Rethinking immunologic risk: a retrospective cohort study of severe SARS-CoV-2 infections in individuals with congenital immunodeficiencies (preprint)

Background. Debates on the allocation of medical resources during the COVID-19 pandemic revealed the need for a better understanding of immunologic risk. Studies highlighted variable clinical outcomes of SARS-CoV-2 infections in individuals with defects in both adaptive and innate immunity, suggesting additional contributions from other factors. Notably, none of these studies controlled for variables linked with social determinants of health. Objective. To determine the contributions of determinants of health to risk of hospitalization for SARS-CoV-2 infection among individuals with inborn errors of immunodeficiencies. Methods. This is a retrospective, single-center cohort study of 166 individuals with inborn errors of immunity, aged two months through 69 years, who developed SARS-CoV-2 infections from March 1, 2020 through March 31, 2022. Risks of hospitalization was assessed using a multivariable logistic regression analysis. Results. The risk of SARS-CoV-2-related hospitalization was associated with underrepresented racial and ethnic populations (odds ratio [OR] 5.29; confidence interval [CI], 1.76-17.0), a diagnosis of any genetically-defined immunodeficiency (OR 4.62; CI, 1.60-14.8), use of B cell depleting therapy within one year of infection (OR 6.1; CI, 1.05-38.5), obesity (OR 3.74; CI, 1.17-12.5), and neurologic disease (OR 5.38; CI, 1.61-17.8). COVID-19 vaccination was associated with reduced hospitalization risk (OR 0.52; CI, 0.31-0.81). Defective T cell function, immune-mediated organ dysfunction, and social vulnerability were not associated with increased risk of hospitalization after controlling for covariates. Conclusions. The associations between race, ethnicity, and obesity with increased risk of hospitalization for SARS-CoV-2 infection indicate the importance of variables linked with social determinants of health as immunologic risk factors for individuals with inborn errors of immunity.

Study protocol of a phase 2, randomised, placebo-controlled, double-blind, adaptive, parallel group clinical study to evaluate the efficacy and safety of recombinant alpha-1-microglobulin in subjects at high risk for acute kidney injury following open-chest cardiac surgery (AKITA trial).

INTRODUCTION: Acute kidney injury (AKI) is a common complication after cardiac surgery (CS) and is associated with adverse short-term and long-term outcomes. Alpha-1-microglobulin (A1M) is a circulating glycoprotein with antioxidant, heme binding and mitochondrial-protective mechanisms. RMC-035 is a modified, more soluble, variant of A1M and has been proposed as a novel targeted therapeutic protein to prevent CS-associated AKI (CS-AKI). RMC-035 was considered safe and generally well tolerated when evaluated in four clinical phase 1 studies. METHODS AND ANALYSIS: This is a phase 2, randomised, double-blind, adaptive design, parallel group clinical study that evaluates RMC-035 compared with placebo in approximately 268 cardiac surgical patients at high risk for CS-AKI. RMC-035 is administered as an intravenous infusion. In total, five doses will be given. Dosing is based on presurgery estimated glomerular filtration rate (eGFR), and will be either 1.3 or 0.65 mg/kg.The primary study objective is to evaluate whether RMC-035 reduces the incidence of postoperative AKI, and key secondary objectives are to evaluate whether RMC-035 improves postoperative renal function compared with placebo. A blinded interim analysis with potential sample size reassessment is planned once 134 randomised subjects have completed dosing. An independent data monitoring committee will evaluate safety and efficacy data at prespecified intervals throughout the trial. The study is a global multicentre study at approximately 30 sites. ETHICS AND DISSEMINATION: The trial was approved by the joint ethics committee of the physician chamber Westfalen-Lippe and the University of Münster (code '2021-778 f-A') and subsequently approved by the responsible ethics committees/relevant institutional review boards for the participating sites. The study is conducted in accordance with Good Clinical Practice, the Declaration of Helsinki and other applicable regulations. Results of this study will be published in a peer-reviewed scientific journal. TRIAL REGISTRATION NUMBER: NCT05126303.

