Association between HLA-C alleles and COVID-19 severity in a pilot study with a Spanish Mediterranean Caucasian cohort.

The clinical presentations of COVID-19 may range from an asymptomatic or mild infection to a critical or fatal disease. Several host factors such as elderly age, male gender, and previous comorbidities seem to be involved in the most severe outcomes, but also an impaired immune response that causes a hyperinflammatory state but is unable to clear the infection. In order to get further understanding about this impaired immune response, we aimed to determine the association of specific HLA alleles with different clinical presentations of COVID-19. Therefore, we analyzed HLA Class I and II, as well as KIR gene sequences, in 72 individuals with Spanish Mediterranean Caucasian ethnicity who presented mild, severe, or critical COVID-19, according to their clinical characteristics and management. This cohort was recruited in Madrid (Spain) during the first and second pandemic waves between April and October 2020. There were no significant differences in HLA-A or HLA-B alleles among groups. However, despite the small sample size, we found that HLA-C alleles from group C1 HLA-C*08:02, -C*12:03, or -C*16:01 were more frequently associated in individuals with mild COVID-19 (43.8%) than in individuals with severe (8.3%; p = 0.0030; pc = 0.033) and critical (16.1%; p = 0.0014; pc = 0.0154) disease. C1 alleles are supposed to be highly efficient to present peptides to T cells, and HLA-C*12:03 may present a high number of verified epitopes from abundant SARS-CoV-2 proteins M, N, and S, thereby being allegedly able to trigger an efficient antiviral response. On the contrary, C2 alleles are usually poorly expressed on the cell surface due to low association with ß2-microglobulin (ß2M) and peptides, which may impede the adequate formation of stable HLA-C/ß2M/peptide heterotrimers. Consequently, this pilot study described significant differences in the presence of specific HLA-C1 alleles in individuals with different clinical presentations of COVID-19, thereby suggesting that HLA haplotyping could be valuable to get further understanding in the underlying mechanisms of the impaired immune response during critical COVID-19.

Phyx.io: Expert-Based Decision Making for the Selection of At-Home Rehabilitation Solutions for Active and Healthy Aging

While the importance of physical activity in older adults is beyond doubt, there are significant barriers limiting the access of older adults to physical exercise. Existing technologies to support physical activity in older adults show that, despite their positive impacts on health and well-being, there is in general a lack of engagement due to the existing reluctance to the use of technology. Usefulness and usability are two major factors for user acceptance along with others, such as cost, privacy, equipment and maintenance requirements, support, etc. Nevertheless, the extent to which each factor impacts user acceptance remains unclear. Furthermore, other stakeholders, besides the end users, should be considered in the decision-making process to develop such technologies, including caregivers, therapists and technology providers. In this paper, and in the context of physical rehabilitation and exercise at home, four different alternatives with incremental characteristics have been defined and considered: a software-based platform for physical rehabilitation and exercise (Alternative 1), the same software platform with a conventional RGB camera and no exercise supervision (Alternative 2), the same software platform with a convention RGB camera and exercise supervision (Alternative 3) and finally, the same software platform with a depth camera and exercise supervision (Alternative 4). A multiple attribute decision-making methodology, based on the ordinal priority approach (OPA) method, is then applied using a group of experts, including end users, therapists and developers to rank the best alternative. The attributes considered in this method have been usefulness, cost, ease of use, ease of technical development, ease of maintenance and privacy, concluding that Alternative 3 has been ranked as the most appropriate.

Impaired Antibody-Dependent Cellular Cytotoxicity in a Spanish Cohort of Patients With COVID-19 Admitted to the ICU.

