ID: 219407 The Cardiac Patient and Neuromodulation, When Anticoagulation Dictates the Intervention

Introduction: Patients with cardiac comorbidities present unique challenges for undergoing interventional pain procedures. Consensus guidelines on safe anticoagulation management are categorized by procedure, patient specific bleeding risk factors, and class of anticoagulation (Table 1, Table 2).1 Specifically, some procedures occur in close proximity to the spinal cord, require large gauge needles and styletted leads, while others are in compressible locations with minimal tissue disruption. Further, pain-induced hypercoagulation increases the risk of thrombo-vascular events.1 This accentuates the importance of interdisciplinary perioperative coordination with the prescribing cardiologist. Case: A 71-year-old male with past-medical-history of CABG, bilateral femoral-popliteal bypass, atrial fibrillation on apixaban and ticagrelor, and multiple cardiac stents presented with intermittent shooting axial back pain radiating to right buttock, lateral thigh, and calf, worsened with activity. MRI demonstrated thoracic myelomalacia, multi-level lumbar disc herniation, and moderate central canal stenosis. An initial multi-model treatment approach utilizing pharmacologic agents, physical therapy, ESI's, and RFA failed to alleviate symptoms. After extensive discussion with his cardiologist, he was scheduled for a three-day SCS trial. Ticagrelor and apixaban were held throughout the 3-day trial and for 5 and 3 days prior, respectively, while ASA was maintained. Successful trial with tip placement at T6 significantly improved function and pain scores (Figure 1). Upon planned percutaneous implant, the cardiologist recommended against surgical implantation and holding anticoagulation. Alternatively, the patient underwent bilateral lumbar medial branch PNS implant with sustained improvement in lower back symptoms. However, he contracted COVID, resulting in delayed lead explanation (>60 days) without complication. Conclusion(s): Interventional pain practice advisories are well established for anticoagulation use in the perioperative period.1,2 However, there is limited high-quality research on the appropriate length to hold anticoagulation prior to surgery for high thrombotic risk patients. Collegial decision making with the cardiologist was required to avoid deleterious procedural complications. However, they may be unfamiliar with the nuances between interventions or between trial and implant. Prospective studies have shown that low risk procedures, such as the PNS, may not require holding anticoagulants.3 Other case data has demonstrated post-SCS epidural hematoma with ASA use after being held for 1-week prior to surgery. Our patient was unable to undergo SCS implant and instead elected for a lower risk procedure with excellent efficacy. 4 However, delayed PNS lead extraction due to COVID19 hospitalization presented further risk of infection and lead fracture.5 PNS may prove to be an appropriate treatment option for patients who are anticoagulated and are not SCS candidates. Disclosure: Elliot Klein, MD,MPH: None, Clarence Kong, MD: None, Shawn Sidharthan, MD: None, Peter Lascarides, DO: None, Yili Huang, DO: NoneCopyright © 2023

Frequencies of Adenovirus Types in U.S. Children with Acute Respiratory Illness, 2016-2019

Background. Adenovirus (AdV) is a common cause of acute respiratory illness (ARI). Multiple respiratory AdV types have been identified in humans, but it remains unclear which are the most common in U.S. children with ARI. Methods. We conducted a multicenter, prospective viral surveillance study at seven U.S. children's hospitals, the New Vaccine Surveillance Network, during 12/1/ 16-11/30/19, prior to the COVID-19 pandemic. Children < 18 years of age seen in the emergency department or hospitalized with fever and/or respiratory symptoms were enrolled, and mid-turbinate nasal +/- throat swabs were tested using multiplex respiratory pathogen assays or real time polymerase chain reaction (PCR) test for AdV, respiratory syncytial virus (RSV), human metapneumovirus, rhinovirus/enterovirus (RV), influenza, parainfluenza viruses, and endemic coronaviruses. AdV-positive specimens were subsequently typed using single-plex qPCR assays targeting sequences in the hexon gene specific for types 1-7, 11, 14, 16 and 21. Demographics, clinical characteristics, and outcomes were compared between AdV types. Results. Of 29,381 enrolled children, 2,106 (7.2%) tested positive for AdV. The distribution of types among the 1,330 (63.2%) successfully typed specimens were as follows: 31.7% AdV-2, 28.9% AdV-1, 15.3% AdV-3, 7.9% AdV-5, 5.9% AdV-7, 1.4% AdV-4, 1.2% AdV-6, 0.5% AdV-14, 0.2% AdV-21, 0.1% AdV-11, and 7.0% >=1 AdV type. Most children with AdV-1 or AdV-2 detection were < 5 years of age (Figure 1a). Demographic and clinical characteristics varied by AdV types, including age, race/ethnicity, smoke exposure, daycare/school attendance, and hospitalization (Table 1). Co-detection with other viruses was common among all AdV types, with RV and RSV being the most frequently co-detected (Figure 1b). Fever and cough were the most common symptoms for all AdV types (Figure 2). Children with AdV-7 detected as single pathogen had higher odds of hospitalization (adjusted odds ratio 6.34 [95% CI: 3.10, 12.95], p= 0.027). Conclusion. AdV-2 and AdV-1 were the most frequently detected AdV types among children over the 3-year study period. Notable clinical heterogeneity of the AdV types warrants further surveillance studies to identify AdV types that could be targeted for pediatric vaccine development. (Figure Presented).

