Bidirectionality between Cardiometabolic Diseases and COVID-19: Role of Humoral Immunity.

Cardiometabolic diseases and abnormalities have recently emerged as independent risk factors of coronavirus disease 2019 (COVID-19) severity, including hospitalizations, invasive mechanical ventilation, and mortality. Determining whether and how this observation translates to more effective long-term pandemic mitigation strategies remains a challenge due to key research gaps. Specific pathways by which cardiometabolic pathophysiology affects humoral immunity against severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), and vice versa, remain unclear. This review summarizes current evidence of the bidirectional influences between cardiometabolic diseases (diabetes, adiposity, hypertension, CVDs) and SARS-CoV-2 antibodies induced from infection and vaccination based on human studies. Ninety-two studies among >408,000 participants in 37 countries on 5 continents (Europe, Asia, Africa, and North and South America) were included in this review. Obesity was associated with higher neutralizing antibody titers following SARS-CoV-2 infection. Most studies conducted prior to vaccinations found positive or null associations between binding antibodies (levels, seropositivity) and diabetes; after vaccinations, antibody responses did not differ by diabetes. Hypertension and CVDs were not associated with SARS-CoV-2 antibodies. Findings underscore the importance of elucidating the extent that tailored recommendations for COVID-19 prevention, vaccination effectiveness, screening, and diagnoses among people with obesity could reduce disease burden caused by SARS-CoV-2. Adv Nutr 2023;xx:xx-xx.

COVID-19 Mortality by Demographics in a Brooklyn Hospital

Previous publications have shown worse COVID-19 outcomes in African American and LatinX patients. We are sharing the experience of a 750-bed tertiary safety net hospital in Brooklyn, NY. Copyright © Wolters Kluwer Health, Inc. All rights reserved.

Occupational health and safety trainees reflect on their education and future careers during COVID-19

Background: The National Institute for Occupational Safety and Health (NIOSH) funded Education and Research Centers (ERCs), located at 18 universities, with the mission to train occupational safety and health (OSH) leaders. The Florida Sunshine ERC has trained hundreds of students since its inception in 1997 through seven programs that collaboratively foster interdisciplinary education and applied research and practice. The COVID-19 pandemic has presented practical challenges for educators, students, and trainees, forcing institutions to move to remote learning. The pandemic also magnifies the importance of public health and OSH. Purpose: This evaluation elicited feedback from ERC trainees early in the pandemic (2020) and again in 2021 on how the pandemic affected their training, professional development, career plans, and wellbeing. Methods: Open-ended surveys were collected and focus groups were held with currently enrolled trainees from seven Sunshine ERC programs. Descriptive statistics were calculated, and qualitative transcripts were analyzed using MAXQDA software. Results: Through survey responses (45 respondents) and focus group discussions (9 participants), ERC trainees shared their perspectives on pandemic impacts in their performance and wellbeing, transition to remote learning, their respective OSH fields, and career plans during the pandemic. Programs should consider enhancing OSH curricula to respond to training needs and issues related to occupational stress and well-being, pragmatism and disaster response, and even more interdisciplinary training to prepare for emerging population-wide threats. Conclusions: OSH training will require shifts in teaching modalities and content to prepare OSH professionals for the future. Evaluation results informed teaching and training modifications to ensure that ERC objectives continue to be met and that trainees are well-prepared and supported.

POST HOC ANALYSIS OF IMPLEMENTING BEDSIDE PERCUTANEOUS ULTRASOUND GASTROSTOMY IN A CRITICAL CARE UNIT: ASSESSING ADVERSE EVENTS AND SEVERITY OF ILLNESS BETWEEN GROUPS

