Theme 12 - Clinical Management and Support

Power wheelchair prescription, utilization, satisfaction, and cost for patients with amyotrophic lateral sclerosis: preliminary data for evidence-based guidelines. Stage at which riluzole treatment prolongs survival in patients with amyotrophic lateral sclerosis: a retrospective analysis of data from a dose-ranging study. Support needs and interventions for family caregivers of patients with amyotrophic lateral sclerosis (ALS): a narrative review with report of telemedicine experiences at the time of COVID-19 pandemic. [Extracted from the article]

Evaluation of the Antibody Response Induced by the Pfizer-BioNTech COVID-19 Vaccine and the Effect Prior COVID-19 Infection has on the Response Elicited by the Vaccine

Introduction Understanding the immune memory of individuals who have naturally contracted SARS CoV-2 versus naïve individuals might help to optimise the vaccination campaigns. Here we describe the Anti-SARS-CoV-2 IgG response induced by the Pfizer-BioNTech COVID-19 Vaccine in both naive individuals and those with prior confirmed SARS-CoV-2 infection. We also look at the durability of that response over a six-month period. Methods This study enrolled a total of 219 participants who had completed the full course of the Pfizer BioNTech BNT162b1 COVID 19 vaccine. SARS CoV-2 IgG levels were measured at two different stages over a period of six months using Abbott Architect SARS-CoV-2 IgG II quantitative assay. Results After two doses of the Pfizer BioNTech BNT162b1 COVID 19 vaccine, the median SARS CoV-2 IgG concentration from all participants was 4866 AU/mL (IQR 2738-8424). Median IgG levels in naïve individuals were 4219 AU/mL (IQR 2450-7602). Median SARS CoV-2 IgG levels were significantly higher in those with a previous SARS CoV-2 infection at 8323 AU/mL (IQR 4728-16579 p<0.001). Median SARS-CoV-2 IgG levels decreased to 953 AU/mL (IQR 512-1730) after six months post vaccination. This represented a median decrease of 80% between the two testing periods Conclusion Our findings suggest that those with natural infection before vaccination produce a higher IgG response than naïve individuals as shown by a nearly 2-fold increase in the mean concentrations between the two groups.SARS-CoV-2 IgG levels showed a median decline of 2% per day. © 2021, Irish Medical Association. All rights reserved.

Prior sars-cov-2 infection is associated with subclinical changes in the cardiovascular morphology, function, energetics and exercise capacity

Background: COVID-19 has documented multisystem effects. Whether clinically significant cardiac involvement is related to severity of disease in a working age military population remains unknown, but has implications for occupational grading and ability to deploy. Aims: To determine in the military population 1) whether prior SARS-CoV-2 infection causes clinically significant cardiac disease and 2) whether changes are related to disease severity. Methods: 105 military personnel were recruited, 85 with prior SARS-CoV-2 infection (39±10 years, 87% male;50 mild (community), 35 severe (hospitalized) and 20 healthy volunteers (mean age 39 ±8.4 years, 90% male) underwent comprehensive cardiopulmonary investigations including;cardiopulmonary exercise test, exercise echocardiography, cardiac31MRI and P-MR spectroscopy (rest and dobutamine stress). Results: Prior SARS-CoV-2 infection was related to lower VO2max (110±18.2 vs 133±6.7% predicted, p<0.05), anaerobic threshold (45±10 vs 56±14% of peak VO2, p<0.05), VO2/HR (102±21 vs 128±24% predicted, p<0.05) and VE/VCO2 slope (28.3±5.0 vs 25.8±2.7, p<0.05) and an increase in average E/e' change from rest to exercise stress (+1.49±2.4 vs-0.16±3.6, p<0.05). Whilst resting myocardial energetics were similar, prior SARS-CoV-2 infection was associated with a fall in PCr/ATP during stress (by 8%, p=<0.01) which was not seen in healthy controls. When groups were ordered normal> mild> severe disease, RVEDVi, RV stroke volume, VO2peak, VO2pulse and VE/VCO slope were reduced (Jonckheere-Terpstra, all p<0.05). Conclusion: In a young military population, prior SARS-CoV-2 infection is associated with subclinical cardiovascular changes including;lower right ventricular volumes, reduced markers of exercise capacity and reduced myocardial energetics during stress.

