Covid-19 Vaccine-Induced Myositis

Background/Aims Through the COVID pandemic there have emerged reports of autoimmunity or new rheumatic diseases presenting in patients after they had COVID-19. This is thought to be caused by cross-reactivity of the COVID-19 spike protein to human antigens. Given the use of mRNA COVID-19 vaccinations which express the spike protein we might expect to see presentation of new rheumatic diseases following their use. We discuss a case where this appears to have occurred. Methods Our patient is a 24-year-old male with mixed phenotype acute leukaemia who had been treated with allogenic stem cell transplant and was currently in remission. He presented with fevers, palpitations, myalgia and bilateral arm and leg swelling. Symptoms began the day after receiving the first dose of an mRNA COVID-19 vaccination (Pfizer/BioNTech.) There were no other symptoms or recent change in medications. Physical examination revealed tender oedema in his forearms, biceps and thighs bilaterally with sparring of the hands. He had reduced power with shoulder (MRC 3/5), elbow (4), wrist (4+) and hip (4) movements. Observations revealed tachycardia and fevers up to 40C. Results Laboratory studies showed markedly elevated C-reactive protein (202), creatinine kinase (6697) and troponin (593) whilst investigations for infection were negative. An autoimmune panel was positive for anti- PM-SCL-75-Ab. An electrocardiogram showed sinus tachycardia. Echocardiogram was normal. Bilateral upper limb dopplers revealed no deep vein thrombus. An MRI of his thighs showed diffuse symmetrical oedema within the muscles, in keeping with an inflammatory myositis. A quadricep muscle biopsy showed evidence of MHC class 1 up-regulation, suggesting an inflammatory process. In addition, there were numerous macrophages evident in the endomysium. While this can be seen in graft-versus-host disease (GVHD), they would usually be found in the perimysium. After discussion between haematology, rheumatology and neurology, this was felt to be a case of vaccine induced myositis and myocarditis. Autoimmune myositis was thought to be less likely due to the relative sparing of the hands and the absence of Raynaud's phenomenon. 1 gram of intravenous methylprednisolone was then given for 3 days. The patient had a marked response with defervescence, improving laboratory markers, improved myalgia and decreased limb swelling. The patient was stepped down to a reducing regime of prednisolone and discharged. Due to relapse whilst weaning he has started on mycophenalate mofetil and rituximab and now continues to improve. Conclusion There are case reports of myositis following COVID-19 vaccination but our patient's case is complicated by the differential diagnosis of GVHD and concurrent myocarditis. Ongoing work is needed to clarify the exact link between vaccination and the presentation of a new inflammatory myositis, but it is important to recognise and start treatment early in order to preserve muscle bulk and ensure recovery.

Using high-frequency household surveys to describe energy use in rural North India during the COVID-19 pandemic

COVID-19 continues to exact a substantial toll on health. While mortality and morbidity associated with the pandemic are the most obvious impacts, social and economic disruptions are becoming apparent. There is reason to believe that the COVID-19 pandemic has slowed or reversed gains in clean household energy use in rural India. Here we describe phone surveys deployed repeatedly in Jharkhand and Bihar to describe pandemic-related changes in household socio-economic conditions and energy-use patterns. Over three-quarters of households reported hardships during the pandemic, including loss of employment and an inability to search for jobs. In turn, some of these households relied more on polluting fuels. Despite nearly all households preferring gas and electricity, we observed varied behaviours related to the cost of and access to these modern energy sources. We highlight the success of India's three-free-cylinders scheme, with 90% of households aware of the programme and utilizing at least one free cylinder. These findings illustrate the utility of high-frequency energy-related questionnaires and suggest that interventions to improve clean fuel accessibility and affordability can increase the resilience of transitions to clean household energy. © 2023, The Author(s).

