ON A JOURNEY INTO THE UNKNOWN: Critical Care Pedagogy, COVID, and Teacher Education

In this chapter, the authorial team reflects on caring classroom practices during and after the COVID-19 pandemic. Through their reflection, they consider the question: Why should we-and how can we-enact a critical care pedagogy within teacher education programs now and into the future? This chapter addresses how the redesign of coursework should institutionalize caring classroom practices and what specific classroom practices can be used to center critical care pedagogy. The chapter concludes by questioning how teacher educators might institutionalize these practices in colleges of education. © 2023 selection and editorial matter, Melanie Shoffner and Angela W. Webb;individual chapters, the contributors.

Risk Factor Analysis for Hospital Admission Following Severe Acute Respiratory Syndrome Coronavirus-2 (SARS-CoV-2) Monoclonal Antibody Treatment

Background. The FDA has issued emergency use authorization (EUA) for neutralizing monoclonal antibodies (mAb) for the treatment of mild-moderate coronavirus disease 2019 (COVID-19) in patients who are at high risk of disease progression. The EUA allows for COVID-19 mAb infusion to occur up to 10 days from symptom onset and due to logistics, mAb treatment typically occurs later in this 10 day window. Efficacy of early versus late mAb treatment is unknown Methods. In this single center, retrospective case-control study, we performed a risk factor analysis of patients with mild COVID-19 infection treated with mAb on the composite outcome of subsequent evaluation in the Emergency Department (ED) or inpatient admission December 2020 through May 2021. Multivariate analysis of variables found to be significant in univariate analysis was performed using STATA 15 statistical software Results. Two-hundred eighty-eight patients who received mAb treatment were included in analysis. The mean age was 58.6 years and 59.7% were female, 64.9% white, and 27.1% African American. Following mAb infusion, 31 (10.8%) had disease progression resulting in an ED encounter or inpatient admission. Patients who received early (days 1-5 of symptoms) mAb infusion were less likely to have progressive disease than patients with late (days 6-12 of symptoms) infusion;(6.1% vs 13.2%;P= 0.048). Zero of 21 patients who received mAb infusion on day 1-3 of symptoms had disease progression. Patients with CHF (7.4% vs 19.4%;P=0.038), cirrhosis (9.3% vs 25.8%;p=0.012), CKD (12.5% vs 35.5%;p=0.001) and hypertension (70.8% vs 90.3%;p=0.021) were more likely to have disease progression. There were no differences in sex, race, BMI, or symptoms between groups. Multivariate analysis revealed cirrhosis (OR 3.0;95% CI 1.1-7.9) and CKD (OR 2.6;95% CI 1.0-6.4) increased risk of disease progression while early mAb infusion was protective (OR 0.38;95% CI 0.14-1.0) Conclusion. Infusion of mAb for the treatment of mild to moderate Covid-19 within 5 days of symptom onset reduces rate of disease progression compared to delayed (day 6-12 of symptoms) infusion. This finding was significant when controlling for comorbidities. Efforts should be made to infuse high risk patients with COVID-19 mAb therapy within 5 days of symptom onset.

