Indirect Calorimetry Critical in Identifying Early Hypometabolism and Late-Stage Hypermetabolism in Post-surgical Patients

Background: Indirect calorimetry (IC) is the gold-standard procedure for measuring resting energy expenditure (REE) in hospitalized patients. Predictive energy equations commonly use static variables and rarely account for changes in REE throughout hospitalization. We hypothesize that predictive equations are typically inaccurate in surgical intensive care unit (ICU) patients. More specifically, we hypothesize that predictive equations often overpredict measured resting energy expenditure (mREE) in early-stage critical illness and underpredict needs later in surgical ICU stay, leading to over-/under-feeding and associated complications. Method(s): This prospective observational trial enrolled surgical ICU patients who underwent emergent or urgent operations for abdominal trauma, perforated viscus, or ischemic bowel within 72 hours of their surgical procedure. Metabolic assessments were performed using the COSMED Q-NRG + Metabolic Monitor ventilator, mask, and canopy at regular intervals during and post ICU admission until hospital discharge. Measurements were categorized by post-surgical intervention ICU admission days 0-3, 4-7, 8-14, 15-21, and 22-28. Patients with multiple measurements taken during the same time interval were averaged. mREE reported in calories (kcal) per kilogram (kg) of admission body weight per day were compared in obese (BMI > 30 kg/m2) and non-obese (BMI < 30 kg/m2) subgroups. Compared to IC, the Mifflin St Jeor (MSJ) equation determined predicted REE using ICU admission anthropometrics. Data are reported as mean+/-standard error of the mean (SEM) and median (interquartile range), and a two-sided p-value of <0.05 was determined significant. Result(s): In total, 18 surgical ICU patients who contributed 47 IC measurements were included in the analysis (Table 1). Most measures were obtained within the first 7 days of post-surgical ICU admission (72%). mREE peaked between days 8-14 in obese and non-obese subgroups (20.6 vs 28.5 kcal/kg;p = 0.02) and was lowest during 0-3 days of post-surgical ICU admission in both groups. Across all 5-time intervals, average kcal/ kg ranged from 14.7-20.6 among obese patients and from 20.1-28.5 in non-obese counterparts (Table 2). Non-obese patients had higher mREE per kg of body weight than obese patients at all time points (Figure 1). MSJ over-predicted mREE during the first 7 days post ICU admission in non-obese patients and within the first 3 days in obese patients and underpredicted mREE in both groups thereafter. Conclusion(s): Equations such as MSJ over- and under-predict mREE in post-operative surgical ICU patients depending on the days elapsed since post-surgical ICU admission. ASPEN's current guideline recommendation of 12-25 kcal/kg may also underfeed post-surgical populations while 25 kcal/kg may not support hypermetabolism among non-obese patients seen in week 2 following post-surgical ICU admission. Alternatively, MSJ multiplied by a 1.2 activity factor may account for hypermetabolism during this time. Notably, non-obese patients experienced greater hypermetabolism than obese patients during week 2 which is consistent with our previously published data in mechanically ventilated COVID- 19 patients. Additionally, the striking dichotomy between the mREE of obese and non-obese patients at all post-surgical time points should be considered in the clinical care of patients. Ultimately, IC remains the gold-standard means of measuring REE and is a critical tool to capture the dynamic nature of energy requirements in post-surgical populations as weight-based and predictive equations continually fall short. (Table Presented).

Trans/feminist collaborative autoethnographic storying of gender-based violence, during the COVID-19 pandemic

The COVID-19 crisis has spotlighted particular insidious social problems, including gender-based violence (GBV), and their relationship with movement and confinement. As well as changing configurations of GBV, the experience of the global pandemic and the immobilities of national lockdowns have created space to imagine GBV - to connect with past experiences in the context of our rethinking of current experiences across multiple spaces. In this article we explicate a transdisciplinary feminist collaborative autoethnographic storying of GBV during the COVID-19 pandemic. Based on the 'trans/feminist methodology' of Pryse (2000), we seek to contribute knowledge of GBV through the lens of COVID-19 using our own experiential life storying. In this article we show the potential of this method in understanding lived experiences over time that are situated in a specific context. Our experiences of GBV, as viewed through the pandemic, are presented as fragments, which then make up a collective narrative that illustrates our shared experiences of GBV in all its forms, across multiple spaces and throughout our life histories. In this common story, GBV is considered to im/mobilise - to stagnate our range of mobilities to varying degrees across these spaces and times.