SESSION TITLE: Late Breaking Investigations From Pulmonary and Critical Care SESSION TYPE: Original Investigation Posters PRESENTED ON: 10/18/2022 01:30 pm - 02:30 pm PURPOSE: Critical care patients receive over 50% of gastrostomy tubes placed in the United States. Studies support performing concomitant tracheostomy and gastrostomy to improve efficiencies in care and reduce healthcare costs. Prior research has supported the safe performance of Percutaneous Ultrasound Gastrostomy (PUG) by interventional radiologists. Our recent study, Length of Stay and Hospital Cost Reductions After Implementing Bedside Percutaneous Ultrasound Gastrostomy (PUG) in a Critical Care Unit, demonstrated that PUG placement by ICU physicians in patients with ventilator-dependent respiratory failure significantly reduced ICULOS and hospital LOS by 5 and 8 days respectively, and total hospital costs by $26,621 per patient. 70% of PUG procedures were performed concomitantly with tracheostomy (TPUG), compared to 0 in the usual care gastrostomy group. We now report a post hoc safety analysis assessing adverse events and patient comorbidity between these groups. METHODS: Post hoc analysis was performed on a retrospective cohort of patients with ventilator-dependent respiratory failure, grouped by those who received a gastrostomy consultation with gastroenterology or interventional radiology (usual care) and those who received a bedside PUG by a critical care physician. Adverse events related to gastrostomy placement were compared between groups using Fisher’s Exact tests. Charlson Scores were calculated for each patient and compared, as well as for the subgroup of patients with adverse events, using Student’s t-tests. RESULTS: There were 43 patients in the usual care group and 45 in the PUG group. Adverse events (AEs) in the usual care group totaled 16;7 major and 9 minor. AEs in the PUG group totaled 13;5 major and 8 minor. There were no significant differences between groups related to AEs (p=0.498). 28 of the usual care patients and 31 of the PUG patients were COVID-19 positive, respectively (p=0.71). The usual care and PUG groups had average Charlson scores of 2.88 (SD 2.13) and 3.23 (SD 2.32), respectively (p=0.537). The subgroup of patients with complications in each group had statistically equivalent Charlson scores (p=0.624). CONCLUSIONS: Our analysis demonstrates no difference in adverse events between PUG and usual care. PUG may be safely performed by Critical Care physicians at the bedside and in combination with tracheostomy. Performing PUG as the initial gastrostomy option in ventilatory-dependent patients decreases LOS and total hospital costs, without negatively affecting procedural adverse events. CLINICAL IMPLICATIONS: This research supports PUG as a safe method of gastrostomy placement by Critical Care physicians which may be performed at the bedside concomitantly to tracheostomy, driving reductions in ICULOS, hospital LOS, and total hospital costs per patient, with no significant increase in adverse events. DISCLOSURES: No relevant relationships by Jason Heavner No relevant relationships by Jeffrey Marshall No relevant relationships by Peter Olivieri No relevant relationships by Janelle Thomas No relevant relationships by Hannah Van Ryzin No relevant relationships by R. Gentry Wilkerson

Testing vaccines: essential steps in clinical trial design

A vaccine clinical trial is a research study in humans which aims to investigate or confirm the clinical, pharmacological, or immunological effects of a vaccine to establish the vaccine’s safety and/or efficacy. Once a promising vaccine candidate has been chosen from preclinical studies, it goes through a number of phases of clinical trials in humans before and after licensure. Ensuring the trial is designed correctly to answer the specific question(s) or objective(s) is of primary importance. In addition, the clinical trial must be conducted according to the principles of good clinical practice (GCP). The primary tenants of GCP are minimizing risk to the participant, safeguarding participants, informed consent, adhering to an approved research protocol, and ensuring data integrity. This chapter outlines how to plan and run a clinical vaccine trial including the principles and application of GCP, trial design, documentation, regulatory requirements, data quality, and safety considerations. © 2022 Elsevier Inc. All rights reserved.

Engaged, overextended, or burned out: What is the state of the disaster response workforce?

The prolonged coronavirus-2019 (COVID-19) pandemic and co-occurring disasters during 2020 took a toll on everyone, taxing public health and disaster management personnel particularly. This initial study evaluated levels of exhaustion, cynicism, and professional efficacy among a broad array of the disaster workforce responding to these events through an online survey. Responses were compared to normative standards from an international dataset using a one-sample t-test and described using k-means cluster analysis. Results from 111 emergency management and disaster services, public health, healthcare, first responders, and other professionals and volunteers indicated high levels of emotional exhaustion and cynicism, along with high levels of personal efficacy compared to normative samples. Perceptions of the heightened risk of contracting COVID-19 were significantly associated with increased emotional exhaustion and cynicism. Cluster analysis results indicated three different patterns of burnout: half of the respondents were overextended (high levels of emotional exhaustion, cynicism, and efficacy) or burned out (high emotional exhaustion and cynicism, low efficacy), while 50 percent were engaged (low emotional exhaustion, low cynicism, and high personal efficacy). This suggests that despite the COVID-19 pandemic, a substantial proportion of the disaster response workforce is still thriving. However, a large proportion is burned out or at high risk (overextended). Limitations of this study include a lack of diversity in the sample, which, although similar to the demographic characteristics of the emergency manager population, may limit the generalizability of the study results. System-level planners can use this information to develop comprehensive workforce approaches, policies, and procedures to prevent burnout for these essential personnel working behind the scenes. © 2021 Weston Medical Publishing. All rights reserved.

