CLUSTER-RANDOMIZED TRIAL COMPARING TWO SARS-CoV-2 TESTING MODELS IN AFRICA

Background: Most programs use a screen and test strategy to identify SARS-CoV-2 infection, but this strategy does not identify individuals with asymptomatic infection. We determined the SARS-CoV-2 case detection rates in a test-all model compared to the standard screen-and-test model in Kenya and Cameroon. Method(s): A cluster-randomized trial was conducted in 20 health facilities between May-October 2022. In each country, 5 facilities were randomized to test all (testing offered regardless of screening outcome) or screen and test (testing offered if screened positive) arms. Additional staff were hired to support implementation of the two models in Kenya (K) and the test all model in Cameroon (C). Clients age>2 years attending HIV, TB and MNCH clinics were tested using SARS-CoV-2 rapid antigen tests. We estimated case detection rates (CDR) with facility level weighted averages and used a weighted t-test with robust standard errors for between arm comparison. Result(s): Overall, 80,828 attendee visits were reported in the test-all arm (63,492 C and 17,336 K) and 71,254 attendee visits were reported in the screenand- test arm (56,589 C and 14,665 K). In the test-all arm, 42,325 (52.4%) were screened for COVID-19 symptoms (46.7% C and 73.2% K) and 21,536 (26.6%) were tested (29.2% C and 17.4% in Kenya) with a positivity rate of 1.4% (2.0% C and 1.1% K). In the screen-and-test arm, 48,314 (67.8%) were screened (72.8% C and 48.6% K), and 3,629 (7.5%) were eligible for testing (8.2% C and 3.7% K) - of those, 2,139 (58.9%) were tested (57.1% C and 82.4% K) with a positivity rate of 4.1% (3.4% C and 10% K). The estimated CDR was 3.59 (95% CI:1.55-5.64) per 1,000 attendee visits in the test-all arm and 1.46 (95% CI:0.60-2.32) per 1,000 attendee visits in the screen-and-test arm. Compared to the screen-and-test arm, the test-all arm had significantly higher COVID-19 CDR in MNCH clinics (3.57 vs.1.29, p=0.034). There were no significant differences in COVID-19 CDR between the two arms in HIV (4.20 vs.1.98, p=0.174) and TB (10.33 vs. 5.03, p=0.283) clinics, though the number of SARS-CoV-2 infections was small. Conclusion(s): The test-all arm identified more SARS-CoV-2 cases than the routine screen-and-test model, despite overall low testing coverage. The test-all model should be considered in future epidemics to improve early detection of SARS-CoV-2 infection among vulnerable populations, but effective implementation requires additional human resources to manage the clinic volumes. COVID-19 Case Detection Rates Per 1,000 Attendees: Comparison of Screen-and- Test and Test-All Arms.

Relational approaches to employability

As policymakers consider how best to respond to increased labour market volatility in post-Covid-19 economies, there is concern that vulnerable groups such as lone parents may be left behind, and consensus that we need to develop more responsive and person-centred approaches to employability. Drawing on Cottam's (2011, 2018) work on ‘relational welfare', and the principles of the capabilities approach that underly it, this article discusses the experiences of unemployed lone parents and stakeholders involved in an innovative employability initiative operating across five localities in Scotland. We argue that relational approaches are valuable in supporting such vulnerable jobseekers to achieve outcomes that they have reason to value in terms of employability, learning, wellbeing and relationships (with balancing work and family relationships of particular importance for lone parents). We also discuss facilitators of, and challenges for, relational approaches to employability before identifying lessons for future policy. © 2023 The Author(s). Published by Informa UK Limited, trading as Taylor & Francis Group.

Deconstructing the Romanticization of Solidarity: Reflections on Social Worker Performativity and Resistance During COVID-19

This article explores how COVID-19 has impacted our understanding of our frontline practice and professional identity as four doctoral social work students. When the pandemic unfolded, we were completing a collaborative autoethnographic research project that revealed how our professional practices were shaped by both performativity and resistance. Because of COVID-19, this project was paused. When we reconvened to draft our research paper, we noted a collective change in our perceptions of performativity and resistance in our practice. In this article we share the insights that arose in the context of our roles as frontline workers. We consider the "romanticizing" of discourses related to frontline workers during the pandemic. We also reflect on the heightened pressure that the four of us have felt to "perform" these discourses in our work. We argue that, while outwardly positive, such discourses have their roots in capitalist neo-liberal ideals, and thus they occlude spaces of resistance in already prescriptive practice environments and ultimately maintain oppression for service users.