COVID-19 and Antibiotic Prescriptions in the United States: A County-level Analysis

Background. Declines in outpatient antibiotic prescribing were reported during the beginning of the COVID-19 pandemic in the United States;however, the overall impact of COVID-19 cases on antibiotic prescribing remains unclear. Methods. We conducted an observational, ecological study to assess the impact of COVID-19 cases and pandemic-related, non-pharmaceutical interventions (NPIs) (e.g., school closures and facemasks) on antibiotic prescribing from February to December 2020 in the US. A random effects panel regression of county-level monthly reported COVID-19 case data and corresponding systemic antibiotic prescription data from IQVIA was used. The model controlled for county demographics, NPIs, and prior years' prescribing. Results. Total antibiotic prescriptions fell 26.1% between March and December 2020 compared to this period from 2017 to 2019. Prescribing rates dropped most among children (Figure 1). A 1% increase in county-level monthly COVID-19 cases was associated with a 0.9% increase (95% CI 0.7%, 1.1%;p< 0.01) in monthly prescriptions dispensed to adults and a 1.2% decrease (95% CI -1.7%, -0.8%;p< 0.01) in prescriptions dispensed to children (Table 1). Counties with schools open for in-person instruction were associated with a 4.4% increase (95% CI 2.3%, 6.4%;p< 0.01) in prescriptions among children compared to counties that closed schools. Internal movement restrictions and requiring facemasks were also associated with lower prescribing among children. Figure 1 A) Total prescriptions per 100,000 population by month (2017-2020). B) Mean prescriptions per 100,000 population for seven age groups (2017-2019 vs 2020). Table 1 Conclusion. Though the number of antibiotic prescriptions in 2020 was lower than previous years, the positive association of COVID-19 cases with prescribing for adults and the negative association for children indicates increases in prescribing occurred primarily among adults. The rarity of bacterial co-infection in COVID-19 patients suggests a large fraction of these prescriptions may have been inappropriate. Facemasks and school closures were correlated with reductions in prescribing among children, likely due to the prevention of other upper respiratory infections (e.g., the cold and influenza). Despite reductions, the strongest predictors of prescribing were prior years' prescribing trends, suggesting the possibility that behavioral norms are an important driver of prescribing practices.

Healthcare Personnel Interactive Pathogen Exposure Response System

Background. Infectious disease exposure investigations in the hospital are labor-intensive for the infection prevention and control (IPC) team and vulnerable to healthcare personnel (HCP) recall bias. We developed an electronic health record (EHR) algorithm to identify and rank patient-HCP interactions based on the likelihood and intensity of exposure. Methods. We compared conventional and EHR-based findings from seven exposure investigations conducted between November 1, 2020 and February 1, 2022 at The Johns Hopkins Hospital (JHH), a 1095 bed academic tertiary center in Baltimore, MD. Conventional exposure investigations were conducted for hospitalized patients who tested positive for SARS-CoV-2 while not in COVID-19 isolation precautions. IPC contacted department managers to identify and report potentially exposed HCPs to occupational health. The EHR-based method identified HCP-patient interactions based on clinical data such as documentation in the flowsheet, medication administration, etc. A score was calculated for each HCP based on the estimated duration and intensity of the contact. Genomic sequencing of available samples was performed to investigate transmission events. Results. Overall, the EHR-based system identified 75% (59/79) of the HCPs identified by conventional exposure investigations and 100% of those who document in the EHR. In contrast, it was unable to identify any potentially exposed individuals who do not document in the EHR (Table 1). All patient-HCP COVID-19 transmissions identified by conventional investigation and confirmed through genomic sequencing were identified by the EHR-based system, and all had high-intensity scores (i.e., top quartile of the list of exposed individuals). Conclusion. We found clinical EHR data was highly sensitive and specific in identifying potentially exposed HCPs compared with conventional exposure investigations. The inability to detect interactions with support staff or others who do not document in the EHR was a limitation and suggests that EHR data can augment but not replace conventional exposure investigations. The system's speed, ease, and lower resource requirements make it a promising tool to more efficiently complete exposure investigations in healthcare settings.

