Implementing patient-initiated follow-up in dermatology: a local departmental experience

As part of the National Health Service's response to the COVID-19 pandemic (https://www.england.nhs.uk/outpatienttransformation- programme/patient-initiated-follow-up-givingpatients- greater-control-over-their-hospital-follow-up-care/), and in line with the personalized care agenda (https://www.bad. org.uk/shared/get-file.ashx?itemtype=document&id=7237), 'patient-initiated follow-up' (PIFU) is being implemented across secondary care. This has been introduced by the National Outpatients Transformation Team and the aim of this initiative is to encourage self-management in patients and facilitate shared decision-making, together with supporting clinical waiting list reviews. The expected benefits include flexible personalized pathways and better access to specialist care when needed, thus benefiting general practitioners and the department. It replaces the old-style 'open appointment', which was rigid, without a clear pathway and not accurately recorded, impacting on demand and capacity planning. The British Association of Dermatologists has adapted this guidance and produced a document to support the roll out of this initiative throughout dermatology departments in England.4 It is important that clinicians appropriately assess which patients are suitable for PIFU. Criteria for selection include a low risk of urgent follow-up;confident to take responsibility of their care by understanding the condition, symptoms and when to seek advice;and understanding how to re-access care. Our experiences in setting up and using the PIFU pathway are shared. In our trust, it was first rolled out in dermatology and urology, two specialities with a high number of follow-ups. For dermatology, we included clinics in the main department and across all four community sites. In order to set up this service, engagement was sought with key stakeholders (service managers, administrative teams and clinicians). A Standard Operating Procedure was created to classify the pathway, agreed processes for the administrative and secretarial team, and written information for patients and general practitioners. Education sessions were given on how to use PIFU, assess patient suitability and measure outcomes. From September 2021 to November 2021, 548 patients have been added onto a PIFU and, as of December 2021, 11 have used it to re-access care. A staff survey has been done and has shown overall positive feedback, with 68% having a positive experience and only 8% having a negative experience. Seventy-six per cent of staff feel it is better for patients and doctors/administrators, and 95% would recommend it to other departments. The only negative issues have been an increase in workload for the secretaries who send out the written information. We aim to obtain patient feedback once more have re-accessed care, which we hope to present alongside our experiences on the benefits and challenges of implementing PIFU.

"I'm a man now”: Using Narrative Therapy to support an adult with Down syndrome transition to a new life

Background: Residential transitions have long been recognised as challenging for people with learning disabilities and can be packed with problem stories. Narrative Therapy practices have the potential to centre the voice of people with learning disabilities;to enable alternative stories to be told;and to shine a light on their own and their support system's resources for change. Methods: Colin, a 36-year-old man with Down syndrome and a learning disability, met with the first author for nine sessions. Narrative Therapy practices (also drawing on systemic ideas) were used, including the Tree of Life, Outsider Witness Practice, Therapeutic Documentation and Definitional Ceremony. Feedback from Colin and the staff team was gathered through qualitative and quantitative means. Findings: Colin was keen to share his life stories and explored ideas about his "new life”, wanting to "stay strong” and "stay happy”. Staff noted an improvement in household stress and perceived ability to support Colin. An improvement in quality of life was also demonstrated with a self-report questionnaire. Conclusions: By acknowledging the power of language, narrative practices offer tools to help people with learning disabilities and their support system in making sense of and navigating important life transitions. © 2023 The Authors. British Journal of Learning Disabilities published by John Wiley & Sons Ltd.

COVID-19 Policies, Pandemic Disruptions, and Changes in Child Mental Health and Sleep in the United States.