Group dynamics when battling a pandemic

Background: This special issue of Group Dynamics presents six articles that address aspects of how group dynamics and processes have been impacted by, and have the potential to impact, the SARS-CoV-2 or COVID-19 pandemic. Method: This introduction briefly reviews and comments on each article. Results: The articles highlight a number of issues and findings: the natural inclination of people to congregate in groups both exacerbate the spread of the virus and can provide solace during these times of stress;the concept of groupthink may explain the seemingly irrational rejection of public health measures among some in society;group psychotherapy is effective, but we need more research to understand how it works when delivered in an online format as necessitated by the current pandemic;an emotional management intervention might help virtual work groups to perform better;how members perceive their virtual environment could affect the quality of their groupwork;and today's virtual work environments requires group members to have a common understanding of the technologies they are using. Conclusions: The current crisis has highlighted that groups to which we belong are important to our mental health and productivity. The pandemic also has made clear the need for a broader scholarly and professional investment in the understanding and use of groups. Such an investment would not only move the fields of group research forward, but would also inform public health policy, and ease our adjustment to and capacity to flourish in the current and future pandemics.

Mourning and restoration

During the endless days of March and April 2020, New York City experienced more than 20,000 COVID-19 deaths and was considered the "epicenter" of a new global pandemic. Nursing homes witnessed the virus's contagion at staggering rates, with elderly and debilitated patients coming in by the dozens, gasping for breath, scared they would die and never see their loved ones again. Our hospital and our lives were quickly transformed. The author spent most of his clinical effort during those months running a new eight-bed hospice unit in our hospital. The author then presents the story of a hospice patient, a fifty-nine-year-old Black male-to-female transgender homeless woman. She had been diagnosed with an aggressive squamous cell carcinoma. She underwent chemotherapy, radiation therapy, and surgery, including a diverting colectomy, leaving her with a permanent ostomy. She had several other medical problems-chronic kidney disease, heart disease, diabetes, major depression, and chronic lymphedema. Taking care in her last days of life was agonizing. The possibility to have spent more time getting to know her. To explore her world and navigate the challenges of her health and condition together. This is the privilege of the doctor-patient relationship. (PsycInfo Database Record (c) 2023 APA, all rights reserved)

Assessing Public Confidence Towards COVID-19 Vaccines Through Social Media Insights Leveraged Using Artificial Intelligence Techniques

Introduction. In areas where public confidence is low and there is a lack of understanding around behaviors, such as COVID-19 vaccine hesitancy, there is a need to explore novel sources of evidence. When leveraged using artificial intelligence (AI) techniques, social media data may offer rich insights into public concerns around vaccination. Currently, sources of 'soft-intelligence' are underutilized by policy makers, health technology assessment (HTA) and other public health research agencies. In this work, we used an AI platform to rapidly detect and analyze key barriers to vaccine uptake from a sample of geo-located tweets. Methods. An AI-based tool was deployed using a robust search strategy to capture tweets associated with COVID-19 vaccination, posted from users in London, United Kingdom. The tool's algorithm automatically clustered tweets based on key topics of discussion and sentiment. Tweets contained within the 12 most populated topics with negative sentiment were extracted. The extracted tweets were mapped to one of six pre-determined themes (safety, mistrust, underrepresentation, complacency, ineffectiveness, and access) informed using the World Health Organization's 3Cs vaccine hesitancy model. All collated tweets were anonymized. Results. We identified 91,473 tweets posted between 30 November 2020 and 15 August 2021.Asample of 913 tweets were extracted from the twelve negative topic clusters. Of these, 302 tweets were coded to a vaccine hesitancy theme. 'Safety' (29%) and 'mistrust' (23%) were the most commonly coded themes;the least commonly coded was 'under-representation' (3%). Within the main themes, adverse reactions, inadequate assessment, and rushed development of the vaccines as key findings. Our analysis also revealed widespread sharing of misinformation. Conclusions. Using an AI-based text analytics tool, we were able to rapidly assess public confidence in COVID-19 vaccination and identify key barriers to uptake from a corpus of geo-located tweets. Our findings support a growing body of evidence and confidence surrounding the use of AI tools to efficiently analyze early sources of soft-intelligence evidence in public health research.

