I am surprised that it works so well”: clinicians' views on delivering psychological assessments and therapy to young people in a fully-digital mental health service

Purpose: Many mental health clinicians have delivered services digitally in response to the COVID-19 pandemic. Emerging research suggests that, despite some initial discomfort, therapists appear to adjust to remote working. The purpose of this study is to explore the views of clinicians working within a fully digital organisation towards digital service provision. Design/methodology/approach: Clinicians (N = 52) providing digital mental health assessments and treatments at Healios anonymously completed a mixed-methods questionnaire. Findings: In all, 85% of participants enjoyed working remotely and 71% thought they would continue to work online over the next 5–10 years. Of the participants, 40% reported low confidence in online work's efficacy before working remotely, but 96% reported confidence at the time of questionnaire completion: suggesting confidence increased with experience. An exploratory "inverted” factor analysis generated a two-factor solution, grouping clinicians into two factors based on key views. Factor 1 was predominantly characterised by satisfaction with training received and factor 2 by quality of technical experiences (encountering problems less often and greater personal confidence in resolving them). Qualitative feedback described some benefits of, and barriers to, digital service provision. Clinicians reflected on a perceived change in cultural norms, with more openness to digital services following the COVID-19 pandemic. On a personal level, teletherapy was viewed more favourably with increased personal experience. Originality/value: Clinicians' confidence in providing services digitally is discussed, with reference to how this may be affected by extent of remote working experience and availability of technical support. Staff well-being within the digital workspace is also discussed. © 2023, Emerald Publishing Limited.

Pandemic Parallels: Common Threads between the COVID-19 Pandemic and the Ebola Virus Disease Epidemic of 2014

Purpose This analysis explored the parallels between the 2014-2016 Ebola virus disease (EVD) epidemic in West Africa and SARS-CoV-2 and its associated disease (Coronavirus disease 2019 [COVID-19] in order to compare and contrast patterns that enable or exacerbate epidemics of novel or non-endemic pathogens. Methods & Materials Our research team developed a core set of ten questions focused on features common to major disease epidemics, including the natural reservoir of the infectious agent, the initially impacted populations, resulting societal impacts, the political response parameters and dynamics, resulting scientific discoveries, long-term morbidity in patients, and disproportionately impacted populations. We utilized both the primary literature and contemporary accounts such as news coverage and documentary accounts to determine full answers to the core questions. Commonalities between the emergence of Ebola and SARS-CoV-2 were identified. Results Seven of the ten questions identified positive parallels between the Ebola and COVID-19 pandemics. These include the the damaging effects of public mistrust of health officials on disease transmission, negative impact of slow country-level responses, the introduction of lifelong morbidities in patients, disproportionate disease impacts on vulnerable populations, and the positive impact of governmental research funding on the pace of vaccine development and distribution. Conclusion This analysis identifies multiple common factors that influenced the epidemic dynamics and disease burdens of Ebola Virus Disease and SARS-CoV-2/COVID-19, despite the differences in transmission dynamics. Policies mindful of these impacts can guide future responses to rapidly growing outbreaks.

Renin-angiotensin-aldosterone system inhibition is associated with reduced in-hospital mortality in critically ill covid-19 patients with pre-existing hypertension

Background: The virus responsible for COVID-19 enters human cells by binding angiotensinconverting enzyme 2. The influence of renin-angiotensin-aldosterone system (RAAS) inhibitors, including angiotensin-converting enzyme inhibitors (ACEi) and angiotensin receptor blockers (ARBs), remains uncertain. Aim: To examine the role of ACEi / ARB exposure on outcomes in COVID-19 patients with preexisting hypertension (HTN) admitted to intensive care units (ICU). Methods: The COVID-19 Critical Care Consortium is a prospective, observational cohort study of patients requiring ICU admission for active COVID-19 spanning 354 participating sites in 54 countries. Patients >18 years old with pre-existing HTN requiring antihypertensive therapy were analysed. Length of stay and in-hospital mortality to 90 days post ICU admission were analysed as time-to-eventoutcomes by multistate survival analysis, and the influence of ACEi / ARB use on the hazards of death and discharge by multi-state Cox proportional hazard modelling and sensitivity analysis. Results: From December 1, 2019 through December 30, 2020, 663 eligible patients were registered. Of these, 480 patients had received ACEi and / or ARB therapy (median age 65 years, 67% male) in the 2 weeks before ICU admission, while 183 had not (66 years, 61% male). Average lengths of ICU and general ward stays were longer in the ACEi / ARB than non-ACEi / ARB group (20.8 days and 6.5 days vs. 15.5 and 6.0 days, respectively). ACEi / ARB use was associated with a decreased hazard of death (HR, 0.69, 95% CI, 0.54 -0.88) that persisted after adjusting for propensity scores (0.67, 0.53 -0.86). Cumulative probabilities (unadjusted for baseline characteristics) for death and discharge post ICU admission are depicted in the figure for ACEi/ARB (red) and non-ACEi / ARB (blue) patients. Conclusions: In 663 critically ill COVID-19 patients with pre-existing HTN, RAAS inhibition pre-ICU admission was linked to reduced in-hospital mortality.

