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Background. Electronic hand hygiene (HH) monitoring systems have many potential advantages but there are limited data on wide-scale implementation of these systems. Methods. We deployed an electronic HH monitoring system in over 2,100 acute and critical care rooms across 9 hospitals in an academic health system. Badges with a Bluetooth beacon were issued to over 7,000 healthcare workers. Deployment began in early 2020 and was interrupted by the pandemic. The rollout of interventions to improve HH adherence was managed at the hospital level. Healthcare-associated infections (HAIs) were determined by the infection prevention team using standard CDC definitions. Hospital-level HH adherence rates were compared to a composite SIR including SIRs for CLABSI, CAUTI, hospital-onset MRSA bloodstream infections and hospital-onset Clostridiodes difficile infections. Results. Between January 2020 and April 2022, there were over 36 million hand hygiene opportunities with an average of 19 observations per staffed room per day. Overall HH adherence improved from 46% to 60%, with significant variation by hospital (4 improving by >25% and 3 by < 5%). Hospitals whose implementation was most delayed showed the least improvement. Preliminary analysis found no relationship between hand hygiene improvement and the SIR composite aggregated by calendar year. Conclusion. Despite the challenges of large-scale implementation of an electronic HH system during a pandemic, we demonstrated an overall improvement in HH adherence. The wide variation in improvement among hospitals was due to timing of implementation, variation in the dedicated hospital-specific project management resources and leadership engagement. In addition to technology, successful implementation of electronic HH systems requires dedicated resources and culture change. Pandemic-related staffing challenges, disruption of standard HAI prevention efforts and intensive device utilization confounded our ability to show a relationship between HH adherence and HAI rates.
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Introduction: Most reports related to humoral immune response to COVID 19 vaccines in people with Multiple Sclerosis (pwMS) were performed on mRNA-based vaccines. Objective(s): to analyze the longitudinal humoral immune responses to adenovirus-based vaccines (Sputnik V and AZD1222) in pwMS under different diseases modifying therapies (DMTs) Methods: IgG anti- SARS-COV-2 spike titers in a cohort of 101 pwMS and 28 healthy controls (HC) were measured 6 weeks after vaccination using the COVID-AR kit according to the manufacture instructions. Both patients and controls received two or three doses of Sputnik, AZD1222 or a mixed schedule (MS) of both vaccines. The neutralizing capacity was evaluated by measuring antibody neutralizing titers using SARS COV-2 pseudotyped particles. Result(s): 60.5% of pwMS were female, mean EDSS: 2.49 +/-1.5, age: 36.6 +/-10.7, disease duration 7.6 +/- 5.1 years. DMTs: 45 pwMS were under fingolimod, 23 under dimethyl fumarate, 14 under cladribine and 19 under antiCD20 monoclonal antibodies. Vaccines: 35.7% Sputnik V, 51.9% AZD1222 and 12.4 % MS. No antibody response to a 2nd dose was found in 41.3% of pwMS under fingolimod and 73.6% under antiCD20. We found a correlation between lower lymphocyte count and lower antibody titers in pwMS under fingolimod (r: 0.67, 95% CI: 0.46-0.81, p=<=0.0001). A correlation was also found between the antibody titer and the last dose of antiCD20 (r: 0.49, 95% CI: 0.03-0.7, p=0.03). In March 2022, 57 pwMS received their 3nddose, 6 patients under fingolimod and 7 under antiCD20 remained without any antibody response. We did not find differences in the neutralization capacity with different DMT and or vaccines. Multivariate regression analysis showed antiCD20 (beta= -,349, 95% CI: -3655.6-369.01, p=0.017) and fingolimod (beta=-,399, 95% CI: -3363.8-250.9, p=0.023) treatments as independent factor associated with low antibody response (r2 adjusted=0.157). Conclusion(s): This is the first report of longitudinal humoral immune response of patients under adenovirus-based vaccines, specially Sputnik V, that demonstrate that these vaccines have similar results to those obtained with mRNA-based vaccines.
