Prolonged unconsciousness in severe COVID-19 infection with veno-venous ECMO support

Objectives: Patients with severe COVID-19 infections have been shown to have prolonged periods of coma followed by meaningful neurological recovery. Therefore, neurological prognostication is challenging, particularly in those who require veno-venous extracorporeal membrane oxygenation (VV-ECMO) support. We hoped to evaluate which variables can be considered when trying to predict neurological recovery. Method(s): We conducted a case-control retrospective chart review of patients on VV-ECMO from March 2020 to January 2022. This time-frame was selected to limit the effect of post-pandemic changes in sedation practices. Our outcome was duration of unconsciousness, defined as days with GCS motor score <6. We first conducted a matched cohort analysis, comparing COVID and non-COVID patients. We then performed a Classification and Regression Tree (CART) analysis to determine the Relative Variable Importance (RVI) of clinical variables associated with duration of unconsciousness. Result(s): Our matched analysis included 52 patients, 27 (52%) of whom had COVID-19. There were no significant differences in the baseline characteristics of the groups (Table 1). Patients with COVID-19 had a significantly longer median duration on ECMO (p<0.001) and hospital length of stay (p=0.003). The median duration of unconsciousness was similar between COVID-19 and non-COVID patients (p=0.58). The CART analysis results (Figure 1) showed that the most important variables to predict duration of unconsciousness were successive variations in GCS (RVI 100%) and GCS standard deviation (RVI 99%). COVID positivity only had a weak predictability (RVI 4%). Conclusion(s): Our analysis has shown that in patients on VV-ECMO, those with COVID-19 spent a longer time on ECMO and in the hospital. While there was no significant difference in the duration of unconsciousness, we found that patients who had high fluctuations of GCS during ECMO had a shorter duration of coma. (Figure Presented).

The Effects of Partisan Media in the Face of Global Pandemic: How News Shaped COVID-19 Vaccine Hesitancy

Some might expect the promise of ending a global pandemic via vaccination to interrupt conventional partisan media effect processes. We test that possibility by bringing together sentiment-scored COVID vaccine stories (N > 17,000) from cable and mainstream news outlets, N > 180,000 Vaccine Adverse Event Reporting System (VAERS) reports, and six original surveys (N = 6,499), in order to investigate (1) whether partisan news outlets covered COVID vaccination in different ways, and (2) if differences in coverage increased vaccine hesitancy. We find that Fox News' (FXNWS) coverage was significantly more negative than that of other cable and mainstream sources, and is associated with increased negative public vaccine sentiment. In the aggregate, adverse event reports tended to increase following periods of heightened negativity on FXNWS. At the micro-level, self-reported FXNWS exposure is associated with increased vaccine refusal. Collectively, the results provide new insights into the public health consequences of vaccine politicization. © 2023 Taylor & Francis Group, LLC.

Prolonged Unconsciousness in Severe Covid-19 Pneumonia with Venovenous Ecmo Support

