Impact of the COVID-19 pandemic on working conditions and mental well-being of mental health professionals in the Netherlands: a cross-sectional study.

OBJECTIVES: To examine the extent of the impact of the COVID-19 pandemic on the mental health and well-being of mental health professionals (MHPs) in the Netherlands and understand their needs during the COVID-19 pandemic. DESIGN AND SETTING: A cross-sectional, mixed-methods study was conducted with MHPs from the Netherlands from June 2020 to October 2020, consisting of an online survey and three online focus group discussions. PARTICIPANTS: Participants were MHPs from various occupational groups (psychologists, social workers, mental health nurses, developmental education workers, etc). PRIMARY AND SECONDARY OUTCOME MEASURES: The online survey included questions about work-related changes due to COVID-19 perceived resilience to stress, changes in lifestyle behaviours and mental health symptoms. The focus group discussions focused mostly on work experiences during the first wave of the COVID-19 pandemic. RESULTS: MHP's reported an increase in experience workload during the pandemic (mean score 8.04 based on a scale of 1-10) compared to before the pandemic (mean score of 7). During the first wave of the pandemic, 50% of respondents reported increased stress, 32% increased sleeping problems and 24% increased mental health problems. Adverse occupational (eg, increased workload OR 1.72, 95% CI 1.28-2.32), psychological (eg, life satisfaction OR 0.63, 95% CI 0.52-0.75), lifestyle (eg, increased sleep problems OR 2.80, 95% CI 2.07-3.80) and physical factors (decline in physical health OR 3.56, 95% CI 2.61-4.85) were associated with a decline in mental health. Participants expressed significant concern in the focus group discussions about the duration of the pandemic, the high workload, less work-life balance and lack of contact with colleagues. Suggestions to improve working conditions included ensuring clear communication about guidelines and facilitating worker contact and support via peer-to-peer coaching where experiences can be shared. CONCLUSIONS: The current study indicates that MHP experienced a decline in mental health status during the first wave of the COVID-19 pandemic, which should be taken into consideration by employers, policymakers and researchers.

Prevalence of Depression in an Urban, Predominantly Black ESKD Population During the COVID-19 Pandemic

Background: The COVID-19 pandemic has had far-reaching implications in terms of physical and mental health ramifications, and minority communities have been disproportionately impacted;particularly, prevalence of depression increased. Throughout the pandemic, ESKD patients have continued thrice-weekly in-center hemodialysis sessions or home therapies. We explored whether there was an increase in depression prevalence after the start of the pandemic in our urban predominantly Black ESKD population. Method(s): We used data from social worker-administered PHQ-2 questionnaire depression screenings (required by Centers for Medicare & Medicaid Services) in eligible patients treated at four Emory University affiliated in-center dialysis units and three home dialysis units from 2018-2019 (pre-pandemic) to 2020-2021 (pandemic). Excluded from this study were patients with no assessments or incomplete assessments. Data were analyzed using chi-square tests comparing the prevalence of depression in pre-pandemic versus pandemic period. Result(s): In 2021, 91.5% of our patients were Black. There were 2433 in-center patient depression scores and 586 home dialysis patient depression scores. Excluded from the study were 1045 patients in the in-center and 214 patients in the home population. Of the 2433 patient scores analyzed in the in-center group, 1289 were pre-pandemic and 1144 were in the pandemic period. 155 (12%) in-center patient scores in the prepandemic period were classified as depressed while 128 (11.2%) in-center patient scores during the pandemic were classified as depressed (two-sided p-value 0.5272). Of the 586 home dialysis patient scores, 325 were pre-pandemic and 261 in the pandemic period. 71 (21.8%) patient scores in the pre-pandemic period had a positive depression screening while 29 (11.1%) patient scores during the pandemic period had depression (two-sided p-value 0.0006). Conclusion(s): We did not observe an increase in depression prevalence during the COVID-19 pandemic in in-center dialysis patients, and surprisingly observed a statistically significant decrease in depression among our home dialysis patients. The decrease in depression in our home dialysis patients during the pandemic may reflect being at home is a protective mechanism, and this observation should be further investigated.

