Creating an Effective Clinic Model for Post-COVID Mental Health Treatment

Background: The University of Colorado (UCH) Consultation-Liaison Psychiatry (CLP) service and Psychiatric Consultation for the Medically Complex clinic (PCMC) are developing a brain health outreach program for those hospitalized with COVID. Patients with COVID have increased risk of cognitive and psychiatric sequelae due to intrinsic viral properties, hyperinflammatory state, and increased disposition to ICU level care (Inoue, 2019;Cothran, 2020). Development of a post COVID brain health program has become paramount and UCH is not alone in creation of new clinic protocols to meet the needs of this population (Rovere Querini, 2020;O'Brien, 2020). Hospitals around the globe are developing new screeners to identify patients at higher risk of neuropsychiatric sequelae and refer them to appropriate resources. Methods: The program makes use of two arms: The first assesses those discharged from the hospital using a screener developed by the UCH post-COVID hospitalization program. The second screens patients currently admitted to the hospital with COVID using psychiatric and neurocognitive screeners. Both allow patients to be referred to PCMC for evaluation and treatment. Evaluation includes psychiatric interview and additional screeners including: Hospital Anxiety and Depression Scale (HADS), Montreal Cognitive Assessment (MoCA) and PTSD Checklist for DSM-5 (PCL-5). Additional neuropsychiatric evaluation via Repeatable Battery for the Assessment of Neuropsychological Status (RBANS), and cognitive rehabilitation referral, are available. Clinic treatment includes pharmaceuticals, individual therapy referral, or referral to the PCMC COVID Survivorship Support Group. Results: To date, 100 patients have been screened in arm 1 (outpatient outreach) and arm 2 (inpatient outreach). In arm 2, about 54% of the population identifies as female, 46% as male, 61% identified as white, and 86% spoke English. Of those in arm 2 that agreed to full participation, 26% agreed to future check-ins and 6% were seen in the clinic. There was a difference in those who did and didn't fully participate based on ethnicity, language, and insurance status;though not of statistical significance. HADs scores demonstrated different trends based on these same demographic factors, though also not statistically significant. Discussion: By using this two-armed approach, the service has been able to more effectively outreach patients and refer them to appropriate care. Though data is not complete, referral needs seem to differ based on demographic data. Conclusions: As data continues to be collected, the clinic model is expanding to outreach high risk patients for neuropsychiatric sequelae. This will strengthen our existing system, with risk of reoccurrence of similar events, and inform a new standard of care for COVID survivors. 1. Cothran, T. P., Tam, J. W.;et.al. (2020). A brewing storm: The neuropsychological sequelae of hyperinflammation due to COVID-19. Brain Behav Immun, 88, 957-958. 2. Inoue, S., Nishida, O, et.al. (2019). Post-intensive care syndrome: its pathophysiology, prevention, and future directions. Acute Med Surg, 6(3), 233-246. 3. O'Brien, H., Hurley, K., et.al. (2020). An integrated multidisciplinary model of COVID-19 recovery care. Ir J Med Sci, 1-8. 4. Rovere Querini, P., Ciceri, F., et.al. (2020). Post-COVID-19 follow-up clinic: depicting chronicity of a new disease. Acta Biomed, 91(9-s), 22-28.

The use of dirty fuels by low-income households on the South African Highveld

Meaningful proportions of households on the South African Highveld regularly use energy carriers that result in the emission of significant quantities of particulate and gaseous pollutants. Dirty fuels are mostly used by lower-income households, with the exception of recreational wood use that is also prevalent in higher-income households. The dirty fuel use patterns and trends observed on the Highveld are the result of the unique combination of the utility, accessibility, affordability, availability, and desirability of the energy carriers and equipment, climatological factors, markets and infrastructure, as well as the inertia of historic energy use patterns. There are no systematic reviews and prognosis of the use of dirty fuels by low-income households on the South African Highveld that consider critical recent events such as the Covid pandemic and emerging dynamics such as the just transition movement. In this article we will use a literature review as well as our own research to describe dirty fuel use by low-income households on the Highveld, paying specific attention to changes over time. We will attempt to describe what is being used, who the users are, and for which utilities fuels are being used. From these descriptions, specific patterns emerge that shed light on possible avenues and prospects for ending dirty fuel use on the Highveld. © 2022

Antibiotic Use Is Increased in Patients with Acute Respiratory Distress Syndrome (ARDS) Requiring Extracorporeal Membrane Oxygenation (ECMO) due to COVID-19 Compared with Influenza

