Covid-19 abruptly halted the 2020 afl season. what was the impact on athlete performance?

Introduction: The coronavirus pandemic (COVID-19) lead to the implementation of strict lockdown measures in 2020 for all residents. Self-isolation rules meant that sporting seasons, such as the typical 23-week Australian Football League (AFL) season were suspended for 12 weeks soon after the season commenced. While popular opinion suggested training limitations associated with lockdownd would have negative effects on athletes' performance, medal tallys in the Olympics and Paralympics indicated otherwise. However, little is known about Australian professional sports. Objective(s): To determine if there was a difference in the rate of non-opponent related ball handling skills errors and contests between a COVID-19 impacted Australian Football League (AFL) season and the season directly preceding it. Design(s): Cohort study. Method(s): Retrospective analysis of prospectively collected cohort data from 23 professional male Australian footballers from a single club. Twelve variables were extracted from Champion Data. Variables representing skill errors were: ineffective kick, ineffective handball, missed tackle, ineffective ground kick, clanger kick and clanger handball. Variables representeing contested possessions were: contested mark, contested knock on, gathers from a hit out, hard-ball gets, loose-ball gets and crumbs. The number of events per game per player were extracted and then normalised to events per minute played for both seasons. Generalised estimating equations using a linear scale response were fitted for each variable to compare a COVID-19 impacted season (2020) with the season preceding it (2019). Result(s): As compared with the 2019 season, there were more errors and more contested possessions per minute played in the 2020 season. Of the skill errors, there was a significant difference between the 2019 and 2020 seasons for clanger handballs (0.001 events/minute played [95% CI=0.000, 0.002], p=0.049), clanger kicks (0.002 events/minute played [0.001, 0.004], p=0.005), missed tackles (0.002 events/minute played [0.011, 0.013], p=0.024) and ineffective ground kicks (0.003 events/minute played [0.001, 0.013], p=0.001). Of the contested possessions there was significant differences between the 2019 and 2020 seasons for contested knock ons (0.002 events/minute played [0.000, 0.003], p=0.015). contested marks (0 events/minute played [0.000, 0.004] p=0.019), crumbs (0.003 events/minute played [0.001, 0.005] p=0.006) and gather from hit-outs (0.007 events/minute played [0.001, 0.013] p=0.021).There were no statistically significant differences between the 2 years when considering ineffective kicks, ineffective handballs, hard-ball gets or loose-ball gets. Discussion(s): The rates of both positive and negative aspects of the game were increased in 2020, with some markers of successful competition increasing by up to 48% relative to the 2019 season. The reasons for this are yet to be explored and may reflect a general advancement of the game or be a consequence of the logistical changes required by COVID-19. Impact: Despite the unlikeliness of future global pandemics halting professional sports, it is possible that the need for playing hubs, shortened seasons and reduced game-times may happen again. Our study indicates that the impact of such changes is likely to have both positive and negative effects on player performance, rather than being purely negative. Conflict of interest statement: I can confirm that my co-authors and I acknowledge that we have no conflict of relevance to the submission of this and there was no financial input for this project. Copyright © 2022

Intravenous Immunoglobulin in Treating Nonventilated COVID-19 Patients with Moderate-to-Severe Hypoxia: A Pharmacoeconomic Analysis

Objective: To compare the costs of hospitalization of patients with moderate-to-severe COVID-19 who received intravenous immunoglobulin (IVIG) with those of patients of similar comorbidity and illness severity who did not. Design(s): Analysis 1 was a case-control study of 10 nonventilated, moderately to severely hypoxic patients with COVID-19 who received IVIG (Privigen [CSL Behring]) matched 1:2 with 20 control patients of similar age, body mass index, degree of hypoxemia, and comorbidities. Analysis 2 consisted of patients enrolled in a previously published, randomized, open-label prospective study of 14 patients with COVID-19 receiving standard of care vs 13 patients who received standard of care plus IVIG (Octagam 10% [Octapharma]). Setting and participants: Patients with COVID-19 with moderate-to-severe hypoxemia hospitalized at a single site located in San Diego, California. Measurements: Direct cost of hospitalization. Result(s): In the first (case-control) population, mean total direct costs, including IVIG, for the treatment group were $21,982 per IVIG-treated case vs $42,431 per case for matched non-IVIG-receiving controls, representing a net cost reduction of $20,449 (48%) per case. For the second (randomized) group, mean total direct costs, including IVIG, for the treatment group were $28,268 per case vs $62,707 per case for untreated controls, representing a net cost reduction of $34,439 (55%) per case. Of the patients who did not receive IVIG, 24% had hospital costs exceeding $80,000;none of the IVIG-treated patients had costs exceeding this amount (P=.016, Fisher exact test). Conclusion(s): If allocated early to the appropriate patient type (moderate-to-severe illness without end-organ comorbidities and age <70 years), IVIG can significantly reduce hospital costs in COVID-19 care. More important, in our study it reduced the demand for scarce critical care resources during the COVID-19 pandemic. Copyright © 2022 Turner White Communications Inc.. All rights reserved.