Antimicrobial use and antimicrobial resistance in Enterobacterales and Enterococcus faecium: a time series analysis.

BACKGROUND: Irish and European antimicrobial resistance (AMR) surveillance data have highlighted increasing AMR in Enterobacterales and vancomycin resistance in Enterococcus faecium (VRE). Antimicrobial consumption (AC) in Irish hospital settings is also increasing. METHODS: A retrospective time series analysis (TSA) was conducted to evaluate the trends and possible relationship between AC of selected antimicrobials and AMR in Enterobacterales and vancomycin resistance in E. faecium, from January 2017 to December 2020. RESULTS: Increased AC was seen with ceftriaxone (P = 0.0006), piperacillin/tazobactam (P = 0.03) and meropenem (P = 0.054), while ciprofloxacin and gentamicin use trended downwards. AMR rates in Escherichia coli, Klebsiella pneumoniae and other Enterobacterales were largely stable or decreasing, an increase in ertapenem resistance in the latter from 0.58% in 2017 to 5.19% in 2020 (P = 0.003) being the main concern. The proportion of E. faecium that was VRE did not changed significantly (64% in 2017; 53% in 2020, P = 0.1). TSA identified a correlation between piperacillin/tazobactam use and the decreasing rate of ceftriaxone resistance in E. coli. CONCLUSION: Our data suggest that the hospital antimicrobial stewardship programme is largely containing, but not reducing AMR in key nosocomial pathogens. An increase in AC following the COVID-19 pandemic appears as yet to have had no impact on AMR rates.

Tocilizumab rescue therapy in severe COVID-19 pneumonia

Aim COVID-19 refers to a spectrum of disease caused by the severe acute respiratory coronavirus type 2 (SARS-CoV-2), an RNA virus first reported in December 2019 which has since resulted in a global pandemic. Multiple reports suggest that a hyper-inflammatory immune response contributes to multi-organ failure and death in a subset of patients. This is triggered by a cytokine cascade, in which interleukin-6 (IL-6) plays a key role. Methods We describe our experience with the anti-IL-6 monoclonal antibody tocilizumab. Retrospective data from 8 patients in ICU with severe COVID-19 was collected. Results 8 patients were included. Tocilizumab was associated with a statistically significant defervescence of fever in the at day 2 and day 4 post administration (paired t-test, p=0.029, p = 0.009 respectively) and marked reduction in CRP levels (mean decrease 277mg/l day 0 to 3). One patient was managed with non-invasive ventilation and was discharged 11 days later. 7 patients had a prolonged period of IMV (median duration 21 days +/- 23). 3 patients subsequently died and 5 were discharged alive after a median hospital admission duration of 48 days (+/- 23.5). Conclusion Overall, clinical outcomes were mixed, but positive biomarker response and an absence of severe side-effects attributed to this treatment is encouraging.

Safety of elective paediatric surgery during the coronavirus disease 2019 pandemic.

INTRODUCTION: Corona-virus Disease 2019 (COVID-19) has had a huge impact on the delivery of healthcare worldwide, particularly elective surgery. There is a lack of data regarding risk of postoperative COVID-19 infection in children undergoing elective surgery, and regarding the utility of pre-operative COVID-19 testing, and preoperative "cocooning" or restriction of movements. The purpose of this present study was to examine the safety of elective paediatric Otolaryngology surgery during the COVID-19 pandemic with respect to incidence of postoperative symptomatic COVID-19 infection or major respiratory complications. MATERIALS AND METHODS: Prospective cohort study of paediatric patients undergoing elective Otolaryngology surgery between September and December 2020. Primary outcome measure was incidence of symptomatic COVID-19 or major respiratory complications within the 14 days after surgery. Parents of prospectively enrolled patients were contacted 14 days after surgery and enquiry made regarding development of postoperative symptoms, COVID-19 testing, or diagnosis of COVID-19. RESULTS: 302 patients were recruited. 125 (41.4%) underwent preoperative COVID-19 RT-PCR testing. 66 (21.8%) restricted movements prior to surgery. The peak 14-day COVID-19 incidence during the study was 302.9 cases per 100,000 population. No COVID-19 infections or major respiratory complications were reported in the 14 day follow-up period. CONCLUSION: The results of our study support the safety of elective paediatric Otolaryngology surgery during the pandemic, in the setting of community incidence not exceeding that observed during the study period.

