Missed and Lost to Follow-up Cases in HIV Positive Patients and the Impact of Lockdown During COVID-19 Pandemic on Adherence to Anti-retroviral Therapy at ART Center, Jhansi, Uttar Pradesh

Background: Anti-retroviral therapy (ART) for HIV has changed a highly fatal disease to a chronic manageable condition. National technical guidelines by NACO say that adherence of >95%(optimal) is required for optimal viral load suppression which is a challenge both for the patient and the health system.Objectives: This study was conducted to determine the reasons for missed and lost to follow-up (LFU) cases and to assess the impact of the COVID pandemic on ART adherence.Settings and Design: Cross-sectional study conducted at ART center, Jhansi.Methods and Material: 357 patients were administered a self-designed questionnaire after taking informed consent to enquire about the reasons for missing doses and LFU and whether they missed treatment during the lockdown.Statistical analysis used: the results were expressed in frequencies and percentages and appropriate statistical tests were applied.Results: 72% HIV patients had optimal adherence and 6.7% were on second-line treatment. Out of 357 patients, 56 had missed treatment and 10 were LFU. The main reasons for the missing were run out of pills, busy with other things and being away from home. The number of episodes of missed and LFU increased during the pandemic. The main problems faced were lack of transport (24), fear of catching the disease (7), no money to hire a vehicle (5).Conclusions: Constant monitoring and handholding of those with suboptimal adherence is required. Travel allowance to such patients and regular counseling will help to ensure adherence. Long-term solutions include vocational rehabilitation and awareness programs to reduce stigma and discrimination.

Prevalence and diagnostic significance of novel 12-lead ECG patterns following COVID-19 infection in elite soccer players

Background: Identification of athletes with cardiac inflammation following COVID-19 can prevent exercise fatalities. The efficacy of pre and post COVID-19 infection electrocardiograms (ECGs) for detecting athletes with myopericarditis has never been reported. We aimed to assess the prevalence and diagnostic significance of novel 12-lead ECG patterns following COVID-19 infection in elite soccer players. Method(s): We conducted a multicentre study over a 2-year period involving 5 centres and 34 clubs and compared pre COVID and post COVID ECG changes in 455 consecutive athletes. ECGs were reported in accordance with the International recommendations for ECG interpretation in athletes. The following patterns were considered abnormal if they were not detected on the pre COVID-19 infection ECG: (a) biphasic T-waves;(b) reduction in T-wave amplitude by 50% in contiguous leads;(c) ST-segment depression;(d) J-point and ST-segment elevation >0.2 mV in the precordial leads and >0.1 mV in the limb leads;(e) tall T-waves >=1.0 mV (f) low QRS-amplitude in >3 limb leads and (g) complete right bundle branch block. Athletes exhibiting novel ECG changes underwent cardiovascular magnetic resonance (CMR) scans. One club mandated CMR scans for all 28 (6%) athletes, despite the absence of cardiac symptoms or ECG changes. Result(s): Athletes were aged 22+/-5 years (89% male and 57% white). 65 (14%) athletes reported cardiac symptoms. The mean duration of illness was 3+/-4 days. The post COVID ECG was performed 14+/-16 days following a positive PCR. 440 (97%) athletes had an unchanged post COVID- 19 ECG. Of these, 3 (0.6%) had cardiac symptoms and CMRs resulted in a diagnosis of pericarditis. 15 (3%) athletes demonstrated novel ECG changes following COVID-19 infection. Among athletes who demonstrated novel ECG changes, 10 (67%) reported cardiac symptoms. 13 (87%) athletes with novel ECG changes were diagnosed with inflammatory cardiac sequelae;pericarditis (n=6), healed myocarditis (n=3), definitive myocarditis (n=2), and possible/probable myocarditis (n=2). The overall prevalence of inflammatory cardiac sequelae based on novel ECG changes was 2.8%. None of the 28 (6%) athletes, who underwent a CMR, in the absence of cardiac symptoms or novel ECG changes revealed any abnormalities. Athletes revealing novel ECG changes, had a higher prevalence of cardiac symptoms (67% v 12% p<0.0001) and longer symptom duration (8+/-8 days v 2+/-4 days;p<0.0001) compared with athletes without novel ECG changes. Among athletes without cardiac symptoms, the additional yield of novel ECG changes to detect cardiac inflammation was 20% (n=3). Conclusion(s): 3% of elite soccer players demonstrated novel ECG changes post COVID-19 infection, of which almost 90% were diagnosed with cardiac inflammation during subsequent investigation. Most athletes with novel ECG changes exhibited cardiac symptoms. Novel ECGs changes contributed to a diagnosis of cardiac inflammation in 20% of athletes without cardiac symptoms.