An Adapted Delivery of the Brick-by-Brick™ Programme to Develop Communicative Competence in Children with Acquired Brain Injury (ABI) who use Augmentative and Alternative Communication (AAC) Systems

Background: Communicative rehabilitation can be complex and challenging for children with an acquired brain injury (ABI) who use augmentative and alternative communication (AAC) systems. The development of communicative competence (CC) in children with use AAC systems is in itself complex and multifaceted (Light, 1989, Light and McNaughton, 2014) and it can be challenging for clinicians to target multiple competencies effectively through direct intervention. The Brick-by-Brick™ programme (previously known as LEGObased therapyR) has an evidence base routed in research with verbal young people with Autism Spectrum Condition. The programme is a collaborative play therapy originally designed as a social intervention to target the development of social communication and interaction skills (LeGoff, 2004). Introduction: The presentation aims to explore a use of the Brick-by-Brick™ programme with children with ABI who use AAC to support or replace their verbal communication, as well as the areas of potential clinical need for adaptations to its delivery to increase access for this client group. It will also discuss the theory behind adaptations and the need for evidence to support decision making clinically around this topic. The aims and methods of the presenter's current research will be discussed using Janice Light's framework of communicative competence (Light, 1989;Light and McNaughton, 2012) to discuss areas of competence during the presentation. Methods: The research agenda of an embedded quasiexperimental mixed methods design will be shared, along with considerations for the commencement of data collection in a country still significantly affected by the health, social, and educational repercussions of the Covid-19 pandemic. Clinical adaptations to the programme made by the presenter in her role as highly specialist speech and language therapist will be discussed and linked to her current research. Discussion, Conclusions and Recommendations: Adapting the delivery of the Brick-by-Brick™ programme for use with AAC users with ABI is not without difficulties, but these are not insurmountable. Practical and theoretical recommendations for the adaptation of the programme in both educational and healthcare rehabilitation settings will be shared. Future thoughts on the development of the current research base will also be discussed.

Pandemic Pulse: Unraveling and Modeling Social Signals during the COVID-19 Pandemic

COVID-19 has presented society with a unique set of challenges, including seeking a scientific understanding of the novel coronavirus, modeling its epidemiology, and inferring appropriate societal response. In this article, we posit that fighting a pandemic is as much a social endeavor as a medicinal and scientific one and focus on developing a platform for understand the social pulse of the United States during the COVID-19 crisis. We collected a multitude of data that includes longitudinal trends of news topics, social distancing behaviors, community mobility changes, web searches, and other descriptors of the COVID-19 pandemic's effects on the United States. Our preliminary results show that the number of COVID-19-related news articles published immediately after the World Health Organization declared the pandemic on March 11 have steadily decreased - regardless of changes in the number of cases or public policies. Additionally, we found that politically moderate and scientifically grounded sources have, relative to baselines measured before the beginning of the pandemic, published a lower proportion of COVID-19 news articles than more politically extreme sources - a fact that has implications for the spread and consequences of misinformation during the pandemic. We suggest that further analysis of these multi-modal signals could produce meaningful social insights and present an interactive dashboard to aid further exploration.1 © 2020 ACM.

