Performance of General Surgical Procedures in Outpatient Settings Before and After Onset of the COVID-19 Pandemic.

Importance: The American College of Surgeons (ACS) has advocated for the expansion of outpatient surgery to conserve limited hospital resources and bed capacity, while maintaining surgical throughput, during the COVID-19 pandemic. Objective: To investigate the association of the COVID-19 pandemic with outpatient scheduled general surgery procedures. Design, Setting, and Participants: This multicenter, retrospective cohort study analyzed data from hospitals participating in the ACS National Surgical Quality Improvement Program (ACS-NSQIP) from January 1, 2016, to December 31, 2019 (before COVID-19), and from January 1 to December 31, 2020 (during COVID-19). Adult patients (≥18 years of age) who underwent any 1 of the 16 most frequently performed scheduled general surgery operations in the ACS-NSQIP database were included. Main Outcomes and Measures: The primary outcome was the percentage of outpatient cases (length of stay, 0 days) for each procedure. To determine the rate of change over time, multiple multivariable logistic regression models were used to assess the independent association of year with the odds of outpatient surgery. Results: A total of 988 436 patients were identified (mean [SD] age, 54.5 [16.1] years; 574 683 women [58.1%]), of whom 823 746 underwent scheduled surgery before COVID-19 and 164 690 had surgery during COVID-19. On multivariable analysis, the odds of outpatient surgery during COVID-19 (vs 2019) were higher in patients who underwent mastectomy for cancer (odds ratio [OR], 2.49 [95% CI, 2.33-2.67]), minimally invasive adrenalectomy (OR, 1.93 [95% CI, 1.34-2.77]), thyroid lobectomy (OR, 1.43 [95% CI, 1.32-1.54]), breast lumpectomy (OR, 1.34 [95% CI, 1.23-1.46]), minimally invasive ventral hernia repair (OR, 1.21 [95% CI, 1.15-1.27]), minimally invasive sleeve gastrectomy (OR, 2.56 [95% CI, 1.89-3.48]), parathyroidectomy (OR, 1.24 [95% CI, 1.14-1.34]), and total thyroidectomy (OR, 1.53 [95% CI, 1.42-1.65]). These odds were all greater than those observed for 2019 vs 2018, 2018 vs 2017, and 2017 vs 2016, suggesting that an accelerated increase in outpatient surgery rates in 2020 occurred as a consequence of COVID-19, rather than a continuation of secular trends. Despite these findings, only 4 procedures had a clinically meaningful (≥10%) overall increase in outpatient surgery rates during the study period: mastectomy for cancer (+19.4%), thyroid lobectomy (+14.7%), minimally invasive ventral hernia repair (+10.6%), and parathyroidectomy (+10.0%). Conclusions and Relevance: In this cohort study, the first year of the COVID-19 pandemic was associated with an accelerated transition to outpatient surgery for many scheduled general surgical operations; however, the magnitude of percentage increase was small for all but 4 procedure types. Further studies should explore potential barriers to the uptake of this approach, particularly for procedures that have been shown to be safe when performed in an outpatient setting.