Maternal and Infant Outcomes Following Maternal Exposure to SARS-CoV-2 During Pregnancy in an Australian Cohort

Background: Infections during pregnancy can increase the risk for neurodevelopmental disorders in offspring. This study aimed to prospectively monitor children exposed in utero to SARS-CoV-2 from birth to 15 years of age with a secondary aim to identify biomarkers of neurodevelopmental impairments. Method(s): Women infected with SARS-CoV-2 during pregnancy and sociodemographic and age matched non-exposed women were recruited from Monash Health, Australia (N=112 mother-infant dyads). Demographics, biospecimens and clinical data are collected at multiple time points from birth-15 years using standardised sample collection and neurological and behavioural scales. We present here the birth data. Result(s): Mother-infant dyads are classified as;non-exposed, mild SARS-CoV-2 (limitation of activities) and severe SARS-CoV-2 (hospitalised). Edinburgh postnatal depression scale scores were significantly higher in severe SARS-CoV-2 vs. non-exposed mothers (p<0.05). Maternal attachment scores were unchanged. Hammersmith neonatal neurological assessment scores were unchanged across groups, as were anthropometric measures. Severe SARS-CoV-2 exposed infants had lower scores on the sensory profile 2 questionnaire auditory domain than non-exposed infants (p<0.05). Analysis of infant buccal DNA (Illumina MethylationEPIC BeadChip >850,000 CpGs, N=8) showed hypomethylation of the gene AFAP-1 (q value<0.0008), and hypermethylation of neurodevelopmental pathways;'dendrite morphology' and 'axogenesis' in SARS-CoV-2 infants vs. non-exposed. Conclusion(s): While most assessments show no group differences thus far, the severe SARS-CoV-2 exposed group are faring worse in terms of maternal mental health, infant auditory domains and infant hypermethylation of genes belonging to neurodevelopmental pathways. Follow up assessments at 1-15 years will inform as to whether these initial group differences are early signs of more severe neurodevelopmental outcomes. Funding Source: Other - One in Five Philanthropic organisation Keywords: SARS-CoV-2, Pregnancy, DNA methylation, in utero, Neurodevelopmental trajectoriesCopyright © 2023

Simulating Percentage of Workers Opting to Work from Home During the COVID-19 Pandemic Using N-Player Iterative Game Theory

The outbreak of the COVID-19 virus has led to several countries establishing guidelines asking citizens to stay secluded and at their homes as much as possible. This has a profound impact on the working lives in almost all professions. Hence, people have been advised to work from home. However, working from home has several limitations and on average will cause financial losses to an individual. This has given rise to a dilemma where each person has the choice of working from home or going outside with the incentive of earning more capital but also increasing the risk of capturing the virus. We have modeled this situation using an n-player game where each player is trying to maximize their payoff, i.e., trying to make as much money as possible but limiting the risk of catching the virus. We aim to predict the proportion of a population cooperating, i.e., the following work from home guidelines at a particular stage of spread. This project presents an algorithm to model the n-player game and has used actual COVID-19 case numbers from various Indian states to simulate the situation. © 2023, The Author(s), under exclusive license to Springer Nature Singapore Pte Ltd.

ICU Clinician Perspectives on Machine Learning and the Implementation of a Mechanical Ventilation Prediction Tool: A Single Center Survey Study

Rationale Although there is considerable interest in machine learning (ML) algorithms to improve patient care, implementation of these algorithms into practice has been limited. Our team developed and validated a deep learning algorithm to predict respiratory failure requiring mechanical ventilation in patients in the intensive care unit (ICU), including those with COVID-19. To help optimize implementation of this tool, we developed and disseminated a survey assessing ICU physician perspectives on the acceptability and feasibility of this tool at our institution. Methods We distributed an 8-item survey to 99 critical care trainees and faculty at our institution via email. The survey consisted of 6 multiple choice and 2 free response questions, with an ordinal scale of 1-5 used in perception-based questions. The survey was designed in accordance with international recommendations for web-based surveys. Our survey was reviewed for completeness by a team of critical care, machine learning, and implementation science experts. Data were collected over a 2- week period in May of 2021. This survey was anonymous and exempt from IRB review. Results Fifty-three critical care physicians (53.5% of providers contacted) started the survey, and of these, 88.7% (47/53) completed the survey. Fifty-nine percent (n=31) of respondents were attendings, 36% (n=19) fellows, and 3.7% (n=2) residents. Baseline knowledge of ML was low (mean= 2.40/5), with only 7.5% (n=4) of respondents rating their knowledge as a 4 or 5. Fifteen percent (n=8) had knowingly used an ML-based tool in their clinical practice. Confidence in predicting the need for mechanical ventilation due to COVID-19 (mean=3.57/5) was slightly lower than for respiratory failure due to all other causes (mean=3.89/5). Overall willingness to utilize an ML-based algorithm was favorable (mean=3.32/5). Factors most likely to increase likelihood of utilization were “high quality evidence that it outperformed trained clinicians” (mean=4.28/5), “transparency of the data utilized” (mean= 4.13/5), and “limited workflow interruption” (mean=4.09/5). Shared concerns from participants included “alarm fatigue” and “workflow interruption.” Conclusion The results suggest that ICU physicians have had limited exposure to ML-based tools, but feel such a tool would be beneficial in the context of predicting need for mechanical ventilation in ICU patients and those with COVID-19. Evidence of the tool's efficacy and data transparency were high priorities for respondents, and there was concern over workflow interruptions. This survey provided a baseline assessment of physician acceptance of a novel ML-based tool, which will be crucial in optimizing its implementation into clinical practice at our institution.

