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Background: To describe characteristics of COVID-19 infection among patients requiring admission to pediatric intensive care units (PICU) in the USA. Method(s): Observational surveillance study of COVID-19 infected patients admitted to PICUs in 27 US states between April 1, 2020 - May 1, 2021. Result(s): Four hundred fifty-three patients were included;the majority were from institutions in the South and Midwest regions (40% and 34%). The population was mainly male (57%) and Hispanic (36%), with a median age of 10 years (IQR 4-15). 76% had 1 or more comorbidity. Patient's or caregiver's reported sources for COVID-19 infection were household and community contacts (31% and 24%). One hundred sixty-seven (40%) individuals were diagnosed with the multisystem inflammatory syndrome in children (MISC) within 7 days of PICU admission. Compared to COVID-19 cases without MISC, gastrointestinal, mucocutaneous, and neurological signs and symptoms were more frequent at PICU admission. Nasal cannula (20%) and high-flow oxygen (12.4%) were the most common respiratory support strategies at day 1 of admission, and mechanical ventilation by day 7. Overall, 104 (23%) and 8 (1.8%) individuals were placed on mechanical ventilation and extracorporeal membrane oxygenation (ECMO) within the interval of observation. Steroids and remdesivir were the most delivered COVID-19 targeted therapies (60% and 33%), and only 3% of the patients received convalescent plasma;IVIG (86.8%) and anakinra (61%) were commonly used among individuals with MISC. The overall mortality proportion (MP) was 2.65 (n= 12), and mortality was more frequent among individuals > 2 years old. Of the 167 children with MISC, only 1 died, MP (0.6). Conclusion(s): Mortality associated with pediatric COVID-19 infection is less frequent than in critically ill COVID-19-infected adults. Among pediatric/ adolescent patients, children > 2 years are the most vulnerable to adverse COVID-19-associated outcomes. MISC cases were frequent, yet mortality was low.
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Background: SARS-CoV-2 evolution has contributed to successive waves of infections and severely compromised the efficacy of available SARS-CoV-2 monoclonal antibodies. Decaying vaccine-induced immunity, vaccine hesitancy, and limited vaccine protection in older and immunocompromised populations further compromises vaccine efficacy at the population level. Early antiviral treatments, including intravenous remdesivir (RDV), reduce hospitalization and severe disease due to COVID-19. An orally bioavailable RDV analog could facilitate earlier widespread administration to non-hospitalized COVID-19 patients. Method(s): We synthesized monoalkyl glyceryl ether phosphodiesters of GS-441524 (RVn), lysophospholipid analogs which allow for oral bioavailability and stability in plasma. We evaluated the in vivo efficacy of our lead compound, 1-O-octadecyl-2-O-benzyl-sn-glyceryl-3-phospho-RVn (V2043), in an oral treatment model of murine SARS-CoV-2 infection. We then synthesized numerous phospholipid analogs of RVn and determined which modifications enhanced in vitro antiviral activity and selectivity. The most effective compounds against SARS-CoV-2 were then evaluated for antiviral activity against other RNA viruses. Result(s): Oral treatment of SARS-CoV-2 infected BALB/c mice with V2043 (60 mg/kg once daily for 5 days, starting 12 hrs after infection) reduced lung viral load by more than 100-fold versus vehicle at day 2 and to below the LOD at day 5. V2043 inhibited previous and contemporary SARS-CoV-2 Variants of concern to a similar degree, as measured by the half maximal effective concentration (EC50) in a human lung epithelial cell line (Calu-3). Evaluation of multiple RVn analogs with hydrophobic esters at the sn-2 of glycerol revealed that in vitro antiviral activity was improved by the introduction of a 3-fluoro-4-methoxysubstituted benzyl or a 3-or 4-cyano-substituted benzyl. These compounds showed a 2-to 6-fold improvement in antiviral activity compared to analogs having an unsubstituted benzyl, such as V2043, and were more active than RDV. These compounds also showed enhanced antiviral activity against multiple contemporary and emerging RNA viruses. Conclusion(s): Collectively, our data support the development of RVn phospholipid prodrugs as oral antiviral agents for prevention and treatment of SARS-CoV-2 infections and as preparation for future outbreaks of pandemic RNA viruses.
