Obesity associated with improved mortality of extracorporeal membrane oxygenation for severe COVID-19 pneumonia.

INTRODUCTION: Determining a patient's candidacy for extracorporeal membrane oxygenation (ECMO) in severe COVID-19 pneumonia is a critical aspect of efficient healthcare delivery. A body mass index (BMI) ≥40 is considered a relative contraindication for ECMO by the Extracorporeal Life Support Organization (ELSO). We sought to determine the impact of obesity on the survival of patients with COVID-19 on ECMO. METHODS: This project was a retrospective review of a multicenter US database from January 2020 to December 2021. The primary outcome was in-hospital mortality after ECMO initiation, with a comparison between patients classified into body mass index categories (<30, 30-39.9, and ≥40). Secondary outcomes included ventilator days, intensive care days, and complications. RESULTS: We completed records review on 359 patients, with 90 patients excluded because of missing data. The overall mortality for the 269 patients was 37.5%. Patients with a BMI <30 had higher odds of mortality compared to all patients with BMI >30 (OR 1.98; p = 0.013), those with BMI 30-39.9 (OR 1.84; p = 0.036), and BMI ≥40 (OR 2.33; p = 0.024). There were no differences between BMI groups for ECMO duration; length of stay (LOS); or rate of bloodstream infection, stroke, or blood transfusion. Age, ECMO duration, and modified-Elixhauser index were not independent risk factors for mortality. CONCLUSIONS: In patients receiving ECMO for severe COVID-19, neither obesity (BMI >30) nor morbid obesity (BMI >40) were associated with in-hospital mortality. These results are consistent with previous reports and held true after adjusting for age and comorbidities. Our data suggest further examination of the recommendations to withhold ECMO in patients who are obese.

Human rights, COVID-19, and barriers to safe water and sanitation among people experiencing homelessness in Mexico City

Access to safe water, sanitation, and hygiene (WASH) are human rights and play a fundamental role in protecting health, which has been particularly evident during the SARS-CoV2 (COVID-19) pandemic. People experiencing homelessness face frequent violations of their human rights to water and sanitation, negatively affecting their health and dignity and ability to protect themselves from COVID-19. This research aimed to identify barriers to safe water, sanitation and hygiene access for people experiencing homelessness in Mexico City during the COVID-19 pandemic. A survey of 101 respondents experiencing homelessness was conducted using mobile data collection tools in collaboration with El Caracol A.C., an NGO that contributes to the visibility and social inclusion of homeless people in Mexico. We report findings according to the following themes: general economic impacts of COVID-19;experiences with reduced access to WASH services due to COVID-19, challenges in accessing hand washing to follow COVID-19 public health advice;and coping mechanisms used to deal with reductions in access to WASH. We discuss the broader implications of the findings in terms of realization of the human rights to water and sanitation (HRtWS), and how people experiencing homelessness are left behind by the existing approaches to ensure universal access to water and sanitation under SDG 6. Copyright © 2023 Liera, Dickin, Rishworth, Bisung, Moreno and Elliott.

A role for Von Willebrand Factor-ADAMTS13 axis imbalance and abnormal angiogenesis in long COVID syndrome

