Mobility changes following COVID-19 stay-at-home policies varied by socioeconomic measures: An observational study in Ontario, Canada (preprint)

In Canada, lower income households and essential workers and were disproportionately at risk of SARS-CoV-2. Early in the pandemic, stay-at-home restriction policies were used to limit virus transmission. There remains an evidence gap in how changes in mobility, in response to the policies, varied across socioeconomic measures in Canada. The study objective was to describe the variability in mobility change to two restrictions, by neighborhood-level income and by proportion essential workers across five regions in Ontario, Canada. The first restriction was implemented on March 17, 2020 in all five regions; and the second restriction was implemented in November 23, 2020 in two of the regions. Using cell-phone mobility data aggregated to the census tract, we compared the average mobility (% of devices that travelled outside their "primary location") three weeks before and after each restriction. We defined the adjusted mobility change via pre-restriction mobility subtracted from post-restriction, adjusted for 2019 levels. We used difference-in-differences analysis to quantify effect modification of the second restrictions effect by socioeconomic measures. With the first restriction, crude mobility fell from 77.7% to 41.6% across the five regions. The adjusted mobility change to the first restriction was largest in the highest-income neighborhoods (-43.3% versus -38.4%) and in neighborhoods with the fewest essential workers (-44.5% versus -37.6%). The overall adjusted mobility change to the second restriction was small: -0.96% (95% confidence intervals, -1.53 to -0.38%). However, there was evidence of effect modification by socioeconomic measures (less pronounced decrease in lower-income neighborhoods and more essential workers). The findings suggest a temporal saturation effect of restrictions over subsequent waves, and a saturation effect by income and occupation, leading to prevention gaps across populations by socioeconomic measures. Findings highlight the need for tailored approaches at the intersections of income and occupation when addressing epidemics of novel and resurging respiratory pathogens.

Social inequalities in COVID-19 deaths by area-level income: patterns over time and the mediating role of vaccination in a population of 11.2 million people in Ontario, Canada (preprint)

ImportanceSocial inequalities in COVID-19 deaths were evident early in the pandemic. Less is known about how vaccination may have influenced inequalities in COVID-19 deaths. ObjectivesTo examine patterns in COVID-19 deaths by area-level income over time and to examine the impact of vaccination on inequality patterns in COVID-19 deaths. Design, setting, and participantsPopulation-based retrospective cohort study including community-living individuals aged [≥]18 years residing in Ontario, Canada, as of March 1, 2020 who were followed through to January 30, 2022 (five pandemic waves). ExposureArea-level income derived from the 2016 Census at the level of dissemination area categorized into quintiles. Vaccination defined as receiving [≥] 1 dose of Johnson-Johnson vaccine or [≥] 2 doses of other vaccines. Main outcome measuresCOVID-19 death defined as death within 30 days following, or 7 days prior to a positive SARS-CoV-2 PCR test. Cause-specific hazard models were used to examine the relationship between income and COVID-19 deaths in each wave. We used regression-based causal mediation analyses to examine the impact of vaccination in the relationship between income and COVID-19 deaths during waves four and five. ResultsOf 11,248,572 adults, 7044 (0.063%) experienced a COVID-19 death. After accounting for demographics, baseline health, and area-level social determinants of health, inequalities in COVID-19 deaths by income persisted over time (adjusted hazard ratios (aHR) [95% confidence intervals] comparing lowest-income vs. highest-income quintiles were 1.37[0.98-1.92] for wave one, 1.21[0.99-1.48] for wave two, 1.55[1.22-1.96] for wave three, and 1.57[1.15-2.15] for waves four and five). Of 11,122,816 adults alive by the start of wave four, 7,534,259(67.7%) were vaccinated, with lower odds of vaccination in the lowest-income compared to highest-income quintiles (0.71[0.70-0.71]). This inequality in vaccination accounted for 57.9%[21.9%-94.0%] of inequalities in COVID-19 deaths between individuals in the lowest-income vs. highest-income quintiles. ConclusionsInequalities by income persisted in COVID-19 deaths over time. Efforts are needed to address both vaccination gaps and residual heightened risks associated with lower income to improve health equity in COVID-19 outcomes. Summary boxO_ST_ABSSection 1: What is already known on this topicC_ST_ABSO_LIEmerging data suggest social inequalities in COVID-19 deaths might have persisted over time, but existing studies were limited by their ecological design and/or inability to account for potential confounders. C_LIO_LIVaccination has contributed to reducing COVID-19 deaths but there were social inequalities in vaccination coverage. C_LIO_LIThe impact of inequalities in vaccination on inequalities in COVID-19 deaths has not yet been well-studied. C_LI Section 2: What this study addsO_LIAcross five pandemic waves (2020-2021) in Ontario, Canada, COVID-19 deaths remained higher in individuals living in lower-income neighbourhoods, even after accounting for individual-level demographics and baseline health, and other area-level social determinants of health. C_LIO_LIDuring later waves (following the vaccination roll-out), over half (57.9%) of the inequalities in COVID-19 deaths between individuals living in the lowest and highest income neighbourhoods could be attributed to differential vaccination coverage by income. This means that if vaccine equality was achieved, inequalities in deaths would persist but be reduced. C_LIO_LIAddressing vaccination gaps, as well as addressing the residual heightened risks of COVID-19 associated with lower income could improve health equity in COVID-19 outcomes. C_LI

