Similar symptoms at 3 months post discharge in ICU, COVID-19 ICU, and COVID-19 patients that received non-invasive ventilation in high dependency areas

Introduction: It is well documented that survivors of ICU admissions struggle to return to pre-admission level of function because of both physical and psychological burden. Current guidance therefore recommends a follow-up service to review patients 2-3 months post discharge from ICU [NICE 2009]. Prior to 2020 University Hospitals Bristol and Weston (UHBW) had no such service. With the increase in patient numbers seen during the COVID-19 pandemic, funding was received to provide a follow-up clinic to COVID-19 survivors. Spare clinic spaces were used for non COVID ICU patients. Objective(s): To review symptoms reported by patients in the following 3 groups, COVID-19 patients treated in ICU (COVID ICU), COVID-19 patients treated with continuous positive airway pressure ventilation in high dependency areas (COVID CPAP) and non COVID-19 ICU patients (ICU), at 2-3 months post discharge from UHBW. Method(s): Referred patients had an initial phone call at 8 weeks post discharge. The call identified both physical and psychological symptoms. Advice regarding recovery, signposting to resources and onwards referrals to appropriate specialities were provided. If symptoms indicated, patients would then be referred into the multidisciplinary team follow up clinic. Here they met with an intensivist, clinical psychologist, physiotherapist, occupational therapist, speech and language therapist and dietitian. Result(s): As Graph 1 shows all 3 patient groups had a wide variety of ongoing symptoms at 2-3 months post discharge. Fatigue was the most common symptom reported in all 3 groups. Breathlessness was the second most common symptom reported by COVID patients but was less frequently reported in the ICU population who had a variety of non-respiratory related reasons for admission. COVID ICU patients more commonly reported ongoing problems with their swallowing, voice and communication compared to the COVID CPAP group, most probably due to invasive ventilation. Psychological burden post critical illness was high in all 3 groups. More than 20% of all patients scored =10 on a PHQ-9 depression scale showing moderate to severe depression. More than 15% of all patients scored =10 on a GAD-7 showing moderately severe to severe anxiety. COVID ICU group had the highest incidence of post-traumatic stress disorder (PTSD). This may be linked to the higher level of delirium we saw in this group, as a result of change in practice, such as full PPE and absence of visiting during the pandemic. ICU patients presented with a significantly higher percentage of physiotherapy needs. This is likely because patients with the longest and most complex ICU admissions were selected for the clinic. Sleep likely goes under reported in these results as we only began questioning specifically about this later on in the clinic. Conclusion(s): This data goes some way in supporting current literature that the rehabilitation needs of COVID ICU patients equal that of ICU patients (Puthucheary et al 2021). It also shows the need to follow up patients who receive advanced respiratory support outside of the ICU environment, as their symptoms, and therefore rehabilitation needs are very similar to ICU patients at 2-3 months post discharge.

