Executive summary of consensus clinical practice guidelines for the prevention of infection in patients with multiple myeloma.

Infection remains a significant contributor to morbidity and mortality in patients with myeloma. This guideline was developed by a multidisciplinary group of clinicians who specialise in the management of patients with myeloma and infection from the medical and scientific advisory group from Myeloma Australia and the National Centre for Infections in Cancer. In addition to summarising the current epidemiology and risk factors for infection in patients with myeloma, this guideline provides recommendations that address three key areas in the prevention of infection: screening for latent infection, use of antimicrobial prophylaxis and immunoglobulin replacement and vaccination against leading respiratory infections (severe acute respiratory syndrome coronavirus 2, influenza and Streptococcus pneumoniae) and other preventable infections. This guideline provides a practical approach to the prevention of infection in patients with myeloma and harmonises the clinical approach to screening for infection, use of prophylaxis and vaccination to prevent infectious complications.

Management of the Normal and Difficult Pediatric Airway: Unique Challenges in the Time of COVID-19.

Purpose of Review: This review focuses on the challenges faced by acute care healthcare workers in the management of the normal and difficult pediatric airway during the COVID-19 pandemic and how these protocols and practices evolved during the pandemic. The current state of knowledge on timing of surgery and anesthesia is also discussed. Recent Findings: In the early days of the pandemic, information about the SARS-CoV-2 virus and disease process was scarce. Governmental, healthcare, and professional organizations created several guidelines to protect invaluable healthcare workers from the contagious virus while also delivering appropriate care to children with COVID-19. With the emergence of new studies and the deployment of new life-saving COVID-19 vaccines and other therapies, these guidelines evolved. The use of aerosol containment devices such as aerosol boxes and flexible barrier techniques was found to be ineffective in reliably containing virus particles while posing potential harm to both healthcare workers and patients. Also, the definition of aerosol-generating and dispersing medical procedures was vastly broadened. To date, use of appropriate personal protection equipment and COVID-19 vaccination are the most effective ways to protect healthcare workers and safely manage children infected with SARS-CoV-2 who require airway intervention. Summary: Evidence-based public health measures and appropriate personal protective equipment remain the best way to protect both healthcare workers and patients. As the virus and population evolve and COVID-19 vaccines become more widely available, clinicians must be willing to adapt to the emerging evidence of their impact on how safe pediatric perioperative care is delivered.

The effect of COVID rehabilitation for ongoing symptoms Post HOSPitalisation with COVID-19 (PHOSP-R): protocol for a randomised parallel group controlled trial on behalf of the PHOSP consortium.

INTRODUCTION: Many adults hospitalised with COVID-19 have persistent symptoms such as fatigue, breathlessness and brain fog that limit day-to-day activities. These symptoms can last over 2 years. Whilst there is limited controlled studies on interventions that can support those with ongoing symptoms, there has been some promise in rehabilitation interventions in improving function and symptoms either using face-to-face or digital methods, but evidence remains limited and these studies often lack a control group. METHODS AND ANALYSIS: This is a nested single-blind, parallel group, randomised control trial with embedded qualitative evaluation comparing rehabilitation (face-to-face or digital) to usual care and conducted within the PHOSP-COVID study. The aim of this study is to determine the effectiveness of rehabilitation interventions on exercise capacity, quality of life and symptoms such as breathlessness and fatigue. The primary outcome is the Incremental Shuttle Walking Test following the eight week intervention phase. Secondary outcomes include measures of function, strength and subjective assessment of symptoms. Blood inflammatory markers and muscle biopsies are an exploratory outcome. The interventions last eight weeks and combine symptom-titrated exercise therapy, symptom management and education delivered either in a face-to-face setting or through a digital platform ( www.yourcovidrecovery.nhs.uk ). The proposed sample size is 159 participants, and data will be intention-to-treat analyses comparing rehabilitation (face-to-face or digital) to usual care. ETHICS AND DISSEMINATION: Ethical approval was gained as part of the PHOSP-COVID study by Yorkshire and the Humber Leeds West Research NHS Ethics Committee, and the study was prospectively registered on the ISRCTN trial registry (ISRCTN13293865). Results will be disseminated to stakeholders, including patients and members of the public, and published in appropriate journals. Strengths and limitations of this study • This protocol utilises two interventions to support those with ongoing symptoms of COVID-19 • This is a two-centre parallel-group randomised controlled trial • The protocol has been supported by patient and public involvement groups who identified treatments of symptoms and activity limitation as a top priority.