INTRODUCTION: Neurological prognostication is an important part of caring for critically ill patients and can help guide goals of care. This has become a challenge when caring for patients with severe COVID-19 pneumonia, as they have been shown to often have prolonged periods of coma followed by meaningful neurological recovery. However, this has not been studied in patients who require venovenous extracorporeal membrane oxygenation (VV-ECMO) support. We hypothesize that patients with COVID-19 pneumonia on VV-ECMO will have a more prolonged period of unconsciousness when compared to their COVID-negative counterparts. METHOD(S): We conducted a retrospective chart review of all patients who received VV-ECMO support at our institution from March 2020 to January 2022. This timeframe was selected to limit the effect of any changes in sedation practices that were brought about by the COVID-19 pandemic. We compared the daily Glascow Coma Scale (GCS) of patients with COVID-19 pneumonia to those who were cannulated for other etiologies. Our outcomes were duration of unconsciousness, which was defined as time from intubation to GCS motor score=6 for 48 hours, as well as changes in GCS over time. RESULT(S): Our preliminary analysis included 84 patients, 57 (68%) of whom were COVID-19 positive. There were no significant differences in the baseline characteristics of the groups, including initial Sequential Organ Failure Assessment score and need for renal replacement therapy. Patients with COVID-19 pneumonia had a significantly longer duration on ECMO in hours (952 vs 312, p< 0.001) and hospital length of stay in days (42 vs 30, p=0.01). There was no significant difference in the duration of unconsciousness (days) between the two groups (11 vs 9, p=0.21). However, the trend in GCS over time was notable as we found that patients with COVID-19 spent more days unresponsive, defined as a GCS=3 (8 vs 5, p=0.04). CONCLUSION(S): Our preliminary analysis found that in patients on VV-ECMO, those with COVID-19 pneumonia spent a longer time on ECMO and in the hospital. While there was no difference in the duration of unconsciousness, patients with COVID-19 spent more of that period unresponsive prior to recovery. While additional analysis is needed, this finding may assist providers when prognosticating neurological recovery.

Poliomyelitis survivors in the time of a covid-19 pandemic

Introduction: Poliomyelitis is an inflammatory viral disease that causes destruction of motoneurons. Despite being eradicated in Brazil, it left sequelae on survivors, making them need continuous treatments. Considering the sequelae and new symptoms related to Post-Polyomyelitis Syndrome (PPS), these patients may be vulnerable in the Covid-19 Pandemic. Objective(s): To characterize and analyze the prevalence of risk factors for contracting COVID-19 as well as developing its severe form in patients with Sequelae of Poliomyelitis and Post-polio Syndrome. Method(s): An epidemiological study was carried out through an online questionnaire, where epidemiological, physical and psycho-emotional health issues were addressed in the pandemic. Approved by CEP UNIFESP under Ndegree4,087,073. Result(s): 383 responses were obtained in the following groups: Sequelae of Poliomyelitis (GP-49%;n=190) and PPS (GPPS-50.4%;n=193). Female and age 50-59 years were more prevalent. The most common disorders were monoparesis (38.9% GP;21.7% GSPP), followed by paraparesis in GP (18.9%) and tetraparesis in GSPP (16.6%). As for comorbidities, 37.4% of the GP and 37.3% of the GSPP reported Hypercholesterolemia;42.6% (GP) and 47.1% (GSPP) Hypertension and 19.5% (GP) and 14.5% (GSPP) Diabetes. About 29% of the GP were obese against 35.2% (GSPP). In the physical aspects, 57.9% (GP) and 65.8% (GSPP) reported worsening in the quarantine and 19.7% (GSPP). Discussion(s): Patients affected with Poliomyelitis had a proportion of Hypercholesterolemia, Hypertension and Diabetes about twice that of the Brazilian population over 18 years (14.6%;23.9 and 7.7%, respectively) (1). In this sense, research shows an increased risk for severity and death from COVID- 19 in patients with Hypertension (2,3), Diabetes (2,3) and Hypercholesterolemia (2). People with disabilities can be disproportionately impacted by emergencies and the disruption of services can be a contributing factor (4). This impact could be perceived by the reports of worsening in the physical aspect during the quarantine, especially in GPPS who have a higher frequency of tetraparesis, which can difficult to carry out the necessary hygiene measures. Conclusion(s): Poliomyelitis survivors have comorbidities, in addition to limitations and dependence in their activities of daily living that can make them more vulnerable to contagion by COVID-19 as well as making them more susceptible to the severe form of the disease.