COVID-19 COMPLICATED BY THE INVASION OF ASPERGILLUS TERREUS

TOPIC: Chest Infections TYPE: Medical Student/Resident Case Reports INTRODUCTION: Coronavirus associated pulmonary aspergillosis (CAPA) appears to be emerging on a global scale. Studies have consistently indicated that CAPA is associated with significantly higher mortality rates, when compared to patients with COVID-19 alone [1]. Unfortunately, definitive guidelines regarding the surveillance, diagnosis, & treatment of CAPA are currently lacking. CASE PRESENTATION: A 59 year old male with hypertension & diabetes presented with dyspnea & cough. On arrival, he was initially afebrile, though hypoxic & tachycardic. He tested positive for COVID-19 & influenza B on admission. Dexamethasone & remdesivir were initiated, along with oseltamivir & empiric antibiotics. CT of the chest was notable for bilateral ground glass opacities. On hospital day 11, he developed respiratory failure on BiPAP therapy, prompting intubation & ICU transfer. He subsequently succumbed to septic shock requiring hemodynamic support. Given concern for bacterial superinfection, antibiotic therapies were escalated. Despite the initial defervescence, he continued to have persistent febrile recrudescence. Blood & sputum cultures remained negative. He ultimately required tracheostomy and PEG tube placement. On day 38, his lower respiratory culture revealed growth of Aspergillus terreus. Voriconazole was initiated. On day 43, his fever returned again. Repeat CT of the chest revealed progressive fibrosis, with a cavitation in the right lower lung. He remained ventilator dependent, given his persistently high FiO2 requirements. On day 52, he became markedly hypoxemic with copious mucoid secretions, prompting emergent bronchoscopy. Despite clearance, he eventually became bradycardic & developed PEA arrest. The patient ultimately expired. DISCUSSION: CAPA remains a diagnostic challenge, fraught by logistical burdens & a variety of crudely defined criteria. Cases may currently be underreported, undertreated, or clinically overlooked. Obscure species such as A. terreus are of particular concern, given the proposed lethality of this strain & it's widely reported resistance to amphotericin B [3]. Unfortunately, guidelines for the surveillance of superinfections are currently insufficient. This is troublesome, considering the well documented risk of invasive pulmonary aspergillosis with the use of immunosuppressive agents, such as tocilizumab & corticosteroids [2]. Co-infection with influenza may augment this risk further. CONCLUSIONS: CAPA presents clinicians with a multitude of clinical uncertainties, which necessitate further analysis & investigation. Given the heightened risk of mortality, we propose a lower threshold for the suspicion, diagnosis & treatment of CAPA in patients with refractory respiratory distress, and/or febrile recrudescence despite the appropriate therapies. Surveillance should be particularly stringent, in those treated with immunosuppressive agents, or concomitantly diagnosed with influenza. REFERENCE #1: Apostolopoulou A, Esquer Garrigos Z, et al. Invasive Pulmonary Aspergillosis in Patients with SARS-CoV-2 Infection: A Systematic Review of the Literature. Diagnostics. 2020;10(10):807. REFERENCE #2: Koehler, P., Bassetti, M, et al. Defining and managing COVID-19-associated pulmonary aspergillosis: the 2020 ECMM/ISHAM consensus criteria for research and clinical guidance. The Lancet. Infectious diseases. 2020, Dec 20 REFERENCE #3: Steinbach, W, Benjamin, D, et al. Infections Due to Aspergillus terreus: A Multicenter Retrospective Analysis of 83 Cases, Clinical Infectious Diseases, Volume 39, Issue 2, 15 July 2004, Pages 192–198 DISCLOSURES: No relevant relationships by Huda Asif, source=Web Response No relevant relationships by Sunil Bali, source=Web Response No relevant relationships by Christopher Siriphand, source=Web Response No relevant relationships by Christopher Wood, source=Web Response

Asymptomatic COVID-19 in the elderly: Dementia and viral clearance as risk factors for disease progression

Rationale SARS-CoV-2 infected individuals elders have the highest hospitalization rates and represent >80% fatalities. However, most infected seniors remain asymptomatic and never progress to experience severe disease. Among those without symptoms, the rate of pre-symptomatic illness is unclear and potential predictors of progression are unknown. Our objective was to delineate the natural evolution of asymptomatic SARS-CoV-2 infection and identify determinants of progression to symptomatic illness. Methods We established a medical surveillance team monitoring 63 geriatric institutions in Buenos Aires between June and July 2020. When an index COVID-19 case emerged in one of these residencies, we tested all other eligible participants for SARS-CoV-2. Participating seniors were asymptomatic individuals ≥75 years of age, or between 65-74 years with ≥1 comorbidity. SARS-CoV-2 infected, asymptomatic elders were followed daily for 28 days by a medical team using pre-designed questionnaires. Disease was diagnosed when any COVID-19 manifestation occurred within 14 days of SARS-CoV-2 detection. SARS-CoV-2 load at enrollment and shedding on day 15, and antibody responses at the end of study participation were also studied. Results 113 asymptomatic SARS-CoV-2-infected elderly participated in the study. After 28 days of follow up, 75(66%) elders remained asymptomatic. In 38(34%) presymptomatic patients, median time to onset of symptoms was 3 days(IQR 5). 20/38(56%) pre-symptomatic patients developed hypoxemia, a presenting sign in 10/20(50%). Ten pre-symptomatic patients [26%;10/113(9%)] died(median day 14, IQR 12). Dementia was the only clinical risk factor associated with disease (OR 2.36(95%CI 1.05 to 5.29);P=.036;Table 1). PCR mean cycle threshold was similar in both groups at the time of enrollment. SARS-CoV-2 RT-PCR re-testing on day 15(IQR 1) was detectable in 61% of pre-symptomatic vs. 30% asymptomatic subjects(P=.012). Anti-S SARS-CoV-2 IgM and IgG assays on day 28 detected similar rates of antibody seropositivity in both groups (Table 1). Conclusion Our findings suggest that disease inception and disease progression may be driven by different pathogenic pathways. Dementia was the sole baseline difference potentially predicting progression to symptomatic disease in our study. Other comorbidities associated with progression from mild to severe symptoms did not affect the odds of experiencing pre-symptomatic illness. Evolution to symptomatic disease associated with longer viral shedding, suggesting that control of viral replication may influence symptom inception. In summary, dementia and persistent SARS-CoV-2 shedding associated with progression from asymptomatic to symptomatic infection in elders. These observations suggest that the mechanistic pathway to experiencing disease symptoms differs from the pathways determining severity in COVID-19.

