Plasmapheresis and Rituximab for Prevention of Focal Segmental Glomerulosclerosis Recurrence Post-Kidney Transplantation

Purpose: Primary focal segmental glomerulosclerosis (FSGS) recurs after kidney transplantation (KT) in 30-50% of recipients with a median time of 1.5 months post- KT. Recurrence is associated with early graft loss in 60% of cases. The aim of this study is to assess the efficacy of pre-emptive therapeutic plasma exchange (TPE) and rituximab for the prevention of FSGS recurrence post-KT. Method(s): This single-center, retrospective study included patients receiving KT for primary FSGS between May 2016 and August 2021. Living-donor KT recipients received three sessions of TPE prior to scheduled transplant. Recipients of both living and deceased donor KT received 3 postoperative sessions of TPE followed by one dose of 375 mg/m2 rituximab with or without intravenous immune globulin (IVIG) 0.5 g/kg. Recipients underwent protocol biopsy at one month to screen for FSGS recurrence. The primary endpoint was a composite for disease recurrence including proteinuria (>=1 g/day) or/and biopsy-proven FSGS within one month. Result(s): 54 patients received KT for FSGS during the study period using the TPE/ rituximab protocol. 5 patients (9%) experienced FSGS recurrence within one month of transplant. A total of 10 patients (19%) were found to have disease recurrence within a year, with median (IQR) time to recurrence of 37 days (27-66). White race and history of hypertension were independent risk factors for recurrence, whereas African American race and diabetes were associated with a reduced risk of recurrence. 31 patients (57%) also received IVIG prior to discharge due to concerns for hypogammaglobulinemia. There were 18 documented infections in 13 patients (24%) within 3 months of transplant. Patients who received IVIG had significantly fewer cases of infection (3 cases: 1 viral and 2 COVID-19) compared to patients who did not receive IVIG (15 cases: 4 bacterial, 9 viral, 1 fungal, and 1 COVID-19), p<0.001. At one year, 9 patients (19%) had biopsy-proven rejection (5 acute cellular rejection, 1 antibody-mediated rejection, and 3 mixed rejection). There were no instances of graft loss or mortality observed at one year. Conclusion(s): The utilization of plasma exchange and rituximab may prevent early disease recurrence of FSGS without significant rates of infection, graft loss, or mortality.

Establishing outpatient ureteric stent changes under local aesthetic in the Northeast region;a safety and feasibility study

Introduction: The COVID19 pandemic has led to unprecedented pressures on theatre waiting lists. The numbers of patients requiring regular ureteric stent changes under general anesthetic (GA) can be significant. We performed a regional study of these patients to assess;i) suitability for procedures under local anaesthetic (LA) and ii) outcomes for those then having LA rather than GA procedures. Patients and Methods: A retrospective cohort study from 3 urology centres was performed. Feasibility criteria for transition to LA stent change was determined on;comorbidities, indication for stent placement and operative factors. 2 centres subsequently initiated regular out-of-theatre LA stent change lists and outcomes were reviewed. Results: 216 cases were included. Median age was 68 and sex ratio 1:1 (M:F). Commonest indications for indwelling stents included benign strictures (37%), non-urological malignancy (24.1%) and urological malignancy (22.2%). 34 patients were suitable for/awaiting definitive procedures. Average number of changes was 2.4/year with 49% of patients being ASA3 or higher. LA stent changes were deemed feasible in 70 patients. 63 procedures were performed under LA with a 98% success rate. Complications (30d) included stent migration (2), haematuria (2) and infection (1). Conclusion: Innovation is required to deal with significant COVID-19 related problems. LA ureteric stent changes are safe and tolerable in appropriately selected patients. Performing these outside of the theatre environment increases capacity on surgical waiting lists. Patient benefits include reduced risks of multiple GA procedures in elderly and co-morbid patients. This data encourages expansion of this initiative.

The Influence of the COVID-19 Pandemic on Author Gender and Manuscript Acceptance Rates Among Pulmonary and Critical Care Journals