Stressors Experienced by Primary Caregivers of Severe Acute Brain Injury Patients Recovering from Coma in Neurointensive Care Units: Preliminary Findings from a Multicenter Qualitative Study

Objective: To understand the psychosocial stressors reported by caregivers of severe acute brain injury (SABI) patients recovering from coma in neuroICUs. Background: Caregivers of SABI patients are at risk of developing long-term adverse psychological outcomes following neuroICU discharge, particularly those of patients admitted in a comatose state and remaining disabled. Understanding the top psychosocial stressors reported by these caregivers is critical for design of interventions to improve psychological outcomes. Design/Methods: At the time of neuroICU discharge, we conducted semi-structured, recorded interviews with 15 primary caregivers of SABI patients, all of whom were comatose for greater than 24 hours and needed tracheostomy and/or feeding tube placement. Participants were recruited as a convenience sample from 6 US centers. A codebook for psychosocial stressors was developed from open coding of the first 5 interview transcripts amongst 9 study team members. Using NVivo software, two team members then independently coded each transcript, refined the codebook, and resolved coding discrepancies. Results: Fourteen of 15 caregivers provided demographic data: 13 (92.9%) were female, 5 (35.7%) were racial minorities, and 9 (64.3%) reported fewer than 4 years of college. Six of the 15 (40.0%) patients had recovered to a Glasgow Coma Scale of 9 or higher at the time of interview. The psychosocial stressors most commonly reported by participants were: navigation of the healthcare system, including hospital visitor restrictions due to COVID-19;uncertainty about prognosis;communication with healthcare providers;juggling of practical matters beyond the hospitalization;and navigation of social relationships. Caregivers also referenced challenges with direct caregiving responsibilities, changes to the relationship dynamic with the hospitalized patient, and loss of normality. Conclusions: Across multiple US centers, caregivers of SABI patients in various stages of coma recovery at time of neuroICU discharge share a wide variety of psychosocial stressors. Interventions designed to improve psychological outcomes will need to acknowledge these stressors directly.

Complementary or Competing Frames? The Impact of Economic and Public Health Messages on COVID-19 Attitudes

The American reaction to the COVID-19 pandemic is polarized, with conservatives often less willing to engage in risk-mitigation strategies such as mask-wearing and vaccination. COVID-19 narratives are also polarized, as some conservative elites focus on the economy over public health. In this registered report, we test whether combining economic and public health messages can persuade individuals to increase support for COVID-19 risk mitigation. We present preliminary evidence that the combination of messages is complementary, rather than competing or polarizing. When given a message emphasizing COVID-19's negative health and economic effects in a pilot study, conservatives increased their support for a broad range of risk-mitigation strategies, while liberals maintained high levels of support. A preregistered larger-n follow-up study, however, failed to replicate this effect. While complementary frames may be a promising way to persuade voters on some issues, they may also struggle to overcome high levels of existing polarization.

Minimal Residual Disease-Driven Treatment Intensification By Sequential Addition of Ibrutinib to Venetoclax in Relapsed/Refractory Chronic Lymphocytic Leukemia: Results of the Monotherapy and Combination Phases of the Improve Study