A case of COVID-19 induced myocarditis in a healthcare-worker

Case report-IntroductionThe most recognised presentation of SARS-CoV-2 infection thus far has been respiratory, with hypoxia secondary to bilateral pneumonia and severe acute respiratory distress syndrome as a result of the host response to the virus.We describe the investigation and management of a case of severe life threatening myocarditis, with no respiratory symptoms, occurring in a young healthcare-worker during the early pandemic.Case report-Case descriptionA 37-year-old male healthcare-worker presented with dizziness, fever, and diarrhoea. He had no previous medical history. A month prior he had experienced a 5-day fever which self-resolved.On presentation, he was in cardiogenic shock with raised temperature. Blood tests demonstrated lymphocytopenia, raised troponin (peak 490ng/L) and BNP>35,000ng/L. He was transferred directly to critical care.Repeated PCR-swab testing for SARS-CoV-2 were negative. All other viral-testing and autoimmune screen were negative. ECG showed sinus-rhythm and CT-chest demonstrated lower-lobe consolidation with pleural-effusions.Echocardiogram revealed significantly impaired biventricular-function with LVEF of 21%. He had evidence of LV-wall thickening, bi-atrial dilation and raised pulmonary-artery systolic pressures. Despite IV antibiotics for pneumonia and shock-dose hydrocortisone 50mg QDS, he deteriorated requiring two inotropes. He was discussed with the ECMO-team at a tertiary-centre who suggested referral to our centre for consideration of immunosuppression and the patient was transferred.Serology was sent for SARS-CoV-2 to GOSH on a research basis as at the time there was not commercially available or approved assay.Cardiovascular Magnetic Resonance (CMR) was delayed due to inability to lie flat. After much discussion (Pre-RECOVERY trial results) 0.75mg/kg prednisolone was started with rapid effect. Inotropes were weaned within 24 hours with subsequent step-down to a cardiac ward. CMR-imaging confirmed myocarditis with characteristic tissue characterisation (raised T1/T2 mapping) and patchy late gadolinium-enhancement. Serial echocardiograms and serum cardiac biomarkers all improved in keeping with the clinical picture. The serological result returned and revealed the presence of the SARS-CoV-2 IgG.ACE-inhibitors, beta-blockade and diuretics were utilised to manage secondary heart failure from myocarditis. He was discharged on weaning oral prednisolone with close follow-up from the rheumatology and cardiology teams. Blood tests 1-month post-discharge demonstrated normalisation of troponin and BNP. Repeat CMR demonstrated normalisation of LV function with no evidence of oedema or myocarditis, with only residual late gadolinium-enhancement.Case report-DiscussionThis previously healthy young man presented during the initial peak of the COVID-19 pandemic and had considerable occupational exposure. At that point, although multiple confirmed cases of this condition had been identified, experience was still limited regarding extra-pulmonary manifestations.Since that time our understanding of the variability of COVID-19 has become apparent. Literature describes a variety of presentations beyond pulmonary including cardiac, ENT, neurological and gastrointestinal, as well as systemic manifestation including hyperinflammatory states and vasculitis.Myocarditis was identified at an early stage from imaging and blood tests, and this was presumed to be likely viral in origin. At that time, there were limited case reports of COVID-19 induced myocarditis, although this remained a differential once routine viral-screening returned negative. Repeated viral swabs for COVID-19 returned negative, however it was noted that he initially did have symptoms a month prior, and it was unclear whether his acute presentation was related to active COVID-19 infection or the sequelae of this. Serum antibody tests were sent to a specialist laboratory, and this ultimately confirmed previous COVID-19 exposure.The decision was made to implement high-dose prednisolone therapy to manage what was felt to be a li ely secondary inflammatory phenomenon of COVID-19 at a time when this was not really recognised. There was initial caution regarding this approach due to previous significant negative outcomes of steroid use in the SARS and MERS pandemics.In the subsequent period after this gentleman's case, the preliminary findings from the RECOVERY trial were made available, from which national guidance advises dexamethasone as the only current licensed therapy in managing COVID-19 in certain circumstances. Use and subsequent recovery following high-dose prednisolone suggests similar principles with this treatment, as well as managing cases who may present with non-pulmonary involvement of COVID-19.Case report-Key learning pointsOur experience in this case suggests multiple factors from which we can learn from, although since the time of this gentleman's presentation, a greater understanding of COVID-19 has already highlighted key areas of learning.For this case, the recognition of possible myocarditis without respiratory symptoms as among the possible presentations of COVID-19 is notable. We were able to utilise different methods of imaging to assess the extent of cardiac inflammation and cardiac function. Of highlight would be through use of Cardiovascular Magnetic Resonance, which was implemented as part of the initial diagnostic process, as well as ongoing monitoring post-discharge. With this method we can identify subtle changes of the myocardium which can help detect early relapse, and in future may be of significance for diagnosis and monitoring of potential future COVID-19 associated myocarditis.As we hope to one day move towards a post-COVID-19 global climate, perhaps the most important learning point is the possibility of delayed organ/systemic manifestation secondary to COVID-19 infection. For this case, the presumption is that he may have developed the primary infection 1 month prior to presentation. The context of repeated negative PCR-swab results, but the subsequent confirmation of prior exposure on antibody testing would potentially support this. His first presentation appeared to be a mild self-limiting illness, although his later acute presentation was that of significant potential risk, which fortunately he was able to recover from. This however highlights a particular concern regarding the long-term impact of COVID-19 not just on chronic co-morbidity such as long term cardiac failure or respiratory disease, but also the potential re-presentation of those who are deemed to have fully recovered from the virus. As time continues following the first wave of cases, we must remain vigilant of future complications yet to manifest.

