Changes in ischemic stroke presentations and associated workflow during the first wave of the COVID-19 pandemic: A population study

Background: Pandemics may promote hospital avoidance among patients with emergencies, and added precautions may exacerbate treatment delays. Methods: We used linked administrative data and data from the Quality Improvement and Clinical Research Alberta Stroke Program – a registry capturing stroke-related data on the entire Albertan population(4.3 million) – to identify all patients hospitalized with stroke in the pre-pandemic(01/01/2016-27/02/2020) and COVID-19 pandemic(28/02/2020-30/08/2020) periods. We examined changes in stroke presentation rates and use of thrombolysis and endovascular therapy(EVT), adjusted for age, sex, comorbidities, and pre-admission care needs;and in workflow, stroke severity(National Institutes of Health Stroke Scale/NIHSS), and in-hospital outcomes. Results: We analyzed 19,531 patients with ischemic stroke pre-pandemic versus 2,255 during the pandemic. Hospitalizations/presentations dropped(weekly adjusted-incidence-rate-ratio[aIRR]:0.48,95%CI:0.46-0.50), as did population-level incidence of thrombolysis(aIRR:0.49,0.44-0.56) or EVT(aIRR:0.59,0.49-0.69). However, proportions of presenting patients receiving thrombolysis/EVT did not decline (thrombolysis:11.7% pre-pandemic vs 13.1% during-pandemic, aOR:1.02,0.75-1.38). For out-of-hospital strokes, onset-to-door times were prolonged(adjusted-coefficient:37.0-minutes, 95%CI:16.5-57.5), and EVT recipients experienced greater door-to-reperfusion delays(adjusted-coefficient:18.7-minutes,1.45-36.0). NIHSS scores and in-hospital mortality did not differ. Conclusions: The first COVID-19 wave was associated with a halving of presentations and acute therapy utilization for ischemic stroke at a population level, and greater pre-/in-hospital treatment delays. Our data can inform public health messaging and stroke care in future pandemic waves.

Editors' Note: Association of Loneliness With 10-Year Dementia Risk and Early Markers of Vulnerability for Neurocognitive Decline

Dr. Salinas and colleagues examined the association of loneliness at baseline with 10-year all-cause dementia risk and early cognitive and neuroanatomic imaging markers of Alzheimer disease and related dementia (ADRD) vulnerability in 2,308 participants in the population-based Framingham study cohorts. They found that loneliness was associated with increased dementia risk, with the risk tripling in adults whose baseline risk would otherwise be fairly low on the basis of age and genetic risk and that loneliness was also associated with worse markers of ADRD vulnerability, implying a potential early pathogenetic role. In response, Dr. Daly notes that a similar association was seen between frailty and 10-year dementia risk. He suggests studying the relationship between longitudinal changes in loneliness and neuroanatomical or neuropathologic measures, and the relationship of loneliness to frailty. He also emphasizes the importance of taking action against loneliness in society, which was aggravated by the COVID-19 pandemic especially among lower socioeconomic strata, to mitigate further social disparities in dementia risk. Responding to these comments, Dr. Salinas notes that the study team has begun exploring longitudinal associations of loneliness with dementia-related measures in another cohort, and points to compelling findings of greater cortical amyloid and entorhinal tau accumulation in patients with loneliness in the Harvard Aging Brain Study. Dr. Salinas echoes the need for interventions targeting loneliness and social isolation. This correspondence underscores our growing understanding of the role that psychosocial determinants of health play in the development of dementia. Although it seems clear that a social brain fares better than a lonely one over time, the question remains as to whether the lonely brain can be "rescued" by social interventions.