High grip strength attenuates risk of severe COVID-19 in males but not females with obesity: A short communication of prospective findings from UK Biobank.

We examined the joint associations of BMI category and grip strength tertile with risk of severe COVID-19 (inpatient COVID-19 or COVID-19 mortality) in 327 500 UK Biobank participants. Compared to normal-weight males with high grip strength, the odds ratio (95 % confidence interval) for males with obesity with low grip strength was 2.39 (1.59-3.60), but 1.52 (0.98-2.35) for males with obesity with a high grip strength. A higher grip strength did not appear to be associated with lower risk of severe COVID-19 in females. Muscle mass and strength development should be considered as a means to reduce risk of severe COVID-19 for males with obesity.

The joint associations of physical activity and TV viewing time with COVID-19 mortality: An analysis of UK Biobank.

We used logistic regression to investigate the joint associations of physical activity level (high: ≥3000 MET-min/week, moderate: ≥600 MET-min/week, low: not meeting either criteria) and TV viewing time (low: ≤1 h/day, moderate: 2-3 h/day, high: ≥4 h/day) with COVID-19 mortality risk in UK Biobank. Additional models were performed with adjustment for body mass index (BMI) and waist circumference. Within the 373, 523 included participants, there were 940 COVID-19 deaths between 16 March 2020 and 12 November 2021. Compared to highly active individuals with a low TV viewing time, highly active individuals with a high TV viewing time were at significantly higher risk of COVID-19 mortality (odds ratio = 1.54, 95% confidence interval = 1.11-2.15). However, the greatest risk was observed for the combination of a low physical activity level and a high TV viewing time (2.29, 1.63-3.21). After adjusting for either BMI or waist circumference, only this latter combination remained at a significantly higher risk, although the effect estimate was attenuated by 43% and 48%, respectively. In sum, a high TV viewing time may be a risk factor for COVID-19 mortality even amongst highly active individuals. Higher adiposity appears to partly explain the elevated risk associated with a low physical activity level and a high TV viewing time.

Television Viewing Time, Overweight, Obesity, and Severe COVID-19: A Brief Report From UK Biobank.

BACKGROUND: Overweight and obesity are well-established risk factors for COVID-19 severity; however, less is known about the role of sedentary behaviors such as television (TV) viewing. The purpose of this brief report was to determine whether lower TV viewing time may mitigate the risk of severe COVID-19 in individuals with excess weight. METHODS: We analyzed 329,751 UK Biobank participants to investigate the independent and combined associations of BMI and self-reported TV viewing time with odds of severe COVID-19 (inpatient COVID-19 or COVID-19 death). RESULTS: Between March 16 and December 8, 2020, there were 1648 instances of severe COVID-19. Per 1-unit (hours per day) increase in TV viewing time, the odds of severe COVID-19 increased by 5% (adjusted odds ratio = 1.05, 95% confidence interval = 1.02-1.08). Compared with normal-weight individuals with low (≤1 h/d) TV viewing time, the odds ratios for overweight individuals with low and high (≥4 h/d) TV viewing time were 1.17 (0.89-1.55) and 1.66 (1.31-2.11), respectively. For individuals with obesity, the respective ORs for low and high TV viewing time were 2.18 (1.61-2.95) and 2.14 (1.69-2.73). CONCLUSION: Higher TV viewing time was associated with higher odds of severe COVID-19 independent of BMI and moderate to vigorous physical activity. Additionally, low TV viewing time may partly attenuate the elevated odds associated with overweight, but not obesity.

Development, implementation, and uptake of a novel Canadian Resident Matching Service (CaRMS) residency recruitment committee strategy in the era of COVID-19.

