ABSTRACT
Rationale: As COVID-19 cases surged, new intensive care units (ICUs) were established to care for patients on mechanical ventilation. To staff these units, clinicians volunteered or were assigned from multiple units which led to the creation of teams with varying practice styles. The purpose of our qualitative study was to identify challenges with, and potential improvements to, team dynamics in newly created ICUs to guide quality improvement efforts. Methods: We conducted 14 semi-structured interviews with clinicians (6 nurses, 8 physicians) from a newly formed 36-to-50 bed medical ICU in an academic hospital;this ICU was designed to care for COVID-19 patients. Participants were purposively sampled to reflect the diversity in disciplines in the ICU: ICU nurses, medical/surgical nurses, Pulmonary Critical Care Fellows, Anesthesia Fellows and Attending physicians (Pulmonary/Critical Care and Anesthesia). In one-on-one interviews, participants were asked about team dynamics in the ICU, potential issues, and solutions to challenges. We used a rapid analytic approach to explore team dynamics. First, data was deductively categorized into themes based on our interview guide;this allowed us to create a unique data summary for each interview. Data from each data summary was then transferred to a matrix to easily compare data across all interviews. Data was then re-analyzed inductively to provide deeper insight into clinicians' perspectives and suggested solutions for how to improve team dynamics in the COVID ICU. Results: We identified 3 themes that impacted team dynamics positively (facilitator) and negatively (barrier): interpersonal factors (affecting team interactions and professional relationships), structural factors (unit level factors affecting unit organization and administration), and roles and responsibilities (factors affecting clinician duties/workflow). Clinicians also provided several ways to improve team dynamics such as: purposeful introductions at the start of each shift to increase clinician recognition;clear guidelines for medical/surgical nurse responsibilities;and more explicit communication from leadership about transitions in unit organization and its impact on the staff. Conclusions: In a newly formed ICU during the COVID pandemic, interpersonal factors, structural factors and roles and responsibilities impacted the team's perceptions about their ability to work together effectively. Considering team dynamics during rapid ICU organization is crucial and requires thoughtful attention to how familiar clinicians are, changes in staffing and the importance of empathetic leadership.
ABSTRACT
Objective: COVID-19 caused by the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), utilises the catalytic site of membrane-bound angiotensin converting enzyme 2 (ACE2) for cell entry. It is thought that endocytosis of ACE2 results in a decrease in membrane bound ACE2 expression, and disruption of the local tissue renin angiotensin system protection. In this study, we hypothesised that SARS-CoV-2 infection would be associated with shedding of ACE2 leading to increased plasma ACE2 activity. Design and method: Australians aged >18 years (n=66) who had recovered from SARS-CoV-2 infection (positive result by PCR testing) and uninfected controls (n=70) were recruited. Serial samples were available in 23 recovered SARS-CoV-2 patients. Plasma ACE2 activity was measured using a fluorescent substrate-based assay and levels were compared using the Mann-Whitney or Kruskal-Wallis test. Serial ACE2 activity were analysed using the Friedman test for repeated measures. Post-hoc analysis was performed with a Bonferroni correction. Two-tailed P-values <0.05 were considered significant. Results: Controls and SARS-CoV-2 recovered patients were matched for age (mean±SD, 54±11 vs. 53±14 years, p=0.47) and gender (53% vs. 59% male, p=0.49). There were no significant differences (p>0.05) in the proportion of hypertension, obesity, diabetes, cardiovascular disease, or use of anti hypertensive, lipid lowering, and anti-platelet medications between the controls and SARSCoV-2 patients. Plasma ACE2 activity at median 35 days post-infection [interquartile range 30-38 days] was 97-fold higher in SARS-CoV-2 patients compared to controls (5.8 [2-11.3] vs. 0.06 [0.02-2.2] pmol/min/ml, p<0.0001). Plasma ACE2 activity was significantly different across disease severity (p=0.033), with severe COVID-19 associated with higher ACE2 activity compared to mild disease (11.2 [8.3-23.2] vs. 5.4 [1.8-9.0] pmol/min/ml, p=0.027). Men recovered from SARS-CoV-2 had higher ACE2 levels compared to women (9.2 [5.8-15.3] vs. 2.1 [0.2-5.1] pmol/min/ml, p<0.0001). In 23 patients who had serial blood samples at 63 [56-65] and 114 [111-125] days post infection, median ACE2 activity remained persistently elevated with no differences between time-points (p>0.05). Conclusions: Plasma ACE2 activity is elevated after SARS-CoV-2 infection and remains elevated post-infection. Our findings indicate the need for ongoing investigation to determine if ACE2 levels identify people at risk of prolonged illness following COVID-19.
ABSTRACT
Immunity to severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection is central to long-term control of the current pandemic. Despite our rapidly advancing knowledge of immune memory to SARS-CoV-2, understanding how these responses translate into protection against reinfection at both the individual and population levels remains a major challenge. An ideal outcome following infection or after vaccination would be a highly protective and durable immunity that allows for the establishment of high levels of population immunity. However, current studies suggest a decay of neutralizing antibody responses in convalescent patients, and documented cases of SARS-CoV-2 reinfection are increasing. Understanding the dynamics of memory responses to SARS-CoV-2 and the mechanisms of immune control are crucial for the rational design and deployment of vaccines and for understanding the possible future trajectories of the pandemic. Here, we summarize our current understanding of immune responses to and immune control of SARS-CoV-2 and the implications for prevention of reinfection.
ABSTRACT
Biomedical waste poses various health and environmental hazards. Hence, it should be handled with the utmost care and disposed off safely. Several lacunas exist in the management of biomedical waste in India, and the pandemic posed by the coronavirus has made it even more challenging. The sudden outbreak of the virus led to an exponential rise in the quantity of biomedical waste. Furthermore, the poor infrastructure and lack of human resources have aggravated this situation. To combat this serious problem in a timely manner, the government has formulated various standard operating procedures and has amended the existing rules and guidelines.