SARS-CoV-2 infection causes COVID-19, ranging from mild to critical disease in symptomatic subjects. It is essential to better understand the immunologic responses occurring in patients with the most severe outcomes. In this study, parameters related to the humoral immune response elicited against SARS-CoV-2 were analysed in 61 patients with different presentations of COVID-19 who were recruited in Hospitals and Primary Healthcare Centres in Madrid, Spain, during the first pandemic peak between April and June 2020. Subjects were allocated as mild patients without hospitalization, severe patients hospitalized or critical patients requiring ICU assistance. Critical patients showed significantly enhanced levels of B cells with memory and plasmablast phenotypes, as well as higher levels of antibodies against SARS-CoV-2 with neutralization ability, which were particularly increased in male gender. Despite all this, antibody-dependent cell-mediated cytotoxicity was defective in these individuals. Besides, patients with critical COVID-19 also showed increased IgG levels against herpesvirus such as CMV, EBV, HSV-1 and VZV, as well as detectable CMV and EBV viremia in plasma. Altogether, these results suggest an enhanced but ineffectual immune response in patients with critical COVID-19 that allowed latent herpesvirus reactivation. These findings should be considered during the clinical management of these patients due to the potential contribution to the most severe disease during SARS-CoV-2 infection.

Clinical debriefing during the COVID-19 pandemic: hurdles and opportunities for healthcare teams.

The COVID-19 pandemic and the subsequent pressures on healthcare staff and resources have exacerbated the need for clinical teams to reflect and learn from workplace experiences. Surges in critically ill patients, the impact of the disease on the workforce and long term adjustments in work and life have upturned our normality. Whilst this situation has generated a new 'connectedness' within healthcare workers, it also continues to test our resilience.An international multi-professional collaboration has guided the identification of ongoing difficulties to effective communication and debriefing, as well as emerging opportunities to promote a culture of dialogue. This article outlines pandemic related barriers and new possibilities categorising them according to task management, teamwork, situational awareness and decision making. It describes their direct and indirect impact on clinical debriefing and signposts towards solutions to overcome challenges and, building on new bridges, advance team conversations that allow us to learn, improve and support each other.This pandemic has brought clinical professionals together; nevertheless, it is essential to invest in further developing and supporting cohesive teams. Debriefing enables healthcare teams and educators to mitigate stress, build resilience and promote a culture of continuous learning and patient care improvement.

Impaired Cytotoxic Response in PBMCs From Patients With COVID-19 Admitted to the ICU: Biomarkers to Predict Disease Severity.

Infection by novel coronavirus SARS-CoV-2 causes different presentations of COVID-19 and some patients may progress to a critical, fatal form of the disease that requires their admission to ICU and invasive mechanical ventilation. In order to predict in advance which patients could be more susceptible to develop a critical form of COVID-19, it is essential to define the most adequate biomarkers. In this study, we analyzed several parameters related to the cellular immune response in blood samples from 109 patients with different presentations of COVID-19 who were recruited in Hospitals and Primary Healthcare Centers in Madrid, Spain, during the first pandemic peak between April and June 2020. Hospitalized patients with the most severe forms of COVID-19 showed a potent inflammatory response that was not translated into an efficient immune response. Despite the high levels of effector cytotoxic cell populations such as NK, NKT and CD8+ T cells, they displayed immune exhaustion markers and poor cytotoxic functionality against target cells infected with pseudotyped SARS-CoV-2 or cells lacking MHC class I molecules. Moreover, patients with critical COVID-19 showed low levels of the highly cytotoxic TCRγδ+ CD8+ T cell subpopulation. Conversely, CD4 count was greatly reduced in association to high levels of Tregs, low plasma IL-2 and impaired Th1 differentiation. The relative importance of these immunological parameters to predict COVID-19 severity was analyzed by Random Forest algorithm and we concluded that the most important features were related to an efficient cytotoxic response. Therefore, efforts to fight against SARS-CoV-2 infection should be focused not only to decrease the disproportionate inflammatory response, but also to elicit an efficient cytotoxic response against the infected cells and to reduce viral replication.

