Intravenous iron in patients with heart failure and iron deficiency: an updated meta-analysis.

AIMS: For patients with heart failure (HF) and iron deficiency (ID), randomized trials suggest that intravenous (IV) iron reduces hospitalizations for heart failure (HHF), but uncertainty exists about the effects in subgroups and the impact on mortality. We conducted a meta-analysis of randomized trials investigating the effect of IV iron on clinical outcomes in patients with HF. METHODS AND RESULTS: We identified randomized trials published between 1 January 2000 and 5 November 2022 investigating the effect of IV iron versus standard care/placebo in patients with HF and ID in any clinical setting, regardless of HF phenotype. Trials of oral iron or not in English were not included. The main outcomes of interest were a composite of HHF and cardiovascular death (CVD), on HHF alone and on cardiovascular and all-cause mortality. Ten trials were identified with 3373 participants, of whom 1759 were assigned to IV iron. IV iron reduced the composite of recurrent HHF and CVD (rate ratio 0.75, 95% confidence interval [CI] 0.61-0.93; p < 0.01) and first HHF or CVD (odds ratio [OR] 0.72, 95% CI 0.53-0.99; p = 0.04). Effects on cardiovascular (OR 0.86, 95% CI 0.70-1.05; p = 0.14) and all-cause mortality (OR 0.93, 95% CI 0.78-1.12; p = 0.47) were inconclusive. Results were similar in analyses confined to the first year of follow-up, which was less disrupted by the COVID-19 pandemic. Subgroup analyses found little evidence of heterogeneity for the effect on the primary endpoint, although patients with transferrin saturation <20% (OR 0.67, 95% CI 0.49-0.92) may have benefited more than those with values ≥20% (OR 0.99, 95% CI 0.74-1.30) (heterogeneity p = 0.07). CONCLUSION: In patients with HF and ID, this meta-analysis suggests that IV iron reduces the risk of HHF but whether this is associated with a reduction in cardiovascular or all-cause mortality remains inconclusive.

Construct validity and internal consistency of the Home and Family Work Roles Questionnaires: a cross-sectional study with exploratory factor analysis.

INTRODUCTION: Exploratory Factor Analysis (EFA) measures the underlying relationships between questionnaire items and the factors ("constructs") measured by a questionnaire. The Home and Family Work Roles Questionnaire has not been assessed using EFA; therefore, our objective was to identify the factors measured by this questionnaire. METHODS: We recruited 314 persons to complete the questionnaire and to answer several demographic questions. We determined if the data was factorable by performing Bartlett's test of sphericity and the Kaiser-Meyer-Olkin measure of sampling adequacy. We used the Factor package in Jamovi statistical software to perform EFA. We employed an Oblimin rotation and a Principal Axis extraction method. We also calculated the internal consistency of the questionnaire as a whole as well as each individual question. RESULTS: Our sample consisted of 265 (85%) women, 45 (14%) men, and 3 (1%) non-binary or other genders. The mean age of our participants was 34.65 (SD = 11.57, range = 18-65) years. EFA suggested a three-factor model. Questions 11, 13, 14, 15, and 16 measured one factor (we interpreted this as "Caregiving Roles"), questions 1, 3, 4, 8, 9, 10, 18, and 19 measured a different factor ("Traditionally Feminine Roles"), and questions 2, 5, 6, and 12 measured the "Traditionally Masculine Roles". The questionnaire and each individual question demonstrated excellent internal consistency (Cronbach's α > 0.90). CONCLUSION: The Home and Family Work Roles Questionnaire may measure three distinct factors, which we have named Caregiving, Traditionally Feminine, and Traditionally Masculine Roles. This aligns with the theory used in developing the questionnaire. Separation of the Home and Family Work Roles Questionnaire into three sub-scales with distinct scores is recommended to measure each of the recommended constructs.

