ABSTRACT
Background: The COVID-19 pandemic has impacted our community in many ways, with negative downstream effects on the mental health system. Greater limitations on community resources have resulted in increased emergency room visits for acute mental health treatment. The increase in patients, along with limited resources, has led to patients boarding for hours to days in emergency rooms and medical floors. Method(s): Given the need for acute psychiatric treatment in the ED and medical floor, a rapid psychiatric stabilization (RPS) team was created. This team consists of 2 complex case BH managers, ED BH case managers, advanced practice clinicians, and psychiatrists;they meet virtually each morning to deploy resources where needed. The goal is to start active psychiatric treatment at time of presentation. Result(s): Examples of cases treated by the RPS team: Example #1: J.R. is a 10 yr. old who presented to the ED for increasing aggressive behaviors. Initial recommendation was for inpatient psychiatric admission;however, no bed was able to be secured. A psychiatrist met with J.R. daily and started medication for his aggression. After 4 days in the ED, J.R was stable for discharge, with an aftercare plan arranged by the complex BH case manager. Additionally, the team collaborated with his pediatrician to obtain prior authorization for psychotropic medication until an outpatient psychiatric appointment was secured. Example #2: H.B. is a 28 yr. old who presented to the ED with SI, however, was medically admitted due to being COVID positive. She was treated psychiatrically on the medical floor. As a result, she was discharged prior to her 10-day quarantine was completed, due to her positive response to treatment, and with psychiatric follow up arranged by the complex BH case manager. Prior to establishing the RPS team, discharges from the medical floor would have been difficult due to the inability to set up aftercare. Discussion(s): The American Academy of Child and Adolescent Psychiatry and Children's Hospital Association have declared a national emergency in children's mental health (1). Data from Mental Health America showed that any mental illness has increased 5% nationally, with a 7.6% increase in Pennsylvania (2). Additionally, adults with serious thoughts of suicide have increased 6% nationally and 16% in Pennsylvania. At LVHN-Lehigh Valley, psychiatric emergency room presentations have increased 1,401 (20%) compared to last year and are projected at 8,398. Clearly, demand for psychiatric treatment has grown, creating strain on the limited recourses available. Conclusion(s): The increased need for psychiatric treatment, coupled with the reduction of community resources, will cause psychiatric providers to rethink and redesign care in the post-pandemic world. The deployment of a RPS team to actively treat patients in non-traditional psychiatric settings is just one attempt at dealing with the psychiatric crises. Copyright © 2022
ABSTRACT
Aim: Due to the Covid-19 pandemic, specialist palliative care services have had to adapt the delivery of service for patient safety, particularly outpatient group interventions.The physiotherapy department had successfully run an exercise and education programme for patients with advanced lung disease who are severely deconditioned, breathless and unsuitable for inclusion in standard rehabilitation programmes. The aim of this project was to adapt the programme from its original format and transition it to an evidence-based telehealth(TH) programme. Design: We reviewed evidence-based literature examining successful TH service delivery and liaised with an established TH pulmonary rehabilitation service. Results: Through our research, we identified the following areas of concern;Technology-Considerations for selecting a videoconferencing platform included user-friendliness and quality of audio-visual functions. Instruction leaflets to assist patients navigate the platform were developed. Security measures such as the ability to provide password protected meetings and data encryption were considered. Safety-A home visit was completed, including a review of exercise precautions. It was recommended that a second person be present during classes. A risk assessment was completed for those without a second person. Classes were facilitated by two physiotherapists;one leading the class while the other monitored patients for adverse events. This programme has been successfully running for 3 months with no adverse events. Conclusion/Lessons learned: This project has given us insight into the benefits of having an online platform. Initial concerns regarding patients' ability to master technology were eased and only minimal troubleshooting was required. Future research should investigate whether it is sustainable over a longer period without affecting quality of care. Existing research was limited and this project has provided a platform for which guidelines may be developed.
