmann reagents), HBA1C, 25OHD and other biomarkers on the Abbott Architect ci8200. Full Blood Count was measured on Sysmex CS-2500. The statistical analysis used the EP Evaluator 11.3.0.23 and SPSS 22.0 software. Results The RI based on the central 95% of data was 8-78 U/L. This is higher than the RI proposed by the manufacturer (20-70 U/L) but is very close to our RI (5-79 U/L) from 2019. We found a significant positive correlation between ACE concentration and HBA1c, Urea, Creatinine, White Blood Cells (p<0.0001), Glucose (p=0.02), LDL (p=0.03), Neutrophils (p=0.003), Lymphocytes (p=0.001). A significant negative correlation was observed with 25OHD (p<0.0001). Conclusions This study did not show any notable change in the RI for ACE after COVID in Ireland. The significant positive correlations with HBA1c and other biomarkers may indicate the importance for ACE testing for diabetic management and progression, but further studies will be needed. Patients' overall health and medical history should always be considered when evaluating ACE results, including Vitamin D levels.

Motivations and barriers to exercise among clinicians.

According to Kirk & Rhodes (2011), Nooijen et al. (2018), and Saridi et al. (2019), the motivators and barriers to exercise are influenced by one's occupation, especially among those in the healthcare field. We sought to examine the barriers and motivators to physical activity that are distinctive to clinicians. Community hospital clinicians were surveyed regarding motivators and barriers to exercise that they experience, their burnout levels as described by an adaptation of the Mini-Z single item burnout scale, and average weekly exercise habits. The top barriers and motivators were then correlated to burnout levels, levels of physical activity, and demographics. We received 64 total responses from clinicians. The overall average level of burnout was 2.37 and the median level was 2. Approximately 38% of clinicians reported adhering to American Heart Association (AHA) guidelines of 150 minutes of exercise per week, while 33% of clinicians exercise <75 minutes per week. The top general motivator was for one's own well-being and the top clinician-related motivator was reducing stress. The top two barriers to exercise were COVID-19 concerns at an indoor exercise facility and a lack of time. Higher average levels of burnout were experienced by those who marked being too stressed or too burnt out as barriers to exercise. Because of clinicians' roles in propagating healthy practices in their patients from their own habits, wellness programs should be aimed at capitalizing motivators to combat barriers that this group distinctively experiences. Efforts to improve physical and mental wellness among clinicians will translate into better provider and patient health outcomes.

A Case-Control Study Investigating Household, Community, and Clinical Risk Factors Associated with Multisystem Inflammatory Syndrome in Children (MIS-C) after SARS-CoV-2 Infection

Background. Risk factors for MIS-C, a rare but serious hyperinflammatory syndrome associated with SARS-CoV-2 infection, remain unclear. We evaluated household, clinical, and environmental risk factors potentially associated with MIS-C. Methods. This investigation included MIS-C cases hospitalized in 14 US pediatric hospitals in 2021. Outpatient controls were frequency-matched to case-patients by age group and site and had a positive SARS-CoV-2 viral test within 3 months of the admission of their matched MIS-C case (Figure 1). We conducted telephone surveys with caregivers and evaluated potential risk factors using mixed effects multivariable logistic regression, including site as a random effect. We queried regarding exposures within the month before hospitalization for MIS-C cases or the month after a positive COVID-19 test for controls. Enrollment scheme for MIS-C case-patients and SARS-CoV-2-positive outpatient controls. MIS-C case-patients were identified through hospital electronic medical records, while two outpatient controls per case were identified through registries of outpatient SARS-CoV-2 testing logs at facilities affiliated with that medical center. Caregivers of outpatient controls were interviewed at least four weeks after their positive test to ensure they did not develop MIS-C after their infection. Results. We compared 275 MIS-C case-patients with 494 outpatient SARS-CoV-2-positive controls. Race, ethnicity and social vulnerability indices were similar. MIS-C was more likely among persons who resided in households with >1 resident per room (aOR=1.6, 95% CI: 1.1-2.2), attended a large (>=10 people) event with little to no mask-wearing (aOR=2.2, 95% CI: 1.4-3.5), used public transportation (aOR=1.6, 95% CI: 1.2-2.1), attended school >2 days per week with little to no mask wearing (aOR=2.1, 95% CI: 1.0-4.4), or had a household member test positive for COVID-19 (aOR=2.1, 95% CI: 1.3-3.3). MIS-C was less likely among children with comorbidities (aOR=0.5, 95% CI: 0.3-0.9) and in those who had >1 positive SARS-CoV-2 test at least 1 month apart (aOR=0.4, 95% CI: 0.2-0.6). MIS-C was not associated with a medical history of recurrent infections or family history of underlying rheumatologic disease. Conclusion. Household crowding, limited masking at large indoor events or schools and use of public transportation were associated with increased likelihood of developing MIS-C after SARS-CoV-2 infection. In contrast, decreased likelihood of MIS-C was associated with having >1 SARS-CoV-2 positive test separated by at least a month. Our data suggest that additional studies are needed to determine if viral load, and/or recurrent infections in the month prior to MIS-C contribute to MIS-C risk. Medical and family history were not associated with MIS-C in our analysis.