The atypical ß-blocker S-oxprenolol reduces cachexia and improves survival in a rat cancer cachexia model.

BACKGROUND: Beta-blockers and selected stereoisomers of beta-blockers, like bisoprolol and S-pindolol (ACM-001), have been shown to be effective in preclinical cancer cachexia models. Here, we tested the efficacy of stereoisomers of oxprenolol in two preclinical models of cancer cachexia-the Yoshida AH-130 rat model and the Lewis lung carcinoma (LLC) mouse model. METHODS AND RESULTS: In the Yoshida AH130 hepatoma rat cancer cachexia model and compared with placebo, 50 mg/kg/d S-oxprenolol (HR: 0.49, 95% CI: 0.28-0.85, P = 0.012) was superior to 50 mg/kg/d R-oxprenolol (HR: 0.83, 95% CI 0.38-1.45, P = 0.51) in reducing mortality (= reaching ethical endpoints). Combination of the three doses (12.5, 25 and 50 mg/kg/d) that had a significant effect on body weight loss in the S-oxprenolol groups vs the same combination of the R-oxprenolol groups lead to a significantly improved survival of S-oxprenolol vs R-oxprenolol (HR: 1.61, 95% CI: 1.08-2.39, P = 0.0185). Interestingly, there is a clear dose dependency in S-oxprenolol-treated (5, 12.5, 25 and 50 mg/kg/d) groups, which was not observed in groups treated with R-oxprenolol. A dose-dependent attenuation of weight and lean mass loss by S-oxprenolol was seen in the Yoshida rat model, whereas R-oxprenolol had only had a significant effect on fat mass. S-oxprenolol also non-significantly reduced weight loss in the LLC model and also improved muscle function (grip strength 428 ± 25 and 539 ± 37 g/100 g body weight for placebo and S-oxprenolol, respectively). However, there was only a minor effect on quality of life indicators food intake and spontaneous activity in the Yoshida model (25 mg/kg/S-oxprenolol: 11.9 ± 2.5 g vs placebo: 4.9 ± 0.8 g, P = 0.013 and also vs 25 mg/kg/d R-oxprenolol: 7.5 ± 2.6 g, P = 0.025). Both enantiomers had no effects on cardiac dimensions and function at the doses used in this study. Western blotting of proteins involved in the anabolic/catabolic homoeostasis suggest that anabolic signalling is persevered (IGF-1 receptor, Akt) and catabolic signalling is inhibited (FXBO-10, TRAF-6) by S-pindolol, but not he R-enantiomer. Expression of glucose transporters Glut1 and Glut 4 was similar in all groups, as was AMPK. CONCLUSIONS: S-oxprenolol is superior to R-oxprenolol in cancer cachexia animal models and shows promise for a human application in cancer cachexia.