Factors Influencing Emergency Medical Services Burnout

Study Objectives: Increased rates of suicide and suicidal thoughts amongst Emergency Medical Service (EMS) professionals continue to be reported in literature which has directed attention to potential causative factors. Burnout is one of the factors most discussed as being associated with this increase. There are limited studies of factors that correlate with increased burnout. Our objective was to conduct a survey of a statewide population of emergency services providers to evaluate their rate of burnout in addition to identifying both work and personal factors that may contribute to their burnout level. We also looked at self-reported burnout prior to the Covid 19 pandemic and during. Method(s): A voluntary, anonymous electronic survey was distributed to all registered emergency medical providers in the state of Louisiana through the Louisiana Bureau of EMS and the Louisiana Ambulance Alliance from 5/18/2020 to 7/24/2020. These participants represented paid and volunteer providers from a variety of systems to include;fire based, private, third city and air medical services. Data was analyzed utilizing descriptive statistics. Results/Findings: We received a total of 1,505 responses from the 24,000 EMS providers licensed with the Louisiana Bureau of EMS. The overall response rate when factoring all active Louisiana providers was 6.09% However, the response rate increases with increasing level of provider with more 50% of responses from paramedic and advanced emergency medical technicians (AEMT) The paramedic response rate was 22.39%. The advanced EMT response rate was 28.74% The EMT response rate was much lower at 9.03%. Burnout level increased with number of years of EMS experience, increased years at current EMS provider level and more advanced levels of provider. Shift length of 12-24 hours showed the highest level of burnout (2.8, IQR 2-4). Decreased amounts of sleep correlated with increasing burnout levels. Supervisory positions correlated with higher levels of burnout. Services that did transfers only showed the lowest burnout levels (1, IQR 0-2) and those who did scene calls with and without transfer and special events showed the highest levels of burnout (2.75, IQR 2-3.5). Burnout level for pre-COVID (at 2.1) was statistically lower than burnout during COVID (2.7, p=3.15x10- 24). Burnout level pre-COVID was highest when respondents were contemplating leaving the profession and expected their profession to end within less than 1.75 years (135 individuals fall into this category). Burnout during COVID was highest not only with those two categories influencing it, but also with the perception of unfair compensation, typical shift length and years of experience. Unfair compensation had a greater impact for the COVID burnout measurement than years of expected continued service. Conclusion(s): Pressures resulting in high burnout changed in this time;although contemplating leaving was still the greatest factor contributing to burnout, the second-most important decision changed from predictions about continued employment to concerns regarding fair compensation. Burnout was significantly higher during COVID and was subject to more variables than pre-COVID burnout. [Formula presented] [Formula presented] No, authors do not have interests to disclose Copyright © 2022

Fetoplacental transmission and placental response to SARS-CoV-2: Evidence from the literature.

Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) is a dreadful novel coronavirus with global health concerns among pregnant women. To date, the vertical transmission of SARS-CoV-2 during pregnancy remains controversial. We briefly report recent findings of placental response to SARS-CoV-2 infection and updates on vertical transmission. We systematically searched PubMed and Google Scholar databases according to PRISMA guidelines for studies reporting the effects of SARS-CoV-2 infection on the placenta and possibility of vertical transmission. We identified 45 studies reporting 1,280 human placentas that were analyzed by molecular pathology methods and 11,112 placenta-derived cells from a publicly available database that was analyzed using bioinformatics tools. The main finding of this study is that the SARS-CoV-2 canonical entry receptors (ACE2 and TMPRSS2) are abundantly expressed on the placenta during the first trimester, and this expression diminishes across gestational age. Out of 45 eligible studies identified, 24 (53.34%) showed no evidence of vertical transmission, 15 (33.33%) supported the hypothesis of very rare, low possibility of vertical transmission and 6 (13.33%) were indecisive and had no comment on vertical transmission. Furthermore, 433 placentas from 12 studies were also identified for placental pathology investigation. There was evidence of at least one form of maternal vascular malperfusion (MVM), 57/433 (13.1%), fetal vascular malperfusion (FVM), 81/433 (18.7%) and placental inflammation with excessive infiltration of CD3+ CD8+ lymphocytes, CD68+ macrophages and CD20+ lymphocytes in most of the eligible studies. Decidual vasculopathy (3.2%), infarction (3.2%), chronic histiocytic intervillositis (6.0%), thrombi vasculopathy (5.1%) were also observed in most of the MVM and FVM reported cases. The results indicated that SARS-CoV-2 induces placenta inflammation, and placenta susceptibility to SARS-CoV-2 decreases across the pregnancy window. Thus, SARS-CoV-2 infection in early pregnancy may adversely affect the developing fetus.