Analysis of the potential impact of effectiveness and availability of mRNA influenza vaccine on hospitalization and mortality

Background. Influenza viruses constantly change because of antigenic drift. Due to the time currently needed to develop and distribute flu shots, vaccines are often illmatched to circulating influenza strains. One silver lining of the COVID-19 pandemic was the acceleration of mRNA technology, which could significantly reduce the timeline between strain choice and deployment, potentially increasing vaccine efficacy. Significant private and public investments would be required to accommodate accelerated vaccine development and approval. Hence, it is important to understand the potential impact of mRNA technology on influenza hospitalizations and mortality. Methods. We developed a compartmental model stratified by age group to evaluate the potential effect of increased vaccine effectiveness (defined as a two-level measure of protection against infection and hospitalization) on influenza hospitalizations and mortality in the United States. We assume that mRNA technology can only shorten the time from strain choice to distribution but not distribution and administration. Thus, later decisions on vaccine composition would increase effectiveness but reduce availability. To assess this tradeoff, we evaluated two scenarios where strain choice was delayed until summer resulting in a more effective vaccine: (1) available to all age groups in the fall, or (2) available by August but only for adults 65 years and older. Results. Assuming current vaccine coverage rates, if not available until October, the vaccine would need a minimum of 80% effectiveness against infection to see a decrease in hospitalizations and deaths (Figures 1A and 1B). When delayed until November, even a 100% effective vaccine could not reduce hospitalizations or deaths (Figures 1C and 1D). For the elderly, a 50% effective vaccine against infection (Figures 1E and 1F) or a vaccine 40% effective against infection and 60% against hospitalization available in late summer was similar to an 80% effective vaccine available in October for all ages. Age-stratified weekly number of influenza-associated hospitalization per 100,000 population and total number of deaths in the United States for an mRNA vaccine that would be available in either October (A and B), November (C and D), or by late summer but only for the 65+ age group (E and F). The Baseline represents the 10-year average weekly hospitalization rate and mortality during the Flu Season (October to May). Conclusion. As the majority of influenza-associated hospitalizations and deaths are in adults 65 years and older, a combination policy targeting higher vaccine effectiveness for this age group in the short term would be the most efficacious. (Figure Presented).

Developpement et validation externe d'un modele de prediction du passage d'une forme legere a moderee ou severe de COVID-19, a l'aide du scanner thoracique

Declaration de liens d'interets: Les auteurs declarent ne pas avoir de liens d'interets. Copyright © 2022

Schools’ improvement capacity and responses to the COVID-19 pandemic: Evidence from schools serving disadvantaged communities

The goal of this paper is to analyze the relationship between six different dimensions of school improvement capacity (SIC) and schools’ efforts to sustain teaching and learning as well as student well-being during the first lockdown in the context of the COVID-19 pandemic. Based on data from 13 qualitative interviews with principals and data from a standardized teacher survey at schools serving disadvantaged communities in North Rhine-Westphalia, Germany (N = 385 teachers), we assessed (1) the schools’ level of SIC shortly before the lockdown, (2) their reported response to the lockdown with regard to sustaining student learning and well-being, and (3) similarities between the schools in terms of the combination of the level of SIC and the reported effort to address the challenges of distance learning. Our results suggest that two major groups of schools can be distinguished in terms of level of SIC. Furthermore, we identified a range of thematic clusters related to how schools acted during distance learning, each of which can be assigned to one or more dimensions of SIC. Finally, we identified four patterns, referring to different combinations of SIC and the schools’ reported actions. The results indicate that schools with a higher initial SIC were more able to find flexible and pragmatic solutions in order to sustain student learning and well-being during distance learning. Our findings stress the importance of school improvement activities at schools serving disadvantaged communities in dealing with sudden challenges for teaching and learning, such as those encountered during COVID-19. Copyright © 2022 Beckmann, Kötter-Mathes, Klein, Bremm and van Ackeren.