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Emerging evidence suggests that the consequences of childhood adversity impact later psychopathology by increasing individuals' risk of experiencing difficulties in adjusting to stressful situations later in life. The goals of this study were to: (a) identify sociodemographic factors associated with subgroups of psychological adjustment prior to and after the onset of the COVID-19 pandemic and (b) examine whether and to what extent types of childhood adversity predict transition probabilities. Participants were recruited via multiple social media platforms and listservs. Data were collected via an internet-based survey. Our analyses reflect 1942 adults (M = 39.68 years);39.8% reported experiencing at least one form of childhood adversity. Latent profile analyses (LPAs) and latent transition analyses (LTAs) were conducted to determine patterns of psychological adjustment and the effects of childhood adversity on transition probabilities over time. We identified five subgroups of psychological adjustment characterized by symptom severity level. Participants who were younger in age and those who endorsed marginalized identities exhibited poorer psychological adjustment during the pandemic. Childhood exposure to family and community violence and having basic needs met as a child (e.g., food, shelter) significantly moderated the relation between latent profile membership over time. Clinical and research implications are discussed. © 2023 by the authors.
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A COVID-19 cluster was identified in an industrial manufacturing workforce soon after being recalled to the workplace following a furlough period. All cases in the cluster (21/85) were male, worked on one side of the plant, and took breaks and lunch together. All non-cases worked on the opposite side of the plant and similarly took breaks and lunch together. Review of the timing of return from furlough determined that workplace transmission was possible. However, a high percentage of the cases lived in apartment settings where high neighbourhood incidence rates were observed, whereas that was not the case for non-cases. The investigation illustrates the difficulties of distinguishing potential occupational from community transmission.
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Background. Healthcare workers are at high risk of Covid-19 (C19) infection and received priority for C19 vaccinations. Therefore, we conducted a serosurvey to determine anti-C19 antibodies and evidence of C19 infection in health care employees who did or did not have direct contact with patients. Methods. 49 participants provided finger stick blood samples collected onto filter papers and tested for antibodies to C19 using Bio-Plex Pro Human SARS-CoV-2 IgG reagents. Antibodies to C19 nucleocapsid (N), receptor-binding domain (RBD), spike 1 (S1), and spike 2 (S2) were measured. Samples were collected 8 to 11 months after C19 vaccines were made available. Results. All participants received two doses of Pfizer BioNTech or Moderna RNA-based C19 vaccines, and all showed serological evidence of antibodies to C19 RBD, S1, and S2. Antibodies to N, considered a marker of C19 infection, were detected in 16 individuals, of whom 10 reported having a PCR documented C19 infections. 6 individuals had evidence of C19 infection of which they were not aware. Antibody levels were notably higher following infection and for not infected participants following Pfizer-BioNTech vaccination. There was a 20% higher infection rate in participants with direct patient contact. Conclusion. This vaccinated population had significant rates of strong antibody responses to C19 infection and a notable rate of C19 infections, most notable in those providing direct patient care.
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Introduction: Dexamethasone use in patients hospitalized with COVID-19 significantly reduces mortality;however, commonly results in hyperglycemia. Optimal treatment of dexamethasone-induced hyperglycemia is not well established. Research Question or Hypothesis: What is the difference in point of care (POC) blood glucose (BG) control between insulin glargine, Neutral Protamine Hagedorn (NPH) insulin, and insulin glargine plus NPH insulin for dexamethasone-induced hyperglycemia in patients with type 2 diabetes (T2DM) and COVID-19 infection. Study Design: Retrospective cohort study Methods: This study was conducted in adult inpatients with T2DM and COVID-19 infection who received dexamethasone 6 mg once daily and insulin during the 5-day study period. The primary outcome was the difference in mean POC BG levels between study insulins. Secondary outcomes included the difference between mean daily inpatient and home basal insulin doses, incidence of hyperglycemia and hypoglycemia, and length of stay. Nominal data were analyzed using Chi-square test of association, and continuous data were analyzed using Kruskal Wallis or analysis of variance (ANOVA) test, as appropriate. All tests of significance were two-tailed with an a priori significance level of p < 0.05. Result(s): Ninety-six patients were included in the analysis (67 insulin glargine, 10 NPH insulin, 19 insulin glargine plus NPH insulin). The difference in mean POC BG was not different among groups (254.2 +/- 59.8 mg/dL vs 234.4 +/- 39.1 mg/dL vs 250.4 +/- 50.7 mg/dL, respectively;p=0.548). The median difference between average daily home and inpatient basal insulin doses was different among groups [-5 units (-17.2, 7) vs. -6.5 units (-10.7, 30.5) vs. -20.2 units (-26.6, -7.2);p=0.049] with higher insulin doses administered inpatient. There were no significant differences in the other secondary outcomes. Conclusion(s): No difference in mean POC BG was observed between groups. This study demonstrated that dexamethasone-induced hyperglycemia was poorly controlled in patients with T2DM and COVID-19 infection.
