Managing severe warm autoimmune haemolytic anaemia after the SARS-Cov- 2 vaccine with emergency splenectomy and eculizumab

Autoimmune haemolytic anaemia (AIHA) is rare but described after the SARS-CoV- 2 Pfizer-BioNTech vaccine. We present a case of severe refractory warm AIHA after this vaccine, managed with emergency splenectomy and complement inhibition with eculizumab. A male in his teens with a history of liver transplant for biliary atresia (aged 2 years) and AIHA (aged 6 years) presented to his district general hospital with jaundice, dark urine, fatigue and chest discomfort 48 h after the first dose of SARS-CoV- 2 Pfizer-BioNTech vaccine (BNT162b2 mRNA). Investigations revealed haemoglobin (Hb) of 70 g/L and bilirubin of 98 mumol/L, which was treated as AIHA. The patient initially responded to prednisolone (1 mg/kg, 60 mg) but subsequently deteriorated and failed to respond to second-line rituximab (375 mg/m2) and two units of packed red blood cells (PRBC). By day 29 the patient had developed life-threatening anaemia culminating in a Hb of 35 g/L (after transfusion), lactate dehydrogenase (LD) of 1293 units/L and bilirubin of 228 mumol/L. This necessitated an immediate transfer to our tertiary centre for specialist support. Further investigations revealed a haptoglobin <0.1 g/L and direct antiglobulin test (DAT) strongly positive for IgG (4+) and negative for C3d. The peripheral blood film showed severe anaemia, nucleated red cells, anisocytosis and spherocytes with no autoagglutination, schistocytes or platelet clumps. Thrombocytopaenia (platelets 49 +/- 109/L) was present. Differentials were ruled out, such as paroxysmal nocturnal haemoglobinuria and heparin-induced thrombocytopaenia. HIV and hepatitis serology were negative, as were adenovirus, cytomegalovirus and Epstein-Barr virus PCR assays. A CT showed splenomegaly of 15.5 cm. Urinalysis found urobilinogen and bilirubin at high concentrations and negative urinary haemosiderin. Together, the investigations were consistent with warm AIHA. On day 29, four units of PRBC were transfused alongside 100 mg methylprednisolone and 1 g/kg IVIG. On day 30 the patient deteriorated despite the escalated treatment: Hb had only increased to 54 g/L, bilirubin was 200 mumol/L and LD was rising. Considering this life-threatening fulminant haemolysis, an emergency splenectomy was performed. This slowed haemolysis but did not completely ameliorate it: by day 33 the patient had received 15 units of PRBC. Thus, eculizumab, a terminal complement pathway inhibitor, was trialled to arrest intravascular haemolysis, alongside rituximab, repeat IVIG 1 g/kg, prednisolone 40 mg and tacrolimus 2 mg. This showed a favourable response, requiring less frequent transfusions and settling haemolysis. This case highlights the rare complication of warm AIHA with the SARS-CoV- 2 Pfizer-BioNTech vaccine, the use of emergency splenectomy for disease control, and the potential of eculizumab for refractory cases.

"working in the dark but expected to be an expert": Reflecting on critical care preparations for COVID-19