Length of Pre-Ecmo Mechanical Ventilation Is Not Associated with Mortality in Patients with Covid-19

INTRODUCTION: Previous studies suggest that delayed initiation of extracorporeal membrane oxygenation (ECMO) is associated with higher patient mortality. Hence, we hypothesized that prolonged invasive mechanical ventilation (IMV) prior to ECMO was associated with higher mortality in patients with COVID-19. METHOD(S): The COVID-19 Critical Care Consortium, a prospective international multicenter registry, was queried for all patients with COVID-19 infection who received IMV and ECMO. Patients who were intubated prior to transfer to a study site were excluded. The primary variable was number of days on IMV prior to ECMO initiation and study endpoint was death or discharge from the study site. Cox proportional hazards model for the time between ECMO initiation and death was built using covariates including age, gender, selected comorbidities, and time intervals from ICU admission to IMV and IMV to ECMO initiation. RESULT(S): Between 1/1/2020 and 6/6/2022, A total of 593 patients from 107 study sites and 25 countries were included in the analysis. In this cohort, the median age was 50 (Interquartile range [IQR]: 40-58) years. Obesity and hypertension were prevalent among 220 (38.4%) and 223 (38.8%) of the patients, respectively. Twenty-four (4.2%) patients had chronic pulmonary disease. Prior to ECMO initiation, patients spent a median of 3.68 (IQR: 1.36-8.07) days in the ICU and a median of 2.49 (IQR: 0.88-5.65) days on IMV. Overall mortality was 47.2% with 3.9% patients' status not finalized or unknown. According to the final survival model, the number of days on IMV prior to ECMO initiation was not associated with mortality. The hazard ratios for 0, 3, 7, and 14 days of pre-ECMO IMV were 0.94 (95% confidence interval [CI]: 0.83 to 1.07), 1.02 (95% CI: 0.97 to 1.08), 1.09 (95% CI: 0.92 to 1.3) and 1.09 (95% CI: 0.83 to 1.42), respectively. Other noticeable contributory factors in the model included age and gender. CONCLUSION(S): Among patients with COVID-19 who received ECMO, the length of pre-ECMO IMV was not associated with hospital mortality. Further studies evaluating the ventilator settings before and after ECMO initiation are needed.

Evaluating SARS-CoV-2 Surveillance Strategies at the United States Naval Academy: A Comparison of Saliva and Dried Blood Spot Serosurveillance Against Molecular-Confirmed Case Detection

Background. Congregate military populations remain at risk of SARS-CoV-2 outbreaks and the optimal surveillance approach in such settings remains unclear. We enrolled midshipmen at the United States Naval Academy (USNA) in a setting of frequent PCR screening use of prevention strategies. Methods. Dried blood spots (DBS) and saliva were collected in August 2020, December 2020, February 2021 (saliva only) and April/May 2021 to measure anti-SARS-CoV-2 spike (S) and nucleoprotein (NP) IgG. COVID-19 vaccine history and records of SARS-CoV-2 PCR tests and routine asymptomatic screening assays were obtained from the USNA Brigade Medical Clinic. Attack rates were compared with cumulative frequencies of infections. Concordance of saliva and DBS anti-NP and anti-S IgG positivity was determined using Cohen's kappa coefficient. Results. The study enrolled 181 midshipmen. COVID-19 vaccinations were administered in March/April 2021. Samples were collected for 101 participants in August, 73 in December, 57 in February (saliva only), and 63 in April/May. In August, 17 (17%) participants showed evidence of SARS-CoV-2 infection based on anti-S IgG values from DBS and/or saliva. By December 2020, anti-S seroconversion was observed for 5 more based on DBS and/or saliva. By May 2021, 100% of participants were anti-S IgG seropositive after vaccination based on DBS and/or saliva;48% of participants had seroconverted to anti-NP IgG. Among participants with both DBS and saliva samples, a coefficient of 0.64 showed substantial agreement between anti-S IgG results in August and perfect agreement in December (Table 1). DBS and saliva results for anti-NP IgG were in perfect agreement through December and in substantial agreement in May (0.68, Table 2). Prior to vaccination in March/April 2021, 4/48 of participants had at least one documented SARS-CoV-2 PCR positive result (Table 3). Cumulative PCR test positivity concordance with DBS seroconversion was 37.5% and 60% for anti-S IgG and anti-NP IgG, respectively. Conclusion. There was a substantive SARS-CoV-2 attack rate before vaccination;all vaccinees mounted an anti-S IgG response in blood. We note high agreement between DBS and saliva for IgG measurement. Serology-based surveillance identified substantially more SARS-CoV-2 infections than PCR screening.

