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Background: Underutilization of proven therapies in peripheral artery disease (PAD) remains a critical problem. Implementation science aims to improve this, but few trials exist. We describe a randomized trial designed with pragmatic elements in PAD patients. Method(s): OPTIMIZE PAD-1 was designed to evaluate the efficacy of a multidisciplinary vascular care team using an intensive lipid reduction program in PAD patients versus usual care. The primary endpoint is low density lipoprotein-cholesterol (LDL-C) reduction at 12 months. A second objective is to assess the impact of a structured quality assurance program (EQuIP) on variability in 6-minute walk test (6MWT) distance. Due to COVID-19, pragmatic aspects were introduced, including virtual consent/recruitment, home-based subject conducted lab testing, and virtually monitored homebased 6MWT. Result(s): A total of 114 subjects with PAD were recruited over ~18 months at the University of Colorado and randomized to algorithm-driven lipid management by a multidisciplinary vascular care team with pharmacist support or to usual care (Figure). Subjects were also randomized to 6MWT conducted by site versus EQuIP staff. Potential participants and clinical events during follow up were identified via electronic medical records. Adjustments to enable remote study conduct were successfully implemented. Conclusion(s): Pragmatic randomized trials in PAD patients are feasible to strengthen implementation science.
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Covid-19 presented many challenges to universities as brick-and-mortar courses were moved to an online format. This work is an unofficial study of learner-instructor interaction and student engagement in two 7-week online graduate-level courses conducted in Spring 2020, Fall 2020, and early Spring 2021. Research shows that instructor presence in online courses leads to increased student engagement, as well as motivation, well-being, and academic achievement. Student engagement is shown to have a direct impact on a student's emotional, behavioral, and cognitive successes. This work proposes that increased learner-instructor interaction in online courses using strategies lead to greater student engagement with the course, and greater student success in overcoming barriers and challenges to online learning.
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UK media and political discourse has increasingly been dominated by concerns about the economic disadvantages experienced by post-industrial communities collectively labelled ‘left behind’ – and the deepening cultural fault-lines between them and wider society recent democratic events are said to have exposed. An overlapping narrative has re-cast many such communities as ‘red-wall’/‘blue-wall’ constituencies, following the 2016 Brexit referendum and subsequent general elections – leading to a growing political focus on ‘levelling up’ infrastructural investment, employment and training opportunities to address economic inequalities between South-East England and much of the rest of the UK. To date, though, the primary political focus of these discourses has been on areas of northern and eastern England, the Midlands and Wales, with only a handful of contributions to the debate emphasizing the plight of comparably ‘left-behind’ areas of Scotland – notably an Institute for Fiscal Studies (IFS) report highlighting COVID-19’s disproportionate economic impact on Scottish cities like Glasgow and Dundee with significant pockets of poverty (Davenport & Zaranko, 2020). This article draws on interviews with people from a range of disadvantaged groups in Scotland to explore how communities that have often been left out of the ‘national conversation’ about the ‘left behind’ are both experiencing economic inequality and starting to fight back – through incipient forms of grassroots ‘DIY levelling up’. © Edinburgh University Press.