COVID­19 in pregnant women in South Africa: A retrospective review.

BACKGROUND: The majority of maternal deaths in South Africa (SA) occur as a result of non-pregnancy-related infections (NPRI). Pregnancy is a known risk factor in severe COVID­19, increasing the burden of NPRI in SA. In this study, we describe the prevalence, profile and clinical outcomes of pregnant women with COVID­19 admitted to a tertiary facility. OBJECTIVES: To describe the prevalence, profile and clinical outcomes of pregnant women with COVID­19 admitted to a tertiary facility in Gauteng, SA. METHODS: We performed a retrospective review of all pregnant women with COVID­19 admitted to Charlotte Maxeke Johannesburg Academic Hospital between 6 March and 30 August 2020. Data collected included demographics, medical history, obstetric history, clinical findings and laboratory variables. Outcomes assessed were mortality, admission to intensive care unit (ICU), symptomatic v. asymptomatic disease, maternal and fetal outcome and mode of delivery. RESULTS: A total of 204 pregnant women were included in the study. Of these, 33 (16.2%) women were critically ill, with 21 (10.3%) admitted to the ICU and 3 (1.5%) deaths related to COVID­19. The median gestational age was 37 weeks and median birthweight 2 940 g. Sixty-seven women (33%) were HIV-positive, in keeping with national statistics regarding HIV in pregnancy. Caesarean section was the most common mode of delivery (n=105, 60%). However, no women underwent caesarean section for indications related to COVID­19. CONCLUSION: COVID­19-related mortality in our cohort was higher than that seen internationally, likely due to differences in background maternal mortality rates and difficulty in accessing care.

Communication in the Context of Glioblastoma Treatment: What Matters Most

BACKGROUND: Given the poor prognosis of glioblastoma, it is critical that the benefits and burdens of treatments are clearly discussed with patients and family caregivers. We investigated experiences and preferences around glioblastoma treatment communication in patients, caregivers, and healthcare professionals (HCPs). METHOD(S): Semi-structured qualitative interviews were conducted with adult glioblastoma patients, their caregivers, and HCPs. Purposive sampling was used to capture views across the entire disease trajectory and different specialties. Interviews were recorded, transcribed verbatim, and analysed thematically. RESULT(S): In total, 15 patients, 13 caregivers (in N=12 individual and N=8 dyadic interviews), and five HCPs participated (N=5 individual interviews). Four main themes were identified. 1) Communication practice and preferences. Risks and sideeffects of anti-tumour treatments were explained clearly, with information layered and revisited frequently to aid understanding. Treatment was often understood to be 'the only option', particularly at recurrence. Understanding the impact of side-effects on daily life could be enhanced, including those from supportive medication (e.g., corticosteroids);alongside more proactive communication about support services. 2) What matters most. Patients/ caregivers valued being well-supported by a trusted treatment team, feeling involved, having a sense of control, and quality of life. HCPs similarly highlighted trust, maintaining independence and quality of life, and emotional support as key. 3) Decision-making. With limited treatment options, trust and control are crucial in decision-making among patients, caregivers, and HCPs. While patients ultimately prefer to follow HCP advice they want to be involved, consider all alternatives, and voice what matters to them. 4) Impact of Covid-19. During the pandemic, greater efforts to maintain good communication were necessary. While negative impacts of Covid-19 were limited, caregivers appeared most disadvantaged by pandemic-related restrictions (e.g., limited visiting). DISCUSSION: In glioblastoma treatment communication, building trusting relationships, maintaining a sense of control, and good support are identified by patients, caregivers, and HCPs as critical.

Changes in inpatient medicine prescribing during COVID-19 lockdown.

BACKGROUND: New Zealand went into lockdown March 2020 successfully eliminating the circulation of the coronavirus disease 2019 (COVID-19) virus. During lockdown there were reduced rates of respiratory infections and hospital admission numbers were low. At the time, rumours of benefit and harm of medicines for COVID-19 were widespread in the lay and medical media. AIM: To describe changes in inpatient prescribing in an acute general medicine service during the New Zealand COVID-19 lockdown in 2020. METHODS: Rates of prescribing of medicines during the 33 days of lockdown were compared with a 33-day control period before lockdown. Prescriptions, patients and bed days were calculated from the hospital patient administration and electronic prescribing and administration systems. RESULTS: In the general medicine service, acute admissions were 20% lower during lockdown (from 1216 pre-lockdown to 974). There was a small decrease in the rate of prescriptions per patient (10.1 vs 10.4, P = 0.01) during lockdown, and the average length of stay was shorter (3.2 vs 3.6 days). Nebulised administration decreased by 75% (1.3% vs 5.3% of admissions) but unexpectedly there was no change in the prescribing rates of antibacterial medicines, e.g. amoxicillin (26% vs 26%). There were no changes in rates of prescribing of medicines being rumoured to potentially improve (e.g. hydroxychloroquine) or worsen (e.g. angiotensin-converting enzyme inhibitors) COVID-19 outcomes. CONCLUSIONS: Acute medical admissions decreased 20% during lockdown for COVID-19, with a proportional decrease in prescriptions. Reduced rates of respiratory tract infections did not lead to decreased prescribing of antibacterial medicines. Rumour-based prescribing did not eventuate.