Impact of COVID-19 pandemic restrictions on pregnancy duration and outcome in Melbourne, Australia.

OBJECTIVE: To investigate the effect of restriction measures implemented to mitigate severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) transmission during the coronavirus disease 2019 (COVID-19) pandemic on pregnancy duration and outcome. METHODS: A before-and-after study was conducted with cohort sampling in three maternity hospitals in Melbourne, Australia, including women who were pregnant when restriction measures were in place during the COVID-19 pandemic (estimated conception date between 1 November 2019 and 29 February 2020) and women who were pregnant before the restrictions (estimated conception date between 1 November 2018 and 28 February 2019). The primary outcome was delivery before 34 weeks' gestation or stillbirth. The main secondary outcome was a composite of adverse perinatal outcomes. Pregnancy outcomes were compared between women exposed to restriction measures and unexposed controls using the χ-square test and modified Poisson regression models, and duration of pregnancy was compared between the groups using survival analysis. RESULTS: In total, 3150 women who were exposed to restriction measures during pregnancy and 3175 unexposed controls were included. Preterm birth before 34 weeks or stillbirth occurred in 95 (3.0%) exposed pregnancies and in 130 (4.1%) controls (risk ratio (RR), 0.74 (95% CI, 0.57-0.96); P = 0.021). Preterm birth before 34 weeks occurred in 2.4% of women in the exposed group and in 3.4% of women in the control group (RR, 0.71 (95% CI, 0.53-0.95); P = 0.022), without evidence of an increase in the rate of stillbirth in the exposed group (0.7% vs 0.9%; RR, 0.83 (95% CI, 0.48-1.44); P = 0.515). Competing-risks regression analysis showed that the effect of the restriction measures on spontaneous preterm birth was stronger and started earlier (subdistribution hazard ratio (HR), 0.81 (95% CI, 0.64-1.03); P = 0.087) than the effect on medically indicated preterm birth (subdistribution HR, 0.89 (95% CI, 0.70-1.12); P = 0.305). The effect was stronger in women with a previous preterm birth (RR, 0.42 (95% CI, 0.21-0.82); P = 0.008) than in parous women without a previous preterm birth (RR, 0.93 (95% CI, 0.63-1.38); P = 0.714) (P for interaction = 0.044). Composite adverse perinatal outcome was less frequent in the exposed group than in controls (all women: 2.1% vs 2.9%; RR, 0.73 (95% CI, 0.54-0.99); P = 0.042); women with a previous preterm birth: 4.5% vs 8.4%; RR, 0.54 (95% CI, 0.25-1.18); P = 0.116). CONCLUSIONS: Restriction measures implemented to mitigate SARS-CoV-2 transmission during the COVID-19 pandemic were associated with a reduced rate of preterm birth before 34 weeks. This reduction was mainly due to a lower rate of spontaneous prematurity. The effect was more substantial in women with a previous preterm birth and was not associated with an increased stillbirth rate. © 2021 International Society of Ultrasound in Obstetrics and Gynecology.