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The present study examined the prevalence and correlates of psychosocial impairment in a large, national sample of Peruvian children and adolescents (ages 5.0–17.9) during the COVID-19 pandemic in late 2020. A sample of 8263 online questionnaires were completed by caregivers in Peru between October 23rd–November 26th, 2020. In addition to sociodemographic and pandemic-related factors, the survey administered the Peruvian Spanish version of the Pediatric Symptom Checklist (PSC-17) to assess child psychosocial risk. The Patient Health Questionnaire (PHQ-9), Kessler-6 (K-6), and Brief Resilience Scale (BRS-6) assessed caregiver depression, psychological distress, and resilience, respectively. In this case, 33% of the children were at overall risk on the PSC-17. In adjusted models, caregiver distress, depression, and low resilience, as well as having a family member with a health risk factor were the strongest predictors of child psychosocial risk, accounting for nearly 1.2 to 2.1 times the likelihood of risk individually and 2.4 to 3.4 times the likelihood of risk when summed. Due to the opt-in sampling method, the obtained sample was likely skewed toward more advantaged families, suggesting that the study's high prevalence of PSC-17 positivity might have been even higher in a more economically representative sample. Given the prevalence of psychosocial problems in Peruvian youth during COVID-19, preventive interventions, with a special focus on family-level approaches that involve and support parents as well as children, are clearly warranted.
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SESSION TITLE: Imaging, ECMO, and other Procedures in the ICU Case Posters SESSION TYPE: Case Report Posters PRESENTED ON: 10/19/2022 12:45 pm - 01:45 pm INTRODUCTION: Central Venous Catheter placement is a common procedure in the ICU setting and provides a valuable route for medication delivery and venous access. The Seldinger method is the most commonly used method for placement of the catheter, and is the standard of care [1] with current recommendations. However, central line placement is still associated with complications including infection, thrombotic events, and mechanical malfunctions. Guidewire related complications are less common, but can occur [2]. Wire retention is a known, but avoidable complication of central venous catheter placement. Guidewire errors have been associated with operator fatigue, inexperience, and inadequate supervision of trainees. CASE PRESENTATION: An immunocompromised 40 year old female who presenting with hypoxia secondary to COVID-19, ultimately requiring intubation. She required initiation of continuous sedatives, analgesics, and vasopressors, for which a CVC was placed. The procedure proceeded in usual fashion with ultrasound and sterilization. Standard seldinger technique with US guidance was utilized. However, during advancement of the catheter, the wire was also advanced and lost within the catheter. DISCUSSION: Using ultrasound the wire could be seen within the lumen of the catheter and approximately 1-2 cm deep. A chest plain film was obtained and displayed above (Figure 1). Given the superficial location of the wire, bedside removal was attempted. Counter-traction was applied anterior to the catheter entry site with a second operator while suction was applied to the terminal catheter port using a 30 cc syringe. A debakey hemostat was utilized to clamp the catheter as it penetrated the dermis. The catheter was removed 2 cm and then the hemostat was released while still applying suction and then again replaced at the same site. This process was repeated three subsequent times and then the catheter was completely removed revealing the guidewire protruding from the initial entry site. The wire was safely removed. The patient was otherwise unharmed and would later discharge to rehab facility. CONCLUSIONS: Central venous catheter placement is a common ICU procedure than can be associated with complications. The above case reflects one complication that occurs per few thousands [3]. Fortunately, bedside retrieval was possible and further invasive procedures were avoided. The above method represents one possible method for removal of a guidewire that is only superficially buried. Finally, this case demonstrates that a thoughtful