Do upper respiratory viruses contribute to racial and ethnic disparities in emergency department visits for asthma?

BACKGROUND: There are marked disparities in asthma-related emergency department (ED) visit rates among children by race and ethnicity. Following the implementation of coronavirus disease 2019 (COVID-19) prevention measures, asthma-related ED visits rates declined substantially. The decline has been attributed to the reduced circulation of upper respiratory viruses, a common trigger of asthma exacerbations in children. OBJECTIVES: To better understand the contribution of respiratory viruses to racial and ethnic disparities in ED visit rates, we investigated whether the reduction in ED visit rates affected Black, Latinx, and White children with asthma equally. METHODS: Asthma-related ED visits were extracted from electronic medical records at Dell Children's Medical Center in Travis County, Texas. ED visit rates among children with asthma were derived by race/ethnicity. Incidence rate ratios (IRRs) and 95% CIs were estimated by year (2019-2021) and season. RESULTS: In spring 2019, the ED visit IRRs comparing Black children with White children and Latinx children with White children were 6.67 (95% CI = 4.92-9.05) and 2.10 (95% CI = 1.57-2.80), respectively. In spring 2020, when infection prevention measures were implemented, the corresponding IRRs decreased to 1.73 (95% CI = 0.90-3.32) and 0.68 (95% CI = 0.38-1.23), respectively. CONCLUSIONS: The striking reduction of disparities in ED visits suggests that during nonpandemic periods, respiratory viruses contribute to the excess burden of asthma-related ED visits among Black and Latinx children with asthma. Although further investigation is needed to test this hypothesis, our findings raise the question of whether Black and Latinx children with asthma are more vulnerable to upper respiratory viral infections.

Influence of Increasing Age and Body Mass Index of Gender in COVID-19 Patients.

Background: The impact of gender on outcomes in patients suffering from coronavirus disease 2019 (COVID-19) is frequently debated. However, the synchronous influence of additional risk factors is seldom mentioned. With increasing emphasis on identifying patients who are at risk of complications from COVID-19, we decided to conduct a retrospective review to assess the influence of age and body mass index (BMI) on gender-based differences in outcomes. Materials and Methods: A retrospective review of 1288 patients was conducted at a tertiary care hospital. Binary logistic regression was used to assess differences in risk factors and outcomes between genders. The associations between predictors and outcomes were described using odds ratios in tables, forest plots, and regression curves plotted using Sigma Plot. Results: Majority of patients were women (53.6% vs. 46.4%). Median BMI in men was higher than women (p = 0.003). Key predictors for all-cause morbidity/mortality in men were diabetes, chronic kidney disease, and regular use of angiotensin-converting enzyme inhibitors. In women, age >65 and regular use of inhaled steroid were additional risk factors. Men had a higher risk of acute respiratory distress syndrome (2.83 [1.70-4.70]), acute renal failure (1.96 [1.20-3.20]), and had a longer length of stay (0.11 [1.52]). Obesity has a stronger bearing on outcomes in women, and age has a more pronounced effect on outcomes in men. Conclusion: Extremes of BMI and older age are associated with worse outcomes in both men and women. Obesity has a stronger bearing on outcomes of COVID-19 infection in women, while the effect of older age on outcomes is more pronounced in men.

Teaching Instrumental Analysis during the Pandemic: Application of Handheld CO2 Monitors to Explore COVID-19 Transmission Risks.

The COVID-19 pandemic has posed a challenge for maintaining an engaging learning environment while using remote laboratory formats. In this work, we describe a Student Choice Project (SCP) in an undergraduate instrumental analysis course that was adapted for remote learning without sacrificing research-based learning goals. We discuss the implementation and assessment of this SCP, selected student results, and student feedback. Students were provided handheld carbon dioxide monitors and charged with designing and implementing an investigation centered on COVID-19 airborne transmission. The real-time monitors provided experience with a new analytical tool that demanded considerations and analysis not common to other methods discussed in the course. Students were motivated by the ability to design their own projects and by the real-world implications of their findings. They performed well for all assessments, reported a positive experience, and recommended these monitors be added to the typical repertoire of instrumentation for the course.

Development of an Easily Reproducible Cough Simulator With Droplets and Aerosols for Rapidly Testing Novel Personal Protective Equipment.

INTRODUCTION: The current COVID-19 pandemic has produced numerous innovations in personal protective equipment, barrier devices, and infection mitigation strategies, which have not been validated. During high-risk procedures such as airway manipulation, coughs are common and discrete events that may expose healthcare workers to large amounts of viral particles. A simulated cough under controlled circumstances can rapidly test novel devices and protocols and thus aid in their evaluation and the development of implementation guidelines. Physiologic cough simulators exist but require significant expertise and specialized equipment not available to most clinicians. METHODS: Using components commonly found in healthcare settings, a cough simulator was designed for clinicians to easily assemble and use. Both droplet and aerosol particle generators were incorporated into a bimodal experimental system. High-speed flash photography was used for data collection. RESULTS: Using a gas flow analyzer, video recordings, and high-speed digital photography, the cough and particle simulators were quantitatively and qualitatively compared with known physiologic cough parameters and in vivo Schlieren imaging of human coughs. CONCLUSIONS: Based on our validation studies, this cough and particle simulator model approximates a physiologic, human cough in the context of testing personal protective equipment, barrier devices, and infection prevention measures.

