Answering the Call: Inpatient Vaccination for SARS-CoV2 Infection in an Academic Hospital

Background. While the available SARS-CoV2 vaccines are up to 94% effective at preventing COVID-19-related death or invasive mechanical ventilation, only 76% of the United States population aged >=18 years have received a primary series and 49% have received a booster. Vaccine administration has been complicated by changing schedule recommendations, packaging in multi-dose vials, and federal reporting requirements that may have limited the locations offering vaccines. We therefore implemented a pharmacy-based initiative to provide SARS-CoV2 vaccination to patients admitted to an academic health center, in order to encourage vaccination when patients had presented for other care. Methods. A pharmacy committee developed a protocol for administering the three authorized SARS-CoV2 vaccines to interested inpatients while minimizing vaccine waste, monitoring for safety events, and providing next dose education. Associated training included multidisciplinary education on requirements related to vaccine Emergency Use Authorization (EUA) status. While developing the protocol, the vaccine committee utilized a temporary procedure to administer vaccines once weekly through review by antimicrobial stewardship pharmacists during August 2021. The protocol went live in September 2021 for inpatient and emergency department sites, with subsequent tracking of the number of doses ordered (stratified by vaccine type and dose number) and number administered. Results. From August 3 2021 to March 25 2022, a total of 389 vaccine orders were placed with 302 doses (78%) administered, including 126 Moderna (48 first, 20 second, 15 third, 42 booster, and 1 undesignated), 165 Pfizer/BioNTech (80 first, 24 second, 41 third, 14 booster, and 6 undesignated), and 11 Janssen COVID-19 vaccine doses. Only 18 vaccine orders were placed on patients in the ED, with 14 (78%) of those doses administered. Of the 87 vaccine orders not administered, 6 were placed but not given, and 81 were placed and then discontinued. Conclusion. With multidisciplinary collaboration, SARS-CoV2 vaccination can be performed in inpatient and ED settings. However, orders should be monitored for protocol compliance and order discontinuation, as these may increase potential for waste.

A MUSEUM-BASED ELECTIVE TO ADDRESS COGNITIVE BIAS IN 4TH YEAR MEDICAL STUDENTS THROUGH ART AND OBSERVATION EXERCISES: A COMPARISON OF VIRTUAL VS. INPERSON DELIVERY FORMATS Chuan Hao Chen1

SETTING AND PARTICIPANTS: Fourth-year medical students at the Perelman School of Medicine enrolled in a one-week elective based at the Philadelphia Museum of Art. DESCRIPTION: Cognitive bias and heuristics are essential to clinical decision-making but have the potential to increase diagnostic error, undermine doctor-patient relationships, and further healthcare inequity. There is currently minimal practical training in undergraduate medical education designed to manage the negative effects of cognitive bias. We describe here a unique art museum-based course that uses art observation exercises to help students recognize and manage the negative side effects of their cognitive bias. The course combined didactics, self-directed learning exercises, and group activities led by professional art educators and physician educators. The week-long course was meant to spark difficult personal reflections in settings free from the pressures of the clinical curriculum. While the course was in-person in its initial iterations, the COVID-19 pandemic necessitated the adoption of virtual group discussions and individual guided exercises in the museum. We compare between the two formats in their ability to achieve the course goals of 1) fostering student understanding of different cognitive biases and their impact on clinician perception and behavior, 2) develop student reflection and identification of personal cognitive biases, and 3) encourage application of art observational techniques in the clinical encounter. EVALUATION: In order to assess the course's ability to change visual observation skill, students were given images and asked to describe them both before and after the course. Student responses were graded for their ability to describe images in detail, use evidential reasoning, envision multiple interpretive possibilities, and empathize with perspectives other than their own. Qualitative interviews and surveys delivered before and after the course assessed student understanding of cognitive bias and the use of heuristics, how they identify and reflect on their own cognitive biases, and how they might deploy their lessons learned in their future clinical practice. Finally, Likert-scale course evaluations were used to assess student desire for and general perception of the course. DISCUSSION / REFLECTION / LESSONS LEARNED: Qualitative student evaluations of both in-person and virtual course-delivery formats show that the course gave students actionable tools to improve their observational skills and concretize their understanding of cognitive bias and how it may affect their clinical practice. While students found that five days of in-person museum activities were worthwhile, the combination of self-directed gallery sessions and virtual group discussions achieved similar educational objectives while mitigating the time-intensive nature of daily museum visits. This opens up the possibility for medical schools to offer similar courses regardless of their physical proximity to art museums and art educator resources.

