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Background: The clinical course of coronavirus disease-2019 (COVID-19) varies from those who are asymptomatic, experience mild symptoms such as fever, cough, and dyspnea, to more severe outcomes including acute respiratory distress, pneumonia, renal failure, and death. Early reports suggested severe outcomes in patients with primary immunodeficiency (PID), particularly those with type 1 interferon signalling defects. This prompted a rigid approach to social distancing to protect this patient population, particularly children. To date, real-world data describing the course and outcome of COVID-19 in paediatric PID patients remains scarce. Method(s): In this retrospective case series, we describe the clinical course of 36 paediatric patients with underlying primary immunodeficiency (PID) followed by SickKids Hospital (Toronto, Canada) who were symptomatic and tested positive for SARS-CoV-2 infection between October 2020 to November 2022. Result(s): Our cohort consisted of patients with combined immunodeficiency (66.7%), antibody deficiency (22.2%), neutrophil dysfunction (8.3%), and immune dysregulation (2.8%). The median age was 7.5 years (range: 8 months - 17 years), with 21 male and 15 female patients. Three (8.3%) patients were post-hematopoietic stem cell transplant (HSCT) and 12 (33%) patients were on immunoglobulin replacement. Nine (25%) patients had underlying lung problems including bronchiectasis (1), interstitial lung disease on home oxygen therapy (1), and underlying asthma (7). Most patients had mild clinical course and were managed at home. The most common symptoms were fever (80%), cough (75%) and other upper respiratory tract symptoms (72%). Nineteen (52.7%) patients experienced other symptoms which included headache, lethargy, or gastrointestinal upset. At the time of the infection, 13 patients (36.1%) had received 2 doses of a SARS-CoV-2 vaccine, 5 patients (13.9%) had received 1 dose, and 18 (50%) were not vaccinated. None of the patients received antiviral or monoclonal antibody as prophylaxis or treatment. Only 1 patient required hospital admission out of precaution given the close proximity to HSCT. All patients recovered without complications. Conclusion(s): The paediatric patients with PID followed by our centre experienced mild to moderate COVID-19 symptoms and recovered fully without complications. These findings support the return of much needed social interactions among children, which were impacted severely during the COVID-19 pandemic.Copyright © 2023 Elsevier Inc.
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Currently, 640 million cases of coronavirus disease 2019 (COVID-19) and 6.6 million deaths have been reported world-wide. Risk factors for severe COVID-19 are known, including those with compromised immunity. Among patients with inborn errors of immunity (IEI), early reports of severe outcomes lead to strict masking and social distancing measures. While this resulted in relatively low infection rates among those with IEI, real-world data describing the clinical course of COVID-19 in this patient population have remained limited. We performed a retrospective study of adult IEI patients followed by our center in which a positive test (rapid antigen or PCR) for COVID-19 was determined between November 2021-November 2022. Medical charts were reviewed, and patient interviews conducted. All patients provided informed consent. Twenty-nine patients were enrolled (22 females, 7 males), aged between 18-69 years (median: 20-29 years). The cohort included those with antibody deficiencies (41.37%), combined immunodeficiencies (34.48%;HIES, CARD11, STAT1-GOF), immune dysregulation disorders (20.69%;LRBA deficiency, AIRE deficiency) and phagocyte defect (3.45%;CGD). The duration of symptoms ranged between 3 days-4 weeks (median: < 1 week). Upper respiratory symptoms (including sore throat, congestion) were reported in 97% while fever was present in 41% of patients. Prior to infection, 14 (48%) patients had underlying asthma or bronchiectasis - 2 subsequently experienced shortness of breath and were treated with inhalers or Sotrovimab, respectively. No treatment was required in 65.5% of cases. The remaining received Paxlovid (10.3%), Sotrovimab (13.79%), or antibiotics (10.3%). Of the 2 patients with STAT1-GOF, one tested positive during a repeat episode of febrile neutropenia which required hospitalization. No other patients were hospitalized or needed ICU admission. No deaths were recorded. In light of these favourable outcomes, patients with IEI can gradually and safely return to normal activities.Copyright © 2023 Elsevier Inc.