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SESSION TITLE: Expanding Considerations in Management of Pulmonary Embolism SESSION TYPE: Rapid Fire Original Inv PRESENTED ON: 10/19/2022 11:15 am - 12:15 pm PURPOSE: Patients with COVID have an increased risk of thrombotic events including pulmonary embolism (PE). The primary objective of this study was to understand the differences in risk factors, clinical presentation, treatment modalities, and outcomes in patients with PE who were COVID positive at time of admission compared to those who were not. METHODS: Patients diagnosed with PE and activated by the Pulmonary Embolism Response Team (PERT) at Spectrum Health hospital system between November 2019 through January 2022 were included. Clinical, demographic, laboratory, and therapeutic characteristics were compared between patients with COVID and without COVID. Continuous variables were evaluated by t-test and categorical variables by Chi square. Survival after PE was evaluated using Kaplan Meier survival analysis. RESULTS: Of the 479 PERT-activated patients at our institution, 84 (17.5%) were diagnosed with COVID upon admission. Demographics such as age, gender, BMI, and race were similar between patients with and without COVID (all p>0.05). Patients with COVID were less likely to have PE risk factors such as recent surgery (4.8% vs 16.2%, p=0.011), recent trauma (0% vs 8.1%, p=0.014), and reduced mobility (10.7% vs 26.6%, p=0.003) although they were more likely to be recently hospitalized (19.1% vs 8.9%, p<0.001). Patients with COVID were more likely to have a fever (7.1% vs 2.5%, p=0.045), hypoxia (60.7% vs 29.9%, p<0.001), tachypnea (high respiratory rate/min of 28.2 vs 24.8, p<0.001), and lower O2 saturation (low O2 mean of 87.3 vs 90.5, p<0.001) upon presentation. Compared to non-COVID patients, mean troponin (116.5 vs 83.6 ng/ml, p=0.033) was higher in patients with COVID. There was DVT in 36.9% of COVID patients and 30.63% of non-COVID patients (p=0.321). Severity of PE was similar between COVID and non-COVID patients (massive: 18% vs. 15%;sub-massive: 70% vs. 75%, p=0.661). COVID and non-COVID patients had similar rates of thrombolysis (4.7% vs 2.3%) and catheter-based interventions (56% vs 59%). Patients with COVID had longer ICU (10 vs 5.2 days, p=0.001) and hospital stays (10 vs 6.1 days, p=0.006) compared to non-COVID patients. Major bleeding in the follow-up period was higher in the COVID group (10.7% vs 3.5%, p=0.01). There was no difference in mortality between COVID and non-COVID patients at 30 days, (11.9% vs 7.6%), 90 days (15.5% vs 10.4%), or 1 year (16.7% vs 13.7%). CONCLUSIONS: Patients who presented with PE and COVID had less traditional risk factors for PE and were more hypoxemic and tachypneic at the time of PERT activation. They received similar treatment to non-COVID patients but had increased risk for major bleeding. There were no differences in short or intermediate term survival between COVID and non-COVID patients. CLINICAL IMPLICATIONS: Similar severity, treatment, and mortality show promise for PE patients with COVID but bleeding complications require further investigation. DISCLOSURES: no disclosure submitted for Wael Berjaoui;Speaker/Speaker's Bureau relationship with Bristol Myers Squibb Please note: 2015 to present Added 04/17/2022 by Trevor Cummings, value=Honoraria Speaker/Speaker's Bureau relationship with Pfizer Please note: 2015 to present Added 04/17/2022 by Trevor Cummings, value=Honoraria Speaker/Speaker's Bureau relationship with Inari Medical Please note: 2020 to Present Added 04/16/2022 by Trevor Cummings, value=Honoraria No relevant relationships by Catherine Kelty Consultant relationship with Inari Medical Please note: July 2020 - present Added 04/02/2022 by Michael Knox, value=Consulting fee No relevant relationships by marzia leacche no disclosure submitted for Renzo Loyaga-Rendon;No relevant relationships by James Morrison No relevant relationships by Joseph Pitcher No relevant relationships by Nabin Shrestha Consultant relationship with Inari Medical Please note: 1/2021 to current Added 04/08/2022 by Erin VanDyke, value=Consulting fee No relevant relationships by Glenn VanOtteren
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Background and aims: National clinical quality registries facilitate reliable monitoring of stroke care by providing local hospital teams with data on their performance compared to national benchmarks. We aimed to assess changes in stroke care over time from public hospitals participating in the Australian Stroke Clinical Registry (AuSCR). Methods: AuSCR stroke quality care indicators were compared between 2017 and 2020, using a matched-hospital design. Analyses were limited to adults with stroke or transient ischaemic attack admitted to hospitals contributing ≥30 episodes each year during the study period. Descriptive statistics and linear tests for trend were used to assess changes in quality indicators across years. Results: Among 47 eligible hospitals, admissions increased from 13,508 (2017) to 18,139 (2020). Overall, half were aged ≥75 years, 45% were female, and 59% had a severe stroke (no differences by year). Between 2017 and 2020, improvements were observed for: endovascular retrieval (+8%;P<0.001), hyperacute antithrombotics (+6%;P<0.001), mobilisation during admission (+3%;P<0.001), swallow screen/assessment within 4 hours (+12%;P<0.001), discharge care planning (+11%;P<0.001), and discharge secondary prevention medications (+10%;P<0.001). However, delivery of thrombolysis remained unchanged (-1%;P=0.07), door-toneedle within 60 minutes decreased (-6%;P=0.008), and access to stroke unit care declined in 2020 (76% 2019 vs 72% 2020;P<0.001). Conclusion: Improvements in many indicators of quality stroke care have been observed within Australian hospitals participating in a national registry. Declines in timeliness to thrombolysis and access to stroke units in 2020 represent a likely consequence of the COVID-19 pandemic that requires national action.
