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Background/Aims First Contact Physiotherapists (FCPs) assess, diagnose and manage patients presenting with musculoskeletal disorders in primary care, without the need for prior GP consultation. Prior to COVID-19 almost every consultation was conducted in-person. Since the pandemic, many consultations are now undertaken remotely, a trend that is set to continue in line with the 'Digital first' strategy which seeks to enhance patient access to appointments. This aim of this study was to explore FCP views of remote consultations and how this impacted their role satisfaction and wellbeing. Methods This mixed methods two phase study consisted of an online survey investigating distributed via professional networks and through social media. The phase one survey explored consultation methods;levels of training;challenges and benefits;and a stress appraisal. Data were analysed descriptively. Respondents were invited to take part in phase two which included a semi-structured interview to gain an in-depth understanding of FCPs lived experience of remote consultation ways of working. Transcripts were thematically analysed. Results The online survey received n=109 responses from UK-based FCPs. Data revealed that despite the 'Digital First' push for continued remote consultations, the majority of FCPs (62%) used them for less than a quarter of their appointment slots. Whilst recognising that many patients found this format convenient, FCPs highlighted their own stress levels, citing poor efficacy, anxiety of misdiagnosis, feelings of isolation and increased administrative workload. Nearly two thirds (66%) of respondents had not received any training in how to conduct effective remote consultations. Follow-up interviews with n=16 FCPs highlighted coping strategies including following up with an in-person consultation and directing patients to other community health and wellbeing resources. In areas of high socioeconomic deprivation and poor health literacy additional problems associated with communication difficulties, poor IT access and capability, and digital poverty were all cited. Conclusion Remote consultations may offer a convenient alternative for some patients. FCP responses suggest that the continued offer of remote consultation is decreasing now pandemic restrictions have been lifted, despite the push for continued digital working practices. The perceived lack of efficacy, and fear of missing important diagnostic information means that many FCPs are either returning to in-person consultation or following up with a second face-to-face assessment resulting in potential service inefficiencies. Additional challenges were identified in areas of high deprivation and low health literacy, and the value of this consultation format needs to be considered in this context. Future work should focus on the training and support needs of FCP staff who are engaging with remote working to ensure clinical effectiveness and staff wellbeing.
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Background. Over 600,000 SARS-CoV-2 infections and 20,000 deaths have occurred among users of the Veterans Health Administration, the US's largest integrated health care system. We explored early outcomes of SARS-COV-2 infection in Veterans. Methods. An ongoing, prospective longitudinal cohort study of Veterans ages >= 18 enrolled 1,826 participants (29.0% inpatient;49.1% vaccinated;68.3% SARS-CoV-2-positive;85.0% male, mean age = 57.1 years) seeking inpatient or outpatient care after SARS-CoV-2 testing at 15 Department of Veterans Affairs medical centers in July 2020 to February 13, 2022. Using multivariable regression, we estimated relationships of baseline demographic characteristics, COVID-19 vaccination, and clinical history to illness severity and cumulative length of hospital stay within 60 days of study entry. Illness severity was defined by a Veterans Affairs adaptation of the WHO COVID-19 severity scale and included 4 levels (mild, moderate, severe, or death). We derived the Charlson co-morbidity index (CCI) and other baseline characteristics from electronic health data and study questionnaires, and reported qualitative SARS-CoV-2 IgG responses using inpatients' study-collected blood specimens. Results. High CCI scores (>= 5) occurred in 47 (42.7%) vaccinated SARS-CoV-2-positive inpatients and 47 (21.2%) unvaccinated. Severe illness occurred in 17 (15.5%) vaccinated inpatients, 37 (16.7%) unvaccinated inpatients, 4 (0.9%) vaccinated outpatients, and 3 (0.7%) unvaccinated outpatients. Eleven (10%) of 110 vaccinated SARS-CoV-2-positive inpatients died, as did 15 (6.8%) of the 222 unvaccinated. In SARS-CoV-2-positive inpatients, a one-step higher CCI was associated with more severe illness (aOR 1.10, 95%CI 1.01-1.20) and more hospitalization days (aIRR 1.06, 95% CI 1.03-1.10), adjusting for vaccination status. Respectively, 93% of vaccinated and 63% of unvaccinated SARS-CoV-2 positive inpatients with baseline antibody results had an anti-spike IgG response. Conclusion. In an ongoing longitudinal cohort study of COVID-19 in US Veterans, comorbidity burden was higher among vaccinated than unvaccinated inpatients and was associated with more severe illness and hospitalization days, independent of vaccination status.
