Impact of an Implementation Science-Based Project to Address COVID-19 Vaccine Hesitancy

Background. COVID-19 vaccine uptake remains suboptimal. This project aimed to identify and mitigate reasons for vaccine hesitancy. Baseline patient knowledge and attitudes about COVID-19 vaccination Methods. Between 9/2021 and 1/2022, 16 live in-person and/or virtual patient education programs were held in community centers/clinics in NC and GA. Surveys were administered before/after each session, and longitudinal outcomes 3 weeks later. Results. Surveys were conducted amongst the 1381 participating patients. 64% were already fully vaccinated against COVID-19, 19% had received 1 of 2 doses, and 17% were either unvaccinated (14%) or unsure of their status (3%). Baseline vaccine knowledge was higher among fully vaccinated patients, with patient attitudes varied per vaccination status (Figure). Patients not planning to get vaccinated cited concern for long-term (21%) and short-term (18%) side effects, thinking the vaccines were developed too quickly (16%), not feeling the vaccine would protect them (10%), and not feeling at risk for serious illness (10%). When asked what they thought would increase patient interest in vaccination, providers (n = 28) identified a strong recommendation (39%) or more information (36%) from a patient's own doctor, while patients prioritized transportation (28%) , vaccine availability in their doctor's office (23%), and information from their doctor (23%). Provider confidence in counseling patients improved after the program;more providers felt confident discussing vaccine safety (69%) and efficacy (69%) after the program than at baseline (33% and 41%, respectively). More patients felt confident sharing COVID-19 vaccine information with family and friends after the program (73%) than before (53%). Gains in patient views about COVID-19 vaccination were greatest among those who were unvaccinated/unsure;among this group, more patients agreed that vaccines are safe (72%), effective (76%), and important (78%) after the education, compared to 42%, 46%, and 52% at baseline, respectively. In the longitudinal patient follow-up survey 86% of unvaccinated patients got vaccinated after completing the education session. Conclusion. Patient knowledge and attitudes varied based on vaccine experience, as did patient and provider perceptions about improving vaccine acceptance. Vaccine uptake was high following the program.

BARICITINIB and PULSE STEROIDS COMBINED TREATMENT in SEVERE COVID-19 PNEUMONIA: PRELIMINARY DATA from A RHEUMATOLOGIC EXPERIENCE in INTENSIVE CARE UNIT

Background: Growing evidence from in vitro and clinical studies have highlighted important similarities between severe COVID-19 and rapidly progressive interstitial lung diseases (ILD) occurring in systemic autoimmune disorders. These data supported the use of anti-rheumatic drugs, baricitinib and glucocor-ticoids, for the treatment of COVID-19 pneumonia. Objectives: To compare mortality rate and infammatory response in critically ill COVID-19 patients treated with either a 'rheumatologic approach' based on baricitinib plus pulse steroids (BPS) or with a 'conventional approach' (Standard of Care, SoC). Methods: In this retrospective study, we enrolled patients admitted to the Intensive Care Unit (ICU) with CT-proven SARS-CoV2 pneumonia, from September 2020 to April 2021. Demographic, laboratory, and clinical data were collected at the admission to ICU and after one week of treatment. SoC included dexameth-asone 6 to 8 mg daily plus remdesivir (+/-antibiotics and hydroxychloroquine);BPS approach was based on baricitinib 4 mg daily for 10-14 days plus 6-methyl-prednisolone pulses (250-500 mg) for three consecutive days followed by rapid tapering. The primary endpoint was the intra-ICU mortality rate;the secondary endpoint was the change in infammatory biomarkers at week 1 after treatment. Results: We enrolled a total of 210 consecutive patients with SARS-CoV2 pneumonia (male 61.4%, mean age 66.6 ± 10.9 years);137/210 (male 59.8%, mean age 66.3 ± 11.9 years) were treated with SoC and 73/210 (male 64.3%, mean age 67.3 ± 8.8 years) with BPS. At admission in ICU, all patients presented lag time from the frst symptom of SARS-CoV2 infection ≤ 10 days, laboratory biomarkers' alterations suggestive of hyper-infammatory response (CRP 10.8 ± 11.9 mg/dL, ferritin 1238 ± 1005 μ g/L, fbrinogen 575 ± 173 mg/dL, LDH 385 ± 152 U/L) and severe respiratory failure, requiring non-invasive or invasive ventilatory support. Lung-CT pattern showed multiple and diffuse areas of ground glass opacities, septal thickening, and/or consolidation. No statistically signifcant differences were found between SoC and BPS groups in terms of demographic, laboratory, and clinical features at enrolment. 59/210 (28.1%) patients died during ICU hospitalization (mean ICU length of stay 14.6 ± 9.6 days). Mortality rate in the BPS group (13/73, 17.8%) resulted signifcantly lower compared to that in the SoC group (46/137, 33.6%) (p= 0.016). Furthermore, patients in the BPS group had signifcantly lower levels of CRP (BPS=1.9 ± 2.8 vs SoC 6.1 ± 7.3, p<0.001) and fbrinogen (BPS=335 ± 108 vs SoC 453 ± 172, p<0.001) at one week after the start of treatment. Conclusion: Our real-life experience, in an ICU setting, showed that baricitinib and pulse steroids combination was associated with a lower mortality rate paralleled by a prompt reduction of infammatory biomarkers. These results shed new light on the possible usefulness of baricitinib for the treatment of rapidly progressive ILD in patients with systemic autoimmunity and hyper-infammation.