Rapid and Sustained Decline in CXCL-10 (IP-10) Annotates Clinical Outcomes Following TNF-α Antagonist Therapy in Hospitalized Patients with Severe and Critical COVID-19 Respiratory Failure

Background. TNFα and IFN-γ may synergize to induce cytokine-driven lethal hyperinflammation and immune exhaustion in COVID-19 illness. Methods. To assess TNFα-antagonist therapy, 18 hospitalized adults with hypoxic respiratory failure and COVID-19 pneumonia received single-dose infliximab-abda therapy 5mg/kg intravenously between April and December 2020. The primary endpoint was time to increase in oxygen saturation to fraction of inspired oxygen ratio (SpO2/FiO2) by ≥ 50 compared to baseline and sustained for 48 hours. Secondary endpoints included 28-day mortality, dynamic cytokine profiles (Human Cytokine 48-Plex Discovery Assay), secondary infections, duration of supplemental oxygen support and hospitalization. Hospitalized patients with SARS-COV2 infection and pneumonia that were referred to the infliximab-abda study team for evaluation. Results. Patients were predominantly in critical respiratory failure (15/18, 83%), male (14/18, 78%), above 60 years (median 63 yrs, range 31-80), race-ethnic minorities (13/18, 72%), lymphopenic (13/18, 72%), steroid-treated (17/18, 94%), with a median ferritin of 1953ng/ml. Sixteen patients (89%) met the primary endpoint within a median of 4 days, 15/18 (83%) recovered from respiratory failure, and 14/18 (78%) were discharged in a median of 8 days and were alive at 28-day follow-up. Deaths among three patients ≥ 65 years age with pre-existing lung disease or multiple comorbidities were attributed to secondary lung infections. Mean plasma IP-10 levels declined sharply from 9183 pg/ml to 483 pg/ml at Day 3 and 146 pg/ml at Day 14/discharge. Significant declines in IFN-γ, TNFα, IL-27, IL-6 (baseline above 10pg/ml), CRP and ferritin were specifically observed at Day 3 whereas other cytokines were unaffected. Among 13 lymphopenic patients, six (46%) had resolution of lymphopenia by day 3, and 11 by day 14. CXCR3-ligand (IP-10 and CXCL-9) declines were strongly correlated among patients with lymphopenia reversal (Day 3, Pearson r: 0.98, p-value: 0.0006). following treatment with infliximab-abda. The status of the patient at last follow-up (discharged, alive or dead) is indicated. ECMO: extracorporeal membrane oxygenation Control of inflammatory markers and cytokines following infliximab therapy Values from individuals are connected with solid lines, with deceased individuals indicated in red. Statistics: n=18, paired ratio t-test compared to baseline;∗: P<0.05, ∗∗: P<0.01, ∗∗∗: P<0.001, ∗∗∗∗: P<0.0001, n.s.: not significant. Conclusion. Consistent with a central role of TNFα, the clinical and cytokine data indicate that infliximab-abda may rapidly abrogate pathological inflammatory signaling to facilitate clinical recovery in severe and critical COVID-19. Randomized studies are formally evaluating infliximab therapy in this context. Funding: National Center for Advancing Translational Sciences.

Convalescent plasma for hospitalized patients with COVID-19: an open-label, randomized controlled trial.

The efficacy of convalescent plasma for coronavirus disease 2019 (COVID-19) is unclear. Although most randomized controlled trials have shown negative results, uncontrolled studies have suggested that the antibody content could influence patient outcomes. We conducted an open-label, randomized controlled trial of convalescent plasma for adults with COVID-19 receiving oxygen within 12 d of respiratory symptom onset ( NCT04348656 ). Patients were allocated 2:1 to 500 ml of convalescent plasma or standard of care. The composite primary outcome was intubation or death by 30 d. Exploratory analyses of the effect of convalescent plasma antibodies on the primary outcome was assessed by logistic regression. The trial was terminated at 78% of planned enrollment after meeting stopping criteria for futility. In total, 940 patients were randomized, and 921 patients were included in the intention-to-treat analysis. Intubation or death occurred in 199/614 (32.4%) patients in the convalescent plasma arm and 86/307 (28.0%) patients in the standard of care arm-relative risk (RR) = 1.16 (95% confidence interval (CI) 0.94-1.43, P = 0.18). Patients in the convalescent plasma arm had more serious adverse events (33.4% versus 26.4%; RR = 1.27, 95% CI 1.02-1.57, P = 0.034). The antibody content significantly modulated the therapeutic effect of convalescent plasma. In multivariate analysis, each standardized log increase in neutralization or antibody-dependent cellular cytotoxicity independently reduced the potential harmful effect of plasma (odds ratio (OR) = 0.74, 95% CI 0.57-0.95 and OR = 0.66, 95% CI 0.50-0.87, respectively), whereas IgG against the full transmembrane spike protein increased it (OR = 1.53, 95% CI 1.14-2.05). Convalescent plasma did not reduce the risk of intubation or death at 30 d in hospitalized patients with COVID-19. Transfusion of convalescent plasma with unfavorable antibody profiles could be associated with worse clinical outcomes compared to standard care.