Humoral and Cellular Responses to SARS-CoV-2 Vaccines in MS Patients on Ocrelizumab and Other Disease-modifying Therapies: A Prospective Study From NYU Multiple Sclerosis Care Center

Objective: To compare humoral and cellular responses to COVID-19 vaccines in 400 consecutive MS patients who were on Ocrelizumab ('OCR') and other disease-modifying therapies ('nonOCR') at the time of vaccination. Background: Peripheral B-cell depletion with anti-CD20 therapies, attenuates humoral responses to vaccines, but less is known about cellular responses. Design/Methods: Consecutive MS patients from NYU MS Care Center were invited to participate if they completed COVID-19 vaccination ≥6 weeks previously. Immune testing included anti-spike RBD antibody (Elecsys Anti-SARS-CoV-2) (Roche Diagnostics);multiepitope bead-based immunoassays (MBI) of antibody-responses to SARS-COV-2 spike proteins (threshold of 'positivity'was chosen as 2 SD below non-OCR mean);T-cell responses to SARSCoV-2 Spike protein using IFNγ enzyme-linked immune-absorbent spot (Invitrogen) and TruCulture (Myriad RBM) assays;high dimensional immunophenotyping;live virus immunofluorescence-based microneutralization assay. Results: Antibody and T cell data was available on 145/355 patients enrolled to date (mean age: 40.0 years;75% female;48% non-white;39% on OCR;12% with prior COVID-19 infection;vaccines: 58% Pfizer/BioNTech, 36% Moderna and 6% Johnson&Johnson;median vaccine-tosample time: 93 (+/-32) days). In OCR, Elecsys Anti-SARS-CoV-2 Ab titers were detected in 30/63 (48%;mean antibody titer in log scale: 1.63) and in non-OCR - in 78/81 (96%, mean Ab titer in log scale: 2.83;p<0.0001). In OCR, antibody response by MBI were detected in 41/57 (72%, mean level in log scale: 3.09) and in non OCR - in 68/72 (94%, mean level in log scale: 4.08;p<0.001). Neutralizing antibodies were detected in 10/42 (38%) of OCR and 24/43 (56%) of non-OCR (p=0.1). T-cell activation based on induced IFNg secretion (TruCulture) was observed in 50/64 (78%) OCR and 43/81 (53%) non-OCR (p=0.002). Conclusions: Preliminary results suggest robust vaccine-specific T-cell immune response to SARS-CoV2 vaccines in B-cell depleted patients, but markedly attenuated antibody responses. Final results of pre-planned multivariable analyses stratified by DMT class and high-dimensional immunophenotyping will be presented.

Robust immune responses are observed after one dose of BNT162b2 mRNA vaccine dose in SARS-CoV-2 experienced individuals

[Figure: see text].

Antibody and T-cell responses to SARS-CoV-2 vaccines in MS patients on Ocrelizumab and other disease-modifying therapies: Preliminary results of an ongoing, prospective study

Objective: To compare humoral and T-cell responses to COVID- 19 vaccines in 400 MS patients who were on Ocrelizumab ('OCR') v. other disease-modifying therapies ('non-OCR') at the time of vaccination. Introduction: Peripheral B-cell depletion with anti-CD20 therapies attenuates humoral responses to vaccines. Whether immune responses to COVID-19 vaccines differ between B-cell depleted and non-B cell depleted MS patients is not known. Methods: Consecutive MS patients from NYU MS Care Center were invited to participate if they completed COVID-19 vaccination ≥6 weeks previously. Immune testing included anti-spike RBD antibody (Elecsys Anti-SARS-CoV-2) (Roche Diagnostics);multiplex bead-based immunoassays of antibody-responses to SARS-COV-2 spike proteins;T-cell responses to SARS-CoV-2 Spike protein using IFNγ enzyme-linked immune-absorbent spot (Invitrogen) and TruCulture (Myriad RBM) assays;high dimensional immunophenotyping;and live virus immunofluorescencebased microneutralization assay. Results: As of 7/15/2021, 105 MS subjects were enrolled (mean age: 40.5 years;76% female;41% non-white;38% on OCR;12% with prior COVID-19 infection). 95% were fully vaccinated with mRNA vaccines (Pfizer/Moderna);5% - with adenovirus-based vaccine (Johnson&Johnson). Median time from sample collection to last vaccine was 79 days. Positive Elecsys Anti-SARS-CoV-2 Ab titers post-vaccine were detected in 11/37 (30%) in OCR (mean level: 702 U/mL among seropositives) and 54/54 (100%) patients in non-OCR (mean level: 2310 U/mL;p<0.0001). Positive response by multiplex assay (threshold of 'positive' defined as 2 SD below the mean for the non-OCR) were detected in 10/27 (37%) OCR and 29/31 (94%) non-OCR (p<0.00001). T-cell activation based on induced IFNγ secretion (TruCulture) was detected in 20/25 (80%) OCR and 16/19 (84%) non-OCR patients (p=0.71). Conclusions: Preliminary results suggest robust T-cell immune response to SARS-CoV2 vaccines in approximately 80% of both OCR and non-OCR MS patients. Antibody responses were markedly attenuated in OCR compared to non-OCR group. Updated results will be presented.