The Use of the Alveolar Gas Meter for Assessment of Gas Exchange Abnormalities in COVID-19

Introduction: COVID-19 pneumonia varies in clinical expression from asymptomatic to severe ARDS. In early COVID-19, some patients have subtle abnormalities and their clinical trajectory is often unclear. We used an alveolar gas meter (AGM), which is designed to measure gas exchange parameters non-invasively while obviating the need for arterial blood gas measurement. The AGM has previously been compared to arterial blood gas analysis with the suggestion that the oxygen deficit by the AGM provides a useful surrogate to the alveolar to arterial oxygen difference (AaDO2) and it is sensitive to minor changes in pulmonary gas exchange. We sought to test the hypothesis that the AGM could be a useful instrument to identify COVID-19 patients at risk of deterioration before obvious respiratory failure had ensued. Methods: We identified 13 patients in the emergency department or non-ICU medical ward who were COVID-19 positive or strongly suspected to be COVID-19 positive. We enrolled patients with informed consent who did not require high dose oxygen. In patients with low dose oxygen, we removed supplemental oxygen with IRB consent to study room air gas exchange. Data were analyzed using Microsoft Excel and an unpaired, two-tailed student's t-test with equal variance was performed to assess for statistical significance between means. Results: Among the 13 patients enrolled, 12 were COVID positive, 5 were discharged home, and 8 were admitted. The AGM readings revealed an oxygen deficit of 55.4 ± 19.9 (mean ± SD) in the hospitalized patients vs. 31.6 ± 14.0 in those sent home (P=0.041). Among the 13 patients, 6 required supplemental oxygen whereas 7 did not. The AGM readings revealed an oxygen deficit of 65.0 ± 9.12 in those requiring supplemental oxygen vs. 30.1 ± 12.7 in those who remained on room air (P=0.00016). There was no statistically significant difference in the end-tidal CO2 between those who were admitted and discharged home or between those who required supplemental oxygen and those who did not. None of our participants required intubation, mechanical ventilation, high flow nasal cannula oxygen, or non-invasive ventilation. Conclusion: The AGM provides an early marker of gas exchange impairment in COVID-19. The data suggest that patients at risk of respiratory failure may be identified early, prior to obvious clinical deterioration in a rapid, non-invasive fashion. Such strategies may be helpful in the triage of patients or for enrolling high risk patients into interventional clinical trials.

The effect of steroid dosing on risk of secondary infection in COVID-19 critically ill patients

Introduction: The COVID pandemic has led to devastating consequences for those afflicted. The use of dexamethasone has proven benefit, although the risks and benefits are not fully characterized nor is the optimal dose of steroid. The benefits of steroids may include reduced inflammation in patients with acute respiratory distress syndrome (ARDS), but the risk might include increased viral replication and/or risk of secondary infection. Using a retrospective review of our ICU experience (prior to RECOVERY NEJM publication) we sought to characterize the relationship between steroid use and secondary infections in COVID-19 patients in order to test the hypothesis that steroid dose may be associated with worse ICU outcomes in some patients. Methods: We conducted a retrospective review of our ICU experience from a large academic medical center. We defined secondary infection as positive bacterial or fungal culture from blood stream, urine or sputum deemed by the clinical team to require intervention. Among 130 consecutive patients who received critical care for COVID-19, we identified 41 who had received steroids in the ICU. Among these, 13 had received steroids prior to secondary infection (GP1) whereas 13 had secondary infection documented prior to receiving steroid (GP2) and 15 received steroids without secondary infection (GP3). Results: We observed mortality in all patients involved in this study (n=130) of 27.7%. Among patients who received steroids (n=41) of 29.3% vs. patients who never received steroids (n=89) of 27%. Mortality specific to the steroids groups was 15.4% for GP1 (n=13) vs. 53.8% for GP2 (n=13) vs. 20% for GP3 (n=15). Conclusions: We did not observe an impact of steroid dosage on the risk of secondary infection in a critically ill cohort of COVID-19 patients. We did observe a high mortality among patients who received steroids following documented secondary infection, but further work will be required to determine if this finding reflects confounding by indication i.e. whether steroids are a marker of sicker patients. Optimal steroid dosage in COVID remains unclear, but higher doses (as were given in the DExa-ARDS study) should be rigorously studied.

