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INTRODUCTION: Bivalirudin remains a viable strategy during extracorporeal membrane oxygenation (ECMO). The accuracy of activated partial thromboplastin time (aPTT) for bivalirudin intensity in ECMO may be imperfect resulting in suboptimal dosing, which may increase the risk of bleeding or thrombotic complications. The purpose of this study was to evaluate the correlation between PTT and thromboelastography (TEG) reaction (R) time in adult ECMO patients anticoagulated with bivalirudin. METHOD(S): This was a multicenter, retrospective study conducted over a 22-month period (January 2020 to October 2021. Adult ICU patients requiring ECMO and bivalirudin therapy with >=1 corresponding TEG and aPTT samples drawn <=4 hours of each other were included. The primary endpoint was to determine the correlation coefficient between the TEG R time and bivalirudin aPTT serum concentrations. Pearson's correlation coefficient was used to evaluate the correlation using a kappa measure of agreement between TEG results and bivalirudin aPTT serum concentrations. RESULT(S): A total of 104 patients consisting of 848 concurrent laboratory assessments of R time and aPTT were included. COVID-19 positive tests were confirmed in 48.1% (n=50) of included patients. A moderate correlation between TEG R time and aPTT was demonstrated in the study population (r=0.41;p< 0.001). A similar relationship between TEG R time and aPTT was observed in both COVID-19 positive (r=0.44;p< 0.0001) and negative (r=0.45;p< 0.0001). Overall, 59.2% of all concurrent TEG R time and aPTT values showed agreement on the study institution's therapeutic category (sub-, supra-, and therapeutic) of bivalirudin. 78.3% (n=277) of aPTT values were categorized as therapeutic among all discordant assessment (n=346) between TEG R time and aPTT. The discordant TEG R times with a therapeutic PTT were almost equally distributed between subtherapeutic and supratherapeutic categories. CONCLUSION(S): Moderate correlation was found between TEG R time and aPTT associated with bivalirudin during ECMO in critically ill adults. Further research is warranted to address the optimal test to guide clinical decision-making for anticoagulation dosing in ECMO patients with discordant results.
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INTRODUCTION: Severe COVID increases the risk of thrombotic complications. Therapeutic anticoagulation with unfractionated heparin (UH) is commonly utilized to prevent venous thromboembolism (VTE). Thromboelastography (TEG) provides a dynamic and global assessment of hemostasis, which may be advantageous or complimentary with standard coagulation tests like anti-Xa activity or activated partial thromboplastin time (aPTT). The purpose of this study was to evaluate the correlation between anti-Xa activity and aPTT with the TEG parameters of reaction (R) time and coagulation index (CI) in patients with severe COVID receiving UH. METHOD(S): This was a single-center, retrospective study conducted over a 15-month period (2020-2021). Adult patients with severe COVID receiving UH with >=1 corresponding TEG and anti-Xa / aPTT samples assessed <=2 hours of each other were included. The primary endpoint was the correlation between anti-Xa activity and R time. Additional associations were determined for aPTT and R time and anti-Xa activity and aPTT with CI. Pearson's coefficient was used to evaluate the correlation using a kappa measure of agreement. RESULT(S): A total of 423 assessments across 237 patients were included. R time did not correlate with anti-Xa activity (r2=0.032;p< 0.0001) nor aPTT (r2=0.007;p=0.061). CI did not correlate with anti-Xa activity (r2=0.093;p< 0.0001) nor aPTT (r2=0.017;p=0.0073). Overall, 188 (45%) R times and anti-Xa values showed agreement in terms of both demonstrating therapeutic anticoagulation, sub-therapeutic anticoagulation, or supra-therapeutic anticoagulation. Twentyeight patients (11.8%) and 21 patients (8.9%) developed a clinically relevant bleed or VTE, respectively, but all coagulation and TEG parameters were similar between those with a bleed or VTE and those without. CONCLUSION(S): The TEG parameters of R time and CI did not correlate with anti-Xa activity or aPTT for monitoring of intensity of anticoagulation with UH in patients with severe COVID-19. Using TEG in these patients to monitor UH anticoagulation offers no benefit over anti-Xa activity or aPTT. Further research is necessary to address the laboratory tests needed to help with decision-making on anticoagulation dosing in patients with severe COVID.