Mourning and restoration

During the endless days of March and April 2020, New York City experienced more than 20,000 COVID-19 deaths and was considered the "epicenter" of a new global pandemic. Nursing homes witnessed the virus's contagion at staggering rates, with elderly and debilitated patients coming in by the dozens, gasping for breath, scared they would die and never see their loved ones again. Our hospital and our lives were quickly transformed. The author spent most of his clinical effort during those months running a new eight-bed hospice unit in our hospital. The author then presents the story of a hospice patient, a fifty-nine-year-old Black male-to-female transgender homeless woman. She had been diagnosed with an aggressive squamous cell carcinoma. She underwent chemotherapy, radiation therapy, and surgery, including a diverting colectomy, leaving her with a permanent ostomy. She had several other medical problems-chronic kidney disease, heart disease, diabetes, major depression, and chronic lymphedema. Taking care in her last days of life was agonizing. The possibility to have spent more time getting to know her. To explore her world and navigate the challenges of her health and condition together. This is the privilege of the doctor-patient relationship. (PsycInfo Database Record (c) 2023 APA, all rights reserved)

The Connection between Climate Change, Surgical Care and Neglected Tropical Diseases.

The surgical burden of neglected tropical diseases (NTDs) is set to rise alongside average temperatures and drought. NTDs with surgical indications, including trachoma and lymphatic filariasis, predominantly affect people in low- and middle-income countries where the gravest effects of climate change are likely to be felt. Vectors sensitive to temperature and rainfall will likely expand their reach to previously nonendemic regions, while drought may exacerbate NTD burden in already resource-strained settings. Current NTD mitigation strategies, including mass drug administrations, were interrupted by COVID-19, demonstrating the vulnerability of NTD progress to global events. Without NTD programming that meshes with surgical systems strengthening, climate change may outpace current strategies to reduce the burden of these diseases.

A Simplified Adult Expiratory Support Device: First Clinical Cases in a Low-Resource Setting.

PURPOSE: In low and middle-income countries, mechanical ventilators or commercially available devices used to offer continuous positive airway pressure are not readily affordable and available. In Ghana, nearly 10% of critically ill patients presenting to the emergency department require ventilator support. DESCRIPTION: We designed, built, and tested a simple expiratory positive airway pressure (EPAP) device to provide adult respiratory support in low resource environments with or without supplemental oxygen and without the need for electricity. EVALUATION: Laboratory tests demonstrated that the device is capable of delivering EPAP at levels expected to provide significant assistance to some patients. We present the first 2 cases where the use of this simple EPAP device provided critical respiratory support during weaning of patients from mechanical ventilation. CONCLUSIONS: A low-cost 3-dimensional printable adult respiratory support device could provide substantial benefit to patients suffering from respiratory distress through the delivery of appropriate levels of EPAP in a low-resource setting with limited infrastructure. Further clinical validation is needed for broader application in low-resource settings.

Potential Factors That Contribute to Post-COVID-19 Fatigue in Women.

Mortality of acute coronavirus disease (COVID-19) is higher in men than in women. On the contrary, women experience more long-term consequences of the disease, such as fatigue. In this perspective article, we proposed a model of the potential factors that might contribute to the higher incidence of post-COVID-19 fatigue in women. Specifically, psycho-physiological factors are features that might increase central factors (e.g., inflammation) and result in greater perceptions of fatigue. Furthermore, pre-existing conditions likely play a prominent role. This model offers a framework for researchers and clinicians, and future research is required to validate our proposed model and elucidate all mechanisms of the increased incidence and prevalence of post-COVID-19 fatigue in women.