Randomized multicenter trial of 3 weekly cabazitaxel versus weekly paclitaxel chemotherapy in the first-line treatment of HER2 negative metastatic breast cancer (MBC)

Background: Paclitaxel is commonly used as first line chemotherapy for HER2 negative MBC. However, with response rates of 21.5-53.7% and a significant risk of peripheral neuropathy there is a need for more effective and better tolerated chemotherapy (CCT). Methods: This open label randomised (1:1) phase 2 trial compared 6 cycles of cabazitaxel (25 mg/m2 ) every 3 weeks, with weekly paclitaxel (80mg/m2 ) over 18 weeks as first line CCT. HER2 negative and performance status ≤1 patients were eligible. Patients on cabazitaxel received GCSF prophylaxis. Primary endpoint was Progression Free Survival (PFS) with 127 events required to detect a hazard ratio (HR) of 0.65 with 85% power. Secondary endpoints included objective response rate (ORR;RECIST 1.1), time to response (TTR), overall survival (OS), safety and tolerability and quality of life (QoL). Results: 158 patients were recruited from 14 UK hospitals (79 in each arm). Median age (range) was 56(34-81) in the cabazitaxel arm and 61(34-79) in the paclitaxel arm. 61% of patients were performance status 0. Median time on treatment was 15 weeks for both arms, but more patients on paclitaxel had a treatment delay (61% vs 39%) or dose reduction (37% vs 24%). Comparing cabazitaxel to paclitaxel after 146 PFS events, median PFS was 6.7 vs 5.8 months (HR 0.84;95%CI 0.60-1.18, P = 0.3). There was no difference in OS, median 19.3 vs 20.0 months (HR 0.94;95%CI 0.63-1.40, P = 0.7), ORR (42% vs 37%) or TTR (HR 1.09;95%CI 0.68- 1.74, P = 0.7). Grade ≥3 adverse events occurred in 42% of patients on cabazitaxel and 48% on paclitaxel. Diarrhoea, febrile neutropenia and nausea were the most common grade ≥3 events in the cabazitaxel arm with rates of 11%, 11% and 10% respectively compared to 1%, 1% and 0% in the paclitaxel arm. In the paclitaxel arm the top grade ≥3 events were lung infection and peripheral neuropathy, 6% and 5% respectively compared to 2.5% and 0% in the cabazitaxel arm. Peripheral neuropathy of any grade was reported by 55% of patients treated with paclitaxel vs 17% on cabazitaxel. Alopecia occurred in 41% of patients on paclitaxel compared to 27% on cabazitaxel. Adverse events leading to discontinuation were more frequent with paclitaxel (22%) than cabazitaxel (14%). Over the course of treatment, mean EQ5D single index utility score (+0.05;95%CI 0.004-0.09, P = 0.03) and visual analogue scale score (+7.7;95%CI 3.1-12.3, P = 0.001) were higher in the cabazitaxel arm compared to paclitaxel suggestive of better QoL on Cabazitaxel. Conclusions: 3 weekly cabazitaxel as first line chemotherapy in HER2 negative MBC does not significantly improve PFS compared to weekly paclitaxel, though it has a lower risk of peripheral neuropathy with better patient reported overall health outcomes. Cabazitaxel is safe and well tolerated for MBC and requires fewer hospital visits, an important consideration in the COVID pandemic and beyond.

Helmet noninvasive ventilation versus high flow nasal cannula for COVID-19 related acute hypoxemic respiratory failure