COVID-19 Infection in Dialysis Patients: Efficacy of Vaccination

Background: End stage kidney disease (ESKD) patients are particularly susceptible to poor outcomes from Covid-19 infection (C19). Vaccination has been the cornerstone of mortality prevention. We examine the efficacy of C19 vaccine in ESKD patients. Method(s): All patients dialyzed at Emory dialysis centers from December 1, 2020 until February 2022 represent the study population. Date of completed vaccines series was recorded. Confirmed C19 cases were also registered. Time from vaccination to C19 and from C19 to death was recorded. Mortality risk was compared between vaccinated and unvaccinated patients. Patients that received vaccination after an episode of C19 were excluded from the analysis (n=89). Result(s): 935 patients received maintenance dialysis during the study period. 68% completed 2 doses of C19 vaccine. 46% of vaccinated patients received a booster dose after 294 days (IQR: 251-273) of completing the primary vaccination series. Non-vaccinated patients were younger (55 vs 60y/o), with shorter dialysis vintage (1.0 vs 2.8 years). The proportion of home and in-center dialysis was similar among vaccinated and unvaccinated patients. The prevalence of diabetes, CHF, PVD, COPD, atrial fibrillation, and previous transplants was also similar. 71 vaccinated patients died during follow up (11%) after 196 days (IQR 122-290), compared to 70 in the non-vaccinated group (24%) after 86 days (IQR 39-166), p<0.001. Adjusting for age, dialysis vintage, diabetes and CHF, ESKD vaccinated patients had a 78% reduction in mortality risk (A). 73 vaccinated patients (11%) acquired C19 after 250 days (IQR 150-288) compared to 48 unvaccinated patients (16%) who acquired C19 after 64 days (IQR 30-215), p<0.001. The mortality odds ratio after C19 infection was 3.9 [CI: 1.3-11.9] for unvaccinated patients 30 days post infection, 4.7 [CI: 1.7-14.2] at 60 days and 4.1 [CI: 1.6-11.5] at 90 days (B). Conclusion(s): Vaccination against C-19 infection resulted in a 78% reduction of mortality risk in patients receiving dialysis. Non-vaccinated patients diagnosed with C19 had higher mortality rates than vaccinated patients (OR 4.1 at 90 days post infection).

Effect of COVID-19 Vaccination Drive on COVID-19 Outcomes in Urban Dialysis Centers

Vaccination is a critical strategy to prevent COVID-19. We describe the effects of a vaccine drive implemented in Emory Dialysis centers on COVID-19 vaccine uptake, infection rates and outcomes. Emory Dialysis, serving an urban population, conducted a COVID-19 vaccination drive (i.e. vaccine education and onsite vaccine administration) across its 4 dialysis centers (~750 patients) from March—April 2021. Monthly COVID-infection and vaccination rates were tracked from March 2020—September 2021. We assessed the effect of the drive on the COVID-19 vaccine uptake, infection rates and outcomes including hospitalizations and 30-day mortality. Patients were included if they were diagnosed with COVID-19, 14 days after the vaccination drive (to reflect fully vaccinated status). Patients were stratified by vaccination status and descriptive statistics were performed. From March 2020–April 2021, monthly COVID-19 infection rates were 0.41—4.97% and vaccination rates were 0–6%. From May–September 2021 (post-vaccination drive), the monthly COVID-19 infection rates ranged from 0–2.50% and vaccination rates were 67.4–76.1%. In the post-vaccination period, 34 patients were diagnosed with COVID-19;26 were fully vaccinated and 8 were unvaccinated. Among the 34 patients, the median age was 57 years [interquartile range (IQR) 47–73], 29% were female and 79.4% were Black. Compared to unvaccinated group, the vaccinated group was older (62 years [IQR 50-73] vs. 50 years [IQR 41-60], p=0.06), and had a higher prevalence of cardiovascular disease (46.2% vs. 25.0%, p=0.62);otherwise, patient characteristics were similar between the groups. Twelve patients (48.1%) in the vaccinated group vs. 6 patients (75.0%) in the unvaccinated group were hospitalized for COVID-infection (p=0.26). Three patients (11.5%) in the vaccinated group vs. 2 patients (25%) in the unvaccinated group (p=0.35) died within 30-days of COVID-19 diagnosis. Providing vaccinations at dialysis centers may improve COVID-19 vaccine uptake and outcomes. Studies evaluating the long-term effects of vaccination programs in dialysis centers are needed.

Understanding self-harm urges and behavior amongst non-binary young adults: A grounded theory study

Introduction: This study aims to gain a greater understanding of self-harm amongst non-binary young adults and what helps to manage these urges. Method: Data was collected from 11 participant interviews and analyzed in line with grounded theory principles. Results: Findings highlighted how factors associated with growing up feeling outside of the binary, family discord, and the pain of living in a cisnormative society were associated with self-harm. Results describe what helps to manage selfharm and the impact of COVID-19. Conclusion: Findings extend existing research and offer clinical implications and highlight a need for increased understanding and acceptance of non-binary identities.

SARS-CoV-2 Causes Lung Inflammation through Metabolic Reprogramming and RAGE.

