A two-ward acute care hospital outbreak of SARS-CoV-2 delta variant including a point-source outbreak associated with the use of a mobile vital signs cart and sub-optimal doffing of personal protective equipment.

BACKGROUND: The arrival of the Delta variant of SARS-CoV-2 was associated with increased transmissibility and illness of greater severity. Reports of nosocomial outbreaks of Delta variant COVID-19 in acute care hospitals have been described but control measures varied widely. AIM: Epidemiological investigation of a linked two-ward COVID-19 Delta variant outbreak was conducted to elucidate its source, risk factors, and control measures. METHODS: Investigations included epidemiologic analysis, detailed case review serial SARS-CoV-2 reverse transcriptase-polymerase chain reaction (RT-PCR) testing of patients and healthcare workers (HCWs), viral culture, environmental swabbing, HCW-unaware personal protective equipment (PPE) audits, ventilation assessments, and the use of whole genome sequencing (WGS). FINDINGS: This linked two-ward outbreak resulted in 17 patient and 12 HCW cases, despite an 83% vaccination rate. In this setting, suboptimal adherence and compliance to PPE protocols, suboptimal hand hygiene, multi-bedded rooms, and a contaminated vital signs cart with potential fomite or spread via the hands of HCWs were identified as significant risk factors for nosocomial COVID-19 infection. Sudden onset of symptoms, within 72 h, was observed in 79% of all Ward 2 patients, and 93% of all cases (patients and HCWs) on Ward 2 occurred within one incubation period, consistent with a point-source outbreak. RT-PCR assays showed low cycle threshold (CT) values, indicating high viral load from environmental swabs including the vital signs cart. WGS results with ≤3 SNP differences between specimens were observed. CONCLUSION: Outbreaks on both wards settled rapidly, within 3 weeks, using a `back-to-basics' approach without extraordinary measures or changes to standard PPE requirements. Strict adherence to recommended PPE, hand hygiene, education, co-operation from HCWs, including testing and interviews, and additional measures such as limiting movement of patients and staff temporarily were all deemed to have contributed to prompt resolution of the outbreak.

Assessment of conservations actions for the critically endangered spotted handfish (Brachionichthyidae), following curation of data collected by multiple investigators into a long-term time-series

Multi-decadal datasets for endangered species that track both populations and performance of management interventions are rare. One such dataset is for the critically endangered Spotted handfish, a species which has been used as a conservation model for the most endangered of the marine bony fish families the Brachionichthyidae. We assessed a 23-year, multi-site, time-series of population density surveys for the spotted handfish as well as a conservation intervention, the planting of ∼14,000 artificial spawning habitats (ASH). Data ownership spanned multiple Principal Investigators (PIs) and key data and covariates, such as monitoring and interventions, were often documented within personal files and difficult to access grey literature. We consolidated and curated these data, identifying gaps in the time-series and their causes and isolating confounding factors before we assessed population trends and the effectiveness of ASH planting. Both funding gaps and the 2020 Covid-19 lockdown produced breaks in the time-series. Breeding season observations mostly occurred in the early part of the dataset and there was also a change in method that needed to be considered when interpretating of the time-series. There was an overall decline in fish observed between 1997-2019 but, at least since 2014, there has been stabilisation of the population. Local populations of spotted handfish can either be highly dynamic or relatively stable but population increases were linked to the long-running, conservation intervention of planting ASH. As local populations can be dynamic, the functional life span of the ASH is limited and threats to the species - chronic, stochastic and climate - are ongoing, spotted handfish may be a ‘conservation reliant’ species that require annual site-specific monitoring, insitu interventions and existu captive husbandry.

Time, cost and carbon-efficiency: a silver lining of COVID era virtual urology clinics?