Background. During the COVID-19 pandemic, >50% of hospitalized patients (pts) received an antimicrobial. ECMO is increasingly used in COVID-19 pts with severe ARDS. ECMO has been used for ARDS due to influenza at our center in prior years. Pts on ECMO are at high risk for infections. We compared the rates of antibiotic (Ab) and antifungal (AF) use in pts on ECMO for COVID-19 vs influenza ARDS. Methods. This was a retrospective review of pts on ECMO for COVID-19 (2020-2021) or influenza (2013-2019). Antimicrobials (Abs and AFs) were categorized as anti-MRSA, anti-pseudomonal β-lactams (AP-BL), carbapenems, and new broader spectrum β-lactams. We calculated total Ab and AF utilization, adjusted for ECMO duration. Results. Seventy-one pts (36 COVID-19 and 35 influenza) were included. COVID-19 pts had longer ECMO duration (median: 25 vs 11 days, p=.03). 100% and 97% of pts with COVID-19 and influenza received ≥1 Ab, respectively, and 42% and 33% an AF, respectively. COVID-19 pts received longer duration of Abs (26 vs 10 days, p< 0.001) and but not AF. COVID-19 group (gp) were more likely to receive anti-MRSA Ab (69% vs 33%, p=.004);otherwise, there were no differences between gps in types of Abs used. When adjusted for ECMO days, COVID-19 gp received higher median number of Abs (1.23 vs 1, p=.06). Specifically, COVID-19 gp received higher median number of anti-MRSA Ab (0.2 vs 0, p=.007) and AP-BL (0.44 vs 0.28, p=.08). There was no difference in Ab-free days between gps, though the proportion of Ab-free days was lower (0.2 vs 0.36) in COVID-19 pts (p=.08). More COVID-19 pts had pathogens recovered from clinical cultures, especially S. aureus and Enterobacterales (Figure). Pathogens recovered from clinical cultures Patients recovered from clinical cultures of patients with COVID-19 and Influenza ARDS requiring ECMO Conclusion. Among pts on ECMO, those with COVID-19 received significantly longer courses of Abs than those with influenza, even after adjusting for longer durations of ECMO. Differences were driven by receipt of anti-MRSA and AP-BLs. Recovery of pathogenic bacteria was greater in COVID-19 pts than influenza pts. Given difficulties in distinguishing pneumonia from airway colonization among ARDS pts on ECMO, development of diagnostic criteria for pt care, rational antimicrobial stewardship and further research are needed.

An Audit to investigate the incidence of face-to-face patient review by gps prior to referral to surgical assessment unit

Aims: Since COVID-19, GP's have been encouraged to do fewer face-toface consultations to prevent unnecessary patient contact1. Anecdotally, this initially resulted in many patients being referred to SAU who had not been seen by a GP, and then being discharged back to the community the same day, causing potentially increased risk of contracting COVID-19 through hospital attendance. The aim of this audit was to investigate the incidence of patients referred to SAU not seen by a GP and discharged the same day. Methods: GP referrals were identified over a 7 day period through the surgical take electronic system AramisVC . The case notes and GP documentation were reviewed to identify whether a face-to-face GP consultation occurred, and then whether the patient was admitted to SAU or discharged the same day. Results: During a 7 day period, there were 24 (n=24) GP referrals of which only 3 (12.5%) were not seen by the GP, all of whom were admitted for at least one night. However, of the patients referred and seen by GP, 7 (29%) were discharged the same day. Conclusions: This demonstrates that during this 7-day period, there was no incidence of inappropriate GP referral to SAU of patients not seen by a GP, and the majority of GP referrals warranted admission. This suggests that in most cases, GPs are avoiding unnecessary emergency surgical referrals and attempt to review patients face-to-face prior to referral, thus reducing patient risk of contact with COVID-19 in the hospital setting.

Alternative Qualitative Fit Testing Method for N95 Equivalent Respirators in the Setting of Resource Scarcity at the George Washington University (preprint)

The 2019 Novel Coronavirus (COVID-19) has caused an acute shortage of personal protective equipment (PPE) globally as well as shortage in the ability to test PPE such as respirator fit testing. This limits not only the ability to fit PPE to medical practitioners, but also the ability to rapidly prototype and produce alternative sources of PPE as it is difficult to validate fit. At the George Washington University, we evaluated an easily sourced method of qualitative fit testing using a nebulizer or atomizer and a sodium saccharin solution in water. If aerosolized saccharin entered candidate masks due to poor fit or inadequate filtration, then a sweet taste was detected in the mouth of the user. This method was tested against previously fit tested Milwaukee N95 and 3D Printed Reusable N95 Respirator as a positive control. A Chinese sourced KN95, cotton cloth material, and surgical mask were tested as other masks of interest. Sensitivity testing was done with no mask prior to fit test. A sweet taste was detected for both the surgical mask and cotton cloth, demonstrating a lack of seal. However, there was no sweet taste detected for the Milwaukee N95, 3D Printed Reusable N95 Respirator, or Chinese KN95. These results demonstrate this could be a valuable methodology for rapid prototyping, evaluation, and validation of fit in a non-clinical environment for use in creation of PPE. This method should be not be used without confirmation in a formal qualitative or quantitative fit test but can be used to preserve those resources until developers are confident that potential new N95 comparable respirators will pass. We strongly suggest validation of masks and respirators with Occupational Safety and Health Administration (OSHA) approved fit testing prior to use in a clinical environment.

Rapid Prototyping of Reusable 3D-Printed N95 Equivalent Respirators at the George Washington University (preprint)

The 2019 Novel Coronavirus (COVID-19) has caused an acute reduction in world supplies of personal protective equipment (PPE) due to increased demand. To combat the impending shortage of equipment including N95 masks, the George Washington University Hospital (GWUH) developed a 3D printed reusable N95 comparable respirator that can be used with multiple filtration units. We evaluated several candidate prototype respirator models, 3D printer filaments, and filtration units detailed here. Our most recent working model was based on a respirator found on an open source maker website and was developed with PLA (printer filament), a removable cap, a removable filtration unit consisting of two layers of MERV 16 sandwiched between MERV 13, and removable elastic bands to secure the mask. Our candidate mask passed our own suction test protocol to evaluate leakage and passed a qualitative Bitrix N95 fit test at employee health at GWUH. Further efforts are directed at improving the current model for seal against face, comfort, and sizing. The 3D model is available upon request and in the supplement of this paper. We welcome collaboration with other institutions and suggest other facilities consider mask fit for their own population when exploring this concept.