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Introduction Children with idiopathic chronic constipation are extremely challenging to manage. Before review by tertiary specialist teams, Children have suffered for years with constipation, which leads to significant behaviour related issues around toileting, despite adequate medical treatment. The involvement of the health play specialist (HPS) in the nurseled constipation clinic is to address behaviours around toileting. Aims To demonstrate involvement of HPS in the clinic led to improved outcomes for children and families. This will be identified through the use of parental satisfaction questionnaires and four case studies. Case Studies We demonstrate four extremely complex constipation cases referred to clinic and successfully managed by HPS with unique individualised approach with support and plans for parents and school. 9-year-old boy with history of sexual abuse, with soiling and wetting accidents. 5 sessions with the HPS, focusing on toileting behaviours. Sessions involved desensitizing play around the body, use of toilet related games/activities, videos and mobile apps. All issues resolved. 5-year-old boy: Stool with-holding, will only pass stools in a nappy and soiling. 8 sessions with HPS - Intense toilet training for 2-4 days with hourly sits. Reward charts to compliment interests, targets adjusted when goal reached, prizes given. Desensitization play around toileting behaviours. Using analogies to improve behaviour, he loved dustbin lorries - body empties the waste (poo) just like the bin men collecting the rubbish to get rid of it from home. No more accidents, independent toileting achieved 5-year-old girl Issues with constipation, soiling and toilet refusal. All bowel movements in knickers. Complete HPS treatment virtually, secondary to COVID restrictions. 6 Video call sessions- individualised plan of regular sits to relax, with no pressure to perform. To do an activity whilst on the toilet. Visual pictures/videos explaining how the body works and the plan was adjusted on the video. Rewards when child reached the target, and prize sent in post. Outcome -no fear of the toilet, bowels open on the toilet, no accidents. 8 year old boy premature 33 + 5 weeks. Constipation with overflow since birth. Referred to surgeons for rectal biopsies and botox injections at the age of 3 but no improvement. Age 4 admitted to the ward for 1 week for observation, transit marker study and toilet training was unsuccessful. Referred to another unit for second opinion at parental request. Started to refuse medications. ACE surgery discussed. Diagnosed with Autism at 7 years. Invited for a week of intense toileting with HPS, hourly sits and desensitization activities on medication taking, toileting, with-holding, signs and signals of body. Reward system in place, when reached expectations, reward given by hospital. Outcome bowels open daily in the toilet, wears pants all the time. Satisfaction questionnaires were given to parents and feedback was extremely positive. Conclusion The health play specialist involvement in the nurse led constipation clinic allows for individualised intervention guided by the child's needs. Pharmacological interventions alone may be unsuccessful without addressing behavioural needs.
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Background: Hemodialysis (HD) patients are at increased risk for COVID-19 infection, hospitalization, and mortality. Early COVID-19 diagnosis is thus critical to mitigate SARS-CoV-2 spread and improving patients' health outcomes. Generally, nasopharyngeal (NP) specimens are considered the most sensitive biological samples to diagnose SARS-CoV-2 infections. However, NP swabbing is considered uncomfortable by most patients, and it requires health professionals, thus impacting its cost-effectiveness. In a previous proof-of-principle study, we demonstrated that face masks worn by in-center HD patients can harbor SARS-CoV-2. In this Kidney-X funded study, we determined efficiency of face mask testing by comparing results to saliva specimen collected from same individuals. Method(s): Disposable 3-layer masks were provided to each subject at the time of entering the dialysis center. Masks were collected 4 hours after worn. Saliva was collected using Salivette kit at the time of mask collection. RT-PCR based testing were performed using Thermo Fisher COVID-19 Combo Kit (A47814). Result(s): We collected 179 pairs of saliva/masks, 114 from 42 dialysis staff and patients without recent COVID-19 infection (control group), and 65 from 30 HD patients with COVID-19, diagnosed by NP RT-PCR (COVID-19 group). Patients provided 1 to 7 sample pairs on average 11+/-8 days (0 to 36) after COVID-19 diagnosis. Thirty-one of the 65 sample pairs were SARS-CoV-2 positive either in the saliva or the mask samples (26 positive saliva;20 positive masks). Saliva and mask testing sensitivities were 84% and 65% with a mean cycle threshold (CT) of 31.8 and 32.2, respectively. Fifteen pairs tested positive for both worn masks and saliva. Mask and saliva CT values did not differ significantly. Of note, in 5 sample pairs saliva tested negative while masks tested positive. In the control group, all 114 saliva samples tested negative;one mask tested weakly positive, resulting in saliva and mask testing specificities of 100% and 99%, respectively. S gene dropout was observed in all positive samples, indicating Omicron BA.1 infection. Conclusion(s): While the sensitivity of mask testing is less compared to saliva testing, its operational ease, lack of patient discomfort, seamless repeatability, and lower costs make it a viable option for SARS-CoV-2 screening.