Addressing malnutrition and food insecurity with breadfruit in a rural, developing country: a case study and lessons learned in Thomassique, Haiti

Haiti's Central Plateau region suffers from significant malnutrition, economic hardship, and a crisis level of food insecurity. Already the poorest country in the Western Hemisphere in terms of gross domestic product (GDP) per capita, Haiti has pervasively high malnutrition rates, but the Central Plateau is among the most severely affected areas. One in five children of the Central Plateau suffers from malnutrition, and the region exhibits a devastating 30% rate of child stunting. Our US-based team affiliated with Klinik Sen Jozef, a community-respected medical clinic in the Central Plateau city of Thomassique. We partnered with local Haitian leadership, a local agronomist, and Trees That Feed Foundation to introduce breadfruit (Artocarpus altilis) and an innovative development model to combat local malnutrition. Five years into the program, we have partnered with 152 farmers, and we have enhanced our malnutrition program with breadfruit derivatives. This report addresses the lessons we learned to assist others looking to introduce models or crops in a similar manner. Our experience is particularly significant in light of the COVID-19 pandemic, as supply chain disruptions have worsened food insecurity for more than 800 million people in low-income countries.

SARS-CoV-2 mRNA vaccine BNT162b2 triggers a consistent cross-variant humoral and cellular response.

As the SARS-CoV-2 pandemic continues to rage worldwide, the emergence of numerous variants of concern (VOC) represents a challenge for the vaccinal protective efficacy and the reliability of commercially available high-throughput immunoassays. Our study demonstrates the administration of two doses of the BNT162b2 vaccine that elicited a robust SARS-CoV-2-specific immune response which was assessed up to 3 months after full vaccination in a cohort of 37 health care workers (HCWs). SARS-CoV-2-specific antibody response, evaluated by four commercially available chemiluminescence immunoassays (CLIA), was qualitatively consistent with the results provided by the gold-standard in vitro neutralization assay (NTA). However, we could not observe a correlation between the quantity of the antibody detected by CLIA assays and their neutralizing activity tested by NTA. Almost all subjects developed a SARS-CoV-2-specific T-cell response. Moreover, vaccinated HCWs developed a similar protective neutralizing antibodies response against the EU (B.1), Alpha (B.1.1.7), Gamma (P.1), and Eta (B.1.525) SARS-CoV-2 variants, while Beta (B.1.351) and Delta (B.1.617.2) strains displayed a consistent partial immune evasion. These results underline the importance of a solid vaccine-elicited immune response and a robust antibody titre. We believe that these relevant results should be taken into consideration in the definition of future vaccinal strategies.

The impact of the colorado state-wide lockdown on non-COVID-19 related ICU admissions and mortality