Background: Acute COVID-19 is associated with marked endotheliopathy, VWF-ADAMTS13 axis imbalance and abnormal pulmonary angiogenesis. Persistent endotheliopathy and elevated VWF levels have also been reported in convalescent COVID-19 patients. Aim(s): We investigated the hypothesis that altered pulmonary microvascular architecture may persist in COVID-19 convalescence, resulting in ongoing endothelial cell (EC) activation and VWF-ADAMTS13 axis imbalance, possibly contributing to Long COVID pathogenesis. Method(s): 50 patients (median age 50 years, 60% male, median 68 days post acute COVID-19) were reviewed. Six-minute- walk tests (6MWT) were performed (median 6MWT distance 430m) and plasma samples collected. Plasma VWF:Ag and ADAMTS13 levels were measured by ELISA, and angiogenesis markers assessed by membrane-based antibody array. Result(s): Plasma VWF:Ag levels were significantly elevated in convalescent COVID-19 patients compared to controls (1.1 vs. 0.84 IU/ml;p = 0.004), with 30% (15/50) having VWF:Ag levels above the upper limit of normal. In contrast, plasma ADAMTS13 was significantly reduced in convalescent COVID-19 (median 467 ng/ml vs. 636 ng/ ml p < 0.001). ADAMTS13 levels were significantly lower in those who required hospitalization for acute COVID-19 compared with those managed as outpatients (median 454 ng/ml vs. 513 ng/ml, p = 0.04). Overall, the VWF/ADAMTS13 ratio was significantly elevated in convalescent COVID-19 compared with controls (2.1 vs. 1.1 p = 0.0002) and interestingly was elevated in patients with reduced 6MWT distance (distance >=430 m or <430 m: 1.8 vs. 2.4, p = 0.02). In total, 15 angiogenesis markers were elevated in convalescent COVID-19 compared to controls. An additional 17 angiogenesis (Figure Presented) markers were unique to convalescent COVID-19 and were not found in control plasma (Table 1). Conclusion(s): Collectively, these novel findings demonstrate that endotheliopathy is sustained for months following acute COVID-19 in some patients. As a result, plasma VWF levels are significantly increased;ADAMTS13 levels reduced, and there is ongoing dysregulation of angiogenesis. Further studies will be required to define whether these alterations play a role in Long COVID pathogenesis.

Endothelial cell activation, Weibel-Palade body secretion and enhanced angiogenesis in severe COVID-19

Background: Severe COVID-19 is associated with marked endothelial cell (EC) activation that plays a key role in immunothrombosis and pulmonary microvascular occlusion. However, the biological mechanisms through which SARS-CoV-2 causes EC activation and damage remain poorly defined. Aim(s): We investigated EC activation in patients with acute COVID-19, and in particular focused on how proteins stored within Weibel-Palade bodies (WPBs) may impact key aspects of disease pathogenesis. Method(s): 39 patients with confirmed COVID-19 were recruited. Weibel-Palade body biomarkers [von Willebrand factor (VWF), angiopoietin-2 (Ang-2) and osteoprotegerin (OPG)] and soluble thrombomodulin (sTM) levels were determined. In addition, EC activation and angiogenesis were assessed in the presence or absence of COVID-19 plasma incubation. Result(s): Markedly elevated plasma VWF:Ag, Ang-2, OPG and sTM levels were observed in acute COVID-19 patients. The increased levels of both sTM and WPB components (VWF, OPG and Ang-2) correlated with COVID-19 severity. Incubation of COVID-19 plasma with ECs triggered enhanced VWF secretion and increased Ang-2 expression (Figure 1). In keeping with the autopsy reports of intussusceptive angiogenesis, treatment with COVID-19 plasma also caused significantly increased EC angiogenesis (Figure 1). Conclusion(s): We propose that as COVID-19 develops, progressive loss of TM and increased sTM, as well as increased Ang-2 expression result in loss of EC quiescence, WPB exocytosis, and a local pro-angiogenic state.

The impact of COVID-19 restrictions on perceived health and wellbeing of adult Australian sport and physical activity participants.

Individuals' access to sport and physical activity has been hampered due to COVID-19 lockdown restrictions. In Australia participation in community sport was cancelled during lockdowns. There is limited research on the impact of sport participation restrictions on the health and wellbeing of adults.AimThe aim of this study was to investigate the perceived health and wellbeing of a sample of predominantly active Australian adults, both during COVID-19 and in comparison with one year earlier (pre COVID-19).MethodsA survey was conducted during the first COVID-19 restrictions and lockdowns in Australia in May-June 2020. It was distributed by national and state sporting organisations and through researchers' social media accounts. This particular paper focuses on adults aged 18-59 years. The survey collected information on participant demographics, the sport and physical activity patterns pre- COVID-19, and health and wellbeing outcomes during COVID-19 lockdown and compared to one year earlier. The health measures were cross-tabulated against the demographic and sport and physical activity variables, and group profiles compared with chi-square tests. Scales were derived from three wellbeing questions, and group differences were analysed by t-tests and F-tests.ResultsThe survey sample included 1279 men and 868 women aged 18-59 years. Most (67%) resided in metropolitan cities. The great majority (83%) were sport participants. During COVID-19 lockdown men were significantly more likely than women to report worse or much worse general (p = 0.014), physical (p = 0.015) and mental health (p = 0.038) and lower life satisfaction (p = 0.016). The inactive adults were significantly more likely to report poorer general health (p = 0.001) and physical health (p = 0.001) compared to active adults. The younger age cohort (18-29 years) were significantly more likely to report poorer general wellbeing (p < 0.001), and lower life satisfaction (p < 0.001) compared to the older age groups.ConclusionIt seems that the absence of playing competitive sport and training with friends, teams and within clubs has severely impacted males and younger adults in particular. Sports clubs provide an important setting for individuals' health and wellbeing which is why clubs require the capacity to deliver sport and individuals may need to regain the motivation to return.