INTRODUCTION: Given restrictions on electives outside of medical students' home institutions during the COVID-19 pandemic, the objective of this study was to create a novel recruitment strategy for the University of Ottawa's (uOttawa) urology residency program. METHODS: A steering committee was formed and created a three-part recruitment strategy that included a new uOttawa urology website, a residency program social media campaign (Twitter and Instagram), and a virtual open house (VOH). Descriptive data from the website and Instagram and Twitter accounts were collected. Attendees of the VOH completed a mixed-methods survey, which collected quantitative and qualitive responses assessing aspects of the VOH and virtual resource use. RESULTS: From August 1 to December 31, 2020, the uOttawa urology website had 1707 visits. The Twitter account had a total of 29 000 views with 1000-5000 views per tweet. Thirty-one candidates attended the VOH. Survey responders reported that the most frequently used resources to gain knowledge of the program were the website (81%) and Twitter account (71%). The most helpful and informative resources were the uOttawa urology website, the VOH, and direct conversations with residents arranged through the website. Despite not having completed an elective, 26 students (84%) felt they had an understanding of what it might feel like to train in the program. Suggestions by students for future initiatives included one-on-one virtual meetings, another VOH, and more information on selection processes. CONCLUSIONS: A multifaceted, virtual recruitment strategy can be implemented to improve candidate understanding and engagement with residency programs while visiting elective opportunities remain limited.

Anti-platelet factor 4 immunoglobulin G levels in vaccine-induced immune thrombocytopenia and thrombosis: Persistent positivity through 7 months.

Background: Anti-platelet factor 4 (PF4) antibodies that activate platelets via FcγRIIA drive the pathophysiology of vaccine-induced immune thrombocytopenia and thrombosis (VITT). Evolution of these antibodies and their ability to activate platelets after initial treatment remains unknown. Objectives: To assess how clinical and platelet parameters, anti-PF4 antibody levels, and patient serum reactivity changes during follow-up after VITT presentation. Methods: We describe cases of seven discharged VITT patients that were followed from diagnosis up to 280 days (range 199-280) after vaccination. We measured anti-PF4 antibodies and PF4 levels in patient serum during follow-up and tested the ability of patient serum to activate healthy donor platelets and patient platelets over time. Results: Anti-PF4 immunoglobulin G antibody levels are very high at diagnosis (0.9-2.6 OD) and remain relatively high (>1.0 OD) in all patients, except one treated with rituximab, at 7 months post vaccination. All patients were on direct oral anticoagulants throughout follow-up and no patients had recurrent thrombosis. Patients' platelets during follow-up have normal FcγRIIA levels and responsiveness to platelet agonists. Patient diagnostic serum strongly activated control platelets, either alone or with PF4. Most follow-up serum alone was weaker at stimulating donor and patient platelets. However, follow-up serum beyond 150 days still strongly activated platelets with PF4 addition in three patients. Patient serum PF4 levels were lower than controls at diagnosis but returned within normal range by day 50. Conclusions: Explanations for reduced platelet activation during follow-up, despite similar total anti-PF4 antibody levels, remains unclear. Clinical implications of persistent anti-PF4 antibodies in VITT require further study.

Suboptimal COVID-19 vaccine uptake among hospitalised patients: an opportunity to improve vulnerable, hard-to-reach population vaccine rates.

BACKGROUND: COVID-19 vaccination represents a key preventative part of the Australian public health approach to the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) pandemic. Hospital inpatients are frequently high risk for severe COVID-19 and death. Anecdotes of high-risk inpatients being unvaccinated and a lack of electronic medical record (EMR) visibility of COVID-19 vaccination status prompted the present study as these patients could represent a risk to themselves, staff, other patients and service provision. AIMS: To determine the uptake of COVID-19 vaccine among inpatients at an adult Australian tertiary public hospital and identify reasons for non-vaccination. METHODS: A point-prevalence study of patient-reported COVID-19 vaccine status was conducted on 26 October 2021 through an in-person interview with collection of demographic factors and reasons for non-vaccination. RESULTS: Of 368 (68% of inpatients) participants, 280 (76%) reported receiving at least one COVID-19 vaccine dose. Vaccination status was associated with older age, having received the flu vaccine, being born in Australia and not requiring an English-language interpreter. The majority (88%) of participants had at least one comorbid risk factor for severe COVID-19. Of the unvaccinated (n = 88), 67% were willing to be vaccinated with 54% of those indicating vaccination in hospital would be helpful and 42% requesting approval from their doctor. CONCLUSIONS: Vaccine uptake in our cohort is suboptimal. Existing public health programmes have failed to reach this high-risk, vulnerable population. Changes to the national vaccination strategy to include a parallel inhospital programme for all hospital encounters and target culturally and linguistically diverse individuals might improve uptake among this high-risk, hard-to-reach group of patients.

Baseline procalcitonin as a predictor of bacterial infection and clinical outcomes in COVID-19: A case-control study.