RATIONALE: The COVID-19 pandemic has rapidly become the most significant worldwide public health crisis in the modern era. Like other states around the country, the state of Colorado instituted a statewide lockdown to combat increasing case and hospitalization rates for COVID-19 throughout the state. The impact of this mandate on the ICU admission rates and outcomes of other medical problems has never been investigated. Our study aimed to determine the effects of stay-at-home orders on outcomes for other diagnoses by analyzing ICU admission rates and outcomes of patients presenting to the ICU for non-COVID related issues before, during, and after the statewide mandate. METHODS: We performed a retrospective analysis of all ICU admissions in three phases: before (2 months prior), during, and 1.5 months after the statewide lockdown (March 26 to April 27, 2020). We included all patients admitted to the University of Colorado Health System hospitals ICUs within this defined time period. A time-to-event analysis was performed with the date of index ICU stay set as time zero. Baseline characteristics were obtained. Primary outcome measures were 28-day mortality and all-time mortality. Kaplan-Meier curves were used to estimate survival probabilities, while Cox regression and multivariable logistic regression were utilized to model phase-specific mortality controlling for comorbidities, demographics, and admission diagnoses. Counts of typical ICU admission diagnoses were also analyzed to determine any changes across lockdown periods. RESULTS: 9201 total ICU admissions occurred, of which 8154 (88.6%) were non-COVID-19 related. Approximately 57.4% were male with a mean age of 60.4 years. 28-day mortality rates for non-COVID-19 ICU admissions were 475 (11.0%), 127 (13.8%), and 306 (10.5%) before, during, and after the lockdown, respectively. The increased mortality during lockdown persisted after adjustment for comorbidities and demographics (HR=1.23, 95% CI, 1.007 to 1.512, p = 0.043). Acute respiratory failure was the most common diagnosis in each time period, and increased during lockdown (p<0.001). Admissions for sepsis increased during lockdown and decreased after (p = 0.001);myocardial infarction (MI) admission decreased during lockdown but increased after (p = 0.014);and alcohol withdrawal (AW) admission increased both during and after lockdown (p < 0.001). CONCLUSIONS: For non-COVID-19 related ICU admissions, the mortality rate increased during the state-wide shutdown but decreased after shutdown, although this difference became insignificant after controlling for patient admission diagnoses. Admission diagnoses also differed with more admissions for sepsis and AW during lockdown and more admissions for MI and AW after lockdown.

Inactivation of SARS-CoV-2 in the Liquid Phase: Are Aqueous Hydrogen Peroxide and Sodium Percarbonate Efficient Decontamination Agents?

A diluted 3% w/w hydrogen peroxide solution acidified to pH 2.5 by adding citric acid inactivated SARS-CoV-2 virus by more than 4 orders of magnitude in 5 min. After a contact time of 15 min, no viral replication was detected. Aqueous solutions of sodium percarbonate inactivated coronavirus by >3 log10 diminution in 15 min. Conversely, H2O2 solutions with no additives displayed a scarce virucidal activity (1.1 log10 diminution in 5 min), confirming that a pH-modifying ingredient is necessary to have a H2O2-based disinfectant active against the novel coronavirus. © 2021 American Chemical Society.

Activated macrophages are the main inflammatory cell in COVID-19 interstitial pneumonia infiltrates. Is it possible to show their metabolic activity and thus the grade of inflammatory burden with 18F-Fluorocholine PET/CT?

The recent outbreak of Covid-19 has represented a major challenge for the countries affected by the disease, not only in terms of loss of human life, economic downturn, and constraint on individual freedom, but also for the great pressure on the national health systems and hospitals. The 380 kDa virus has been a perfect storm, especially for those national health systems used to working with limited resources and high intensity rhythms, such as Italy. For the first time in the new century, a virtually unknown fast-spreading disease has caused a public health emergency thus forcing most countries to deal with an insurmountable logistic gap. Hence, every branch of Medicine, even though not directly involved in the treatment, has been called upon to provide its contribution to resolve the crisis. It is now becoming more apparent that Covid-19 is not solely a lung disease, but a complex systemic disease involving several organs and systems. This is due to an abnormal inflammatory response which eventually leads to multisystemic coagulopathy which mainly, but not uniquely, targets the lungs. Although the pathophysiology of this syndrome is still not fully understood, macrophages and their immune complex system seem to play a key role. It is not yet clear why some patients develop the violent immune response which results in pneumonitis while others do not. There are clues indicating that the systemic hyper-inflammation defined as macrophage activation syndrome (MAS), or cytokine storm, requires an increase in choline consumption to synthesize phosphatidylcholine and stimulate phagocytosis, organelle biogenesis, secretory functions, and endocytosis. 18F-Fluorocholine is a synthetic analog of the naturally occurring choline normally used for PET/CT imaging of prostate cancer patients. 18F-Fluorocholine could image and quantify the macrophage activity in pulmonary interstitial infiltrates of Covid-19 pneumonia. If the hypothesis is confirmed experimentally, 18F-Fluorocholine PET/CT could be used to in vivo image and quantify the degree of lung inflammation and potentially stratify the gravity of this disease.