High Case Fatality Rate Among Fully Vaccinated Kidney Transplant Recipients with Breakthrough Covid-19 During the Delta Surge

Purpose: Organ transplant recipients (OTR) have worse outcomes from COVID-19 and weaker antibody responses to vaccination than do immunocompetent individuals. Data on clinical outcomes among OTR with breakthrough COVID-19 are urgently needed, given decreased vaccine efficacy against the B.1.617.2 (Delta) variant. We compared crude case fatality rates (CFR) between fully vaccinated and unvaccinated kidney transplant recipients (KTR) with COVID-19. Method(s): We identified KTR with COVID-19 at our institution between 3/1/20 and 11/17/21. Multi-organ transplant recipients, KTR who received additional ("booster") doses, and those with partial or unknown vaccination status were excluded due to small numbers. KTR were considered fully vaccinated 2 weeks after receiving either the second dose of an mRNA vaccine series (Moderna, Pfizer-BioNTech) or one dose of the Janssen viral vector vaccine. Demographics, clinical characteristics, and in-hospital or hospice care mortality were extracted from electronic medical records. Result(s): Among 109 KTR with COVID-19, 19 were fully vaccinated at symptom onset. Vaccinated KTR with COVID-19 were older (median: 63.5 vs. 57.5 years, P<0.05) and waited longer to seek care after symptom onset (median: 6 vs. 3 days, P<0.05). Comorbidities and time from transplant were comparable between the two groups. CFR was higher among vaccinated KTR (26% vs. 10%, HR 0.34, 95%CI 0.11-1, P=0.05;Fig. 1), although the difference was not significant after adjustment for age (aHR 0.53, 95%CI 0.17-1.61, P>0.1). All fatal breakthrough infections occurred when the Delta variant accounted for >98% of COVID-19 cases in our HHS region. Conclusion(s): Vaccinated OTR remain at high risk for fatal COVID-19. Younger OTR are likely more immunoprotected than older OTR, which-combined with the emergence of the Delta variant and easing of restrictions-may have contributed to the observed shift toward older age among KTR with breakthrough COVID-19 and the high resultant CFR. Vaccinated OTR may delay seeking care for breakthrough symptoms due to a false sense of security. Our findings highlight the importance of pretransplant vaccination, and, among OTR, the need for ongoing preventive measures (masks, social distancing, vaccination of close contacts, post-vaccine education) and additional vaccine doses. OTR should be linked to care immediately after exposure or onset of symptoms consistent with COVID-19, given the availability of anti-spike monoclonal antibodies for prevention or treatment. (Figure Presented).

Complications and severity of COVID-19 in patients with (HNC): A COVID-19 and Cancer Consortium (CCC19) registry analysis

Background: Patients with cancer have worse outcomes from COVID-19 infection. However, the specific impact of COVID-19 on patients with (HNC) is largely unknown. The COVID-19 and Cancer Consortium (CCC19) maintains an international registry (NCT04354701) aimed to investigate the clinical course and complications of COVID-19 in patients with cancer. Here, we report severity of COVID-19 and its complications among HNC patients. Methods: The CCC19 registry was queried for patients with HNC and laboratory confirmed SARS-CoV-2 infection. The co-primary outcomes were severity of COVID-19 illness on an ordinal scale (0: no complications;1: hospitalized, no oxygen (O2);2: hospitalized, required O2;3: ICU admission;4: mechanical ventilation (MV);5: death), and severity of complications (mild, moderate, serious). The outcomes were further stratified by demographics, recent treatment (systemic vs local;surgery, radiation (RT) vs systemic), treatment intent (palliative vs curative), and cancer status (remission, responding, stable, progressing). Results: From March 2020 to December 2021, 356 HNC patients were identified. Median age was 65 (interquartile range 58-74), 29% were female, 56% were white, 67% were former or current smokers, 20% had a BMI >30, 15% had an ECOG performance status >2, and 57% had >2 comorbidities. 154 (43%) had no complications, 61 (17%) were hospitalized without O2, 135 (38%) were hospitalized with O2, 50 (14%) required ICU, 32 (9%) required MV, and 74 (21%) died. 88 (25%) had mild, 59 (17%) had moderate, and 132 (37%) had serious complications. 33% of patients who received systemic therapy and 30% who received RT within 3 mo prior to COVID-19 diagnosis died. Mortality was higher in patients receiving palliative when compared to curative intent treatment (44% vs 16%). In addition, 50% of patients with actively progressing cancer, and 45% who had serious complications died. Importantly, 37 (n=12 palliative systemic therapy and n=25 local therapy) patients had a treatment delay due to COVID-19 diagnosis. Conclusions: Our study is the largest cohort to date describing COVID-19 outcomes in HNC patients and suggest a high rate of mortality even in those receiving local and curative intent treatment. Variables stratified by COVID-19 severity. Note: Ordinal levels 3 and 4 not shown due to small case numbers.