COVID-19: Highlighting Health Disparities in the Los Angeles Latinx Community.

Objective: Characterization of COVID-19 in the Latinx community is necessary for guiding public health initiatives, health system policy, clinical management practices, and improving outcomes. Our aim was to describe the socioeconomic background and clinical profile of patients with COVID-19 at a large public hospital in Los Angeles to improve health disparities leading to poor outcomes during the pandemic.Design, Setting and Participants: A single center retrospective cross-sectional study of all patients with a positive polymerase chain reaction (PCR) test for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) who presented to Los Angeles County (LAC)+University of Southern California (USC) Medical Center between March 15, 2020 and April 30, 2020.Methods: We describe patient characteristics, socioeconomic factors, laboratory findings, and outcomes of the first 278 patients to present to LAC+USC Medical Center with COVID-19.Results: Patients self-identified as Hispanic (82.4%) or non-Hispanic (17.6%). Hispanic patients presented later from symptom onset (6 days vs 3 days, P = 0.027) and had higher post-intubation mortality (40.9% vs. 33.3%, P = 1), intensive care unit (ICU) mortality (31.1% vs. 22.2%, P = 0.87), and overall mortality (11.1% vs 10.2%, P = 1). However, the difference in admission rates, mechanical ventilation rates, and overall mortality rates were not statistically significant. A majority of patients, 275/278 (98.9%), reported residency ZIP codes in areas of higher population density, higher percentage of Latinx, born outside the United States, lower median income, and lower high school graduation rate when compared to the rest of Los Angeles County. Regression analysis within the Hispanic cohort found that age, history of hypertension, history of diabetes, lactate dehydrogenase (LDH), and C-reactive protein (CRP) were predictors of mechanical ventilation and mortality.Conclusion: We show the Latinx community has been disproportionally affected by the pandemic in Los Angeles and we identified multiple socioeconomic and clinical characteristics that predispose this population to COVID-19 infection. This study highlights the need for change in local and national strategies to protect vulnerable communities during public health outbreaks.

Evaluation of a new mobile diagnostic imaging services at a tertiary Spinal Cord Rehabilitation Program during the COVID-19 pandemic

Background: As a standalone tertiary spinal cord rehabilitation program, our patients requiring diagnostic imaging during their inpatient stay need to be transported to an acute care hospital to receive these services. Over the course of inpatient rehabilitation, patients routinely travel to acute care hospitals for diagnostic imaging for surgical follow-up, musculoskeletal injuries, vascular complications such as deep vein thrombosis and other medical complications. Due to travel and wait time, patients typically miss at least a half day of therapy to attend imaging appointments. At the beginning of the COVID-19 pandemic, an urgent need arose to develop a new approach to diagnostic imaging due to a significant reduction in access to acute care diagnostic imaging and in order to reduce the risk of patient exposure to COVID-19. Objective: The goal of this initiative was to implement a new, mobile diagnostic imaging service that would minimize external travel during inpatient rehab, reduce risk of exposure to COVID-19, reduce lost therapy hours, while at least remaining cost-neutral. In order to evaluate this service, the costs and benefits associated with this mobile x-ray and ultrasound service were examined. Methods: With the support of Joint Department of Medical Imaging, our SCI rehab program partnered with STL Diagnostic Imaging to provide onsite x-ray and ultrasound imaging.The service began on May 11, 2020 and consisted of mobile x-ray imaging twice per week and mobile ultrasound scans once per week for two hours each. All imaging was conducted in patient rooms by STL technologists. Monthly STL billing costs were compared to estimated transportation costs for patients. Typical transportation costs range from $60-$284 depending on mode of transportation. Results: Between May 11, 2020 and January 28, 2021, 144 patients received 203 x-ray images over 67 x-ray days and 81 patients received 105 ultrasound scans over 37 ultrasound days. Over this timeframe, the approximate savings in transportation costs ranged from $7114 to $20,753. In addition, it is estimated that 225 - 450 lost therapy hours were avoided since patients did not have to travel for imaging and therefore avoided missing scheduled therapy appointments. Although not formally evaluated, physician, patient and nursing staff satisfaction regarding this new service has also been extremely positive. Conclusion: Although implemented out of necessity during the pandemic, this partnership to provide mobile diagnostic imaging has been cost-effective and beneficial to patients.