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Background: Hemodialysis (HD) patients are vulnerable to COVID-19. Early detection of COVID-19 in dialysis clinics informs isolation and infection control policies. Saliva testing is an alternative to nasopharyngeal swab to detect SARS-CoV-2. The understanding of viral shedding in HD patients is limited. We explore viral shedding duration in HD patients and determine its correlation with immunosuppression. Method(s): Eligible patients diagnosed with COVID-19, confirmed by nasal swab RTPCR within 2 weeks of COVID-19 diagnosis, were recruited. They were given Salivette Saliva Collection kits and instructed to chew a cotton swab for 60 seconds. Result(s): 30 COVID-19 positive patients participated (Table 1). Each patient provided up to 7 saliva samples. 65 samples were collected for an average of 11+/-8 days (range 0-36) after diagnosis. 26 samples showed at least one COVID-19 target gene (N, ORF1ab) with cycle threshold <38 cycles. 12 patients had at least 1 positive sample, and 23 patients had at least 1 negative sample. Of the 23 patients who had at least one negative sample, median days to first negative sample is 9 days (range 0-36). For the 7 patients who only had positive samples, median days to last positive sample is 9 days (range 0-36). There is no observed difference between vaccinated (n=24) and vaccinated patients (n=6). 6 out of 30 patients took immunosuppressants such as Tacrolimus, Hydroxychloroquine, and Mycophenolate sodium. Median days to turn negative (or use last positive date if negative results never achieved) was 15 days for immunocompromised group and 8 days for nonimmunocompromised group (Fig.1) Conclusion(s): Immunocompromised HD patients shed COVID-19 virus for a significantly longer period. While our study did not explore the shedding of viable SARS-CoV-2, a longer isolation should be considered in immunosuppressed HD patients. Studies on shedding of viable SARS-CoV-2 are warranted in immunocompromised HD patients to inform policies regarding isolation and contact tracing protocols, and vaccination strategies.
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Background: Hemodialysis (HD) patients are less likely to mount a response to the COVID-19 vaccination (CoVac). Poor sleep is associated with blunted vaccination response in the general population. We aim to explore the association between CoVac and sleep quality (SQ) in HD patients. Method(s): Patients from 3 HD clinics were enrolled if they were >=18 years and able to give written consent. Patients were administered the Insomnia Severity Index (ISI) and the Pittsburg Sleep Quality Index (PSQI). Blood specimen were collected after the primary series of COVID-19 vaccination. SARS-CoV-2 neutralization antibodies (nAB) were assayed using the GenScript SARS-CoV-2 Surrogate Virus Neutralization Test Kit (Cat#L00847-A). nAB titers are presented as Unit/ml on a natural log scale. PSQI scores of >5 were categorized as poor SQ and <=5 as good SQ. ISI scores were grouped as no clinically significant insomnia (NI;score 0-7), subthreshold insomnia (SI;score 8-14), and clinical insomnia (CI;score 14-28). T-test and ANOVA analysis were performed on PSQI and ISI scores, respectively, to determine the statistical association between SQ and nAB levels Results: 58 patients were included (60+/-9 years old, HD vintage 4.7+/-4.5 years, 62% male, 66% Black, 21% Hispanic). In the PSQI, 72% (n=42) had poor SQ. In the ISI, 52% = NI, 31% = SI, and 17% CI. Box plots of nAB levels with median and IQR are shown in Fig. 1. There is no association between SQ and nAB levels. Conclusion(s): There is no association between SQ and CoVac response. Given the immune dysfunction in this population, any modifying effect SQ has on CoVac, as observed in the general population, is unlikely. Other methods of improving CoVac response in this vulnerable population should be explored. (Figure Presented).