FACT OR MYTH: BLACK PATIENTS DO NOT WANT TO PARTICIPATE IN CLINICAL TRIALS

Introduction Underrepresentation of minority groups, particularly Black patients, has been a major issue for most clinical trials. A commonly cited reason is mistrust amongst Black patients due to historical abuse. In a Historically Black College and University (HBCU) at a major metropolitan area with predominant Black patient population, we examined the patient participation rate in a clinical trial compared to other study sites with primarily White patient population. Methods In April 2021, a large prospective, multi-center clinical trial designed to validate a multiomics blood test for early detection of CRC (PREEMPTCRC) was initiated at a HBCU. To optimize study recruitment, culturally-sensitive methods were employed, including racially congruent recruitment staff, and synchronized timing of consent/study procedures with pre-endoscopy COVID testing and clinic visits. Information for all eligible participants screened for the study were recorded and evaluated for a 7- month period (April 1 - October 31, 2021). The enrollment numbers (defined as those consented to the study and had blood samples drawn) for the HBCU and across all other study sites were compared. Demographic and socio-economic data for patients who enrolled and not enrolled at the HBCU were collected to identify potential factors that affect participation. Results During the study period, the number of patients enrolled at the HBCU site (N=229) was significantly higher than the average number enrolled across the other 168 sites (N=90, p<0.0001). In fact, the HBCU site ranked at the top 11th percentile for patient enrollment across all study sites. The main difference between the HBCU site and other study site was race: participants at HBCU were 88.2% Black and 5.2% White, while at the other sites, the participants were 12.0% Black and 71.5% White (p< 0.0001). Comparison of demographic characteristics and socio-demographic data of the enrolled and not-enrolled subjects at the HBCU were similar (Table 1) and did not identify factors that affect participation in clinical trials. Discussion The enrollment of Black patients at a HBCU site was comparable to other study sites in a large prospective, multi-center study of a multiomics blood test for average-risk CRC screening. The findings of our study highlight the importance of providing access to Black patients to clinical trials to ensure adequate representation in research studies. (Table Presented) Table 1. Baseline Patient Demographic and Sociodemographic Information

Patient Impact and Economic Burden of Waiting for Cataract Surgery in Canada: A Targeted Literature Review

Objectives: To collate and review published evidence to assess patient impact and economic burden of cataract surgery wait times in Canada. Methods: A targeted literature search was conducted using PubMed from January 1, 2007–December 10, 2021, and supplemented by grey literature search. Included studies were those reporting Canada-specific data. Results: Overall, six publications were included. All 6 reported patient impact related to waiting for cataract surgery in Canada, including decline in visual acuity(n=4);greater risk of falls(n=4), motor vehicle accidents(n=3), and depression(n=3);reduced quality life(n=3);interference with treating other eye diseases such as glaucoma, diabetic retinopathy, and AMD(n=1);permanent disability(n=1);and even increased risk of death(n=1). Eye Physicians and Surgeons of Ontario (2018) also highlighted challenges recent ophthalmology graduates face to secure operating room time. This can potentially lead to a lack of surgical competency resulting in more complications, greater incidence of unsuccessful surgeries, decline in ophthalmologists able to perform cataract surgery, and ultimately longer wait times. Canadian Council of the Blind reported an estimated 143,000 necessary eye surgeries missed or delayed in 2020 due to COVID-19, resulting in increased risk of vision loss (vision loss costing $27,251/person/year). It’s also projected from 2021 to 2023, costs of vision loss due to additional wait times of ophthalmic surgeries (most specifically cataract surgery) will be $520.2 million annually in Canada;owing 85% of these costs to loss of well-being ($442.2 million/year) and the remainder to direct healthcare system costs ($78 million/year). Further, average costs incurred by someone with vision loss until they receive surgery is $54/day. Conclusions: Increased cataract surgery wait times in Canada has negative implications, including worse patient outcomes and increased patient and healthcare system costs. There remains an urgent need to reduce wait times to ensure timely treatment access for individuals undergoing cataract surgery in Canada.