Acute Kidney Injury and Renal Replacement Therapy in COVID-19 Versus Other Respiratory Viruses: A Systematic Review and Meta-Analysis.

BACKGROUND: Acute kidney injury (AKI) is a potentially fatal complication of Coronavirus Disease-2019 (COVID-19). Binding of the Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2), the virus responsible for COVID-19, to its viral receptor, angiotensin converting enzyme 2 (ACE2), results in viral entry and may cause AKI. OBJECTIVES: We performed a systematic review and meta-analysis of the frequencies of AKI and renal replacement therapy (RRT) in critically ill COVID-19 patients and compared those frequencies with patients who were infected by respiratory viruses that bind or downregulate ACE2 (ACE2-associated viruses) and viruses that do not bind nor downregulate ACE2 (non-ACE2-associated viruses). DESIGN: Systematic review and meta-analysis. SETTING: Observational studies on COVID-19 and other respiratory viral infections reporting AKI and RRT were included. The exclusion criteria were non-English articles, non-peer-reviewed articles, review articles, studies that included patients under the age of 18, studies including fewer than 10 patients, and studies not reporting AKI and RRT rates. PATIENTS: Adult COVID-19, Severe Acute Respiratory Syndrome (SARS), Middle East Respiratory Syndrome (MERS), and influenza patients. MEASUREMENTS: We extracted the following data from the included studies: author, year, study location, age, sex, race, diabetes mellitus, hypertension, chronic kidney disease, shock, vasopressor use, mortality, intensive care unit (ICU) admission, ICU mortality, AKI, and RRT. METHODS: We systematically searched PubMed and EMBASE for articles reporting AKI or RRT. AKI was defined by authors of included studies. Critical illness was defined by ICU admission. We performed a random effects meta-analysis to calculate pooled estimates for the AKI and RRT rate within each virus group using a random intercept logistic regression model. RESULTS: Of 23 655 hospitalized, critically ill COVID-19 patients, AKI frequencies were not significantly different between COVID-19 patients (51%, 95% confidence interval [CI]: 44%-57%) and critically ill patients infected with ACE2-associated (56%, 95% CI: 37%-74%, P = .610) or non-ACE2-associated viruses (63%, 95% CI: 43%-79%, P = .255). Pooled RRT rates were also not significantly different between critically ill, hospitalized patients with COVID-19 (20%, 95% CI: 16%-24%) and ACE2-associated viruses (18%, 95% CI: 8%-33%, P = .747). RRT rates for both COVID-19 and ACE2-associated viruses were significantly different (P < .001 for both) from non-ACE2-associated viruses (49%, 95% CI: 44%-54%). After adjusting for shock or vasopressor use, AKI and RRT rates were not significantly different between groups. LIMITATIONS: Limitations of this study include the heterogeneity of definitions of AKI that were used across different virus studies. We could not match severity of infection or do propensity matching across studies. Most of the included studies were conducted in retrospective fashion. Last, we did not include non-English publications. CONCLUSIONS: Our findings suggest that viral ACE2 association does not significantly alter the rates of AKI and RRT among critically ill patients admitted to the ICU. However, the rate of RRT is lower in patients with COVID-19 or ACE2-associated viruses when compared with patients infected with non-ACE2-binding viruses, which might partly be due to the lower frequencies of shock and use of vasopressors in these two virus groups. Prospective studies are necessary to demonstrate whether modulation of the ACE2 axis with Renin-Angiotensin System inhibitors impacts the rates of AKI and whether they are beneficial or harmful in COVID-19 patients.