IMPROVING COLORECTAL CANCER SCREENING IN A SAFETY NET CLINIC THROUGH A RETURN- BY-MAIL FECAL IMMUNOCHEMICAL TEST PROGRAM

STATEMENT OF PROBLEM/QUESTION: Can establishing a return-bymail fecal immunochemical test (FIT) program increase the colorectal cancer screening rate in a safety net primary care clinic? DESCRIPTION OF PROGRAM/INTERVENTION: Colorectal cancer (CRC) screening rates are typically lower in safety net health systems. This trend has been exacerbated by the COVID-19 pandemic, which has limited access to colonoscopy for screening. There is evidence that FITs are costeffective and mailed FIT programs can increase screening rates for vulnerable patients. We implemented a return-by-mail FIT program in the adult primary care clinic of New York City Health + Hospitals/Bellevue, a public safety net hospital. We evaluated adults aged 50-75 who were not up to date with CRC screening. All patients due for CRC screening were only offered FIT as a screening modality. We implemented a partial mailed FIT program, in which FIT tests picked up in clinic could be returned by mail directly to the lab. Prior to our intervention, patients were required to return FITs to the clinic in person. MEASURES OF SUCCESS: We evaluated FIT completion rates within our clinic 30 days before and after the introduction of return-by-mail FIT kits in July 2021. We also evaluated our clinic's pre- and post-intervention performance relative to other clinics within the New York City Health + Hospitals system using claims data. Additionally, we randomly surveyed patients who received a FIT and did not complete it in the period prior to our intervention to assess reasons for incompletion. FINDINGS TO DATE: A total of 5,153 and 5,180 patients aged 50-75 were seen in clinic 30 days before and 30 days after the implementation of a mailed FIT program. 571 patients were provided a return-in-person FIT kit 30 days prior to our intervention. Of these patients, 289 (50.6%) completed a FIT. By contrast, 781 patients were provided a return- by-mail FIT kit 30 days following our intervention. Of these patients, 464 (59.4%) completed a FIT (p < 0.01). Additionally, the proportion of patients who completed annual CRC screening prior to our intervention was lower in our clinic (48.2%) compared to the average across the New York City public hospital system (51.4%) according to managed care Medicaid claims data (MetroPlus, June 2021). Four months following our intervention, our clinic's year-to-date CRC screening rate exceeded the average system-wide rate (59.3% vs. 57.6%, November 2021). We also called 45 patients who were provided a FIT test prior to our intervention and did not complete it. 12 patients were reached, and 2 of these patients cited difficulty dropping off the test as the primary barrier to FIT completion (16.7%). KEY LESSONS FOR DISSEMINATION: By implementing a return-bymail FIT program, we were able to increase our clinic's CRC screening rate by 8.8%. Our data are similar to previous programs implementing mailed FIT programs in safety net patient populations. Future aims are to implement a mail-to-patient FIT program in addition to our initial return-by-mail program.

INCREASE IN COLORECTAL CANCER SCREENING IN A SAFETY-NET HOSPITAL AFTER IMPLEMENTING MAIL-ABLE FECAL IMMUNOCHEMICAL TESTS

Background Colorectal cancer (CRC) screening rates are typically lower in public safety-net hospital systems, and optimal screening modalities have yet to be determined in this population. There is evidence that fecal immunochemical test (FIT) is a cost-effective approach in this setting, especially as the COVID-19 pandemic decreased the accessibility of colonoscopy. Mailed FIT outreach programs have been shown to markedly increased CRC screening for vulnerable patients. However, there is limited evidence regarding individual facets of these programs, such as returning FIT by mail. In the process of establishing a complete mailed FIT program during the pandemic, we evaluate the effect of allowing patients to mail back a completed FIT they received in person. Methods Patients at a safety-net hospital in New York City aged 50-75 who were not up to date with CRC screening were evaluated. We included patients 30 days before and after the implementation of mail-able FIT kits in July 2021. All patients due for CRC screening were only offered FIT as a screening modality, and prior to the intervention were required to visit the clinic to both obtain and return the FIT. We implemented a partial mailed FIT program, in which FITs picked up in clinic can be mailed directly to the lab after completion. We also randomly surveyed patients who received a FIT and did not complete it in the period prior to our intervention to assess reasons for incompletion. Results A total of 5,153 and 5,180 patients aged 50-75 were seen in clinic 30 days prior and 30 days after the implementation of the mail-able FIT kit respectively. A total of 571 patients were provided a FIT kit that required a return trip to the clinic for completion. Of these patients, 289 (50.6%) completed a FIT. In comparison, there were a total of 781 patients who were provided a FIT kit allowed to be mailed back for completion. Of these patients, 464 (59.4%) completed a FIT (p < 0.01). A total of 45 patients with an incomplete FIT prior to the intervention were called, and 12 patients were reached. Of these patients, 10 endorsed forgetting about the test, and 2 endorsed difficulty scheduling time to drop off the test. Conclusion Organized mailed FIT outreach was previously shown to improve CRC screening in a safety-net setting. We have further shown that implementing a program with FIT kits that can be mailed back significantly improves screening. While our mail-able kits would improve screening in patients with difficulty returning to clinic, many in our population would potentially benefit from reminders to complete. Future work could assess long-term completion rates of our program, and compare it with a full mailed FIT outreach program to quantify the potential increased benefit of also mailing kits to patients.