Changes in ischemic stroke presentations and associated workflow during the first wave of the COVID-19 pandemic: A population study

Background: Pandemics may promote hospital avoidance among patients with emergencies, and added precautions may exacerbate treatment delays. Methods: We used linked administrative data and data from the Quality Improvement and Clinical Research Alberta Stroke Program - a registry capturing stroke related data on the entire Albertan population (4.3 million) - to identify all patients hospitalized with stroke in the pre-pandemic (01/01/2016-27/02/2020) and COVID-19 pandemic (28/02/ 2020-30/08/2020) periods. We examined changes in stroke presentation rates and use of thrombolysis and endovascular therapy (EVT), adjusted for age, sex, comorbidities, and preadmission care needs;and in workflow, stroke severity (National Institutes of Health Stroke Scale/NIHSS), and in-hospital outcomes. Results: We analyzed 19,531 patients with ischemic stroke pre-pandemic versus 2,255 during the pandemic. Hospitalizations/presentations dropped (weekly adjusted-incidencerate-ratio[aIRR]:0.48,95%CI:0.46-0.50), as did population-level incidence of thrombolysis (aIRR:0.49,0.44-0.56) or EVT (aIRR:0.59,0.49-0.69). However, proportions of presenting patients receiving thrombolysis/EVT did not decline (thrombolysis:11.7% pre-pandemic vs 13.1% during-pandemic, aOR:1.02, 0.75-1.38). For out-of-hospital strokes, onset-to-door times were prolonged(adjusted-coefficient:37.0-minutes, 95%CI:16.5-57.5), and EVT recipients experienced greater door-to-reperfusion delays (adjusted-coefficient:18.7-minutes,1.45-36.0). NIHSS scores and in-hospital mortality did not differ. Conclusions: The first COVID-19 wave was associated with a halving of presentations and acute therapy utilization for ischemic stroke at a population level, and greater pre-/in-hospital treatment delays. Our data can inform public health messaging and stroke care in future pandemic waves.

Frequency, Persistence, and Patient-reported Outcomes of Neurological Symptomsin Mild COVID-19: Resultsfrom the ALBERTA HOPE COVID-19 Trial

Objective: To examine the natural history of neurological symptoms in mild COVID-19. Background: Various neurological manifestations have been reported with COVID-19, mostly in retrospective studies of hospitalized patients. There are few data on patients with mild COVID19. Design/Methods: Consenting participants in the ALBERTA HOPE COVID-19 trial( NCT04329611, hydroxychloroquine vs placebo for 5-days), managed as outpatients, were prospectively assessed 3-months and 1-year after their positive test. They completed detailed neurological symptom questionnaires, Telephone Montreal Cognitive Assessment(T-MoCA), Kessler Psychological Distress Scale(K10), and the EQ-5D-3L(quality-of-life). Informants completed the Mild Behavioural Impairment Checklist(MBI-C) and Informant Questionnaire on Cognitive Decline(IQCODE). We tracked healthcare utilization and neurological investigations using medical records. Results: Among 198 patients (median age:45, IQR:37-54, 43.9% female);28(14.1%) had preexisting neurological/psychiatric disorders. Among 179 patients with symptom assessments, 139(77.7%) reported ≥1 neurological symptom, the most common being anosmia/dysgeusia(56.3%), myalgia(42.6%), and headache(41.8%). Symptoms generally began within 1-week of illness(median:6-days, IQR:4-8). Most resolved after 3-months;40 patients(22.3%) reported persistent symptoms at 1-year, with 27(15.1%) reporting no improvement. Persistent symptoms included confusion(50%), headache(52.5%), insomnia(40%), and depression(35%). Body mass index, prior neurologic/psychiatric history, asthma, and lack of full-time employment were associated with presence and persistence of neurological symptoms;only female sex was independently associated on multivariable logistic regression(aOR:5.04, 95%CI:1.58-16.1). Patients with persistent symptoms had more hospitalizations and family physician visits, worse MBI-C scores, and were less often independent for instrumental daily activities at 1-year(77.8% vs 98.2%, p=0.005). Patients with any or persistent neurological symptoms had greater psychological distress defined as K10≥20(aOR:21.0, 95%CI:1.96-225) and worse quality-of-life ratings(mean EQ-5D VAS:67.0 vs 82.8, p=0.0002). 50.0% of patients had T-MoCA<18 at 3-months versus 42.9% at 1-year;patients reporting memory complaints were more likely to have informant-reported cognitive-behavioural decline (aOR[1-year IQCODE>3.3]:12.7, 95%CI:1.08-150). Conclusions: Neurological symptoms were commonly reported in survivors of mild COVID-19 and persisted in one in five patients 1-year later. These symptoms were associated with worse patient-reported outcomes.

