Impact of COVID-19 infection and vaccination in pancreatobiliary IgG4-related disease patients: An international multicenter study.

BACKGROUND AND AIM: Dedicated studies evaluating the impact of COVID-19 on outcomes of pancreatobiliary IgG4 related disease (IgG4-RD) patients are scarce. Whether COVID-19 infection or vaccination would trigger IgG4-RD exacerbation remains unknown. METHODS: Pancreatobiliary IgG4-RD patients ≥ 18 years old with active follow-up since January 2020 from nine referral centers in Asia, Europe, and North America were included in this multicenter retrospective study. Outcome measures include incidence and severity of COVID-19 infection, IgG4-RD disease activity and treatment status, interruption of indicated IgG4-RD treatment. Prospective data on COVID-19 vaccination status and new COVID-19 infection during the Omicron outbreak were also retrieved in the Hong Kong cohort. RESULTS: Of the 124 pancreatobiliary IgG4-RD patients, 25.0% had active IgG4-RD, 71.0% were on immunosuppressive therapies and 80.6% had ≥ 1 risk factor for severe COVID. In 2020 (pre-vaccination period), two patients (1.6%) had COVID-19 infection (one requiring ICU admission), and 7.2% of patients had interruptions in indicated immunosuppressive treatment for IgG4-RD. Despite a high vaccination rate (85.0%), COVID-19 infection rate has increased to 20.0% during Omicron outbreak in the Hong Kong cohort. A trend towards higher COVID-19 infection rate was noted in the non-fully vaccinated/unvaccinated group (17.6% vs 33.3%, P = 0.376). No IgG4-RD exacerbation following COVID-19 vaccination or infection was observed. CONCLUSION: While a low COVID-19 infection rate with no mortality was observed in pancreatobiliary IgG4-RD patients in the pre-vaccination period of COVID-19, infection rate has increased during the Omicron outbreak despite a high vaccination rate. No IgG4-RD exacerbation after COVID-19 infection or vaccination was observed.

Meningococcal disease in North America: Updates from the Global Meningococcal Initiative.

This review summarizes the recent Global Meningococcal Initiative (GMI) regional meeting, which explored meningococcal disease in North America. Invasive meningococcal disease (IMD) cases are documented through both passive and active surveillance networks. IMD appears to be decreasing in many areas, such as the Dominican Republic (2016: 18 cases; 2021: 2 cases) and Panama (2008: 1 case/100,000; 2021: <0.1 cases/100,000); however, there is notable regional and temporal variation. Outbreaks persist in at-risk subpopulations, such as people experiencing homelessness in the US and migrants in Mexico. The recent emergence of ß-lactamase-positive and ciprofloxacin-resistant meningococci in the US is a major concern. While vaccination practices vary across North America, vaccine uptake remains relatively high. Monovalent and multivalent conjugate vaccines (which many countries in North America primarily use) can provide herd protection. However, there is no evidence that group B vaccines reduce meningococcal carriage. The coronavirus pandemic illustrates that following public health crises, enhanced surveillance of disease epidemiology and catch-up vaccine schedules is key. Whole genome sequencing is a key epidemiological tool for identifying IMD strain emergence and the evaluation of vaccine strain coverage. The Global Roadmap on Defeating Meningitis by 2030 remains a focus of the GMI.

Surge in Incidence and Coronavirus Disease 2019 Hospital Risk of Death, United States, September 2020 to March 2021.

Background: Studies of the early months of the coronavirus disease 2019 (COVID-19) pandemic indicate that patient outcomes may be adversely affected by surges. However, the impact on in-hospital mortality during the largest surge to date, September 2020-March 2021, has not been studied. This study aimed to determine whether in-hospital mortality was impacted by the community surge of COVID-19. Methods: This is a retrospective cohort study of 416 962 adult COVID-19 patients admitted immediately before or during the surge at 229 US academic and 432 community hospitals in the Vizient Clinical Database. The odds ratios (ORs) of death among hospitalized patients during each phase of the surge was compared with the corresponding odds before the surge and adjusted for demographic, comorbidity, hospital characteristic, length of stay, and complication variables. Results: The unadjusted proportion of deaths among discharged patients was 9% in both the presurge and rising surge stages but rose to 12% during both the peak and declining surge intervals. With the presurge phase defined as the referent, the risk-adjusted ORs (aORs) for the surge periods were rising, 1.14 (1.10-1.19), peak 1.37 (1.32-1.43), and declining, 1.30 (1.25-1.35). The surge rise in-hospital mortality was present in 7 of 9 geographic divisions and greater for community hospitals than for academic centers. Conclusions: These data support public policies aimed at containing pandemic surges and supporting healthcare delivery during surges.