Hemorrhagic, coagulopathic, and thrombotic (HECTOR) complications among critically-ill patients with COVID-19: An International COVID-19 critical care consortium study

Background: Hemorrhage, coagulopathy and thrombosis (HECTOR) are reported complications of coronavirus disease 2019 (COVID-19) however, more information is needed on the prevalence of these complications and their associated outcomes in intensive care unit (ICU) settings. Aim(s): To determine the prevalence and outcomes of HECTOR complications in ICU patients with COVID-19. Method(s): Observational cohort study spanning 229 ICUs across 32 countries. Patients >=16 years admitted for severe COVID-19 from 1st January 2020, through 31st December 2021 were included. Patient characteristics and clinical data were collected. Survival analysis estimated the instantaneous impact of HECTOR complications on ICU-mortality and discharge. Result(s): HECTOR complications occurred in 1,735 (14%) of 11,972 study-eligible patients. Acute thrombosis occurred in 1,249 (10%) patients, including 712 (57%) with pulmonary embolism, 413 (33%) with myocardial infarction, 93 (7.4%) with deep vein thrombosis, and 49 (3.9%) with ischemic stroke. Hemorrhagic complications were reported in 582 (4.9%) patients, including 276 (48%) with gastrointestinal hemorrhage, 83 (14%) with hemorrhagic stroke, and 77 (13%) with pulmonary hemorrhage. Disseminated intravascular coagulation occurred in 11 (0.09%) patients. Univariate analysis identified diabetes, hypertension, cardiac and kidney disease and ECMO as statistically-significant risk factors for HECTOR complications. Patients with versus without HECTOR complications suffered higher ICU-mortality at 28 days (25%vs.13%, p < 0.001), 90 days (32%vs.15%, p < 0.0001) and overall (44%vs.36%, p < 0.001). Among ICU survivors, the ICU stay was longer (median days 19vs.12, p < 0.001). ICU mortality was similar between patients with and without HECTOR complications (HR = 1.01, 95%CI 0.92-1.12, p = 0.783) where an increased hazard of ICU mortality with hemorrhage (HR = 1.26, 1.09-1.45, p = 0.002) was balanced by a reduced hazard of thrombosis (HR = 0.88, 0.79-0.99, p = 0.03). Kaplan-Meier curves are presented in the Figure. Conclusion(s): HECTOR events are frequent complications of severe COVID-19 in ICU patients. Hemorrhagic, but not thrombotic complications are associated with increased ICU-mortality.

Intravenous ferric derisomaltose in patients with heart failure and iron deficiency in the UK (IRONMAN): an investigator-initiated, prospective, randomised, open-label, blinded-endpoint trial.

BACKGROUND: For patients with heart failure, reduced left ventricular ejection fraction and iron deficiency, intravenous ferric carboxymaltose administration improves quality of life and exercise capacity in the short-term and reduces hospital admissions for heart failure up to 1 year. We aimed to evaluate the longer-term effects of intravenous ferric derisomaltose on cardiovascular events in patients with heart failure. METHODS: IRONMAN was a prospective, randomised, open-label, blinded-endpoint trial done at 70 hospitals in the UK. Patients aged 18 years or older with heart failure (left ventricular ejection fraction ≤45%) and transferrin saturation less than 20% or serum ferritin less than 100 µg/L were eligible. Participants were randomly assigned (1:1) using a web-based system to intravenous ferric derisomaltose or usual care, stratified by recruitment context and trial site. The trial was open label, with masked adjudication of the outcomes. Intravenous ferric derisomaltose dose was determined by patient bodyweight and haemoglobin concentration. The primary outcome was recurrent hospital admissions for heart failure and cardiovascular death, assessed in all validly randomly assigned patients. Safety was assessed in all patients assigned to ferric derisomaltose who received at least one infusion and all patients assigned to usual care. A COVID-19 sensitivity analysis censoring follow-up on Sept 30, 2020, was prespecified. IRONMAN is registered with ClinicalTrials.gov, NCT02642562. FINDINGS: Between Aug 25, 2016, and Oct 15, 2021, 1869 patients were screened for eligibility, of whom 1137 were randomly assigned to receive intravenous ferric derisomaltose (n=569) or usual care (n=568). Median follow-up was 2·7 years (IQR 1·8-3·6). 336 primary endpoints (22·4 per 100 patient-years) occurred in the ferric derisomaltose group and 411 (27·5 per 100 patient-years) occurred in the usual care group (rate ratio [RR] 0·82 [95% CI 0·66 to 1·02]; p=0·070). In the COVID-19 analysis, 210 primary endpoints (22·3 per 100 patient-years) occurred in the ferric derisomaltose group compared with 280 (29·3 per 100 patient-years) in the usual care group (RR 0·76 [95% CI 0·58 to 1·00]; p=0·047). No between-group differences in deaths or hospitalisations due to infections were observed. Fewer patients in the ferric derisomaltose group had cardiac serious adverse events (200 [36%]) than in the usual care group (243 [43%]; difference -7·00% [95% CI -12·69 to -1·32]; p=0·016). INTERPRETATION: For a broad range of patients with heart failure, reduced left ventricular ejection fraction and iron deficiency, intravenous ferric derisomaltose administration was associated with a lower risk of hospital admissions for heart failure and cardiovascular death, further supporting the benefit of iron repletion in this population. FUNDING: British Heart Foundation and Pharmacosmos.