Anti-Spike Monoclonal Antibody Therapy for Kidney Transplant Recipients with COVID-19

Background. Organ transplant recipients may not mount an adequate immune response to COVID-19 infection, and therefore may benefit greatly from passive immunization with anti-spike monoclonal antibodies (mAb), which have been shown to decrease hospitalization rates in the general outpatient population. We evaluated the efficacy of mAb therapy in decreasing hospitalizations or emergency room (ER) visits among kidney transplant recipients (KTR) with COVID-19. Methods. We identified KTR with COVID-19 between 3/1/2020 and 4/30/2021. Patients were excluded if they had multiorgan transplant or hospital-acquired COVID-19. Data were analyzed by Cox regression with mAb administration as time-dependent variable, and the day of symptom onset as baseline. Results. We studied 95 KTR;20 received mAb. Comorbidities and immunosuppression were balanced between the two groups. mAb administration was associated with a significant decrease in hospitalizations or ER visits (15 vs. 76%, P< 0.001). This association remained significant after adjustment for confounders and by analyzing mAb administration as a time-dependent variable (Table: adj. HR 0.2, P=0.04). No KTR who received mAb died or required mechanical ventilation. Black or Hispanic KTR were less likely to receive mAb and more likely to be admitted to the hospital or visit the ER (Table). Factors significantly associated with hospitalization or ER visit. Conclusion. In our KTR population, mAb therapy for COVID-19 may have helped decrease hospitalizations and ER visits. Healthcare inequities, including access to investigational treatments, were exacerbated by the COVID-19 pandemic. Acknowledging the nonconcurrent control group as a limitation, we found a strong signal for benefit from mAb treatment. Antiviral mAb are a promising therapeutic modality for immunosuppressed patients.

Circulation of Rhinovirus/Enterovirus Respiratory Infections in Children during 2020-21 in the United States

Background. Sharp declines in influenza and respiratory syncytial virus (RSV) circulation across the U.S. have been described during the pandemic in temporal association with community mitigation for control of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). We aimed to determine relative frequencies of rhinovirus/ enterovirus (RV/EV) and other respiratory viruses in children presenting to emergency departments or hospitalized with acute respiratory illness (ARI) prior to and during the COVID-19 pandemic. Methods. We conducted a multi-center active prospective ARI surveillance study in children as part of the New Vaccine Surveillance Network (NVSN) from December 2016 through January 2021. Molecular testing for RV/EV, RSV, influenza, and other respiratory viruses [i.e., human metapneumovirus, parainfluenza virus (Types 1-4), and adenovirus] were performed on specimens collected from children enrolled children. Cumulative percent positivity of each virus type during March 2020-January 2021 was compared from March-January in the prior seasons (2017-2018, 2018-2019, 2019-2020) using Pearson's chi-squared. Data are provisional. Results. Among 69,403 eligible children, 37,676 (54%) were enrolled and tested for respiratory viruses. The number of both eligible and enrolled children declined in early 2020 (Figure 1), but 4,691 children (52% of eligible) were enrolled and tested during March 2020-January 2021. From March 2020-January 2021, the overall percentage of enrolled children with respiratory testing who had detectable RV/EV was similar compared to the same time period in 2017-2018 and 2019-2020 (Figure 1, Table 1). In contrast, the percent positivity of RSV, influenza, and other respiratory viruses combined declined compared to prior years, (p< 0.001, Figure 1, Table 1). Figure 1. Percentage of Viral Detection Among Enrolled Children Who Received Respiratory Testing, New Vaccine Surveillance Network (NVSN), United States, December 2016 - January 2021 Table 1. Percent of Respiratory Viruses Circulating in March 2020- January 2021, compared to March-January in Prior Years, New Vaccine Surveillance Network (NVSN), United States, March 2017 - January 2021 Conclusion. During 2020, RV/EV continued to circulate among children receiving care for ARI despite abrupt declines in other respiratory viruses within this population. These findings warrant further studies to understand virologic, behavioral, biological, and/or environmental factors associated with this continued RV/EV circulation.

