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To explore laryngeal function of tracheostomised patients with COVID-19 in the acute phase, to identify ways teams may facilitate and expedite tracheostomy weaning and rehabilitation of upper airway function. Consecutive tracheostomised patients underwent laryngeal examination during mechanical ventilation weaning. Primary outcomes included prevalence of upper aerodigestive oedema and airway protection during swallow, tracheostomy duration, ICU frailty scores, and oral intake type. Analyses included bivariate associations and exploratory multivariable regressions. 48 consecutive patients who underwent tracheostomy insertion as part of their respiratory wean following invasive ventilation in a single UK tertiary hospital were included. 21 (43.8%) had impaired airway protection on swallow (PAS ≥ 3) with 32 (66.7%) having marked airway oedema in at least one laryngeal area. Impaired airway protection was associated with longer total artificial airway duration (p = 0.008), longer tracheostomy tube duration (p = 0.007), multiple intubations (p = 0.006) and was associated with persistent ICU acquired weakness at ICU discharge (p = 0.03). Impaired airway protection was also an independent predictor for longer tracheostomy tube duration (p = 0.02, Beta 0.38, 95% CI 2.36 to 27.16). The majority of our study patients presented with complex laryngeal findings which were associated with impaired airway protection. We suggest a proactive standardized scoring and review protocol to manage this complex group of patients in order to maximize health outcomes and ICU resources. Early laryngeal assessment may facilitate weaning from invasive mechanical ventilation and liberation from tracheostomy, as well as practical and objective risk stratification for patients regarding decannulation and feeding.
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Purpose of Study: Clinical trial participation remains low among US minority groups, who account for <1/10 of trial participants.1,2 Diverse, equitable and inclusive participation is needed to lessen disparities in health status and clinical outcomes.3 Community-based participatory research (CBPR) strategies identify salient community issues, and may be useful for understanding and addressing participation barriers among minority groups.4,5 The Louisiana Community Engagement Alliance Against COVID-19 Disparities (LA-CEAL) - a partnership of universities, community pharmacies, faith-based organizations (FBOs), and federally qualified health centers (FQHCs) - aims to strengthen and leverage community relationships to address barriers to uptake of preventive/therapeutic strategies in underserved populations. This study examines the utility of LA-CEAL's CBPR approach in facilitating inclusive participation in clinical trials. Methods Used: Listening forums were held with a diverse group of LA community stakeholders, including healthcare providers, community pharmacists, FBO leaders and other trusted community members, to gather views on the need for and challenges to inclusive trial participation. Ongoing discussions between community representatives and leaders, academics and program staff facilitated outreach and guided development of informational strategies targeting minority groups. Summary of Results: Listening forums (N = 4;20 participants) revealed limited awareness, mistrust and fear stemming from historical and present injustices, and difficulty accessing opportunities as key themes underlying barriers to participation. To address identified barriers, 8 video testimonials featuring participants, investigators, and health advocates (62.5% Black;12.5% Hispanic;50% female) were developed to educate on expectations and experiences, motivations to participate, human subject protections, and the importance of diversity. Two animated videos featuring trusted community leaders and cultural ambassadors (e. g., New Orleans cultural icon, Irma Thomas) were created to explain trial processes, discuss participation benefits, and address the history of racism in medicine. Finally, connections between the Tulane Clinical Translational Unit and rural FQHCs enabled clinical trial study buses to visit and recruit in diverse LA communities. Conclusion(s): Via LA community stakeholder discussions, targeted strategies to address barriers to minority participation in clinical trials were developed and applied. Use of CBPR strategies was critical to developing intentional action reflective of LA community needs. Copyright © 2023 Southern Society for Clinical Investigation.