Combining cell therapy and extracorporeal membrane oxygenation for Acute Respiratory Distress Syndrome: Back to no future?

Introduction: After more than 50 years of research we are yet to develop an effective treatment for the Acute Respiratory Distress Syndrome (ARDS). This stands in contrast to the advances made in supportive care, a prime example of which is the maturation of Extracorporeal Membrane Oxygenation (ECMO). While technologies such as ECMO 'buy time' for recovery, the identification of a therapy remains crucial to improving outcomes. Recently, mesenchymal stem cells (MSCs) have shown promise as a novel treatment.1 Importantly, cell therapy may represent a means to overcome the hurdles associated with successful pharmacological intervention in ARDS. Little is known about the interaction between cell therapy and ECMO. This is a deficiency, given that those receiving ECMO for ARDS are among the most severely ill and therefore most likely to benefit. This programme of work was designed to close that gap. Objectives: Using a translational pipeline, our objective was to assess the safety and efficacy of MSCs during ECMO for ARDS. Methods: We employed several diverse methods to address our objectives, including an ex-vivo ECMO simulation, complex sheep models of ARDS and ARDS and venovenous ECMO, systematic review methodology, and unsupervised machine learning techniques. Results: In our ex-vivo model, we were the first to demonstrate potential harms associated with MSC therapy during ECMO.2 When 40 × 10∧6 clinical-grade human MSCs (Cynata Therapeutics Ltd., Australia) were added to fresh whole human blood and subjected to extracorporeal circulation using commercial components, oxygenator and pump performance was severely impaired within 4 hours. These experiments also demonstrated benefits associated with MSCs, including trends toward lower inflammatory cytokine concentrations and less neutrophil activation.3 To validate our findings, we sought to test hMSCs in a clinicallyrelevant sheep model. At the outset we undertook a systematic review of existing pre-clinical models of ARDS and ECMO.4 This has since produced an international collaborative effort to characterise pre-clinical models of ECMO across a range of indications. We subsequently described a 'double-hit' model of ARDS which combines oleic acid and intra-tracheal E. coli lipopolysaccharide. Using cluster analysis, we showed that this model shares qualitative similarities with the 'hypo-inflammatory' phenotype identified in clinical cohorts [Millar JE et al. Physiological Reports 2021. In Press]. Finally, in a 24-hour model, combining our novel injury method, VV-ECMO, and best practice ventilatory and supportive care, we performed a controlled trial of intra-tracheal hMSC therapy5 [Editorial: Del Sorbo L, Fan E. AJRCCM 2020]. This study showed that hMSCs reduce histological evidence of lung injury and ameliorate shock. However, hMSC-mediated impairment of oxygenator function was evident again. Conclusion: This work addresses a gap in our understanding of cell therapy in critical illness. The findings are of direct clinical relevance, highlighting the potential harms of cell therapy during extracorporeal circulation. With a recent explosion in the number of registered clinical trials of MSCs for severe COVID-19 in mind, the use of MSCs during ECMO cannot be recommended.