RATIONALE: A high percentage of patients with Covid-19 associated acute hypoxemic respiratory failure (AHRF) receive invasive mechanical ventilation, which is associated with a high mortality. Noninvasive ventilation (NIV) offers an alternative to invasive mechanical ventilation, though its role in both de novo AHRF and pandemic viral pneumonia has been controversial. Our group has previously demonstrated that NIV delivered by helmet reduces endotracheal intubation rates and improves mortality in patients with acute respiratory distress syndrome when compared to facemask NIV in a randomized controlled clinical trial (1). Limited data are available on the comparative efficacy of noninvasive respiratory support strategies in patients with AHRF due to Covid-19. NIV by helmet interface offers a promising strategy for these patients and may avert the need for endotracheal intubation. METHODS: All patients with Covid-19 associated AHRF admitted to the intensive care unit and managed initially with noninvasive respiratory support between March 1 and July 31, 2020 were identified. Those who received helmet NIV were matched with patients who received HFNC (high flow nasal cannula) using propensity scores in a 1:1 ratio without replacement. Baseline characteristics and therapies that differed on univariable analysis were used for matching. After matching, univariable analysis was conducted comparing the HFNC and helmet NIV groups. RESULTS: 78 patients initially managed with HFNC and 31 patients managed with helmet NIV (excluding 7 patients who received helmet NIV after intubation) were identified. Matching resulted in similar groups according to baseline characteristics and therapies received. The primary composite outcome of intubation or inhospital mortality occurred in 20 (64.5%) patients in the helmet group and 20 (64.5%) patients in the control group (absolute difference, 0%;95% CI,-23.4% to 23.4%;p=1.00). In-hospital mortality in the helmet NIV group was similar to that of the HFNC control group (absolute difference-9.7%;95% CI,-34.4% to 15.0%;p=0.45). In patients treated with helmet NIV, gas exchange improved significantly following application with an increase in the ratio of arterial partial pressure of oxygen to fraction of inspired oxygen from 72 to 141 (mean difference, 69;95% CI 26 to 112;p=0.003). CONCLUSIONS: While limited by the small sample size and observational nature, there was no significant difference observed in outcomes of patients with Covid-19 associated AHRF managed with helmet NIV compared to HFNC. After application of helmet NIV, a significant improvement in gas exchange was observed. REFERENCES: 1. Patel BK, et al. JAMA, 2016.

Long-term psychological and cognitive outcomes of patients with COVID-19

Rationale: Intensive care unit (ICU) survivorship has well documented physical disability1,2 psychological sequelae, and cognitive dysfunction3,4 all combined under the umbrella of Post-Intensive Care Syndrome (PICS). The COVID-19 pandemic is concerning for overwhelming health care resources in the short-term, but the longterm consequences of this large cohort of patients surviving critical illness remains ill-defined. It also remains unclear if the unique context of health care delivery such as lack of visitors and cohorting patients during the pandemic exacerbates the psychological and cognitive impairments of PICS. Methods: All patients admitted to the ICU with COVID-19 were eligible for enrollment in this prospective observational study. We performed a global assessment of cognitive function (using the Montreal Cognitive Assessment tool (T-MoCA)), posttraumatic stress disorder (using the Impact event scale (IES-Revised)), and depression/anxiety (using Hospital Anxiety and Depression scale (HADS)) in ICU survivors at 6 months after hospital discharge. Interviews were conducted via telephone or in-person when possible. Results: From April 10, 2020 thru November 17th, 2020 one hundred patients were enrolled upon hospital discharge. Eighty-two patients reached the 6-month milestone after hospital discharge and 22 (26.8%) of these patients required invasive mechanical ventilation. Of this eligible cohort, seven patients died, two were cognitively unable to complete the evaluations, four refused to participate, and thirteen were lost to follow-up. Fifty-six patients completed the evaluation with 74.7% follow-up (56/75 alive patients). Symptoms of probable post-traumatic stress disorder were reported in 2 patients (3.6%). Depression and Anxiety was reported in 5 patients (8.9%) respectively. Cognitive impairment was present in 47.3% of patients with a median T-MoCA score of 18 [15.5-19]. There was no difference in T-MoCA scores based on whether patients required invasive mechanical ventilation (IMV) (IMV 17 [15-20.5] vs not intubated 18 [16-19];p=0.89). Conclusions: Our preliminary long-term follow-up data suggest that symptoms of post-traumatic stress after COVID-19 infection are rare. In addition, less than 10% of patients reported anxiety and depression six months after hospital discharge. Interestingly, cognitive impairment as measured by T-MOCA was present in almost half of the patients. Further follow-up on the long term effects of COVID-19 related critical illness is warranted as we adapt during this pandemic.