Rare loss-of-function variants in type I IFN immunity genes are not associated with severe COVID-19.

A recent report found that rare predicted loss-of-function (pLOF) variants across 13 candidate genes in TLR3- and IRF7-dependent type I IFN pathways explain up to 3.5% of severe COVID-19 cases. We performed whole-exome or whole-genome sequencing of 1,864 COVID-19 cases (713 with severe and 1,151 with mild disease) and 15,033 ancestry-matched population controls across 4 independent COVID-19 biobanks. We tested whether rare pLOF variants in these 13 genes were associated with severe COVID-19. We identified only 1 rare pLOF mutation across these genes among 713 cases with severe COVID-19 and observed no enrichment of pLOFs in severe cases compared to population controls or mild COVID-19 cases. We found no evidence of association of rare LOF variants in the 13 candidate genes with severe COVID-19 outcomes.

Prevalence of Poor Sleep Quality Among Physicians During the COVID-19 Pandemic.

BACKGROUND: Sleep quality is influenced adversely or favorably by various intrinsic and extrinsic factors and sleep deprivation is a common problem facing doctors. OBJECTIVES: To assess sleep quality among physicians during coronavirus disease 2019 (COVID-19) pandemic and correlate it with possible predictors. METHODS: This cross-sectional four-months study included a total of 344 physicians from different medical centers in the period between July 2020 and October 2020, during the COVID-19 pandemic. Physicians were aged between 24 and 60 years from different specialties. Data were collected using the Pittsburgh Sleep Quality Index (PSQI) questionnaire and Hospital Anxiety Depression Scale (HADS). RESULTS: Among our participant physicians there was poor sleep quality in 71.2%, while good sleep quality was present in 28.8%. There were significant correlations between poor sleep quality and the following parameters in the univariate logistic regression analysis: anxiety features (P value <0.001), depressive features (P value <0.001), and past history of COVID-19 (P value 0.003). However, multivariate logistic regression analysis showed that only the presence of anxiety features (P value <0.001) and depressive features (P value <0.001) could be used as significant independent predictor of poor sleep quality among physicians during COVID-19. CONCLUSION: Presence of anxiety and or depressive features among physicians are the most significant independent predictors of poor sleep quality during the COVID-19 pandemic.

Assessment of contact lens wearers' attitude toward contact lens wear and care during Coronavirus Disease 2019 (COVID-19) pandemic: A cross-sectional online survey.

AIM: COVID-19 is caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). Several reports have provided conflicting recommendations regarding contact lenses (CL) use during COVID-19, causing confusion among CL wearers. The aim of this study is to assess CL wearers' attitudes toward CL wear and care during COVID-19 pandemic. METHODS: A web-based cross-sectional online survey was used to assess the participants' attitude toward CL wear and care during the COVID-19 pandemic. The survey layout was based on Google form® specifically developed for CL wearers. Demographic characteristics and CL history and profile were also collected for each participant. RESULTS: A total of 196 CL wearers completed the online survey with an average age was 26 (± 4.1) and 90.8 % of participants were females. As reported by the participants, social media was the main source of information about COVID-19. 38.8 % of the study population reported stopping CL wear during the pandemic. The main stated reason for lens discontinuation was decreased social activities during the pandemic. 61.2 % of participants continued lens wear, with the majority reported considerable changes in their behaviors toward CL wear and care during the pandemic. This includes reinforced hands cleaning before and after lens wear, disinfecting of CLs and CL case and less frequent CL aftercare visits. CONCLUSION: The majority of the study population have continued CL wear during the pandemic. Contact lens wearers reported profound changes in attitudes toward CL wear including improved care and maintenance. Additionally, changes in CL purchase habit have been reported with more tendency for online purchase. CL cessation has been associated with several perceived reasons mainly attributed to reduced outdoor activity and fear of ocular infection. Levels of compliance among CL wearers should be assessed and reinforced during the current pandemic and similar lockdown situation to reduce possible CL-related complications and dropout.