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Background: Few published studies focus on the effects of collaboration between nephrology and ethics. It is widely accepted by nephrologists that there are ethical concerns which arise in daily practice. In addition to the impact on the individual, societal concerns include equitable access to care for kidney disease. The American Society of Nephrology, with the European Renal Association-European Dialysis and Transplant Association and International Society of Nephrology Joint Working Group released ten topics, which should serve as an ethical priority (2020). These include: Equity in access to integrated kidney failure care;Setting priorities in kidney disease prevention and care;Supporting shared decision making about kidney failure care;Avoiding futile or overly burdensome dialysis treatment;Reducing the cost of dialysis care without compromising quality;Preventing organ trafficking and transplant tourism;Evaluating the risks and outcomes of living kidney donation;Addressing the ethical implications of genetic kidney disease;Managing conflicts of interest in nephrology;Advocating responsibly for kidney health. Yet, there is no clear guidance on how to manage these concerns. Additionally, training does not focus on this in a standardized manner. This pilot study sought to describe the ethical framework necessary towards improving overall outcomes. Method(s): IRB approval was obtained to perform a retrospective chart review of bioethics consults for renal patients treated in a tertiary medical system in New York State. This included pediatric and adult patients. The authors reviewed the consults. Reasons for consult were extracted and categorized based on the priorities set forth in 2020. This included: organ transplantation;genetic kidney disease;avoidance of futile/ overly burdensome dialysis;shared decision- making. Result(s): Population-level concerns did not emerge in consults. More than one reason for consult could be identified, as well as a "none of the above" category. Continued analysis is on-going. Conclusion(s): It is likely that the concurrent COVID-19 global pandemic and its effect on renal health and resource allotment heavily impacted these results. However, it is apparent that there is a large focus on the burden of dialysis, suggesting that these should be more clear approaches to these concerns, used by practicing nephrologists. Additional studies are required to further evaluate this initiative.
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Introduction: Our case is a patient with AGT of multiple failed kidney transplants. Case Description: A 15 year old F with Nephronphthisis and ESKD had a living unrelated kidney transplant (LUKT), when poor graft perfusion prompted arterial reanastomosis with improvement. After closure intrarenal doppler waveforms were poorly visualized. Given decreasing serum creatinine (SCr) and good urine output, she was observed. Hours later SCr rose with intrarenal blood flow (BF) on doppler. The graft was found mottled with AGT and thrombi in the right (Rt) external iliac artery, renal artery (RA) and vein (RV). Graft was removed, flushed with heparin/alteplase and reimplanted with doppler-confirmed BF. After closure BF was not detected with diminished Rt lower extremity pulses. The graft was necrotic and removed. Thrombi were removed from the Rt common/ iliac, femoral and popliteal arteries. HD was restarted with heparin. Within hours, thrombocytopenia worsened. Elevated D-dimer and positive platelet factor-4 antibodies (PF-4Ab) suggested heparin-induced thrombocytopenia (HIT) despite negative serotonin release assay (SRA). Heparin was changed to argatroban then apixiban. Following resolved thrombocytopenia and negative PF-4 Ab, she had a second LUKT on therapeutic argatroban. She again had AGT with intrarenal, RV and RA thrombi requiring graft removal. Workup showed positive Coombs and negative heparin Ab, suggestive of Ab-mediated consumptive coagulopathy consistent with vaccine induced thrombotic thrombocytopenia (VITT). Discussion(s): Initially HIT was presumed, and heparin discontinued, yet AGT occurred despite heparin avoidance. Thus, symptoms were more consistent with VITT, a syndrome that can occur after COVID-19 vaccines with adenovirus vector. Yet, she was not vaccinated. Like HIT, VITT is thought to be from IgG binding to the PF-4-heparin complex, activating platelets and initiating a hypercoagulable cascade with platelet consumption. Although clinically similar, HIT and VITT are treated differently, thus it is vital to differentiate the two. (Table Presented).