Feasibility of physical and occupational therapy in critically ill patients with COVID-19 infection

Rationale:Early mobilization and physical rehabilitation improve functional outcomes and are essential to high quality critical care. Despite its importance, it is common for rehabilitation to be deferred in the critically ill due to a variety of barriers, including infection with SARS-CoV-2. We present a single academic center's experience providing physical and occupational therapy to critically ill patients infected with SARS-CoV-2. Methods:All patients with Coronavirus Disease 2019 (COVID-19) associated illness admitted to the intensive care unit (ICU) from March 1st to July 31st, 2020 were identified in this retrospective chart review. Patients who received at least one therapy treatment session were included in the study. Results:Three-hundred and seventy-nine physical and occupational therapy sessions were conducted with 116 patients. The majority (85%) of patients were admitted to the ICU for hypoxemic respiratory failure. The median number of treatment sessions during ICU admission per patient was 2, (IQR: 1-4). The median time from ICU admission to first PT session was 4 days (IQR, 3-5). The median percentage of ICU days with physical and occupational therapy treatment was 33% (IQR, 21-50). The median session length was 25 minutes (IQR, 25-30min). Sitting was achieved in 353 sessions, (93%) standing was achieved in 261 sessions (69%), walking was achieved in 185 sessions (48%), and sitting in the bedside chair 118 times (31%).Patients with respiratory failure completed therapy sessions while receiving mechanical ventilation (21% of sessions), high flow nasal cannula (45% of sessions), non-invasive positive pressure ventilation by helmet and facemask (7% of sessions), and ECMO (12% of sessions). Patients requiring vasoactive medications (4%) and continuous renal replacement therapy (6%) were also treated by physical and occupational therapy. Delirium, determined by confusion assessment method (CAM-ICU), was frequently encountered by the physical and occupational therapy teams and was not an absolute barrier (32%) (Table 1). Discharge destinations included: home (n=57, 61%), acute rehabilitation units (n=16, 17%), long term acute care hospitals (n=9, 10%), sub-acute care centers (n=8, 8%), and skilled nursing facilities (n=4, 4%). No members of the therapy team were diagnosed with SARS-CoV-2 during the study period. Conclusions:This report demonstrates the feasibility of conducting physical and occupational therapy in COVID-19 specific ICUs. Providing therapy services appeared to be safe for patients and members of the therapy team, as adverse events were rare and no therapist was diagnosed with COVID-19.

Predictors of mortality in COVID 19 associated respiratory failure among predominantly African American patients

Rationale:Patients with COVID-19 frequently develop severe respiratory disease and may require invasive mechanical ventilation. A study of primarily white patients intubated for COVID-19 associated respiratory failure found predictors of 28-day mortality to be respiratory system compliance, age, tidal volume, arterial pH and heart rate. Little is known about the outcomes of minority populations with severe COVID-19 pneumonia. Therefore, we present an analysis of the predictors of mortality in a group of primarily African American patients with COVID-19 associated respiratory failure. Methods:All adult patients admitted to the University of Chicago COVID-19 intensive care unit receiving invasive mechanical ventilation between March 1st and June 31st, 2020 were identified. Patients were included in the study if they had at least one recorded measure of plateau airway pressure while receiving volume-controlled ventilation allowing determination of driving pressure and lung compliance. Univariable analysis was conducted comparing survivors with those who died in-hospital followed by construction of a multivariable logistic regression model predicting in-hospital mortality based on significant factors from univariable analysis, excluding colinear variables. Results:Eighty-five patients were included in this retrospective study. Patients were primarily African American (n=73, 86%). Among all study patients, median tidal volume was 6.0 cc/kg ideal body weight (IQR 5.8-6.2), PEEP was 8 cm H2O (IQR 5.0-10), and driving pressure was 14 cm H2O (IQR 11-16). Median respiratory system compliance was 27 ml/cm H2O (IQR 21-34). Salvage therapies for refractory hypoxemia in the cohort included prone positioning (27%), paralysis (27%), inhaled pulmonary vasodilators (19%), and extracorporeal membrane oxygenation (1%). In the multivariable logistic regression model, age (OR 1.077, 95% CI 1.031 to 1.125, p=0.001) and driving pressure (OR 1.174, 95% CI 1.009 to 1.366, p=0.038) were found to be independent predictors of mortality. Conclusions:In a predominantly African American patient population with COVID-19 pneumonia requiring invasive mechanical ventilation, higher driving pressure was predictive of overall mortality. These finding are consistent with the work of Botta et al (2020), who demonstrated reduced lung compliance was predictive of mortality among a largely white group of patients with severe COVID-19 pneumonia. While minority populations infected with COVID-19 have been found worse outcomes, early lung mechanics appear to be comparable to white patients. These findings support that higher driving pressures and low lung compliance are indicative of serious lung injury which may lead to death.