The Impact of Morbid Obesity on Patients with COVID-19 who Develop Respiratory Failure requiring Extracorporeal Membrane Oxygenation

Background: In patients with COVID-19 and respiratory failure, class 3 obesity (body mass index > 40 kg/m2) has been associated with worse survival. Obese patients on mechanical ventilation with progressively more severe acute respiratory syndrome (ARDS) may be offered venovenous (VV) extracorporeal membrane oxygenation (ECMO) therapy. The impact of morbid obesity on the outcome of COVID-19 patients supported with VV ECMO has been underexplored. Methods: This is a multicenter, retrospective observational cohort analysis of critically ill adults with COVID-19 ARDS requiring advanced mechanical ventilation with or without VV ECMO. Data was collected from 236 international institutions forming the COVID-19 Critical Care Consortium international registry. Patients were admitted between January 2020 to December 2021. Included patients were stratified by ECMO status and a BMI threshold at 40 kg/m2. Median values with interquartile range (IQR) were used to summarize continuous variables and multi-state analysis was used to explore the effect of Class 3 obesity on the study endpoints of patient survival to discharge or death. Results: Complete data was available on 8851 of 9059 patients on mechanical ventilation, of which 767 patients required VV ECMO. For the entire study group, older age and male gender were associated with an increased risk of death. The demographics and comorbidities of the higher BMI (H >40 kg/m2) and lower BMI (L ≤40 kg/m2) cohorts were similar with the exception of age and weight. Patients with a higher BMI were younger. The median age of the H, non-ECMO cohort was 56 years (46-64), and the H, ECMO cohort was 41 years (35-51) versus the L, non-ECMO cohort of 64 years(55-71), and the L, ECMO cohort of 53years (45-60). Patients requiring VV ECMO had higher SOFA scores, experienced longer ICU and hospital lengths of stay, and a longer duration of total mechanical ventilation. Table The median time to intubation was longer in the mechanical ventilation only group (2 versus 0 days). Predictors for requiring ECMO included younger age, higher BMI and male gender. Risk factors for death included advancing age (every 10 years), male gender and increasing BMI (every 5kg/m2). The association between BMI and a higher rate of death was reduced in the mechanical ventilation only group (HR 0.92, 95% confidence interval 0.85 to 0.99). Conclusion: In patients with severe ARDS due to COVID-19 requiring mechanical ventilation, the likelihood of progressing to VV ECMO therapy or experiencing death is impacted by age, gender and higher BMI. The cohort of COVID-19 patients that ultimately required ECMO appear to be sicker at time hospital admission owing to the shorter time until mechanical ventilation. It appears the association between increasing BMI and death differs among the ECMO and mechanical ventilation alone cohorts. We would advocate for a prospective study to determine the benefit of VVECMO for the obese patient requiring VV-ECMO for COVID-19 ARDS. (Figure Presented).

Number Soup: Case Studies of Quantitatively Dense News

Numbers don’t speak for themselves–yet taking numbers for granted (numerism) is widespread. In fact, journalists often rely heavily on numbers precisely because they are widely considered objective. As a team of journalists and social scientists, we undertook a qualitative exploration of clauses and entire news reports that are particularly quantitatively dense. The dense clauses were often grammatically complex and assumed familiarity with sophisticated concepts. They were rarely associated with explanations of data collection methods. Meanwhile, the dense news reports were all about economy or health topics, chiefly brief updates on an ongoing event (e.g., stock market fluctuations;COVID-19 cases). We suggest that journalists can support public understanding by: Providing more detail about research methods;Writing shorter, clearer sentences;Providing context behind statistics;Being transparent about uncertainty;and Indicating where consensus lies. We also encourage news organizations to consider structural changes like rethinking their relationship with newswires and working closely with statisticians. © 2022 Informa UK Limited, trading as Taylor & Francis Group.

Mid and Long-term Neurological and Neuropsychiatric Manifestations of PostCOVID-19 Syndrome: A Meta-analysis