PURPOSE: Coronavirus disease-2019 (COVID-19) is associated with a wide spectrum of clinical symptoms including acute respiratory failure. Biomarkers that can predict outcomes in patients with COVID-19 can assist with patient management. The aim of this study is to evaluate whether procalcitonin (PCT) can predict clinical outcome and bacterial superinfection in patients infected with severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2). METHODS: Adult patients diagnosed with SARS-CoV-2 by nasopharyngeal PCR who were admitted to a tertiary care center in Boston, MA with SARS-CoV-2 infection between March 17 and April 30, 2020 with a baseline PCT value were studied. Patients who were presumed positive for SARS-CoV-2, who lacked PCT levels, or who had a positive urinalysis with negative cultures were excluded. Demographics, clinical and laboratory data were extracted from the electronic medical records. RESULTS: 324 patient charts were reviewed and grouped by clinical and microbiologic outcomes by day 28. Baseline PCT levels were significantly higher for patients who were treated for true bacteremia (p = 0.0005) and bacterial pneumonia (p = 0.00077) compared with the non-bacterial infection group. Baseline PCT positively correlated with the NIAID ordinal scale and survival over time. When compared to other inflammatory biomarkers, PCT showed superiority in predicting bacteremia. CONCLUSIONS: Baseline PCT levels are associated with outcome and bacterial superinfection in patients hospitalized with SARS-CoV-2.

Associations of obesity, physical activity level, inflammation and cardiometabolic health with COVID-19 mortality: a prospective analysis of the UK Biobank cohort.

OBJECTIVES: To investigate the associations of physical activity level with COVID-19 mortality risk across body mass index (BMI) categories, and to determine whether any protective association of a higher physical activity level in individuals with obesity may be explained by favourable levels of cardiometabolic and inflammatory biomarkers. DESIGN: Prospective cohort study (baseline data collected between 2006 and 2010). Physical activity level was assessed using the International Physical Activity Questionnaire (high: ≥3000 Metabolic Equivalent of Task (MET)-min/week, moderate: ≥600 MET-min/week, low: not meeting either criteria), and biochemical assays were conducted on blood samples to provide biomarker data. SETTING: UK Biobank. MAIN OUTCOME MEASURES: Logistic regressions adjusted for potential confounders were performed to determine the associations of exposure variables with COVID-19 mortality risk. Mortality from COVID-19 was ascertained by death certificates through linkage with National Health Service (NHS) Digital. RESULTS: Within the 259 397 included participants, 397 COVID-19 deaths occurred between 16 March 2020 and 27 February 2021. Compared with highly active individuals with a normal BMI (reference group), the ORs (95% CIs) for COVID-19 mortality were 1.61 (0.98 to 2.64) for highly active individuals with obesity, 2.85 (1.78 to 4.57) for lowly active individuals with obesity and 1.94 (1.04 to 3.61) for lowly active individuals with a normal BMI. Of the included biomarkers, neutrophil count and monocyte count were significantly positively associated with COVID-19 mortality risk. In a subanalysis restricted to individuals with obesity, adjusting for these biomarkers attenuated the higher COVID-19 mortality risk in lowly versus highly active individuals with obesity by 10%. CONCLUSIONS: This study provides novel evidence suggesting that a high physical activity level may attenuate the COVID-19 mortality risk associated with obesity. Although the protective association may be partly explained by lower neutrophil and monocyte counts, it still remains largely unexplained by the biomarkers included in this analysis.

Perspectives From the Foot and Ankle Department at an Academic Orthopedic Hospital During the Surge Phase of the COVID-19 Pandemic in New York City