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Background. Bacterial co-infection has been reported with COVID-19, but the extent of co-infection nationally is unclear. We sought to describe the temporal and spatial trends in bacterial co-infection across the US among COVID-19 positive admissions to Veterans Affairs (VA) hospitals. Methods. This retrospective cohort study included patients admitted to VA hospitals from March 1, 2020 through May 31, 2022 with a positive COVID-19 test within the previous 14 days and up to 2 days after admission. We summarized temporal and spatial patterns of bacterial co-infection, defined as a positive clinical microbiology culture for the bacterial pathogens listed in Table 1, defined as either community-onset (COI, within 2 calendar days of admission), or hospital-onset (HOI, > 2 calendar days after admission). We performed a univariate analysis including facility and patient factors and generated descriptive statistics to describe the frequency of occurrence over time and space overall, and within each organism. Results. By the end of June 2021, there were 35,299 hospitalizations observed from 33,383 patients admitted with positive COVID-19 tests in VA. Co-infection was detected among 7.4% of hospitalizations (2.9% for COI and 4.7% for HOI). VA patients older than 70, Asian or unknown race, higher Charlson Comorbidity Index were more likely to experience HOI and COI. Facility-level rates of HOI and COI over the study period presented substantial geographic variability, ranging from 0 to 45.5 per 1000 patient days and from 0 to 6.98 per 100 hospitalizations for HOI and COI, respectively [Fig 1]. Between March 2020 and June 2021, monthly facilitylevel rates of HOI and COI also varied substantially within and between facilities [Fig 2]. Average monthly co-infection rates increased in the first three months of the pandemic, with HOIs subsequently declining gradually and COIs remaining stable across VA. The correlation coefficients between hospital mortality and facility-level coinfection rates for HOI and COI ranged from -0.5 to 0.7 [Fig 3]. Conclusion. Bacterial co-infection was infrequent during hospitalization with COVID-19 in the VAhealthcare system, and has mild tomoderate association with hospital mortality. However, substantial geographic and temporal variation was observed.
ABSTRACT
Background. Bacterial co-infection has been reported with COVID-19, but risk factors for bacterial co-infection remain unclear due to limited large scale studies. We seek to identify predictive factors associated with risk of co-infection with multidrug-resistant organisms for patients hospitalized at Veterans Affairs (VA) hospitals with COVID-19. Methods. This retrospective cohort study included Veterans admitted to VA hospitals from March 1, 2020 through May 31, 2022 with a confirmed positive COVID-19 test within the previous 14 days and up to 2 days after admission. Outcomes of interest were hospital-onset co-infection (HOI, > 2 calendar days after admission) and community-onset co-infection (COI, within 2 calendar days of admission). Potential risk factors included both patient- (e.g. vital sign, medication use) and facility-level covariates (e.g. bed size, antibiotic use rate). We compared the covariate distributions for patients with and without HOI and COI. Our analytical approaches included variance inflation factors to detect the presence of multicollinearity among these factors, and Least Absolute Shrinkage and Selection Operator to identify the subset of factors associated with HOI and COI. We conducted a two-stage analysis, first performing feature selection among the individual-level risk factors followed by identification of facility-level risk factors. Optimal models were identified using 10-fold cross validation. Results. By July 2021, 33,383 patients were admitted to VA with positive COVID-19 test. We found that medications for ventilator induction (OR with 95% CI: 2.9 (2.2, 3.9)), norepinephrine (OR with 95% CI: 1.6 (1.2, 2.2)) and antimicrobial therapies for gram-positive infections (OR with 95% CI: 4.5 (3.6, 5.6)) [Table 1] were associated with the increased risk of HOI and patients in facilities with high C difficile infection rates were more likely to have COI detected (OR with 95% CI: 1.14 (1.11, 1.18)) [Table 2]. Homeless Veterans had higher risk of developing an HOI (OR with 95% CI: 1.5 (1.1, 2.0)), but not a COI. Conclusion. Risk factors for HOI and COI in COVID-19 were distinct, with specific classes of medications and antibiotics as well as patient factors resulting in increased risk for HOI. Further work is needed to better understand the risk factors for COI. (Table Presented).