Supply chain risk identification: a real-time data-mining approach

Purpose The global pandemic COVID-19 unveils transforming the supply chain (SC) to be more resilient against unprecedented events. Identifying and assessing these risk factors is the most significant phase in supply chain risk management (SCRM). The earlier risk quantification methods make timely decision-making more complex due to their inability to provide early warning. The paper aims to propose a model for analyzing the social media data to understand the potential SC risk factors in real-time. Design/methodology/approach In this paper, the potential of text-mining, one of the most popular Artificial Intelligence (AI)-based data analytics approaches for extracting information from social media is exploited. The model retrieves the information using Twitter streaming API from online SC forums. Findings The potential risk factors that disrupt SC performance are obtained from the recent data by text-mining analyses. The outcomes carry valuable insights about some contemporary SC issues due to the pandemic during the year 2021. The most frequent risk factors using rule mining techniques are also analyzed. Originality/value This study presents the significant role of Twitter in real-time risk identification from online SC platforms like "Supply Chain Dive", "Supply Chain Brain" and "Supply Chain Digest". The results indicate the significant role of data analytics in achieving accurate decision-making. Future research will extend to represent a digital twin for identifying potential risks through social media analytics, assessing risk propagation and obtaining mitigation strategies.

Mobile Covid Sanitization Robot

As the second wave of the Novel Coronavirus hits the world, a staggering number of COVID-19 cases have been reported. The COVID-19 cases in India also are substantially high. Most of the existing systems require a human to be physically present to manually disinfect the surfaces. To reduce and limit the COVID-19 cases, person-to-person interaction, cleaning and sterilization from time to time is the demand of the present day. Robots can be employed to save time as well as support these processes in hospitals, thus minimizing the life threat to people. In the present work, a robot (Covid Bot) is equipped with a sanitizing mechanism which can be operated remotely to sanitize all required areas. © 2021 IEEE.

Quantifying changes in acute stroke presentations and associated workflow during the COVID-19 pandemic: A population-based study

Objective: To understand the effect of the COVID-19 pandemic on the presentation and treatment of acute ischemic stroke. Background: Pandemics may result in hospital avoidance among patients with emergencies, and the added demands of precautions during stroke codes may exacerbate treatment delays. There is a paucity of population-based data on these phenomena. Design/Methods: We extracted data from the Quality Improvement and Clinical Research(QuICR) Alberta Stroke Program, a Canadian population-based stroke registry capturing stroke-related data on the entire population of Alberta, Canada. We used linked administrative data to identify all patients hospitalized with stroke pre-COVID-19(1-January- 2016 to 27-February-2020) and post-COVID-19 (28-February-2020 to 30-June-2020). We used Poisson regressions to evaluate changes in stroke hospitalizations and use of thrombolysis and endovascular therapy(EVT), adjusted for age, sex, comorbidities, and continuing care needs. We compared proportions receiving treatment using logistic regressions, and compared workflow metrics and stroke severity (National Institutes of Health Stroke Scale, NIHSS) using generalized linear models. Results: We analyzed 19,531 patients with ischemic stroke pre-COVID-19 versus 1,400 postCOVID-19. Hospitalizations dropped post-COVID-19 (weekly aIRR:0.49,95%CI 0.46-0.52), as did incidence of thrombolysis (aIRR:0.50,0.42-0.59) and EVT (aIRR:0.56,0.44-0.72). However, the proportions of presenting patients receiving thrombolysis and EVT among all ischemic patients were unchanged (thrombolysis 12.9% pre- and post-COVID, aOR:0.86,0.58-1.29;EVT 6.2% pre- vs 6.8% post-COVID, aOR:1.30, 0.91-1.84). Call-to-ambulance-dispatch and call-toparamedics-on-scene times were prolonged post-COVID-19 (adjusted-coefficient for call-toparamedics-on-scene:9.05min, 5.41-12.7), and EVT recipients experienced a greater delay in CT-to-groin-puncture and door-to-groin-puncture times (e.g. CT-to-groin-puncture median 53min, IQR 35-79 pre- vs 73min, 44-108 post-COVID;adjusted-coefficient: 15.33min, 95%CI 2.09-28.6). Among treated patients, there were no relevant differences in NIHSS, onset-to-call, door-to-CT, or door-to-needle times. Conclusions: The pandemic was associated with a halving of presentations for ischemic stroke and use of acute therapies at a population level, and greater pre-hospital and in-hospital workflow delays. Our results may help inform public health messaging and help optimize stroke workflow.