Seroprevalence of Anti-SARS CoV-2 Nucleocapsid IgG in a Cohort of Healthcare Workers Over Nine Months

Study Objectives: Healthcare workers (HCWs) in acute-care hospitals are inherently more likely than the general population to be exposed to the SARS-Cov-2 virus. There is great diversity among HCWs in degree of exposure based on intensity and duration of patient contact. The use of personal protective equipment and other infection prevention measures would be expected to significantly modify the risk of acquiring COVID-19. We hypothesized that patient-facing HCWs (PF) are more likely to acquire COVID-19 illness over time than non-patient facing HCWs (non-PF). Methods: All HCWs who were either employed or part of the medical staff at six acute-care hospitals in Phoenix, Arizona in June 2019 were invited to participate. A cohort of 1358 HCWs provided informed consent, filled out a questionnaire regarding their healthcare role, and had blood drawn between June 15th and August 15th, 2020 (Draw 1). The questionnaire and blood draws were repeated in October 2020 (Draw 2), January 2021 (Draw 3), and April 2021 (Draw 4). 881 physicians/APPs and nurses with direct patient care responsibilities, respiratory therapists, phlebotomists, and patient care technicians were categorized as PF, 477 other participants considered non-PF. SARS-CoV-2 anti-nucleocapsid IgG was measured using the Abbott Architect platform, using a cut-off of greater than 1.4 arbitrary units as a positive result. This assay does not detect anti- spike IgG and is therefore insensitive to Covid vaccination status. Because previous studies suggest that anti- nucleocapsid IgG levels decay over time, participants were treated as seropositive for all draws following their first positive draw regardless of the index result. Participants who missed a draw were treated as negative on that draw. Differences in seroprevalence were tested with a Z-score test for differences in proportion. Proportions were expressed as percentages +/- 95% confidence intervals. Results: Overall seroprevalence increased from 8.8% +/- 1.5% on Draw 1 to 11.3% +/- 1.7% on Draw 2, 19.9% +/- 2.1% on Draw 3, and 20.8% +/- 2.2% on Draw 4. There were no significant between-group differences in seroprevalence on Draw 1 (PF 9.7% +/- 2.0% vs non-PF 7.3% +/- 2.3%, p=0.136), but PF HCWs were significantly more likely to be seropositive on Draw 2 (12.6% +/- 2.2% vs. 9.0% +/- 2.6%, p=0.046), Draw 3 (22.3% +/- 2.7% vs 15.5% +/- 3.2%, p=0.0027), and Draw 4 (23.0% +/- 2.8% vs 16.6% +/- 3.3%, p=0.0049). See Figure 1 with CDC cumulative COVID-19 case rate for Arizona presented for reference. Subgroup analysis within the PF group shows that physicians/APPs were less likely than other PF groups to be seropositive at all time points (Draw 1: 6.2% +/- 2.8% vs. 11.3% +/- 2.5%, p=.018;Draw 2: 8.7% +/- 3.3% vs. 14.4% +/- 2.8%;p=.018;Draw 3: 17.4% +/- 4.4% vs. 24.5% +/- 3.4%, p=.019;Draw 4: 17.8% +/- 4.4% vs. 25.5% +/- 3.4%, p=0.0016) Conclusion: PF HCWs were more likely that non-PF HCWs to seroconvert acquire COVID-19. Among PF HCWs, physicians and APPs were the least likely to seroconvert, and their seroconversion rate was similar to the non-PF HCWs. [Formula presented]

COVID-19: Minimizing COVID-19 Transmission in High Occupant Density Settings, Part 2

This article is the second in a two-part series aimed at quantifying strategies to reduce the probability of infection by airborne disease in the indoor environment. It focuses on the virus that causes COVID-19, SARS-CoV-2. A modified form of the Wells-Riley model is used to predict the conditional probability of infection within high occupant density indoor environments such as classrooms. Results are presented for three distinct airborne exposure scenarios and a range of protective measures that include facility-related factors such as air change rates and in-room recirculating air filtration, and the occupant-related factor of masks with varying levels of effective filtration efficiency. © 2021 Amer. Soc. Heating, Ref. Air-Conditoning Eng. Inc.. All rights reserved.