MISE EN CONTEXTE: L'insuffisance rénale aiguë (IRA) est une complication potentiellement mortelle de la maladie à coronavirus-2019 (COVID-19). Obligatoire du Coronavirus 2 du Syndrome Respiratoire Aigu Sévère (SARS-CoV-2), le virus responsable du COVID-19, à son récepteur, l'enzyme de conversion de l'angiotensine 2 (ACE2), entraîne une entrée virale et peut provoquer une IRA. OBJECTIFS DE L'ÉTUDE: Nous avons effectué une revue systématique et une méta-analyse des fréquences de l'IRA et de la thérapie de remplacement renal (RRT) chez les patients COVID-19 gravement malades et a comparé ces fréquences avec les patients qui ont été infectés par des voies respiratoires virus qui lient ou régulent négativement l'ACE2 (virus associés à l'ACE2) et les virus qui ne régulent pas négativement ni ne lient l'ACE2 (virus non associés à l'ACE2). CADRE ET TYPE D'ÉTUDE: Revue systématique et méta-analyse. Des études d'observation sur le COVID-19 et d'autres infections virales respiratoires signalant une AKI et une RRT ont été incluses. Les critères d'exclusion étaient des articles non anglophones, des articles non évalués par des pairs, des articles de revue, des études incluant des patients moins de 18 ans, les études incluant moins de 10 patients et les études ne rapportant pas les taux d'IRA et de RRT. PATIENTS: Adultes COVID-19, syndrome respiratoire aigu sévère (SRAS), syndrome respiratoire du Moyen-Orient (MERS) et malades de la grippe. MESURES: Nous avons extrait les données suivantes des études incluses : auteur, année, lieu de l'étude, âge, sexe, race, diabète sucré, hypertension, maladie rénale chronique, état de choc, utilisation de vasopresseurs, mortalité, admission en unité de soins intensifs (USI), Mortalité en soins intensifs, AKI et RRT. MÉTHODOLOGIE: Nous avons systématiquement recherché dans PubMed et EMBASE les articles rapportant AKI ou RRT. AKI a été défini par les auteurs des études incluses. La maladie grave a été définie par l'admission aux soins intensifs. Nous avons effectué une méta-analyse à effets aléatoires pour calculer estimations regroupées pour le taux d'IRA et de RRT au sein de chaque groupe de virus à l'aide d'un modèle de régression logistique d'interception aléatoire. RÉSULTATS: Sur 23 655 patients hospitalisés et gravement malades COVID-19, les fréquences AKI n'étaient pas significativement différentes entre patients COVID-19 (51 %, intervalle de confiance à 95 % [IC] : 44 %-57 %) et patients gravement malades infectés par l'ACE2 associé (56 %, IC à 95 % : 37 % à 74 %, P = 0,610) ou des virus non associés à l'ACE2 (63 %, IC à 95 % : 43 % à 79 %, P = 0,255). Tarifs RRT groupés n'étaient pas non plus significativement différents entre les patients hospitalisés gravement malades atteints de COVID-19 (20 %, IC à 95 % : 16 % à 24 %) et virus associés à l'ACE2 (18 %, IC à 95 % : 8 % à 33 %, P = 0,747). Taux de RRT pour les virus associés au COVID-19 et à l'ACE2 étaient significativement différents (P < 0,001 pour les deux) des virus non associés à l'ACE2 (49 %, IC à 95 % : 44 % à 54 %). Après ajustement pour le choc ou l'utilisation de vasopresseurs, les taux d'IRA et de RRT n'étaient pas significativement différents entre les groupes. LIMITES DE L'ÉTUDE: Les limites de cette étude incluent l'hétérogénéité des définitions de l'IRA qui ont été utilisées pour différents virus études. Nous n'avons pas pu faire correspondre la gravité de l'infection ou faire une correspondance de propension entre les études. La plupart des études incluses ont été menées de manière rétrospective. Enfin, nous n'avons pas inclus les publications non anglophones. CONCLUSIONS: Nos résultats suggèrent que l'association virale ACE2 ne modifie pas de manière significative les taux d'IRA et de RRT parmi les patients gravement malades admis aux soins intensifs. Cependant, le taux de RRT est plus faible chez les patients atteints de COVID-19 ou associés à l'ACE2 virus par rapport aux patients infectés par des virus ne se liant pas à l'ACE2, ce qui pourrait être dû en partie à la plus faible fréquences de choc et utilisation de vasopresseurs dans ces deux groupes de virus. Des études prospectives sont nécessaires pour démontrer si la modulation de l'axe ACE2 avec les inhibiteurs du système rénine-angiotensine a un impact sur les taux d'IRA et si ells sont bénéfiques ou nocifs chez les patients COVID-19.