Importance: The adverse effects of COVID-19 containment policies disrupting child mental health and sleep have been debated. However, few current estimates correct biases of these potential effects. Objectives: To determine whether financial and school disruptions related to COVID-19 containment policies and unemployment rates were separately associated with perceived stress, sadness, positive affect, COVID-19-related worry, and sleep. Design, Setting, and Participants: This cohort study was based on the Adolescent Brain Cognitive Development Study COVID-19 Rapid Response Release and used data collected 5 times between May and December 2020. Indexes of state-level COVID-19 policies (restrictive, supportive) and county-level unemployment rates were used to plausibly address confounding biases through 2-stage limited information maximum likelihood instrumental variables analyses. Data from 6030 US children aged 10 to 13 years were included. Data analysis was conducted from May 2021 to January 2023. Exposures: Policy-induced financial disruptions (lost wages or work due to COVID-19 economic impact); policy-induced school disruptions (switches to online or partial in-person schooling). Main Outcomes and Measures: Perceived stress scale, National Institutes of Health (NIH)-Toolbox sadness, NIH-Toolbox positive affect, COVID-19-related worry, and sleep (latency, inertia, duration). Results: In this study, 6030 children were included in the mental health sample (weighted median [IQR] age, 13 [12-13] years; 2947 [48.9%] females, 273 [4.5%] Asian children, 461 [7.6%] Black children, 1167 [19.4%] Hispanic children, 3783 [62.7%] White children, 347 [5.7%] children of other or multiracial ethnicity). After imputing missing data, experiencing financial disruption was associated with a 205.2% [95% CI, 52.9%-509.0%] increase in stress, a 112.1% [95% CI, 22.2%-268.1%] increase in sadness, 32.9% [95% CI, 3.5%-53.4%] decrease in positive affect, and a 73.9 [95% CI, 13.2-134.7] percentage-point increase in moderate-to-extreme COVID-19-related worry. There was no association between school disruption and mental health. Neither school disruption nor financial disruption were associated with sleep. Conclusions and Relevance: To our knowledge, this study presents the first bias-corrected estimates linking COVID-19 policy-related financial disruptions with child mental health outcomes. School disruptions did not affect indices of children's mental health. These findings suggest public policy should consider the economic impact on families due to pandemic containment measures, in part to protect child mental health until vaccines and antiviral drugs become available.

Transdiagnostic considerations of mental health for the post-COVID era: Lessons from the first surge of the pandemic.

BACKGROUND: The Coronavirus disease 19 (COVID-19)-related psychiatric burden partly results from prolonged social stress world-wide. Studies have examined the psychiatric impact of COVID-19 on Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM 5) and International Classification of Diseases 11th Revision (ICD-11) categories, implicating multiple diagnoses, complicating clinical management. AIM: To verify whether COVID-19-related psychopathology spans multiple DSM-5 and ICD-11 diagnoses, but not in a random pattern. Consequently, empirical analysis of the multiple associated symptoms will better describe COVID-19-related psychopathology. METHODS: We conducted a bi-national study during the first surge of the pandemic: an Italian sample (n = 21217, studied March-April 2020); and three representative longitudinal samples from Israel (n = 1276, 1189, and 1432 respectively, studied May-July 2020). Data in Italy were collected by a national internet-based survey with an initially approached sample of about one million persons and in Israel by the Israeli Central Bureau of Statistics using probability-based national representative sampling. Data analysis focused on the frequency and patterns of reported multiple mental health symptoms. RESULTS: Combinations with all symptoms were more prevalent than combinations with fewer symptoms, with no majorities-minorities differences in both countries, demonstrating the generalizability of the transdiagnostic pattern of mental health issues in both nations. A history of previous mental disorder (Italian study) and an increase in symptom prevalence over time (Israel study) were associated with an increased number of symptoms. Conclusions: Based on finding correlated symptom diversity spanning conventional diagnostic categories, we suggest that the pattern of mental health issues associated with the COVID-19 pandemic is transdiagnostic. CONCLUSION: The findings have implications for improving prevention and treatment of COVID-19 related psychopathology and for post-pandemic times in conditions resulting from multiplicity of stressors with mixed symptomatology in the clinical picture.

USING VIRTUAL REALITY IN AGED CARE SETTINGS: A SCOPING REVIEW

Recent advancement of virtual reality (VR) technology has led to growing interest in using VR in aged-care settings. VR can help ameliorate experiences of loneliness and social isolation, which is especially important during the COVID-19 pandemic. As a result, increasingly more studies are being published on this topic, and a comprehensive review of studies examining the facilitators and barriers of adopting VR in these settings is needed. This scoping review reports the facilitators and barriers to implementing VR in care settings among older adults, as well as the impact on social engagement and/or loneliness. We followed the Joanna Briggs Institute scoping review methodology, and searched the following databases: CINHAL, Embase, Medline, PsycInfo, Scopus, and Web of Science. Inclusion criteria includes articles published in the last five years that focus on older adults using VR in aged-care settings. 199 articles were retrieved and 21 articles were included in our review. Most of the articles (38%) originated from Australia. Key facilitators for using VR in aged care settings are the technology being user-friendly, comfortable, and easy to clean. Barriers included: technology issues (e.g., internet connectivity), staff attitude/ worries, and impact on residents, and structural considerations (e.g., lack of staff and time to assist with the VR program). VR technology can decrease loneliness and feelings of isolation, and provide opportunities to engage with others. Our review of the current evidence offers insights and recommendations for health care professionals to use VR technology in aged care settings, maximizing benefits and minimizing risks among users.

