Hyperglycemia and Hypoglycemia Contributions to Acute Respiratory Distress Syndrome

Purpose of Study Non-diabetic COVID-19 patients with elevated admission fasting blood glucose levels ('hyperglycemia') inexplicably have an increased 28 day mortality and higher inhospital complications including the Acute Respiratory Distress Syndrome (ARDS) but potentially contributing blood glucose changes during ARDS development were not reported (Wang S et al: Diabetologia 2020). Our goal was to determine blood glucose alterations before and during acute lung injury development in a rat model used to study ARDS. Methods Used We sequentially evaluated blood glucose levels for 24 hours and lung lavage protein levels (lung permeability) and lung lavage neutrophil numbers (lung inflammation) at 24 hours to assess acute lung injury ('ARDS') in young (~3 month) and old (~12 month) control and a novel strain of hyperoxia surviving 'resistant' rats before and after administering high and low insulin doses and before and after interleukin- 1/lipopolysaccharide (IL-1/LPS) insufflation. Summary of Results Glucose levels increase rapidly and sequentially in young control, but not young resistant, rats peaking ~2 hours after insufflation. Glucose levels also increase in old control and old resistant rats after insufflation compared to young control and young resistant rats after insufflation. The pattern of glucose levels at 2 hours after insufflation resembles lung lavage proteins and neutrophils at 24 h after insufflation (table 1). Administering high insulin (High In) doses decreases glucose levels ('hypoglycemia') and worsens ARDS while administering low insulin (Low In) doses correct glucose levels and improve ARDS. Conclusions Hyperglycemia develops in both young and old rats developing ARDS and high or low glucose levels parallel worse acute lung inflammation and acute lung injury ('ARDS'). Controlling glucose judiciously with insulin may be beneficial in combatting ARDS caused by SARS-CoV-2 infection and other insults.

Comparison of FEV on a remote spirometry device with hospital software in an adult cystic fibrosis cohort

Objectives: The use of digital technology for remote monitoring has increased within CF care in recent years, including the use of remote spirometry. The challenges posed by the COVID-19 pandemic have also meant that delivery of CF care virtually has been required. The NuvoAir platform allows for remote lung function monitoring and is validated for spirometry, however there is no real-world data comparing results to hospital spirometry within an adult CF cohort. FEV1 is an established marker of disease progression within CF. Accurate spirometry results are therefore key in guiding appropriate decision-making. Repeatability of FEV1 and FVC is defined as results being within 150 mls of each other. Methods: FEV1 (L) completed by CF patients at St Bartholomew’s Hospital, on the same day on the NuvoAir Air Next spirometer and SentrySuite Vyaire Medical software, were recorded. Spirometry was completed at either an outpatient review, MDT clinic or during admission. Results were collected between August 2020 and December 2021. Results: A total of 46 sets of results were recorded. The mean difference between FEV1 (L) on the 2 devices was 0.035L (1.6%). The correlation between the FEV1 (L) on the NuvoAir Air Next and SentrySuite was statistically significant (p = 0, r = 0.97). The number of FEV1 results that varied by more than 150mls between devices was 22/46 (47.8%). Conclusion: FEV1 results from the 2 devices showed a statistically significant correlation and a small mean difference. However, as almost half of the sets of results varied by more than is acceptable for determining repeatability, the 2 devices cannot consistently be perceived to be comparable in clinic practice. Further data collection is needed to review the sensitivity to change on the NuvoAir Air Next device compared with hospital spirometry software within a CF cohort.

Wastewater-based epidemiology in hazard forecasting and early-warning systems for global health risks.

With the advent of the SARS-CoV-2 pandemic, Wastewater-Based Epidemiology (WBE) has been applied to track community infection in cities worldwide and has proven succesful as an early warning system for identification of hotspots and changingprevalence of infections (both symptomatic and asymptomatic) at a city or sub-city level. Wastewater is only one of environmental compartments that requires consideration. In this manuscript, we have critically evaluated the knowledge-base and preparedness for building early warning systems in a rapidly urbanising world, with particular attention to Africa, which experiences rapid population growth and urbanisation. We have proposed a Digital Urban Environment Fingerprinting Platform (DUEF) - a new approach in hazard forecasting and early-warning systems for global health risks and an extension to the existing concept of smart cities. The urban environment (especially wastewater) contains a complex mixture of substances including toxic chemicals, infectious biological agents and human excretion products. DUEF assumes that these specific endo- and exogenous residues, anonymously pooled by communities' wastewater, are indicative of community-wide exposure and the resulting effects. DUEF postulates that the measurement of the substances continuously and anonymously pooled by the receiving environment (sewage, surface water, soils and air), can provide near real-time dynamic information about the quantity and type of physical, biological or chemical stressors to which the surveyed systems are exposed, and can create a risk profile on the potential effects of these exposures. Successful development and utilisation of a DUEF globally requires a tiered approach including: Stage I: network building, capacity building, stakeholder engagement as well as a conceptual model, followed by Stage II: DUEF development, Stage III: implementation, and Stage IV: management and utilization. We have identified four key pillars required for the establishment of a DUEF framework: (1) Environmental fingerprints, (2) Socioeconomic fingerprints, (3) Statistics and modelling and (4) Information systems. This manuscript critically evaluates the current knowledge base within each pillar and provides recommendations for further developments with an aim of laying grounds for successful development of global DUEF platforms.