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Objective: To identify factors associated with the need for supportive hospitalised care among children admitted for COVID-19. Design and Methods: A multicentre retrospective descriptive cohort of children <17 years , hospitalized with COVID- 19 in nine hospitals in Barbados, The Bahamas, and Jamaica from September 2020 to July 2021. The need for supportive therapy was explored by age, and among children with and without a range of comorbidities. Result(s): Among 238 hospitalized children, 56% were < 5 years of age. Comorbidities were present in 107 (45%), with proportionately more comorbidities among older children (> 5 years of age, p < 0.001). Comorbidities included asthma 21(9%), sickle cell disease 20 (8%), neurological 12 (5%) or cardiac 11 (5%) diseases, and diabetes 11 (5%). Multisystem Inflammatory Syndrome (MISC) was present among 32 (13%) children, and of these the largest proportion 12 (29%) were between 5 and 9 years of age (p = 0.04). All diabetic children had diabetic ketoacidosis (DKA), and 83% of neurology cases had seizures. Oxygen use was common among children with asthma (50%), obesity (75%) and MIS-C (40%). Blood products were required among children with MISC (40%), or with malignancy (50%). Almost three-quarters of children with MISC had additional complications, including liver dysfunction, acute kidney injury, and anaemia, and these children regularly required inotropes (22%), non-invasive ventilatory support (12%), or ICU admission (34%). Conclusion(s): Children with asthma, obesity, malignancy, diabetes and neurological disease require additional support with more ICU support needed in MISC cases. Care of vulnerable groups and early recognition and intervention for severe MISC should be prioritized.
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Objective: The objectives are to determine the incidence of malnutrition and anemia and evaluate the association of nutritional status and COVID-19-related clinical outcomes in children hospitalized for COVID-19. Method(s): This multi-island inpatient survey presents data from nine hospitals in three Caribbean islands in children from birth to 17 years from September 2020 to July 2021. We explore statistical associations with inpatient characteristics and potential differences between malnourished and well-nourished children. Result(s): Among children hospitalized for COVID-19, 6.8% were stunted, 6.6% were underweight, 13.6% were overweight/ obese, and 30% had anemia. Anemia was associated with multi-system inflammatory syndrome (MIS-C) in children but not with malnutrition. The prevalence of underweight children exceeded the 4.4% prevalence in the general pediatric population in islands and there was a greater-than-expected prevalence of overweight children hospitalized with COVID-19. No clear associations were detected between malnutrition and indicator outcomes. There were two deaths in children with severe malnutrition, COVID and septicemia identified after the study window. Conclusion(s): Hospitalizations exceeded baseline population rates of undernutrition but no significant associations were detected possibly due to small numbers. T cell activity is associated with less disease severity in SARS-CoV-2 infection and the diverse repertoire of naive T lymphocytes in children may confer protection to undernourished children. The deaths in two children with severe malnutrition and sepsis may suggest a compound effect on immunity by nutrition severity and COVID-19 disease. Overweight children in this cohort may reflect an increased prevalence of overweight children in the general population that requires further evaluation and intervention.
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Low demand response (DR) participation and high program drop-out rates continue to impede DR goals that could save up to $13 billion in annual grid expansion and electricity demand costs. Yet, the literature lacks a thorough understanding of how different residential customer segments enrolled in DR programs respond to utility signals in view of occupant comfort considerations. The objective of this study is to gain a clear understanding of the effects of four different customer personas on residential DR. Given current data limitations, this work developed an array of hypothetical personas with varied priorities, activity levels, and comfort thresholds based on demographic variables that have been found in previous studies to influence energy consumption. A BEopt™ DR model for a reference residential single-family building located in Colorado was built to isolate the effect of differences in buildings or climate. The results provide useful evidence on how persona-comfort differences lead to significant deviations in DR goals (especially peak demand reduction), ranging from 0.1% to 20%. This work presents a novel framework representing comfort preferences in DR models. The data generated, albeit synthetic, and the results could inform DR program design considerations of how different people respond to different comfort priorities. Copyright © 2021 by ASME and The United States Government