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Background: The continuing spread of SARS-CoV-2 provides opportunities for the virus to evolve. Compared to ancestral strains, the 4 major variants of concern (VOC) exhibit Spike mutations that improve entry and/or diminish antibody neutralization. However, mutations have arisen in other viral genes. Several of these genes may counteract innate immunity mediated by antiviral interferons (IFNs). IFNs show extensive diversity, but only IFNα2 and IFNβ are approved for clinical use. We showed previously that diverse IFNs exhibit variable activities against HIV-1 and trigger distinct transcriptomes. Methods: To assess whether SARS-CoV-2 acquired human IFN resistance over time, isolates representing early lineages A, B, B.1, and VOC lineages B.1.1.7 (alpha), B.1.351 (beta), P.1 (gamma) and B.1.617.2 (delta) were tested for sensitivity to multiple IFNs in an alveolar type II epithelial cell (AT2) line, A549, overexpressing ACE2. Cells were pre-treated with IFNs for 18 h in triplicate, then infected to yield ∼105 copies/reaction. Virus copy numbers were evaluated at 24 h by qPCR. We compared the sensitivity of 5 SARS-CoV-2 isolates to 12 IFNα subtypes, IFNβ, IFNω and 3 IFNa;subtypes at 2 pM, within the dynamic range of preliminary IFN inhibition curves. IC50s for IFNβ and IFNa;1 were compared between lineage B and VOC isolates. Results: Among the 17 IFNs tested, IFNβ, IFNα8, IFNω and IFNα5 most potently inhibited SARS-CoV-2 in A549-ACE2 cells. Inhibition curves with a delta variant isolate showed that IFNα2 and IFNa;1 had >10-fold and >1000-fold higher IC50 than IFNβ, respectively. Interestingly, the antiviral activity patterns of diverse IFNα subtypes against SARS-CoV-2 and HIV-1 were different and did not significantly correlate. Compared to the ancestral lineage B, the alpha, beta, gamma and delta variants exhibited on average 5.2-fold (range: 1.9-8.2) and 6.7-fold (range: 1.3-21) fold higher IC50s for IFNβ and IFNa;1, respectively. The alpha and delta isolates were also more resistant to IFNβ and IFNa;1 than a lineage B.1 isolate in another AT2 cell line, Calu-3. Conclusion: Our findings suggest that diverse IFNs may have evolved to restrict distinct virus families. Emerging SARS-CoV-2 variants are more effective than earlier pandemic viruses at antagonizing antiviral IFN responses. These data have implications for deploying IFNs for early COVID-19 therapy and suggest that innate immunity may be a driving force for SARS-CoV-2 evolution.
