Five-year review of a tertiary paediatric sleep service for complex patients

Introduction Our paediatric sleep unit commenced service for children with complex medical problems in July 2015. Service capacity includes 12 inpatient level 1 studies (two neonates) and one home study per week. FTE includes senior scientists 2.6, sleep technologists 1.7, administration 1.0, nursing 0.7 and medical 1.2. The primary aim of this study was to evaluate activity during the first 5-years. The secondary aim was to document the impact of the COVID-19 pandemic. Methods Sleep unit operational & diagnostic data were collected from sleep booking sheets, sleep study reports, electronic medical records. Descriptive statistics are presented. Results A total of 2186 sleep studies were performed (July 2015 to June 2020) with a range of 368–472 studies per annum. Overall, 61.7% were diagnostic studies, 20.8% titration studies (CPAP, oxygen, bi-level or invasive ventilation), 10% neonatal and 7.5% home studies. Between 2016–2020, the average waiting time (days) for a neonatal study was 16, a titration study was 106, a diagnostic study was 110 and a home study was 76. Further delays were caused by the COVID19 pandemic. Mean waiting time rose 229% from 108 days (Feb 2020) to 355 days (Feb 2021). Referrals for sleep studies have exceeded bed capacity since the beginning of the pandemic. Discussion This audit describes activity in a tertiary complex paediatric sleep service during the first 5 years. The service has struggled on current FTE and bed capacity to manage waiting times, exacerbated further by the COVID-19 pandemic. A new business and clinical model are warranted.

Lessons learned from COVID-19: provider suggestions for improving service delivery in sexual violence resource centers and children's advocacy centers in Kentucky

The COVID-19 pandemic has presented unique challenges for human service providers, especially as face-to-face services were limited by both formal and informal efforts to protect public health. Telehealth has emerged as a main strategy to ensure continuity of care. This study explored adaptations to services in child advocacy centers (CACs) and sexual violence resource centers (SVRCs) across the Commonwealth of Kentucky, particularly using telehealth. This study highlights respondents' suggestions about improving these service delivery systems and the particular emphasis on challenges and strengths of telehealth for reaching those in rural areas.

Physiological evidence of escalating stress during COVID-19: a longitudinal assessment of child welfare workers

Studies have shown that stress has contributed to employee turnover and retention problems for agencies, and at the individual level, chronic stress has been associated with coronary heart disease, anxiety, depression, and many other negative effects. In the past, the extent of stress one has felt has been measured by subjective paper-and-pencil instruments;however, recent technological advances have improved our ability to obtain accurate biofeedback assessments from wearable instruments. The Kentucky Child Welfare Workforce Wellness Initiative is the first known study to explore physiological stress in a sample (n = 32) of child welfare professionals using biometric technology (Firstbeat Bodyguard 2) and the first to report that data longitudinally over a four-month period. The study revealed that a variable associated with the strength of the Autonomic Nervous System (RMSSD) remained below the norms for a healthy population as participants experienced consistent and prolonged physiological stress. When examined relatively to the agency's lifting of COVID restrictions and returning to face-to-face service delivery, stress levels began to further rise almost to significant levels (p < .10) and the participants' ability to achieve a state of physiological relaxation significantly decreased. Future research employing biometric technology is also suggested. © 2023 Taylor & Francis Group, LLC.

Efficacy of a Polyclonal Ovine Fab (PR020) Against SARS-CoV-2 Infection

Background. Passive immune therapies may be useful in mitigating severe COVID-19. The hamster model has been successfully used to study efficacy of COVID-19 treatments. Our objective with this research is to demonstrate initial efficacy of a new polyclonal ovine Fab raised against the SARS-CoV-2 spike protein (PR020) as a treatment for COVID-19. Methods. Hamsters were treated with PR020 via intraperitoneal route at a dose of 120 mg/kg or a vehicle control once every 24 hours for 8 days, starting 1 day prior to viral challenge with Victoria/1/2020 SARS-CoV-2. Sampling to detect viral RNA and clinical observations were taken throughout the challenge phase. Necropsy occurred 1 day following the last dose of PR020, and tissues were assessed for histopathology and viral RNA. Results. Hamsters receiving vehicle alone lost weight more rapidly than the PR020 group (Figure 1, p< 0.05 day 4 onward). Clinical illness scores for the PR020 group were lower compared to control animals (Figure 2, p< 0.05 day 3 onward). While viral shedding assessed by throat swab did not differ between groups, viral RNA levels in lung tissue was significantly lower in PR020-treated animals (Figure 3, p< 0.05). PR020-treated animals also showed significantly less pathological changes in the lung compared to controls (Figure 4, p=0.0022). (Figure Presented) Conclusion. Treatment with PR020 resulted in a positive clinical outcome (e.g. less weight loss and lower clinical signs). While treatment appeared to have little effect in the nasopharynx, there was a positive effect in the lower respiratory tract, with substantially less viral RNA in the lungs of the group given PR020 and a decrease in the lung histopathology, including consolidation.