Clinical studies indicate that patients infected with SARS-CoV-2 develop hyperinflammation, which correlates with increased mortality. The SARS-CoV-2/COVID-19-dependent inflammation is thought to occur via increased cytokine production and hyperactivity of RAGE in several cell types, a phenomenon observed for other disorders and diseases. Metabolic reprogramming has been shown to contribute to inflammation and is considered a hallmark of cancer, neurodegenerative diseases, and viral infections. Malfunctioning glycolysis, which normally aims to convert glucose into pyruvate, leads to the accumulation of advanced glycation end products (AGEs). Being aberrantly generated, AGEs then bind to their receptor, RAGE, and activate several pro-inflammatory genes, such as IL-1b and IL-6, thus, increasing hypoxia and inducing senescence. Using the lung epithelial cell (BEAS-2B) line, we demonstrated that SARS-CoV-2 proteins reprogram the cellular metabolism and increase pyruvate kinase muscle isoform 2 (PKM2). This deregulation promotes the accumulation of AGEs and senescence induction. We showed the ability of the PKM2 stabilizer, Tepp-46, to reverse the observed glycolysis changes/alterations and restore this essential metabolic process.

Predictors of Burnout, Job Satisfaction, and Turnover Among CRNAs During COVID-19 Surging

This study examined the relationship between demographic factors, job characteristics, relations between Certified Registered Nurse Anesthetists (CRNAs) and administration, and conflict between work and personal responsibilities using structural equation modeling to determine levels of burnout, job satisfaction, and turnover intention among CRNAs during COVID-19 surges. Survey data were collected from CRNAs practicing in Massachusetts and Texas through an email link distributed by their respective state associations of nurse anesthetists. Results of the structural equation modeling showed a decrease in feedback, low CRNA-administration relations scores, and prioritizing work over personal responsibilities were predictive of CRNA burnout. In addition, burnout levels were correlated with job satisfaction and turnover intention. Based on these findings, employers could decrease CRNA burnout and turnover by creating organizational strategies focused on improving job feedback, relationships between CRNAs and administrators, and work-life integration. Through these approaches, healthcare managers and leaders may support CRNA resiliency and retention, particularly during times of professional change, such as the COVID-19 pandemic.

Impacts of COVID-19 on the Early Care and Education Sector in California: Variations Across Program Types

The COVID-19 crisis has overwhelmed and weakened the United States early care and education (ECE) sector, jeopardizing a system that was already precariously situated atop a weak foundation. While multiple national- and state-level studies have highlighted the overwhelming impacts of the pandemic on the ECE sector, little has been reported about how much variation in impacts exists, and in what forms, within the ECE sector. Based on a statewide survey of 953 licensed care providers in California conducted in June 2020, this paper examines the impact of COVID-19 experienced by ECE providers, focusing on the variations between centers and family child care homes (FCCs) and among center-based programs. Results indicate that the challenges programs face differ greatly depending on program type and funding source. Compared to center-based programs, FCCs fared worse in most measures of economic hardship that directly impact individual providers with medium to large effect sizes. Centers were more likely than FCCs to struggle with reduced attendance and changes in program operations by medium to large effect sizes and report staffing challenges by small to medium effect sizes. Among the center-based programs, subsidized programs holding contracts with Head Start or the California Department of Education (such as state preschool programs) were more stable and better able to financially support their staff during the pandemic, with effect sizes ranging from medium to large. Centers receiving government subsidies in the form of vouchers were more likely to be negatively impacted by the pandemic compared to unsubsidized centers and Head Start and state-contracted centers. Implications for future research and policy are discussed in the context of addressing the complex delivery system of ECE services and supporting outcomes that are effective and equitable for children, families, and the ECE workforce.

Temporary changes in hemodialysis parameters in patients affected by COVID-19 infection: A visual guide