Covid-19 impact on the cost of index testing hiv case detection in 5 indian districts

Background: Index testing is a viable strategy to identify HIV cases globally and is a cornerstone of all PEPFAR programs. COVID-19 and associated lockdowns impacted access to health services including HIV testing. The financial impact of these lockdowns on HIV case detection has not been studied in-depth. Methods: Program ACCELERATE implemented Facility-Based Index Testing (FBIT;n=5 districts) and Community-Based Index Testing (CBIT;n=3 districts) in 2 high-burden Indian states. Retrospective costing data were obtained from expenditure records, including cost of labor, supplies/equipment, capital, training, and operational costs. Fixed and recurrent costs at the programmatic level, both overall and per district, were estimated, excluding the cost of HIV testing. On 03/24/2020, India implemented a nationwide lockdown. 10/2019- 03/2020 was classified as pre-COVID and 04/2020-09/2020 as post-COVID. To derive the unit cost per individual, the number of clients offered and accepted index testing, contacts elicited, contacts who accepted and completed HIV testing, contacts who tested positive, and new PLHIV initiated on ART were retrieved for each district. Results: The total programmatic cost to implement FBIT pre-COVID was $265,061, which reduced by 21.5% to $207,333 post-COVID, including startup cost for both periods. The cost to implement CBIT reduced by 63% from $160,851 to $59,605, pre and post pandemic. Pre-COVID, labor accounted for 77% of the overall implementation cost vs. 90.3% post-COVID. The total number of contacts who tested positive over 6 months of FBIT implementation reduced by 65.3% pre- to post-COVID (1048 vs 364) and by 30.6% (399 vs 277) for CBIT. Newly diagnosed PLHIV initiated on ART declined by 65.1% (895 vs 312) for FBIT and by 19.3% (311 vs 251) for CBIT. Across all districts implementing FBIT, the cost per new HIV diagnosis increased from $253 to $728, and for CBIT, from $403 to $581. The per unit cost of PLHIV initiated on ART for FBIT increased from $296 to $850, and for CBIT, from $517 to $641. Conclusion: The average pre-COVID cost per new HIV diagnosis through FBIT among 5 Indian districts is below the estimated cost in most LMICs. Post-COVID, the cost per diagnosis and ART initiation almost tripled for FBIT, primarily driven by a lower volume of cases. Innovative strategies, such as integrating homebased testing and HIV-self testing, may be required to offset travel restrictions imposed by COVID-19 and improve program efficiency, while minimizing exposure to SARS-CoV-2.

Observational study of culture positive sepsis in COVID-19 critically ill patients-emerging pattern at a tertiary ICU center