approach to procedural complications and use of available resources can avoid more invasive procedures, increased risk of further complications, and increased costs to the patient and healthcare system. Reference #1: Thaut L, Weymouth W, Hunsaker B, Reschke D. Evaluation of Central Venous Access with Accelerated Seldinger Technique Versus Modified Seldinger Technique. J Emerg Med. 2019 Jan;56(1):23-28. doi: 10.1016/j.jemermed.2018.10.021. Epub 2018 Nov 30. PMID: 30503723. Reference #2: Kornbau C, Lee KC, Hughes GD, Firstenberg MS. Central line complications. Int J Crit Illn Inj Sci. 2015;5(3):170-178. doi:10.4103/2229-5151.164940 Reference #3: Bessoud B, de Baere T, Kuoch V, Desruennes E, Cosset MF, Lassau N, Roche A. Experience at a single institution with endovascular treatment of mechanical complications caused by implanted central venous access devices in pediatric and adult patients. AJR Am J Roentgenol. 2003 Feb;180(2):527-32. doi: 10.2214/ajr.180.2.1800527. PMID: 12540466. DISCLOSURES: No relevant relationships by John Craver Scientific Medical Advisor relationship with Synspira Please note: 3 years Added 03/29/2022 by Bryan Garcia, value=Salary Speaker/Speaker's Bureau relationship with Insmed Please note: 3 years Added 03/29/2022 by Bryan Garcia, value=Honoraria Advisory Committee Member relationship with Zambon Pharmaceuticals Please note: 2 ears Added 03/29/2022 by Bryan Garcia, value=Honoraria No relevant relationships by John Murphy
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Advanced therapeutic medicinal products (ATMPs) have emerged as novel therapies for untreatable diseases, generating the need for large volumes of high-quality, clinically-compliant GMP cells to replace costly, high-risk and limited scale manual expansion processes. We present the design of a fully automated, robot-assisted platform incorporating the use of multiliter stirred tank bioreactors for scalable production of adherent human stem cells. The design addresses a needle-to-needle closed process incorporating automated bone marrow collection, cell isolation, expansion, and collection into cryovials for patient delivery. AUTOSTEM, a modular, adaptable, fully closed system ensures no direct operator interaction with biological material; all commands are performed through a graphic interface. Seeding of source material, process monitoring, feeding, sampling, harvesting and cryopreservation are automated within the closed platform, comprising two clean room levels enabling both open and closed processes. A bioprocess based on human MSCs expanded on microcarriers was used for proof of concept. Utilizing equivalent culture parameters, the AUTOSTEM robot-assisted platform successfully performed cell expansion at the liter scale, generating results comparable to manual production, while maintaining cell quality postprocessing.
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The Trans Mountain Pipeline Expansion Project is the most largest technically challenging pipeline project ever constructed in Canada and possibly in North America. This project consists of 987 km (613 mi) of NPS 36 and NPS 42 pipeline, 11 pump stations, 3 berths, addition of 19 petroleum storage tanks, and elevation changes not normally designed for in liquid pipelines. The challenges are many and diverse. With similar challenging projects like Keystone XL being cancelled, Trans Mountain stands out in that this challenging project is under construction now with completion planned for late 2023. Challenges include environmental, regulatory, technical, geotechnical, geological, topographical, equipment, manpower, COVID-19, safety, schedule, public perception, design, and recent concerns in BC like fires, extreme temperatures, and overland flooding as well as others. Conceived by Kinder Morgan Corporation (KMC) as an expansion of its existing pipeline to expand offshore markets, ultimately the risk for the pipeline completion was such that KMC sold the pipeline to the Canadian government, essentially the people of Canada. It is very likely that once completed, Trans Mountain Corporation, the owners of the TMC system, will be sold to a major pipeline operator as the Canadian government is not in the pipeline operating business. This paper will outline where the project is now, how it got here, and how it managed all of the challenges faced. © 2022 ASCE.