Canada National and Provincial Cataract Surgery Wait Times (2017-2021): A Targeted Literature Review

Objectives: Pan-Canadian benchmark for cataract surgery wait times is 16 weeks, with aim for 90% of patients to meet this target timeframe. A targeted literature review was conducted to assess recent trends of Canada’s cataract surgery wait times, including impact of COVID-19. Methods: PubMed was searched January 1, 2017–December 10, 2021, and supplemented by grey literature search. Search terms included cataract surgery, wait times, epidemiology, Canada, and COVID-19. Inclusion criteria comprised of literature reporting national and provincial (Ontario, Quebec, British Columbia, Alberta) data with outcomes of interest: percentage of patients treated within 16-week benchmark, 90th percentile wait time (10% waited >x weeks), and 50th percentile/median wait time (half waited >x weeks). Results: Published data from 8 unique sources were included (n=3 white papers, n=5 government data). Canadian Institute for Health Information (CIHI) reported percentage of patients treated within 16 weeks nationally (2017=71%, 2018=70%, 2019=71%, 2020=45%) and by province (Ontario: 2017=69%, 2020=40%;Quebec: 2017=85%, 2020=53%;British Columbia: 2017=63%, 2020=53%;Alberta: 2017=56%, 2020=34%). Five sources reported 90th percentile: CIHI national data showed 10% waited >30.0-31.0 weeks from 2017–2019, and >44.0 weeks in 2020;for Ontario in 2018, 10% waited >28.9 weeks, according to the Eye Physicians and Surgeons of Ontario;provincial government data showed similar results for Alberta (2017–2018=>38.6, 2020–2021=>41.0-63.0) and British Columbia (2021=>27.9). Median wait times (weeks) were reported by 5 sources, with similar national results by CIHI and OECD (2017–2019=9.3-9.6, 2020=18.9);Fraser Institute also reported 2020 national (20.6 [12.0-64.0]) and provincial (Ontario=17.0, Quebec=12.0, British Columbia=28.0, Alberta=24.0) data. Conclusions: Approximately 30% of patients experienced a wait longer than the 16-week pan-Canadian benchmark from 2017–2019, growing to 55% in 2020 amidst COVID-19. To mitigate the impact of COVID-19 and bring wait times to the recommended threshold, collaboration among provincial health authorities and clinicians may be necessary with prioritization of stable funding and reimbursement for cataract surgery.

Enrollment rate of African Americans in a colon cancer screening trial at a historically black college and university is similar to other patient populations

Introduction: Clinical trials often have low enrollment of minorities, particularly African-Americans (AAs), which may limit the generalizability of research findings. Previously identified barriers to AAs recruitment include historical abuses leading to mistrust, communication issues with providers, socio-economic factors, and a lack of access to clinical trials. In a Historically Black College and University (HBCU) serving a primarily AA population at a large safe-net hospital, we evaluated the enrollment of eligible AA patients for a colorectal cancer (CRC) screening clinical trial. This was compared to the enrollment rates across other study sites. Methods: A large, prospective, multi-centered clinical trial to validate a blood-based test for early detection of CRC (PREEMPT-CRC) was initiated at a HBCU, where 84% of patients are AAs. To maximize study recruitment, culturally sensitive methods were employed including racially congruent recruitment staff as well as synchronized timing of consent/study procedures with preendoscopy COVID testing/clinic visits. Detailed information for all eligible subjects was recorded. Demographic and socio-economic data including census information for enrolled and not enrolled subjects were compared. The enrollment rate (defined as enrolled/eligible patients) over the first 6 weeks at the HBCU and that of the other study sites providing screening logs was analyzed. Results: The enrollment rate at the HBCU was 55% (44 out of 80 eligible patients;95% CI 43.5- 66.2%), compared to 49.8% (258 out of 518 eligible patients;95% CI 45.4- 54.2%) at the other 26 study sites. While age and gender of enrolled patients at the HBCU were comparable to other sites, the main difference was race: at the HBCU the study participants were 79.5% AAs and 9.1% whites, while at the other sites the participants were 11.5% AAs and 82.8% whites (p< 0.001). At the HBCU, the demographic characteristics and socio-demographic data including income, marital status insurance status/type, and census tract median household income of the 44 enrolled and 36 notenrolled subjects were similar (Table 1). Conclusion: Contrary to conventional belief that AAs do not want to be involved in clinical trials, we find their enrollment is similar to a predominant white study population when offered the opportunity in a culturally sensitive setting. Future trials should consider including HBCU sites in order to attain adequate AA enrollment to improve the generalizability of research findings. (Table Presented).