Which Curve Are We Flattening? The Disproportionate Impact of COVID-19 Among Economically Marginalized Communities in Ontario, Canada, Was Unchanged From Wild-Type to Omicron.

Person-level surveillance (N = 14 million) and neighborhood-level income data were used to explore magnitude of inequalities in COVID-19 hospitalizations and deaths over 5 waves in Ontario, Canada. Despite attempts at equity-informed policies alongside fluctuating levels of public health measures, the magnitude of inequalities in hospitalizations and deaths remained unchanged across waves.

Vaccine-induced immune thrombotic thrombocytopenia: Updates in pathobiology and diagnosis.

Coronavirus disease 2019 (COVID-19) is a viral respiratory infection caused by the severe acute respiratory syndrome virus (SARS-CoV-2). Vaccines that protect against SARS-CoV-2 infection have been widely employed to reduce the incidence of symptomatic and severe disease. However, adenovirus-based SARS-CoV-2 vaccines can cause a rare, thrombotic disorder termed vaccine-induced immune thrombotic thrombocytopenia (VITT). VITT often develops in the first 5 to 30 days following vaccination and is characterized by thrombocytopenia and thrombosis in unusual locations (e.g., cerebral venous sinus thrombosis). The diagnosis is confirmed by testing for anti-PF4 antibodies, as these antibodies are capable of platelet activation without any cofactor. It can be clinically challenging to differentiate VITT from a similar disorder called heparin-induced thrombocytopenia (HIT), since heparin is commonly used in hospitalized patients. VITT and HIT have similar pathobiology and clinical manifestations but important differences in testing including the need for PF4-enhanced functional assays and the poor reliability of rapid immunoassays for the detection of anti-platelet factor 4 (PF4) antibodies. In this review we summarize the epidemiology of VITT; highlight similarities and differences between HIT and VITT; and provide an update on the clinical diagnosis of VITT.

COVID-19 Cases Among Congregate Care Facility Staff by Neighborhood of Residence and Social and Structural Determinants: Observational Study.

BACKGROUND: Disproportionate risks of COVID-19 in congregate care facilities including long-term care homes, retirement homes, and shelters both affect and are affected by SARS-CoV-2 infections among facility staff. In cities across Canada, there has been a consistent trend of geographic clustering of COVID-19 cases. However, there is limited information on how COVID-19 among facility staff reflects urban neighborhood disparities, particularly when stratified by the social and structural determinants of community-level transmission. OBJECTIVE: This study aimed to compare the concentration of cumulative cases by geography and social and structural determinants across 3 mutually exclusive subgroups in the Greater Toronto Area (population: 7.1 million): community, facility staff, and health care workers (HCWs) in other settings. METHODS: We conducted a retrospective, observational study using surveillance data on laboratory-confirmed COVID-19 cases (January 23 to December 13, 2020; prior to vaccination rollout). We derived neighborhood-level social and structural determinants from census data and generated Lorenz curves, Gini coefficients, and the Hoover index to visualize and quantify inequalities in cases. RESULTS: The hardest-hit neighborhoods (comprising 20% of the population) accounted for 53.87% (44,937/83,419) of community cases, 48.59% (2356/4849) of facility staff cases, and 42.34% (1669/3942) of other HCW cases. Compared with other HCWs, cases among facility staff reflected the distribution of community cases more closely. Cases among facility staff reflected greater social and structural inequalities (larger Gini coefficients) than those of other HCWs across all determinants. Facility staff cases were also more likely than community cases to be concentrated in lower-income neighborhoods (Gini 0.24, 95% CI 0.15-0.38 vs 0.14, 95% CI 0.08-0.21) with a higher household density (Gini 0.23, 95% CI 0.17-0.29 vs 0.17, 95% CI 0.12-0.22) and with a greater proportion working in other essential services (Gini 0.29, 95% CI 0.21-0.40 vs 0.22, 95% CI 0.17-0.28). CONCLUSIONS: COVID-19 cases among facility staff largely reflect neighborhood-level heterogeneity and disparities, even more so than cases among other HCWs. The findings signal the importance of interventions prioritized and tailored to the home geographies of facility staff in addition to workplace measures, including prioritization and reach of vaccination at home (neighborhood level) and at work.