Category: Other Introduction/Purpose: Cases of the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) virus (COVID-19) first emerged in Wuhan, China, in December 2019. Since then, the virus has spread globally at a rapid pace. The first case in New York City was reported on March 1, 2020, and the World Health Organization (WHO) declared a pandemic on March 11, 2020. New York City rapidly became the epicenter of the pandemic, with hospitals across the city making a number of changes to accommodate the influx of COVID-19 patients. Here, we describe our experience in adapting to the COVID-19 pandemic as a department consisting of 10 foot and ankle fellowship-trained surgeons with up to 28 years of individual experience in an academic orthopedic hospital. Methods: Information was obtained from direct interviews with surgeons in the Foot and Ankle Service and from our institution’s intranet. Additional information was obtained by viewing twice-weekly livestreams from March 27th, 2020 to May 1st, 2020 held by the Surgeon-In-Chief, which detailed hospital-wide policies and initiatives being implemented in the wake of the COVID-19 pandemic. Results: On March 17, 2020, all elective surgeries were suspended at our institution, and a list of essential procedures was established. In-person clinical visits were limited to new patients being evaluated for essential procedures and first postoperative visits for returning patients, with all patients receiving pre-visit and on-site screening for COVID-19. All other new patient and follow-up appointments were conducted via telehealth visits. Much of our main hospital was repurposed to accept transfers of both COVID-negative and COVID-positive patients. A postanesthesia care unit and a floor of 9 operating rooms were repurposed as negative-pressure rooms for the care of critical COVID-positive patients on ventilators. An Orthopedic Triage Center (OTC) was established to relieve the patient load in the emergency departments of other hospitals in the city. Conclusion: By changing the way we delivered foot and ankle care and repurposing the roles of our employees and our institution, we have adapted strategies to continue delivering care to our patients. As we transition toward a ‘new normal,’ our goals are to gradually progress toward normal operations while keeping our patients and employees safe. With these gradual steps, we hope to emerge from this pandemic stronger and ready to adapt to the ever-changing needs of our community.

Characteristics and Outcomes of Latinx Patients With COVID-19 in Comparison With Other Ethnic and Racial Groups.

BACKGROUND: There is a limited understanding of the impact of coronavirus disease 2019 (COVID-19) on the Latinx population. We hypothesized that Latinx patients would be more likely to be hospitalized and admitted to the intensive care unit (ICU) than White patients. METHODS: We analyzed all patients with COVID-19 in 12 Massachusetts hospitals between February 1 and April 14, 2020. We examined the association between race, ethnicity, age, reported comorbidities, and hospitalization and ICU admission using multivariable regression. RESULTS: Of 5190 COVID-19 patients, 29% were hospitalized; 33% required the ICU, and 4.3% died. Forty-six percent of patients were White, 25% Latinx, 14% African American, and 3% Asian American. Ethnicity and race were significantly associated with hospitalization. More Latinx and African American patients in the younger age groups were hospitalized than whites. Latinxs and African Americans disproportionally required the ICU, with 39% of hospitalized Latinx patients requiring the ICU compared with 33% of African Americans, 24% of Asian Americans, and 30% of Whites (P < .007). Within each ethnic and racial group, age and male gender were independently predictive of hospitalization. Previously reported preexisting comorbidities contributed to the need for hospitalization in all racial and ethnic groups (P < .05). However, the observed disparities were less likely related to reported comorbidities, with Latinx and African American patients being admitted at twice the rate of Whites, regardless of such comorbidities. CONCLUSIONS: Latinx and African American patients with COVID-19 have higher rates of hospitalization and ICU admission than White patients. The etiologies of such disparities are likely multifactorial and cannot be explained only by reported comorbidities.

COVID-19 in solid organ transplant recipients: Dynamics of disease progression and inflammatory markers in ICU and non-ICU admitted patients.

BACKGROUND: COVID-19 infection varies in severity from minimal symptoms to critical illness associated with a hyperinflammatory response. Data on disease progression in immunosuppressed solid organ transplant (SOT) recipients are limited. METHODS: We examined the electronic medical records of all SOT recipients with COVID-19 from 12 Massachusetts hospitals between February 1, and May 6, 2020. We analyzed the demographics, clinical parameters, course, and outcomes of illness in these patients. RESULTS: Of 52 COVID-19-positive SOT patients, 77% were hospitalized and 35% required ICU admission. Sixty-nine percent of hospitalized patients had immunosuppression reduced, 6% developed suspected rejection. Co-infections occurred in 45% in ICU vs 5% in non-ICU patients (P = .037). A biphasic pattern of evolution of laboratory tests was observed. In the first 5 days of illness, inflammatory markers were moderately increased. Subsequently, WBC, CRP, ferritin, and D Dimer increased with increasing stay in the ICU, and lymphocyte counts were similar. Five patients (16%) died. CONCLUSIONS: Our data indicate that SOT is associated with high rate of hospitalization, ICU admission, and death from COVID-19 compared to data in the general population of patients with COVID-19. Despite reduction in immunosuppression, suspected rejection was rare. The clinical course and trend of laboratory biomarkers is biphasic with a later, pronounced peak in inflammatory markers seen in those admitted to an ICU. CRP is a useful marker to monitor disease progression in SOT.