Our Priorities Are Not Evolving, but Our Strategies Are

Submitted May 19,2021;accepted June 28,2021;published February 2022 Keywords: priorities, strategic planning, disruption, resilience, collaboration To the Editor: Dr. Daniel Malcom's commentary, "The Challenge of Coming to Terms with Evolving Priorities," resonated with us as we begin the process of recovering from the overwhelming number of personal and professional changes we've experienced in the wake of the COVID-19 pandemic.1 The disappointment described by Malcom and other faculty members in his department was faced by various institutions around the world. Identifying one's priorities and values in times of relative calm can provide clear navigation when the road becomes bumpy and unpredictable, whether it presents itself as a literal flat tire, not matching for a residency position at the end of pharmacy school, or a global pandemic. Activities designed to improve self-awareness such as emotional intelligence, CliftonStrengths and other character trait inventories can help us understand who we are, what we value, and how we present ourselves.2 Knowledge of one's guiding values or priorities can serve as a compass, pointing you towards your final destination, even if you're momentarily on a detour.

The Use of Portable Oxygen Concentrators in Low-Resource Settings: A Systematic Review.

INTRODUCTION: Portable oxygen concentrators (POCs) are medical devices that use physical means to separate oxygen from the atmosphere to produce concentrated, medical-grade gas. Providing oxygen to low-resources environments, such as austere locations, military combat zones, rural Emergency Medical Services (EMS), and during disasters, becomes expensive and logistically intensive. Recent advances in separation technology have promoted the development of POC systems ruggedized for austere use. This review provides a comprehensive summary of the available data regarding POCs in these challenge environments. METHODS: PubMed, Google Scholar, and the Defense Technical Information Center were searched from inception to November 2021. Articles addressing the use of POCs in low-resource settings were selected. Three authors were independently involved in the search, review, and synthesis of the articles. Evidence was graded using Oxford Centre for Evidence-Based Medicine guidelines. RESULTS: The initial search identified 349 articles, of which 40 articles were included in the review. A total of 724 study subjects were associated with the included articles. There were no Level I systematic reviews or randomized controlled trials. DISCUSSION: Generally, POCs are a low-cost, light-weight tool that may fill gaps in austere, military, veterinary, EMS, and disaster medicine. They are cost-effective in low-resource areas, such as rural and high-altitude hospitals in developing nations, despite relatively high capital costs associated with initial equipment purchase. Implementation of POC in low-resource locations is limited primarily on access to electricity but can otherwise operate for thousands of hours without maintenance. They provide a unique advantage in combat operations as there is no risk of explosive if oxygen tanks are struck by high-velocity projectiles. Despite their deployment throughout the battlespace, there were no manuscripts identified during the review involving the efficacy of POCs for combat casualties or clinical outcomes in combat. Veterinary medicine and animal studies have provided the most robust data on the physiological effectiveness of POCs. The success of POCs during the coronavirus disease 2019 (COVID-19) pandemic highlights the potential for POCs during future mass-casualty events. There is emerging technology available that combines a larger oxygen concentrator with a compressor system capable of refilling small oxygen cylinders, which could transform the delivery of oxygen in austere environments if ruggedized and miniaturized. Future clinical research is needed to quantify the clinical efficacy of POCs in low-resource settings.

18F-FDG-PET Imaging for Post-COVID-19 Brain and Skeletal Muscle Alterations.

Scientific evidence concerning the subacute and long-term effects of coronavirus disease 2019 (COVID-19) is on the rise. It has been established that infection by serious acute respiratory syndrome coronavirus 2 (SARS-CoV-2) is a systemic process that involves multiple organs. The complications and long-term consequences of COVID-19 are diverse and patients need a multidisciplinary treatment approach in the acute and post-acute stages of the disease. A significant proportion of COVID-19 patients experience neurological manifestations, some enduring for several months post-recovery. However, brain and skeletal muscle changes resultant from SARS CoV-2 infection remain largely unknown. Here, we provide a brief overview of the current knowledge, and usefulness, of [18F]fluorodeoxyglucose positron emission tomography/computed tomography (18F-FDG-PET/CT) to investigate brain and skeletal muscles changes in Post-COVID-19 patients with persistent symptoms. Furthermore, a brief discussion of future 18F-FDG-PET/CT applications that might advance the current knowledge of the pathogenesis of post-COVID-19 is also provided.