Association of Finerenone Use With Reduction in Treatment-Emergent Pneumonia and COVID-19 Adverse Events Among Patients With Type 2 Diabetes and Chronic Kidney Disease: A FIDELITY Pooled Secondary Analysis.

Importance: Patients with chronic kidney disease and type 2 diabetes have a higher risk of developing pneumonia as well as an increased risk of severe COVID-19-associated adverse events and mortality. Therefore, the anti-inflammatory effects of mineralocorticoid receptor antagonists via blockade of the mineralocorticoid receptor may alter the risk of pneumonia and COVID-19-associated adverse events in patients with chronic kidney disease and type 2 diabetes. Objective: To evaluate whether the selective, nonsteroidal mineralocorticoid receptor antagonist finerenone is associated with protection against pneumonia and COVID-19 adverse events in patients with type 2 diabetes and chronic kidney disease. Design, Setting, and Participants: This secondary analysis used patient-level data from FIDELITY, a prespecified pooled analysis of 2 multicenter, double-blind, placebo-controlled, event-driven, phase 3 randomized clinical trials: FIDELIO-DKD and FIGARO-DKD, conducted between September 2015 and February 2021. Patients in FIDELIO-DKD or FIGARO-DKD with type 2 diabetes and chronic kidney disease (urine albumin to creatine ratio, 30-5000 mg/g, estimated glomerular filtration rate ≥25 mL/min/1.73 m2) were assessed. Data were analyzed from May 15, 2021, to July 28, 2022. Exposure: Patients were randomized to finerenone (10 or 20 mg once daily) or matching placebo. Main Outcomes and Measures: The main outcomes were investigator-reported incidences of treatment-emergent infective pneumonia adverse events and serious adverse events (during and up to 3 days after treatment) and any COVID-19 adverse events. Results: Of 13 026 randomized patients (mean [SD] age, 64.8 [9.5] years; 9088 [69.8%] men), 12 999 were included in the FIDELITY safety population (6510 patients receiving finerenone; 6489 patients receiving placebo). Over a median (range) treatment duration of 2.6 (0-5.1) years, finerenone was consistently associated with reduced risk of pneumonia and serious pneumonia vs placebo. Overall, 307 patients (4.7%) treated with finerenone and 434 patients (6.7%) treated with placebo experienced pneumonia (hazard ratio [HR], 0.71; 95% CI, 0.64-0.79; P < .001). Serious pneumonia occurred in 171 patients (2.6%) treated with finerenone and 250 patients (3.9%) treated with placebo (HR, 0.69; 95% CI, 0.60-0.79; P < .001). Incidence proportions of COVID-19 adverse events were 86 patients (1.3%) in the finerenone group and 118 patients (1.8%) in the placebo group (HR, 0.73; 95% CI, 0.60-0.89; P = .002). Conclusions and Relevance: These findings suggest that mineralocorticoid receptor blockade with finerenone was associated with protection against pneumonia and COVID-19 adverse events in patients with type 2 diabetes and chronic kidney disease. Further clinical studies may be warranted. Trial Registration: ClinicalTrials.gov identifiers: FIDELIO-DKD: NCT02540993; FIGARO-DKD: NCT02545049.

