ABSTRACT
Background: Internationally, researchers have called for evidence to support tackling health inequalities during the severe acute respiratory syndrome coronavirus 2 (COVID19) pandemic. Despite the 2020 Marmot review highlighting growing health gaps between wealthy and deprived areas, studies have not explored social determinants of health (ethnicity, frailty, comorbidities, household overcrowding, housing quality, air pollution) as modulators of presentation, intensive care unit (ITU) admissions and outcomes among COVID19 patients. There is an urgent need for studies examining social determinants of health including socioenvironmental risk factors in urban areas to inform the national and international landscape. Methods: An in-depth retrospective cohort study of 408 hospitalized COVID19 patients admitted to the Queen Elizabeth Hospital, Birmingham was conducted. Quantitative data analyses including a two-step cluster analysis were applied to explore the role of social determinants of health as modulators of presentation, ITU admission and outcomes. Results: Patients admitted from highest Living Environment deprivation indices were at increased risk of presenting with multi-lobar pneumonia and, in turn, ITU admission whilst patients admitted from highest Barriers to Housing and Services (BHS) deprivation Indies were at increased risk of ITU admission. Black, Asian and Minority Ethnic (BAME) patients were more likely, than Caucasians, to be admitted from regions of highest Living Environment and BHS deprivation, present with multi-lobar pneumonia and require ITU admission. Conclusion: Household overcrowding deprivation and presentation with multi-lobar pneumonia are potential modulators of ITU admission. Air pollution and housing quality deprivation are potential modulators of presentation with multi-lobar pneumonia. BAME patients are demographically at increased risk of exposure to household overcrowding, air pollution and housing quality deprivation, are more likely to present with multi-lobar pneumonia and require ITU admission. Irrespective of deprivation, consideration of the Charlson Comorbidity Score and the Clinical Frailty Score supports clinicians in stratifying high risk patients.
ABSTRACT
Background: Neutrophil serine proteases (NSPs) are involved in the pathogenesis of COVID19 and are increased in severe and fatal infection. We investigated whether treatment with Brensocatib, an inhibitor of dipeptidyl peptidase-1, an enzyme responsible for the activation of NSPs, would improve outcomes in hospitalized patients with COVID19. Method(s): In a randomized, double-blind, placebo-controlled trial, 406 hospitalized patients with COVID19 with at least one risk factor for severe disease were randomized 1:1 to once-daily Brensocatib 25mg (n=192) or placebo (n=214) for 28 days. Primary outcome was the 7-point World Health Organisation Clinical Status scale at day 29. Secondary outcomes included time to clinical improvement, national early warning score, new oxygen and ventilation use, neutrophil elastase activity in blood and mortality. Finding(s): Brensocatib treatment was associated with worse clinical status at day 29 (adjusted odds ratio 0 72, 95%CI 0 57-0 92) compared to placebo. The adjusted hazard ratio (aHR) for time to clinical improvement was 0 87 (95%CI 0 76-1 00) and time to hospital discharge was 0 98 (95%CI 0 84-1 13). During the 28-day follow-up period, 23 (11%) and 29 (15%) patients died in the placebo and Brensocatib treated groups respectively). Oxygen and new ventilation use were greater in the Brensocatib treated patients. Neutrophil elastase activity in blood was significantly reduced in the Brensocatib group from baseline to day 29. Prespecified subgroup analyses of the primary outcome supported the primary results.
ABSTRACT
IntroductionCommunity acquired pneumonia is a leading cause of admission to hospital during the winter months. In the winter of 2020–21 the United Kingdom remained under social distancing measures to limit transmission of COVID-19. These measures should also limit transmission of other respiratory pathogens and therefore reduce admission to hospital. Work to date has demonstrated reduced hospital attendances. We aimed to investigate whether hospitalised cases of non-COVID-19 community acquired pneumonia differed between winter 2019–20 and winter 2020–21.MethodsCommunity acquired pneumonia hospital admissions were compared between 01/09/2019–31/01/2020 and 01/09/2020–31/01/2021 using Pioneer the Health Data Research Hub in Acute Care. Data were collected to compare demographics, severity, complications, and outcomes. Cases were identified using ICD coding. For the winter 20–21 cohort, all cases had a negative COVID PCR on admission to hospital.ResultsAdmissions fell by 16% in the 20/21 time period with 2073 admissions in 19/20 and 1757 in 20/21. The median age of cases was similar across both timepoints (74 in 19/20 and 72 in 20/21). Length of stay was similar between the two timepoints. However, mortality significantly increased from 13.5% in 19/20 to 21.6% in 20/21 (p<0.001). Admission to ICU did not change significantly during the time periods (21.2 vs. 24.6%).ConclusionWe demonstrate that changes in social distancing guidance impacts non COVID CAP in keeping with other studies. The increased mortality seen in winter 20/21 is likely multi-factorial but may be related to perceived reduced access to healthcare by patients resulting in delayed treatment. Additionally, we show that intensive care admission was unchanged despite the increased mortality and therefore severity of cases, suggesting that accessing critical care may have been more challenging in the winter of 20/21 than previous years. Further analyses to characterise the difference in cases and understand increase in mortality are underway.