Machine Learning: The Next Paradigm Shift in Medical Education.

Machine learning (ML) algorithms are powerful prediction tools with immense potential in the clinical setting. There are a number of existing clinical tools that use ML, and many more are in development. Physicians are important stakeholders in the health care system, but most are not equipped to make informed decisions regarding deployment and application of ML technologies in patient care. It is of paramount importance that ML concepts are integrated into medical curricula to position physicians to become informed consumers of the emerging tools employing ML. This paradigm shift is similar to the evidence-based medicine (EBM) movement of the 1990s. At that time, EBM was a novel concept; now, EBM is considered an essential component of medical curricula and critical to the provision of high-quality patient care. ML has the potential to have a similar, if not greater, impact on the practice of medicine. As this technology continues its inexorable march forward, educators must continue to evaluate medical curricula to ensure that physicians are trained to be informed stakeholders in the health care of tomorrow.

Racial Disparity in COVID-19 Symptoms

Study Objectives: COVID-19 first emerged as an unknown respiratory virus in late 2019. Since the onset of the pandemic, the question of racial differences has been at the forefront of prognostic thought in determination of high-risk groups. Limited data is currently available about racial differences in symptoms of COVID-19. This research performed a retrospective data collection of patients in a hospital system in North Louisiana to determine if there was a statistical difference in presenting symptoms based on race. Methods: A total of 410 unique Medical Record Numbers (MRNs) were identified retrospectively. Data was collected from a mix of rapid and regular PCR nasal swabs collected from 4/1/2020 to 4/30/2020. Data collected included symptoms, race, ethnicity, occupation, sex and age. Symptoms were collected from their chief complaint, HPI, review of systems as well as nursing evaluation. Similar symptoms expressed in different wording were collapsed into larger categories. The rpart algorithm was used to perform association rule mining in both uncollapsed and collapsed data. Results: Black patients were the most represented race (74%) in our study. 399 patients were admitted with COVID-19 in April 2020. In Black patients, 306 were admitted (76.692%) compared to 79 White patients (19.799%). There were also significant differences on the basis of race between both the number of “typical” symptoms (Black=2.925 +- 2.067, White=2.367 +- 2.014, p=0.0330) and the more general “collapsed” categories of atypical symptoms (Black=1.036 +- 0.765, White=0.823 +- 0.844, p=0.026), but not concerning the number of atypical symptoms more specifically associated with COVID-19 (Black=0.428 +- 0.770, White=0.468 +- 0.749, p=0.589). This is concordant with our association rule mining results, which indicated that in Black patients, fever was frequently associated with myalgias, cough, and shortness of breath (lift=1.897) Conclusion: While evaluating the racial distribution of COVID-19 as it pertained to symptoms, Black patients were statistically more affected by COVID-19 in North Louisiana. Blacks make up 38% of the region's population but were 74% of the region’s COVID-19 cases. This was not observed in South Louisiana. Additionally, Black patients were more likely to be admitted than their White counterparts and were likely to have both more typical and atypical symptoms at presentation. Further investigation into the corresponding factors such as issues like weight, comorbid conditions, and genetic polymorphisms for ACE-I tropism should be explored to illuminate the proposed racial selection that SARS2-COVID-19 demonstrates for those of African descent.