CODE-EHR best practice framework for the use of structured electronic healthcare records in clinical research.

Big data is central to new developments in global clinical science aiming to improve the lives of patients. Technological advances have led to the routine use of structured electronic healthcare records with the potential to address key gaps in clinical evidence. The covid-19 pandemic has demonstrated the potential of big data and related analytics, but also important pitfalls. Verification, validation, and data privacy, as well as the social mandate to undertake research are key challenges. The European Society of Cardiology and the BigData@Heart consortium have brought together a range of international stakeholders, including patient representatives, clinicians, scientists, regulators, journal editors and industry. We propose the CODE-EHR Minimum Standards Framework as a means to improve the design of studies, enhance transparency and develop a roadmap towards more robust and effective utilisation of healthcare data for research purposes.

CODE-EHR best-practice framework for the use of structured electronic health-care records in clinical research.

Big data is important to new developments in global clinical science that aim to improve the lives of patients. Technological advances have led to the regular use of structured electronic health-care records with the potential to address key deficits in clinical evidence that could improve patient care. The COVID-19 pandemic has shown this potential in big data and related analytics but has also revealed important limitations. Data verification, data validation, data privacy, and a mandate from the public to conduct research are important challenges to effective use of routine health-care data. The European Society of Cardiology and the BigData@Heart consortium have brought together a range of international stakeholders, including representation from patients, clinicians, scientists, regulators, journal editors, and industry members. In this Review, we propose the CODE-EHR minimum standards framework to be used by researchers and clinicians to improve the design of studies and enhance transparency of study methods. The CODE-EHR framework aims to develop robust and effective utilisation of health-care data for research purposes.

COVID Community-Engaged Testing in Alabama: Reaching Underserved Rural Populations Through Collaboration.

Rural communities are often underserved by public health testing initiatives in Alabama. As part of the National Institutes of Health's Rapid Acceleration of Diagnostics‒Underserved Populations initiative, the University of Alabama at Birmingham, along with community partners, sought to address this inequity in COVID-19 testing. We describe the participatory assessment, selection, and implementation phases of this project, which administered more than 23 000 COVID-19 tests throughout the state, including nearly 4000 tests among incarcerated populations. (Am J Public Health. 2022;112(10):1399-1403. https://doi.org/10.2105/AJPH.2022.306985).

Hyposmia in childhood-a comparative evaluation of performance in the 'U-Sniff Test' in children with and without hyperplasia of the lymphoid tissue

Background To date, systematic studies on the cause and prevalence of childhood hyposmia are lacking. The causes of this olfactory dysfunction can vary from simple adenoid hyperplasia or a condition following covid-19 infection to the rare Kallmann syndrome. Regardless of the entity, olfactory disorders can not only severely limit children's quality of life but also present a diagnostic challenge. Methods In the period from March to October 2021, 66 children (33 female, 33 male) between 5 and 18 years of age were examined. 41 of these children showed hyperplasia of the lymphatic tissue (adenoid vegetations and/or tonsillar hyperplasia). 25 healthy children without lymphatic hyperplasia were included in the control group. By means of the 'U-Sniff Test', an olfactory test validated for children, the preoperative olfactory ability was assessed. In addition to the known 12 olfactory sticks, we added two additional odors (chewing gum and ethanol). Results 39 % of the children with lymphoid hyperplasia showed a result below 8 points in the 'U-Sniff Test', while the controle group had regular test results. Children with lymphoid tissue hyperplasia were significantly more likely to be diagnosed with hyposmia than are children from the control group (p < 0.01). Odors unpleasant for children, such as fish or coffee, were more reliably detected than fragrant smells. The odor chewing gum was recognized by 91 % of the children in the age group under 6 years of age. The childrens origin or eating habits showed no correlation with their performance in the 'U-sniff Test'. Conclusion Children with lymphoid hyperplasia suffer significantly more often from hyposmia than children without adenoid/tonsillar hyperplasia. There is an evidence gap in the literature regarding this correlation.