Baseline parameters for non-activated rotational thromboelastometry tests with and without heparinase in healthy pregnant women at term gestation.

OBJECTIVE: To determine the normal values for non-activated thromboelastometry parameters among pregnant women. DESIGN: Prospective, observational study. SETTING: Tertiary care hospital. PATIENTS: Non-laboring women at term gestation without history of bleeding or clotting disorder or anticoagulation use. INTERVENTIONS: Venous blood samples were collected and ROTEM® was performed using NATEM and NaHEPTEM assays. MEASUREMENTS: Reference ranges were derived by calculating 2.5 and 97.5 percentiles for the following parameters: clotting time (CT), clot formation time (CFT), amplitude at 10 (A10) and 20 min (A20), alpha angle, maximum clot firmness (MCF), and lysis index at 30 (LI30) and 60 min (LI60). The NATEM/NaHEPTEM CT ratio was calculated to determine the baseline ratio in term pregnant women. MAIN RESULTS: 146 women were screened and 120 were enrolled. The median age was 34 years [31-36], median gestational age was 39.1 weeks [38.3-39.3], and median parity was 1 [0-2]. Median pre-delivery platelet and hematocrit levels were within the normal ranges. The reference ranges for NATEM parameters were: CT (232-759 (s)), CFT (69-243 (s)), alpha angle (50-77 (°)), A10 (44-69 (mm)), A20 (54-75 (mm)), MCF (57-77 (mm)), LI30 (100-100 (%)), LI60 (90-100 (%)). The reference ranges for NaHEPTEM parameters were: CT (224-717 (s)), CFT (66-210 (s)), alpha angle (53-77 (°)), A10 (44-67 (mm)), A20 (55-73 (mm)), MCF (58-74 (mm)), LI30 (99-100 (%)), LI60 (90-100 (%)). The NATEM to NaHEPTEM CT ratio reference range was 0.73-1.3. CONCLUSIONS: This study is the first to our knowledge to report reference ranges for non-activated ROTEM® tests with and without heparinase in non-laboring term pregnant women. These reference ranges may serve as a baseline comparison and may be useful for future research on anticoagulation management in pregnancy.

Critical Care Simulation Education Program During the COVID-19 Pandemic.

BACKGROUND: Coronaviruses are important emerging human and animal pathogens. SARS-CoV-2, the virus that causes COVID-19, is responsible for the current global pandemic. Early in the course of the pandemic, New York City became one of the world's "hot spots" with more than 250,000 cases and more than 15,000 deaths. Although medical providers in New York were fortunate to have the knowledge gained in China and Italy before it came under siege, the magnitude and severity of the disease were unprecedented and arguably under appreciated. The surge of patients with significant COVID-19 threatened to overwhelm health care systems, as New York City health systems realized that the number of specialized critical care providers would be inadequate. A large academic medical system recognized that rapid redeployment of noncritical providers into such roles would be needed. An educational gap was therefore identified: numerous providers with minimal critical care knowledge or experience would now be required to provide critical-level patient care under supervision of intensivists. Safe provision of such high level of patient care mandated the development of "educational crash courses." METHODS: The purpose of this special article is to summarize the approach adopted by the Institute for Critical Care Medicine and Department of Anesthesiology, Perioperative and Pain Medicine's Human Emulation, Education, and Evaluation Lab for Patient Safety and Professional Study Simulation Center in developing a training program for noncritical care providers in this novel disease. RESULTS: Using this joint approach, we were able to swiftly educate a wide range of nonintensive care unit providers (such as surgical, internal medicine, nursing, and advanced practice providers) by focusing on refreshing critical care knowledge and developing essential skillsets to assist in the care of these patients. CONCLUSIONS: We believe that the practical methods reviewed here could be adopted by any health care system that is preparing for an unprecedented surge of critically ill patients.

The Society for Obstetric Anesthesia and Perinatology Coronavirus Disease 2019 Registry: An Analysis of Outcomes Among Pregnant Women Delivering During the Initial Severe Acute Respiratory Syndrome Coronavirus-2 Outbreak in the United States.