ABSTRACT
INTRODUCTION: Complex critical syndromes like sepsis and COVID-19 may be composed of underlying subclasses, or 'endotypes,' which may respond differently to treatment. We previously reported the discovery and validation of a 33-mRNA host response classifier which defined three sepsis endotypes across 1,300 patients with bacterial sepsis at hospital or ICU admission. Here, we aimed to test whether our 33-mRNA bacterial sepsis endotypes classifier recapitulates the same clinical and immunological endotypes in COVID-19. METHODS: In this prospective, single-center observational cohort study, we recruited adult patients with RT-PCRconfirmed COVID-19 within 24 hours of admission to an Athens, Greece hospital. RNA was extracted from whole blood collected in PAXgene RNA tubes, and then profiled on the NanoString nCounter® platform to quantify the 33 mRNAs. The endotypes classifier then assigned one of three endotypes (Inflammopathic, Adaptive, or Coagulopathic) to each patient. We tested endotype status against other clinical parameters including lab values, severity scores, and outcomes. RESULTS: We enrolled 71 patients with COVID-19, of which 33 went on to severe respiratory failure (SRF), of which 6 (8%) died. Patients were assigned as Inflammopathic (34%), Adaptive (39%), or Coagulopathic (27%);Adaptive patients had lower rates of SRF and no mortalities. Coagulopathic and Inflammopathic endotypes had 12% and 16% mortality rates. The Coagulopathic group was significantly associated with D-dimers, and the Inflammopathic group showed high clinical severity and highest C-reactive protein and IL-6 levels. CONCLUSIONS: Our predefined 33-mRNA endotypes classifier recapitulated immune phenotypes in viral sepsis (COVID-19) despite its prior training and validation only in bacterial sepsis. Further work should focus on continued validation of the endotypes and their interaction with immunomodulatory therapy. If confirmed with future studies, the 33-mRNA classifer could be used as a companiondiagnostic test to guide a precision-medicine-based intervention.
ABSTRACT
Background: COVID-19 is a pandemic caused by the SARS-CoV-2 virus that shares and differs in clinical characteristics of known viral infections. Methods: We obtained RNAseq profiles of 62 prospectively enrolled COVID-19 patients and 24 healthy controls (HC). We collected 23 independent studies profiling 1,855 blood samples from patients covering six viruses (influenza, RSV, HRV, Ebola, Dengue and SARS-CoV-1). We studied host whole-blood transcriptomic responses in COVID-19 compared to non-COVID-19 viral infections to understand similarities and differences in host response. Gene signature threshold was absolute effect size ≥1, FDR ≤ 0.05%. Results: Differential gene expression of COVID-19 vs HC are highly correlated with non-COVID-19 vs HC (r=0.74, p< 0.001). We discovered two gene signatures: COVID-19 vs HC (2002 genes) (COVIDsig) and non-COVID-19 vs HC (635 genes) (nonCOVIDsig). Pathway analysis of over-expressed signature genes in COVIDsig or nonCOVIDsig identified similar pathways including neutrophil activation, innate immune response, immune response to viral infection and cytokine production. Conversely, for under-expressed genes, pathways indicated repression of lymphocyte differentiation and activation (Fig1). Intersecting the two gene signatures found two genes significantly oppositely regulated (ACO1, ATL3). We derived a third gene signature using COCONUT to compare COVID-19 to non-COVID-19 viral infections (416 genes) (Fig2). Pathway analysis did not result in significant enrichment, suggesting identification of novel biology (Fig1). Statistical deconvolution of bulk transcriptomic data found M1 macrophages, plasmacytoid dendritic cells, CD14+ monocytes, CD4+ T cells and total B cells changed in the same direction across COVID-19 and non-COVID-19 infections. Cell types that increased in COVID-19 relative to non-COVID-19 were CD56bright NK cells, M2 macrophages and total NK cells. Those that decreased in non- COVID-19 relative to COVID-19 were CD56dim NK cells & memory B cells and eosinophils (Fig3). Conclusion: The concordant and discordant responses mapped here provide a window to explore the pathophysiology of COVID-19 vs other viral infections and show clear differences in signaling pathways and cellularity as part of the host response to SARS-CoV-2.