FACTORS ASSOCIATED WITH PREFERENCES FOR INPERSON VERSUS REMOTE CONSULTATIONS FOR IBD: A UK-WIDE ONLINE SURVEY

Introduction The COVID-19 pandemic resulted in a forced shift to providing remote (telephone and online) consultations following disruptions to traditional in-person care. As the pandemic wanes and IBD services recover, there is a need to rebalance provision of care and align with patient preference rather than provider convenience. Better knowledge of preferences for remote versus in-person care among people with IBD, and of the factors associated with such preferences, will guide this realignment. We report the results of a large-scale, UK-wide follow-up survey of patients who had completed the COVID-19 IBD Risk Tool during the early pandemic.1 Methods Adult patients who consented for research (n=35,329) were invited by e-mail. The survey included sociodemographics, place of residence, self-reported diagnosis, drug treatments, PRO-2 symptoms, IBD-Control Questionnaire and items relating to experience of, and future preference for, mode of IBD consultations. We investigated factors associated with: 'In-person preference' for future consultations (response option: 'Never by telephone or video' versus all other options);and 'Remote preference' (response: 'Mainly by telephone or video' versus all others) in bivariate and multivariable binary logistic regression analyses, with results expressed as adjusted odds ratios (aOR) and 95% CI. Results 7,341 respondents of which 6,015 (82%) had experienced a remote IBD consultation since the first UK lockdown. Of these, 4,396 (73%) said their first experience of a remote consultation was during the pandemic. A significant minority (9.6%) would prefer to avoid future remote consultations entirely (in-person preference) whereas a quarter (24.5%) wished to have mainly remote consultations (remote preference). The following factors were associated with in-person preference (aOR [95% CI]): Older age (>50 years;1.40 [1.19-1.63]), male gender (1.31 [1.11-1.53]), less-well controlled disease (IBD-Control-8 score <13, 2.06 [1.74-2.45]), and residents of more deprived areas (Quintile 5 [most deprived];1.72 [1.31-2.25] vs Quintile 1 [least deprived]). Conversely, we found the following associations for remote preference: Younger age (<50 years;1.24 [1.12-1.39]), Ulcerative Colitis or IBD-U (1.23 [1.10-1.37]), well-controlled disease (IBD-Control-8 score 13+, 1.55 [1.38-1.73]), not having sought emergency care during the pandemic (1.21 [1.06- 1.37]) and living in least deprived areas (Quintile 1;1.29 [1.05-1.59] vs Quintile 5). Conclusions A number of sociodemographic and clinical variables predicted future consultation preference at the time of survey. These included relatively fixed characteristics (e.g. age, gender, diagnosis, and deprivation status) and more dynamic factors (e.g. current disease control). Better understanding of factors associated with patient preference can inform efforts to realign services to provide the right mix of in-person and remote provision.

Perioperative management of glycaemic control: still room for improvement

Introduction: Following a change in national diabetic guidance [1,2], local audit performed in 2019 identified areas of improvement which were incorporated into a revised care pathway for elective caesarean section (ELCS) in 2020. Shortly after introduction, the COVID-19 pandemic led to telephone (rather than face-to-face) pre-assessment. We performed a re-audit in 2021 to assess the impact of the new pathway and pre-assessment changes. Methods: Following local audit registration, retrospective notes review of all diabetic mothers having ELCS (22/11/21–24/12/21) was performed and results compared to the previous audit (2019) and national recommendations [1,2]. Results: Notes were available for all 10 women having ELCS in 2021 and compared to 10 women in 2019. In 2021 all women had gestational diabetes (GDM) and treatment included diet control (3), metformin alone (5), or insulin and metformin (2). In 2019, eight women had GDM and two were type-1 diabetics, with treatment including diet control (3), metformin alone (2), insulin alone (1) and dual insulin and metformin (4). The revised care pathway advised variable rate insulin infusion for all diabetics with blood glucose >7 mmol/L. In 2021, no women required a VRII, compared to two in 2019 due to type one diabetes and blood glucose over 9 mmol/L. In both audits, all women were admitted on the day of surgery and had ELCS under spinal anaesthesia. A comparison of the audit results in 2019 and 2021 is shown (Table). (Table Presented) Discussion: Despite a revised care pathway, guideline compliance for perioperative management of diabetic women having ELCS did not improve, although no woman had a documented blood glucose >7 mmol/L. Compliance was poor in all areas of perioperative management. We now plan to relaunch the pathway in all perioperative clinical areas to improve awareness. This re-audit highlights the importance of reviewing clinical practice to assess the impact of the pandemic on service improvements in perioperative obstetric care.