Deciphering COVID-19-Associated Effects on Hospital MRSA Transmission and Social Networks

Background. The COVID-19 pandemic was associated with a significant (28%) reduction of methicillin-resistant Staphylococcus aureus (MRSA) acquisition at UVA Hospital (P=0.016). This "natural experiment" allowed us to analyze 3 key mechanisms by which the pandemic may have influenced nosocomial transmission: 1) enhanced infection control measures (i.e., barrier precautions and hand hygiene), 2) patient-level risk factors, and 3) networks of healthcare personnel (HCP)-mediated contacts. Hospital MRSA acquisition was defined as a new clinical or surveillance positive in patients with prior unknown or negative MRSA status occurring >72h after admission. 10 month time periods pre- (5/6/2019 to 2/23/2020) and post-COVID-19 (5/4/2020 to 2/28/2021) were chosen to mitigate the effects of seasonality. A 6-week wash-in period was utilized coinciding with the onset of several major hospital-wide infection control measures (opening of 2 special pathogen units with universal contact/airborne precautions on 4/1/21 and 5/1/21, universal mask 4/10/21 and eye protection 4/20/20 policies instituted along with staff education efforts including the importance of standard precautions). Box and whisker plots depict quartile ranges, median (dotted line), and mean values. Mean MRSA acquisition rates pre- (0.92 events per 1,000 patient days) significantly declined post-COVD-19 (to 0.66;P=0.016). Independent-samples t tests were used (2-tailed) for statistical comparisons except for variables without a normal distribution (Shorr Scores), for which a Mann-Whitney U test was used. Methods. Census-adjusted hospital-acquired MRSA acquisition events were analyzed over 10 months pre- (5/6/2019 to 2/23/2020) and post-COVD-19 (5/4/2020 to 2/28/2021), with a 6-week wash-in period coinciding with hospital-wide intensification of infection control measures (e.g., universal masking). HCP hand hygiene compliance rates were examined to reflect adherence to infection control practices. To examine impacts of non-infection control measures on MRSA transmission, we analyzed pre/post-COVD-19 differences in individual risk profiles for MRSA acquisition as well as a broad suite of properties of the hospital social network using person-location and person-person interactions inferred from the electronic medical record. Figure 2. Social Network Construction We constructed a contact network of hospitalized patients and staff at University of Virginia Hospital to analyze the properties of both person-location and person-person networks and their changes pre- and post-COVID-19. Colocation data (inferred from shared patient rooms and healthcare personnel (HCP)-patient interactions recorded in the electronic health record, e.g., medication administration) were used to construct contact networks, with nodes representing patients and HCP, and edges representing contacts. The above schematic shows how the temporal networks are inferred. In the figure, circles represent patients and the small filled squares represent HCP, while the larger rectangles represent patient rooms. The first room is a shared room with two patients. At each time step, co-location is inferred from the EMR data, which specifies interactions between HCP and patients. This can be represented as the temporal network (t) at the bottom. Results. Hand hygiene compliance significantly improved post-COVD-19, in parallel with other infection control measures. Patient Shorr Scores (an index of individual MRSA risk) were statistically similar pre-/post-COVD-19. Analysis of various network properties demonstrated no trends to suggest a reduced outbreak threshold post-COVD-19. Figure 3. Hand Hygiene Compliance Rates Analysis of hospital-wide hand hygiene auditing data (anonymous auditors deployed to various units across UVA Hospital with an average 1,710 observations per month (range 340 - 7,187)) demonstrated a statistically significant (6%) improvement in average monthly hand hygiene compliance (86.9% pre- versus 93.1% post-COVD-19;P=0.008). Figure 4. Individual MRSA Risk Factors We calculated the Shorr Score (a validated tool to estimate individual risk for MRSA carriage in hospitalized patients;Shorr et al. Arch Intern Med. 2008;168(20):2205-10) for patients using data from the electronic health record to test the hypothesis that individual risk factors in aggregate did not change significantly in the post-COVD-19 period to explain changes in MRSA acquisition. Values for this score ranged from 0 to 10 with the following criteria: recent hospitalization (4), nursing home residence (3), hemodialysis (2), ICU admission (1). Pictured are frequency distributions of Shorr scores in the pre-COVID-19 and post-COVID-19 periods. The Mann-Whitney effect size (E), 0.53 (P=0.51), indicated that pre- and post-COVD-19 distributions were very similar. We analyzed three major types of network properties for this analysis: (1) Node properties of the pre- and post-COVID-19 networks consisted of all the edges in the pre- and post-COVID-19 periods, respectively. We considered a number of standard properties used in social network analysis to quantify opportunities for patient-patient transmission: degree centrality (links held by each node), betweenness centrality (times each node acts as the shortest 'bridge' between two other nodes), closeness centrality (how close each node is to other nodes in network), Eigenvector centrality (node's relative influence on the network), and clustering coefficient (degree to which nodes cluster together) in the first five panels (left to right, top to bottom);(Newman, Networks: An Introduction, 2010). Each panel shows the frequency distributions of these properties. These properties generally did not have a normal distribution and therefore we used a Mann Whitney U test on random subsets of nodes in these networks to compare pre- and post-COVID properties. The mean effect size (E) and P-values are shown for each metric in parenthesis. We concluded that all of these pre- versus post-COVID-19 network properties were statistically similar. (2) Properties of the ego networks (networks induced by each node and its 'one-hop' neighbors). We considered density (average number of neighbors for each node;higher density generally favors lower outbreak threshold) and degree centrality (number of links held by each node) of ego networks (middle right and bottom left panels). The mean effect size and p-values using the Mann Whitney test are shown in parenthesis;there were no statistically significant differences in these properties in the pre- and post-COVID networks. (3) Aggregate properties of the weekly networks, consisting of all the interactions within a week. We considered modularity (measure of how the community structure differs from a random network;higher modularity means a stronger community structure and lower likelihood of transmission) and density (average number of neighbors each node;higher density generally favors lower outbreak threshold) of the weekly networks (bottom middle and bottom right panels). The modularity in the post-COVID weekly networks was slightly lower (i.e., it has a weaker community structure, and the network is more well mixed), while density was slightly higher, the differences of which were statistically significant;a caveat is that these are relatively small datasets (about 40 weeks). These differences (higher density, and better connectivity) both increase the risk of transmission in the post-COVID networks. In summary, the post-COVID networks either have similar properties as the pre-COVID networks, or had changes which are unlikely to have played a role in reducing MRSA transmission. Conclusion. A significant reduction in post-COVD-19 MRSA transmission may have been an unintended positive effect of enhanced infection control measures, particularly hand hygiene and increased mask use. A modest (11.6%) post-COVD-19 reduction in surveillance testing may have also played a role. Despite pandemic-related cohorting and census fluctuations, most network properties were not significantly different post-COVID-19, except for aggregate density and modularity which varied in a directio that instead favored transmission;therefore, HCP-based networks did not play a significant role in reducing MRSA transmission. Multivariate modeling to isolate relative contributions of these factors is underway. Figure 6. Surveillance Testing and Clinical Culturing Post-COVD-19, there was a modest (11.6%) but statistically significant reduction in surveillance PCR testing (42.4 mean tests per 1,000 patient days pre- versus 37.5 post-COVD-19;P<0.002). There was not a statistically significant difference in rates of clinical cultures sent (2.48 cultures per 1,000 patient days pre- versus 2.23 post-COVD-19;P=0.288).