Burnout in the disaster response workforce: The impact of work roles and the COVID-19 pandemic

The coronavirus-2019 (COVID-19) pandemic corresponded with a record-breaking year for billion-dollar disasters. While the pandemic swept across the United States, the country also experienced a record-setting hurricane season on the East Coast and an unprecedented wildfire season on the West Coast. These co-occurring threats have placed unprecedented strain on our disaster response workforce with potential long-term implications for turnover and disaster response efficacy. In this paper, we draw from the Job Demands-Resources model to address the influence of workers’ role stressors and community infection rates during the COVID-19 pandemic and job burnout and turnover in the disaster response workforce. © 2021 Weston Medical Publishing. All rights reserved.

Counselling patients for return to work on immunosuppression: practices of Canadian specialists during the COVID-19 pandemic

Objective The COVID-19 pandemic has infected over 870,000 Canadians and caused 22,000 deaths. Many patients are attempting to balance health and financial stability. Therefore, we sought to determine how physicians who frequently prescribe immunosuppressive medications are counselling patients on return-to-work prior to widespread vaccine distribution and understand their decision processes. Methods We administered a survey through the Canadian Rheumatology, Gastroenterology and Dermatology Associations. Physicians were asked whether patients have requested counselling on return-to-work during the pandemic and how they decide what advice to provide. They were shown seven clinical scenarios of patients on immunosuppressive medications, then asked whether they would provide a medical note advocating for delayed return-to-work or modified duties to reduce exposure. Results 151 physicians took the survey. 94% were asked for advice on return-to-work. 33% felt informed enough to provide counselling. When patients requested a medical note, physicians provided one 25% of the time. Factors most associated with providing notes were patient comorbidities, age, glucocorticoids, high risk work and vulnerable co-inhabitants. Conventional synthetic and biologic immunosuppressants did not prompt most physicians to provide a note. Respondents considered patient perspectives and workplace factors. Several requested guidelines to approach these encounters. Conclusion Almost all rheumatologists, dermatologists and gastroenterologists have been asked to counsel patients on returning to work during the COVID-19 pandemic. Most do not feel informed enough to do so. Medical notes for acconunodations are only provided a minority of the time, unless specific factors (e.g. glucocorticoids) are present. Guidance is needed to inform these decisions.

Convalescent plasma for hospitalized patients with COVID-19 and the effect of plasma antibodies: a randomized controlled, open-label trial (preprint)

The efficacy of convalescent plasma for COVID-19 is unclear. While most randomized controlled trials have shown negative results, uncontrolled studies have suggested that the antibody content may influence patient outcomes. We conducted an open-label, randomized controlled trial of convalescent plasma for adults with COVID-19 receiving oxygen within 12 days of respiratory symptom onset. Patients were allocated 2:1 to 500 mL of convalescent plasma or standard of care. The composite primary outcome was intubation or death by 30 days. The effect of convalescent plasma antibodies on the primary outcome was assessed by logistic regression. The trial was terminated at 78% of planned enrollment after meeting stopping criteria for futility. 940 patients were randomized and 921 patients were included in the intent-to-treat analysis. Intubation or death occurred in 199/614 (32.4%) in the convalescent plasma arm and 86/307 (28.0%) in the standard of care arm; relative risk (RR) 1.16 (95% confidence interval (CI) 0.94-1.43; p=0.18). Patients in the convalescent plasma arm had more serious adverse events (33.4% vs. 26.4%; RR=1.27, 95% CI 1.02-1.57, p=0.034). The antibody content significantly modulated the therapeutic effect of convalescent plasma. In multivariate analysis, each standard log increase in neutralization or antibody-dependent cellular cytotoxicity independently reduced the potential harmful effect of plasma (OR=0.74; 0.57-0.95 and OR=0.66; 0.50-0.87, respectively), while IgG against the full transmembrane Spike protein increased it (OR=1.53, 95% CI 1.14-2.05). Convalescent plasma did not reduce the risk of intubation or death at 30 days among hospitalized patients with COVID-19. Transfusion of convalescent plasma with unfavourable antibody profiles may be associated with worse clinical outcomes compared to standard care.