Covid-19 pneumonia in sickle cell anemia: A case report

Introduction Chronic medical illnesses can increase complications among patients with COVID19 infection. Sickle cell anemia is a chronic illness primarily found in persons of African descent, and COVID-19 has been found to disproportionately affect African Americans. However, there is scant data on the cohort of patients in which COVID-19 and Sickle cell anemia co-exist. Herein, we outline the hospital course of a 62-yearold woman with Hemoglobin (Hb) SS and COVID-19 infection. Case Presentation A 62-year-old woman with a history of Hemoglobin (Hb) SS complicated by avascular necrosis of the left shoulder presented to the emergency department with worsening shortness of breath for two days. She endorsed fevers, chills, cough, diarrhea and back pain similar to her sickle cell pain crises. She also revealed that she had tested positive for COVID-19 a week prior to presentation, after being exposed to a family member who was infected. On presentation, she was afebrile and normotensive but tachycardic, tachypneic, with initial oxygen saturation in the 70's which improved to 95-100% with high flow nasal canula (HFNC) 50% FiO2, 50 liters per minute. Initial labs revealed severe anemia (Hb 3.9, baseline 6.0), acute kidney injury, lactic acidosis, indirect hyperbilirubinemia, and elevated LDH. Chest X-ray showed bilateral multifocal consolidations. She was admitted to the medical intensive care unit for management of acute hypoxemic respiratory failure due to COVID pneumonia and acute chest syndrome. She received intravenous remdesivir, dexamethasone, ceftriaxone, and azithromycin. She underwent simple blood transfusion of 3 units packed red blood cells (PRBC), then a therapeutic RBC exchange transfusion. She was also on intravenous heparin, intravenous fluids and opioids. She was consented and enrolled in a lenzilumab trial. The patient clinically improved and was transferred to the intermediate care unit. Her supplementary oxygen was weaned down from HFNC to two liters per minute via nasal cannula. She was discharged with home oxygen, as well as outpatient follow up with sickle cell and primary care clinics. Discussion COVID-19 should be recognized as a new viral pathogen for acute chest syndrome. This patient had sickle cell pain, and COVID-19 screening should be considered among those presenting with painful crises during this pandemic to avoid overlooking a possible inciting factor. Exchange transfusion was utilized in this case;further case studies and clinical trials would aid clinicians in understanding appropriate management when these illnesses co-exist.

Evaluation of intensified low molecular weight heparin or unfractionated heparin for venous thromboembolism prophylaxis in critically ill patients with COVID-19

Introduction: Initiation of prophylactic anticoagulation is standard of care for severely ill patients, including coronavirus disease 19 (COVID-19) patients who may be hypercoagulable. Determining an optimal prophylactic regimen is crucial to limit the number of inhospital venous thromboembolism (VTE) and bleeding events. Research Question or Hypothesis: What is the proportion of COVID- 19 patients on a COVID-19 intensive care unit (ICU) VTE prophylaxis protocol who develop in-hospital VTE or bleeding events? Study Design: Retrospective cohort study Methods: Hospitalized, COVID-19 positive adult patients who were initiated on intensified and renally-adjusted heparin or enoxaparin VTE prophylaxis were included. The primary endpoint was to determine the proportion of patients on COVID-19 ICU VTE prophylaxis who had an in-hospital VTE event, and secondary endpoints assessed international society of thrombosis and hemostasis bleeding events, other ischemic outcomes including myocardial infarction and stroke, and 30-day readmissions for VTE. Institutional review board approval was obtained. Results: This study included 41 patients who were approximately 57 years old and 65.9% female. This population included 3 patients with a history of VTE and 2 with a history of cancer. The median ICU length of stay was 6 days. No patient experienced an in-hospital VTE event. The median Improve Bleed Score was a 6, and bleeding events occurred in 5 patients (12.2%) with 3 defined as major bleeds and 2 as minor bleeds. An ischemic event (ST-elevation myocardial infarction) occurred in one patient (2.4%) and readmission to a Kaleida Health facility within 30 days of discharge for a new VTE event occurred in 1 patient (2.4%). Conclusion: In patients with COVID-19 who received the Kaleida COVID-19 ICU VTE prophylaxis protocol, no in-hospital VTE events occurred, but 12.2% experienced a bleeding event. Use of this protocol in an expanded population may decrease VTE events, with a potential to increase bleeding rates.