Perceptions of staff and leadership teams on implementation of telepresence robots in long-term care: a qualitative descriptive study

Background: COVID-19's physical distancing mandates have increased the likelihood of experiencing social isolation and loneliness for residents in long-term care (LTC), especially those living with dementia. Social isolation correlates with health risks, including depression and cognitive decline. Telepresence robots can be remotely driven and facilitate social interactions through videoconferencing. Researchers have begun to explore opportunities of using these robots in the healthcare field;however, there is a research gap on examining factors influencing their implementation in LTC from the perspectives of key stakeholders. This qualitative descriptive study focuses on exploring LTC staff and leadership teams' perspectives on facilitators and barriers to implementing telepresence robots. Method(s): We employed purposive and snowballing methods to recruit 22 participants from two LTC homes in British Columbia, Canada: operational and unit leaders, and interdisciplinary staff including nursing staff, care aides and allied health practitioners. Consolidated Framework for Implementation Research (CFIR) guided our data collection and analysis. Semi-structured interviews were conducted by virtual meetings. Thematic analysis was performed to identify themes. Result(s): Analysis of the data produced three themes: (a) perceived needs and values for family-resident connections, (b) engagement through conversation and partnership, and (c) confidence with training and timely support. Based on the findings and CFIR guidance, we offer a preliminary conceptual tool "START": Share benefits and successes;Tailor policies and plans with staff partners;Acknowledge and address staff concerns;Repeated training and demonstrations;and Timely technical support. Conclusion(s): This study offers pragmatic insights into staff and leadership teams' perceptions of facilitators and barriers of implementing telepresence robots in LTC. The complexity of technology implementation will require executive and leadership teams to consider additional factors beyond the Plan-Do-Study-Act (PDSA) cycle. Copyright © 2022 the Alzheimer's Association.

Using telepresence robots to support family virtual visits during the COVID-19 Pandemic

BACKGROUND: The COVID-19 pandemic has disproportionately impacted older adults living with dementia in Long-Term Care (LTC). Social isolation and loss of connections with families among residents have been detrimental and severely impacted quality of life.