SUPPORTING RESIDENTS WITH DEMENTIA LIVING AND DYING IN LONG-TERM CARE AND THEIR FAMILIES DURING COVID-19

TThis presentation will share research findings about experiences during COVID-19 about implementing a virtual palliative toolkit in long-term care in Canada. The toolkit includes tools and practices to: (a) engage residents and families with dementia within a palliative approach to care, (b) develop workforce capacity through online education modules, (c) reduce stress and improve psychological health of residents, families, and staff, and (d) develop organizational structures and processes to promote a palliative approach to care. Individual interviews were conducted with residents, family members, and staff before implementing a palliative toolkit and after using it. Findings highlighted the negative impacts of COVID-19 on resident health due to isolation within home, preventing family from being at the bedside and cancelling stimulatory activities especially at end of life that were exacerbated by the lack of resources and government supports. Families appreciated the virtual supports and stated that they helped prepare them for their loved ones' death while feeling more empowered, engaged, and supported in their journey. Although feedback from families was mostly positive, stating the virtual toolkit improved accessibility to information and supports, it was clear that some misunderstood terms, particularly what a palliative approach to care means;and others had challenges navigating the virtual platform to use the toolkit. Future work is needed to make the virtual tools more user-friendly so that they can be scaled up more widely.

A nurse-led cardiovascular disease prevention clinic

Background: Patients who present to our hospital with a vascular event receive appropriate preventative measures and are discharged to Primary Care without further specialist review. We have initiated a Cardiovascular Disease Prevention Clinic to provide specialist review for all patients at one year following their index event. Purpose: This project was undertaken to assess the implementation of guideline-directed preventative treatment within our current patient pathway, thereby establishing the need for, and the likelihood of benefiting from a secondary care specialist clinic. Methods: The medical notes of all patients on our angiography database over a 6 month period were scrutinised. This included the majority of patients diagnosed with acute coronary syndromes [ACS] and symptomatic coronary artery disease [CAD] over this period. Patients with confirmed atheromatous CAD were screened for clinical features that would put them at high risk of recurrent events. These risk factors were identified in recent landmark trials[1,2] and include: diabetes, eGFR <60, age >65 years, multi-vessel disease, recurrent events within 3 years, and heart failure. Of the high risk patients, those whose management was deemed suboptimal were invited to attend the clinic that is nurse led, protocol driven, with a Consultant available for advice. All appointments were conducted via telephone in view of COVID precautions. Patients were assessed according to guideline targets for cardiovascular risk factors[3,4,5]. Lifestyle habits were reviewed with appropriate guidance provided for the patient. Results: 833 patients were screened, of which 175 patients fulfilled the above criteria and so invited to the clinic. 2 patients declined the appointment. Table 1 summarises the guideline targets not achieved by the high risk cohort. 132 patients (75.8%) met the criteria for consideration for DOAC[6]. Of these, 80 (60%) had a relative bleeding contraindication or declined therapy. 155 (88.6%) met the criteria for consideration for longer-term P2Y12i[7]. Of these 139 (89.7%) had relative bleeding contraindications or declined therapy. Interventions implemented at this clinic are summarised in Table 2. All patients were given advice with regard to lifestyle modification strategies. Conclusion: The discharge pathway for patients diagnosed with ACS and symptomatic CAD includes cardiologist prescribing, cardiac rehabilitation nurse review and primary care follow-up. Despite this, we showed that a significant number of patients with CAD and at high risk of recurrent events failed to achieve secondary prevention targets at one year following their index event. A specialist CVD prevention follow-up clinic can result in significant improvements in patient management over and above the usual standard of care and we should anticipate a reduction in cardiovascular events as a result of this. A nurse led clinic with prescribing protocols based on current guidelines is a successful clinic model. (Figure Presented).