Caregiver-reported delay in presentation to pediatric emergency departments for fear of contracting COVID-19: A multinational cross-sectional study

BACKGROUND: Visits to pediatric emergency departments have decreased up to 75% during the pandemic, with corresponding increases in high acuity visits, inpatient admissions, and intensive care unit admissions compared to historical cohorts. OBJECTIVES: To determine if caregivers of children presenting to pediatric emergency departments (EDs) during the COVID-19 pandemic are delaying presenting to care for fear of contracting COVID-19. Secondary objectives were to: a) evaluate potential predictors of delay;b) describe the proportion of children whose symptoms worsened during time to presentation. DESIGN/METHODS: A multicentre cross-sectional survey study of caregivers accompanying their children aged 0-19 years old to 16 pediatric EDs in 6 countries, from May-June 2020. An anonymous online survey, completed by caregivers via RedCAP, included caregiver and child demographics, presenting complaints, if they delayed presentation and whether symptoms worsened during this interval, as well as caregiver concerns about the child or caregiver having COVID-19 at the time of ED visit. RESULTS: Of 1543 caregivers completing the survey, 287 (18.6%) reported a delay in seeking ED care due to concerns of contracting COVID-19 in the hospital. Of those, 124 (43.2%) stated their child's symptoms worsened during the waiting interval. Caregiver relationship to child [mother] (OR 1.85, 95% CI 1.27-2.76), presence of chronic illness in child (OR 1.78. 95% CI 1.14-2.79), younger age of caregiver (OR 0.965, 95% CI 0.943-0.986), and caregiver concerns about lost work during the pandemic (OR 1.08, 95% CI 1.04-1.12), were independently associated with a COVID-19-related delayed presentation in multivariate regression analysis. CONCLUSION: Almost one in five caregivers reported delaying ED presentation for their ill or injured child, specifically due to fear of contracting COVID-19 while in hospital. Mothers, younger caregivers, caregivers of children with chronic illness, and those concerned about lost work were at highest risk for delay.