DIAPHRAGMATIC PARALYSIS FOLLOWING SECOND DOSE OF THE BNT162B2 MRNA COVID-19 VACCINE

SESSION TITLE: Using Imaging for Diagnosis Case Posters SESSION TYPE: Case Report Posters PRESENTED ON: 10/19/2022 12:45 pm - 01:45 pm INTRODUCTION: The vaccines against SARS-CoV-2 or COVID-19 have been shown to be safe and effective at preventing severe disease and death. In a phase 3 trial the BNT162b2 mRNA COVID-19 vaccine showed a 52% and 95% efficacy after the first and second doses, respectively (1). Side effects following vaccination are common but are typically mild and self limited (2). The most common side effects are headache, fever, fatigue, arthralgias and pain at the injection site (2). More severe and devastating side effects have been reported including cerebral venous thrombosis and myocarditis (3) (4). Here we report a case of unilateral diaphragmatic paralysis following the second dose of the BNT162b2 mRNA COVID-19 vaccine. CASE PRESENTATION: The patient was a 56 year old female with a past medical history of reactive airways disease and hypertension who was seen in the pulmonology clinic shortly after receiving her second dose of the BNT162b2 mRNA COVID-19 vaccine. After her second dose she developed burning shoulder pain, erythema and swelling that extended to the neck and axilla. She went to an urgent care and was advised to treat with ice and NSAIDs, she had a chest radiograph performed which was reported to be negative. Her symptoms persisted and she was sent to the emergency room, chest x-ray showed interval development of an elevated left hemidiaphragm. A CT Chest with inspiratory and expiratory films was performed and the left diaphragm was noted to be in the same location during inspiration and expiration consistent with diaphragmatic paralysis. PFT showed a reduction in her FVC, TLC and DLCO compared to 13 years prior. DISCUSSION: Diaphragmatic paralysis is a well described clinical entity that is most often associated with cardiothoracic surgery where hypothermia and local ice slush application are thought to induce phrenic nerve injury (5). It has also been described as a complication of viral infections, including a recent report of unilateral diaphragm paralysis in a patient with acute COVID-19 infection (6). In a case series of 246 patients with amyotrophic neuralgia which can include diaphragm paralysis, 5 patients received a vaccine in the week before developing symptoms (8) Additionally, Crespo Burrilio et al recently described a case of amyotrophic neuralgia and unilateral diaphragm paralysis following administration of the Vaxzevri (AstraZeneca) COVID-19 vaccine (7). This case highlights a potential side effect of the BNT162b2 mRNA COVID-19 vaccine that has not been previously reported CONCLUSIONS: Reference #1: Polack FP, Thomas SJ, Kitchin N. Safety and efficacy of the BNT162b2 mRNA COVID-19 vaccine. N Engl J Med. 2020;383:2603–2615. Reference #2: Menni, C., Klaser, K., May, A., Polidori, L., Capdevila, J., Louca, P., Sudre, C. H., Nguyen, L. H., Drew, D. A., Merino, J., Hu, C., Selvachandran, S., Antonelli, M., Murray, B., Canas, L. S., Molteni, E., Graham, M. S., Modat, M., Joshi, A. D., Mangino, M., … Spector, T. D. (2021). Vaccine side-effects and SARS-CoV-2 infection after vaccination in users of the COVID Symptom Study app in the UK: a prospective observational study. The Lancet. Infectious diseases, 21(7), 939–949. https://doi.org/10.1016/S1473-3099(21)00224-3 Reference #3: Jaiswal V, Nepal G, Dijamco P, et al. Cerebral Venous Sinus Thrombosis Following COVID-19 Vaccination: A Systematic Review. J Prim Care Community Health. 2022;13:21501319221074450. doi:10.1177/21501319221074450 DISCLOSURES: No relevant relationships by Jack Mann No relevant relationships by John Prudenti

COVID-19 induces CNS cytokine expression and loss of hippocampal neurogenesis.

Infection with the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) is associated with acute and postacute cognitive and neuropsychiatric symptoms including impaired memory, concentration, attention, sleep and affect. Mechanisms underlying these brain symptoms remain understudied. Here we report that SARS-CoV-2-infected hamsters exhibit a lack of viral neuroinvasion despite aberrant blood-brain barrier permeability. Hamsters and patients deceased from coronavirus disease 2019 (COVID-19) also exhibit microglial activation and expression of interleukin (IL)-1ß and IL-6, especially within the hippocampus and the medulla oblongata, when compared with non-COVID control hamsters and humans who died from other infections, cardiovascular disease, uraemia or trauma. In the hippocampal dentate gyrus of both COVID-19 hamsters and humans, we observed fewer neuroblasts and immature neurons. Protracted inflammation, blood-brain barrier disruption and microglia activation may result in altered neurotransmission, neurogenesis and neuronal damage, explaining neuropsychiatric presentations of COVID-19. The involvement of the hippocampus may explain learning, memory and executive dysfunctions in COVID-19 patients.

COVID vaccine cutaneous reactions: a case series of six patients

In response to the COVID-19 pandemic, over 89 million doses of coronavirus vaccines have been administered so far in the UK. An increasing number of mucocutaneous reactions are being seen as a result of the vaccines. These reactions can vary, from pruritus to urticaria and angio-oedema (Robinson LB, Fu X, Hashimoto D et al. Incidence of cutaneous reactions after messenger RNA COVID-19 vaccines. JAMA Dermatol 2021;157: 1000-2). Its recognition is important, as a small proportion of patients can develop potentially life-threatening conditions. Furthermore, initial reactions can have consequences on subsequent vaccine doses. We carried out a retrospective review of patients referred to our dermatology service over a 4-month period (June-October 2021) and identified those with suspected mucocutaneous reactions secondary to COVID-19 vaccines. Six patients were identified, three woman and three men, with a mean age of 56 years. Mucocutaneous reactions seen included: extensive parapsoriasis, widespread blistering rash, urticaria, angio-oedema, lichenoid papular eruption and erythema multiforme. Three reactions occurred after the Pfizer vaccine, two after the AstraZeneca and one was not specified. Two patients were advised not to have further doses. The incidence of cutaneous reactions to the COVID-19 vaccines is estimated to be 4% (McMahon DE, Amerson E, Rosenbach M et al. Cutaneous reactions reported after Moderna and Pfizer COVID-19 vaccination: a registry-based study of 414 cases. J Am Acad Dermatol 2021;85: 46-55). It is important to increase awareness and knowledge of these reactions, to allow appropriate management, and informed discussion regarding the safety of further doses.