CAREGIVER TLC: A VIRTUAL PSYCHOEDUCATIONAL PROGRAM FOR CAREGIVERS: BASELINE PRELIMINARY DATA

Family caregivers are at increased risk for negative impacts on their psychological and physical health compared to non-caregivers. Virtual caregiving programs are beneficial as caregivers may not have time to devote to face-to-face programs and especially important to caregivers in the context of the COVID-19 pandemic. Our team at the University of North Carolina at Charlotte is testing the efficacy of the Caregiver Thrive, Learn & Connect Virtual Program adapted from the Coping with Caregiving evidence-based multicomponent intervention (Gallagher-Thompson et al., 2003). The program offers to registered caregivers six weekly sessions over Zoom teleconferencing in small groups led by trained professionals from community partners serving socio-demographically diverse caregivers. Sessions address stress management, mood management, resilience, self-care, coping strategies, and isolation. Preliminary baseline data on 42 participants indicates that caregivers are primarily female (87%), on average 64 years old, and from diverse racial backgrounds: white (69%), African American (29%) and Asian American (2%). Participants provide care to persons with memory troubles or dementia (66%) and chronic health conditions (34%). Baseline data on initial levels of caregivers' psychosocial outcomes indicated salient levels of mental health outcomes for burden (high = 49%;mild = 35%);anxiety (moderate = 16%;severe = 20%) and depression (mild levels = 35%;moderately and severe level of depression = 33%). Caregivers for chronic health conditions reported significantly higher anxiety compared to dementia caregivers. The Caregiver TLC program offers support to the targeted caregiver population seeking to improve their level of competence, mental health and social isolation.

Co-curricular Engagement of Transfer Students

This is a work-in-progress in the Research category investigating transfer student participation in co-curricular activities. Transfer students at 4-year universities are often considered as secondary-priority students. In this paper, we investigate engineering transfer student participation in co-curricular activities at a predominantly undergraduate polytechnic university. Survey results from Cal Poly in San Luis Obispo, a primarily undergraduate institution on participation in co-curricular activities is presented. We discuss the impact of the COVID pandemic on the survey results, showing that the pandemic has severely decreased participation in co-curricular activities for all students. Survey results also demonstrate a correlation between students to participate in significant co-curricular activities are greater than 20% more likely to attain major-related summer internships than students who do not. Finally, we discuss barriers to co-curricular participation for transfer students, and how the COVID pandemic has impacted this group of students differently than first-time-first-year students. © 2022 IEEE.

CHANGES IN RURAL AND URBAN FAMILY CAREGIVING NETWORKS IN THE MIDWEST DURING THE COVID-19 PANDEMIC

This study elucidates the changes in family caregiving networks during the COVID-19 pandemic and its implications on caregiver well-being. Eighty-two caregivers of individuals diagnosed with dementia within the past 2 years participated in this study to test a post-diagnosis intervention that provides a community care planning service that connects caregivers directly to community-based services. Caregivers completed telephone surveys at baseline and 3- and 6-month follow-up. The number of network members engaging in malfeasant (negative) social interactions increased by 0.798 every 3 months (p=0.002). Members engaging in uplifting interactions decreased, especially among intervention participants, by 1.93 every 3 months (p=0.047);urban caregivers reported greater decrease than rural (p=0.006). Participants in intervention group showed a trend for greater decrease in COVID-19 related distress (10-point scale) over time compared to control group (p=0.059);those with more members engaging in uplifting interactions reported lower distress (p=0.017) regardless of intervention status, network size, and rurality.

Comparison of SARS-CoV-2 spike antibody quantitative titer reporting using the World Health Organization International Standard Units by four commercial assays.

The accurate measurement of serological response to SARS-CoV-2 vaccination is needed to correlate responses with effective protective immunity. The World Health Organization (WHO) has created an international standard to allow harmonization of immune response assessment to an arbitrary unit across different commercial assays; however, the accuracy of reporting of SARS-CoV-2 spike antibody titers in international standard units (BAU or IU/mL) from commercial assays is not well studied. Here, we report the performance comparison of four quantitative commercial assays testing for SARS-CoV-2 spike immunoglobins using the WHO's international standard. Sera, EDTA-plasma and heparinized plasma collected from individuals who are vaccine naïve or received BNT162b2 (Pfizer/BioNTech), mRNA-1273 (Moderna) or ChAdOx1-S (Oxford-AstraZeneca) were tested using Abbott Architect AdviseDx SARS-CoV-2 IgG II, DiaSorin LIAISON SARS-CoV-2 TrimericS IgG, Roche Elecsys Anti-SARS-CoV-2 S and GenScript cPass SARS-CoV-2 surrogate virus neutralization assays. The sensitivities ranged from 90% to 100%, and specificities from 88% to 100%. These four assays had excellent agreement (0.79-0.93) and correlation (0.87-0.97); however, Passing-Bablok regression analysis indicated that data generated by these assays were not comparable. Our data suggests that natural SARS-CoV-2 infection elicited a greater antibody response compared to vaccines, evident by a significantly higher neutralizing antibody titer in unvaccinated individuals who seroconverted.