DECODING COVID-19: A NOVEL ROLE OF ANTITHROMBIN DEFICIENCY IN THE NOVEL CORONAVIRUS

SESSION TITLE: Medical Student/Resident Chest Infections Posters SESSION TYPE: Med Student/Res Case Rep Postr PRESENTED ON: October 18-21, 2020 INTRODUCTION: The mechanisms by which the novel SARS-CoV-2 coronavirus causes coagulopathy are still being studied (1,2). Herein we present a case of a 38-year-old man admitted to the intensive care unit for severe COVID-19 infection. Work-up for fever of unknown origin revealed bilateral deep venous thromboses, and a mechanism of hypercoagulability in COVID-19 infection that is not well-defined in the emerging literature. CASE PRESENTATION: A 38-year-old man with a history of morbid obesity (BMI 71.5 kg/m2) presented to the emergency room with fevers, malaise and myalgias for three days. He endorsed shortness of breath and cough. Vitals on presentation were temperature 38.8 °C, heart rate 124 beats/min, respiratory rate 24 breaths/min, blood pressure 91/79 mmHg and SpO2 55 %. On non-rebreather SpO2 was 88% with increased work of breathing and crackles on examination of the chest. He was intubated and admitted to the intensive care unit. Vancomycin, cefepime and azithromycin were started as empiric coverage for multifocal pneumonia. He tested positive for SARS-COV-2 and parainfluenza. Hydroxychloroquine was started. PaO2/FiO2 ratio worsened from 99 to 73. Interleukin 2 and 6 were 2371 pg/mL and 173 pg/mL respectively. Hemodynamics improved with Tocilizumab, pressor support and stress-dose steroids. However he had persistent fever and tachycardia after antibiotics were broadened to vancomycin and meropenem. Repeat work-up was negative for new infectious source of fever. Doppler ultrasound revealed deep vein thromboses in bilateral popliteal veins. CTPE was not done due to patient’s BMI of 71.5 kg/m2. High-intensity heparin drip was started. Hypercoagulability work up revealed Antithrombin Activity 71.0%, Antithrombin Antigen 56%. ANA screen and lupus anticoagulant were negative. There was clinical improvement and he tested negative for SARS-COV-2 on day 16 of treatment. He was stable for discharge by day 37. There was normalized Antithrombin Activity 93.0% and Antithrombin Antigen 85%. DISCUSSION: This case provides evidence that antithrombin 3 deficiency should be included as a differential for hypercoagulability in patients with COVID-19 infection. Other previously identified causes of hypercoagulability, such as lupus anticoagulant (3), were negative. Though fevers may occur in COVID-19 infection, this case shows the benefit of excluding other potential sources. High intensity heparin was started once deep vein thromboses were discovered. However other cases of antithrombin 3 deficiency may be resistant to the heparin therapy that is being used to treat venous thromboembolism in COVID-19. CONCLUSIONS: Antithrombin 3 Deficiency is a mechanism for hypercoagulability and fever of unknown origin in patients with COVID-19. Recognition of these roles of antithrombin 3 deficiency, can better guide therapy in future cases as there may be resistance to the standard heparin therapy being adopted in COVID-19. Reference #1: Klok FA, Kruip MJHA, van der Meer NJM, et al. Incidence of thrombotic complications in critically ill ICU patients with COVID-19. Thromb Res 2020 April 10 (Epub ahead of print). Reference #2: Helms J, Tacquard C, Severac F, Leonard-Lorant I, Ohana M, Delabranche X, Merdji H, Clere-Jehl R, Schenck M, Fagot Gandet F, Fafi-Kremer S. High risk of thrombosis in patients with severe SARS-CoV-2 infection: a multicenter prospective cohort study. Intensive Care Medicine. 2020 May 4:1-0. Reference #3: Bowles L, Platton S, Yartey N, Dave M, Lee K, Hart DP, MacDonald V, Green L, Sivapalaratnam S, Pasi KJ, MacCallum P. Lupus Anticoagulant and Abnormal Coagulation Tests in Patients with Covid-19. New England Journal of Medicine. 2020 May 5. DISCLOSURES: No relevant relationships by Eric Chang, source=Web Response no disclosure on file for Michelle Lee;No relevant relationships by Krystal Mills, source=Web Response No relevant relationships by Ifedolapo Odebunmi, source=Web esponse No relevant relationships by Timothy Sobukonla, source=Web Response