Background: ESKD patients on dialysis have been significantly affected by the COVID pandemic. By now, a substantial number of patients have survived the disease. We display graphically the temporary changes in dialysis parameters of patients that have survived COVID-19 infection. Methods: All patients receiving hemodialysis at Emory dialysis centers diagnosed with COVID-19 infection between 3/1/20 to 1/31/21 who survived for at least 3 months were identified. The date of COVID-19 diagnosis was used to time-reference dialysis parameters including duration of hemodialysis, weight, ultrafiltration, mean arterial pressure pre-dialysis, hemoglobin, albumin, calcium, phosphorus, potassium, serum bicarbonate, absolute lymphocyte count and Kt/V. The temporary behavior of these parameters is presented graphically. Data manipulation, analysis and graphical display was performed using R-software and tidyverse package. Results: 96 patients were identified. 82% were African-American with a median age of 64y/o. 52% were male and 60% were diabetics, The median time on dialysis was 2.5 years. All studied parameters showed a significant deviation from baseline measurements obtained in the 60 days prior to the diagnosis of COVID-19. The parameter with the least amount of change was Kt/V. In the subsequent 2 months after diagnosis, all of the parameters studied returned to baseline except for Potassium, that remained below premorbid levels 2 months after the COVID-19 diagnosis. These changes are presented in Figure 1. Conclusions: COVID-19 infection has a significant impact on hemodialysis parameters as presented in figure 1. The temporary variation of the most common parameters associated with COVID-19 infection presented in this study can be used as reference for patients, dieticians, and nephrologists caring for ESKD affected by COVID-19. (Figure Presented) .

Prevalence of vitamin D deficiency in a predominantly African-American hemodialysis patient population

Background: Vitamin D insufficiency and deficiency are common abnormalities and high risk groups include kidney disease patients and African-Americans. Recommendations on the evaluation of vitamin D levels in CKD and ESKD are ambiguous due to a lack of studies examining epidemiology and treatment. The COVID-19 pandemic has disproportionately affected minorities and has highlighted the need for evidence as studies have examined vitamin D deficiency as a risk factor for COVID-19 complications. We present a case series examining the prevalence of vitamin D deficiency in a predominantly African-American hemodialysis patient population. Methods: Retrospective chart review of all in-center hemodialysis patients at Emory Dialysis in Atlanta, GA. Data extracted from Sep to Nov 2020. We excluded any patients on home therapies. Serum 25(OH)vitamin D concentration total was analyzed. We defined vitamin D insufficiency as 20-29.9 ng/mL and vitamin D deficiency as a level<20 ng/ml. Results: Patients receiving in-center hemodialysis(n=615). Average length of time on dialysis was 5 years and average age was 59.4 years. Patients were 52.5% male(n=323). 91.5%(n=563) of patients were African-American. Mean calcium level for all patients was 8.73 mg/dL and PTH level of 554 pg/mL. Mean vitamin D in all patients was 26.32 ng/mL. 98%(n=603) of patients had a vitamin D level available. All patients with vitamin D level<30 ng/mL=412(68.3%) and all patients with vitamin D level<20 ng/ mL=244(40.5%). African-American patients with a vitamin D level was 552. African-American patients with vitamin D level<30 ng/mL=382 (69.2%) and African-American patients with vitamin D level<20 ng/ml=229(41.5%). Mean vitamin D in African-American patients 25.7 ng/mL and non-African-American patients 32.7 ng/mL, p=0.01. Conclusions: In comparison to others such as the DIVINE trial, we present a larger and more diverse cohort. In our study, African-Americans had a statistically significant lower vitamin D level. A case for replacing 25(OH) vitamin D even in ESKD patients is based on the action of vitamin D beyond mineral metabolism, especially with regard to autocrine regulation of immune function. Future directions include examining effects of treatment on PTH and study of vitamin D deficient patients' risks for adverse events like COVID-19 infection.

Outcome of hospitalized ESRD-COVID-19 (C19) infected patients

Background: Emory University affiliated hospitals serve the metro Atlanta area, where a significant number of C19 cases have ocurred. In this report we describe the outcomes of AKI and ESRD patients with confirmed C19 admitted to our health-system. Methods: All patients seen by Emory Nephrology at 2 tertiary referral and one county hospital were categorized as ESRD if they required dialysis prior to C19 infection, or AKI if they developed acute kidney injury as a result of C19 infection. Outcomes of interest included patient survival and discharge from the hospital. Admission to Intensive care unit and use of mechanical ventilation were recorded. Comorbid conditions and outpatient use of medications were analyzed. Results: From 3/1/20 to 5/26/20, 474 consecutive patients were seen in COVID-19 related consultation. 287 patients were considered PUI and eventually tested negative for C19. The remaining 187 patients were C19 positive by nasopharyngeal swab or tracheal aspirate and represent the study population for this report. There were 43 ESRD (23%) and 144 AKI (77%) patients. Age (64 vs 63 years), gender (63 vs 66% males) ethnicity (86 vs 82% African-americans) and comorbid conditions were similar in AKI and ESRD patients. AKI patients were more likely to be admitted to ICU (83 vs 35%) and to require mechanical ventilation (73 vs 20%) compared to ESRD patients (p<0.05). Figure 1 presents the outcomes based on the type of renal disease at presentation. The eGFR of AKI patients at time of admission was 50±34 ml/kg/m2. 84 AKI patients required dialysis during their hospitalization (52.5%). Conclusions: Patients with ESRD C19+ were less likely to require ICU admission or mechanical ventilation. Mortality of ESRD patients was 14% compared with 42% of AKI patients, (p<0.002). ESRD patients with C19 were also more likely to be discharged from the hospital compared to those with AKI. Despite similar demographics and comorbidities, hospitalized C19 AKI patients had worse mortality than those receiving chronic dialysis.