INNOVATIVE USE OF TELEHEALTH TO MANAGE COVID-19 INFECTED OUTPATIENTS BY A VETERANS HEALTH CARE CENTER

STATEMENT OF PROBLEM/QUESTION: In the spring of 2020 during the initial outbreak of COVID-19, the Rocky Mountain Regional VA (RMR) was tasked with ensuring the health of infected veterans. The RMR COVID-19 Telehealth Clinic was developed to support veterans in the community diagnosed with COVID-19, identify those with clinical deterioration requiring a higher level of care, and encourage appropriate isolation protocols. DESCRIPTION OF PROGRAM/INTERVENTION: Patients were stratified by risk factors (obesity, CHF, DM, cancer, CAD, HTN, age > 64) and clinical status into 3 tiers, with high-risk (Tier 3) receiving daily telehealth, moderate-risk (Tier 2) telehealth every other day, and low-risk (Tier 1) telehealth every three or more days. Providing care seven days a week, Tier 1 veterans were contacted by nurses and advanced practitioners, while Tier 2 and 3 veterans were managed predominantly by resident physicians and attendings, who provided clinical care for exacerbations of chronic disease as well as comprehensive care of COVID-19 infection. Hypoxic patients were provided oxygen and closely monitored with pulse oximeters. MEASURES OF SUCCESS: Between April 13 to October 5, 2020, 351 veterans testing positive for COVID-19 were followed. Thirty-eight were excluded (26 were outside study dates, 7 covid negative, 5 never received care). Charts for the remaining 313 patients were retrospectively evaluated for demographic data, comorbid conditions, duration of follow-up, and interventions provided, including prescribing and managing medications, referrals for emergency services, and escalating tiers. FINDINGS TO DATE: Of the cohort, 88% were male, 43% obese, 34% over age 64, 40% HTN, and 27% DM. Veterans were followed for 10.4 days on average. Approximately 54% were assigned to Tier 1, 29% to Tier 2, and 16% to Tier 3. Medications were prescribed for 45% and 27% of Tier 3 and Tier 2 patients respectively, and emergency care was advised for 22% and 20% of Tier 3 and Tier 2 veterans. Of Tier 1 patients, medications were ordered on 5%, emergency care recommended for 3%, and only 7% were escalated to Tier 2. Of the five deaths that occurred, two were directly attributed to COVID-19. KEY LESSONS FOR DISSEMINATION: A dedicated telehealth clinic for veterans with Covid-19 appropriately identified patients into low, moderate, and high-risk categories based on risk factor assessment. Low-risk patients were safely followed with intermittent telehealth emphasizing self-care and isolation, avoiding unnecessary Emergency Department visits. More frequent monitoring of symptoms and pulse oximetry in moderate to high-risk patients facilitated identification of patients with clinical deterioration requiring emergency evaluation and avoiding admissions for at-risk clinically stable patients. Tiered management resulted in judicious utilization of health care resources during a critical time marked by scarcity of hospital beds and personal protective equipment.

Microglia Do Not Restrict SARS-CoV-2 Replication following Infection of the Central Nervous System of K18-Human ACE2 Transgenic Mice

Unlike SARS-CoV-1 and MERS-CoV, infection with SARS-CoV-2, the viral pathogen responsible for COVID-19, is often associated with neurologic symptoms that range from mild to severe, yet increasing evidence argues the virus does not ex-hibit extensive neuroinvasive properties. We demonstrate SARS-CoV-2 can infect and replicate in human iPSC-derived neurons and that infection shows limited antiviral and inflammatory responses but increased activation of EIF2 signaling following infection as determined by RNA sequencing. Intranasal infection of K18 human ACE2 transgenic mice (K18-hACE2) with SARS-CoV-2 resulted in lung pathology associated with viral replication and immune cell infiltration. In addition, similar to 50% of infected mice exhibited CNS infection characterized by wide-spread viral replication in neurons accompanied by increased expression of chemokine (Cxcl9, Cxcl10, Ccl2, Ccl5 and Ccl19) and cytokine (Ifn-lambda and Tnf-alpha) transcripts associated with microgliosis and a neuroinflammatory response consisting primarily of monocytes/macrophages. Micro-glia depletion via administration of colony-stimulating factor 1 receptor inhibitor, PLX5622, in SARS-CoV-2 infected mice did not affect survival or viral replication but did result in dampened expression of proinflammatory cytokine/chemokine transcripts and a reduction in monocyte/macrophage infiltration. These results argue that microglia are dispensable in terms of controlling SARS-CoV-2 replication in in the K18-hACE2 model but do contribute to an inflammatory response through expression of pro-inflammatory genes. Collectively, these findings contribute to previous work dem-onstrating the ability of SARS-CoV-2 to infect neurons as well as emphasizing the potential use of the K18-hACE2 model to study immunological and neuropathological aspects related to SARS-CoV-2-induced neurologic disease. IMPORTANCE Understanding the immunological mechanisms contributing to both host defense and disease following viral infection of the CNS is of critical importance given the increasing number of viruses that are capable of infecting and replicating within the nervous system. With this in mind, the present study was undertaken to evaluate the role of microglia in aiding in host defense following experimental infection of the central nervous system (CNS) of K18-hACE2 with SARS-CoV-2, the causative agent of COVID-19. Neurologic symptoms that range in severity are common in COVID-19 patients and understanding immune responses that contribute to restricting neurologic disease can provide important insight into better understanding consequences associated with SARS-CoV-2 infection of the CNS.