Decay of Anti-SARS-CoV-2 Nucleocapsid IgG in Seropositive Health Care Workers Over Time

Study Objectives: Our understanding of the quality and duration of immunity to COVID-19 following natural infection remains important area of public health research. The long-term kinetics of IgG antibodies to the spike and nucleocapsid (N) proteins of the SARS-CoV-2 virus are of particular interest as easily measurable potential indirect markers of both previous infection and resistance to reinfection. Previous studies in hospitalized patients have found that anti-N IgG levels decline over time. We undertook this study to characterize the kinetics of anti-N IgG in a longitudinal cohort of health care workers in an acute hospital setting. Methods: All HCWs who were either employed or part of the medical staff at six acute-care hospitals in Phoenix, AZ in June 2019 were invited to participate in a long-term study of the impact of the COVID-19 pandemic on HCWs. A cohort of 1358 HCWs provided informed consent, filled out a questionnaire regarding their health care role and potential COVID-19 symptoms, and had blood drawn between June 15 th and August 15 th, 2020 (Draw 1). The questionnaire and blood draws were repeated in October 2020 (Draw 2), January 2021 (Draw 3), and April 2021. SARS-CoV-2 anti-N IgG was measured using the Abbott Architect platform, using a signal to cutoff ratio (S/Co) greater than 1.4 as a positive result. A participant’s first positive result was treated as Time 0. Anti-N IgG S/Co values at each time point were summarized as mean, median, and inter-quartile range, and differences over time were tested using the Friedman’s test. Results: 290 participants (21.4%) had at least one positive IgG, with a median S/Co of 4.96, IQR 2.37-6.67. The Month 3 median S/Co was 2.32, IQR 1.34-4.22, Month 6 median was 0.96, IQR 0.51-2.05, and Month 9 median was 0.60, IQR 0.26-1.29 (See Figure). Freidman’s test for differences was significant at p<0.0001 at all time points. No participant was hospitalized for their acute COVID-19 illness. 68/244 participants (27.4%) were seronegative at 3 months, 81/126 (64.3%) at six months, and 65/84 (77.4%) at nine months. Conclusion: In a cohort of health care workers with mild to moderate COVID-19, anti-N IgG levels steadily decreased over 9 months from the initial positive IgG. The high rates of conversion to seronegative over a relatively short time frame illustrate why antibody-based testing must be interpreted cautiously when used as a definitive marker of prior COVID infection. [Formula presented]

The differing pathophysiologies that underlie COVID-19-associated perniosis and thrombotic retiform purpura: a case series.

BACKGROUND: There are two distinctive acral manifestations of COVID-19 embodying disparate clinical phenotypes. One is perniosis occurring in mildly symptomatic patients, typically children and young adults; the second is the thrombotic retiform purpura of critically ill adults with COVID-19. OBJECTIVES: To compare the clinical and pathological profiles of these two different cutaneous manifestations of COVID-19. METHODS: We compared the light microscopic, phenotypic, cytokine and SARS-CoV-2 protein and RNA profiles of COVID-19-associated perniosis with that of thrombotic retiform purpura in critical patients with COVID-19. RESULTS: Biopsies of COVID-19-associated perniosis exhibited vasocentric and eccrinotropic T-cell- and monocyte-derived CD11c+ , CD14+ and CD123+ dendritic cell infiltrates. Both COVID-associated and idiopathic perniosis showed striking expression of the type I interferon-inducible myxovirus resistance protein A (MXA), an established marker for type I interferon signalling in tissue. SARS-CoV-2 RNA, interleukin-6 and caspase 3 were minimally expressed and confined to mononuclear inflammatory cells. The biopsies from livedo/retiform purpura showed pauci-inflammatory vascular thrombosis without any MXA decoration. Blood vessels exhibited extensive complement deposition with endothelial cell localization of SARS-CoV-2 protein, interleukin-6 and caspase 3; SARS-CoV-2 RNA was not seen. CONCLUSIONS: COVID-19-associated perniosis represents a virally triggered exaggerated immune reaction with significant type I interferon signaling. This is important to SARS-CoV-2 eradication and has implications in regards to a more generalized highly inflammatory response. We hypothesize that in the thrombotic retiform purpura of critically ill patients with COVID-19, the vascular thrombosis in the skin and other organ systems is associated with a minimal interferon response. This allows excessive viral replication with release of viral proteins that localize to extrapulmonary endothelium and trigger extensive complement activation.