Midwifery lecturers’ reflections of midwifery education during covid-19 in ireland

The COVID-19 pandemic has caused major disruption to midwifery education. Traditional approaches to teaching and assessment have been transformed. Creative thinking is required to ensure a positive and caring virtual learning environment is maintained. Collegiality and human kindness have never been so important. The long-term effects of COVID-19 for undergraduate midwifery education remains to be seen. The pandemic may represent a catalyst for the transformation of midwifery education in the future. © 2021, All4Holdings Ltd. All rights reserved.

Shifting from in-person to virtual programming to provide intergenerational social support for patients with dementia: The virtual TimeOut@ucla program

Background: TimeOut@UCLA is an intergenerational program that recruits and mobilizes college student volunteers to provide weekly one-on-one social interaction sessions with older adults with Alzheimer's disease and related dementias (ADRD). We previously demonstrated that our in-person program alleviates loneliness among seniors, offers caregivers respite, and strengthens student interest and knowledge in aging. In response to the COVID-19 pandemic, we modified the delivery of our program to an innovative virtual format. The aim of this preliminary study was to evaluate the success of this transition. Methods: Following focused training on aging and dementia, college students volunteered 1-2 times week for 10 week sessions. Each student was paired with a cognitively-impaired older adult based on shared interests and/or cultural/language backgrounds. Using Zoom as the virtual platform, students led seniors through online activities and engaged in conversation over about 60 minutes each session. The program was evaluated through virtual session auditing, qualitative outcome data in the form of student and caregiver interviews, and quantitative data in the form of student and caregiver surveys. Results: Between March and December 2020, 41 students and 38 seniors participated in the program. Preliminary caregiver surveys indicated improved mood, focus, and quality of life for 100% of participants with dementia (N=10). Moreover, 100% of caretakers reported the most important benefit to be observing their loved ones enjoying conversation and the opportunity to relax and gain relief from the monotonous routine. The students (N=17) experienced a significant (P < 0.001) increase (31 points on a 170-point scale) on the Dementia Attitude Scale. More data will be presented from ongoing data collection. Conclusion: Innovative interventions may address the unintended consequences of the Covid-19 mitigation measures. Virtual TimeOut@UCLA provides an innovative way to alleviate loneliness in older adults with ADRD through intergenerational interactions. Additionally, it provides a rewarding way for young adults to develop interest, knowledge, and skills to interact with cognitively-impaired older adults.

Surgical morbidity during covid-19 pandemic-a gynaecology oncology persective

Introduction COVID-19 has had significant repercussions on the provision of oncological surgical services worldwide. Within any Gynaecological Oncology service, careful consideration needs to be given when weighing up peri-operative risks & potential inpatient exposure to COVID-19 versus the risk of delaying surgery. Often, for these patients, deferral of surgery may result in disease progression. Since March 2020, we identified 118 Gynaecological Oncology patients referred to the Ireland East Gynaecological Group between the Mater Misericordiae University Hospital (MMUH) & St. Vincent's University Hospital (SVUH) for whom major oncological surgery was deemed clinically urgent. To minimise peri-operative morbidity and the risk of onward hospital transmission of COVID-19, screening questionnaires were administered before hospital admission. These screened for epidemiological risk, symptoms, recent travel & contacts. If asymptomatic, testing for SARS-CoV-2 was not performed. Methods We analysed the clinical data of the above 118 patients to determine their baseline characteristics/risk factors for COVID-19, suspected diagnoses, surgical procedures & 7- day morbidity. Results This cohort consisted of ovarian (n=57), endometrial (n=41), cervical (n=6) and vulvo-vaginal (n=14) cancer patients. 44% of cases were laparoscopic and 18% were major cytoreductive surgeries. All patients screened were deemed asymptomatic & low risk- therefore proceeded to surgery. 49 (41.5%) patients had a defined risk factor for COVID-19. 7- day post-operative morbidity was 13% (N=16). 3 patients met symptomatic criteria for COVID-19 testing post-operatively, however none tested positive. Conclusion Careful patient selection based on risk factors and symptoms allows units to continue to perform safe oncological surgery during a pandemic.