Introduction: Aim: •To identify the incidence of culture-positive sepsis in critically ill COVID-19 patients at our tertiary intensive care unit. •To categorize patients based on their comorbidities, the severity of illness and treatments underwent to see if there is any correlation toward their predisposition toward culturepositive sepsis. Materials and methods: We studied a total of 23 critically ill COVID- 19 patients admitted over a month retrospectively. We observed that there was no incidence of bloodstream infections in any of the patients during their stay in ICU. The incidence of blood culture testing for BSI was among 43% of the patients. VAP was not observed in any of them either when 21% of the patients underwent culture and sensitivity of their endotracheal aspirate. However, there were six patients with catheter-associated urinary tract infection accounting for nearly 26% of the patients, and the positivity rate was as high as 66% when tested. We observed a very low positivity rate for bloodstream infection and ventilator-associated pneumonia whereas a very high positivity rate for catheter-associated urinary tract infection. All the patients had antiviral drug therapy with remdesivir and steroid therapy during their stay in ICU. Use of procalcitonin to ascertain the presence of infection was also seen in at least 50% of the clinically suspected septic patients. Results: •In our cohort of critically ill COVID19 patients' the incidence of catheter associated urinary tract infection was very high •We also observed that there was surprisingly very low positivity rate for ventilator associated pneumonia and blood stream associated infections when cultures were undertaken •Though the positivity rate was low in tested samples, clinical decision to cover the episodes of suspected sepsis with antibacterial agents might be substantiated due to reduced mortality rate observed within our cohort of patients Discussions: Though the positivity rate was low in tested samples, the clinical decision to cover the episodes of suspected sepsis with antibacterial agents might be substantiated due to the reduced mortality rate observed within our cohort of patients. Conclusion: •In our cohort of critically ill COVID-19 patients, the incidence of catheter-associated urinary tract infection was very high. •We also observed that there was a surprisingly very low positivity rate for ventilator-associated pneumonia and bloodstream associated infections when cultures were undertaken. •Though the positivity rate was low in tested samples, the clinical decision to cover the episodes of suspected sepsis with antibacterial agents might be substantiated due to the reduced mortality rate observed within our cohort of patients.

The Positive Allosteric Modulation of alpha7-Nicotinic Cholinergic Receptors by GAT107 Increases Bacterial Lung Clearance in Hyperoxic Mice by Decreasing Oxidative Stress in Macrophages.

Supplemental oxygen therapy with supraphysiological concentrations of oxygen (hyperoxia; >21% O2) is a life-saving intervention for patients experiencing respiratory distress. However, prolonged exposure to hyperoxia can compromise bacterial clearance processes, due to oxidative stress-mediated impairment of macrophages, contributing to the increased susceptibility to pulmonary infections. This study reports that the activation of the α7 nicotinic acetylcholine receptor (α7nAChR) with the delete allosteric agonistic-positive allosteric modulator, GAT107, decreases the bacterial burden in mouse lungs by improving hyperoxia-induced lung redox imbalance. The incubation of RAW 264.7 cells with GAT107 (3.3 µM) rescues hyperoxia-compromised phagocytic functions in cultured macrophages, RAW 264.7 cells, and primary bone marrow-derived macrophages. Similarly, GAT107 (3.3 µM) also attenuated oxidative stress in hyperoxia-exposed macrophages, which prevents oxidation and hyper-polymerization of phagosome filamentous actin (F-actin) from oxidation. Furthermore, GAT107 (3.3 µM) increases the (1) activity of superoxide dismutase 1; (2) activation of Nrf2 and (3) the expression of heme oxygenase-1 (HO-1) in macrophages exposed to hyperoxia. Overall, these data suggest that the novel α7nAChR compound, GAT107, could be used to improve host defense functions in patients, such as those with COVID-19, who are exposed to prolonged periods of hyperoxia.

Integrating New Staff into Endovascular Stroke-Treatment Workflows in the COVID-19 Pandemic.

A health care crisis such as the coronavirus disease 2019 (COVID-19) pandemic requires allocation of hospital staff and resources on short notice. Thus, new and sometimes less experienced team members might join the team to fill in the gaps. This scenario can be particularly challenging in endovascular stroke treatment, which is a highly specialized task that requires seamless cooperation of numerous health care workers across various specialties and professions. This document is intended for stroke teams who face the challenge of integrating new team members into endovascular stroke-treatment workflows during the COVID-19 pandemic or any other global health care emergency. It discusses the key strategies for smooth integration of new stroke-team members in a crisis situation: 1) transfer of key knowledge (simple take-home messages), 2) open communication and a nonjudgmental atmosphere, 3) strategic task assignment, and 4) graded learning and responsibility. While these 4 key principles should generally be followed in endovascular stroke treatment, they become even more important during health care emergencies such as the COVID-19 pandemic, when health care professionals have to take on new and additional roles and responsibilities in challenging working environments for which they were not specifically trained.