A double-edged sword: Prolongeddetection of SARS-COV-2 in patients receiving cancer-directed therapy

Introduction: SARS-CoV2 (S-2) infection duration (S-2-D) and its impact on patients with cancer and mild tomoderate COVID-19 undergoing cancer-directed therapy (CDT), especially in the underserved population, is notwell described. We conducted a retrospective study to analyze S-2 positive (+) patients on CDT to describe the S-2-D and its impact on CDT. Methods: 299 patients with cancer were tested with nasopharyngeal (NP) S-2 PCR assay at Columbia UniversityMedical Irving Center (CUIMC), a Minority-NCI Community Oncology site, of whom 77(26%) tested positive. Weretrospectively analyzed 25 S-2 (+) patients with mild to moderate COVID-19 receiving CDT. NP PCR wererepeated every one to two weeks until two successive negative (-) PCRs were obtained prior to restarting CDT. Timeto two (-) PCR and serology results were recorded. Cycling thresholds (Ct) were obtained for S-2 specific targetsand represented an indirect measure of viral load. Results: Demographics of N=25 patients included Hispanic (N=17, 68%), Black (N=1, 4%), White (N=6, 24%), andundeclared (N=1, 4%). Among the tumor histologies represented, gastrointestinal (N = 9, 36%), breast (N = 4, 16%), sarcoma (N = 3, 12%), and myeloma (N=2, 8%) were most common. Median time in days (d) to two (-) PCR was 24(6-69). Nine (36%) patients were persistently (+) for more than six weeks. 20 patients had CDT interruption with amedian time of 55 days off CDT. Two (10%) patients experienced disease progression during CDT interruption. 13patients had >1 sequential (+) PCR. The mean time between 1st and 2nd NP S-2 PCR was 16d. There was a non-statistically significant trend towards a higher S-2 specific Ct on the 2nd NP S-2 PCR as compared to the 1st (31.21vs 22.31, p=0.10). One patient was noted to be PCR (+) despite having developed S-2-specific IgG. Conclusion: Patients with cancer receiving CDT appear to have prolonged detectable S-2 by PCR, which can leadto interruption of CDT and POD in patients. Patients from underserved communities may be at greater risk givenhealth care disparities. Further data are needed to help select patients with mild to moderate COVID-19 who cansafely continue CDT while balancing the risk of worsening infection and risk of spread. The increased Ct over time inour patients suggest a decrease in viral load and infectious probability. Our lack of statistical significance is likelydue to small sample size. Ct along with serology can be tools to help guide when and which patients can restartCDT. However, these tests need further investigation for applicability and validity.

Failure to replicate the association of rare loss-of-function variants in type I IFN immunity genes with severe COVID-19 (preprint)

A recent report found that rare predicted loss-of-function (pLOF) variants across 13 candidate genes in TLR3- and IRF7-dependent type I IFN pathways explain up to 3.5% of severe COVID-19 cases. We performed whole-exome or whole-genome sequencing of 1,934 COVID-19 cases (713 with severe and 1,221 with mild disease) and 15,251 ancestry-matched population controls across four independent COVID-19 biobanks. We then tested if rare pLOF variants in these 13 genes were associated with severe COVID-19. We identified only one rare pLOF mutation across these genes amongst 713 cases with severe COVID-19 and observed no enrichment of pLOFs in severe cases compared to population controls or mild COVID-19 cases. We find no evidence of association of rare loss-of-function variants in the proposed 13 candidate genes with severe COVID-19 outcomes.