COVID-19 in the Perioperative Period of Cardiovascular Surgery: the Brazilian Experience.

INTRODUCTION: We investigated the clinical course and outcomes of patients submitted to cardiovascular surgery in Brazil and who had developed symptoms/signs of coronavirus disease 2019 (COVID-19) in the perioperative period. METHODS: A retrospective multicenter study including 104 patients who were allocated in three groups according to time of positive real time reverse transcriptase-polymerase chain reaction (RT-PCR) for the SARS-CoV-2 (severe acute respiratory syndrome coronavirus 2): group 1, patients who underwent cardiac surgery > 10 days after positive RT-PCR; group 2, patients with a positive RT-PCR within 10 days before or after surgery; group 3, patients who presented positive RT-PCR > 10 days after surgery. The primary outcome was mortality and secondary outcomes were postoperative complications, intensive care unit (ICU) length of stay, and postoperative days of hospitalization. RESULTS: The three groups were similar with respect to age, the European System of Cardiac Operative Risk Evaluation score, and comorbidities, except hypertension. Postoperative complications and death were significantly higher in groups 2 and 3 than in group 1, and no significant difference between groups 2 and 3 was seen. Group 2 showed a high prevalence of surgery performed as an urgent procedure. Although no significant differences were observed in ICU length of stay, total postoperative hospitalization time was significantly higher in group 3 than in groups 1 and 2. CONCLUSION: COVID-19 affecting the postoperative period of patients who underwent cardiovascular surgery is associated with a higher rate of morbidity and mortality. Delaying procedures in RT-PCR-positive patients may help reduce risks of perioperative complications and death.

Fighting for America's Paradise: The Struggle against Structural Racism.

Structural racism is a fundamental cause of racial inequities in health in the United States. Structural racism is manifested in inequality in the criminal justice system; de facto segregation in education, health care, and housing; and ineffective and disproportionately violent policing and economic disenfranchisement in communities of color. The inequality that Black people and communities of color face is the direct result of centuries of public policy that made Black and Brown skin a liability. The United States is now in an unprecedented moment in its history with a new administration that explicitly states, "The moment has come for our nation to deal with systemic racism . . . and to deal with the denial of the promise of this nation-to so many." The opportunities for creating innovative and bold policy must reflect the urgency of the moment and seek to dismantle the systems of oppression that have for far too long left the American promise unfulfilled. The policy suggestions made by the authors of this article speak to the structural targets needed for dismantling some of the many manifestations of structural racism so as to achieve health equity.

Assessment of commercial SARS-CoV-2 antibody assays, Jamaica.

BACKGROUND: The performance of the Roche Elecsys® Anti-SARS-CoV-2, Abbott Architect SARS-CoV-2 IgM, Abbott Architect SARS-CoV-2 IgG, Euroimmun SARS-CoV-2 IgA, Euroimmun SARS-CoV-2 IgG ELISA, and Trillium IgG/IgM rapid assays was evaluated in Jamaica. METHODS: Diagnostic sensitivities of the assays were assessed by testing serum samples from SARS-CoV-2 PCR-confirmed persons and diagnostic specificity was assessed by testing serum samples collected during 2018-2019 from healthy persons and from persons with antibodies to a wide range of viral infections. RESULTS: Serum samples collected ≥14 days after onset of symptoms, or an initial SARS-CoV-2 RT-PCR positive test for asymptomatics, showed diagnostic sensitivities ranging from 67.9 to 75.0% when including all possible disease severities and increased to 90.0-95.0% when examining those with moderate to critical disease. Grouping moderate to critical disease showed a significant association with a SARS-CoV-2 antibody positive result for all assays. Diagnostic specificity ranged from 96.7 to 100.0%. For all assays examined, SARS-CoV-2 real-time PCR cycle threshold (Ct) values of the initial nasopharyngeal swab sample testing positive were significantly different for samples testing antibody positive versus negative. CONCLUSIONS: These data from a predominantly African descent Caribbean population show comparable diagnostic sensitivities and specificities for all testing platforms assessed and limited utility of these tests for persons with asymptomatic and mild infections.