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Background: Implementation of the Affordable Care Act (ACA) has resulted in improvements in cancer outcomes but the extent to which these apply to specific racial and ethnic populations is unknown. We examined changes in health insurance distributions pre- and post-ACA and assessed cancer-specific mortality rates by race and ethnicity. Methods: The population included 167,181 newly diagnosed breast (n = 117,738), colorectal (n = 38,334), and cervix cancer (n = 11,109) patients younger than 65 years and 141,026 patients 65 years or older in the California Cancer Registry. Hazard rate ratios (HRRs) and 95% confidence intervals (CIs) were calculated using multivariable Cox regression to estimate associations with risk of 5-year cancer-specific death for each cancer site pre- (2007-2010) and post-ACA (2014-2017), and by race and ethnicity (American Indian/Alaska Natives, AIAN;Asian Americans;Hispanics;Native Hawaiian/Pacific Islanders, NHPI;non-Hispanic Blacks, NHB;and non- Hispanic whites, NHW). Difference-in-difference analysis was conducted to compare changes over time between younger (< 65 years) and older (65 years and older) patients. Results: Cancer-specific mortality for patients age < 65 was significantly lower post- vs. pre-ACA for colorectal cancer among Hispanic (HRR = 0.83;95% CI: 0.74-0.93), NHB (HRR = 0.69;95% CI: 0.58-0.81), and NHW (HRR = 0.90 95% CI: 0.84-0.97) but not Asian American (HRR = 0.95;95% CI: 0.82-1.10) patients. The HRR for younger NHB colorectal cancer patients was significantly lower than that for patients 65 years of and older (HRR = 1.09;95% CI, 0.95-1.25, p-interaction < 0.0001). A significantly lower risk of dying from cervix cancer was observed in the post- vs. pre-ACA period among younger NHB women (HRR = 0.68;95% CI: 0.47-0.99), but this was not significantly different than that for older women (HRR = 0.41;95% CI, 0.16-1.01, p-interaction = 0.30). No significant differences in breast cancer-specific mortality were observed for any racial or ethnic group. Conclusions: Findings show decreases in cancer-specific mortality for colorectal and cervix cancers for some racial and ethnic groups following ACA implementation in California. These results shed light on ongoing discussions as additional states consider Medicaid expansion. Future studies should assess shifts between health insurance plans resulting from the economic impact of the 2019 novel coronavirus (COVID-19) pandemic.
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Covid-19 infection presents with highly variable symptoms many of which can affect nutritional status, such as taste changes, gastrointestinal symptoms, breathlessness, and fatigue. Therefore, diet plays a role in the treatment and recovery from Covid-19. For patients with long-Covid recovery may take months or years, and has a major impact on patients' everyday life, putting pressure on health and social care services. Despite the growing amount of research and the important role of nutrition, available information is highly variable in quality and accessibility. The aim of this project was to map out the evidence and support available and guide decision-making in the nutrition and dietary aspects of care for adult patients recovering from Covid-19. We used nominal group technique to gain consensus from both healthcare professionals and patients recovering from Covid-19 on what is needed to support both patients and professionals in terms of nutritional care. We adapted data collection due to lockdown restrictions by holding virtual expert panels;one panel for professionals and one for patients. Information for silent generation was e-mailed to participants ahead of Zoom (zoom.us) meetings;a whiteboard functionality replaced a flip chart, and Mentimeter (mentimeter.com) was used for anonymous voting and ranking of ideas. We held a total of six meetings (three with each panel), collected votes from each panel and thematically analysed final discussions held among both panels. Professionals spoke about a lack of awareness and resources to address dietary issues. Patients felt that optimal nutritional intake would be an important part of recovery, but struggled to identify reliable sources of information. Healthcare professionals were not able to provide the information they desired. Both groups recognised that support for nutritional care may need to be provided by non-professionals, particularly in the community and that there is a need to identify and train these people to empower them to deliver nutrition care, as well as pateints recovering form Covid-19. Both groups stated that improvements were necessary in health services for people with long-Covid in relation to nutrition and that since Covid-19 presents with highly variable symptoms and severity, a highly flexible and adaptable resource is needed to support nutritional care. In response to these findings we have developed a virtual knowledge hub to provide appraised and updated information mapping out nutritional support for Covid-19 recovery (www.plymouth.ac.uk/research/dietetics-and-health/covid-knowledge-hub). The information is organised in two parts;one targeting patients and one for professionals. Each section starts with the relevant consensus statements generated by the expert panels, which guided the content. The content for professionals includes identification of those in need of nutritional care, assessing nutritional needs, advice on first line and more advanced dietary modifications, monitoring nutritional status and dietary change, managing symptoms linked to nutrition, and challenges for the delivery of nutritional care. For patients content includes identifiying nutritional risk, managing symptoms and nutrition, improving dietary intake, understanding the evidence, where to find additional support, and finding a registered dietitian or nutritionist. In response to themes and questions generated by the patient panel we also organised a series of public talks by experts within the field, which are freely available and incorporated into the knowledge hub. These include “Is there an anti-inflammatory diet?”, “Is there a link between food and my symptoms?”, “Psychological well-being and communicating with healthcare professionals”, and “Diet & Covid”. These outputs could encourage others to roll out locally adapted care pathways linked to these resources, and thus optimise recovery and reduce the likelihood of further deterioration in patients recovering from Covid-19. This demonstrates a strategic and evidence based approach o address the current crisis and future problems from a nutritional perspective.