Adapting services during the COVID-19 pandemic – a patient evaluation of physiotherapy telephone reviews within multidisciplinary team virtual clinics

Background: The COVID-19 pandemic forced the evolution of face-to-face cystic fibrosis (CF) multidisciplinary team (MDT) clinics into an entirely remote service. Our virtual clinics included telephone reviews with specialist physiotherapists. Aims: To understand the experiences of our People with CF (PwCF) during their physiotherapy telephone review;to support the collaborative development of our service. Methods: Patient representatives assisted in the development of a user-friendly questionnaire. With patient consent, the questionnaire was distributed via email to patients attending clinics between 28th August–25th September 2020. Results: Of the 142 patients who consented to receiving a questionnaire, 61 (43%) responded. 90% (n = 55) of PwCF were satisfied with their telephone physiotherapy review. 33% (n = 20) of PwCF were not aware they would be called by a physiotherapist. 93% (n = 57) of PwCF found it useful to speak to a physiotherapist, covering the “same (topics) as a face-to-face review.” When stable, some felt a review was not required. PwCF felt good aspects of their review included discussing physiotherapy-related concerns (18%, n = 11) and gaining specialist advice (26%, n = 16). The main area for improvement was providing an allocated appointment time (33%, n = 20). Patient preference for time of call was 26% (n = 16) morning;26% (n = 16) afternoon;49% (n = 29) said call anytime. Conclusions: Feedback was positive for the new entirely remote clinic service. The service now allocates time slots to improve the user experience. Continuing to develop this service with user feedback is an ongoing priority as virtual services will be at the forefront of future CF care.

New type 2 diabetes pilot prevention programme that used gamification and motivating digital technology resulted in increased physical activity levels and an unplanned high BAME uptake and retention rate

Aims: Historically the National Diabetes Prevention Programme (NDPP) has low retention rates which are accentuated in the BAME population. We aimed to design and deliver a fun, alternative type 2 diabetes prevention programme that would have an increased retention rate and increase participant's physical activity levels. The Diabetes Prevention Decathlon (DPD) structured education programme featured;weekly health and well-being workshops and physical activity sessions, gamification and the use of a mobile phone application that incentivised continued physical activity between sessions. Method: An innovation grant awarded the opportunity for collaboration between multiple partners within the NHS, public health, community charities, patient groups, and a digital enterprise. This resulted in the creation of the DPD which was piloted in a deprived South West London borough. The inclusion criteria for participants included a HbA1c between 42 and 47 mmol/mol (6.0-6.4%), indicative for non-diabetic hypoglycaemia. Referrals, retention rates, weight loss and physical activity data were recorded over the ten-week programme alongside key demographic markers. Results: With an 87% completion rate (n31), 39 kg group weight loss and 40% increase in activity levels, the programme yielded excellent results compared to the NDPP. Semi-structured interviews highlighted the importance of group interactions and regular opportunities to be physically active. Positive but unplanned outcomes were the high BAME uptake of 77% and subsequent retention 67%, and covid driven agile conversion to virtual delivery. Conclusions: The DPD successfully piloted a new and fun approach to diabetes prevention with further intentions to work with local communities to increase and improve BAME resources.

COVID-19 Cliff Notes: A COVID-19 Multidisciplinary Care Compendium.

As we pass the nearly 9 month mark of the coronavirus virus disease 2019 (COVID-19) pandemic in the United States, we sought to compile a brief multi-disciplinary compendium of COVID-19 information learned to date. COVID-19 is an active viral pandemic caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) that confers high morbidity and mortality. COVID-19 has been associated with: pulmonary compromise and acute respiratory distress syndrome, thrombotic events, inflammation and cytokine, and post-infectious syndromes. Mitigation of these complications and expeditious therapy are a global urgency; this is brief summary of current data and management approaches synthesized from publications, experience, cross-disciplinary expertise (Figure 1).

Clinical predictors of donor antibody titre and correlation with recipient antibody response in a COVID-19 convalescent plasma clinical trial.

BACKGROUND: Convalescent plasma therapy for COVID-19 relies on transfer of anti-viral antibody from donors to recipients via plasma transfusion. The relationship between clinical characteristics and antibody response to COVID-19 is not well defined. We investigated predictors of convalescent antibody production and quantified recipient antibody response in a convalescent plasma therapy clinical trial. METHODS: Multivariable analysis of clinical and serological parameters in 103 confirmed COVID-19 convalescent plasma donors 28 days or more following symptom resolution was performed. Mixed-effects regression models with piecewise linear trends were used to characterize serial antibody responses in 10 convalescent plasma recipients with severe COVID-19. RESULTS: Donor antibody titres ranged from 0 to 1 : 3892 (anti-receptor binding domain (RBD)) and 0 to 1 : 3289 (anti-spike). Higher anti-RBD and anti-spike titres were associated with increased age, hospitalization for COVID-19, fever and absence of myalgia (all P < 0.05). Fatigue was significantly associated with anti-RBD (P = 0.03). In pairwise comparison amongst ABO blood types, AB donors had higher anti-RBD and anti-spike than O donors (P < 0.05). No toxicity was associated with plasma transfusion. Non-ECMO recipient anti-RBD antibody titre increased on average 31% per day during the first three days post-transfusion (P = 0.01) and anti-spike antibody titre by 40.3% (P = 0.02). CONCLUSION: Advanced age, fever, absence of myalgia, fatigue, blood type and hospitalization were associated with higher convalescent antibody titre to COVID-19. Despite variability in donor titre, 80% of convalescent plasma recipients showed significant increase in antibody levels post-transfusion. A more complete understanding of the dose-response effect of plasma transfusion amongst COVID-19-infected patients is needed.