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The aim of this COVID-19 Practical Manual for the prevention, detection, control and surveillance of SARS-CoV-2 is to standardize and regulate the best strategy for the prevention and control of SARS-CoV-2 infections. All of this to provide better care quality to patients and their families/caregivers, and to promote a safe working environment for health personnel within the institution. The manual has been prepared with the aim of guiding health personnel in decision-making for the prevention, detection, control and surveillance of SARS-CoV-2 infections. This document describes various multidisciplinary care algorithms in different scenarios, considering the recommendations for isolation, use of personal protective equipment, transfer within various services in the hospital, admission to procedures and recommendations for healthcare personnel. Copyright © 2022 Hospital Infantil de Mexico Federico Gomez. Publicado por Permanyer.
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Background: Si nce the onset of the COVID-19 pandemi c, a mai n chal l enge for cl i ni ci ans and publ i c heal th deci si on-makers has revol ved around ri sk strati fi cati on i n vul nerable popul ati ons, i n parti cul ar i ndi vi dual s wi th i nborn errors of i mmuni ty (I EI ). However, avai l abl e report s of t he cl i ni cal course of COVID-19 in patients with IEI show wide variability, from a complete lack of symptoms to severe and compli-cated disease. Objective(s): To present the clinical features and outcomes of SARS-CoV-2 infection in adult patients with IEI. Method(s): We performed a retrospective chart review documenting patient characteristics and clinical course of SARS-CoV-2 infection between December 2021 and July 2022. Result(s): Ten adult patients with IEI followed in our center were diagnosed with COVID-19, as determined by RT-PCR or rapid antigen testing. IEI in this cohort included those with humoral and combined immunodeficien-cies, as well as phagocytic defects. An underlying lung comorbidity was identified in 3 patients. Symptoms were mostly mild and self-limiting, and no severe outcomes, complications, or mortality were noted in this study. Conclusion(s): We suggest that patients affected by a wide range of both humoral and combined IEI may demonstrate resilience, while highlighting the possible protective effects of vaccination and immunoglobulin replacement in this population. Statement of Novelty: We report on the mild COVID-19 clinical course of 10 adults with IEI. Copyright © The Authors.
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Introduction: The health care system had to evolve rapidly to adapt to the multiple challenges posed by SARS-CoV-2 pandemic although significant progress has been made with vaccines and immunisation programmes, the challenge seems to be far from over. At Maidstone and Turnbridge Wells NHS trust we provide tertiary paediatric gastroenterology services to paediatric patients from Kent and East Sussex, including new patients with suspected Coeliac disease and long-term follow-up. Objective: We looked at the patient and their family's experience with regards to multiple aspects of management of Coeliac disease (CD) during the government-imposed lockdown and various restrictions from March 2020 to November 2021. Methods: We designed a questionnaire to assess patient's experience of management of their coeliac disease and included identifying symptoms during lockdown, access to gluten free (GF) products, and emotional wellbeing. Patient details were collected from our database. Phone calls were made and data was collected after obtaining verbal consent from patients and caregivers. Results: 50 telephone questionnaires were completed with patients (or parents of the patient) with diagnosed coeliac disease. The patients interviewed were between 3 years to 16 years. Our standard follow-up practice for patients with confirmed diagnosis with CD clinic is an annual review with specialist gastroenterology nurse and dietician and this target was met for 72% (36/50) of patients (both virtual and face to face clinic reviews). 98% (49/50) of patients denied development or worsening of any GI symptoms during the lockdown. 96% (48/50) of patients reported normal development in growth and height since the lockdown. 98% of patients (49/50) were able to procure GF product during the lockdown. During the initial 3-4 weeks of lockdown, some families reported of limited options of GF products but were still able to procure them. Patients and their families reported being emotionally well. All families were made aware to contact MTW nursing team for advice. The primary online resource used by families for guidance was Coeliac UK website with 50% (25/50) of families using the service. Conclusion: During SARS-CoV-2 pandemic, patients with coeliac disease managed CD well despite the lockdown. We managed to see majority of our patients (virtual/face to face clinics) There was no significant impact on procuring GF products and emotional well-being despite multiple challenges.