The Surgical Mask Microbiome Among Children with Asthma

Rationale: Exposure to respiratory pathogens, aeroallergens, and air pollution can lead to asthma exacerbations. The SarsCoV2 (COVID-19) pandemic led to widespread public health mandates including mask-wearing. We hypothesize that mask-wearing sequesters respiratory pathogens, leading to observed reduction in asthma exacerbations. The goal of this study was to characterize the bacterial microbiome from surgical masks in a cohort of school children with and without asthma. By identifying what is on both inside and outside the masks, we will be able to build a catalogue as a baseline for future analyses. Methods: We performed a cross-sectional study of children (4-18 years) attending an inner-city public school district. Students wore a surgical mask for a minimum of one school day. Parents completed a questionnaire about their child's demographics, respiratory history, and level of asthma impairment. To establish the protocol, we piloted the extraction and sequencing procedures among a sample of used masks from a hospital clinical personnel. DNA was extracted using a commercial DNA extraction kit on separated mask layers: inner, middle, and outer. 16S rRNA gene sequencing was then performed and then mapped against the most recent Greengene 16S rRNA gene database.Results: Recruitment and mask wearing occurred during an 8-week period (May 2021-July 2021). 34 students (18 with asthma;16 without asthma) from four schools were enrolled and completed the study. 74% of participants were in grades K-4, mean age was 8.4 years, and 53% identified as Hispanic/Puerto Rican. 59% of participants wore the mask one school day. 44% reported an asthma-related ED visit in their lifetime, while only 16% reported an ED visit in the past 12-months;53% of participants reported asthma symptoms with upper respiratory infections, however 77% reported zero respiratory infections in the past 12-months. In the masks worn by medical staff, bacterial genera including Staphyloccus, Haemophilus, Lawsonella, Streptococcus as well as Actinomyces, were identified similarly on inner and outer layers in the masks worn by clinicians. (Figure 1).Conclusions: We have demonstrated that recruiting and enrolling students from a medium-sized, inner-city public school district and obtaining facial mask samples is feasible. We demonstrate that self-reported rates of asthmarelated ED visits and respiratory infections differed pre-pandemic as compared to during. In addition, identifying the microbiome from surgical masks is possible. Bacteria genera identified were similar to known human nasal, oral and skin microbiomes. Current work is now in process characterizing and comparing the mask microbiomes among students with and without asthma.

Peritonsillar Abscess at a Dedicated Otolaryngology Emergency Department

Aim Peritonsillar abscess (PTA) is the most common suppurative complication of acute tonsillitis. It requires urgent specialist treatment due to the risk of progression to airway compromise. We aimed to review referral pathways to a dedicated otolaryngology emergency department (ORL-ED), identify causative organisms and discuss COVID-19 implications. Methods A retrospective review of patients presenting to the ORL-ED between January 2018 and December 2019 was undertaken. Data extracted included demographics, referral source, treatment, microbiology results and length of stay. Statistical analysis of seasonal variation of presentation and causative organisms employed Chi-Square and Fisher’s Exact Test, respectively. Results There were 53 PTA presentations. 51 were admitted accounting for 44.3% (51/115) of ED admissions. The median patient age was 31 years (IQR 20-40yrs). GP referral accounted for 48/53 (90.6%). There was no statistically significant seasonality (χ2=5.94, p=0.11) in presentation. Microbiology samples were available for 44 patients. Streptococcus was identified in 19/44 (43.2%) patients. 85% (45/53) of patients received Co-amoxiclav. Discussion PTA is a perennial condition with diverse causative organisms. Antibiotic choice should reflect this. The majority of patients are referred from primary care, emphasising the role of the GP in initial diagnosis and the importance of clinical education in this regard. © 2021, Irish Medical Association. All rights reserved.