Elucidating Design Principles for Engineering Cell-Derived Vesicles to Inhibit SARS-CoV-2 Infection.

The ability of pathogens to develop drug resistance is a global health challenge. Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) presents an urgent need wherein several variants of concern resist neutralization by monoclonal antibody (mAb) therapies and vaccine-induced sera. Decoy nanoparticles-cell-mimicking particles that bind and inhibit virions-are an emerging class of therapeutics that may overcome such drug resistance challenges. To date, quantitative understanding as to how design features impact performance of these therapeutics is lacking. To address this gap, this study presents a systematic, comparative evaluation of various biologically derived nanoscale vesicles, which may be particularly well suited to sustained or repeated administration in the clinic due to low toxicity, and investigates their potential to inhibit multiple classes of model SARS-CoV-2 virions. A key finding is that such particles exhibit potent antiviral efficacy across multiple manufacturing methods, vesicle subclasses, and virus-decoy binding affinities. In addition, these cell-mimicking vesicles effectively inhibit model SARS-CoV-2 variants that evade mAbs and recombinant protein-based decoy inhibitors. This study provides a foundation of knowledge that may guide the design of decoy nanoparticle inhibitors for SARS-CoV-2 and other viral infections.

Adapting Research to a Global Pandemic: A Fully Remote Actigraphy and Ecological Momentary Assessment Study.

BACKGROUND: Mandated social distancing practices and quarantines in response to COVID-19 have resulted in challenges for research on healthcare workers, such as hospital nurses. It remains unknown whether nursing studies utilizing complex methodology like sleep actigraphy and ecological momentary assessment (EMA) can be conducted remotely without compromising data quality. OBJECTIVES: We aimed to (a) disseminate our remote study protocol for sleep actigraphy and EMA data from hospital nurses during COVID-19, (b) assess feasibility and acceptability of this approach for studies on hospital nurses, and (c) examine the reliability and ecological validity of sleep characteristics measured across 14 days. METHODS: Using an online platform, we provided 86 outpatient nurses from a cancer hospital with detailed video/text instructions regarding the study and facilitated virtual study onboarding meetings. Feasibility was assessed by comparing adherence rates to a similar in-person study of nurses from the same hospital; acceptability was evaluated through content analysis of qualitative study feedback. Multilevel modeling was conducted to assess changes in sleep characteristics as a function of study day and daily stressful experiences. RESULTS: Adherence to EMA (91.8%) and actigraphy (97.9%) was high. EMA adherence was higher than the in-person study of inpatient day-shift nurses from the same hospital. Content analyses revealed primarily positive feedback, with 51.2% reporting "easy, clear, simple onboarding" and 16.3% reporting the website was "helpful." Six participants provided only negative feedback. Sleep characteristics did not change as a function of study day except for self-reported quality, which increased slightly during Week 1 and regressed toward baseline after that. A higher incidence of stressor days or higher stressor severity followed nights with shorter-than-usual time in bed or poorer-than-usual sleep quality, supporting the ecological validity for these methods of assessing sleep in nurses. DISCUSSION: Findings suggest that a fully remote study protocol for EMA and actigraphy studies in nursing yields robust feasibility, acceptability, reliability, and validity. Given the busy schedules of nurses, the convenience of this approach may be preferable to traditional in-person data collection. Lessons learned from COVID-19 may apply to improving nursing research postpandemic.