Pregnant womenʼs concerns and antenatal care during covid-19 lock-down of the danish society

INTRODUCTION: Pandemics are known to cause stress and anxiety in pregnant women. During the coronavirus disease 2019 (COVID-19) lockdown of the Danish society, pregnant women were considered to be at increased risk, and access to antenatal care changed. METHODS: On 8 April 2020A, a questionnaire was sent to 332 pregnant women previously sampled by general practitioners in two Danish regions. The women were contacted via secured e-mail (e-Boks), and questionnaires were returned until 6 May. RESULTS: The questionnaire was returned by 257 women (77%). More than half believed that they were at a high risk of infection with COVID-19, and a third of the women were concerned about the risk of serious disease – especially for their unborn child. Almost 90% isolated at home most of the time. The majority were worried about possible consequences of the pandemic for antenatal care, but very few had actually missed a scheduled preventive consultation with their general practitioner, and only 15% had missed an appointment with their midwife. The majority of the women preferred normal consultations and found no added safety in shifting the consultation from the normal clinical setting. CONCLUSIONS: The COVID-19 pandemic and lockdown have had a major impact on Danish pregnant women. Even so, concerns were more focused on access to care than on the risk of COVID-19 infection. Contacts with the antenatal healthcare system have only been moderately affected. © 2020, Almindelige Danske Laegeforening. All rights reserved.

Is SARS-CoV-2 (COVID-19) postviral olfactory dysfunction (PVOD) different from other PVOD?

BACKGROUND: The SARS-CoV-2 virus continues to spread rapidly across the globe afflicting many with Coronavirus Disease 2019 (COVID-19). As the infection rates rise, a growing number of SARS-CoV-2 positive individuals have been reported to complain of olfactory disturbances at an alarming rate. Postviral olfactory dysfunction (PVOD) is a well-known phenomenon that may explain the olfactory dysfunction reported by SARS-CoV-2 infected individuals. METHODS: A scoping literature review was performed to identify studies that investigated the mechanisms of postviral olfactory dysfunction. Studies demonstrating pathophysiological, histological, immunochemical, and epidemiological outcomes of PVOD were included. RESULTS: Fourteen studies were included in addition to one international news article. Three studies reported destruction of the olfactory epithelium following intranasal inoculation of various viral strains in mice. Three studies isolated pathogenic, anosmia inciting viruses (Parainfluenza virus, Human Coronavirus, Rhinovirus) through nucleic acid amplification. Eleven studies demonstrated female predilection in patients with PVOD and COVID-19 associated olfactory dysfunction, of which the majority were over 50 years old. CONCLUSIONS: PVOD and COVID-19 associated olfactory dysfunction demonstrates considerable similarities in epidemiological trends and disease sequela of other viruses to suggest identical pathophysiological mechanisms. Further studies such as intranasal inoculation and histological biopsies are needed to support our hypothesis.

Colon capsule endoscopy: an innovative method for detecting colorectal pathology during the COVID-19 pandemic?

AIM: The coronavirus pandemic has led to significant challenges for healthcare delivery across the globe. Non-emergency endoscopic activity in the UK has been postponed, raising concerns of increased delays in the diagnosis of colorectal cancer and a surge in demand once services resume. Measures to mitigate this risk must be considered. METHOD: This paper reviews various investigative modalities for colorectal disease which could be deployed during cessation of colonoscopy services. We focus on colon capsule endoscopy (CCE) due to its relevance during the COVID-19 pandemic and its ability to triage patients effectively to further endoscopic investigations. RESULTS: CT of the abdomen and pelvis has been suggested as a triage tool while access to colonoscopy is limited. However, CT may lead to the spread of COVID-19 as patients attend the hospital, and it exposes them to the risks of radiation. Faecal immunochemistry tests have been demonstrated as a good predictor of colonic pathology and could be safely used to risk stratify patients when prioritizing colonoscopy. CCE is a safe and innovative technology for investigating the colon. Procedures can be carried out in the community and can be conducted safely during the coronavirus pandemic. It has been shown to be an accurate detector of colonic neoplasia and can reduce demand for colonoscopy. CONCLUSION: As colonoscopy services resume, they will probably experience high demand leading to further delays for patients. CCE could be used to reduce the number of patients requiring colonoscopy and triage those requiring further endoscopic investigations appropriately.