INTRODUCTION: The COVID-19 pandemic has demanded radical changes in service delivery. Our centre adopted the use of outpatient telemedicine to reduce close-contact interactions between patients and staff. We hypothesised that incidental gains may be associated with this. We evaluated financial, practical and environmental implications of substituting virtual clinics (VCs) for in-person urology outpatient appointments. METHODS: VCs were studied over a 3-month period. Based on patient-reported 'usual mode of transport' to the hospital, travel distance, time, petrol and parking costs, and the carbon emissions avoided by virtue of remote consultations were calculated. The underlying symptom/diagnosis and the 'effectiveness' of the VC were evaluated. RESULTS: Of 1,016 scheduled consultations, 736 (72.44%) were conducted by VCs over the study period. VCs resulted in an agreed treatment plan in 98.4% of a representative patient sample. The use of VCs was associated with an overall travel distance saving for patients of 31,038 miles (49,951km) over 3 months, with an average round-trip journey of 93.8 miles (151km) avoided for each rural-dwelling patient and an average financial saving of £25.91 (€28.70) per rural-dwelling car traveller. An estimated 1,257.8 hours of patient time were saved by avoidance of travel and clinic waiting times. Based on car-travelling patients alone, a 6.07-tonne reduction in carbon emissions was achieved with the use of VCs. CONCLUSIONS: In appropriate clinical circumstances, VCs appear to provide efficiency across a number of domains. Future healthcare may involve offering outpatients the option of telemedicine as an alternative to physical attendance.

Inflammatory Arthritis Post Covid-19 Infection

Presentation A 63-year-old man developed polyarthritis two months post recovery from COVID-19 infection. Diagnosis We concluded that the diagnosis was rheumatoid arthritis based upon raised inflammatory markers, positive rheumatoid factor and anti-cyclic citrullinated peptide antibodies. Treatment His symptoms improved with naproxen, corticosteroids, and methotrexate. Discussion We describe a patient with late onset rheumatoid arthritis possibly triggered or unmasked by COVID-19.

Common Lung Ultrasound Patterns in COVID-19: Correlation With Vital Signs and Inflammatory Biomarkers

Study Objectives: Subpleural consolidations and B-lines are common lung ultrasound (LUS) patterns seen in patients infected with COVID-19. The aim of this study is to describe how each LUS pattern correlates with patient vital signs and inflammatory biomarkers. Methods: This is a retrospective analysis of adult patients who presented to a large urban tertiary emergency department between May 1, 2020 and June 30, 2020. Patients were included in the study if they 1) presented with a respiratory chief complaint;2) met systemic inflammatory response syndrome (SIRS) criteria;3) were confirmed to have COVID-19 diagnosed by PCR;and 4) had point-of-care LUS performed and recorded in our imaging storage database. All clinical data was reviewed using the hospital's electronic medical records. The study was approved through the Institutional Review Board (IRB). All LUS images were obtained by emergency medicine physicians during the patient's emergency department course and were considered adequate if they included a minimum of 4 lung fields (bilateral anterior and posterior fields). Images were reviewed by ultrasound fellowship trained emergency physicians who were blinded to patient clinical outcome data. Images were assessed for subpleural consolidations, B-lines, and merging B-lines. LUS patterns were measured against patient vital signs (temperature, heart rate, respiratory rate, SpO2) and inflammatory biomarkers (CRP, D-Dimer, Ferritin, LDH, Procalcitonin) that were collected on initial hospital presentation. Linear correlations were performed using Pearson's r coefficient. Statistical analysis was completed with SPSS. Statistical significance was set at p< 0.05. Results: A total of 39 patients were included in the study. There were 33 men and 6 women ranging in age between 23 and 77 years old with a mean age of 49 years. Conclusions: Subpleural consolidations were found to have a positive correlation with increasing respiratory rate (p=0.046) and ferritin levels (p=0.0016). An increasing percentage of intercostal spaces with B-lines and confluent B-lines had a positivenegative correlation with ferritin levels (SpO2 (p=0.0021).016, 0.034). LUS did not correlate with inflammatory biomarkers. Lastly, merging B-lines were found to have a positive correlation with D-Dimer (p= 0.013) and ferritin levels (p=0.0015). Subpleural consolidations, B-lines, and mergingconfluent B-lines appear to correlate with elevated ferritin, a marker that has been associated with severe COVID-19 disease. Additionally, subpleural consolidations were found to correlate with worse clinical and respiratory status. These LUS patterns may be manifestations of more severe lung injury and systemic pathophysiological processes that take place over the course of a COVID-19 infection., specifically SpO2. However, furthersurprisingly these common LUS findings did not correlate with inflammatory lab values, which some studies suggest may have prognostic value for patients with COVID. Our study has limitations. This study specifically was limited to only patient's that had a recorded LUS image in our storage database. Therefore, many patients with covid may have been excluded. Our study highlights that there is a potential role for US in the assessment of disease severity. Further investigation is needed to determine prognostication of these LUS patterns.