PG105 Every pandemic has a silver lining: building on the COVID experience

IntroductionThe SARS-CoV-2 pandemic has posed extraordinary pressures on individuals, teams and organisations. It has also considerably impacted on simulation training. Initially by enhancing its role in promoting clinical preparedness, learning new drills and upskilling redeployed staff. Later because of its potential to contribute to viral transmission, which has mandated new considerations regarding how we deliver simulation safely now and in the foreseeable future.1 Lastly by accentuating a trend towards virtual means of collaborating, teaching and learning.2Health Education and Improvement Wales (HEIW) was created in 2018 as a Special Health Authority, which sits alongside health boards as part of NHS Wales. One of its key priorities is to facilitate the consolidation of the Welsh Simulation Network (WSN) and the delivery of high standard simulation education in Wales.MethodsHEIW has established an expert simulation education team this summer. All interviews and meetings have been carried out virtually. As a consequence, this new team is defining a new simulation strategy, governance structures and portfolios as well as identifying ways to revitalise the Welsh network without being able to meet in person.We cannot underestimate the impact of developing a team virtually rather than through physical encounters. As simulation educators we often rely on subtle non-verbal cues and eye contact to facilitate constructive communication and individual engagement. Trying to communicate effectively with new colleagues as well as learning to use all the new resources at our disposal has constituted a challenge but has provided us with new opportunities.ResultsWe aim to identify positive elements to build on, in order to exemplify a culture of positivity:Virtual meetings have offered an accessible forum regardless of geographical location, particularly relevant in Wales, as our hospital sites can be distant with poor road infrastructure (4.5 hours car travel). A wider application of this principle is guiding the establishment of new opportunities for all in the WSN.Numerous examples of good simulation practice have arisen since March, with all Welsh health boards drawing on simulation training sessions in readiness for crises.Celebrating excellence will be key in building the way forward together.DiscussionWhilst this pandemic has inflicted a great deal of stress on clinical and educational personnel, it has also highlighted the adaptability, resilience and vocation of our colleagues. Identifying successes will contribute to overcoming current and future hurdles, as we delineate a new way for safe, accessible, high-standard simulation education in Wales.3 4Reference1. Ingrassia PL, Capogna G, Diaz-Navarro C, et al. COVID-19 crisis, safe reopening of simulation centres and the new normal: food for thought. Adv Simul 2020;5(13). https://doi.org/10.1186/s41077-020-00131-32. Cheng A, Kolbe M Grant V, et al. A practical guide to virtual debriefings: communities of inquiry perspective. Adv Simul 2020;5(18). https://doi.org/10.1186/s41077-020-00141-13. Dieckmann P, Patterson M, Lahlou S, et al. Variation and adaptation: learning from success in patient safety-oriented simulation training. Adv Simul 2017;2(21). https://doi.org/10.1186/s41077-017-0054-14. Fields J, Kenny NA, Mueller RA. Conceptualizing educational leadership in an academic development program. International Journal for Academic Development 2019;24(3)DOI: 10.1080/1360144X.2019.1570211

PG115 Adapting to redeployment challenges: interventional cardiology simulation training for anaesthetists

IntroductionThe need to provide ‘clean, non-COVID’ surgical areas during the current pandemic has mandated many changes within our organisation, such as the redeployment of cardiac surgical services (albeit without the transfer of interventional cardiology) to a different hospital within our health board. This move necessitated the upskilling of general anaesthetists to provide anaesthesia for emergency procedures in the cardiac catheterisation suite (cath-lab). This is an unfamiliar remote environment which may challenge anaesthetic teams, as they face limited access to the patient, radiation hazards and lack of familiarity with these procedures. As a result, an immediate training response was required to ensure patient safety.MethodsWe conducted a survey to assess baseline staff experiences and opinions. Following this we created a workgroup to develop specific anaesthesia guidelines, which were provided to candidates. A simulation course was developed, including scenarios designed to familiarise anaesthetists with common cath-lab emergencies and challenges and their potential solutions. Anaesthetists completed surveys before and after their simulation training. Notably, these courses were conducted during the COVID outbreak, hence adhering to social distance and infection control procedures.ResultsOur surveys highlighted that anaesthetists found the cath-lab a stressful environment, and all felt that multiprofessional teamwork could be improved. 25 individuals completed the simulation training. We measured self-assessed anxiety to the prospect of dealing with an unexpected emergency in the cath lab, both pre and post training, on a Likert scale (0 to 10). This decreased from an average of 7.55 to 5.63. All candidates commented that they found the course useful and advocated for further in situ training. Remarkably, the course provided a number of unexpected clinical safety outcomes: It facilitated interdisciplinary conversations and further team training was agreed upon;infection control measures for aerosol generating procedures were revisited in collaboration with anaesthetists, and the need for a consistent anaesthetic link was identified.DiscussionOur results demonstrated that anaesthetists felt safer and better prepared to manage emergencies or unstable patients in the cardiac catheterisation laboratory. Post course reflection identified a need to expand scenarios to include cardiac arrest within the cath lab. Further training will be carried out wearing FFP3 masks and visors in order to increase fidelity and help prepare the team to communicate in this manner. We look forward to continuing exploring non-technical skill challenges during forthcoming multiprofessional training sessions.