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Recent research has shown how experts may fail in their duty as advisors by providing advice that leads to a worse outcome than that anticipated by the user of expert opinion. However, those models have focused on the immediate effects of the failure on experts and nonexperts. Using a cascading network failure model, I show how expert failure can cascade throughout multiple sectors, even those not necessarily purchasing the expert opinion. Consequently, even relatively small failures end up having outsized aggregate effects. To provide evidence of my theory, I look at two case studies of COVID expert advice to show how one seemingly minor failure ended up contributing to the pandemic. I conclude with a discussion on institutional frameworks that can prevent such cascades.
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Methods: Target enrollment in the wHOPE (Whole Health Options in Pain Education) trial is 750 veterans with moderate to severe chronic pain from five geographically diverse VA facilities across the U.S. We are creating an inclusive and generalizable sample through few exclusion criteria, over-sampling and stratified randomization, prioritizing women veterans and those prescribed opioids, while closely monitoring racial and ethnic diversity. The primary aim of the trial is to determine whether a Whole Health Team (WHT) (interdisciplinary Whole Health/integrative pain team) is superior to Primary Care Group Education (PC-GE, abbreviated group Cognitive Behavioral Therapy for Chronic Pain), and whether both are superior to Usual Primary Care (UPC) in decreasing pain interference and secondarily, in improving quality of life and use of non-pharmacological modalities to manage chronic pain. An implementation evaluation and budget impact analysis will provide information about feasibility, maintenance, and sustainability. Descriptive statistics characterized wHOPE study participants including COVID-19-related impacts. Results: To date, of 248 randomized participants, mean age is 60.2 (SD+/-12.3) years;39% women;23% Black or African American and 9.2% Hispanic/Latinx;27% were prescribed opioids. Roughly half endorsed moderate to severe depression, moderate PTSD symptoms, and 58% reported sleep difficulties. Roughly 20% engaged in hazardous drinking and 10% problem drug use. At baseline, veterans reported high rates of non-pharmacological and CIH pain management, e.g., mindfulness (42%);spinal manipulation (32%). As a result of COVID, wHOPE participants reported worsening: mental and emotional health (73%);access to healthcare (59%);pain intensity (48%) and use of tobacco (44%) and cannabis products (36%). Background: To conduct a pragmatic trial to establish evidence for the VA Whole Health model for chronic pain care. Conclusion: This ongoing multi-site pragmatic trial in a diverse group of veterans with chronic pain and high rates of comorbidity indicates high baseline use of CIH and substantial negative COVID-related impacts.
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Defense support of civil authorities (DSCA) is military support provided in response to requests for assistance from civilian authorities for domestic emergencies, special events, designated law enforcement support, and other domestic activities. Multiple jurisdictions across the US have recently or are now in the process of developing detailed strategies for integrating available Title 32 (i.e., National Guard) and/or Title 10 (i.e., Active Duty and Reserve) military units/resources into their respective disaster response plans, training, and exercise operations. As evidence provides from catastrophic disasters such as the oil spill in the Gulf of Mexico in 2010, Hurricane Katrina in 2005, and Hurricane Andrew in 1992, and the 2020 coronavirus (COVID-19) pandemic, US military units and activities have proven to be a critical component for successful response and recovery operations. Therefore, it is vital for emergency managers at every jurisdictional level to possess a rudimentary understanding (at a minimum) of military resources;their capabilities and limitations and how to access and integrate them in their respective jurisdiction’s disaster response and recovery operations. Without this understanding, there are significant risks of missed opportunities to save lives, mitigate human suffering, and mitigate significant property and/or environmental damage © 2022 Taylor & Francis.