Objective: To determine the prevalence of neurological and neuropsychiatric symptoms reported 12 weeks (3 months) or more after acute COVID-19 onset in adults. Background: Neurological and neuropsychiatric symptoms that persist or develop three months after the onset of COVID-19 pose a significant threat to the global healthcare system. These symptoms are yet to be synthesized and quantified via meta-analysis. Design/Methods: A systematic search of PubMed, EMBASE, Web of Science, Google Scholar and Scopus was conducted for studies published between January 1 , 2020 and August 1 , 2021. Studies were included if the length of follow-up satisfied the National Institute for Healthcare Excellence definition of post-COVID-19 syndrome. Additional criteria included reporting of neurological or neuropsychiatric symptoms in individuals with COVID-19. The primary outcome was the prevalence of neurological and neuropsychiatric symptoms reported ≥3 months post onset of COVID-19. Results: Of 1,458 articles, 19 studies, encompassing a total of 11,324 patients, were analysed. Overall prevalence for neurological post-COVID-19 symptoms were: fatigue (37%, 95% CI: 24%- 50%), brain fog (32%, 9%-55%), memory issues (27%, 18%-36%), attention disorder (22%, 10%- 34%), myalgia (18%, 4%-32%), anosmia (12%, 7%-17%), dysgeusia (11%, 4%-17%) and headache (10%, 1%-21%). Neuropsychiatric conditions included sleep disturbances (31%, 18%-43%), anxiety (23%, 13%-33%) and depression (12%, 7%-21%). Neuropsychiatric symptoms substantially increased in prevalence between mid- and long-term follow-up. Compared to non-hospitalised patients, patients hospitalised for acute COVID-19 had reduced risk of anosmia, anxiety, depression, dysgeusia, fatigue, headache, myalgia, and sleep disturbance at three (or more) months post-infection. Conversely, hospital admission was associated with higher frequency of memory issues (OR: 1.9, 95% CI: 1.4-2.3). Conclusions: Fatigue, brain fog and sleep disturbances appear to be key features of post-COVID19 syndrome. Psychiatric manifestations (sleep disturbances, anxiety, and depression) increase significantly in prevalence over time. Randomised controlled trials are necessary to develop intervention strategy to reduce disease burden.

Optimizing the complexities of unforeseen risk in healthcare with innovation and technology: a proposed framework

Today, healthcare must be willing to take risks while advancing clinical transformation, starting from research to innovations, patient care technicians to physicians, management thinking lean to maximizing inventory flow, building a supply chain of healthcare workers to allowing engineering strategies, and building community facilities to establishing remote reusable facilities. In recent months, the ongoing pandemic (COVID-19) has changed everyone’s perspective globally. The United States healthcare system is linked with financial needs. The stakeholders must understand the growth and possibility of the unforeseen new medical risks, including how to challenge the dataset used for decision making, increasing the required acceptance level for the verification and validation of growing medical risk models, because healthcare is a stochastic system, forecasting always changes and so does the final decision of investing the cost. The global fear brought on by the ongoing pandemic is playing a major role in the economic and social consequences. Experts recommend that physicians must be willing to take over the key roles and lead these strategies, but at the same time better integration of engineering fields can play a huge role in helping physicians to understand the strategies. It is very important to help them craft a solution that healthcare workers can stick to. In this article, we propose three key frameworks (viz., health surveillance, workforce, and modular facilities) that would be helpful in creating a balance within the healthcare industry daily operation which is the paramount need of the “new normal” and sustainability. © Journal of Hospital Management and Health Policy. All rights reserved.

TOSCANA: The Observational Seroepidemiologic Study of COVID-19 at the United States Naval Academy

Background. University students, including those at military service academies, are at increased risk of acute respiratory infection (ARI), including SAR-CoV-2, due to crowded living conditions, frequent social interaction and other factors that facilitate pathogen transmission. Unlike many universities, the United States Naval Academy (USNA) continued in-person instruction in Fall 2020 in the midst of the COVID-19 pandemic. The Observational Seroepidemiologic Study of COVID-19 at the United States Naval Academy (TOSCANA,) a longitudinal cohort characterizes the burden and risk factors of SARS-CoV-2 in USNA midshipmen. Methods. Midshipmen were enrolled August- October 2020. Participants were queried about their ARI risk factors, COVID-19 history, and recent receipt of medical care for any ARI at enrollment, in December 2020 and again in May 2021. Subjects were also asked to provide blood and saliva samples to assess their SARS-CoV-2 serostatus at the same three timepoints. A saliva sample was collected by a subset of subjects in February 2021. Presence of anti-SARS-CoV-2 serum IgG in dried blood spots and saliva was measured by multiplex magnetic microparticle-based immunoassays. Results. 181 midshipmen consented to the study and completed the baseline survey (Table 1). 17 (17.5%) of the 97 subjects who submitted baseline blood sample were SARS-CoV-2 seropositive. Only 4 (24%) positive individuals reported having been tested for or diagnosed with COVID-19 prior to arrival at USNA. 121 participants completed the midyear survey, of whom 61 (50%) submitted a blood sample. 16 (26%) of the midyear specimens were SARS-CoV-2 positive. Of these, 3 were new infections. 73 subjects completed the May survey, and 63 (100%) of the submitted blood samples were positive. 83 subjects provided baseline saliva samples, and ~55 submitted saliva at each successive time point. 1 (5%) was positive at enrollment, 9 (17%) were positive at midyear and 47 (96%) were positive in May. Conclusion. SAR-CoV-2 prevalence in a sample of USNA midshipmen was < 20% at enrollment. A small proportion of subjects seroconverted between the September and December visits. SARS-CoV-2 positivity rose in May, following a COVID-19 outbreak in February and COVID-19 vaccination efforts in March at USNA.