Physical Violence and Psychological Distress Among Asian and Pacific Islander Sexual Minority Men in the United States Before and During the COVID-19 Pandemic.

Purpose: This study examined differences in self-reported physical violence and psychological distress among Asian American and Pacific Islander (AAPI) sexual minority men (SMM) before and during the 2019 novel coronavirus (COVID-19) pandemic (2019 vs. 2020). Methods: We used data from 1127 AAPI SMM who completed the 2019 (August 2019-December 2019) and 2020 (August 2020-January 2021) cycles of the American Men's Internet Survey (AMIS). We assessed differences in experiencing physical violence and serious psychological distress by year of survey completion. We used Poisson regression with robust variance estimation to examine whether physical violence was associated with serious psychological distress before and during COVID-19. Multivariate analyses adjusted for sociodemographic characteristics and the interaction between year and violence. Results: A greater percentage of AAPI SMM had serious psychological distress in 2020 during the pandemic relative to 2019 before the pandemic (56.6% vs. 35.64%, p < 0.001). AAPI SMM who experienced physical violence in the last 6 months were more likely to experience serious psychological distress than those who never experienced physical violence. The association between violence and psychological distress among AAPI SMM was not significantly different before and during the COVID-19 pandemic. Conclusions: Violence against AAPI SMM in the United States is widespread. Although we did not find significant differences in exposure to physical violence among AAPI SMM before and during the COVID-19 pandemic, the increase in serious psychological distress during the pandemic among AAPI SMM may indicate heightened need of mental health services.

Interventions to reengage people living with HIV who are lost to follow-up from HIV treatment programs: A systematic review and meta-analysis.

BACKGROUND: Optimizing services to facilitate engagement and retention in care of people living with HIV (PLWH) on antiretroviral therapies (ARTs) is critical to decrease HIV-related morbidity and mortality and HIV transmission. We systematically reviewed the literature for the effectiveness of implementation strategies to reestablish and subsequently retain clinical contact, improve viral load suppression, and reduce mortality among patients who had been lost to follow-up (LTFU) from HIV services. METHODS AND FINDINGS: We searched 7 databases (PubMed, Cochrane, ERIC, PsycINFO, EMBASE, Web of Science, and the WHO regional databases) and 3 conference abstract archives (CROI, IAC, and IAS) to find randomized trials and observational studies published through 13 April 2020. Eligible studies included those involving children and adults who were diagnosed with HIV, had initiated ART, and were subsequently lost to care and that reported at least one review outcome (return to care, retention, viral suppression, or mortality). Data were extracted by 2 reviewers, with discrepancies resolved by a third. We characterized reengagement strategies according to how, where, and by whom tracing was conducted. We explored effects, first, among all categorized as LTFU from the HIV program (reengagement program effect) and second among those found to be alive and out of care (reengagement contact outcome). We used random-effect models for meta-analysis and conducted subgroup analyses to explore heterogeneity. Searches yielded 4,244 titles, resulting in 37 included studies (6 randomized trials and 31 observational studies). In low- and middle-income countries (LMICs) (N = 16), tracing most frequently involved identification of LTFU from the electronic medical record (EMR) and paper records followed by a combination of telephone calls and field tracing (including home visits), by a team of outreach workers within 3 months of becoming LTFU (N = 7), with few incorporating additional strategies to support reengagement beyond contact (N = 2). In high-income countries (HICs) (N = 21 studies), LTFU were similarly identified through EMR systems, at times matched with other public health records (N = 4), followed by telephone calls and letters sent by mail or email and conducted by outreach specialist teams. Home visits were less common (N = 7) than in LMICs, and additional reengagement support was similarly infrequent (N = 5). Overall, reengagement programs were able to return 39% (95% CI: 31% to 47%) of all patients who were characterized as LTFU (n = 29). Reengagement contact resulted in 58% (95% CI: 51% to 65%) return among those found to be alive and out of care (N = 17). In 9 studies that had a control condition, the return was higher among those in the reengagement intervention group than the standard of care group (RR: 1.20 (95% CI: 1.08 to 1.32, P < 0.001). There were insufficient data to generate pooled estimates of retention, viral suppression, or mortality after the return. CONCLUSIONS: While the types of interventions are markedly heterogeneity, reengagement interventions increase return to care. HIV programs should consider investing in systems to better characterize LTFU to identify those who are alive and out of care, and further research on the optimum time to initiate reengagement efforts after missed visits and how to best support sustained reengagement could improve efficiency and effectiveness.