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Background. There is significant global concern that the COVID-19 pandemic may negatively impact tuberculosis (TB) control. This is a descriptive analysis of TB evaluations and diagnosis during 2019 (pre COVID-19 period) and 2020 (COVID-19 period) at the largest safety net hospital in Los Angeles County (LAC+USC Medical Center). Methods. The medical records of patients diagnosed with pulmonary TB from January 1, 2019 to December 31, 2020 were identified through laboratory and electronic medical records. We included all patients with ≥ 1 sputum positive result for Mycobacterium tuberculosis (MTB) culture and reviewed their Xpert MTB/RIF MTB PCR. Results. Table 1 shows summary of results. During the COVID-19 period, the number of patients evaluated for pulmonary TB decreased by 64% compared to the previous year (Figure 1). The proportion of patients with culture-confirmed TB disease however, was nearly identical (P=0.913) (Table 1). Sputum acid-fast bacilli (AFB) smear positivity increased 52% to 64% during COVID-19 (P=0.324) and disease severity as measured by chest radiograph, was significantly higher during the COVID-19 period (P = 0.031) (Figure 2). Trend of sputum AFB smear and culture samples collected from January 1, 2019 to December 31, 2020. Summary of results of patients diagnosed with pulmonary TB from January 1, 2019 to December 31, 2020 at LAC+USC Medical Center. Results of two-sample test for proportions of 2019 vs 2020 for cavitary lesions, extent of disease, and sputum positive AFB smear microscopy. Conclusion. These preliminary results suggest that when compared to the previous year, the number of pulmonary TB evaluations decreased by 64% during the COVID period. Whereas the proportion of patients diagnosed with TB disease was similar, TB patients during the COVID-19 period had more advanced disease at diagnosis, as measured by sputum smear AFB microscopy and disease severity on chest radiograph (P=0.031). These data suggest potentially consequential interruptions and delays in pulmonary TB diagnosis during the COVID-19 period.
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We examine a cohort of 4307 COVID-19 case fatalities from a de-identified national registry in the U.S. using Latent Dirichlet Allocation and group each patient by topic based on their pre-existing conditions in the years prior to infection and again during the last three weeks of life. We show that certain pre-existing condition topics have strong associations with certain COVID-19 mortality topics suggesting that the major clinical pathways leading to COVID-19 death may be through failures of already weakened organ systems. We then explore the demographics for these groups and generate several insights and hypotheses. © 2021 IEEE.
ABSTRACT
Background: Monitoring genomic variation of SARS-CoV-2 is crucial in mitigating adaptation to the human host and developing effective treatments that safeguard global health. Bamlanivimab and etesevimab are monoclonal antibodies (mAbs) that have demonstrated potent SARS-CoV-2 neutralizing activity in both pre-clinical and clinical settings and have distinct but overlapping binding sites. Here, the selection and characterization of variants in a pre-clinical setting is presented alongside the impact of emerging variants on antibody binding affinity and viral neutralization potency. Methods: Variant selection was carried out via directed evolution of the receptor binding domain (RBD) and serial passage of authentic SARS-CoV-2 in the presence of bamlanivimab and etesevimab individually or in combination. Sequence confirmed, putative-resistance variants identified in both selection methodologies were incorporated into different assessment platforms (VSV-based SARS-CoV-2 pseudovirus neutralization, a yeast RBD display hACE2 competition, and binding affinity to mAb and hACE2) to evaluate potency loss of the selecting mAb and test activity against the mAb combination. Results: Serial passage of SARS-CoV-2 and directed evolution of the RBD protein were unable to select for resistant viral variants under the pressure of mAb combination therapy. In the same experimental paradigm, variants were identified when each mAb was evaluated alone (E484D/K/Q, F490S, Q493R, and S494P for bamlanivimab and K417N, D420N and N460K/S/T/Y for etesevimab). Neutralization and binding assessments confirmed reduced susceptibility of the variants to the single selecting mAb with 50-fold or greater reductions in potency. Importantly, aside from the Q493R variant, all other resistant viruses were neutralized by the mAb combination therapy. Conclusion: In vitro selection studies using single mAbs, bamlanivimab or etesevimab, identified key positions within the SARS-CoV-2 S-protein that have potential for viral resistance in the clinic, whereas similar studies with the mAb combination therapy were unable to select variants. Binding and competition assays confirmed the neutralization phenotyping data and indicates the mechanism of resistance is due to a reduction in binding affinity. The preclinical selection and functional characterization of resistant viral variants directly supports the observation that mAb combination therapy results in a lower frequency of treatment-emergent resistance in clinical treatment studies.