PIMS-TS: Neurological, quality of life and adaptive functioning outcomes and associated factors

Background: Paediatric multisystem inflammatory syndrome temporally associated with SARS-CoV-2 (PIMS-TS) causes prolonged hospitalisation and morbidity. The longer term neurological and health outcomes in children following PIMS-TS are largely unknown. Methods: In this single-institution study, we evaluated the domains of daily living, physical, emotional, and quality of life outcomes at 6 months following PIMS-TS. Data were collected by telephone questionnaire interviews with parents and children and also using standardized assessment tools -PedsQL-Multidimensional Fatigue Scale, and Paediatric Symptom Checklist (PSC). Results: Data were obtained from 81 children admitted with PIMS-TS between April and August 2020. 49 were males (60%) and 52 (63%) non-white. Median age was 9 years (8-17 years) with length of stay of 6 days (range 1-22 days). Prior to discharge, 34 children (42%) had difficulties with activities of daily living whereas only 5 (6%) persisted on 6 months follow up. Exercise intolerance/mobility difficulty was observed in 40 children (9%) at discharge compared to 20 (25%) 6 months later. Predictors associated with difficulty in exercise tolerance/mobility were obesity (OR=4.0;95% CI: 1.1-13.7;p=0.03) and older age (OR=1.1;95% CI: 0.99-1.3;p=0.086). Inflammatory markers on admission (CRP, fibrinogen, D-dimer and ferritin) did not correlate with worse outcome at follow-up nor did sex and length of stay. The PedsQL-Multidimensional Fatigue Scale revealed a median score of 94 (IQR: 83-100) indicating an overall average range quality of life. The PSC were in line with population prevalence of behavioural/emotional difficulties: 10% had difficulties with attention;7% and 4% of patients had internalizing and externalizing difficulties, respectively Conclusion: Overall, patients with PIMS-TS have good short-term outcomes at 6 months with respect to daily functioning, quality of life, and behaviour. One in four had some difficulty with mobility/pain requiring rehabilitation, with main risk factors being obesity and older age. Further studies are required to evaluate long-term sequelae.

Navigating COVID-19: Preparing medical students in a time of pandemic

AFRICAN DEVELOPMENT Abstract: The COVID-19 pandemic has resulted in an upheaval in health sciences education. Globally, training of medical students on university campuses and clinical platforms was suspended and rapidly transitioned to online learning. In some countries, graduation of senior medical students was expedited in order to contribute to a health workforce in crisis. The transition to online learning has been particularly challenging in low- and middle-income countries where access to remote learning opportunities is limited for some students and further widens societal inequities. The pandemic, however, also provides an opportunity to re-imagine clinical learning and develop innovative ways to strengthen the clinical training platform and health system

Does asthma control change when patients transition to home administration of mepolizumab?