Reactivation mycobacterium tuberculosis associated acute respiratory distress syndrome following COVID-19 infection

Introduction: Acute respiratory distress syndrome (ARDS) is rare sequela of Mycobacterium tuberculosis (MTb) associated with miliary MTb in setting of immunosuppression. To date, five cases have been reported with MTbassociated ARDS in absence of miliary type of disease. We present a case of reactivation MTb ARDS following recent self-limited COVID-19 infection in otherwise immunocompetent patient. Case presentation: Patient is an 18-year-old male immigrant from Guatemala with past medical history only for confirmed COVID-19 infection one month before initial presentation, not requiring hospital admission. He presented at outside hospital with 5-day history of dyspnea, fever, and cough productive of sputum. Blood cultures, COVID-19 PCR, HIV, and respiratory viral panel were negative;broad-spectrum empiric antibiotics were started. Initial CT chest revealed bilateral consolidation with necrotizing pneumonia and right upper lobe cavitation. He was subsequently intubated for worsening hypoxemic, hypercapnic respiratory failure. Despite paralysis and prone ventilation with lungprotective strategy, he continued to worsen clinically with refractory hypoxemia and hypercapnia;APACHE-II and SOFA scores were 22 and 11, respectively. Patient was transferred to our facility 4 days after initial presentation for consideration of extracorporeal membrane oxygenation (ECMO) support and was immediately placed on venovenous ECMO. Sputum AFB smear was positive, later confirmed to be pan-sensitive MTb by culture;bronchoalveolar lavage (BAL) was positive MTb by PCR and culture. Patient was started on rifampin, isoniazid, pyrazinamide, ethambutol within 48 hours of transfer. He was continued on vasopressor and inotrope support for shock, likely cardiogenic, with left ventricle ejection fraction of 35% and global hypokinesis. Hospital course was complicated by massive hemoptysis requiring bronchial artery embolization. On CT chest angiography, bilateral extensive near-complete airspace opacification with progressive cavitation was seen (see Figure 1). After 35 days on ECMO, patient continued to have no significant clinical improvement with persistent severe shock and multi-organ dysfunction syndrome. Palliative care was consulted. After discussion with family, ECMO support was withdrawn, and patient expired. Discussion: MTb-associated ARDS has a mortality of 60-80%. Early detection and initiation of antitubercular therapy are crucial in successful management. The presence of shock unrelated to sepsis is a poor prognostic factor, as seen in our patient. This case is unique given it is one of few reported cases of reactivated latent MTb after recovery from COVID-19 pneumonia. We postulate that the aggressive nature and rapidity of clinical decompensation of this patient's MTb ARDS may be related to altered immune host mechanisms following COVID-19 infection.

Physical function comparison of acutely unwell COVID-negative olderadults pre-pandemic and through-pandemic;“COVID-protected”

Introduction The risk of severe morbidity after COVID-19 infection is high inolder adults (Lithander et al, 2020). Subsequent responsive UKGovernment guidance for older adults included self-isolationduring the pandemic. It is therefore hypothesised that during thepandemic older adults are inadvertently deconditioned due toiatrogenic factors such as inactivity, social isolation, hospital-avoidance and malnutrition, and present with reduced resilienceto illness and lower levels of function. The OPU continued to admitCOVID-negative, or recently termed “COVID-protected”, patientsthroughout the pandemic. Data captured prior to, and during theCOVID-19 pandemic has been compared to explore theimplications on older adults, and elicit whether they are protectedfrom the consequences of the pandemic? Method Demographic and physical function data (average 6 m gait-speed,Elderly Mobility Scale) were captured pre-and through-pandemicfor all patients admitted to a COVID-negative OPU ward over a onemonth period. Ethical review was provided through local Trustgovernance process. Results Pre-pandemic 2019 (n = 67, mean(±SD) age 82.7(±8.2) years, 61%,hospital length-of-stay (LOS) 7.9(±7.3) days, hospital mortality-rate 7.2%) and through-pandemic 2020 (n = 73, 83.1(±8.3) years,59%♀, LOS 9.0(±9.1) days, hospital mortality-rate 7.5%) datawere captured during July 2019 and May 2020 respectively. Therewere no between-group differences in age [t(-.313) = 138, p = 0.755], gender [X , 1 df, p = 0.782], LOS [t(0.78) = 134, p = 0.44], orhospital mortality-rate [X 1 df, p = 0.96]. Through-pandemicpatients had a significantly slower 6 m gait-speed (0.11(±0.05)m.s-1) than pre-pandemic (0.16(±0.24) m.s-1);[t(2.74) = 93, p = 0.007] and lower median (IQR) Elderly Mobility Scale (4(6 IQR) vs9 (12 IQR) [u = 866, p = 0.015]). Conclusion Our data indicates this relatively short period of self-isolationmight have significant implications on the physical function of older adults. The likely mechanism is iatrogenic deconditioning.Critical Public Health and policy responses are required to mitigatethese unforeseen risks by deploying prehabilitative counter-measures and accurately targeted hospital and communityrehabilitation. 2 2.