Renin-angiotensin-aldosterone system inhibition is associated with reduced in-hospital mortality in critically ill covid-19 patients with pre-existing hypertension

Background: The virus responsible for COVID-19 enters human cells by binding angiotensinconverting enzyme 2. The influence of renin-angiotensin-aldosterone system (RAAS) inhibitors, including angiotensin-converting enzyme inhibitors (ACEi) and angiotensin receptor blockers (ARBs), remains uncertain. Aim: To examine the role of ACEi / ARB exposure on outcomes in COVID-19 patients with preexisting hypertension (HTN) admitted to intensive care units (ICU). Methods: The COVID-19 Critical Care Consortium is a prospective, observational cohort study of patients requiring ICU admission for active COVID-19 spanning 354 participating sites in 54 countries. Patients >18 years old with pre-existing HTN requiring antihypertensive therapy were analysed. Length of stay and in-hospital mortality to 90 days post ICU admission were analysed as time-to-eventoutcomes by multistate survival analysis, and the influence of ACEi / ARB use on the hazards of death and discharge by multi-state Cox proportional hazard modelling and sensitivity analysis. Results: From December 1, 2019 through December 30, 2020, 663 eligible patients were registered. Of these, 480 patients had received ACEi and / or ARB therapy (median age 65 years, 67% male) in the 2 weeks before ICU admission, while 183 had not (66 years, 61% male). Average lengths of ICU and general ward stays were longer in the ACEi / ARB than non-ACEi / ARB group (20.8 days and 6.5 days vs. 15.5 and 6.0 days, respectively). ACEi / ARB use was associated with a decreased hazard of death (HR, 0.69, 95% CI, 0.54 -0.88) that persisted after adjusting for propensity scores (0.67, 0.53 -0.86). Cumulative probabilities (unadjusted for baseline characteristics) for death and discharge post ICU admission are depicted in the figure for ACEi/ARB (red) and non-ACEi / ARB (blue) patients. Conclusions: In 663 critically ill COVID-19 patients with pre-existing HTN, RAAS inhibition pre-ICU admission was linked to reduced in-hospital mortality.

Hospital-based multidisciplinary lung cancer care in Australia: a survey of the landscape in 2021.

INTRODUCTION: Lung cancer is the leading cause of cancer death in Australia and has the highest cancer burden. Numerous reports describe variations in lung cancer care and outcomes across Australia. There are no data assessing compliance with treatment guidelines and little is known about lung cancer multidisciplinary team (MDT) infrastructure around Australia. METHODS: Clinicians from institutions treating lung cancer were invited to complete an online survey regarding the local infrastructure for lung cancer care and contemporary issues affecting lung cancer. RESULTS: Responses from 79 separate institutions were obtained representing 72% of all known institutions treating lung cancer in Australia. Most (93.6%) held a regular MDT meeting although recommended core membership was only achieved for 42/73 (57.5%) sites. There was no thoracic surgery representation in 17/73 (23.3%) of MDTs and surgery was less represented in regional and low case volume centres. Specialist nurses were present in just 37/79 (46.8%) of all sites. Access to diagnostic and treatment facilities was limited for some institutions. IT infrastructure was variable and most sites (69%) do not perform regular audits against guidelines. The COVID-19 pandemic has driven most sites to incorporate virtual MDT meetings, with variable impact around the country. Clinician support for a national data-driven approach to improving lung cancer care was unanimous. DISCUSSION: This survey demonstrates variations in infrastructure support, provision and membership of lung cancer MDTs, in particular thoracic surgery and specialist lung cancer nurses. This heterogeneity may contribute to some of the well-documented variations in lung cancer outcomes in Australia.