Effect of Continuous Electrocardiogram Monitoring on Detection of Undiagnosed Atrial Fibrillation After Hospitalization for Cardiac Surgery: A Randomized Clinical Trial.

Importance: Postoperative atrial fibrillation (POAF) occurring after cardiac surgery is associated with adverse outcomes. Whether POAF persists beyond discharge is not well defined. Objective: To determine whether continuous cardiac rhythm monitoring enhances detection of POAF among cardiac surgical patients during the first 30 days after hospital discharge compared with usual care. Design, Setting, and Participants: This study is an investigator-initiated, open-label, multicenter, randomized clinical trial conducted at 10 Canadian centers. Enrollment spanned from March 2017 to March 2020, with follow-up through September 11, 2020. As a result of the COVID-19 pandemic, enrollment stopped on July 17, 2020, at which point 85% of the proposed sample size was enrolled. Cardiac surgical patients with CHA2DS2-VASc (congestive heart failure, hypertension, age ≥75 years, diabetes, prior stroke or transient ischemic attack, vascular disease, age 65-74 years, female sex) score greater than or equal to 4 or greater than or equal to 2 with risk factors for POAF, no history of preoperative AF, and POAF lasting less than 24 hours during hospitalization were enrolled. Interventions: The intervention group underwent continuous cardiac rhythm monitoring with wearable, patch-based monitors for 30 days after randomization. Monitoring was not mandated in the usual care group within 30 days after randomization. Main Outcomes and Measures: The primary outcome was cumulative AF and/or atrial flutter lasting 6 minutes or longer detected by continuous cardiac rhythm monitoring or by a 12-lead electrocardiogram within 30 days of randomization. Prespecified secondary outcomes included cumulative AF lasting 6 hours or longer and 24 hours or longer within 30 days of randomization, death, myocardial infarction, ischemic stroke, non-central nervous system thromboembolism, major bleeding, and oral anticoagulation prescription. Results: Of the 336 patients randomized (163 patients in the intervention group and 173 patients in the usual care group; mean [SD] age, 67.4 [8.1] years; 73 women [21.7%]; median [interquartile range] CHA2DS2-VASc score, 4.0 [3.0-4.0] points), 307 (91.4%) completed the trial. In the intent-to-treat analysis, the primary end point occurred in 32 patients (19.6%) in the intervention group vs 3 patients (1.7%) in the usual care group (absolute difference, 17.9%; 95% CI, 11.5%-24.3%; P < .001). AF lasting 6 hours or longer was detected in 14 patients (8.6%) in the intervention group vs 0 patients in the usual care group (absolute difference, 8.6%; 95% CI, 4.3%-12.9%; P < .001). Conclusions and Relevance: In post-cardiac surgical patients at high risk of stroke, no preoperative AF history, and AF lasting less than 24 hours during hospitalization, continuous monitoring revealed a significant increase in the rate of POAF after discharge that would otherwise not be detected by usual care. Studies are needed to examine whether these patients will benefit from oral anticoagulation therapy. Trial Registration: ClinicalTrials.gov Identifier: NCT02793895.

Ultrarapid detection of SARS-CoV-2 RNA using a reverse transcription-free exponential amplification reaction, RTF-EXPAR.

A rapid isothermal method for detecting severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), the virus responsible for COVID-19, is reported. The procedure uses an unprecedented reverse transcription-free (RTF) approach for converting genomic RNA into DNA. This involves the formation of an RNA/DNA heteroduplex whose selective cleavage generates a short DNA trigger strand, which is then rapidly amplified using the exponential amplification reaction (EXPAR). Deploying the RNA-to-DNA conversion and amplification stages of the RTF-EXPAR assay in a single step results in the detection, via a fluorescence read-out, of single figure copy numbers per microliter of SARS-CoV-2 RNA in under 10 min. In direct three-way comparison studies, the assay has been found to be faster than both RT-qPCR and reverse transcription loop-mediated isothermal amplification (RT-LAMP), while being just as sensitive. The assay protocol involves the use of standard laboratory equipment and is readily adaptable for the detection of other RNA-based pathogens.