Experiences of Older Adults with Frailty Not Completing an Advance Directive: A Qualitative Study of ACP Conversations

Advance care planning (ACP) facilitates individuals to proactively make decisions on their end-of-life care when they are mentally competent. It is highly relevant to older adults with frailty because they are more vulnerable to cognitive impairment, disabilities, and death. Despite devoting effort to promoting ACP among them, ACP and advance directive completion rates remain low. This study aims to explore the experiences among frail older adults who did not complete an advance directive after an ACP conversation. We conducted a thematic analysis of audiotaped nurse-facilitated ACP conversations with frail older adults and their family members. We purposively selected ACP conversations from 22 frail older adults in the intervention group from a randomized controlled trial in Hong Kong who had ACP conversation with a nurse, but did not complete an advance directive upon completing the intervention. Three themes were identified: “Refraining from discussing end-of-life care”, “Remaining in the here and now”, and “Relinquishing responsibility over end-of-life care decision-making”. Participation in ACP conversations among frail older adults and their family members might improve if current care plans are integrated so as to increase patients’ motivation and support are provided to family members in their role as surrogate decision-makers.

Endoscopy After the COVID-19 Pandemic-What Will Be Different?

Purpose of Review: This paper reviews the latest literature regarding the impact of COVID on endoscopy service provision. Recent Findings: Endoscopy has been shown to be largely safe when appropriate infection prevention and control measures are in place. Endoscopy training and education has been profoundly affected though novel training models to overcome this have been developed. Proper handling of delayed or cancelled procedures is of utmost importance to minimize delays in diagnosis and treatment of diseases such as cancer. Adoption of new technologies such as non-endoscopy alternatives and telehealth may be a viable alternative to minimize infection risks. Summary: This pandemic has led to tangible differences in how we provide endoscopy service in the future. Future research focusing on better risk stratification of patients who need endoscopy, validating novel endoscopy training models, and adopting new technologies are urgently needed to support these changes in the post-pandemic world.

Lessons from COVID-19: A reflection on the strengths and weakness of early consensus recommendations for pediatric difficult airway management during a respiratory viral pandemic using a modified Delphi method.

BACKGROUND: The authors recognized a gap in existing guidelines and convened a modified Delphi process to address novel issues in pediatric difficult airway management raised by the COVID-19 pandemic. METHODS: The Pediatric Difficult Intubation Collaborative, a working group of the Society for Pediatric Anesthesia, assembled an international panel to reach consensus recommendations on pediatric difficult airway management during the COVID-19 pandemic using a modified Delphi method. We reflect on the strengths and weaknesses of this process and ways care has changed as knowledge and experience have grown over the course of the pandemic. RECOMMENDATIONS: In the setting of the COVID-19 pandemic, the Delphi panel recommends against moving away from the operating room solely for the purpose of having a negative pressure environment. The Delphi panel recommends supplying supplemental oxygen and using videolaryngoscopy during anticipated difficult airway management. Direct laryngoscopy is not recommended. If the patient meets extubation criteria, extubate in the OR, awake, at the end of the procedure. REFLECTION: These recommendations remain valuable guidance in caring for children with anticipated difficult airways and infectious respiratory pathology when reviewed in light of our growing knowledge and experience with COVID-19. The panel initially recommended minimizing involvement of additional people and trainees and minimizing techniques associated with aerosolization of viral particles. The demonstrated effectiveness of PPE and vaccination at reducing the risk of exposure and infection to clinicians managing the airway makes these recommendations less relevant for COVID-19. They would likely be important initial steps in the face of novel respiratory viral pathogens. CONCLUSIONS: The consensus process cannot and should not replace evidence-based guidelines; however, it is encouraging to see that the panel's recommendations have held up well as scientific knowledge and clinical experience have grown.

Intraoperative Measures to Reduce the Risk of COVID-19 Transmission During Minimally Invasive Procedures: A Systematic Review and Critical Appraisal of Societies' Recommendations.