Cardiovascular involvement in COVID-19: not to be missed

In December 2019, a striking appearance of new cases of viral pneumonia in Wuhan led to the detection of a novel coronavirus (SARS-CoV2). By analyzing patients with severe manifestations, it became apparent that 20 to 35% of patients who died had preexisting cardiovascular disease. This finding warrants the important need to discuss the influence of SARS-CoV2 infection on the cardiovascular system and hemodynamics in the context of clinical management, particularly during mechanical ventilation. The SARS-CoV2 enters human cells through the spike protein binding to angiotensin-converting enzyme 2 (ACE2), which is important to cardiovascular modulation and endothelial signaling. As ACE2 is highly expressed in lung tissue, patients have been progressing to acute respiratory injury at an alarming frequency during the Coronavirus Disease (COVID-19) pandemic. Moreover, COVID-19 leads to high D-dimer levels and prothrombin time, which indicates a substantial coagulation disorder. It seems that an overwhelming inflammatory and thrombogenic condition is responsible for a mismatching of ventilation and perfusion, with a somewhat near-normal static lung compliance, which describes two types of pulmonary conditions. As such, positive pressure during invasive mechanical ventilation (IMV) must be applied with caution. The authors of this review appeal to the necessity of paying closer attention to assess microhemodynamic repercussion, by monitoring central venous oxygen saturation during strategies of IMV. It is well known that a severe respiratory infection and a scattered inflammatory process can cause non-ischemic myocardial injury, including progression to myocarditis. Early strategies that guide clinical decisions can be lifesaving and prevent extended myocardial damage. Moreover, cardiopulmonary failure refractory to standard treatment may necessitate the use of extreme therapeutic strategies, such as extracorporeal membrane oxygenation.

Assessment of Commercial SARS-CoV-2 Antibody Assays, Jamaica (preprint)

The performance of the Roche Elecsys(R) Anti-SARS-CoV-2, Abbott Architect SARS-CoV-2 IgG, Euroimmun SARS-CoV-2 IgA, Euroimmun SARS-CoV-2 IgG ELISA, and Trillium IgG/IgM rapid assays was evaluated in Jamaica, the largest country of the English-speaking Caribbean. Diagnostic sensitivities of the assays were assessed by testing serum samples from SARS-CoV-2 PCR-confirmed persons. Serum samples collected [≥]14 days after onset of symptoms, or [≥]14 days after an initial SARS-CoV-2 RT-PCR positive test for asymptomatics, showed diagnostic sensitivities ranging from 67.9-75.0% when including all possible disease severities and increased to 90.0-95.0% when examining those with moderate to critical disease. Grouping moderate to critical disease showed a significant association with a SARS-CoV-2 antibody positive result for all assays. Diagnostic specificity, assessed by testing serum samples collected during 2018-2019 from healthy persons and from persons with antibodies to a wide range of viral infections, ranged from 96.7-100.0%. For all assays examined, SARS-CoV-2 real-time PCR cycle threshold (Ct) values of the initial nasopharyngeal swab sample testing positive were significantly different for samples testing antibody positive versus negative. These data from a predominantly African descent Caribbean population shows comparable diagnostic sensitivities and specificities for all testing platforms assessed and limited utility of these tests for persons with asymptomatic and mild infections.

Cardiovascular involvement in COVID-19: not to be missed.

In December 2019, a striking appearance of new cases of viral pneumonia in Wuhan led to the detection of a novel coronavirus (SARS-CoV2). By analyzing patients with severe manifestations, it became apparent that 20 to 35% of patients who died had preexisting cardiovascular disease. This finding warrants the important need to discuss the influence of SARS-CoV2 infection on the cardiovascular system and hemodynamics in the context of clinical management, particularly during mechanical ventilation. The SARS-CoV2 enters human cells through the spike protein binding to angiotensin-converting enzyme 2 (ACE2), which is important to cardiovascular modulation and endothelial signaling. As ACE2 is highly expressed in lung tissue, patients have been progressing to acute respiratory injury at an alarming frequency during the Coronavirus Disease (COVID-19) pandemic. Moreover, COVID-19 leads to high D-dimer levels and prothrombin time, which indicates a substantial coagulation disorder. It seems that an overwhelming inflammatory and thrombogenic condition is responsible for a mismatching of ventilation and perfusion, with a somewhat near-normal static lung compliance, which describes two types of pulmonary conditions. As such, positive pressure during invasive mechanical ventilation (IMV) must be applied with caution. The authors of this review appeal to the necessity of paying closer attention to assess microhemodynamic repercussion, by monitoring central venous oxygen saturation during strategies of IMV. It is well known that a severe respiratory infection and a scattered inflammatory process can cause non-ischemic myocardial injury, including progression to myocarditis. Early strategies that guide clinical decisions can be lifesaving and prevent extended myocardial damage. Moreover, cardiopulmonary failure refractory to standard treatment may necessitate the use of extreme therapeutic strategies, such as extracorporeal membrane oxygenation.