RESPONDING TO THE COVID CHALLENGE: EVALUATING A NEW METHOD OF ADVERSE EVENT RECORDING IN RESPONSE TO REMOTE WORKING

BACKGROUND: The SARS-COV2 pandemic had huge impact on how clinical research is conducted when clinical research coordinators (CRC) transitioned to working remotely. An urgent transition of paper documentation into electronic formats had to occur without compromising participant safety or data integrity. Adverse event (AE) reporting had previously been captured in various paper formats with wet signature. AEs, attribution, severity, and clinical significance had to be changed into being electronically captured and incorporated into the medical record that captures the events in real time. METHOD: We assessed the satisfaction of the new method of AE recording amongst pediatric hematology oncology physicians and staff in a large academic institution during the COVID pandemic through a REDCap survey. The survey assessed the time, effort, perceived efficacy and overall acceptability of the paper-based and electronic methods of AE documentation. RESULTS: Seventy-one staff members were surveyed. Fifty (65%) responded, including 6 participants who were not involved in the AE reporting process and did not complete the survey. Of the remaining 44 participants, 43 (98%) preferred an electronic documentation method. Secondary results and further analysis will be presented at the meeting. CONCLUSIONS: The COVID pandemic has changed how CRC report AEs and electronic documentation seems to be the preferred method of documentation.

Wellbeing During the COVID-19 Pandemic: Perspectives of Australian Early Childhood Educators

The COVID-19 pandemic presented unprecedented challenges for the early childhood education (ECE) sector in Australia, adding further pressure to a workforce already grappling with high levels of stress and emotional exhaustion. Research shows that poor educator wellbeing has adverse consequences for the sustainability of the ECE workforce and program quality, but less is known about wellbeing from the perspectives of early childhood educators themselves. As part of a larger mixed-method project focusing on early childhood educator wellbeing within the extraordinary circumstances of the COVID-19 pandemic, this chapter presents findings from open-ended survey questions completed by 209 Australian early childhood educators as well as subsequent follow-up focus groups conducted with 15 educators in 2020. Thematic analysis revealed that educators in this study perceived wellbeing as a holistic concept, encompassing healthy boundaries, supportive relationships, professional purpose and contribution, and professional recognition and status. Findings highlight that early childhood educators can clearly identify constitutive elements of wellbeing and articulate why their wellbeing matters not only for their own lives and professional stability, but also to support the children and families they work with. The implications from this work for practice and policy include providing flexible working conditions, empowering educators to prioritise self-care, supporting initiatives that foster strong collegial relationships, encouraging educators to take part in ongoing professional learning and upgrading of qualifications, and lifting the status of the profession by publicly acknowledging the valuable contribution educators make to the lives of children and families. © 2022, The Author(s), under exclusive license to Springer Nature Switzerland AG.

Considerations for COVID-19 vaccination in pregnancy

Pregnant women are at greater risk of severe COVID-19 than non-pregnant women. Despite limited safety data on use of COVID-19 vaccines in pregnancy, many international societies have recommended their use when pregnant women are at particularly high risk of acquiring COVID-19, or have suggested that vaccines should not be withheld from pregnant women where no other contraindications to COVID-19 vaccination exist. A number of vaccines, including those against influenza, tetanus and pertussis, have been shown to reduce both maternal and infant morbidity and mortality when used antenatally. We explore the role of COVID-19 vaccination in the setting of pregnancy, discuss the limited data available, and summarise current international guidelines.