Mortality in organ transplant recipients with COVID-19 compared to non-transplant or waitlisted patients: A meta-analysis

Purpose: Organ transplant recipients (OTR) are considered at high risk for adverse outcomes from COVID-19. However, mortality rates range from <5% to >30%. Some studies found that OTR have comparable outcomes with non-transplant patients, whereas other investigators reported higher mortality rates. To our knowledge, there are no published meta-analyses comparing outcomes between OTR and nontransplant patients with COVID-19. Methods: Two independent abstractors conducted a systematic search of PUBMED and EMBASE databases, references of articles retrieved, and major transplantation journals. We included studies published between 12/1/19 and 2/11/21, and performed a study-level random-effects meta-analysis with pooling of all-cause mortality, comparing separately OTR with non-transplant and waitlisted patients. Results: We included 26 studies with a total of 3,331 OTR. 83% were kidney, 8% liver, 6% heart and 3% lung transplant recipients. 66.3% were men. OTR had higher mortality compared to controls, however the difference did not reach statistical significance, and heterogeneity was high (Fig. 1). When analyzing studies evaluating OTR and controls that were matched for potential confounders, the difference in mortality was statistically significant, with a marked decrease in heterogeneity and risk of publication bias (Fig. 2). OTR did not have significantly higher mortality compared to waitlisted patients, but, again, heterogeneity was high (Fig. 3). Conclusions: OTR with COVID-19 seem to have higher mortality rates compared to immunocompetent individuals, but not waitlisted patients. OTR should be considered a high priority group for preventive and therapeutic interventions.

Use of 5a-reductase inhibitors is associated with lower risk of infection with SARS-CoV-2

INTRODUCTION AND OBJECTIVE: The TMPRSS protein serves as a host co-receptor for the SARS-CoV-2 virus that causes COVID-19 and is present in both prostate and lung tissue. This protein is known to be androgen regulated in the prostate, however, there is conflicting data on whether it is also androgen regulated in the lung, an important site for COVID-19 infection. Two randomized controlled trials have shown 5a-reductase inhibitors (5aRI) reduced the severity of COVID-19 symptoms in infected men, and reduced the likelihood of hospitalization. In the present study, we assessed the effect of 5aRI use on risk of community acquired COVID-19 infection. METHODS: All men without prostate cancer included in an institutional prospective registry of all patients tested for SARS-CoV-2 between March 8, 2020 and February 15, 2021 were included. Patients in the 5ARI cohort were matched at a 1:1 ratio to those not on 5ARI based on demographics and comorbidities that are known to increase the risk of infection. Exact matching was performed on race, diabetes, hypertension, coronary artery disease and immune suppressive disease. The main outcome measures were the effect of 5aRI use on the rate of SARS-Cov-2 positivity and disease severity as measured by hospitalization, ICU admission, and death. RESULTS: 60,474 males without prostate cancer diagnosis were initially selected, of which 1,079 were on 5ARI (1.8%). The matched cohorts included 1,075 on 5ARI and 1,075 non-5ARI, aged 21 to 99 years (Fig. 1). Of all the demographics and risk factors none were significantly different between the 5ARI groups in the matched cohorts. Risk for SARS-CoV-2 was significantly lower in the 5ARI group (OR 0.82, 95% CI 0.69-0.97, p=0.024, Table). Multivariable logistic regression analysis based on the entire data before matching reached the same conclusion. CONCLUSIONS: Men without prostate cancer taking a 5aRI are at lower risk for community acquired COVID-19 infection.