Lung microbiota dysbiosis and the implications of SARS-CoV-2 infection in pregnancy.

There are a great number of beneficial commensal microorganisms constitutively colonizing the mucosal lining of the lungs. Alterations in the microbiota profile have been associated with several respiratory diseases such as pneumonia and allergies. Lung microbiota dysbiosis might play an important role in the pathogenic mechanisms of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) as well as elicit other opportunistic infections associated with coronavirus disease 2019 (COVID-19). With its increasing prevalence and morbidity, SARS-CoV-2 infection in pregnant mothers is inevitable. Recent evidence shows that angiotensin-converting enzyme 2 (ACE2) and transmembrane protease serine 2 (TMPRSS2) act as an entry receptor and viral spike priming protein, respectively, for SARS-CoV-2 infection. These receptor proteins are highly expressed in the maternal-fetal interface, including the placental trophoblast, suggesting the possibility of maternal-fetal transmission. In this review, we discuss the role of lung microbiota dysbiosis in respiratory diseases, with an emphasis on COVID-19 and the possible implications of SARS-CoV-2 infection on pregnancy outcome and neonatal health.

One dose of COVID-19 mRNA vaccine in SARS-CoV-2-experienced people may be sufficient

Background: Understanding if single doses of SARS-CoV-2 mRNA vaccines in SARS-CoV-2-experienced people are fully protective is a public health priority. This study measured immune responses before and after mRNA vaccine in people with or without histories of COVID-19. Methods: Specimens were collected from participants before and 6-14 days after doses 1 and 2. Humoral assays included an S1-specific Ig ELISA and a livevirus microneutralization assay (MN) vs the original SARS-CoV-2 USA-WA1/2020 strain. ELISpot assays and 36-color spectral analysis flow cytometry assessed B- and T-cell responses. Results: 32 adults received Pfizer BioNTech vaccine and 1 received Moderna vaccine. 14 had a history of COVID-19 (median age 41, 71% female, 10 with 3/20 and 2 with 12/20 illness onset, 2 asymptomatic). 19 were SARS-CoV-2-naïve (median age 39, 47% female). S1-specific IgG/A/M ASC were detected readily by ELISpot 6-14 days after dose 1 and were higher in SARS-CoV-2-experienced (median: 200) than -naïve (median: 27) subjects;after dose 2, the converse was observed (medians 53 vs 293). By flow cytometry, T cell activation was broadly observed 6-14 days after 1st vaccination, with increases in CD4+ or CD8+ T cells expressing CD38 and Ki67 (CD4: median fold-changes 1.6 for SARS-CoV-2-experienced and 1.8 for -naïve;CD8: 3.1 and 2.2). S1-specific IgG was present at baseline in experienced subjects (median: 6320), peaked at 6-14 days post-dose 1 (median: 169000), and wasn't boosted by dose 2 (panel A). In naïve participants, S1-specific IgG was not present at baseline, low at day 6-14 (median: 66), higher at day 21 (median: 27000), and boosted by dose 2 (median: 188000). Interestingly, by 6-14 days after dose 2, experienced and naïve subjects had similar S1-specific IgG titers. The MN titers followed a similar pattern (panel B): in experienced subjects, striking increases after dose 1 (median: 9860) but no boosting by dose 2;in naïve subjects, no neutralization was observed at 6-14 days, low titers were present at 21 days post-dose 1 (median: 43), with boosting after dose 2 (median: 513). Conclusion: People with a history of SARS-CoV-2 infection who received a single dose of mRNA vaccine produced binding and neutralizing antibody titers at 6-14 days that were similar to, or higher than, titers in SARS-CoV-2-naïve people who had received 2 doses. Their titers were not boosted by a second dose. These findings support a hypothesis that SARS-CoV-2-experienced people may require only a single dose of mRNA vaccine.