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Cytogenetic abnormalities involving chromosome 16 are found in 5– 8% of acute myeloid leukemia (AML). These are typically a pericentric inversion inv(16)(p13.1q22) or a translocation, t(16;16)(p13.1;q22), involving the MYH11 and CBFB genes localized to chromosome 16p13.1 and 16q22, respectively. In addition, less common rearrangements include deletion of the long arm of chromosome 16, del(16) (q22), and cryptic insertions involving the MYH11 and the CBFB genes with otherwise normal karyotypes. In this report, we present the first AML case with a new translocation involving the CBFB gene. The more common CBFB - MYH11 fusion product resulting from the inversion and/or translocation of chromosome(s) 16 leads to an AML with monocytic and granulocytic differentiation and abnormal eosinophil component with large, purple to violet color eosinophilic granules. This entity typically corresponds to the adult AML-M4Eo in French-American- British (FAB) Classification and now called AML with inv(16)(p13.1q22) or t(16;16)(p13.1;q22);CBFB-MYH1 in the new 2017 WHO Classification. Patients may present with myeloid sarcoma at initial diagnosis or at relapse. We present a case of an 80-year-old male with a history of prostate cancer post radiotherapy who was referred for COVID-19 testing. A complete blood count with differential revealed neutropenia and a macrocytic anemia. A bone marrow biopsy and a bone marrow aspirate confirmed a diagnosis of AML with 33% blasts including myeloblasts and promonocytes. Interphase fluorescence in situ hybridization (FISH) analysis with a break-apart probe for CBFB showed an abnormal hybridization pattern consistent with rearrangement of CBFB in 66% of nuclei. Chromosome analysis revealed an abnormal karyotype with two related clones: 47,XY, t(10;16)(p13;q22),+22[4]/48,idem,+8[16]. Sequential GTG-FISH confirmed that the 3’ region of CBFB was translocated to 10p13 in the t(10;16) and the 5’ region remained on 16q. Based on the karyotype, the patient’s bone barrow exhibits clonal evolution having acquired additional chromosome abnormalities (trisomy 22 and trisomy 8). Molecular studies by next generation sequencing showed NRAS p.Gln61Lys mutation with a VAF of 11.21%. No genomic alterations were detected in KIT, KRAS or FLT3 genes. AML with inv(16)(p13.1q22) or t(16;16)(p13.1;q22) is associated with a high rate of complete remission and favorable overall survival when treated with intensive consolidation therapy. However, their prognostic advantage may be affected by additional cytogenetic abnormalities and/or other gene mutations. Specifically, trisomy 22, is a frequent abnormality additional to inv(16) detected as a secondary finding which has been associated with an improved outcome when compared to the prognosis associated with inv(16) alone. Furthermore, KIT (in 30–40%), FLT3 (in 14%), NRAS (in 45%) and KRAS (in 13%) mutations are common in this AML type. The prognostic implications of KIT mutation (especially involving exon 8) do not appear to be significantly poor prognostic compared to other AML types. On the other hand FLT3-TKD mutations and trisomy 8 are associated with a worse outcome. The patient is currently receiving Vidaza 75 mg/m2, days 1–7 of a 28 days cycle with Venetoclax mg daily of a 28-day cycle and his clinical prognosis is currently unclear. Further analysis by DNA sequencing may help to characterize the molecular nature of the fusion gene product resulting from the novel t(10;16)(p13;q22). To the best of our knowledge, this is the first reported case of an AML patient with translocation t(10;16)(p13;q22) involving the CBFB gene. Given the rarity and lack of additional information regarding the effects of this abnormality, the prognosis and survival cannot be predicted.
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INTRODUCTION: Vaccine hesitancy (VH), delay in acceptance, and/or refusal to vaccinate is influenced by complacency, confidence, unmet safety, and efficacy concerns. A survey was conducted among U.S. healthcare students to identify factors contributing to COVID-19 vaccine hesitancy. METHODS: The World Health Organization 2014 vaccine hesitancy guidelines informed development of a 37-item survey. This cross-sectional survey was distributed to students in 10 randomly selected nursing, pharmacy, and medical programs. Descriptive statistics and logistic regression were used to identify factors contributing to COVID-19 vaccine hesitancy. RESULTS: Of the 902 participants who started the survey, 398 completed all COVID-19 questions. Survey respondents were primarily from private schools (84%) and consisted of medical students (49%), female (71%), and millennials (57%). Students believed COVID-19 vaccine was important and protection of vulnerable communities more important than individual protection. Students in general agreed getting the vaccine was necessary to protect others (school and healthcare facilities) (77.4%);only one-third (33.7%) disagreed that they planned to wait and want to see how vaccine affected others before receiving it. Logistic regression results suggest significant differences based on program and political affiliation. CONCLUSIONS: Engagement of healthcare students may help reach student peers who are vaccine hesitant and help reduce the spread of COVID-19.