COVID-19 crisis, safe reopening of simulation centres and the new normal: food for thought.

BACKGROUND: The world is facing a massive burden from the coronavirus disease 2019 (COVID-19) pandemic. Governments took the extraordinary step of locking down their own countries to curb the spread of the coronavirus. After weeks of severe restrictions, countries have begun to relax their strict lockdown measures. However, reopening will not be back to normal.Simulation facilities (SF) are training spaces that enable health professionals and students to learn skills and procedures in a safe and protected environment. Today's clinicians and students have an expectation that simulation laboratories are part of lifelong healthcare education. There is great uncertainty about how COVID-19 will impact future training in SF. In particular, the delivery of training activities will benefit of adequate safety measures implemented for all individuals involved.This paper discusses how to safely reopen SF in the post-lockdown phase. MAIN BODY: The paper outlines 10 focus points and provides operational tips and recommendations consistent with current international guidelines to reopen SF safely in the post-lockdown phase. Considering a variety of national advices and regulations which describe initial measures for the reopening of workplaces as well as international public health recommendations, we provide points of reflection that can guide decision-makers and SF leaders on how to develop local approaches to specific challenges. The tips have been laid out taking also into account two main factors: (a) the SF audience, mainly consisting of undergraduate and postgraduate healthcare professionals, who might face exposure to COVID-19 infection, and (b) for many simulation-based activities, such as teamwork training, adequate physical distancing cannot be maintained. CONCLUSIONS: The planning of future activities will have to be based not only on safety but also on flexibility principles.Sharing common methods consistent with national and international health guidelines, while taking into account the specific characteristics of the different contexts and centres, will ultimately foster dissemination of good practices.This article seeks to further the conversation. It is our hope that this manuscript will prompt research about the impact of such mitigation procedures and measures in different countries.

Covid-19 communication management in Spain: Exploring the effect of information-seeking behavior and message reception in public’s evaluation

The World Health Organization (2011) has emphasized communication as one of the biggest challenges and places risk communication among the essential competencies required to tackle a pandemic. In light of the Covid-19 crisis, the aim of this paper is to assess how information forms and sources influence the public’s information-seeking behaviors, and the perception of government’s crisis response strategies during the pandemic. An online survey was conducted between March 14 and April 14, 2020, the first four weeks after the declaration of the State of Alarm in Spain. The online questionnaire included questions regarding information-seeking behavior, trust in different sources and channels, per-ception of government communication management, message retention, and demographic questions. Findings show a synchronous use of multiple media and platforms in line with channel complementarity theory. Three of the four most used information channels are considered mainstream news media. However, the second source of information is WhatsApp. People who relied more on the mainstream news media for Covid-19 information are generally most likely to express positive opinions of the government’s communication strategy. Findings also show that people less able to make correct attributions of governmental information were the most critical of the government’s crisis response. Finally, trust in public authorities’ decreases as the crisis evolves as a general matter. It is specially truth for the WHO, but there is also a striking exemption for local governments. Implications for theory and empirical research and recommendations and new issues to address are identified and discussed.