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Purpose: The Coronavirus 2019 (COVID-19) pandemic impacted adult out-of-hospital arrest (OHCA) outcomes in the United States. The impact of the pandemic on pediatric OHCA is unknown. Materials and methods: An analysis of the Cardiac Arrest Registry to Enhance Survival for non-traumatic pediatric OHCAs (≤18 years) was conducted. Outcomes during 3 pandemic surge periods in 2020 (March 16 to May 15, July 1 to August 15, and October 16 to December 31) were compared to the same time periods pre-pandemic in 2019. The primary outcomes were overall survival and neurologically favorable survival, defined as a cerebral performance score of 1 or 2 at the time of hospital discharge. Age groups included infants (<1 year), children (1 to 11 years), and adolescents (≥12 years). Results: A total of 1381 pandemic surge period arrests were compared to 1274 pre-pandemic arrests. There was an increase in OHCAs in adolescents (pandemic 26.6% [368/1381], pre-pandemic 22.4% [286/1274], p = 0.01). Therewere no differences in OHCAs by sex, race/ethnicity, witness status, location, initial rhythm, bystander CPR rates or bystander AED use. There were no differences in overall survival during the pandemic surge periods in 2020 (10.6% [147/ 1381]), as compared to the same months in 2019 (9.7% [123/1274], p = 0.40) or in neurologically favorable survival (2020: 8.9% [123/1381] vs. 2019: 7.3% [93/1274], p = 0.13). Conclusions: During the COVID-19 pandemic surge periods in 2020, pediatric OHCA survival rates in the United Stateswere similar to the rates of pediatric OHCA pre-pandemic. Further study is warranted to determine if pediatric survival for OHCA was affected during the delta and omicron COVID-19 surges in 2021.
ABSTRACT
Background: Regional variations in the impact of the coronavirus disease-2019 (COVID-19) pandemic on out-of-hospital cardiac arrest (OHCA) have been reported. We aimed to examine differences in the community response, emergency medical services (EMS) interventions, and outcomes of OHCA, in Singapore (population 5.7 million) and Atlanta (population 4.16 million), before and during the pandemic. Methods: Using prospectively collected Singapore Pan-Asian Resuscitation Outcomes Study (PAROS) and Atlanta Cardiac Arrest Registry to Enhance Survival (CARES) data, we compared EMS-treated adult OHCAs (≥18 years) during the pandemic period (17weeks from the date of first confirmed COVID-19 case) and pre-pandemic period (corresponding weeks in 2019). The primary outcome was pre-hospital return of spontaneous circulation (ROSC). We reported adjusted odds ratios (aOR) for OHCA characteristics, pre-hospital interventions, and outcomes using binary logistic regression. Results: Of the 3987 EMS-treated OHCAs (overall median age 69 years, 60.1% males) in Singapore and Atlanta, 2084 occurred during the pandemic and 1903 during the pre-pandemic period. Compared with Atlanta, OHCA cases in Singapore were older (median age 72 vs 66 years), received more bystander interventions (65.1% vs 41.4% received cardiopulmonary resuscitation (CPR) and 28.4% vs 10.1% had automated external defibrillator application), yet observed less pre-hospital ROSC (11.3% vs 27.1%). When compared with the pre-pandemic period, the likelihood of residential OHCAs doubled in both cities during the pandemic;in Singapore, OHCAs were more likely to be witnessed (aOR 1.95, 95% confidence interval (CI), 1.59-2.39) yet less likely to receive CPR (aOR 0.81, 95% CI, 0.65-0.99) during the pandemic. OHCAs occurring during the pandemic, compared with pre-pandemic, were less likely to be transported in Singapore and Atlanta (aOR 0.50, 95% CI, 0.42%-0.85%, and 0.36, 95% CI, 0.26-0.50, respectively), without significant differences in overall pre-hospital ROSC. Conclusion: Changes in OHCA characteristics and pre-hospital interventions during the pandemic were likely collateral consequences, with regional variations partly reflecting differences in systems of care and other sociocultural factors. These highlight opportunities for public education and the need for further study into lower transport rates during the pandemic.
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Introduction: Immune checkpoint inhibitors (ICI) are commonly associated with gastrointestinal adverse events including colitis. We present a case of severe immune checkpoint inhibitor colitis managed with vedolizumab after failing standard treatment with steroids and infliximab. Case Description/Methods: A 75-year-old male with metastatic melanoma status post brain tumor resection, radiation therapy and 2 cycles of ipilimumab/nivolumab presented with severe new onset diarrhea 3 weeks after his second cycle of ICI. Given concern for ICI induced colitis, oral prednisone was started with initial improvement of diarrhea. Severe diarrhea recurred with tapering and he was admitted to the hospital. After infectious workup was negative, he received a dose of infliximab for presumed immune-mediated colitis with mild improvement. He was discharged on prednisone 60 mg daily with a rapid 2-week taper before receiving COVID-19 vaccination. He received a second dose of infliximab 2 weeks after the first. However, a week later, he was readmitted to the hospital with grade 3 diarrhea, dehydration, weakness, hypotension, and continued weight loss. Flexible sigmoidoscopy revealed continuous mucosal ulceration with congestion and loss of vascular markings from anus to sigmoid colon (Figure 1). Biopsies showed moderate to severe active colitis with ulceration, increased crypt apoptosis, and crypt dropout-most compatible with immune checkpoint inhibitor colitis. After 1 week of poor response to high dose methylprednisolone, he was given 2 doses of vedolizumab 2 weeks apart which lead to a complete resolution of his GI symptoms. Four months later, he remains asymptomatic with a negative PET scan off vedolizumab and ICI therapy. Discussion: Immune checkpoint inhibitors (ICI) revolutionized therapeutics for malignancy in their enhancement of cytotoxic T cell survival, but the resulting robust immune response engenders adverse gastrointestinal events in 1/3 of patients around 1-2 months after the second or third dose. ICI colitis may result in abscess, perforation, and death, and it is imperative to undergo early endoscopy with biopsy plus initiation of steroids or immunotherapy, especially in severe cases. Our patient presented with grade 3 diarrhea and severe immune-mediated colitis refractory to steroids and infliximab, though vedolizumab was effective in resolution.
ABSTRACT
Recent decades have witnessed a steady increase in efforts from a range of actors to facilitate and support meaningful and effective engagement with coastal communities and stakeholders. Indeed, this move towards improved participatory approaches are increasingly framed as being integral to successful and sustainable management of coastal resources and spaces, including in the context of climate adaptation The effectiveness of the processes, structures and frameworks underpinning coastal community engagement has always been subject to external and internal drivers;however, the global threat posed by COVID-19 presented, and continues to present, an unexpected shift in approach, and the need for rapid adaptation by those of us working within these spheres. Using the Coastal Communities Adapting Together (CCAT) project as a case study, we explore how engagement with coastal communities and stakeholders in the project areas of Fingal, Ireland, and Pembrokeshire, Wales, has been impacted and forced to adapt as a result of COVID-19. Through a qualitative data collection process, we explore how project teams across different scales have rapidly adapted their models of community and stakeholder engagement, identify successes and failures, and explore challenges that have been faced. Finally, we consider if the legacy of COVID-19 has provided an opportunity for coastal community engagement approaches being used across the globe to become more diverse, adapting to new technologies and increasing accessibility and effectiveness. Insights identified as fundamental to successful adaptation and enhancing resilience include: a rapid response to change, adoption of a diversity of techniques, broadened participation and supported social learning and knowledge exchange.