Nicotinamide Adenine Dinucleotide Biosynthetic Impairment and Urinary Metabolomic Alterations Observed in Hospitalized Adults With COVID-19-Related Acute Kidney Injury.

INTRODUCTION: Acute kidney injury (AKI) is common in COVID-19 and associated with increased morbidity and mortality. We investigated alterations in the urine metabolome to test the hypothesis that impaired nicotinamide adenine dinucleotide (NAD+) biosynthesis and other deficiencies in energy metabolism in the kidney, previously characterized in ischemic, toxic, and inflammatory etiologies of AKI, will be present in COVID-19-associated AKI. METHODS: This is a case-control study among the following 2 independent populations of adults hospitalized with COVID-19: a critically ill population in Boston, Massachusetts, and a general population in Birmingham, Alabama. The cases had AKI stages 2 or 3 by Kidney Disease Improving Global Outcomes (KDIGO) criteria; the controls had no AKI. Metabolites were measured by liquid chromatography-mass spectrometry. RESULTS: A total of 14 cases and 14 controls were included from Boston and 8 cases and 10 controls from Birmingham. Increased urinary quinolinate-to-tryptophan ratio (Q/T), found with impaired NAD+ biosynthesis, was present in the cases at each location and pooled across locations (median [interquartile range]: 1.34 [0.59-2.96] in cases, 0.31 [0.13-1.63] in controls, P = 0.0013). Altered energy metabolism and purine metabolism contributed to a distinct urinary metabolomic signature that differentiated patients with and without AKI (supervised random forest class error: 2 of 28 in Boston, 0 of 18 in Birmingham). CONCLUSION: Urinary metabolites spanning multiple biochemical pathways differentiate AKI versus non-AKI in patients hospitalized with COVID-19 and suggest a conserved impairment in NAD+ biosynthesis, which may present a novel therapeutic target to mitigate COVID-19-associated AKI.

Validation of a Crisis Standards of Care Model for Prioritization of Limited Resources During the Coronavirus Disease 2019 Crisis in an Urban, Safety-Net, Academic Medical Center.

OBJECTIVES: The coronavirus disease 2019 pandemic has overwhelmed healthcare resources even in wealthy nations, necessitating rationing of limited resources without previously established crisis standards of care protocols. In Massachusetts, triage guidelines were designed based on acute illness and chronic life-limiting conditions. In this study, we sought to retrospectively validate this protocol to cohorts of critically ill patients from our hospital. DESIGN: We applied our hospital-adopted guidelines, which defined severe and major chronic conditions as those associated with a greater than 50% likelihood of 1- and 5-year mortality, respectively, to a critically ill patient population. We investigated mortality for the same intervals. SETTING: An urban safety-net hospital ICU. PATIENTS: All adults hospitalized during April of 2015 and April 2019 identified through a clinical database search. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Of 365 admitted patients, 15.89% had one or more defined chronic life-limiting conditions. These patients had higher 1-year (46.55% vs 13.68%; p < 0.01) and 5-year (50.00% vs 17.22%; p < 0.01) mortality rates than those without underlying conditions. Irrespective of classification of disease severity, patients with metastatic cancer, congestive heart failure, end-stage renal disease, and neurodegenerative disease had greater than 50% 1-year mortality, whereas patients with chronic lung disease and cirrhosis had less than 50% 1-year mortality. Observed 1- and 5-year mortality for cirrhosis, heart failure, and metastatic cancer were more variable when subdivided into severe and major categories. CONCLUSIONS: Patients with major and severe chronic medical conditions overall had 46.55% and 50.00% mortality at 1 and 5 years, respectively. However, mortality varied between conditions. Our findings appear to support a crisis standards protocol which focuses on acute illness severity and only considers underlying conditions carrying a greater than 50% predicted likelihood of 1-year mortality. Modifications to the chronic lung disease, congestive heart failure, and cirrhosis criteria should be refined if they are to be included in future models.