Association of Social Determinants of Health and Vaccinations With Child Mental Health During the COVID-19 Pandemic in the US.

Importance: The COVID-19 pandemic disproportionately affected mental health in socioeconomically disadvantaged children in the US. However, little is known about the relationship of preexisting and time-varying social determinants of health (SDoH) at individual and structural levels, vaccination eligibility/rates, and the racial and ethnic differences to trajectories of child mental health during the COVID-19 pandemic. Objective: To estimate the association of trajectories of child mental health to multilevel SDoH and vaccination eligibility/rates. Design, Setting, and Participants: This prospective longitudinal cohort study, conducted from May 16, 2020, to March 2, 2021, integrated structural-level, pandemic-related data with the Adolescent Brain Cognitive Development (ABCD) cohort data (release 4.0). The ABCD study recruited 11 878 children (baseline) and conducted 6 COVID-19 rapid response surveys across 21 US sites (in 17 states) from May 16, 2020, to March 2, 2021. Exposures: Preexisting individual (eg, household income) and structural (area deprivation) SDoH and time-varying individual (eg, food insecurity, unemployment) and structural (eg, social distancing, vaccination eligibility/rates) SDoH. Main Outcomes and Measures: Perceived Stress Scale, the National Institutes of Health-Toolbox emotion measures, and COVID-19-related worry. Results: The longitudinal sample included 8493 children (mean [SD] age, 9.93 [0.63] years; 5011 girls [47.89%]; 245 Asian [2.34%], 1213 Black [11.59%], 2029 Hispanic [19.39%], 5851 White [55.93%], and 1124 children of other/multiracial ethnicity [10.74%]). Trajectories of stress, sadness, and COVID-19-related worry decreased after adult vaccination rollout. Compared with younger children, boys, White children, or those living with married parents, those who reported greater perceived stress included older children aged 12 to 15 years (ß = 0.26; 95% CI, 0.12-0.41; P < .001); girls (ß = 0.75; 95% CI, 0.61-0.89; P < .001); Hispanic children (ß = 0.24; 95% CI, 0.01-0.47; P = .04); children living with separated parents (ß = 0.50; 95% CI, 0.03-0.96; P = .04); children experiencing disrupted medical health care access (ß = 0.19; 95% CI, 0.01-0.36; P = .04); children living in economically deprived neighborhoods (ß = 0.28; 95% CI, 0.05-0.51; P = .02); children living in areas with more full-time working-class adults who were unable to social distance (ß = 1.35; 95% CI, 0.13-2.67; P = .04); and children living in states with fewer fully vaccinated adults (ß = 0.59; 95% CI, 0.16-1.02; P = .007). COVID-19 pandemic-related worry was higher among Asian children (ß = 0.22; 95% CI, 0.08-0.37; P = .003), Black children (ß = 0.33; 95% CI, 0.22-0.43; P < .001), children of other/multiracial ethnicity (ß = 0.17; 95% CI, 0.09-0.25; P < .001), and children with disrupted medical health care (ß = 0.15; 95% CI, 0.09-0.21) and disrupted mental health treatment (ß = 0.11; 95% CI, 0.06-0.16). Inability to afford food was associated with increased sadness (ß = 1.50; 95% CI, 0.06-2.93; P = .04). States with later vaccination eligibility dates for all adults were associated with greater COVID-19-related worry (ß = 0.16; 95% CI, 0.01-0.31; P = .03) and decreased positive affect (ß = -1.78; 95% CI, -3.39 to -0.18; P = .03) among children. Conclusions and Relevance: Results of this study suggest a disproportionately adverse association of the COVID-19 pandemic with child mental health among racial and ethnic minority groups, which may be improved by addressing modifiable individual (food insecurity, unemployment, health services, parental supervision) and structural (area deprivation, job protection, vaccination) SDoH.