Inhalant use is associated with sleep quality and mental health during the COVID-19 pandemic

RATIONALE: Cigarette smoking and sleep quality are known to impact mental health considerably. As nicotine is a primary component of both cigarettes and electronic (e)-cigarettes, we launched a survey-based study in order to study the effects of e-cigarettes, conventional tobacco, and dual usage on mental health as well as sleep quality. We sent out this survey in the time of COVID-19 in order to assess the impact of nicotine-based inhalant use on sleep quality and mental health. We hypothesized that e-cigarette use impacts mental illnesses and sleep quality, which is exacerbated by the presence of additional stress such as a global pandemic. METHODS: We combined our established UCSD Inhalant Questionnaire with the Pittsburgh Sleep Quality Index (PSQI), Hospital Anxiety and Depression Scale (HADS), and Patient Health Questionnaire (PHQ-9). Participants were recruited through online advertisements posted to social media sites including Facebook, Craigslist, Reddit, and Twitter. Participants (n=554) were recruited in April 2020, and a subset (n=217) retook the survey in June 2020. The survey was broken up into four sections - past and current type of inhalant use (UCSD Inhalant Questionnaire), PSQI, HADS, and PHQ-9. All participants were incentivized via a weekly lottery for a gift card. RESULTS: Inhalant users reported worse sleep quality (PSQI, 6.74) when compared to non-smokers/non-vapers (PSQI, 5.72, p=0.02). Higher anxiety scores were associated with worse sleep quality (linear regression, r2=0.28, p<0.001). E-cigarette users and dual users of both e-cigarettes and conventional tobacco had higher anxiety scores (HADS anxiety;12.08 and 11.37, respectively) than non-smokers/non-vapers (7.94, p=0.028). Dual users were found to have higher depression scores relative to controls as well (HADS depression;7.42 versus 4.68, p=0.017). Sleep quality improved during the COVID pandemic from April 2020 (PSQI, 7.92) to June 2020 (PSQI, 6.10, p<0.0001). Interestingly, anxiety scores increased over the same period of time (HADS anxiety, 7.51 to 8.76, p<0.01). CONCLUSION: Our finding of diminished sleep quality in inhalant users is novel. Based on these data, we speculate that inhalant users may be more susceptible to sleep disturbances in the setting of a stressor, such as a global pandemic. Higher anxiety scores in e-cigarette and dual users, and higher depression scores in dual users, imply a direct relationship between inhalant use and mental disorders. Higher anxiety scores as the pandemic progressed may in theory reflect the lack of having an end in sight, or having loved ones affected by COVID-19.

Using apache longitudinally in ards to assess disease severity

Introduction: The acute physiology, age, chronic Health Evaluation (APACHE) II score has been used to assess risk of mortality in admitted intensive care unit (ICU) patients since 1985. There are few examples of a longitudinal correlation over time. As the scores rises from 0 to 71, risk of mortality increases. For this study, other scores were also considered - SOFA (Sequential Organ Failure Assessment) was excluded due to a lack of variable diversity and small range of values. APACHE III and IV are more complex scores with additional variables, such that calculating daily scores manually was impracticable. APACHE II has consistent calibration compared to III and IV. We assessed whether APACHE III and IV scores had any additional benefit over APACHE II. Methods: APACHE II score was used to determine clinical severity daily of sixteen critically ill COVID-19 patients and compared to daily changes in cytokine levels. If any studies were unavailable for a given day, data was pulled from a maximum of 24 hours before or after the day of interest. Although GCS (Glasgow Coma Scale) is a large part of the score, and difficult to assess in an intubated patient, however it contributed to documenting sedation and intubation state. Results: APACHE II score assessed clinical severity daily in COVID-19 more effectively relative to SOFA. The wide score range allowed comparison of patients without overlap, as compared to SOFA which has a range of 0-24. With a larger range of 0-71, we believe that it increased the sensitivity for detection of small changes in clinical status. We analyzed APACHE II in context of absolute neutrophil count, plasma cytokine levels, as well as neutrophil functional studies. For our study, APACHE II, not SOFA, was helpful in demonstrating changes in severity of illness, which correlated with some of these assessments. For example, APACHE II showed a significant linear correlation with pro-inflammatory cytokine IL-8 in plasma (r2=0.47, p=0.0017;Fig 1). Conclusion: APACHE II was able to define the severity of illness in COVID-19 patients on a daily basis. APACHE II score allowed us to tie immunophenotyping to clinical disease severity over time and was helpful in broadening our approach to data comparison with clinical status. This was a pilot study to assess the ability of APACHE II to track severity of illness, but in the future, we plan to correlate APACHE II in a larger cohort of a variety of ARDS patients.

