Shifts in recruitment demographics due to the effects of the COVID-19 pandemic for the CAPTURE COPD Study

Context: Primary Care Research seeks to "meet our patients where they are" to make research more accessible and inclusive. During the COVID-19 pandemic, recruitment practices shifted. Letters, emails, phone calls took the place of in-person recruitment. Objective: Evaluate the effect of COVID-19 on recruitment demographics across primary care practices within a single health system for "The CAPTURE study: Validating a unique COPD case finding tool in primary care." Study Design and Analysis: Comparative analysis of demographics including race, gender, age from ten urban and rural clinics. The analysis included five practices with in-person recruitment pre-pandemic and 5 with virtual recruitment practices during the pandemic. Setting : Family and Internal Medicine practices, rural and urban. Population Studied: Patients (45-80, male and female) Intervention/Instrument: Before March 2020, pre-pandemic, our team focused on in-person recruitment. Clinicians' schedules were screened for patients who were then consented and enrolled during a clinic visit. After March 2020, our team transitioned to virtual recruit using a population report to identify patients. An email or mailed letter was sent to patients followed by a phone call. Outcome Measures: Percent enrolled relative to total clinic populations (pop). Results: In-person, 31.6% of enrollees were male compared to the clinic pop. of 41.5%. With virtual recruitment, 40.9% of enrollees were male compared to the clinic pop. of 39.9%. This gender difference was statistically significant (t-test p<0.05). In-person, 21.0% of enrollees were self-reported African American/Black (AA/Black) compared to the clinic pop. of 14.6%. With virtual recruitment, 18.1% of enrollees self-reported as AA/Black compared to the clinic pop. of 23.6%. In-person, 60.0% of enrollees were between the 45-64 compared to the clinic pop. of 55.0%. With virtual recruitment, 54.7% of enrollees were 45-64 compared to the clinic pop. of 60.8%. Although there was a trend toward fewer AA/Black enrollees and enrollees 45-64 through virtual recruitment, the difference was not statistically significant. Conclusion : During the COVID-19 pandemic, remote recruitment significantly increased the proportion of male participants but trended toward reduced proportion of AA/Black participants as well as those between the age of 45-64. These results suggest changing recruitment strategies between in person and virtual can alter recruitment outcomes. Copyright © 2023 Annals of Family Medicine, Inc.

Viral and bacterial infections among adults hospitalized with COVID-19, Coronavirus Disease 2019-Associated Hospitalization Surveillance Network, 14 states, March 2020-February 2022

Background. Coinfections, both bacterial and viral, occur with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection, but prevalence, risk factors, and associated clinical outcomes are not fully understood. Methods. We used the Coronavirus Disease 2019-Associated Hospitalization Surveillance Network (COVID-NET), a population-based surveillance platform to investigate the occurrence of viral and bacterial coinfections among hospitalized adults with laboratory-confirmed SARS-CoV-2 infection during March 2020 and February 2022. Patients receiving additional standard of care (SOC) molecular testing for viral pathogens (14 days prior to admission or 7 days after), including respiratory syncytial virus, rhinovirus/enterovirus (RV/EV), influenza, adenovirus, human metapneumovirus, parainfluenza viruses, and endemic coronaviruses, were included. SOC testing for clinically relevant bacterial pathogens (7 days before admission or 7 days after) from sputum, deep respiratory, and sterile sites were included. The demographic and clinical features of those with and without bacterial infections were compared. Results. Among 2,654 adults hospitalized with COVID-19 and tested for all 7 virus groups, another virus was identified in 3.1% of patients. RV/EV (1.2%) and influenza (0.4%) were the most commonly detected viruses. Half (17,842/35,528, 50.2%) of hospitalized adults with COVID-19 had bacterial cultures taken within 7 days of admission, and 1,092 (6.1%) of these had a clinically relevant bacterial pathogen. A higher percentage of those with a positive culture died compared to those with negative cultures (32.3% vs 13.3%, p< 0.001). Staphylococcus aureus was the most common isolate overall;Pseudomonas aeruginosa was the second most common respiratory isolate This figure includes 1,408 bacterial cultures from 1,066 individuals. Deep respiratory sites include endotracheal aspirate, bronchoalveolar lavage fluid, bronchial washings, pleural fluid, and lung tissue. Commensal organisms were excluded. Conclusion. Consistent with previous studies, a relatively low proportion of adults hospitalized with COVID-19 had concomitantly identified viral or bacterial infections. Identification of a bacterial infection within 7 days of admission is associated with increasedmortality among adults hospitalized with COVID-19. Conclusions about the clinical relevance of bacterial infections is limited by the retrospective nature of this study.