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Objectives: Assess and compare the rate of COVID-19 infection and SARS-CoV2 testing in patients with RA, rheumatoid arthritis (RA), psoriatic arthritis (PsA) and axial spondyloarthritis (AxSpA) association with their treatment and, for testing, the number of symptoms in a Swiss cohort of patients. Methods: Inclusion of patients with RA, AxSpA and PsA from the SCQM using a smartphone app (mySCQM) to record information between March and December 2020. Outcomes of interest were self-reported SARS-CoV2 testing, symptoms compatible with COVID-19 during the previous month and confirmed COVID-19 through PCR nasopharyngeal swab. Outcomes were compared between diseases groups, using logistic regression. We also evaluated the association of baseline treatment (TNF-inhibitors, b/tsDMARDs with other modes of action, no b/tsDMARDs) on the odds of symptoms and testing and the association of the number of symptoms (0-9) on the odds of testing. The analyses of SARS-CoV2 testing and COVID-19 symptoms were additionally adjusted for age, gender, glucocorticoids and csDMARDs. Confirmed cases were not adjusted for treatment and other covariates considering the low number of events. Results: We included 927 patients with RA, 805 with AxSpa and 453 with PsA. 1010 patients reported COVID-19-like symptoms (mostly fever, runny nose and cough), but only 455 of them (45%) reported being tested. 151 patients were tested without symptoms. In between March and December 2020, 7.6% of RA, 8.5% of AxSpA and 10.5% of PsA patients were tested positive for COVID-19 (p = 0.678). The odds of testing, symptoms and confirmed COVID-19 were similar between diseases and not associated with treatment for testing and. The number of symptoms was associated with the odds of testing (OR 1.43, 95%CI 1.37- 1.50 by symptom). Conclusion: Prevalence of COVID-19 symptoms and confirmed cases was similar between diseases, and for symptoms, was not associated with treatment. Despite strong advice from health authorities, less than 50% of patients with inflammatory rheumatic diseases and COVID-19 symptoms were tested. This proportion was not significantly different between diseases and not influenced by type of treatment. Efforts should be made to improve rates of SARS-CoV2 testing in patients with rheumatic diseases.
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Background: Since the beginning of the pandemic in Switzerland, immunosuppressed people were strongly advised to be tested for SARS-CoV2 when symptomatic as it was conjectured that they might be more at risk for infection and/ or severe disease. While patients with autoimmune diseases might be indeed more at risk of death from COVID-191, it remains unknown, whether there are differences in infection or complication rates between patients with rheumatoid arthritis (RA), psoriatic arthritis (PsA) and axial spondyloarthritis (AxSpA), and whether this relates to their disease or their treatment. Additionally, the prevalence of SARS-CoV2 testing in this population is not known. Objectives: This study aimed to assess and compare the rate of COVID-19 and SARS-CoV2 testing in patients with RA, AxSpA and PsA, the potential association with their treatment and, for testing, the number of symptoms. Methods: We included patients with RA, AxSpA and PsA from the Swiss Clinical Quality Management register (SCQM) using a smartphone app (mySCQM) to record information between March and December 2020. The outcomes of interest were self-reported SARS-CoV2 testing, symptoms compatible with COVID-19 during the previous month and confirmed COVID-19 through PCR nasopharyngeal swab. Outcomes were evaluated over the complete length of the aforementioned period (i.e. the outcome has been reported at least once during the period). Outcomes were compared between diseases groups, using logistic regression. We also evaluated the association of baseline treatment (TNF-inhibitors, b/tsDMARDs with other modes of action (OMA), no b/tsDMARDs) on the odds of symptoms and testing and the association of the number of symptoms (0-9) on the odds of testing. The analyses of SARS-CoV2 testing and COVID-19 symptoms were additionally adjusted for age, gender, glucocorticoids and csDMARDs. Confirmed cases were not adjusted for treatment and other covariates considering the low number of events. Results: We included 927 patients with RA, 805 with AxSpa and 453 with PsA (Table 1). 1010 patients reported COVID-19-like symptoms (mostly fever, runny nose and cough), but only 455 of them (45%) reported being tested. 151 patients were tested without symptoms. In between March and December 2020, 7.6% of RA, 8.5% of AxSpA and 10.5% of PsA patients were tested positive for COVID-19 (p=0.678). The odds of testing, symptoms and confirmed COVID-19 were similar between diseases and not associated with treatment for testing and symptoms (Figure 1). The number of symptoms was associated with the odds of testing (OR 1.43, 95%CI 1.37-1.50 by symptom). Conclusion: Prevalence of COVID-19 symptoms and confirmed cases was similar between diseases, and for symptoms, was not associated with treatment. Despite strong advice from health authorities, less than 50% of patients with inflammatory rheumatic diseases and COVID-19 symptoms were tested. This proportion was not significantly different between diseases and not influenced by type of treatment. Efforts should be made to improve rates of SARS-CoV2 testing in patients with rheumatic diseases.