Quality improvement project: Examining urine sediment and microscopic findings in COVID-19 AKI patients

Background: The examination of the urine microscopy manually is common in the work-up of AKI. SARS-CoV-2 has been detected in urine samples of infected patients. There have been safety concerns about the handling of urine samples in patient under investigation and COVID-19 confirmed cases. Limitations in personal protective equipment have provided challenges. There has been limited reports of urine microscopic findings during the COVID-19 pandemic. We developed a QI project examining the urine sediment of COVID-19 AKI patients from digital pictures provided by the IRIS IQ200 Microscopy System. Methods: This QI project took place at Emory University Hospital Midtown. We retrospectively evaluated baseline characteristics, labs, and urine volume. The urinalysis and urine sediment were evaluated for each patient by digital images produced by the IRIS IQ200 Microscopy System. Results: A total of 17 African American patients with a mean age of 71±12.5 years (range, 55 to 98);64.7 % were female. Comorbidities included hypertension (94.1%), diabetes (58.8%), CAD (11.9%) and CKD (52.9%). Average serum creatinine was 3.1 mg/dL. 8 patients (47%) were oliguric;4 patients had FENa < 1%. 8 patients (47%) had 2+ proteinuria. 9 patients (52.9%) had a positive leukocyte esterase and all were nitrate negative. 8 patients (47%) had ATN with visible muddy brown casts. 6 patients (35%) had ≥ 5 rbc/hpf and 11 patients (65%) had ≥ 5 wbc/hpf. 8 patients (47%) had shock requiring vasopressor support, 8 patients (47%) required dialysis and 13 patients (76.5%) required mechanical ventilation. Conclusions: Urinalysis and urine microscopy are important in evaluation of AKI, and there is a paucity of data about findings in COVID-19 AKI patients. Without conclusive evidence of the infective potential of urine samples, it is much needed at this time to device a safe alternative to manual urine microscopic examination. Almost half of our patients had ATN and we were able to arrive at the diagnosis using digital images from this automated urine microscopy system. Use of such technology will help nephrologists safely examine urine sediments and minimize exposure to COVID-19.

Implementing COVID-19 infection control procedures in outpatient dialysis in an urban us population

Background: Emerging data reveal disparities in the burden and severity of disease among racial and ethnic minorities in the US. Emory Dialysis consists of 4 outpatient dialysis facilities, serving an older, urban and predominantly African-American population. These facilities are in counties with the highest number of COVID-19 cases in Georgia. We describe infection control measures implemented to prevent COVID-19 transmission, and the clinical characteristics of patients with COVID-19 in the facilities. Methods: Based on CDC's recommended guidance, we implemented the following infection control procedure between February and April 2020: 1) screening;triaging all patients, and separating patients with symptoms of COVID-19;2) monitoring staff for COVID-19 symptoms;3) limiting healthcare personnel in the facilities;4) universal masking in the dialysis units;5) conducting PPE re-trainings;6) assessing facility preparedness;7) separating high risk patients (nursing home residents);and 8) cohorting patients with COVID-19 to a dedicated dialysis shift. Results: Of the 745 patients followed at the Emory dialysis facilities, 18 (2.4%) were diagnosed COVID-19 between March 25-May 7, 2020. Among the 18 patients, 17 were receiving in-center hemodialysis and 1 was on peritoneal dialysis. The median age was 66.8 years (range 43-84) and 11 (61.1%) were female. Nine (50%) were residents of a skilled nursing facility. Sixteen (88.9%) patients had a diagnosis of hypertension, 10 (55.6%) had diabetes, and 10 (55.6%) had cardiac disease. Eight patients (44.4%) required hospitalization and 4 patients (22.2%) died from COVID-19 related complications. Two patients with COVID-19 were dialyzing at adjacent dialysis stations and the timing of their symptoms suggested possible transmission in the dialysis facility. In response, education, infection control audits and PPE re-trainings were conducted to bolster infection control practices. Conclusions: In a high-risk patient dialysis population, we successfully implemented recommended infection control measures to mitigate the spread of SARS-COV-2 in our facilities. Dialysis facilities must stay vigilant and monitor for possible transmission of COVID-19. Regular audits of infection control practices remains critical.