Prostheses used in hip, knee, ankle, elbow and shoulder replacement procedures 2020

This document reports the numbers of prostheses recorded and reported to the NJR between 1 January and 31 December 2020. The tables show volumes of components as they have been entered into the registry, regardless of construct. The procedure counts in this document are presented without adjustment and may vary from counts found in the corresponding main NJR Annual Report analysis. If a procedure has been submitted with missing implant information this will also cause numbers to differ. Procedure counts below four have been suppressed. Components are listed and described according to the current classifications used in the registry. It must be noted that due to COVID-19, the ratio of revision to primary procedures increased in 2020 and this may affect the relative changes in the types and brands of implants used in comparison to previous years. As this document was not published for 2019 Annual Report data, comparison has been made with the 2018 Annual Report data.

No exponential rise in revision knee replacement surgery over the past 15 years: an analysis from the National Joint Registry.

OBJECTIVE: To investigate trends in the incidence rate and the main indication for revision knee replacement (rKR) over the past 15 years in the UK. METHOD: Repeated national cross-sectional study from 2006 to 2020 using data from the National Joint Registry (NJR). Crude incidence rates were calculated using population statistics from the Office for National Statistics. RESULTS: Annual total counts of rKR increased from 2,743 procedures in 2006 to 6,819 procedures in 2019 (149% increase). The incidence rate of rKR increased from 6.3 per 100,000 adults in 2006 (95% CI 6.1 to 6.5) to 14 per 100,000 adults in 2019 (95% CI 14 to 14) (122% increase). Annual increases in the incidence rate of rKR became smaller over the study period. There was a 43.6% reduction in total rKR procedures in 2020 (during the Covid-19 pandemic) compared to 2019. Aseptic loosening was the most frequent indication for rKR overall (20.7% procedures). rKR for aseptic loosening peaked in 2012 and subsequently decreased. rKR for infection increased incrementally over the study period to become the most frequent indication in 2019 (2.7 per 100,000 adults [95% CI 2.6 to 2.9]). Infection accounted for 17.1% first linked rKR, 36.5% second linked rKR and 49.4% third or more linked rKR from 2014 to 2019. CONCLUSIONS: Recent trends suggest slowing of the rate of increase in the incidence of rKR. Infection is now the most common indication for rKR, following recent decreases in rKR for aseptic loosening. Infection was prevalent in re-revision KR procedures.

Improving Cardiac Rehab Attendance by Providing Transportation Services and Removing Cost

For more than a decade, Cardiac Rehabilitation (CR) has been a Class IA indication for cardiovascular patient populations. While the benefits of CR are well published, enrollment and attendance barriers persist. The overall objective of the PACE Project is to increase enrollment and completion of a CR program in an urban academic health center. It addresses two known barriers to patient CR participation: transportation and affordability. Our hypothesis is that Phase II CR enrollment and attendance can be increased by providing free transportation and removing patient out-of-pocket expenses. The study recruitment period was October 2019 to March 2021, with a pause in services and recruitment during the initial COVID-19 pandemic lockdown. Patient were offer PACE participation during their hospitalization. Once consents were obtained, the standard processes to schedule and enroll in Phase II cardiac rehab and exercise prescription were adhered. Patients were responsible for calling and scheduling transportation services for their CR sessions. Upon completion of the study, 73% (41/56) patients attended at least one Phase II session, with an average of 15 session per attendee. This compared to previously published national participation of 8.2% or 32.6%, of at least one session, depending upon in-patient CR referral. The study had a Phase II graduation rate of 32% (13/41). Transportation was utilized in 10.7% (6/56) of participants, with billed mileage ranging from 1-5 miles. Those utilizing transportation services were all female, with 83% (5/6) being women of color. Out-of-pocket co-payments were observed for 41.4% (17/41) of attendees. For those with co-payments, an average of $40, with a range $2-$60, per session was observed. CR is a proven guideline directed intervention to reduce secondary cardiac events. Our study suggest the removal of frequently cited barriers to participation, cost and transportation, is associated with improved CR participation.