BACKGROUND: Early reports associating severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) infection with adverse pregnancy outcomes were biased by including only women with severe disease without controls. The Society for Obstetric Anesthesia and Perinatology (SOAP) coronavirus disease 2019 (COVID-19) registry was created to compare peripartum outcomes and anesthetic utilization in women with and without SARS-CoV-2 infection delivering at institutions with widespread testing. METHODS: Deliveries from 14 US medical centers, from March 19 to May 31, 2020, were included. Peripartum infection was defined as a positive SARS-CoV-2 polymerase chain reaction test within 14 days of delivery. Consecutive SARS-CoV-2-infected patients with randomly selected control patients were sampled (1:2 ratio) with controls delivering during the same day without a positive test. Outcomes were obstetric (eg, delivery mode, hypertensive disorders of pregnancy, and delivery <37 weeks), an adverse neonatal outcome composite measure (primary), and anesthetic utilization (eg, neuraxial labor analgesia and anesthesia). Outcomes were analyzed using generalized estimating equations to account for clustering within centers. Sensitivity analyses compared symptomatic and asymptomatic patients to controls. RESULTS: One thousand four hundred fifty four peripartum women were included: 490 with SARS-CoV-2 infection (176 [35.9%] symptomatic) and 964 were controls. SARS-CoV-2 patients were slightly younger, more likely nonnulliparous, nonwhite, and Hispanic than controls. They were more likely to have diabetes, obesity, or cardiac disease and less likely to have autoimmune disease. After adjustment for confounders, individuals experiencing SARS-CoV-2 infection exhibited an increased risk for delivery <37 weeks of gestation compared to controls, 73 (14.8%) vs 98 (10.2%) (adjusted odds ratio [aOR], 1.47; 95% confidence interval [CI], 1.03-2.09). Effect estimates for other obstetric outcomes and the neonatal composite outcome measure were not meaningfully different between SARS-CoV-2 patients versus controls. In sensitivity analyses, compared to controls, symptomatic SARS-CoV-2 patients exhibited increases in cesarean delivery (aOR, 1.57; 95% CI, 1.09-2.27), postpartum length of stay (aOR, 1.89; 95% CI, 1.18-2.60), and delivery <37 weeks of gestation (aOR, 2.08; 95% CI, 1.29-3.36). These adverse outcomes were not found in asymptomatic women versus controls. SARS-CoV-2 patients (asymptomatic and symptomatic) were less likely to receive neuraxial labor analgesia (aOR, 0.52; 95% CI, 0.35-0.75) and more likely to receive general anesthesia for cesarean delivery (aOR, 3.69; 95% CI, 1.40-9.74) due to maternal respiratory failure. CONCLUSIONS: In this large, multicenter US cohort study of women with and without peripartum SARS-CoV-2 infection, differences in obstetric and neonatal outcomes seem to be mostly driven by symptomatic patients. Lower utilization of neuraxial analgesia in laboring patients with asymptomatic or symptomatic infection compared to patients without infection requires further investigation.

Monitoring of COVID-19-Associated Coagulopathy and Anticoagulation with Thromboelastometry.

INTRODUCTION: Thrombosis occurs frequently in COVID-19. While the exact mechanism is unclear, 3 processes seem to play important roles in sepsis-related thrombosis and mortality: tissue factor expression on circulating monocytes and microparticles, hypercoagulability (increased clot firmness), and hypofibrinolysis. Rotational thromboelastometry is a point-of-care viscoelastic technique that uses the viscoelastic properties of blood to monitor coagulation. Using various assays, viscoelastometry could monitor this triad of changes in severely ill, COVID-19-positive patients. Similarly, with the increased incidence of coagulopathy, many patients are placed on anticoagulants, making management more difficult depending on the agents utilized. Viscoelastometry might also be used in these settings to monitor anticoagulation status and guide therapy, as it has in other areas. CASE PRESENTATION: We present a case series of 6 patients with different stages of disease and different management plans. These cases occurred at the height of the pandemic in New York City, which limited testing abilities. We first discuss the idea of using the NaHEPTEM test as a marker of tissue factor expression in COVID-19. We then present cases where patients are on different anticoagulants and review how viscoelastometry might be used in a patient on anticoagulation with COVID-19. CONCLUSION: In a disease such as COVID-19, which has profound effects on hemostasis and coagulation, viscoelastometry may aid in patient triage, disease course monitoring, and anticoagulation management.

Barrier Devices, Intubation, and Aerosol Mitigation Strategies: Personal Protective Equipment in the Time of Coronavirus Disease 2019.