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Objective: Evaluate the use of neurological biomarkers to predict discharge outcomes in COVID-19 patients. Background: Altered levels of brain-derived molecular biomarkers in patients with nonneurological critical illness associates with worse outcomes following these systemic insults. We hypothesized that COVID-19 critical illness would increase expression of brain-derived biomarkers and portend worse outcomes. Design/Methods: 38 adults admitted for COVID-19 at a single tertiary care medical center were prospectively enrolled (M = 63.63 ±19.51, 53% female, 71% requiring ICU admission) and clinical information collected including discharge disposition to home/rehabilitation (n=18) or expired/skilled nursing facility (SNF;n=20). Plasma GFAP, Tau, NfL, and UCHL1 were measured by digital ELISA. Results: COVID-19 patients admitted to the ICU exhibited significantly higher levels of NfL (p=0.003, d=1.25) and GFAP (p=0.03, d=0.88). We used binary logistic regression to determine if biomarkers predicted discharge outcome. Models were examined for best fit using biomarker level, age, ICU status, and history of prior neurological disease. A model including NfL level (Wald's χ =6.614, p=0.010, OR=1.043, 95%CI (1.010, 1.076)) predicting disposition was significant (χ = 22.247, p<0.001, Nagelkerke R = .591). The model's prediction success was 84.2% (90.0% for home/rehab and 77.8% for SNF/expired) A model including GFAP level (Wald's χ =3.055, p=0.080, OR=1.003, 95%CI (1.000, 1.007)) and ICU status (Wald's χ =4.073, p=0.044, OR=0.096, 95%CI (0.010, 0.935)) on disposition was also significant (χ = 17.377, p<0.01, Nagelkerke R = .490). The model successfully predicted disposition status at 78.9% (85% for home/rehab and 72.2% for SNF/expired). Adding age, ICU status, or prior neurological history did not improve outcome prediction. Conclusions: COVID-19 patients requiring ICU admission exhibit increases in circulating brainderived proteins. Higher levels of GFAP and NfL is associated with worse discharge outcomes, even after controlling for age, ICU status and prior neurological disease. Future work examining COVID-19 recovery will help determine if these biomarkers are predictive of long-term neurological consequences.
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The Coronavirus pandemic has revealed the fragility of our food systems, affecting all dimensions of food security and nutrition across the world. It has highlighted how deeply our world is interconnected and the importance of better recognising and understanding the interconnections that are intrinsic to these systems and their key role in pursuit of the SDGs of the 2030 Agenda. There is now, more than ever, a stronger need for a “route change” towards a common action on food systems transformation. Dialogues among all stakeholders to redesign the future of tomorrow’s food systems are needed to trigger collective, multi-stakeholder actions on the ground, at local, regional and global level, towards more sustainable food systems, linking sustainable food production to more healthy and sustainable food consumption. In this context CIHEAM, FAO, and the Union for the Mediterranean Secretariat (UfMS) initiated in 2019, a joint collaborative effort for the establishment of a multi-stakeholder platform on Sustainable Food Systems in the Mediterranean to accelerate the shift towards the Agenda 2030 in the Mediterranean region, with the Mediterranean diet acting as a driver. © 2020, Bononia University Press. All rights reserved.
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BACKGROUND: As the world struggles with the COVID-19 pandemic, health care providers are on the front lines. We highlight the value of engaging in humanitarian medical work, contributions of the hip and knee arthroplasty community to date, and future needs after the resolution of the pandemic. We sought to understand how the arthroplasty community can contribute, based on historical lessons from prior pandemics and recessions, current needs, and projections of the COVID-19 impact. METHODS: We polled members of medical mission groups led by arthroplasty surgeons to understand their current efforts in humanitarian medical work. We also polled orthopedic colleagues to understand their role and response. Google Search and PubMed were used to find articles relevant to the current environment of the COVID-19 pandemic, humanitarian needs after previous epidemics, and the economic effects of prior recessions on elective surgery. RESULTS: Hip and knee arthroplasty surgeons are not at the center of the pandemic but are providing an invaluable supportive role through continued care of musculoskeletal patients and unloading of emergency rooms. Others have taken active roles assisting outside of orthopedics. Arthroplasty humanitarian organizations have donated personal protective equipment and helped to prepare their partners in other countries. Previous pandemics and epidemics highlight the need for sustained humanitarian support, particularly in poor countries or those with ongoing conflict and humanitarian crises. CONCLUSION: There are opportunities now to make a difference in this health care crisis. In the aftermath, there will be a great need for humanitarian work both here and throughout the world.