Measures of inflammation, complement activation and coagulation in patients with COVID-19

S56 Table 1Table to show measures of complement activation, inflammation and coagulation in patients with COVID-19 stratified by disease severityMildModerateSevereOverall P-ValueMild vs Mod*Mild vs Sev*Mod vs Sev*Number (%)30289----CRP (mg/L)75.5 [28.5,117.25]93.5 [72,143.5]60 [34,157.5]NSNSNSNSFerritin (ug/L)426 [290.5,847.5]728 [381.25,1071.5]857 [443,1607.5]NSNSNSNSPCT (ug/L)0.08 [0.06,0.19]0.16 [0.09,0.49]0.19 [0.12,0.8]0.019NS0.046NSLDH (U/L)708.5 [523.5,903]830 [569,1122]1037 [927.5,1086]0.008NS0.006NSPlatelets (10*9/L)220 [174.75,328.75]255 [203.5, 335]292 [209.5, 329.5]NSNSNSNSINR1.1 [1.08,1.23]1.1 [1.1, 1.2]1.1 [1.1, 1.15]NSNSNSNSAPTR0.9 [0.9,1.0]0.9 [0.9, 1.0]1.0 [0.95, 1.10]NSNSNS0.038D-dimer (ugFEU/ml)0.56 [0.38,0.95]0.74 [0.55, 1.52]0.85 [0.54, 19.2]NSNSNSNSFibrinogen (g/L)4.45 [4.05,5.22]4.7 [4.3, 6.38]4.3 [3.9, 6.0]NSNSNSNSThrombin-AT III Complex ug/L)4.75 [2.65,12.13]8.8 [5.3, 12]14.3 [6.9, 40.7]0.045NSNSNSProthrombin Fragment 1&2 (pMol/L)275 [164.5,380.5]311 [163, 492]301 [258, 709]NSNSNSNSCH50 (U Eq/ml)123.4 [101.75,174.7]113.4[88.68, 153.43]114.7 [74.6,158.9]NSNSNSNSComplement C5a (ng/ml)29 [21.5, 36]36.5[25.5, 48.75]68 [39.5,122.5]<0.0010.0380.001NSComplement C5 (mg/L)270 [235.25,290.5]263[235.25, 279]276 [220,299.5]NSNSNSNSComplement C3 (g/L)1.5 [1.25,1.77]1.48[1.33, 1.71]1.56 [1.16,1.73]NSNSNSNSSC5b-9 complex (ng/ml)1070.46 [836.41,1632.17]1725.48[1092.62, 2403.3]2392.66 [1245.68,5145.88]0.006NS0.019NSComplement Fragment Bb (µg/ml)0.2[0.15,0.27]0.25[0.17, 0.3]0.29 [0.2,0.43]NSNSNSNSComplement C3a ng/ml)296.88[244.33,345.22]325.88[248.33, 484.03]460.23 [282.49,652.1]NSNSNSNS*P-values given a Bonferroni adjustment to allow for multiple testing between subgroupsDiscussionOur findings demonstrated increased levels of complement activity in patients with COVID-19, particularly in those patients requiring non-invasive and mechanical ventilation and those patients that deteriorate requiring increasing ventilatory support. The complement cascade is a key player in protective immunity against pathogens, with its activation orchestrating key immunoprotective and anti-inflammatory effects Increased activation of the complement cascade may contribute to the dysregulated and destructive inflammatory response that leads to multi-organ failure and our findings suggest a potentially important treatment target for COVID-19.