Comparing an operation tomonitoring, with or without endocrine therapy (COMET): Aprospective randomized trial for low-risk DCIS (AFT-25)

Background: Approximately 50,000 women in the U.S. are diagnosed with ductal carcinoma in situ (DCIS)annually. Without treatment, it is estimated that 20-30% of DCIS will lead to invasive breast cancer. Currently, morethan 97% of women undergo surgery, with many also undergoing radiation. An alternative to surgery for low-riskDCIS is active monitoring (AM), an approach in which regularly scheduled mammography and physical exams areused to monitor breast changes and determine if, or when, surgery is needed. Trial design: COMET, a multicenterphase III prospective randomized trial, opened in the U.S. in June 2017 (clinicaltrials.gov reference: NCT02926911).The hypothesis is that management of low-risk DCIS using an AM approach does not yield inferior invasive breastcancer and/or quality of life outcomes compared to surgery. Eligibility criteria: Patients with a new diagnosis of unilateral, bilateral, unifocal, multifocal, or multicentric DCIS, or atypia verging on DCIS are eligible. Patients mustbe ≥40 years of age, have no contraindication for surgery, and pathologic confirmation of grade I/II DCIS. DCIS mustbe ER and/or PR≥ 10% and HER2-negative without invasion, diagnosed within 120 days of registration. Breasttissue, blood and imaging are collected at trial entry and if invasive cancer subsequently occurs, and are stored incentral repositories. Specific aims: The primary aim is to assess whether the 2-yr ipsilateral invasive breast cancerrate for AM is non-inferior to surgery. Secondary aims include comparison of 2-, 5-, and 10-yr mastectomy rate, contralateral invasive breast cancer rate, overall survival and invasive breast cancer-specific survival, as well as 5-and 10-yr ipsilateral invasive breast cancer rate between groups. Patient reported outcomes (PRO) using validatedtools are critical secondary endpoints, and will enable comparison of health-related quality of life and psychosocialoutcomes between surgery and AM groups at prespecified time points over a period of 5 years. Statisticalmethods: An accrual goal of 1200 was estimated using a 2-group test of noninferiority of proportions, with the 2-yrinvasive breast cancer rate in the surgery group assumed to be 0.10, including accounting for upstaging. Theprojected drop-out rate is 25%, for a total of 900 patients treated per allocation arm. The non-inferiority boundarywas set at 0.05. Based on a 1-sided un-pooled z-test, with alpha=0.05, a sample size of n=446 per group will have80% power to detect the specified noninferiority margin. Intention-to-treat analysis of the 2-yr invasive breast cancerrate will be conducted using all patients as randomized, and will be completed using Kaplan-Meier estimates,stratified by group, combined with Greenwood's confidence interval. Several sensitivity analyses (per protocol, as-treated, and instrumental variable) are also planned to account for loss of follow-up, rejection of randomizationallocation and withdrawals. Present and target accrual: Trial accrual as of 7/1/20 is 540 randomized patients from84 activated Alliance for Clinical Trials in Oncology sites. Despite logistical challenges posed by the COVID-19crisis, patients continue to be recruited to the COMET trial. Over 80% of patients have sample sets/images stored inthe tissue and image repositories. This trial will provide definitive clinical, quality of life and biomarker evidenceregarding the trade-offs of surgery vs AM in patients with low-risk DCIS.

The Impact of the COVID-19 Pandemic on Orthopaedic Surgery Residency Applicants During the 2021 Residency Match Cycle in the United States.

INTRODUCTION: The purpose of this study was to quantify the impact of the COVID-19 pandemic on rising fourth-year medical students' plans to apply to residency in orthopaedic surgery. METHODS: We conducted a survey of rising fourth-year medical students. Primary outcome was the change in students' plans to apply to residency in orthopaedic surgery as measured by Likert scale response. Secondary outcomes were students' concerns about applying to residency during the pandemic. RESULTS: A total of 462 students were planning to apply to residency in orthopaedic surgery. Women said that they were "less likely" to apply to orthopaedic surgery because of the pandemic (14.9% versus 5.5% of men, P < 0.001). Students identifying as Black/African American said that they were "less likely" to apply (16.9% compared with 8.8 of non-Hispanic White, P < 0.001). Students said that they had "somewhat fewer" or "many fewer" opportunities to get adequate exposure to orthopaedic surgery to make a specialty choice (88.9% of students). DISCUSSION: We support the development of robust student advising and mentorship networks to address the uncertainty inherent in applying to residency during a global pandemic and curtail the racial and sex disparities discovered in this survey.