The COVID Complex: A Review of Platelet Activation and Immune Complexes in COVID-19.

Coronavirus disease 2019 (COVID-19) is a highly prothrombotic viral infection that primarily manifests as an acute respiratory syndrome. However, critically ill COVID-19 patients will often develop venous thromboembolism with associated increases in morbidity and mortality. The cause for this prothrombotic state is unclear but is likely related to platelet hyperactivation. In this review, we summarize the current evidence surrounding COVID-19 thrombosis and platelet hyperactivation. We highlight the fact that several studies have identified a soluble factor in COVID-19 patient plasma that is capable of altering platelet phenotype in vitro. Furthermore, this soluble factor appears to be an immune complex, which may be composed of COVID-19 Spike protein and related antibodies. We suggest that these Spike-specific immune complexes contribute to COVID-19 platelet activation and thrombosis in a manner similar to heparin-induced thrombocytopenia. Understanding this underlying pathobiology will be critical for advancement of future research and therapeutic options.

Cardiac Implication in Pediatric Multisystemic Inflammatory Syndrome – Three Case Reports and Review of the Literature

Pediatric multisystem inflammatory syndrome (PMIS) appears to be a relatively rare complication of COVID-19 in children, occurring in less than 1% of children with confirmed SARS-CoV-2 infection. This condition can appear several weeks after the acute SARS-CoV-2 infection and is assumed to be a delayed immune response to coronavirus disease 2019 which can lead to a severe cardiovascular involvement. In this retrospective study, our main purpose was to summarize the clinical data from three types of onsets in patients diagnosed with PMIS and report the experience to the known data in the literature. We put the emphasis on the course of management considering the three different presenting faces of the PMIS in children. All patients received IV immunoglobulin and antiplatelet treatment, 66% (2 of 3) necessitated inotropic support, corticosteroid therapy (metilprednisolon), anticoagulation, 33% (1 of 3) received Anakinra (antagonist of the interleukin 1 receptor). All of them received cardiac remodeling treatment with Lisinopril and Bisoprolol (associated or not with Spironolactone and Furosemide). Evolution was good with discharge in approximately 2 weeks from admission, without symptoms, and with cardiac improvement at echocardiography. PMIS is an alarming situation that necessitate multidisciplinary approach and a complex management. The cardiac evaluation is crucial in risk evaluation and guidance for a correct approach of the disease. © 2021, MediaMed Publicis. All rights reserved.

Geographic concentration of SARS-CoV-2 cases by social determinants of health in metropolitan areas in Canada: a cross-sectional study.