Black Insecurity at the End of the World

"Black Insecurity at the End of the World" examines the sensibility I term black insecurity by reading Colson Whitehead's 2010 novel Zone One against a backdrop of bioinsecurity and police murder of black people. The 2014 Ebola outbreak in West Africa and uprisings in Ferguson, Missouri, from the same year, when situated in dialogue with Whitehead's text, show that black insecurity reframes the spatio-temporal notion of survival by unmasking security structures as dead and dying. Engaged from the standpoint of ongoing racial justice protests and stay-at-home conditions of the COVID-19 pandemic, "Black Insecurity at the End of the World" argues that black speculative fictions uniquely expose the false premises of securitization and show that black love is an essential process for unmaking the forces of anti-Blackness.

Avoid the Vent: Modified Awake Proning for Severe Hypoxemia in COVID-19 ARDS

Introduction: New York City became the epicenter for the coronavirus disease 2019 (COVID-19) pandemic in the spring of 2020. Healthcare workers were faced with patients experiencing rapidly progressive respiratory failure, which led to the need for unconventional treatment approaches. Awake proning modified with alternating lateral decubitus positions was implemented to improve oxygenation in patients with type 2 acute respiratory distress syndrome (ARDS).1 In this case report, we discuss the positive outcome of one of many patients who improved with the modified proning approach implemented early on during their disease course. Case: A 59-year-old previously healthy male presented with fevers and shortness of breath for 10 days. He was febrile with saturation at 86% on room air with improvement to 94% on nasal cannula. Chest x-ray showed patchy bibasilar airspace opacities. His nasal swab for SARS-CoV-2 returned positive. Per protocol at the time, he was treated with Hydroxychloroquine and Azithromycin. He continued to deteriorate with increasing oxygen requirements. On hospital day 3, he desaturated to 77%. Patient was placed on 100% FiO2 via non-rebreather and placed in a prone position with improvement in his O2 saturation to 90%. He felt uncomfortable lying prone and was unable to assume the position for extended period of time. He was advised to alternate between prone positioning with lateral decubitus positions on either side as much as could tolerate. He continued to require oxygen supplementation via non-rebreather. On hospital day 20, he was weaned to room air and was discharged to a short-term facility. Discussion: COVID-19 is a pulmonary disease that causes type 2 ARDS1 at its most severe state. Proning mechanically ventilated patients has been established as a part of management in ARDS with severe hypoxemia. Its mechanism of improving oxygenation includes "affecting recruitment in dorsal lung regions, increasing end-expiratory lung volume, decreasing alveolar shunt, and improving tidal volume".4 During this pandemic, physicians extrapolated this concept and applied a modified maneuver on awake patients in attempts to improve oxygenation without invasive mechanical ventilation. The patient in this case demonstrated marked improvement with not only prone but also lateral decubitus positioning. This is one of many cases that showed the effectiveness of rotating the body in various positions early on during the disease process to prevent worsening of respiratory failure in mild to moderate type 2 ARDS in COVID-19. It also highlights the need for further research to expand it to other causes of ARDS.

Suicide-related calls to a national crisis chat hotline service during the COVID-19 pandemic and lockdown.

BACKGROUND: A COVID-19 pandemic-related rise in suicide rates has been predicted due to social isolation, fear, uncertainty, economic turndown and grief. Detecting an increase in suicide rates is difficult in the absence of real-time data. Alternative data sources for such trends in psychopathology and suicidal behavior must be sought. METHODS: Data from a national chat-based crisis hotline for the first half of 2019 (pre-COVID-19), were compared to data from the first half of 2020 (during COVID-19). Chat sessions were classified by content and demographics and the data compared between the two time periods. OUTCOME: Total chats (n = 6756) were 48% higher during COVID-19 (p < .05). Suicide-related chat (SRC) number was also higher, although the proportion relative to all chats was slightly lower during COVID-19, compared to pre-COVID-19 (p < .05). SRCs increased during the COVID-19 lockdown. The number of severe SRCs resulting in urgent police intervention, increased during the lockdown (April-May 2020) compared with the same period in 2019 (p = .04). Issues of anxiety were higher in 2020 (19.4%) vs. 2019 (16.5%) (p < .00001) while issues of depression were lower (22.4% vs 33%, respectively) (p < .00001). The overall use of chats among adults aged >50 yrs increased during COVID-19 and likewise, the rate of SRCs in this age-group increased 30-fold in this period when compared to pre-COVID-19 (p < .00001). SRCs included more women than men (p < .0001) in both pre-COVID-19 and during the COVID-19 period, when the proportion of women increased from 62% in 2019 to 73% during COVID-19 (p < .0001). INTERPRETATION: The rise in total chats, SRCs and SRCs resulting in police action, commenced during lockdown and was ameliorated by end of the lockdown, indicating that distress created by the lockdown was more impactful than mourning deaths of loved ones, fear and uncertainty, because all these factors persisted beyond the end of the lockdown. Older populations were probably more distressed due to greater risk and less adaptability to isolation, social media and staying home. More calls by women may reflect women's better help-seeking capacity. The increase in SRCs indicates the potential for more suicides and the need for bolstering mental health services and reach-out to older people during pandemic lock-downs.