ABSTRACT
Rationale:The West Midlands in the UK, which includes the City of Birmingham, was disproportionately affected during COVID-19 pandemic first wave. This was thought to be due to a number of factors relating to population demographics and density. At the initial peak, there were more than 700 inpatients at University Hospitals Birmingham NHS Foundation Trust (UHB), one of the largest NHS trusts in the UK (2700 beds and more than 21000 members of staff). The UHB tertiary Sarcoidosis Service looks after over 500 people with the condition. In March 2020 individuals felt to be at very high risk of severe COVID-19 were identified as clinically extremely vulnerable by NHS England and advised to shield March-July 2020. Though not initially specified, those with sarcoidosis were included on the national register following specialist consensus discussion. The aim was to assess whether patients receiving immunosuppression therapy for sarcoidosis (corticosteroids, diseasemodifying agents or biological agents) received and followed guidance to shield, alongside assessing the impact and unintended consequences of this guidance (diagnosis of COVID-19 and psychological impact). Methods:Sarcoidosis patients receiving immunosuppression therapy were identified from existing clinical databases and contacted to complete a telephone interview. Electronic medical records were reviewed to confirm the diagnosis of sarcoidosis and organ system involvement, treatments, co-morbidities, ethnicity and BMI. Results:A total of 115 patients on immunosuppression during the study period were identified. The mean age was 57 and mean BMI was 29. Pulmonary involvement was a feature in 92%, extrapulmonary systemic involvement in 46%. Half the patients (53%) were white British and 37% from Black and Ethnic minorities. Interviews were completed by 76 of the 109 patients. There were 6 deaths, one from confirmed COVID-19. Shielding letters were received by 70, although 75 in total shielded, 16 of whom stopped before government guidance to do so was announced. Symptoms consistent with COVID-19 were experienced by 3 patients none were eligible for a swab at that time. Most interviewed felt they had received enough information in the context of general uncertainty regarding COVID-19, however, some reported confusion as to when to stop shielding. Many spoke of the difficulties of shielding;they felt lonely and isolated. Some people felt fearful that they received the information too late, delaying onset of shielding. Conclusion:Shielding may have helped protect those with sarcoidosis, with few reported cases and one COVID-19 death. This is countered by a not insubstantial impact on fitness and mental health.
ABSTRACT
Rationale: The onset of the COVID-19 pandemic was accompanied by an expectation of a large cohort of deteriorating patients that would require urgent palliative care support. There were valid concerns regarding availability of staff, beds and oxygen delivery. To date, our trust has had more than 3500 confirmed COVID cases with 942 deaths. Our aim was to report on the first 100 deaths on our site in order to better inform subsequent management of death. Methods: The first 100 COVID-19 deaths (18th March and 3rd April 2020) were identified and a retrospective analysis of the electronic care records conducted. Data were collected on resuscitation decision and whether there was an active switch to end of life care. We focussed on palliative care input, use of symptom control medications (anticipatory drug bundle - ACB), oxygen supplementation and the opportunity for family to be present at end of life. Results: Of the first 100 patients, 95% had a valid resuscitation decision recorded at the time of death, indicating active identification of those for whom escalation to advanced support may not be appropriate. However this did not always translate to an early focus on end of life care;only 55% of the patients were actively switched to an end of life pathway, with less than half referred to palliative care. Confidence in the prescription of our ACB was apparent;70% of patients had this available. Despite this, 39% received no ACB drugs in the last 24 hours indicating an ongoing need for support in administration. Despite concern over oxygen supply and comfort (drying of mucus membranes), nearly half were receiving high-flow oxygen at the time of death. Tragically, because of restricted visiting, 59% of the decedents had no family or friends present at their bedside, exacerbating the emotional distress of the pandemic. Conclusions: Our Trust quickly adapted to the COVID-19 challenges with senior decision makers identifying those most appropriate for best supportive care at the front door. Translating this to delivery of best practice in areas less familiar with acute respiratory care could have been and subsequently was improved with further education.