Treatment (TX) of advanced melanoma during the Coronavirus Disease 2019 (COVID-19) pandemic in Kaiser Permanente Northern California (KPNC)

The COVID-19 pandemic brought with it TX changes for many patients (pts) with AMEL, as it did for other pts with cancer. The long-term impacts of mandated area lockdowns, social distancing, medical society guidelines, and patient preference will not be fully understood for some time. The first step to learning from the pandemic is to assess how AMEL care was rendered in 2020. We performed a retrospective analysis of systemic TX for AMEL in KPNC, an integrated community healthcare system with approximately 4 million pts and about 150 de novo diagnoses of AMEL annually. We performed a chart review of pts with AMEL who were treated with standard of care systemic therapy, either immune-checkpoint inhibitors (ICI) or BRAF/MEK inhibitors (BRAF/MEKi), from January 1 to March 15, 2020, as a control group, and between March 15 and May 20, during the first wave of the COVID-19 pandemic in California with follow-up through November 4, 2020. Between January 1 and March 15, 26 pts started palliative ICI of whom 11 started combination PD1 (PD1i) and CTLA4 inhibitors. Among 15 pts who started on single-agent PD1i, 14 pts received short-interval TX (SIT), while 1 started long-interval TX (LIT). All 21 pts who started perioperative PD1i pre-pandemic, started on SIT. Between March 15 and May 20, 21 pts started palliative ICI, of whom only 3 started combination TX. Among pts who started palliative single-agent PD1i 40% started on LIT in this initial phase of the pandemic. 27 pts started perioperative ICI during this time. We found 3 started with neoadjuvant therapy and 78% started on LIT. Among 78 pts who were already on palliative single-agent ICI at the start of the COVID-19 pandemic, 15% remained on SIT and 24% changed to LIT. Sixteen pts (21%) also interrupted palliative ICI between March 15 and April 15 after a median time on TX of 45 weeks and for 63% the cited reason for interruption on chart review was the COVID 19 pandemic. Three of these pts who stopped ICI changed to BRAF/MEKi, the remainder continue in active follow-up as of November 2020. Among 72 pts already receiving perioperative ICI in March 2020, 19% remained on SIT, 35% changed to LIT, and 11% were already on LIT. 39% of pts interrupted perioperative ICI after a median time of 20 weeks on TX and 46% of these cited COVID 19 as the reason for interruption. Three pts have since resumed peri-operative TX, but the others remain in active follow-up off therapy. Between 3/15 and 5/30/2020, we noted a 325% increase in pts started on BRAF/MEKi;69% of pts received therapy for palliative intent. The start of the COVID-19 pandemic saw many different changes in AMEL TX in KPNC, with increased use of single-agent ICI, LIT, and oral therapy, in line with public health guidance, oncology societal guidelines and patient preference. It will be important to assess the long-term outcomes relating to these changes, including the impact of early discontinuation of ICI, to help guide future Melanoma care during and after the pandemic.

Reaching out to early-career astrobiologists: AbGradE's actions and perspectives

Astrobiology Graduates in Europe (AbGradE, pronounced ab-grad-ee) is an association of early-career scientists working in fields relevant to astrobiological research. Conceptualized in 2013, it was initially designed as a mini-conference or workshop dedicated to early-career researchers, providing a friendly environment where early-career minds would be able to present their research without being intimidated by the possibility of facing a more traditional audience, composed mainly of senior scientists. Within the last couple of years, AbGradE became the first point of call for European, but also for an increasing number of non-European, early-career astrobiologists. This article aims to present how AbGradE has evolved over the years (in its structure and in its way of organizing events), how it has adapted with the COVID-19 pandemic, and what future developments are considered. Copyright © The Author(s), 2022. Published by Cambridge University Press.

Understanding the Relationship Between the Emergency Department Built Environment and Physician Burnout Through High Fidelity Virtual Reality Modeling