Perspectives of Remote Volunteer Palliative Care Consultants During COVID: A Qualitative Study.

CONTEXT: A novel remote volunteer program was implemented in response to the initial COVID-19 surge in New York City, allowing out-of-state palliative care specialists to serve patients and families in need. No study has detailed the perceptions of these consultants. OBJECTIVES: To understand the experiences of remote volunteer palliative care consultants during the initial COVID-19 surge. METHODS: This qualitative study utilized a thematic analysis approach. During January and February 2021, we conducted one-on-one semi-structured interviews with 15 board-certified palliative care physicians who participated in the program. Codes and emerging themes were identified through iterative discussion and comparison. RESULTS: Five overarching themes (with sub-themes in parentheses) were identified: 1) motivations for participating in the program, 2) logistical evaluation of the program (integration, telehealth model, dyad structure and debriefing sessions), 3) barriers to delivery (language and cultural differences, culture of high-intensity care, legal and administrative differences), 4) emotional burden (moral distress, burnout), and 5) ideas for improvements. Notably, participants observed institutional and cultural differences that posed challenges to delivery of care. Many expressed feelings of distress related to the uncertainty and scarcity caused by the pandemic, although volunteering may have been protective against burnout. CONCLUSION: This study provides an in-depth look at the experiences of remote volunteer palliative care consultants during the initial COVID-19 surge from the unique perspectives of the consultants themselves. Participants expressed overall positive and meaningful experiences and felt that the model was appropriate given the circumstances. Additionally, participants provided recommendations that could guide future implementations of similar programs.

Personal Protective Equipment Alters Leg Muscle Fatigability Independent of Transcranial Direct Current Stimulation: A Comparison with Pre-COVID-19 Pandemic Results.

In response to the COVID-19 pandemic, the use of personal protective equipment (PPE; e.g., face mask) has increased. Mandating subjects to wear PPE during vigorous exercise might affect the fatigue outcomes of transcranial direct current stimulation (tDCS) studies. The purpose of this study was to investigate whether the use of PPE affected the performance of a tDCS-influenced fatigue task in healthy adults. A total of 16 young and healthy subjects were recruited and wore PPE during an isokinetic fatigue task in conjunction with sham, 2 mA, and 4 mA tDCS conditions. Subjects were matched to subjects who did not wear PPE during our previous pre-pandemic study in which right knee extensor fatigability increased under these same conditions. The results show that right knee extensor fatigability, derived from torque and work (FI-T and FI-W, respectively), was higher in the PPE study compared to the No PPE study in the sham condition. Additionally, there were no differences in knee extensor fatigability or muscle activity between sham, 2 mA, and 4 mA tDCS in the present study, which contrasts with our previous results. Thus, PPE worn by subjects and researchers might have a detrimental effect on fatigue outcomes in tDCS studies irrespective of the stimulation intervention.

Mechanisms underlying genetic susceptibility to multisystem inflammatory syndrome in children (MIS-C).

BACKGROUND: Multisystem inflammatory syndrome in children (MIS-C) is a pediatric complication of severe acute respiratory syndrome coronavirus 2 infection that is characterized by multiorgan inflammation and frequently by cardiovascular dysfunction. It occurs predominantly in otherwise healthy children. We previously reported haploinsufficiency of suppressor of cytokine signaling 1 (SOCS1), a negative regulator of type I and II interferons, as a genetic risk factor for MIS-C. OBJECTIVES: We aimed to identify additional genetic mechanisms underlying susceptibility to severe acute respiratory syndrome coronavirus 2-associated MIS-C. METHODS: In a single-center, prospective cohort study, whole exome sequencing was performed on patients with MIS-C. The impact of candidate variants was tested by using patients' PBMCs obtained at least 7 months after recovery. RESULTS: We enrolled 18 patients with MIS-C (median age = 8 years; interquartile range = 5-12.25 years), of whom 89% had no conditions other than obesity. In 2 boys with no significant infection history, we identified and validated hemizygous deleterious defects in XIAP, encoding X-linked inhibitor of apoptosis, and CYBB, encoding cytochrome b-245, beta subunit. Including the previously reported SOCS1 haploinsufficiency, a genetic diagnosis was identified in 3 of 18 patients (17%). In contrast to patients with mild COVID-19, patients with defects in SOCS1, XIAP, or CYBB exhibit an inflammatory immune cell transcriptome with enrichment of differentially expressed genes in pathways downstream of IL-18, oncostatin M, and nuclear factor κB, even after recovery. CONCLUSIONS: Although inflammatory disorders are rare in the general population, our cohort of patients with MIS-C was enriched for monogenic susceptibility to inflammation. Our results support the use of next-generation sequencing in previously healthy children who develop MIS-C.