Cladribine is a safe and effective treatment for highly active relapsing-remitting multiple sclerosis

Background: Cladribine is a novel disease-modifying therapy (DMT) that has recently been licensed for the treatment of highly active relapsing-remitting multiple sclerosis (rrMS) in Scotland. Lymphocytopaenia (LLC) was reported as the main side-effect of this treatment, in clinical trials. Objectives: 1. Determining the real-world incidence of adverse effects of cladribine 2. Assessing the temporo-spatial likelihood of adverse effects 3. Commenting on current practice for monitoring and managing adverse incidents. Methods: A retrospective cohort analysis of 120 patients prescribed cladribine, over four health boards in Scotland, assessed the incidence of adverse effects at 1 and 2 year intervals, by examination of patient notes, documented self-reported patient comments and follow-up blood monitoring results. Results: It is affirmed that LLC is the main adverse effect of cladribine, occurring in around 68% of patients following receipt of the first treatment cycle and 75% following receipt of the second. Mild to moderate LLC (Grades 0-2) was present in 84% of LLC patients within treatment year 1, but only 58% of LLC patients after year 2. The average lag to peak LLC is noted to be two to four months after first treatment (n patients = 75%) and similarly after the second (n = 66%), indicating the optimal time frame for routine follow-up screening. Other adverse effects were noted in 25 patients (21%), most commonly fatigue (incidence = 0.07), hair loss (incidence = 0.05) and nausea (incidence = 0.03). Allergic-type reactions were also observed in 2% of patients, but these were mild and treatable, without interruption to therapy. All patients in this cohort had adequate V. zoster pre-screening and prophylaxis. Treatment continuation was disrupted in 31% of patients due to COVID-19. Conclusions: Adequate infection prophylaxis and counselling are noted to be key aspects of preassessment. Treatment is interrupted where no adequate protection can be provided. It is essential to ensure adequate lymphocyte populations, via routine screening and follow-up monitoring, before treatment initiation or progression. Shielding of cladribine patients from COVID-19 or similar may be indicated for up to 6 months after treatment, covering the nadir of LLC.

Sex work, essential work: A historical and (necro)political analysis of sex work in times of covid-19 in Brazil

Brazil has made international headlines for the government’s inept and irresponsible response to the COVID-19 pandemic. In this context, sex worker activists have once again taken on an essential role in responding to the pandemic amidst State absences and abuses. Drawing on the theoretical framework of necropolitics, we trace the gendered, sexualized, and racialized dimensions of how prostitution and work have been (un)governed in Brazil and how this has framed sex worker activists’ responses to COVID-19. As a group of scholars and sex worker activists based in Rio de Janeiro and São Paulo, we specifically explore the idea of sex workers as “essential workers”, but also of sex work as, essentially, work, demonstrating complicities, differences, and congruencies in how sex workers see what they do and who their allies in the context of the 21st century’s greatest health crisis to date. © 2020 by the authors. Licensee MDPI, Basel, Switzerland.

Systematic review with meta-analysis: SARS-CoV-2 stool testing and the potential for faecal-oral transmission.

BACKGROUND: Since the start of the COVID-19 pandemic, there have been many scientific reports regarding gastrointestinal manifestations. Several reports indicate the possibility of viral shedding via faeces and the possibility of faecal-oral transmission. AIMS: To critically assess the clinical relevance of testing stool samples and anal swabs and provide an overview of the potential faecal-oral transmission of SARS-CoV-2. METHODS: A systematic literature search with MeSH terms was performed, scrutinising the Embase database, Google scholar, MEDLINE database through PubMed and The Cochrane Library, including articles from December 2019 until July 7 2020. Data were subsequently analysed with descriptive statistics. RESULTS: Ninety-five studies were included in the qualitative analysis. 934/2149 (43%) patients tested positive for SARS-CoV-2 in stool samples or anal swabs, with positive test results up to 70 days after symptom onset. A meta-analysis executed with studies of at least 10 patients revealed a pooled positive proportion of 51.8% (95% CI 43.8 - 59.7%). Positive faecal samples of 282/443 patients (64%) remained positive for SARS-CoV-2 for a mean of 12.5 days, up to 33 days maximum, after respiratory samples became negative for SARS-CoV-2. Viable SARS-CoV-2 was found in 6/17 (35%) patients in whom this was specifically investigated. CONCLUSIONS: Viral shedding of SARS-CoV-2 in stool samples occurs in a substantial proportion of patients, making faecal-oral transmission plausible. Furthermore, detection in stool samples or anal swabs can persist long after negative respiratory testing. Therefore, stool sample or anal swab testing should be (re)considered in relation to decisions for isolating or discharging a patient.