BACKGROUND: Understanding inequalities in SARS-CoV-2 transmission associated with the social determinants of health could help the development of effective mitigation strategies that are responsive to local transmission dynamics. This study aims to quantify social determinants of geographic concentration of SARS-CoV-2 cases across 16 census metropolitan areas (hereafter, cities) in 4 Canadian provinces, British Columbia, Manitoba, Ontario and Quebec. METHODS: We used surveillance data on confirmed SARS-CoV-2 cases and census data for social determinants at the level of the dissemination area (DA). We calculated Gini coefficients to determine the overall geographic heterogeneity of confirmed cases of SARS-CoV-2 in each city, and calculated Gini covariance coefficients to determine each city's heterogeneity by each social determinant (income, education, housing density and proportions of visible minorities, recent immigrants and essential workers). We visualized heterogeneity using Lorenz (concentration) curves. RESULTS: We observed geographic concentration of SARS-CoV-2 cases in cities, as half of the cumulative cases were concentrated in DAs containing 21%-35% of their population, with the greatest geographic heterogeneity in Ontario cities (Gini coefficients 0.32-0.47), followed by British Columbia (0.23-0.36), Manitoba (0.32) and Quebec (0.28-0.37). Cases were disproportionately concentrated in areas with lower income and educational attainment, and in areas with a higher proportion of visible minorities, recent immigrants, high-density housing and essential workers. Although a consistent feature across cities was concentration by the proportion of visible minorities, the magnitude of concentration by social determinant varied across cities. INTERPRETATION: Geographic concentration of SARS-CoV-2 cases was observed in all of the included cities, but the pattern by social determinants varied. Geographically prioritized allocation of resources and services should be tailored to the local drivers of inequalities in transmission in response to the resurgence of SARS-CoV-2.

Clinical characteristics and outcomes of multiple sclerosis patients with COVID-19 in Toronto, Canada.

OBJECTIVE: To report clinical characteristics and outcomes of people with multiple sclerosis (PwMS) who developed COVID-19 infection in Toronto, Canada. METHODS: Descriptive, retrospective, single-center study that included all known PwMS at the St. Michael's Hospital MS Clinic who had PCR-confirmed COVID-19 infection between March 2020 and May 2021. RESULTS: Of 7000 PwMS in our clinic, 80 (1.1%) tested positive for SARS-CoV-2. Fifty-four (67.5%) were on disease-modifying therapy (DMT) without over-representation of any single treatment. Seventy-one patients (88.8%) had mild symptoms, but nine (11.3%) were hospitalized and one 70-year-old male patient not on treatment died. Of those hospitalized, one-third were treated with ocrelizumab. CONCLUSION: In Toronto, PwMS did not appear to have higher prevalence of COVID-19 infection compared to the general population, but disease severity may be affected by DMT use. Our findings add to the accumulating global data regarding COVID-19 infection in PwMS.

Overlaping syndromes: Kawasaki-like disease in pediatric multisystem inflammatory syndrome vs atypical kawasaki disease. british or american? one case, many possibilities

Kawasaki disease is a challenging diagnosis even in typical forms of presentation. The features are represented by long lasting fever, specific mucocutaneous signs and coronary artery dilations as expression of medium artery vasculitis of unknown origin. Kawasaki-like disease emerged as a variant of pediatric multisystem inflammatory syndrome (PMIS) associated with COVID-19 infection. A 1 year 9-month-old boy who presented with fever, semi-consistent stools, vomiting, facial edema and hepatomegaly was transferred in our hospital with suspicion of myocarditis due to the clinical presentation, inflammatory markers and systolic dysfunction. In a few days after presentation, also, dilation of the coronary artery appeared while the child had persistent constant symptomatology. Gradually, a pediatric multisystem inflammatory syndrome (PMIS) developed, but without positive markers of COVID-19 infection, which remained negative (both antigen and antibodies). So, in front of all elements of PMIS except exposure to SARS-CoV-2, we concluded for an atypical Kawasaki disease with elements of PMIS. But the debate between the elaborated criteria British and American for PMIS are circling around the demonstration of the infection, past or present, making some cases difficult to diagnose. In this high affluence of Kawasaki-like disease, with intricated elements of myocarditis and multisystem inflammatory syndrome it is more and more difficult to establish a clear diagnosis. While the diagnosis looks complex, the curative treatment goes in the same direction – immunoglobulin, immunosuppressive treatment, inotropic and antiaggregant or anticoagulant treatment. © 2021, MediaMed Publicis. All rights reserved.