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Low-Dose Radiation Therapy (LD-RT) is an emerging treatment option for patients with COVID-19 related pneumonia. Infectivity of the SARS-CoV-2 virus complicates incorporation of LD-RT into existing radiation oncology clinics. The first phase I/II trial of LD-RT for COVID-19-related pneumonia implemented novel operational protocols to address risk of infection and respiratory events. Patients were transported from hospital rooms to linear accelerators and treated with 0.5 Gy or 1.5 Gy using pre-planned, two-dimensional treatments prepared using diagnostic x-rays and caliper measurements. Workflows were revised over time to balance infection risks with implementation burden. Between April 24 and December 7, 2020, fifty-two patients were enrolled and forty were treated. The end-to-end process comprised 16 distinct teams and > 120 cooperating staff members (> 50 core radiation oncology staff). The trial was operationalized at two hospitals at the onset of the COVID-19 pandemic, prior to vaccine availability. Teams included trial leadership/screening (n > 4), inpatient floor staff (n > 10), clinical trials staff and coordinators (n = 8), transport (n = 2), radiation therapists (n > 20), respiratory therapists (n = 5), radiation nursing (n > 7), ICU nursing (n = 4), rapid response teams (n = 4), medical physics (n > 4), dosimetry (n > 3), infection prevention (n > 3), environmental services (n > 6), security (n = 7), lab personnel (n = 1), and physicians from radiation oncology (n = 7), infectious diseases (n = 2), pulmonary/critical care medicine (n = 2), anesthesia (n = 2), and internal medicine (n > 20) [total > 120]. All non-intubated patients were transported by a multi-disciplinary team, consisting of a physician, nurse, transporter, infection prevention specialist, and (when needed) a respiratory therapist. Treatments occurred after normal clinic hours, were initiated by team huddles, check lists, and included personal protective equipment supervision at multiple time points. Transport routes were 880 to 1760 feet (0.33 miles) one-way, with 1 to 3 elevator banks and required 20-35 minutes for round-trip transport and treatment. Oxygen supplementation in non-intubated patients ranged from 2 to 15 L/min. One intubated patient was transported with a portable ventilator and accompanying ICU staff. There were no code-level events during transport. No patient-facing staff contracted COVID-19 from trial activities. Workflow burden was successfully reduced and protocols relaxed over time with increased staff experience. Whole-lung low-dose radiation therapy (LD-RT) for COVID-19-related pneumonia was successfully incorporated into existing workflows at a major academic university. Forty patients were treated with no code-level events, and no staff contracted the virus during eight months of trial accrual. Instructional materials and implementation check lists are provided. [ABSTRACT FROM AUTHOR] Copyright of International Journal of Radiation Oncology, Biology, Physics is the property of Pergamon Press - An Imprint of Elsevier Science and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use. This abstract may be abridged. No warranty is given about the accuracy of the copy. Users should refer to the original published version of the material for the full abstract. (Copyright applies to all Abstracts.)