The treatment of chronic lymphocytic leukemia (CLL) has been radically changed in the last years thanks to the targeted therapies, including kinase (i.e. ibrutinib) and BCL2 (i.e. venetoclax) inhibitors. Venetoclax (VEN) in particular is able to obtain undetectable minimal residual disease (uMRD), though only in a proportion of patients (pts) when given as single agent, thus warranting the need of different strategies in those not achieving uMRD. We designed a phase 2 multicenter Italian study where ibrutinib (IBR) is added to VEN based on a MRD-driven strategy aiming at obtaining uMRD and discontinuing both treatments in pts who did not achieve uMRD with VEN mono. Study treatment started with VEN (ramp up to 400 mg/day as per current label) for 12 months. MRD status in peripheral blood (PB) and bone marrow (BM) was evaluated using the 6-color flow cytometry assay recommended by ERIC (CD5/CD81/CD79b/CD19/CD43/CD20). Pts with uMRD in both PB and BM at C12D1 discontinued VEN at C12D28 and entered the follow-up phase. Pts with detectable MRD in PB and/or BM added IBR 420 mg/day starting from C13D1 and continued both drugs up to maximum C24D28, uMRD, progression or unacceptable toxicity (whichever occurs first). After C24D28, pts with detectable MRD and still in response continued IBR alone. The primary endpoint was uMRD4 (<1 CLL cell in 104 leukocytes) in both PB and BM. We report here the results as of 15Jul2020 (data cutoff). Thirty-eight pts (recruited from Nov 2017 to Jul 2018) fulfilled eligibility and started VEN. Baseline characteristics included: median number of prior therapies 1 (range 1-4) (60.6% previously treated with FCR or FC);del(17p) in 8/33 (24%);TP53 mutations in 10/30 (33%), and unmutated IGHV in 24/30 (80%). At the data cut-off, 35/38 evaluable pts still in the study have reached C24D1, 1 pt discontinued treatment due to myelodisplasia (considered unrelated to study treatment) before C12D1 and 1 pt progressed on VEN monotherapy shortly before that timepoint, 1 evaluation is still missing due to COVID-19 restrictions. At C12D1, uMRD4 in PB was achieved in 19/38 (50%) pts (Figure 1), 17/19 (89.5%) had uMRD4 confirmed in BM. Overall response rate with VEN single-agent was 36/38 (94.7%), 9 CR and 27 PR. As per protocol, the 17 pts (45%) with uMRD4 in PB and BM at C12D1 discontinued VEN at C12D28. Nineteen responsive cases with detectable MRD at C12D1 added IBR to VEN starting from C13D1. The combination of IBR and VEN led to an improved reduction of the depth of MRD in all but 3 pts with 16/19 (84%) achieving uMRD4 in both PB and BM between C16D1 (first MRD assessment after starting IBR) and C24D1, thus stopping both therapies as per protocol. After a median follow-up of 25.4 months (range 6.1-33.5) from treatment initiation, no clinical progression was observed among those discontinuing treatment in uMRD, while MRD4 relapse occurred in 21/33. Median time to MRD4 relapse in those who achieved uMRD at any timepoint and discontinued treatment was 4 months (range 2-13). Twelve pts (6 treated with VEN only) remain uMRD after stopping treatment, with a median observation of 13 months (range 3+-18+) since confirmed uMRD4. Safety data were analyzed in the intention-to-treat cohort (39 pts). No cases of clinical tumor lysis syndrome (TLS) and/or biochemical TLS were reported in the 39 pts exposed to VEN. Adverse events (AEs) were mild, with no treatment discontinuations or dose reductions. Five Serious AEs (Table 1) and 130 AEs (Table 2) occurred in 28 patients, without any SUSARs. All 5 SAEs were deemed unrelated to study drug(s) and 4/5 have resolved without sequelae. In conclusion, we here present the updated results of our study including the combination phase of VEN with IBR. This sequential MRD-guided approach was feasible and led to deeper responses in about 85% of pts not achieving uMRD4 after VEN alone. With this tailored and time-limited strategy 33 out of 38 pts (87%) obtained uMRD4 in PB and BM either after VEN monotherapy or the IBR-VEN combination, indicating we may reach identical depth of re ponse with a personalized intensification and avoid unnecessary drug exposure. Time to clinical progression and response to VEN retreatment in this cohort remain to be established as well as the biological characteristics of those pts with persistent MRD despite the combined treatment. Updated results with further sequential MRD and clinical monitoring after treatment discontinuation will be presented at the meeting. [Formula presented] Disclosures: Scarfo: Gilead: Membership on an entity's Board of Directors or advisory committees;AstraZeneca: Honoraria;Abbvie: Membership on an entity's Board of Directors or advisory committees, Speakers Bureau;Janssen: Membership on an entity's Board of Directors or advisory committees, Speakers Bureau. Farina: Abbvie: Membership on an entity's Board of Directors or advisory committees;Janssen: Membership on an entity's Board of Directors or advisory committees. Gaidano: Janssen: Membership on an entity's Board of Directors or advisory committees, Speakers Bureau;Abbvie: Membership on an entity's Board of Directors or advisory committees, Speakers Bureau;Astrazeneca: Membership on an entity's Board of Directors or advisory committees;Sunesys: Membership on an entity's Board of Directors or advisory committees. Reda: Janssen: Membership on an entity's Board of Directors or advisory committees;Abbvie: Membership on an entity's Board of Directors or advisory committees;Gilead: Membership on an entity's Board of Directors or advisory committees. Coscia: Gilead: Honoraria, Membership on an entity's Board of Directors or advisory committees;Shire: Honoraria, Membership on an entity's Board of Directors or advisory committees;Janssen: Membership on an entity's Board of Directors or advisory committees, Research Funding, Speakers Bureau;Abbvie: Honoraria, Membership on an entity's Board of Directors or advisory committees, Speakers Bureau;Karyopharm Therapeutics: Research Funding. Laurenti: Roche: Honoraria;Gilead: Honoraria;Janssen: Honoraria;AbbVie: Honoraria. Varettoni: Roche: Consultancy, Membership on an entity's Board of Directors or advisory committees;AbbVie: Other: Travel/accommodations/expenses;Janssen: Consultancy, Membership on an entity's Board of Directors or advisory committees, Other: Travel/accommodations/expenses. Ghia: Lilly: Consultancy, Honoraria;Sunesis: Consultancy, Honoraria, Research Funding;Adaptive, Dynamo: Consultancy, Honoraria;MEI: Consultancy, Honoraria;Celgene/Juno: Consultancy, Honoraria;Janssen: Consultancy, Honoraria, Other: TRAVEL, ACCOMMODATIONS, EXPENSES (paid by any for-profit health care company), Research Funding;BeiGene: Consultancy, Honoraria;Acerta/AstraZeneca: Consultancy, Honoraria;ArQule: Consultancy, Honoraria;Gilead: Consultancy, Honoraria, Research Funding;AbbVie: Consultancy, Honoraria, Other: TRAVEL, ACCOMMODATIONS, EXPENSES (paid by any for-profit health care company), Research Funding;Novartis: Research Funding.