Rationale: The COVID-19 pandemic has profoundly disrupted academic endeavors worldwide, disproportionately influencing female physicians and scientists, and potentially negatively impacting the quantity and quality of research unrelated to COVID-19. We sought to evaluate whether the COVID-19 pandemic was associated with a) changes in manuscript submission and acceptance rates among pulmonary/critical care medicine journals, and b) gender-based disparities in these rates. Methods: We used a validated database of author gender to analyze first, senior, and corresponding authorship of all manuscripts submitted to four pulmonary/critical care journals based in the United States (US) between January 1, 2018 and December 31, 2020. We constructed interrupted time series regression models to evaluate whether the proportion of female first and senior authors of non-COVID-19 original research manuscripts changed coincident with the COVID- 19 pandemic. Next, we performed multivariable logistic regressions to evaluate the association of author gender with acceptance of original research manuscript after adjusting for subject category, author world region, and journal. We then conducted sensitivity analyses including all non-original research manuscripts. Results: Among 8,332 original research submissions, women comprised 39.9% and 28.3% of first and senior authors, respectively. We found no change in the proportion of female first or senior authors of non-COVID-19 or COVID-19 submitted research manuscripts during the COVID-19 era. Although female first authorship was not associated with manuscript acceptance, female senior authorship was associated with decreased acceptance of non-COVID research manuscripts (adjusted odds ratio [aOR] 0.84, 95% confidence interval [CI] 0.71-0.99). Non-COVID-19 manuscripts submitted during the COVID-19 era had reduced odds of acceptance, regardless of author gender (first author analysis: aOR 0.46 [95% CI 0.36-0.59];senior author analysis: aOR 0.46 [95% CI 0.37-0.57]). Conclusions: Women comprise a minority of first and senior authors among research manuscripts submitted to US-based pulmonary and critical care journals, but this was not influenced by the pandemic. Female senior authorship of non-COVID-19 research manuscripts was associated with reduced odds of acceptance. However, non-COVID manuscripts were nearly 50% less likely to be accepted during the COVID-19 era, independent of author gender. These results provide important insights into the influence of the pandemic on gender disparities in academic medicine and on the publication of high-quality research focused on topics unrelated to COVID-19.

COVID-19 IS ASSOCIATED WITH SHORTER SLEEP DURATION AMONG AMERICAN ADULTS

Introduction: The COVID-19 pandemic has deteriorated sleep health in the United States (U.S.) and worldwide. Most studies that have examined the association between COVID-19 and sleep outcomes have used a non-probability sampling with potential sampling bias and limited generalizability. We examined the association between diagnosed COVID-19 and sleep health in a large representative sample of civilian adults aged ≥18 years in the U.S. Methods: This study was based on data from the 2020 National Health Interview Survey (NHIS) of adults (n=17,636). Sleep health was captured by self-reported sleep quantity [(very short (≤ 4 hours), short (5-6 hours), healthy (7-8 hours), or long (≥9 hours)] and sleep complaints (trouble falling and staying asleep;with responses ranging from never to every day) in the past 30 days. To account for correlated residuals among the endogenous sleep outcomes, generalized structural equation modeling (GSEM) was conducted with COVID-19 diagnosis as the predictor of interest. Other covariates (age, sex, race/ethnicity, education, employment, poverty level, marital status, birthplace, health insurance, region of residence, metropolitan areas, number of children and adults in the household, obesity, and sleep medication) were included in the models. NHIS complex probability sampling design was accounted for in descriptive and GSEM analyses. Results: About 4.2% of adults had a positive COVID-19 diagnosis. Among them, 3.1% had very short sleep, 24.2% had short sleep, 59.9% had healthy sleep, and 12.8% had long sleep;37.0% had trouble falling some days, 10.9% most days, and 6.5% every day;and 33.7% had trouble staying asleep some days, 13.9% most days, and 6.6% every day. Findings from GSEM revealed that a history of COVID-19 almost doubled the odds of having short sleep (OR: 1.9;95% CI: 1.1-3.4;p=0.032). No significant associations were found between COVID-19 and the other sleep outcomes. Conclusion: Individuals with a COVID-19 diagnosis were more likely to report very short sleep, although they did not exhibit a greater likelihood of reporting more sleep complaints. Further research using longitudinal national data and examining environmental factors are needed to determine causality.

The impact of coronavirus disease 2019 on the head and neck cancer pathway in the West of Scotland.

OBJECTIVE: The coronavirus disease 2019 pandemic has greatly disrupted head and neck cancer services in the West of Scotland. This study aimed to assess the impact of the first wave of the pandemic on cancer waiting times. METHODS: A retrospective review of multidisciplinary team records was undertaken between March and May in 2019 and the same months in 2020. Time-to-diagnosis and time-to-treatment for new cancers treated with curative intent were compared between the study periods, and subclassified by referral pathway. RESULTS: A total of 236 new cancer patients were included. During the pandemic, pathways benefitted from reduced diagnostic and treatment times resulting from the restructuring of service provisions. A 75 per cent reduction in secondary care referrals and a 33 per cent increase in urgent suspicion of cancer referrals were observed in 2020. CONCLUSION: Head and neck cancer pathway times did not suffer because of the coronavirus pandemic. Innovations introduced to mitigate issues brought about by coronavirus benefitted patients, led to a more streamlined service, and improved diagnostic and treatment target compliance.

Management of acute ureteric colic in a large tertiary centre during the initial COVID-19 pandemic - How did our practice change?