Introduction: Mepolizumab is a biologic agent targeting interleukin (IL)-5 which is currently licensed as add-on therapy for severe eosinophilic asthmatic (SEA). It is usually administered in a hospital setting but with the option of homecare being introduced in 2019, the 4-weekly subcutaneous injections can be self-administered at home. We investigated whether there was a change in asthma control following the transition to home administration and whether a differential response to treatment exists following transition to homecare before and after the onset of the COVID-19 pandemic. Methods: Patients receiving mepolizumab via home care were stratified according to those who had a planned transition to homecare prior to 1st Feb 2020 versus those who had an unplanned transition after this date necessitated by the COVID-19 pandemic. The last Asthma Control Questionnaire-6 (ACQ6) measured in clinic ('baseline') was compared with that collected by telephone consultation 6-8 weeks after transition ('homecare'). Patients were excluded if both values were not available. Results: Of 87 mepolizumab patients included in the analysis, 46 were planned transitions. There was no significant (Figure presented) difference in the pre-biologic ACQ6 (p=0.07) between groups. Immediately prior to transition to homecare (baseline), the planned group had a lower mean ACQ6 than those in the unplanned group (1.19 vs 1.90, P=0.004). The ACQ6 on homecare decreased significantly in both groups (-0.47 in the planned group vs -0.56 in the unplanned group, both P<0.001). The ACQ6 for the planned cohort during homecare was significantly lower than that for the unplanned group (0.72 vs 1.34, P=0.012) (figure 1). (Table presented) Conclusions: We found a significant improvement in ACQ6 for all SEA patients established on Mepolizumab who transitioned to home mepolizumab administration. This improvement occurred irrespective of whether the transition was 'planned' or 'unplanned'. Further research is required to understand the potential influence of shielding during lockdown and the method of ACQ assessment (telephone vs face-to-face ACQ reporting in clinic) on this improvement.

Does asthma control change following transition to home benralizumab administration?

Introduction: The COVID-19 pandemic necessitated the rapid transition of large numbers of patients onto homecare to facilitate on-going therapy in a cohort of patients who were 'shielding'. Alongside this, patients continued to need to be initiated on biologic therapy in spite of the pandemic. The impact of administering biologic therapy at home is largely unknown, yet crucial to optimise patient outcome and minimise steroid burden. We investigated whether there was a differential response following transition to homecare of established patients versus those newly started. Methods: Patients with severe eosinophilic asthma receiving home benralizumab were stratified according to those who had received ≥3 doses prior to COVID-19 lockdown on the 15th March 2020 ('established' patients) versus those who were initiated after this date ('new' patients). We compared the last Asthma Control Questionnaire-6 (ACQ6) measured in clinic with that collected by telephone consultation 8-12 weeks after transition to homecare. Patients were excluded if both values were not available. Results: 246 benralizumab patients were included in the analysis, of whom 49 (20%) were new. There was no significant difference in pre-biologic ACQ6, pre-homecare (baseline) (Figure presented) ACQ6 or post-homecare ACQ6 between the new and established patient groups. Both cohorts exhibited a similar magnitude of improvement in their ACQ6 following the transition to homecare (-0.73 in the established group vs -0.73 in the new group, both P<0.0001) (figure 1). Conclusions: We have demonstrated that early transition to homecare in patients treated with benralizumab is not associated with worse clinical outcomes as assessed by ACQ6. The improvements in ACQ6 were seen irrespective of whether they were 'established' on therapy at time of transition or 'new'. Further research is required to understand the potential influence of lockdown and/or telephone vs face-to-face ACQ reporting.

The adaptive moral challenge of COVID-19

This author offers of narrative of hope in response to the coronavirus pandemic by viewing it as a wake-up call to lean into the adaptive moral challenge of stewardship for the future of humanity and the planet. Acknowledging the many material and social benefits of a global regime of free market urbanism built on advances in science and technology, this is a point in geohistory, the Anthropocene, when the impact of human activities on the Earth has begun to outcompete natural processes. The coronavirus has illuminated systemic moral failures and new moral challenges of the Anthropocene that call for adaptive response if we are to build a hopeful future for humanity and the planet. Pointing to millennia of human adaptive response to threats and disasters, the author asserts an evolutionary hardiness attributable as much to moral capacities as rational intelligence as a singularly defining trait fueling millennia of human adaptive learning and thrival. The current pandemic is the latest point in humanity’s moral evolution of adaptive response to moments of urgent threat that have tested, expanded, and defined our character and moral capacities as a species. Rather than falter under the moral burden of the coronavirus threat and its consequences, the author views this pivotal point as an opportunity to stretch human moral horizons by taking responsibility for the urgent moral challenges we have created and inventing new ethical frameworks and tools that will lead us to new moral understandings and solutions to the moral challenges we face. © 2021, The Author(s), under exclusive licence to Springer-Verlag GmbH, DE part of Springer Nature.

How will the psychological impact of Covid-19 affect different personality types?

Covid-19 has had an impact on everyone in extremely different ways;understanding this, and subsequently approaching everyone's challenges individually, is the starting point to getting your team back on track.