BACKGROUND: Numerous barrier devices have recently been developed and rapidly deployed worldwide in an effort to protect health care workers (HCWs) from exposure to coronavirus disease 2019 (COVID-19) during high-risk procedures. However, only a few studies have examined their impact on the dispersion of droplets and aerosols, which are both thought to be significant contributors to the spread of COVID-19. METHODS: Two commonly used barrier devices, an intubation box and a clear plastic intubation sheet, were evaluated using a physiologically accurate cough simulator. Aerosols were modeled using a commercially available fog machine, and droplets were modeled with fluorescein dye. Both particles were propelled by the cough simulator in a simulated intubation environment. Data were captured by high-speed flash photography, and aerosol and droplet dispersion were assessed qualitatively with and without a barrier in place. RESULTS: Droplet contamination after a simulated cough was seemingly contained by both barrier devices. Simulated aerosol escaped the barriers and flowed toward the head of the bed. During barrier removal, simulated aerosol trapped underneath was released and propelled toward the HCW at the head of the bed. Usage of the intubation sheet concentrated droplets onto a smaller area. If no barrier was used, positioning the patient in slight reverse Trendelenburg directed aerosols away from the HCW located at the head of the bed. CONCLUSIONS: Our observations imply that intubation boxes and sheets may reduce HCW exposure to droplets, but they both may merely redirect aerosolized particles, potentially resulting in increased exposure to aerosols in certain circumstances. Aerosols may remain within the barrier device after a cough, and manipulation of the box may release them. Patients should be positioned to facilitate intubation, but slight reverse Trendelenburg may direct infectious aerosols away from the HCW. Novel barrier devices should be used with caution, and further validation studies are necessary.

Intraoperative aerosol box use: does an educational visual aid reduce contamination?

BACKGROUND: The aerosol box was rapidly developed and disseminated to minimize viral exposure during aerosolizing procedures during the COVID-19 pandemic, yet users may not understand how to use and clean the device. This could potentially lead to increased viral exposure to subsequent patients and practitioners. We evaluated intraoperative contamination and aerosol box decontamination and the impact of a preoperative educational visual aid. METHODS: Using a double-blinded randomized design, forty-four anesthesiology trainees and faculty completed a simulated anesthetic case using an aerosol box contaminated with a fluorescent marker; half of the subjects received a visual aid prior to the simulation. Intraoperative contamination was evaluated at 10 standardized locations using an ultraviolet (UV) light. Next, subjects were instructed to clean the aerosol box for use on the next patient. Following cleaning, the box was evaluated for decontamination using an UV light. RESULTS: Median total contamination score was significantly reduced in the experimental group (5.0 vs. 10.0, P < 0.001). The aerosol box was completely cleaned by 36.4% of subjects in the experimental group compared to 4.5% in the control group (P = 0.009). CONCLUSIONS: The use of a visual aid significantly decreased intraoperative contamination and improved box cleaning. Despite these findings, a potentially clinically significant amount of viral exposure may exist. Thorough evaluation of the risks and benefits of the aerosol box should be completed prior to use. If an aerosol box is used, a visual aid should be considered to remind practitioners how to best use and clean the box.

Managing COVID-19 from the epicenter: adaptations and suggestions based on experience.

In March 2020, the New York City metropolitan area became the epicenter of the United States' SARS-CoV-2 pandemic and the surge of new cases threatened to overwhelm the area's hospital systems. This article describes how an anesthesiology department at a large urban academic hospital rapidly adapted and deployed to meet the threat head-on. Topics included are preparatory efforts, development of a team-based staffing model, and a new strategy for resource management. While still maintaining a fully functioning operating theater, discrete teams were deployed to both COVID-19 and non-COVID-19 intensive care units, rapid response/airway management team, the difficult airway response team, and labor and delivery. Additional topics include the creation of a temporary 'pop-up' anesthesiology-run COVID-19 intensive care unit utilizing anesthesia machines for monitoring and ventilatory support as well as the development of a simulation and innovation team that was instrumental in the rapid prototyping of a controlled split-ventilation system and conversion of readily available BIPAP units into emergency ventilators. As the course of the disease is uncertain, the goal of this article is to assist others in preparation for what may come next with COVID-19 as well as potential future pandemics.

Reductions in commuting mobility correlate with geographic differences in SARS-CoV-2 prevalence in New York City.

SARS-CoV-2-related mortality and hospitalizations differ substantially between New York City neighborhoods. Mitigation efforts require knowing the extent to which these disparities reflect differences in prevalence and understanding the associated drivers. Here, we report the prevalence of SARS-CoV-2 in New York City boroughs inferred using tests administered to 1,746 pregnant women hospitalized for delivery between March 22nd and May 3rd, 2020. We also assess the relationship between prevalence and commuting-style movements into and out of each borough. Prevalence ranged from 11.3% (95% credible interval [8.9%, 13.9%]) in Manhattan to 26.0% (15.3%, 38.9%) in South Queens, with an estimated city-wide prevalence of 15.6% (13.9%, 17.4%). Prevalence was lowest in boroughs with the greatest reductions in morning movements out of and evening movements into the borough (Pearson R = -0.88 [-0.52, -0.99]). Widespread testing is needed to further specify disparities in prevalence and assess the risk of future outbreaks.