Reacting to the emergency by opening perspectives: Design-driven knit therapy as an adaptable tool to answer the change

When the COVID-19 emergency has raised, the entire world had to stop, adapt, and face the challenge. The article reports the reaction undertaken with an ongoing project that in February 2020 was experimenting with the therapeutic effects of knitting on patients. The project, driven by scientific international studies, was bringing the intervention of designers on the topic with experimental pilot actions, designed and led by designers on-field, that were going on inside the hospital environment when the emergency changed the scenario, limited the environment, shifted the eye on a new, wider target of healthy people. Observing the new scenario and the initiatives risen on social media the designers involved in the ongoing project made knitting a tool to help individuals spending the forced time at home in meaningful ways. The project took a new perspective and evolved into a social media campaign, proposing virtual workshops for a better living in emergency times. The two projects, on-field and online, showed knitting to be a meaningful solution not only for healthcare but also for the daily life of people, and outlined how designers and a designdriven approach can act and react on the product-service creation, improvement, consolidation, and communication. © 2020 Universidade do Vale do Rio dos Sinos. All rights reserved.

BRAZILIAN IBD STUDY GROUP POSITION STATEMENT ON SARS-COV2 VACCINATION

Mass vaccination offers the best strategy to fight against COVID-19 pandemic, and SARS-CoV2 vaccines are being approved in several countries for emergency use. In Brazil, vaccine approval is expected in the next few days, however potential concerns exist regarding vaccine recommendations for specific populations, such as patients with inflammatory bowel disease (IBD). To address these questions, the Brazilian IBD Study Group (GEDIIB) provides this practical advice with key recommendations about the COVID-19 vaccines in IBD population.