Predicting peak and cumulative ventilator need for COVID-19 in the US: Development of an epidemiological model

Rationale: The COVID-19 pandemic has caused major challenges for healthcare. The availability of mechanical ventilators was particularly problematic early on, with discussion about the appropriateness of invasive mechanical (IMV) vs. non-invasive ventilation (NIV) in the management of COVID-19. Various prediction models were developed, but few projected COVID-19-related ventilator use. We aimed to estimate peak and cumulative IMV and NIV need in the US through May 2021. Methods: We used a modified Susceptible-Infected-Recovered model with four additional compartments: exposed (E), in-hospital NIV, in-hospital IMV, and NIV or CPAP (HNIV/CPAP) treated out-of-hospital, based on published ventilator use patterns for COVID-19. Three scenarios (best-, moderate-, and worst-case) were modeled to reflect levels of intervention (e.g., shelter-in-place) effectiveness and compliance. Results included initial peak date, peak ventilator events, ventilator shortfall and timing of subsequent waves. Model performance was compared with estimates of IMV use back-calculated from observed mortality data, assuming a 75% mortality rate for patients on an IMV in the ICU based on published estimates. Results: At the start of the pandemic, the US was estimated to have 62,188 full-featured IMV;22,976 NIV;88,462 non full-featured devices in hospitals for use as surge devices;plus 12,700 in the Strategic National Stockpile. The moderate-case scenario aligned most closely to back-calculated IMV use based on observed mortality, and suggested that initial peak ventilator need occurred around May 1, 2020, requiring 94,472 inhospital ventilators (40,930 IMV;53,541 NIV) and 7,931 HNIV/CPAP. In this scenario, the US had sufficient IMV (+21,258) but there may have been a shortfall of 30,565 in-hospital NIV, triggering surge use in some locations. The US is estimated to have 1,915,217 cumulative ventilator use events by May 2021, of which 688,549 are IMV events and 1,226,668 are NIV+HNIV/CPAP events. At least two subsequent waves were estimated to occur prior to May 2021: fall of 2020 and early 2021. Conclusion: We estimated the US may need to utilize surge devices to have sufficient in-hospital NIV during peak need periods. Although IMV supplies seem generally adequate, improved strategies to track and share equipment, i.e., move ventilators from centers with surplus to centers in need, should be developed. This model may inform resource planning and allocation for which patients require ventilators in subsequent waves. Further validation will be beneficial using observed data for hospitalization, ventilator utilization and mortality, as well as adjustments for shifting trends in clinical practice such as use of high-flow nasal cannula.

The influence of paralytics on the safety and efficacy of prone positioning in COVID19 ARDS

Rationale: Prone positioning has proven benefit but is generally underutilized in moderate to severe Acute Respiratory Disease Syndrome (ARDS). Common practice includes administering neuromuscular blockade [paralytic medication] when proning this population, despite equivocal data regarding benefits of routine paralysis in ARDS. During the COVID19 pandemic, drug shortages and other factors have driven clinicians to prone patients without therapeutic paralysis. Recent publications also suggest prone positioning may be beneficial for non-intubated (non-paralyzed patients). We hypothesized that intubated patients with COVID19-related ARDS can be safely proned without therapeutic paralysis and would experience similar improvement in gas exchange (as evidenced by improved PF [Pa02/Fi02] and SF [Sp02/Fi02] ratios). Methods: Observational data on ICU patients were collected at a large tertiary university hospital from March to September 2020. Clinical teams directed use of sedatives, paralytics, mechanical ventilation settings, and timing of prone vs. supine positioning and blood draws. Comparison of demographics, gas exchange in supine and prone positions (within the same subjects), as well as oxygen requirements, ventilator settings, adverse events and hemodynamic parameters were analyzed using descriptive statistics. Results: Among our cohort of 156 patients, a total of 15 patients were identified that changed from supine to prone position with and without the use of paralytics while in the ICU. All 15 patients had moderate to severe ARDS per the Berlin Criteria, secondary to COVID19. PF and SF ratios were compared in the same patient before and after proning with and without paralytics (within subject comparisons). All groups had an improvement in both average PF ratio (34.7% with and 24.0% without paralysis, p=0.52) and average SF ratio (5.2% with and 6.1% without paralysis, p=0.92) after proning (Figure 1). There were no serious adverse events associated with prone positioning with or without paralytics. Conclusions: When proning patients with COVID19 ARDS, we found no statistically significant difference to support routine use of paralytics when proning. Safety and efficacy were similar when COVID19 patients were being proned with or without neuromuscular blockade. Use of paralytic medication should be an individualized decision rather than given routinely. Larger randomized controlled trials comparing proning with or without paralysis are needed to identify the optimal approach in this population.