Furin cleaves SARS-CoV-2 spike-glycoprotein at S1/S2 and S2'for viral fusion/entry: indirect role for TMPRSS2 (preprint)

The Spike (S)-protein of SARS-CoV-2 binds host-cell receptor ACE2 and requires proteolytic 'priming' (S1/S2) and 'fusion-activation' (S2') for viral entry. The S-protein furin-like motifs PRRAR685{downarrow} and KPSKR815{downarrow} indicated that proprotein convertases promote virus entry. We demonstrate that furin and PC5A induce cleavage at both sites, ACE2 enhances S2' processing, and their pharmacological inhibition (BOS-inhibitors) block endogenous cleavages. S1/S2-mutations (S1/S2) limit S-protein-mediated cell-to-cell fusion, similarly to BOS-inhibitors. Unexpectedly, TMPRSS2 does not cleave at S1/S2 or S2', but it can: (i) cleave/inactivate S-protein into S2a/S2b; (ii) shed ACE2; (iii) cleave S1-subunit into secreted S1', activities inhibited by Camostat. In lung-derived Calu-3 cells, BOS-inhibitors and S1/S2 severely curtail 'pH-independent' viral entry, and BOS-inhibitors alone/with Camostat potently reduce infectious viral titer and cytopathic effects. Overall, our results show that: furin plays a critical role in generating fusion-competent S-protein, and indirectly, TMPRSS2 promotes viral entry, supporting furin and TMPRSS2 inhibitors as potential antivirals against SARS-CoV-2

SARS-CoV-2 protein ORF3a is pathogenic in Drosophila and causes phenotypes associated with COVID-19 post-viral syndrome (preprint)

The Coronavirus Disease 2019 (COVID-19) pandemic has caused millions of deaths and will continue to exact incalculable tolls worldwide. While great strides have been made toward understanding and combating the mechanisms of Severe Acute Respiratory Syndrome Coronavirus-2 (SARS-CoV-2) infection, relatively little is known about the individual SARS-CoV-2 proteins that contribute to pathogenicity during infection and that cause neurological sequela after viral clearance. We used Drosophila to develop an in vivo model that characterizes mechanisms of SARS-CoV-2 pathogenicity, and found ORF3a adversely affects longevity and motor function by inducing apoptosis and inflammation in the nervous system. Chloroquine alleviated ORF3a induced phenotypes in the CNS, arguing our Drosophila model is amenable to high throughput drug screening. Our work provides novel insights into the pathogenic nature of SARS-CoV-2 in the nervous system that can be used to develop new treatment strategies for post-viral syndrome.

Updated guidance on the management of COVID-19: from an American Thoracic Society/European Respiratory Society coordinated International Task Force (29 July 2020).

BACKGROUND: Coronavirus disease 2019 (COVID-19) is a disease caused by severe acute respiratory syndrome-coronavirus-2. Consensus suggestions can standardise care, thereby improving outcomes and facilitating future research. METHODS: An International Task Force was composed and agreement regarding courses of action was measured using the Convergence of Opinion on Recommendations and Evidence (CORE) process. 70% agreement was necessary to make a consensus suggestion. RESULTS: The Task Force made consensus suggestions to treat patients with acute COVID-19 pneumonia with remdesivir and dexamethasone but suggested against hydroxychloroquine except in the context of a clinical trial; these are revisions of prior suggestions resulting from the interim publication of several randomised trials. It also suggested that COVID-19 patients with a venous thromboembolic event be treated with therapeutic anticoagulant therapy for 3 months. The Task Force was unable to reach sufficient agreement to yield consensus suggestions for the post-hospital care of COVID-19 survivors. The Task Force fell one vote shy of suggesting routine screening for depression, anxiety and post-traumatic stress disorder. CONCLUSIONS: The Task Force addressed questions related to pharmacotherapy in patients with COVID-19 and the post-hospital care of survivors, yielding several consensus suggestions. Management options for which there is insufficient agreement to formulate a suggestion represent research priorities.

Diabetic Ketoacidosis in Coronavirus Disease Patients With Type 2 Diabetes Mellitus.

The occurrence of diabetes is increasing globally and carries a variety of complications, such as thromboembolism, acute cerebrovascular accidents, and diabetic ketoacidosis (DKA). Although DKA is not commonly associated with type 2 diabetes (T2D), it can manifest in patients who have underlying comorbidities predisposed to DKA. Since the emergence of the coronavirus disease (COVID-19) pandemic, we have seen many cases and studies on the underlying pathophysiology of the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) pneumonia with or without respiratory failure. We have also learned that the angiotensin-converting enzyme receptor is one of the major entry sites of SARS-CoV-2 infection, and it might be one of the causes that predispose patients to DKA. However, few studies exist that explore the development of DKA in T2D with SARS-CoV-2 infection. We present two cases of patients with DKA and COVID-19 treated with an insulin regimen with no further complications.