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Background: The COVID-19 pandemic caused by SARS-CoV-2 has precipitated a global health crisis. In an effort to decrease person-to-person transmission, societal-level non-pharmacologic interventions (NPIs) to maintain social distancing have been enacted. As SARS-CoV-2 shares similar routes of transmission with other respiratory viruses, implementation of these NPIs may have decreased transmission for multiple viral pathogens. We compared influenza and respiratory syncytial (RSV) rates in prior seasons to rates during the 2019 - 2020 season at two large academic centers in Atlanta and Boston. Methods: The clinical records were queried for adults with respiratory virus testing conducted at the Emory Healthcare system and associated clinics in Atlanta and the Mass General Brigham (MGB) Healthcare System in Boston. Total cases for influenza A and B, RSV and SARS-CoV-2 were analyzed for each week of the past 5 seasons (07/01/2015-05/30/2020) for the Atlanta and Boston sites. Systematic changes in viral infection rates were calculated using viral reproduction rates, R(t), between consecutive weeks. R(t) is the ratio of the number of positive cases in one week to the number of positive cases in the previous week. We used statistical bootstrapping to determine whether R(t) for influenza and RSV were lower in 2019-2020 following the introduction of SARS-CoV-2. Analyses were conducted using R (v 4.0.0). Absolute respiratory virus activity by season, Boston (panel A) v. Atlanta (panel B) Results: For the 2019-2020 Atlanta season, R(t) < 1 (which reflects steady decline in infection rates) occurred at week 28 for influenza A, week 33 for influenza B, and week 35 for RSV, which corresponded with the increase of SARS-Cov-2 cases. The R(t) of these viruses stayed at or near 1 during weeks 33-35 in prior seasons, and R(t) was greater than 1 up to week 47. Data from MGB sites showed similar trends with a sudden decline in R(t) to < 1 at the start of the SARS-CoV-2 pandemic. Conclusion: We note decreased transmission of influenza and RSV during a time window where widespread movement restrictions and social distancing were imposed to control COVID-19. This trend was most pronounced for influenza A in Atlanta and influenza B in Boston. These data suggest that NPIs can have important effects across multiple pathogens.
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Introduction: Individuals with advanced age and comorbidities face risk of death from COVID-19, especially onceventilator-dependent, precipitated by an immune cytokine storm in the lungs. Lymphocytes, a mediator of cytokinestorms, are exquisitely sensitive to ionizing radiation. Low doses of radiation therapy (LD-RT) were used to treatinfectious processes during the first half of the 20th century, including pneumonia. It is conceivable that focalimmunosuppression with LD-RT may reduce pulmonary inflammation associated with COVID-19 pneumonia. Methods: The Radiation Eliminates Storming Cytokines and Unchecked Edema as a 1-day Treatment for COVID-19 (RESCUE 1-19) trial explores safety and efficacy of single-fraction, low-dose, whole-lung radiation forhospitalized, oxygen-dependent patients with COVID-19 pneumonia (Clinical Trial NCT04366791 ). Patients had tobe hospitalized with a positive COVID-19 nasopharyngeal swab, have radiographic pneumonic consolidations, require oxygen supplementation, and be clinically deteriorating (i.e., mentation, oxygenation, dyspnea). Patientsreceived a single-fraction dose of 1.5 Gy to the bilateral lungs. The primary endpoint was safety, measured by apreplanned stopping rule. We utilized an established clinical scale to define clinical recovery, the Glasgow ComaScale (GCS), an established radiographic ARDS scale, and 27 serologic biomarkers. Results: Between April 23-28, 2020, nine candidates were evaluated. Of these, one died before enrollment, one didnot meet severity criteria, and seven enrolled. Of these, two were intubated before LD-RT (one died), and fivereceived LD-RT. Median age was 90 (range 64-94). Four had been admitted from nursing homes with COVID-19outbreaks. Comorbidity burden was high. Four were African American and one was Caucasian. Four were female.Median oxygen requirement at the time of LD-RT was 3 L/min (range 1.5-6). Median duration of prehospitalizationsymptoms was 4 days (range 1-7). LD-RT was delivered on median hospital day 5 (range 2-8). Three patientsreceived azithromycin prior to enrollment. During a 14-day observation period, no patients experienced acutetoxicity. Four patients (80%) clinically recovered, 3 within 24 hours, without evidence of COVID symptomexacerbation. Mean time to recovery was 35 hours. Median GCS rose from 10 (range 9-15) to 14 (range 13-15) athour 24. Serial x-rays showed improved or stable disease in 4/5 patients. At day 7, 4/5 patients had 85-92% of allbiomarkers either improve or remain normal. At day 14, all patients were alive, 3 had returned to their nursinghomes (mean time to discharge 12 days), and a 4th was pending discharge. Conclusion: Five hospitalized, oxygen-dependent, and clinically deteriorating patients received low-dose, whole-lung radiation and experienced no acute toxicities. 80% returned to room air at a median time of 1.5 days. Noworsening of the cytokine storm was observed in 4 of 5 patients. Low-dose lung radiation appears safe and meritsfurther evaluation.