Virtual Interinstitutional Palliative Care Consultation during the COVID-19 Pandemic in New York City.

Context: Amid the COVID-19 surge in New York City, the need for palliative care was highlighted. Virtual consultation was introduced to expand specialist-level care to meet demand. Objectives: To examine the outcomes of COVID-19 patients who received virtual palliative care consultation from outside institutions. Design: This is a retrospective case series. Setting/Subjects: Subjects were 34 patients who received virtual palliative care consultation between April 13, 2020, and June 14, 2020. Measurements: Follow-up frequency and duration, code status change, withdrawal of life-sustaining treatment (LST), and multidisciplinary involvement. Results: Twenty-eight patients (82.3%) were in the intensive care unit and 29 patients (85.3%) were on at least two LSTs. Fifteen patients (44.1%) died in the hospital, 9 patients (26.4%) were discharged alive, and 10 patients (29.4%) were signed off. The median frequency of visits was 4.5 (IQR 6) over 11 days follow-up (IQR 17). Code status change was more frequent in deceased patients. LSTs were withdrawn in eight patients (23.5%). Conclusions: Virtual palliative care consultation was feasible during the height of the COVID-19 pandemic.

The Prevalence of Palliative Care Consultation in Deceased COVID-19 Patients and Its Association with End-of-Life Care.

Background: During the height of the coronavirus disease 2019 (COVID-19) pandemic in New York City, COVID-19 hospitalization was associated with high mortality. It is unknown how palliative care was utilized in this context. Objectives: To describe the frequency of palliative care consultation and its association with end-of-life care for deceased patients with COVID-19. Methods: Adults who were admitted to our institution between February 23, 2020, and April 21, 2020, and died from COVID-19 were included. The primary outcome was the frequency of palliative care consultation. Secondary analyses included the association of palliative care consultation with code status at the time of death, life-sustaining treatments, mechanical ventilation, invasive procedures, intensive care unit (ICU) admissions, and length of hospital stay. Results: The 203 patients were 61% male with median age 76 (interquartile range [IQR] 67-84) years. Palliative care was consulted for 113 patients (56%). At baseline, they were less independent in instrumental activities of daily living (28 patients, 26.1%, vs. 47 patients, 49.0%, p < 0.01) and had more do-not-resuscitate orders (35 patients, 32.7%, vs. 11 patients, 11.5%, p < 0.01). Palliative care consultation was associated with fewer invasive procedures (0, IQR 0-2, vs. 2, IQR 0-3, p < 0.01), less mechanical ventilation (32 patients, 29.9% vs. 65 patients, 67.7%, p < 0.01), and fewer ICU admissions (33 patients, 30.8% vs. 69 patients, 71.9%, p < 0.01). Palliative care was associated with shorter ICU stays (0 days, IQR 0-4, vs. 4 days, IQR 0-12, p < 0.01), whereas hospital stays did not differ significantly (8 days, IQR 5-12.5, vs. 10 days, IQR 5-16.3, p = 0.15). Conclusion: Palliative care was consulted for roughly half of deceased patients with COVID-19 and those patients were less likely to undergo invasive procedures or life-sustaining treatments and spent less time in the ICU at the end of life.