TIMING OF INTUBATION AND OUTCOME IN THE COVID-19 PANDEMIC: CHALLENGING THE CONCEPT OF PERMISSIVE HYPOXEMIA

SESSION TITLE: Critical Care Posters SESSION TYPE: Original Investigation Posters PRESENTED ON: October 18-21, 2020 PURPOSE: After the novel coronavirus disease (COVID-19), was declared a pandemic, New York quickly became the new epicenter of the disease, with Queens County reporting the most confirmed cases in the United States. This study was conducted during the peak of COVID-19 in Queens. Due to the severity of the disease and limited resources, patients were intubated at varying degrees of oxygenation. This study examines the preoxygenation state of COVID-19 ARDS patients prior to intubation and its implication on clinical outcomes. METHODS: At a single acute tertiary care hospital located in Queens, New York, all patients admitted between March 15 and April 15, 2020 were screened. Active COVID-19 status was confirmed with reverse transcriptase-polymerase chain reaction assay on nasopharyngeal samples. All COVID-19 patients who were intubated with documented pre-intubation oxygen saturation (PreO2) were included. All data were collected from the electronic health record, including laboratory data, ventilator settings, and hospital course. Peri-intubation cardiac arrest events up to 24 hours post-intubation and mortality during the study period were examined as outcomes. Data was analyzed with SPSS (version 25). Continuous variables were tested using independent T-tests. All tests of significance were two-tailed, and a p-value of 0.05 was considered significant. RESULTS: A total of 192 patients were included in the study. They had a mean age of 61.2 ± 12.2 years, and 130 (64.1%) were men. The mean preO2 of all patients was 71.3 ± 13.6, and the mean peri-intubation PF ratio was 120.84 ± 58.6. 32 out of 192 patients (16.7%) with peri-intubation cardiac arrest demonstrated significantly lower preO2 (p=0.03) compared to those without. These 32 patients also demonstrated more days with symptoms prior to intubation (p=0.004). 121 patients who expired during the clinical course demonstrated lower PreO2 (p=0.60) and PF Ratios (p=0.48) compared to the 71 patients who did not, but these comparisons were not statistically significant. Patients who expired demonstrated fewer symptomatic days prior to intubation than those who did not, but this was not statistically significant (p=0.06). CONCLUSIONS: At the time of intubation, the patients had significant hypoxemia and severe ARDS by PF ratio. Lower oxygenation prior to intubation is associated with an increase in peri-intubation complications. CLINICAL IMPLICATIONS: Due to unclear pathophysiology of ARDS in COVID-19, the optimal timing of intubation continues to be debated. Physicians should consider intubation earlier in the disease course prior to significant hypoxemia, which may have a negative impact on peri-intubation complications. Clinical outcome was further impacted by the restriction on preoxygenation of the patients prior to intubation, given its risk of viral aerosolization. Means of preoxygenating with minimal risk of disease spread should continue to be explored. DISCLOSURES: Advisory Committee Member relationship with Ambu Please note: $1-$1000 by Olumayowa Abe, source=Admin input, value=Honoraria No relevant relationships by Ahmed Al-Ghrairi, source=Web Response No relevant relationships by Christian Castaneda, source=Web Response No relevant relationships by Ettaib El Marabti, source=Web Response No relevant relationships by Hadya Elshakh, source=Web Response No relevant relationships by Teressa Ju, source=Web Response No relevant relationships by Michael Karass, source=Admin input No relevant relationships by Miri Kim, source=Web Response No relevant relationships by Jack Mann, source=Web Response No relevant relationships by Christina Jee Ah Rhee, source=Web Response No relevant relationships by Fizza Sajid, source=Web Response No relevant relationships by Angelina Voronina, source=Web Response