Patient and caregiver satisfaction with novel en masse oral food challenge performance

Background: Oral food challenge (OFC) is the gold standard for the diagnosis of food allergy. OFC are traditionally performed in hospital, as a day ward procedure, with a high medical caregiver to patient ratio. This is likely to enhance communication and patient satisfaction. Despite the high incidence of adverse reactions, families generally report a positive experience . In Sep-Oct 2020 a novel, high throughput, OFC initiative was carried out by a cross-hospital, multidisciplinary Irish paediatric allergy team. Up to 25 OFCs were performed each day at an offsite, COVID-19 stepdown facility. The unique model was designed in response to the impact of the pandemic, on provision of ambulatory allergy services. It was essential to evaluate the patient experience of this unique, alternative OFC model, compounded by COVID related distancing. Method: An anonymised survey was conducted of randomised cross-section of patients attending. The survey was completed by the primary caregiver of the child attending for the OFC. 178 survey responses were collected from a total of 474 families and included for analysis. The survey was designed to assess patient satisfaction across a number of parameters. Results: 81% of respondents were highly satisfied with ease of use of a non-hospital facility. 81% reported that the site was “child friendly”. Patient experience was scored as “excellent” 82.9% of the time with a further 12.35% reporting it as above average. Communication was effective with 89% of carers reporting good understanding of the results of the OFC. 94.7% stated that their questions were answered by the Allergy Team present. Conclusion: Our results are remarkable for enhanced patient satisfaction despite a reduced medical caregiver to patient ratio. The patient's overall satisfaction was rated overwhelmingly as “excellent” despite almost 30% of patients experiencing allergic reactions. The pandemic has forced health services to seek new ways of doing things. This data reassures, that OFC models can be changed without sacrificing patient experience.

Mass food challenges in a vacant COVID-19 stepdown facility: The children's health Ireland food challenge initiative 2020

Background: Internationally, the COVID-19 pandemic severely curtailed access to hospital facilities for those awaiting elective/semi elective procedures. For allergic children in Ireland, already waiting to 4yr for an elective oral food challenge (OFC), the restrictions signified indefinite delay. At the time of the initiative there were approx 900 children on the Chidren's Health Ireland (CHI) waiting list. In July 2020, a project was facilitated by short term (6wk) access to an empty COVID stepdown facility built, in a hotel conference centre, commandeered by the Health Service Executive Ireland (HSE). The aim was to the achieve rapid rollout of an off-site OFC service, delivering high throughput of long waiting patients, while aligning with hospital existing policies and quality standards, international allergy guidelines and national social distancing standards. Method: The working group engaged key stakeholders to rapidly develop an offsite OFC facility. Consultant Paediatric Allergists, Consultant Paediatricians, trainees and Allergy Clinical Nurse Specialists were seconded from other duties. The facility was already equipped with hospital beds, bedside monitors (BP, Pulse, Oxygen saturation) bedside oxygen. All medication and supplies had to be brought from the base hospital. Daily onsite consultant anaesthetic cover was resourced and a resuscitation room equipped. Standardised food challenge protocols were created. Access to onsite hotel chef facilitated food preparation. A risk register was established. Results: After 6wks planning, the remote centre became operational on 7/9/20, with the capacity of 27 OFC/day. 474 challenges were commenced, 465 (98%) were completed, 9(2%) were inconclusive. 135(29.03%) OFC were positive, 25(5%) causing anaphylaxis. No child required advanced airway intervention. 8 children were transferred to the base hospital. The CHI allergy waiting list was reduced by almost 60% in only 24 days. Conclusion: OFCs remain a vital tool in the care of allergic children, with their cost saving and quality of life benefits negatively affected by delay in their delivery. This project has shown it is possible to have huge impacts on a waiting list efficiently, effectively and safely with good planning and staff buy in -even in a pandemic. Adoption of new, flexible and efficient models of service delivery will be important for healthcare delivery in the post-COVID- 19 era.

Social media as the rising voice of ICU nutrition

INTRODUCTION: Twitter has become an information source for healthcare professionals on a variety of critical care topics. The role Twitter plays as a resource for evidence to guide nutrition therapy is unknown. The purpose of this study is to describe dissemination of Pediatric and Adult critical care nutrition knowledge via Twitter, including frequency, scope of network, disciplines involved, and citation of literature. METHODS: Symplur Analytics was used to analyze the digital footprint of nutrition using the #ICU and #PedsICU hashtags between July 1, 2019 through June 30th, 2020. The top 1000 hashtags and keywords used in combination with #ICU or #PedsICU were examined to identify the most common nutrition related terms. RESULTS: The final dataset included 2837 tweets by 1349 users resulting in 7.5 million impressions. Data is presented as n (%). Most users tweeted once, with 222 users tweeting more than one tweet. Over half of tweeters were female [n=710 (53%)]. Most nutrition tweeters were non-physician healthcare providers [n=297 (22%)] with the next highest profession being doctors [n= 228 (17%)]. Fifty users tweeted 21% of the tweets (range 4-96 tweets/user);16 of these were dietitians, 13 physicians, and 12 organizations. Geographic data was available on 451 of the users;most tweets emanated from the US (n=149), the UK (n=132), Australia (n=20) and Canada (n=16). The most common hashtags used in this dataset were #COVID19, #FOAMcc and #CriticalCare and the most common keywords, ?enteral?, ?patients?, and ?early?. Eight of the 11 most tweeted links were journal articles and webinars from professional societies, and 3 were industry sponsored podcasts/webinars. CONCLUSIONS: This is the first analysis of the role Twitter plays in the dissemination of critical care nutrition therapy information. A limitation to this approach is variability in spelling across the globe. Future research should focus on identifying and analyzing those spellings not represented here to formulate a more comprehensive approach to information sharing. Identification and promotion of a single hashtag may further enhance the usability of ICU and Peds ICU nutrition knowledge internationally.