Study Objectives: To understand how the emergency department built environment contributes to physician burnout. Methods: We conducted semi-structured interviews of attending physicians who work regularly at the study institution, an urban ED, Level 1 Trauma Center with an annual census of 85, 000 and an EM residency program. Physicians were first asked about overall burnout followed by questions relating the physical environment to burnout. Subjects participated in a virtual reality (VR) simulation of the study ED. In the VR simulation, subjects placed virtual “sticky notes” to describe elements of the environment that contributed to or relieved burnout. Physicians also completed occupant comfort surveys to measure their overall satisfaction with the built environment for three different ED spaces. The surveys contained prompts for 6 categories: acoustics, air quality, cleanliness and maintenance, lighting, layout and furnishings, temperature (photo). A modified grounded theory approach was used to analyze interview transcripts, VR collected virtual memos and surveys. Results: 19 emergency physicians were enrolled (68% male, 42% early-, 42% mid-, 16% late-career) Average Maslach Burnout Inventory scores were 2.8 for emotional exhaustion, 2.4 for depersonalization and 4.8 for personal accomplishment. Sources of overall ED burnout were most commonly attributed to to ED volume, crowding, lack of resources, lack of institutional support, provider metrics, difficult patients, medico-legal concerns, worsening job market and effects of COVID-19. For the main study question, 71 themes were coded over 6 built environment domains and 25 themes related to impact and burnout. Of the 6 environmental domains, layout, cleanliness and acoustics were more commonly associated with burnout compared to air quality, lighting and temperature. An internal waiting room was the strongest contributor to physician burnout due to the close proximity to unassigned (waiting) patients associated with interruptions, distractions and concern for provider safety which contributed to emotional exhaustion and depersonalization. Increased distance to patient rooms was connected with a sense of depersonalization. Clutter, non-useful displays, poor organization and equipment issues were frequently noted and connected to a sense of disorganization and decreased personal accomplishment. Additionally, poor visualization of patients and monitors from physician workstations contributed to decreased situational awareness, anxiety, lack of provider safety and decreased personal accomplishment. Other frequently cited components included lack of visual/acoustical privacy in hallways, patient proximity to physician workstations associated with patient discomfort, medico-legal concerns, emotional exhaustion and depersonalization. 100% of the physicians agreed or strongly agreed that the VR simulation was helpful to elicit memories and reflection about the built environment. Conclusion: The study reflects associations between the ED built environment and components of physician burnout. Interventions aimed at balancing distance to patients (unassigned and assigned), reducing clutter and disorganization, balancing the acoustical environment and improving patient comfort and privacy may improve provider wellness. [Formula presented]

Covid infection among kidney transplant recipients: Management and outcomes

Purpose: COVID pandemic has posed a significant challenge among kidney transplant recipients (KTR) due to their immunocompromised state. There is uncertainty on immunosuppression management among those who have COVID infection. We sought to better understand the clinical course, management, and outcomes of our KTR who developed COVID infection. Methods: Single-center experience of COVID infected KTR. Baseline demographics, clinical data, management, and outcomes were obtained by manual chart abstraction of the EMR. Results: 50 KTR had COVID infection. Mean age was 53;50% males;74% African-Americans. Fever was the most common symptom (71%);36 patients (71%) required hospitalization;11 (22%) required ICU admission and 8 (16%) required mechanical ventilation. 23 developed AKI with one-third requiring RRT;50% of patients requiring RRT eventually had renal recovery. Majority of admitted patients received dexamethasone, remdesivir, and convalescent plasma. In terms of immunosuppression, 28 of 49 (57%) had their MMF held while 8% had MMF dose reductions;one had everolimus held and one had AZA held;7 (14%) had CNI dose reductions with none held. Six patients (12%) died. Those who died were significantly more likely to receive dexamethasone (42% vs 2%;p=0.002), remdesivir (33% vs 7%;p=0.027), and convalescent plasma (40% vs 0%;p=0.001). Mortality rates were similar across those who had immunosuppressive agents dose reduced vs held vs not adjusted (11% vs 17% vs 12%, respectively;p=0.919). CNI dose reductions tended to be more common in those who died (43% vs 7%;p=0.122). There were no subsequent acute rejections or graft losses in those who recovered. Conclusions: KTR represent a vulnerable patient population during COVID. Due to their immunocompromised state and often more severe clinical presentation, the majority require hospitalization, with a significant number needing ICU admission and mechanical ventilation. Severe illness led to higher use of dexamethasone, remdesivir and covalescent plasma in those who ultimately died of COVID. It is unclear what impact immunosuppression dose reductions had on the COVID clinical course, but these reductions did not appear to increase risk of rejection or graft loss.

PREVALENCE AND IMPACT OF FRAILTY IN PATIENTS HOSPITALISED WITH COVID-19. THE SALFORD EXPERIENCE IN WAVES 1 AND 2

IntroductionThe COVID-19 pandemic has had an extensive impact on the frail older population, with significant rates of COVID-related hospital admissions and deaths amongst this vulnerable group. There is little evidence of frailty prevalence amongst patients hospitalised with COVID-19, nor the impact of frailty on their survival. MethodsProspective observational study of all consecutive patients admitted to Salford Royal NHS Foundation (SRFT) Trust between 27th February and 28th April 2020 (wave 1), and 1st October to 10th November 2020 (wave 2) with a diagnosis of COVID-19. The primary endpoint was in-hospital mortality. Patient demographics, co-morbidities, admission level disease severity (estimated with CRP) and frailty (using the Clinical Frailty Scale, score 1–3 = not frail, score 4–9 = frail) were collected. A Cox proportional hazards regression model was used to assess the time to mortality. ResultsA total of 693 (N = 429, wave 1;N = 264, wave 2) patients were included, 279 (N = 180, 42%, wave 1;N = 104, 38%, wave 2) were female, and the median age was 72 in wave 1 and 73 in wave 2. 318 (N = 212, 49%, wave 1;N = 106, 39%, wave 2) patients presenting were frail. There was a reduction in mortality in wave 2, adjusted Hazard ratio (aHR) = 0.60 (95%CI 0.44–0.81;p = 0.001). There was an association between frailty and mortality aHR = 1.57 (95%CI 1.09–2.26;p = 0.015). ConclusionFrailty is highly prevalent amongst patients of all ages admitted to SRFT with COVID-19. Higher scores of frailty are associated with increased mortality.