DISEASE ACTIVITY IS ASSOCIATED WITH COVID-19 OUTCOMES IN IBD PATIENTS WITH EFFECT MODIFICATION BY AGE

Background: Surveillance Epidemiology of Coronavirus Under Research Exclusion for Inflammatory Bowel Disease (SECURE-IBD) is an international database that monitors COVID-19 outcomes in IBD patients. We examined the influence of IBD disease activity on COVID-19 severity, while accounting for confounders and exploring the modifying effect of age. Methods: This was a retrospective analysis of all cases reported to SECURE-IBD with complete Physician Global Assessment (PGA) of IBD activity and age data (N=3028). PGA was categorized as remission/mild (reference) vs moderate vs severe. Outcomes used as surrogates of severe SARS-CoV2 infection were hospitalization and a composite of ICU/ ventilation/death. We compared cohort characteristics across PGA categories using the Chisquare and Kruskal-Wallis test. Using logistic regression, we determined the unadjusted association between disease activity and COVID-19 outcomes, overall and by age decade. Multivariable logistic regression models included PGA, age, sex, IBD type, comorbidities (0, 1, ≥2) and systemic corticosteroids (CS) a priori and additional confounders if they changed the estimate by ≥10% (we tested BMI, race, and medications). Risk estimates were expressed as crude and adjusted odds ratios (OR) with 95% CI. We also built models stratified by age (≤50 vs >50 years). Results: Race, IBD type, BMI and current medications (CS, anti-TNF, thiopurine monotherapy, aminosalicylates, ustekinumab and tofacitinib) differed across PGA categories (p<0.05). COVID-19 was more severe in patients with more active IBD: hospitalization rates 19% (remission/mild), 26% (moderate) and 45% (severe);ICU/ventilation/death rates 5% (remission/ mild), 6% (moderate) and 12% (severe) (p<0.05 for both outcomes). In unadjusted analyses, higher PGA was associated with an increased risk of hospitalization (moderate: OR 1.52, 95% CI 1.21-1.92;severe: OR 3.57, 95% CI 2.56-4.98) and ICU/ventilation/death (moderate: OR 1.40, 95% CI 0.94-2.10;severe: OR 2.72, 95% CI 1.63-4.55). Figure 1 illustrates the OR for hospitalization and ICU/ventilation/death for severe PGA vs remission/ mild by decade;effect sizes are greatest in patients ≤50 years. In multivariable analyses, PGA remained significantly associated with hospitalization, but not ICU/ventilation/death (effect lost after adjusting for CS) (Table 1). However, in analyses stratified by age, PGA remained significantly associated with both hospitalization and ICU/ventilation/death, even after adjusting for medications, in patients ≤50 but not >50 years (Table 1).Conclusions: The association between IBD activity and severe COVID-19 varied with age. The association was stronger in younger patients and, after adjusting for the confounding effect of medications, particularly CS, disease activity was significantly associated with severe outcomes only in younger (≤50 years) patients.(Figure Presented)Odds Ratios for A) hospitalization and B) ICU/ventilation/death for severe PGA vs remission/mild by decade (Table Presented)Adjusted Odds Ratios for Hospitalization and ICU/ventilation/death by Disease Activity, Overall and Stratified by Age

Structural basis for continued antibody evasion by the SARS-CoV-2 receptor binding domain

[Figure: see text].

Vasovagal reactions reported in COVID-19 convalescent plasma donors-NHSBT experience

Safety and efficacy of COVID-19 Convalescent Plasma (CCP) was tested as part of two large randomised controlled trials in UK (REMAP-CAP and RECOVERY). CCP collections by apheresis were started across NHSBT from early in the pandemic to support the trials. Data from CCP donors who had donated at least once in the period between April 2020 and March 2021 (inclusive) was reviewed. Of the 57 213 attendances during this period, 6908 (12.1%) resulted in at least one adverse event, reported within seven days of attendance. Donors experiencing an adverse event were more likely to be first-time donors than donors with no adverse event were. The risk of having any adverse event reduced from 14% for first-time donors to 7% for repeat donors. Bruising was seen in58%and vasovagal events were the second most commondonor adverse events accounting for 37% (2570/6908). Most (2373/2570, 92%) were mild with no loss of consciousness. CCP donors experienced lower rates of mild vasovagal events to new/returning whole blood donors overall but appear to be at higher risk after stratifying by sex and age. They are significantlymore likely to feel faint than new/returning apheresis donors. Differences between new/returning whole blood and CCP donors are statistically significant (p < 0.05) in both men and women in all age groups from 35 years upwards. In all cases where there is a significant difference, the rate was higher for CCP donors. When compared with new/returning apheresis donors, the rate in CCP donors was higher overall. One serious adverse event of donation was recorded in a new male CCP donor in his mid-40s who had severe immediate vasovagal reaction with hypotensive seizure requiring hospitalisation following his first CCP donation. He recovered subsequently and was withdrawn from donation. Donating CCP was largely safe but complications were seen following donation in 12% with vasovagal events, bruising and arm pain being the most reported donor adverse events. Vasovagal events could be multifactorial with increased anxiety, new/first time donors, vascular dysregulation or subclinical cardiac dysfunction secondary to recent COVID-19 infection possibly contributory. It is encouraging to see that the risk of having any adverse event halved with repeat donations.