Introduction: Before spring 2020, many healthcare organisations did not possess detailed plans for the expansion and delivery of critical care during a pandemic. Furthermore, there was little directly-relevant individual or institutional experience to draw upon. Local, national and international guidance was drawn up rapidly and subject to frequent revision.1 Reflecting on these challenges, we designed a study to explore critical care and anaesthetic doctors' experiences of preparation for the provision of critical care services in the first wave of COVID-19. Objective(s): 1. To establish what factors facilitated and hindered the expansion and delivery of critical care services. 2. To identify important learning points for the provision of critical care during future pandemics. Method(s): We conducted semi-structured interviews with medical staff from the anaesthesia and critical care departments of our hospital, a tertiary centre with general and cardiothoracic intensive care units, including an ECMO service. We classified participants into two groups;1. Decision makers - individuals instrumental in shaping the critical care response, e.g., clinical directors and college tutors. 2. Staff members - clinicians working within the departments, including consultants and trainees. Thirteen interviews were conducted with 15 participants: eight decision makers and seven staff members. The interviews were recorded, transcribed and anonymised. We manually coded transcripts, and carried out an inductive thematic analysis.2 Results: Eight themes were generated from our analysis: * Problem solving with simulation: simulation exercises allowed experienced clinicians to troubleshoot practical issues and helped staff to prepare for unfamiliar tasks. * A sense of togetherness: staff reported that the "all hands-on deck" ethos was protective against fatigue, although this was short-lived. * Delayed and changing guidance: frequent guideline changes created confusion and anxiety. * Leading from the front: leaders with a clinical role were perceived more positively than those operating at a distance from the "shop-floor". * Coordination, collaboration and compromise: departments that accommodated each other's needs fostered productive inter-departmental relationships. * Insecure supply chains: staff took their own measures to ensure PPE availability, including acquisition of items outside NHS supply chains. * Constant communication: rapid methods of personal communication, e.g., WhatsApp were effective, although "WhatsApp fatigue" was endemic. * Balancing skill mix and fatigue: flux in workload required dynamic staff allocation. Underutilised staff groups created frustration and low morale in overworked colleagues. Conclusion(s): The threat to health and society from pandemic events is expected to increase over time.3 We should take this opportunity to gather experiences from those involved in the COVID-19 pandemic to guide future preparations. In early 2020, decision makes in local hospitals were operating with unclear guidance from external agencies. Our data, obtained in the summer of 2021 demonstrates that individual and departmental reflections had already resulted in processes being refined in later waves of COVID-19. Whilst the exact nature of future pandemics will vary, some elements of preparation will remain consistent. We recommend that plans for pandemic management should aim to reduce workload and target the most effective interventions, including by addressing the themes outlined above.

Patterns and Impact of Burnout among Women in the Urology Workforce

INTRODUCTION AND OBJECTIVE: Contemporary rates of burnout amongst urologists are reported to be 60-80%. These rates have significant implications on physician well-being and retention. We investigated predictors of burnout in female surgeons. METHOD(S): An electronic census survey was distributed to residents, fellows and practicing urologists by the Society of Women in Urology in the United States and territories via email and social media between February and May 2022. We assessed participant demographics, personal and professional characteristics, practice environment, compensation, and burnout with chi-square and t-test analyses. RESULT(S): There were 379 survey participants with an average age of 42 years (SD 10). A majority identified as cis-gendered heterosexual females (96%) and were practicing urologists (74%), while 10% were fellows and 15% residents/interns. Average reported time in practice was 9 years (SD 9 years). Most respondents reported burnout (273, 72%), with 87% agreeing COVID worsened burnout in the community. Those reporting burnout worked an average of 58 (SD 15) hours per week versus 49 (SD 18) hours (p<0.00001). Table 1 demonstrates significant personal and professional characteristics for participants who reported burnout. On multivariable logistic regression analysis, increased hours worked per week (OR 1.03, p=0.002), Relative Value Unit based pay versus salary (OR 4.4, p=0.007), correlated to burnout and feeling income is comparable to peers (OR 0.4, p=0.03) was inversely related. Common shared experiences included lack of staffing, reduced operating room time, lack of administrative support, predominance of non-operative referrals, gender and racial inequity or microaggressions, electronic health records with increased documentation demands, increased non-clinical administrative duties, and insufficient compensation or lack of financial advancement. CONCLUSION(S): A majority of women in urology report burnout with work-hours and compensation inequity as leading contributing factors. Concerns raised in this study such as lack of support staff, racial and gender inequity, and poor referral patterns should be further evaluated to determine a comprehensive plan to reduce burnout. (Figure Presented).