Increased care at discharge from COVID-19: The association between pre-admission frailty and increased care needs after hospital discharge; a multicentre European observational cohort study.

BACKGROUND: The COVID-19 pandemic has placed significant pressure on health and social care. Survivors of COVID-19 may be left with substantial functional deficits requiring ongoing care. We aimed to determine whether pre-admission frailty was associated with increased care needs at discharge for patients admitted to hospital with COVID-19. METHODS: Patients were included if aged over 18 years old and admitted to hospital with COVID-19 between 27 February and 10 June 2020. The Clinical Frailty Scale (CFS) was used to assess pre-admission frailty status. Admission and discharge care levels were recorded. Data were analysed using a mixed-effects logistic regression adjusted for age, sex, smoking status, comorbidities, and admission CRP as a marker of severity of disease. RESULTS: Thirteen hospitals included patients: 1671 patients were screened, and 840 were excluded including, 521 patients who died before discharge (31.1%). Of the 831 patients who were discharged, the median age was 71 years (IQR, 58-81 years) and 369 (44.4%) were women. The median length of hospital stay was 12 days (IQR 6-24). Using the CFS, 438 (47.0%) were living with frailty (≥ CFS 5), and 193 (23.2%) required an increase in the level of care provided. Multivariable analysis showed that frailty was associated with an increase in care needs compared to patients without frailty (CFS 1-3). The adjusted odds ratios (aOR) were as follows: CFS 4, 1.99 (0.97-4.11); CFS 5, 3.77 (1.94-7.32); CFS 6, 4.04 (2.09-7.82); CFS 7, 2.16 (1.12-4.20); and CFS 8, 3.19 (1.06-9.56). CONCLUSIONS: Around a quarter of patients admitted with COVID-19 had increased care needs at discharge. Pre-admission frailty was strongly associated with the need for an increased level of care at discharge. Our results have implications for service planning and public health policy as well as a person's functional outcome, suggesting that frailty screening should be utilised for predictive modelling and early individualised discharge planning.

Nosocomial COVID-19 infection: examining the risk of mortality. The COPE-Nosocomial Study (COVID in Older PEople).

BACKGROUND: Hospital admissions for non-coronavirus disease 2019 (COVID-19) pathology have decreased significantly. It is believed that this may be due to public anxiety about acquiring COVID-19 infection in hospital and the subsequent risk of mortality. AIM: To identify patients who acquire COVID-19 in hospital (nosocomial COVID-19 infection (NC)) and their risk of mortality compared to those with community-acquired COVID-19 (CAC) infection. METHODS: The COPE-Nosocomial Study was an observational cohort study. The primary outcome was the time to all-cause mortality (estimated with an adjusted hazard ratio (aHR)), and secondary outcomes were day 7 mortality and the time-to-discharge. A mixed-effects multivariable Cox's proportional hazards model was used, adjusted for demographics and comorbidities. FINDINGS: The study included 1564 patients from 10 hospital sites throughout the UK, and one in Italy, and collected outcomes on patients admitted up to April 28th, 2020. In all, 12.5% of COVID-19 infections were acquired in hospital; 425 (27.2%) patients with COVID died. The median survival time in NC patients was 14 days compared with 10 days in CAC patients. In the primary analysis, NC infection was associated with lower mortality rate (aHR: 0.71; 95% confidence interval (CI): 0.51-0.98). Secondary outcomes found no difference in day 7 mortality (adjusted odds ratio: 0.79; 95% CI: 0.47-1.31), but NC patients required longer time in hospital during convalescence (aHR: 0.49, 95% CI: 0.37-0.66). CONCLUSION: The minority of COVID-19 cases were the result of NC transmission. No COVID-19 infection comes without risk, but patients with NC had a lower risk of mortality compared to CAC infection; however, caution should be taken when interpreting this finding.