BACKGROUND: The coronavirus 2019 pandemic and the hypothetical risk of virus transmission through aerosolized CO2 or surgical smoke produced during minimally invasive surgery (MIS) procedures have prompted societies to issue recommendations on measures to reduce this risk. The aim of this systematic review is to identify, summarize and critically appraise recommendations from surgical societies on intraoperative measures to reduce the risk of severe acute respiratory syndrome coronavirus 2 transmission to the operative room (OR) staff during MIS. METHODS: Medline, Embase, and Google Scholar databases were searched using a search strategy or free terms. The search was supplemented with searches of additional relevant records on coronavirus 2019 resource websites from Surgical Associations and Societies. Recommendations published by surgical societies that reported on the intraoperative methods to reduce the risk of severe acute respiratory syndrome coronavirus 2 transmission to the OR staff during MIS were also reviewed for inclusion. Expert opinion articles were excluded. A preliminary synthesis was performed of the extracted data to categorize and itemize the different types of recommendations. The results were then summarized in a narrative synthesis. RESULTS: Thirty-three recommendation were included in the study. Most recommendations were targeted to general surgery (13) and gynecology (8). Areas covered by the documents were recommendations on performance of laparoscopic/robotic surgery versus open approach (28 documents), selection of surgical staff (13), management of pneumoperitoneum (33), use of energy devices (20), and management of surgical smoke and pneumoperitoneum desufflation (33) with varying degree of consensus on the specific recommendations among the documents. CONCLUSIONS: While some of the early recommendations advised against the use of MIS, they were not strictly based on the available scientific evidence. After further consideration of the literature and of the well-known benefits of laparoscopy to the patient, later recommendations shifted to encouraging the use of MIS as long as adequate precautions could be taken to protect the safety of the OR staff. The release and implementation of recommendations should be based on evidence-based practices that allows health care systems to provide safe surgical and medical assistance.

Walking the nutrition talk: The impact of a community-engaged nonprofit in Selma, Alabama

COVID-19 and its differential impact on those with compromised health have driven home the fundamental importance of nutrition, which is at the root of much chronic disease among the poor. Edmundite Missions, serving Selma and rural Alabama for 80 years, has demonstrated how the actions of a trusted nonprofit providing holistic services in a deeply and historically impoverished population can improve nutrition, inspire youth leadership on nutrition issues, and while simultaneously driving resources into rural economies. In the process, the work has also shown that the poor do indeed understand the importance of good nutrition and both seek and choose positive nutritional options if they are available. The problem among the poor is not knowledge;it is opportunity.

Aerosol barriers in pediatric anesthesiology: Clinical data supports FDA caution.

BACKGROUND: The onset of the COVID19 pandemic drove the rapid development and adoption of physical barriers intended to protect providers from aerosols generated during airway management. We report our initial experience with aerosol barrier devices in pediatric patients and raise concerns that they may increase risk to patients. METHODS: In March 2020, we developed and implemented simulation training and use of plastic aerosol barrier devices as a component of our perioperative COVID-19 workflow. As part of our quality improvement process, we obtained detailed feedback via a web-based survey after cases were performed while using these aerosol barriers. RESULTS: Between March and June 2020, 36 pediatric patients age 1mo-18years with anatomically normal airways and either PCR confirmed or suspected COVID-19 were intubated under an aerosol barrier as part of urgent or emergent anesthetic care at our institution. Experienced providers had more difficulty than expected in six (16.7%) of the cases with four cases requiring multiple attempts to secure the airway and two cases involving pronounced difficulty in a single attempt. The aerosol barrier was perceived as a contributing factor to difficulty in all cases. CONCLUSION: The use of barriers may result in unanticipated difficulties with airway management, particularly in pediatric patients, which could lead to hypoxemia or other patient harm. Our initial experience in pediatric patients is the first such report in patients and provides clinical data which corroborates the simulation data prompting the FDA to withdraw support of barriers.

Association of HLA-B22 serotype with SARS-CoV-2 susceptibility in Hong Kong Chinese patients.

The coronavirus disease 2019 (COVID-19) is a highly infectious disease caused by SARS-CoV-2. Since its first report in December 2019, COVID-19 has evolved into a global pandemic causing massive healthcare and socioeconomic challenges. HLA system is critical in mediating anti-viral immunity and recent studies have suggested preferential involvement of HLA-B in COVID-19 susceptibility. Here, by investigating the HLA-B genotypes in 190 unrelated Chinese patients with confirmed COVID-19, we identified a significant positive association between the B22 serotype and SARS-CoV-2 infection (p = 0.002, Bonferroni-corrected p = 0.032). Notably, the B22 serotype has been consistently linked to susceptibility to other viral infections. These data not only shed new insights into SARS-CoV-2 pathogenesis and vaccine development but also guide better infection prevention/control.