Natural Resource Development and Well-Being in Inuit Nunangat:A Scoping Review

Natural resource developments have significant positive and negative impacts on the health and well-being of communities in Inuit Nunangat (Inuit Homelands) in Canada. Mining, hydroelectric, and oil and gas developments significantly alter the landscapes of communities and often an entire region. As climate change and global demand for natural resources increase, the four regions in Inuit Nunangat-Nunatsiavut, Nunavik, Nunavut, and the Inuvialuit Settlement Region-may experience an increase in development activity. The goal of this scoping review was to map trends in the extent, range, and nature of published research examining the relationship between natural resource development and health and well-being of communities in Inuit Nunangat. A total of 2,861 articles were screened for relevance, and 58 articles met the inclusion criteria and were analyzed in full. The results indicate that: 1) Nunavut was the most discussed region;2) mining and/or mineral exploration was the most commonly discussed resource development;3) communication between researchers and industry officials or health authorities was not frequently reported;4) there were numerous government policies discussed, suggesting policy is a significant factor in the relationship between resource development and well-being;5) holistic health was the most common area of health discussed;6) Inuit inclusion in research varied, with nearly half of articles reporting Inuit involvement in the data collection and/or analysis;7) few articles discussed mine closures and the impacts on Inuit well-being;and, 8) no articles were published in 2020, therefore no articles discussed the impact of COVID-19.

Pancreas and islet transplantation in the United Kingdom during the COVID-19 era

Introduction: WHO declared a pandemic of COVID-19 in March 2020. This study analyses the impact of COVID-19 on beta-cell replacement therapy in the UK. Method(s): Pancreas and islet donation and transplant activity in the period March 2020/2021 was compared with the same period the previous year. Result(s): 2,180 patients had a functioning graft during March 2020/2021. 5.8%(n=126) tested positive for COVID-19 and two died (1%). In this period there was a 43% reduction in solid organ donors n=1,615, compared with the previous year, n=2,840. Of the 625 solid organ donors with a pancreas offered, 32% had the pancreas retrieved compared with 51% the previous period. 97 whole pancreas and islet transplants were performed in the UK down 54% from the prior period. Of the 84 pancreas transplant recipients;four tested positive for COVID-19 but none died, and two grafts failed within the first week from vascular thrombosis (neither were COVID-19 positive). Of the 13 SIK and islet alone transplant recipients, two tested positive for COVID-19 but neither died. Of these SIK transplants, one is known to have failed within a month and this is equivalent to that seen in the previous time period. To our knowledge, no patient receiving beta cell replacement therapy died of COVID during the first year of the pandemic despite immunosuppression. Conclusion(s): In the UK, pancreas, and islet transplantation have continued during the pandemic at a lower rate. Outcomes following transplantation within the COVID era are, so far, similar to those in the period prior. Take-home message: Outcomes following transplantation within the COVID era are, so far, similar to those in the period prior.

Management of tracheostomy-related tracheomegaly in a patient with COVID-19 pneumonitis.

Acquired tracheomegaly is a rare condition associated with pulmonary fibrosis, connective tissue disease and the use of cuffed tracheal tubes. We describe the urgent tracheal re-intubation and subsequent tracheal repair of a previously well 58-year-old man who developed tracheostomy-related tracheomegaly during prolonged mechanical ventilation for coronavirus disease 2019 pneumonitis. Urgent tracheal re-intubation was required due to a persistent cuff leak, pneumomediastinum and malposition of the tracheostomy tube. We describe the additional challenges and risks associated with airway management in patients with tracheomegaly, and discuss how even in urgent cases these can be mitigated through planning and teamwork. We present a stepwise approach to tracheal re-intubation past a large tracheal dilatation, including the use of an Aintree catheter inserted via the existing tracheal stoma for oxygenation or tracheal re-intubation if required. Computed tomography imaging was valuable in characterising the defect and developing a safe airway management strategy before starting the procedure. This report emphasises the role of planning, teamwork and the development of an appropriate airway strategy in the safe management of complex cases.

Covid-19 and the racial equity implications of reopening college and university campuses

COVID-19 forced many colleges and universities to suspend in-person operations in spring 2020. Students and instructors abruptly shifted to virtual learning and teaching, and most employees began working remotely during the global pandemic. Presented in this article are 12 racial equity implications for federal and state policy makers, as well as higher education leaders, as they consider reopening campuses across the United States. © 2020 by The University of Chicago. All rights reserved. 0195-6744/2020/12701-0008$10.00.