Very-low driving pressure ventilation in patients with acute respiratory distress syndrome on extracorporeal membrane oxygenation

Rationale: The ideal ventilator settings in patients with severe acute respiratory distress syndrome (ARDS) while on Extracorporeal Membrane Oxygenation (ECMO) are unknown. ELSO recommends modest driving pressures and PEEP (i.e., “lung rest”) during ECMO to minimize ventilator induced lung injury (VILI) and improve mortality. However, even lower driving pressures (DP) may improve inflammatory and lung injury biomarker profiles, and possibly improve mortality. The focus of this study was to evaluate the feasibility and impact of very-low DP in patients with ARDS on ECMO. Methods: Patients on ECMO due to ARDS from coronavirus disease 2019 had their DP decreased from 10 to 1-5 cmH2O for two hours, as tolerated. The other ventilator settings were unchanged and were consistent with ELSO guidelines;positive end-expiratory pressure (10-15 cmH2O) and a respiratory rate 10 breaths per minute. During the low DP protocol, the transpulmonary pressure was monitored with esophageal manometry. Plasma (for IL6 and sRAGE) and urine were collected before and after the protocol. Results: Thirty patients were enrolled and ultimately 21 patients underwent the low DP protocol. Seventeen were male, aged 51 ± 9 years, median BMI of 31.7 kg/m2 (IQR 27.4-35.2), with a median SOFA score of 10 (IQR 8-12) at ICU admission. There were no complications during the low DP protocol (1-5 cm H2O). The protocol was performed a median of 16 (IQR 13.5-20) hours after ECMO initiation. Average ECMO days were 21 (IQR 12.5-41) with a survival to hospital discharge of 43% (9/21). Baseline average tidal volume (TV) was 3.4±2.6 ml/kg of predicted body weight (PBW), during the low DP protocol the TV decreased to 2.7±3.2 ml/kg of PDW. Two groups were noted-those who had spontaneous breaths vs. those who did not (see Figure 1). Ten patients during the low DP protocol continued to have unchanged TV, 5.2±2.8 to 5.4±2.7 ml/kg of PBW due to spontaneous breathing found on esophageal manometry. Eleven patients had no spontaneous breaths and TV decreased from 1.76±0.57 to 0.2±0.38 ml/kg of PBW during the low DP protocol. The spontaneous vs. nonspontaneous breathing groups has a statistically different TV before, during, and after the low DP protocol (p<0.001). Conclusions: Very-low DP is feasible in patients on ECMO support which may decrease VILI. However, in the absence of neuromuscular blockade patients might spontaneously breathe with the same transpulmonary pressure. Thus, whether low DP offers any advantage in spontaneous breathing vs. non-spontaneous breathing requires further study. (Table Presented).

Unilateral axillary adenopathy following COVID-19 vaccination: a multimodality pictorial illustration and review of current guidelines.

We present a multimodality pictorial review of axillary lymphadenopathy in patients recently vaccinated against COVID-19. As the mass vaccination programme continues to be rolled out worldwide in an effort to combat the pandemic, it is important that radiologists consider recent COVID-19 vaccination in the differential diagnosis of unilateral axillary lymphadenopathy and are aware of typical appearances across all imaging methods. We review current guidelines on the management of unilateral axillary lymphadenopathy in the context of recent COVID-19 vaccination.

The role of transoral fine needle aspiration in expediting diagnosis and reducing risk in head and neck cancer patients in the coronavirus disease 2019 (COVID-19) era: a single-institution experience.

OBJECTIVE: The global coronavirus disease 2019 (COVID-19) pandemic has necessitated rapid alterations to diagnostic pathways for head and neck cancer patients that aim to reduce risk to patients (exposure to the hospital environment) and staff (aerosol-generating procedures). Transoral fine needle aspiration cytology offers a low-risk means of rapidly diagnosing patients with oral cavity or oropharyngeal lesions. The technique was utilised in selected patients at our institution during the pandemic. The outcomes are considered in this study. METHOD: Diagnostic outcomes were retrospectively evaluated for a series of patients undergoing transoral fine needle aspiration cytology of oral cavity and oropharyngeal lesions during the COVID-19 pandemic. RESULTS: Five patients underwent transoral fine needle aspiration cytology, yielding lesional material in 100 per cent, with cell blocks providing additional information. In one case, excision biopsy of a lymphoproliferative lesion was required for final diagnosis. CONCLUSION: Transoral fine needle aspiration cytology can provide rapid diagnosis in patients with oral cavity and oropharyngeal lesions. Whilst limitations exist (including tolerability and lesion location), the technique offers significant advantages pertinent to the COVID-19 era, and could be employed in the future to obviate diagnostic surgery in selected patients.