Disenfranchised: How Lower Income Mothers Navigated the Social Safety Net during the COVID-19 Pandemic

Government programs and other forms of assistance act as critical safety nets in times of crisis. The federal government’s initial response to coronavirus disease 2019 represented a significant increase in the welfare state, but the provisions enacted were not permanent and did not reach all families. Drawing on interviews with 54 lower-income mothers and grandmothers, we analyze how families navigated the safety net to access food during the pandemic. Pandemic aid served as a critical support for many families, but participants also described gaps and barriers. Following the argument that food is a basic human right, we identify how mothers encountered three forms of disenfranchisement: being denied or experiencing delayed public benefits, being afraid to access assistance, and receiving paltry or inedible emergency food. We conclude by arguing for an expanded social safety net that broadens access to necessary food resources before, during, and after crises such as the coronavirus disease 2019 pandemic. © The Author(s) 2021.

Nosocomial or not? A combined epidemiological and genomic investigation to understand hospital-acquired COVID-19 infection on an elderly care ward.

BACKGROUND: COVID-19 has the potential to cause outbreaks in hospitals. Given the comorbid and elderly cohort of patients hospitalized, hospital-acquired COVID-19 infection is often fatal. Pathogen genome sequencing is becoming increasingly important in infection prevention and control (IPC). AIM: To inform the understanding of in-hospital SARS-CoV-2 transmission in order to improve IPC practices and to inform the future development of virological testing for IPC. METHODS: Patients detected COVID-19 positive by polymerase chain reaction on Ward A in April and May 2020 were included with contact tracing to identify other potential cases. Genome sequencing was undertaken for a subgroup of cases. Epidemiological, genomic, and cluster analyses were performed to describe the epidemiology and to identify factors contributing to the outbreak. FINDINGS: Fourteen cases were identified on Ward A. Contact tracing identified 16 further patient cases; in addition, eight healthcare workers (HCWs) were identified as being COVID-19 positive through a round of asymptomatic testing. Genome sequencing of 16 of these cases identified viral genomes differing by two single nucleotide polymorphisms or fewer, with further cluster analysis identifying two groups of infection (a five-person group and a six-person group). CONCLUSION: Despite the temporal relationship of cases, genome sequencing identified that not all cases shared transmission events. However, 11 samples were found to be closely related and these likely represented in-hospital transmission. This included three HCWs, thereby confirming transmission between patients and HCWs.

The structural roots of food insecurity: How racism is a fundamental cause of food insecurity

Rates of food insecurity skyrocketed during the COVID-19 pandemic, doubling overall and tripling among households with children. Even before the pandemic, the rate of food insecurity in the United States was “unusually high” compared to other rich democracies, and rates have not improved substantially over the last 25 years. What explains the lack of progress in addressing food insecurity? This article maps out an overview of the experiences, causes, and consequences of food insecurity in the United States. We demonstrate that racism is a fundamental cause of food insecurity, both because racism contributes to racial disparities in income and wealth, and because racism is linked to food insecurity independent of poverty and socioeconomic status. For example, people of color are more likely to experience racial discrimination, which is associated with food insecurity, and to live in states where stricter regulations and harsher punishments are tied to social assistance programs, including food assistance programs. Because racism is a fundamental cause of food insecurity, eliminating it requires going beyond “just” eliminating poverty. Instead, the fundamental cause must be tackled directly: racism itself, which is built into the structure of American society and entrenched in its institutions. © 2021 John Wiley & Sons Ltd.

Financial Integration's Impact On Care Delivery And Payment Reforms: A Survey Of Hospitals And Physician Practices.

Health systems continue to grow in size. Financial integration-the ownership of hospitals or physician practices-often has anticompetitive effects that contribute to the higher prices for health care seen in the US. To determine whether the potential harms of financial integration are counterbalanced by improvements in quality, we surveyed nationally representative samples of hospitals (n = 739) and physician practices (n = 2,189), stratified according to whether they were independent or were owned by complex systems, simple systems, or medical groups. The surveys included nine scales measuring the level of adoption of diverse, quality-focused care delivery and payment reforms. Scores varied widely across hospitals and practices, but little of this variation was explained by ownership status. Quality scores favored financially integrated systems for four of nine hospital measures and one of nine practice measures, but in no case favored complex systems. Greater financial integration was generally not associated with better quality.