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OBJECTIVES: To analyze the frequencies of 3 types of hospital revisits by patients after treatment for COVID-19 in the emergency department.;MATERIAL AND METHODS: Retrospective observational study of consecutive patients who came to the emergency department in March and April 2020 and were discharged alive with a diagnosis of COVID-19. Baseline and acute episode data were collected and the patients were followed for 1 year. We analyzed variables associated with revisits for any reason, revisits related to COVID-19, and early COVID-19-related revisits (within 30 days).;RESULTS: A total of 1352 patients with a mean age of 62.1 years (52.9% male) were studied. A total of 553 revisits were made by 342 patients (25.3%) for any reason;132 (9.8%) revisited in relation to COVID-19 at least once. Of those, 103 (7.6%) revisited within 30 days (early) and 29 (2.2%) came later. COVID-19-related revisits were associated with thrombotic events (odds ratio [OR], 7.58;95% CI, 1.75-32.81) and pulmonary fibrosis (OR, 4.95;95% CI, 1.27-19.24);early revisits were inversely associated with follow-up management by a contracted health care support service (OR, 0.18;95% CI, 0.03-0.92). Hospital admission during the initial visit was significantly associated with fewer revisits for any reason or related to COVID-19 at any time.;CONCLUSION: Fewer than half the total number of emergency department revisits after initial care for COVID-19 were related to the novel coronavirus infection. Revisits occurred more often in the first 30 days after discharge. Later COVID-19-related revisits were uncommon, but given the large number of patients with this infection, such visits can be expected.
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Background: On March 20, 2020, to stop the spread of the COVID-19, the New York State Governor issued a strict stay at home order for all tasks that were deemed as “nonessential” starting March 22 at 8PM. We would like to determine what change, if any, in physical activity levels (PAL) took place because of the lockdown order in HD patients. Methods: HD patients were enrolled from 4 clinics in New York City starting in May 2018 and followed for a period of up to 1 year. Patients ≥18 years, on HD ≥3 months, able to walk, and owning a smartphone were enrolled. PAL was defined by steps taken per day measured by with a wrist-based monitoring device (Fitbit Charge 2). Patients still in the study as of March 22, 2020 were included in the study cohort. Average steps per day was calculated for Jan 1-Feb 13, 2020 and the five weeks prior to and after the lockdown went into place. A linear mixed-effect model was used to estimate the average steps per day and 95% confidence intervals. Socioeconomic parameters such as age, race, employment status, and education level were taken at the beginning of the study. Results: 42 patients were included in this analysis. At enrollment patients were 55±11 years old with a dialysis vintage of 4.5±4.4 years, and a BMI of 28.9±8.6 kg/ m2. 33% lived alone, 48% were single, 50% unemployed, 69% were African American, and 50% had an education level of some college or higher. Results on average steps per day are presented in Figure 1. Steps per day decreased significantly after the lockdown order with the most significant drop when the COVID-19 pandemic was declared a national emergency Conclusions: There was a decrease in PAL due to the mandated lockdown. As sedentary behavior is a risk factor for negative outcomes in the HD population, we must implement interventions to promote PAL, such as intradialytic exercise. (Figure Presented).
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Background: The need to continue in-center hemodialysis (HD) during COVID-19 pandemic presents a risk of transmission for patients and staff members. The present study aimed to determine if the periodic interactions among patients and staff resulted in spread of COVID-19 in a HD center during a period of 2 months Methods: This is a retrospective analysis on a HD center in New York City (172 patients, 32 staff members, 26 chairs, MWF and TTS schedules, and 4 shifts/day). From March 2nd to April 24th we recorded every HD treatment (chair, patient, and staff member involved in care). We kept dated records for positive COVID-19 cases (patients and staff). To estimate the patient-to-patient interaction, we obtained the location coordinates of each dialysis chair, calculated the Euclidian distance between them and weighted the interaction by proximity between chairs. We conducted network analysis to assess these interactions Results: During the study period, 16 patients and 2 staff members became COVID-19 positive. As shown in Figure 1(a), there were 3 chairs (2, 24, and 25) that had more than 1 positive patient. Clusters in chairs 2 and 25 were ruled out based on a lack of direct contact between the involved patients (at least 2 shifts separating them at all times;no in-between patients became positive);chair 2 had a nonviable temporal direction of transmission. Based on schedule, shift, and a 14-day incubation period, the cluster in chair 24 was dismissed. This was corroborated by network analysis [Fig. 1(b)] where the purple dots represent the COVID-19 positive patients, the blue dots represent negative patients (same shift/schedule), and the edges represent the weighted patient-to-patient interaction. We reasoned that more exposed patients would have had a higher chance of becoming infected. Similar information was found for staff-to-patient interaction Conclusions: Based on our analysis we consider that for patient-to-patient, staffto- patient, and staff-to-staff interactions, in-center spread of COVID-19 was unlikely.