Live-tweeting the discovery of the new multisystem inflammatory syndrome in children (MIS-C)

INTRODUCTION: In April 2020, the COVID-19 pandemic saw a rise in the number of children with a multi-system hyperinflammatory disease with myocardial involvement and characteristics of toxic shock syndrome, Kawasaki Disease Shock Syndrome, atypical Kawasaki disease. Clinicians turned to social media to discuss what they were seeing and several names for this new syndrome were used, including Paediatric Multisystem Inflammatory Syndrome - Temporally Associated with SARSCoV- 2 and MIS-C. The use of these different names and hashtags may have affected the discussion and ability to share information. Our goal was to examine the real-time conversation on Twitter related to the discovery of this new syndrome. METHODS: We examined conversations occurring on Twitter in the pediatric critical care (PCC) community by examining hashtags associated with #PedsICU. Symplur Signals was used to identify the MIS-C related hashtags. We examined the digital footprint containing those hashtags including stakeholders, frequency of use, and the most commonly tweeted links. RESULTS: Between April 1st and July 21st 2020, there were 50,628 tweets by 13,411 users in the #PedsICU dataset resulting in 128,609,673 impressions. Thirteen new hashtags were identified related to MIS-C in 3664 tweets by 1391 users;#PIMSTS and #MISC were the most commonly used in 3085 (84%) of these tweets. Although #PIMSTS was promoted more in the UK and #MISC in the US, there were no significant differences in usage by country. Of the users tweeting with these MIS-C related hashtags, 39% were healthcare providers, 23% were physicians, and 6% were healthcare organizations. The five most commonly shared links were shared 248 times and included links to research articles, government guidelines, news articles, and a review blog. Peaks of usage of these hashtags coincided with the publication of research articles. CONCLUSIONS: New hashtags like #PIMSTS and #MISC have been used in the PCC community to focus and disseminate contents related to a novel pediatric syndrome related to COVID19. The evolving definitions and names used for this new entity are converging, but early confusion in names may have hampered discussion on Twitter and curation of reliable content.

Modeling the consumption response to the cares act∗

To predict the effects of the 2020 U.S. CARES Act on con-sumption, we extend a model that matches responses to past consumption stimulus packages. The extension allows us to account for two novel features of the coronavirus crisis. First, during lockdowns, many types of spending are undesirable or impossible. Second, some of the jobs that disappear during the lockdown will not reappear. We estimate that, if the lock-down is short-lived (the median point of view as we are writing in April 2020), the combination of expanded unemployment insurance benefits and stimulus payments should be sufficient to allow a swift recovery in consumer spending to pre-crisis levels. If the lockdown lasts longer (or there is a “second wave”), an extension of enhanced unemployment benefits will likely be necessary for consumption spending to recover quickly. © 2021, European Central Bank. All rights reserved.

Routine testing of close contacts of confirmed COVID-19 cases - National COVID-19 Contact Management Programme, Ireland, May to August 2020.

OBJECTIVES: The objective of this study was to inform public health practitioners who are designing, adapting and implementing testing and tracing strategies for Coronavirus disease (COVID-19) control. STUDY DESIGN: The study design is monitoring and evaluation of a national public health protection programme. METHODS: All close contacts of laboratory-confirmed cases of COVID-19 identified between the 19th May and 2nd August were included; secondary attack rates and numbers needed to test were estimated. RESULTS: Four thousand five hundred eighty six of 7272 (63%) close contacts of cases were tested with at least one test. The secondary attack rate in close contacts who were tested was 7% (95% Confidence Interval [CI]: 6.3 - 7.8%). At the 'day 0' test, 14.6% (95% CI: 11.6-17.6%) of symptomatic close contacts tested positive compared with 5.2% (95% CI: 4.4-5.9%) of asymptomatic close contacts. CONCLUSIONS: The application of additional symptom-based criteria for testing in this high-incidence population (close contacts) is of limited utility because of the low negative predictive value of absence of symptoms.