Convalescent plasma for adults with acute COVID-19 respiratory illness (CONCOR-1): study protocol for an international, multicentre, randomized, open-label trial.

BACKGROUND: Convalescent plasma has been used for numerous viral diseases including influenza, severe acute respiratory syndrome, Middle East respiratory syndrome and Ebola virus; however, evidence to support its use is weak. SARS-CoV-2 is a novel coronavirus responsible for the 2019 global pandemic of COVID-19 community acquired pneumonia. We have undertaken a randomized controlled trial to assess the efficacy and safety of COVID-19 convalescent plasma (CCP) in patients with SARS-CoV-2 infection. METHODS: CONCOR-1 is an open-label, multicentre, randomized trial. Inclusion criteria include the following: patients > 16 years, admitted to hospital with COVID-19 infection, receiving supplemental oxygen for respiratory complications of COVID-19, and availability of blood group compatible CCP. Exclusion criteria are : onset of respiratory symptoms more than 12 days prior to randomization, intubated or imminent plan for intubation, and previous severe reactions to plasma. Consenting patients are randomized 2:1 to receive either approximately 500 mL of CCP or standard of care. CCP is collected from donors who have recovered from COVID-19 and who have detectable anti-SARS-CoV-2 antibodies quantified serologically. The primary outcome is intubation or death at day 30. Secondary outcomes include ventilator-free days, length of stay in intensive care or hospital, transfusion reactions, serious adverse events, and reduction in SARS-CoV-2 viral load. Exploratory analyses include patients who received CCP containing high titre antibodies. A sample size of 1200 patients gives 80% power to detect a 25% relative risk reduction assuming a 30% baseline risk of intubation or death at 30 days (two-sided test; α = 0.05). An interim analysis and sample size re-estimation will be done by an unblinded independent biostatistician after primary outcome data are available for 50% of the target recruitment (n = 600). DISCUSSION: This trial will determine whether CCP will reduce intubation or death non-intubated adults with COVID-19. The trial will also provide information on the role of and thresholds for SARS-CoV-2 antibody titres and neutralization assays for donor qualification. TRIAL REGISTRATION: Clinicaltrials.gov NCT04348656 . Registered on 16 April 2020.

Aging-Related Concerns of People Living with HIV Referred for Geriatric Consultation.

PURPOSE: People with HIV (PWH) are living longer lives and likely experiencing accentuated aging. Comprehensive geriatric assessment (CGA) has been proposed as a way to identify and help meet each individual patient's needs. PATIENTS AND METHODS: We performed a retrospective review of the results of CGA in an HIV clinic in New York City. CGA included assessment of basic and instrumental activities of daily living, screens for depression, anxiety, frailty, cognition, and quality of life, along with general discussion of concerns and goals. We compared the group of PWH referred for CGA to those of comparable age who were not referred to determine the factors that were associated with referral. We carried out a descriptive analysis of those undergoing CGA, along with regression to determine factors associated with poorer PHQ-2 depression scores and higher VACS score. RESULTS: A total of 105 patients underwent full CGA during the study period. Mean age of referred patients was 66.5 years, ranging from 50 to 84 years (SD 7.99). More than 92% were virally suppressed. Compared with their non-referred counterparts over 50, referred patients were older and had more functional comorbidities like cerebrovascular disease, neuropathy, and urinary incontinence. More than half complained of fatigue, and 2/3 noted poor memory. Almost 60% were frail or prefrail. Ninety patients were asked about their goals, and the most commonly cited were related to health or finances; fifteen patients were unable to articulate any goals. Having fewer goals and noting weight loss or fatigue were predictive of higher scores on the PHQ-2 depression screen. CONCLUSION: Although most older PWH undergoing CGA can manage their ADL, many have concerns and deficits beyond their comorbidities. CGA offers an important window into the psychosocial concerns and needs of older PWH.