Introduction & Objectives: Treatment of acute ureteric colic according to current BAUS guidelines can be challenging, particularly during the COVID-19 pandemic. We aim to audit our practice during the initial COVID-19 pandemic. Materials & Methods: A retrospective analysis of 94 patients admitted with ureteric colic during the initial COVID-19 pandemic (March to June 2020). Data was collected from records and outcomes compared to a pre-pandemic audit of our acute stone service (January to June 2018). Results: Patient demographics were comparable: 33 admissions/month (pre-COVID 37), average age 52 years (pre-COVID 53 years), and median stone size 6 mm (pre-COVID 5mm). Septic patients (23%, pre-COVID 17%) underwent ureteric stenting (23%, pre-COVID 17%) or nephrostomy (10%, pre-COVID <1%). For non-septic patients, 46% underwent primary treatment (ureteroscopy:ESWL = 1:1, pre-COVID = 2:1), 24% ureteric stenting (pre-COVID 31%) and 30% conservative management (pre-COVID 34%). Median time to primary ureteroscopy (94% successful) and ESWL (76% successful;1-2 sessions) was 24 hours (target <48 hours). Median time from stent insertion to definite ureteroscopy was 5.8 weeks (pre-COVID 6.6 weeks, target <4 weeks) and subsequent cystoscopic stent removal was 4 weeks (target <2 weeks). For patients managed conservatively, median time to outpatient review was 7.1 weeks (pre-COVID 5.4 weeks, target <4 weeks) and follow-up imaging 8.2 weeks. Conclusions: These results from one of the largest stone units in the UK show, that despite the pandemic, primary stone intervention was still achievable within 24 hours. There was a greater reliance on ESWL and nephrostomy insertion due to concerns regarding general anaesthesia and COVID-19.

Post-ureteroscopy febrile urinary tract infections are linked to pre-operative stent dwell time: Results from three European endourology centres

Introduction & Objectives: Indwelling ureteric stents are valuable devices used in emergency drainage of upper urinary tract obstruction due to ureteric stones. However, stents can cause significant morbidity with infections, encrustations and blockages. In the study we look at the outcomes of pre-operative stent dwell time on infectious complications following ureteroscopy and laser fragmentation (URSL). Materials & Methods: Data was retrospectively collected for outcomes of URSL from 3 European endourology centres for patients with preoperative indwelling ureteric stents. We included data for patient details, stone demographics, operative details, stone free rate (SFR), outcomes and complications between 2011 and 2020. Patients were divided into two groups based on the stent dwell time: group 1 (<6 months) and group 2 (≥6 months). Descriptive statistics were used to determine the rate of early post-operative infectious complications (defined as the presence of fever?) and ICU access. Binomial logistic regression analysis were used to explore the relationship between stent dwelling time and post-operative early infectious complications. (SPSS v.24). Results: There were 501 patients undergoing URSL in the study period, with 429 and 72 patients in groups 1 and 2 respectively (Table 1). The mean age and operative time in groups 1 and 2 were 71±30 years and 64±22 years, and 51±28 minutes and 59±31 minutes respectively. Infectious complications and ICU admissions were seen in 32 (8%) and 3 (0.7%), and 22 (31%) and 1 (1.4%) in groups 1 and 2 respectively. Stent dwell time of ≥6 months carried significantly higher risk for febrile UTI post URSL (RR=5.45, 95% CI: 2.94-10.10, p<0.001). (Table Presented) Conclusions: Although the overall risk of infectious complication rates from URSL were low, longer indwelling stent time significantly increases the risk of post-operative infections, of which a small proportion of patients end up in ICU. We would recommend having the stent dwell time as short as possible and not to exceed a 6 months’ time period, and our findings will help prioritise these patients in the post-COVID era.

The 5 senses program: A patientcentered family engagement strategy

INTRODUCTION: Patients admitted to pediatric intensive care units (PICU) often experience sensory deprivation and develop maladaptive sensory disorders. Simultaneously, families often endorse feelings of helplessness and fear while their child is critically ill. This study aims to expand ICU family engagement in a unique, patient-centered manner. METHODS: This is a single-centered prospective cohort study performed at a quaternary PICU. Inclusion criteria included age >12 months, were mechanically ventilated, and with a Glasgow Coma Scale < 10. Exclusion criteria included those with baseline cognitive or developmental delay, palliative concerns, or to clinically unstable. The team consisted of occupational therapists and speechlanguage pathologists. Once enrolled, the team created an individualized sensory plan, including any existing sensory needs or aversions. The therapist oriented the family to the program and provided stimulation to all 5 senses. The family was provided an informational handout and a sensory kit to encourage stimulation when the therapist was not present. Following ICU discharge, the families were surveyed regarding their experience. RESULTS: From June 2019 through July 2021, 15 patients were enrolled and 12 completed surveys. Age ranged from 15 months to 17 years with a mean age of 7.6 years. The most common diagnosis was traumatic brain injury (n=5, 33%). All surveyed families provided stimulation at least 3 times following ICU transfer. 92% (n=11) participants provided stimulation more than once a day. Reported difficulty level was labeled as easy (n=9, 69%) or medium (n=3, 23%). CONCLUSIONS: Sensory stimulation can augment recovery and prevent new sensory integration disorders. These targeted plans and environmental modifications have been shown to aid in delirium prevention, family engagement, and non-pharmacologic soothing. Overall, we found that families and caregivers enjoyed the guided engagement and provided very positive feedback. There were several limitations to this project. Primarily, due to the COVID-19 pandemic, the average daily PICU census was very low, inhibiting enrollment ability. Additionally, there was difficulty obtaining consults for the therapist team, thus delaying enrollment. We hope to continue to enroll patients and expand our program to other hospital units.