Functional and quality of life outcomes of critically ill covid-19 survivors at hospital discharge and six months

RATIONALE: Survivors of critical illness are at risk for long-term physical disability and poor quality of life. Changes in health care delivery, such as visitor restrictions and limited availability of therapy services coupled with economic hardship due to the COVID-19 pandemic may exacerbate these long-term consequences. Methods: Patients with respiratory failure requiring advanced respiratory support (endotracheal tube, noninvasive ventilation, or high-flow nasal cannula) and/or shock admitted to the intensive care unit (ICU) with COVID-19 were eligible for enrollment in this prospective observational study. We assessed quality of life (using short form-36 [SF-36]), work status, and independence in activities of daily living (ADLs) in survivors at hospital discharge and 6 months. Quality of life scores were compared to US population norms. An SF-36 score ≥50 is the population norm for both physical and mental scores;scores <45 define significant physical or mental health impairment. Patients underwent assessment for ICU-acquired weakness (ICU-AW) and functional impairment (using Functional Status Score for the ICU (FSS-ICU)) by physical and occupational therapists upon hospital discharge. An FSS-ICU score ≥28 is associated with discharge to home. Analysis of changes over time for the quality of life assessment were performed using paired t-test and tests of proportions. Results: 100 patients were enrolled from April to November 2020. On hospital discharge, 39% of patients had ICU-AW. The median FSS-ICU score on discharge was 24 [20-29], consistent with functional impairment. Fifty-six patients completed the 6-month evaluation with 74.7% follow-up (56/75 alive patients). Mental health impairment was reported by 33% of patients on hospital discharge and declined to 13% at 6 months (p=0.007). Physical health impairment was reported by 70% at discharge and persisted in 46% of patients at 6 months (p=0.007). Patients were independent in ADLs at both hospital admission and 6 months post discharge (90 vs 91%). Only 56% of patients who had been working prior to hospitalization had returned to work at 6 months. Conclusions: Impairments in quality of life and neuromuscular weakness were present at hospital discharge in a significant number of ICU survivors of COVID-19. Similar to the trajectory described in survivors of acute respiratory distress syndrome, despite relatively normal mental health quality of life, persistent physical health impairment was noted in almost half of the survivors at 6 months. Further investigation of the long-term effects of COVID-19 related critical illness and its distinction from post-ICU syndromes from non-COVID-19 critical illness is warranted.

Psychological and cognitive outcomes of critically ill covid-19 patients at hospital discharge

RationaleThe novel coronavirus, COVID-19, can cause critical illness in up to 5% of infected patients. Although the sequelae of surviving critical illness are known, limited data exist regarding the psychological and cognitive outcomes specifically in survivors of COVID-19. Given the social isolation, scarcity of multidisciplinary staff, and socio-economic impact of the pandemic, understanding the cognitive and psychological impact of surviving critical illness due to COVID-19 is of utmost importance. MethodsA prospective observational cohort study at an academic medical center enrolled critically ill patients with confirmed COVID-19 infection. Upon hospital discharge, cognitive and psychological sequelae were measured using the following validated assessments: Montreal Cognitive Assessment (MoCA), Impact of Event Score (IES), and the Hospital Anxiety and Depression scale (HADS). Cognitive impairment was defined as a MoCA score <26. Probable post-traumatic stress disorder (PTSD) was defined as an IES score >32. Significant symptoms of anxiety and depression were defined as a HADS subscale score of ≥8. ResultsFrom April 10, 2020 through November 17, 2020, 100 adult critically ill patients were enrolled, of which 27 were invasively mechanically ventilated. Eighty-nine patients underwent cognitive and psychological evaluation upon hospital discharge. Of the 11 patients who did not complete the evaluation, 2 died prior to discharge, 4 had significant cognitive impairment, 2 were discharged prior to survey completion, and 3 refused. Cognitive impairment was present in 93% of patients (n=83) with a median MoCA score of 17 [13-22]. Patients with cognitive impairment tended to be older (62 years old [53-71] vs 50 [41-58];p=0.17). Ten patients (11%) had probable PTSD with a median IES score of 4 [0-17] in the overall cohort. Seventeen patients (19%) reported significant depressive symptoms and twenty patients (22%) noted significant symptoms of anxiety. ConclusionPrior coronavirus outbreaks of severe acute respiratory syndrome (SARS) and Middle East respiratory syndrome (MERS) were associated with anxiety, depression, impaired memory and confusion occurring in approximately one-third of patients at hospital discharge. In contrast, cognitive impairment in ICU survivors of COVID-19 infection was nearly universal on hospital discharge. This impairment is not completely explained by coexistent psychiatric symptoms of anxiety or depression, which were present in only one-fifth of the ICU survivors.