Nurses Are More Exhausted Than Ever: What Should We Do About It? A review of the evidence leads to timely recommendations

For nurses, the challenges posed by demanding work environments and schedules often lead to fatigue, and this can be exacerbated during crises like the COVID-19 pandemic. In this article, the authors discuss causes and challenges of nurse fatigue and consider several evidence-based strategies and solutions for individual nurses and organizations. Barriers to implementation, including a negative workplace culture and inadequate staffing, are also described, and several resources are presented.

Pausing During the Pandemic: Addressing Cognitive Biases in Providers' Medical Decision-Making During the COVID-19 Era

INTRODUCTION: The COVID-19 pandemic has not only exacerbated traditional cognitive biases but also created new cognitive biases specific to the pandemic that contribute to diagnostic errors. Cases of suspected multisystem inflammatory syndrome in children (MIS-C)-one of the more clinically significant manifestations of COVID-19 in children-need to be reported and reviewed by clinicians as they have varied presentations and lack definitive confirmatory testing, presenting challenges to effective diagnosis. CASE PRESENTATION: We present 3 cases of pediatric patients initially diagnosed with COVID-19/MIS-C who were ultimately found to have alternative diagnoses. DISCUSSION: For each case, we describe conventional and COVID-19-related cognitive biases to enhance awareness of their role in diagnostics and promote strategies to support diagnostic accuracy and timeliness. CONCLUSION: With rapidly changing knowledge about COVID-19 and MIS-C, providers must remain diligent to counteract heuristic thinking and provide timely and accurate diagnostic evaluations.

Flap coverage for necrotising soft tissue infections: A systematic review.

BACKGROUND: Necrotising soft tissue infections (NSTI) are destructive and often life-threatening infections of the skin and soft tissue, necessitating prompt recognition and aggressive medical and surgical treatment. After debridement, the aim of surgical closure and reconstruction is to minimize disability and optimize appearance. Although skin grafting may fulfil this role, techniques higher on the reconstructive ladder, including local, regional and free flaps, are sometimes undertaken. This systematic review sought to determine the circumstances when this is true, which flaps were most commonly employed, and for which anatomical areas. METHODS: A systematic review of the literature was conducted utilising electronic databases (Medline, Embase, Cochrane Library). Full text studies of flaps used for the management of NSTI's (including Necrotising Fasciitis and Fournier Gangrene) were included. The web-based program 'Covidence' facilitated storage of references and data management. Data obtained in the search included reference details (journal, date and title), the study design, the purpose of the study, the study findings, number of patients with NSTI included, the anatomical areas of NSTI involved, the types of flaps used, and the complication rate. RESULTS: After screening 4555 references, 501 full text manuscripts were assessed for eligibility after duplicates and irrelevant studies were excluded. 230 full text manuscripts discussed the use of 888 flap closures in the context of NSTI in 733 patients; the majority of these were case series published in the last 20 years in a large variety of journals. Reconstruction of the perineum following Fournier's gangrene accounted for the majority of the reported flaps (58.6%). Free flaps were used infrequently (8%), whereas loco-regional muscle flaps (18%) and loco-regional fasciocutaneous flaps (71%) were employed more often. The reported rate of partial or complete flap loss was 3.3%. CONCLUSION: Complex skin and soft tissue defects from NSTIs, not amenable to skin grafting, can be more effectively and durably covered using a spectrum of flaps. This systematic review highlights the important contribution that the plastic surgeon makes as an integral member of multidisciplinary teams managing these patients.

Predictors of households at risk for food insecurity in the United States during the COVID-19 pandemic. (Special Issue: Maternal and child nutrition in sub-Saharan Africa.)

Objective: To examine associations between sociodemographic and mental health characteristics with household risk for food insecurity during the COVID-19 outbreak. Design: Cross-sectional online survey analysed using univariable tests and a multivariable logistic regression model. Setting: The United States during the week of 30 March 2020. Participants: A convenience sample of 1965 American adults using Amazon's Mechanical Turk platform. Participants reporting household food insecurity prior to the pandemic were excluded from analyses.