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Background/Aims COVID-19 can manifest as a significant lung inflammation in adults. Although the course of disease is usually mild in children, it occasionally results in Paediatric Inflammatory Multisystem Syndrome temporally associated with COVID-19 (PIMS). We present a cohort of 79 children treated for PIMS-TS in Yorkshire, UK between May 2020 and September 2021. Methods This retrospective multicentre cohort study includes children fulfilling the case definition of PIMS-TS according to Royal College of Paediatrics and Child Health criteria. The collected data include demographics, clinical symptoms, laboratory results, echocardiographic findings, treatment and outcomes. Results Out of 79 PIMS-TS cases, 50 were male, 29 female. Ages were between 3 months and 16 years (median 7 years). 45 children were within the normal weight range for age, 4 underweight, 30 overweight. 41 children were Caucasian, 34 Asian, 2 African and 2 Afro-Caribbean origin. The median duration of admission was 7 days with range 0-21 days. All children had fever. In 51 cardiac involvement was detected (impaired cardiac function, pericardial effusion or changes on coronary arteries by echocardiographic examination). In 51 children a skin rash was observed (usually macular blanching confluent non-pruritic), 48 children had gastrointestinal symptoms such as abdominal pains, vomiting or diarrhoea, 39 children had non-purulent conjunctivitis, 13 children enlarged cervical lymph nodes. All patients initially received antibiotics and all but two were treated with an anti-platelet dose of aspirin, a small number early on with an anti-inflammatory dose of aspirin, 31 were treated with 3 consecutive infusions of intravenous methylprednisolone (IVMP) 10 mg/kg daily followed by a weaning dose of oral prednisolone, 35 by IVMP and intravenous immunoglobulins (IVIG), 9 by IVIG only. The duration of treatment by oral prednisolone was 3-35 days with median 15 days. Inotropic support for hypotension was needed in 18 cases and oxygen therapy in 11 cases. All children had a good outcome and are being followed-up in our Paediatric Rheumatology / Cardiology clinics at 1-2 weeks, 6 weeks, 6 months and 12 months. To date, follow-up at 12 months has shown resolution of cardiac abnormalities including initial mild dilatation of coronary arteries;most of our patients have fully recovered within 6 weeks. No patients had any thromboembolic event identified. After discharge from hospital self-limiting musculoskeletal pains, lethargy, peeling of palms and/or headaches were common. 3 patients received psychology support. Conclusion We report 100% survival in our cohort of patients with PIMS-TS. None of the patients represented with flare of the symptoms. The majority were treated by corticosteroids alone, or in combination with IVIG. We believe that advance knowledge of PIMS-TS (from colleagues in other regions in the UK, affected earlier), prompt treatment and structured follow-up approach by multi-disciplinary team contributed to the good outcomes so far.
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Introduction: Paediatric multisystem inflammatory syndrome (PIMS) began to present in April 2020 midway through the covid-19 pandemic. Occurring 2-4 weeks after initial covid-19 infection, patients presented with persistent fever, evidence of inflammation and single or multiorgan dysfunction1. The Yorkshire and Humber congenital heart disease network is made up of the Leeds congenital heart unit and 18 peripheral hospitals2.With limited local paediatric cardiology availability, the vast majority of children presenting with PIMS required transfer to Leeds. This presentation aims to describe the cohort of children that were seen within the network as well as to identify any markers of significant cardiac involvement which could beusedto reduce the frequency of unnecessary inter hospital transfers. Methods: This was a retrospective case notes review of all patients treated within the Yorkshire and Humber network with symptoms of PIMS between 1st May and 30th November 2020. Patients were classified as to whether or not they had significant cardiac involvement (defined as at least one of: inotrope requirement, ejection fraction <50%, pericardial effusion, coronary artery changes and significant ECG abnormalities). Cardiac markers were analysed at presentation and throughout the hospital admission including plasma NT pro-BNP, LDH, CRP, d-dimer and troponin. Statistical tests (Fisher's exact test for categorical variables, ttest for continuous variables) were used to identify which factors were indicative of significant cardiac involvement (SCI). Results: 22 patients met the inclusion criteria (Table 1). 14/22 patients (63.6%) were judged to have SCI. Markers that were found to be indicative of SCI included CRP and plasma NT pro-BNP (Table 2). Furthermore, when using a threshold of 2000ng/L, plasma NT pro-BNP was found to be 71% sensitive and 80% specific for SCI. In addition, when combined with a CRP threshold of 100mg/L, there was a positive predictive value of 85% and negative predictive value of 75%. Conclusions: PIMS is an important new syndrome affecting paediatric patients across the Yorkshire and Humber region. A significant proportion of the affected patients have cardiac involvement and require management in a specialist centre. Early identification of these patients using serological markers facilitates rapid treatment preventing long term sequelae whilst also reducing unnecessary interhospital transfers.
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Introduction: Inflammatory cytokines are central to the pathogenesis of the systemic autoinflammatory diseases (SAID) and agents targeting these pathways have transformed the management of SAID. These same pathways are involved in the balance between viral clearance and hyperinflammation during infection and have therefore been areas of active research interest into COVID-19. As a result, among patients with SAID on biologics, there are legitimate concerns regarding the risk of COVID-19 infection and safety of vaccination, which are exacerbated by the scarcity of published data on the outcomes of COVID-19 infection and vaccination in these patients. Objectives: This study establishes the prevalence and outcomes of COVID-19 infection and early outcomes of vaccination among a cohort of 248 patients with SAID on biologics. Methods: Data were collected from the electronic medical records of 248 patients with SAID on biologics at a national centre up to 26/7/ 21. Patients were also surveyed using a web-based survey completed in clinic or remotely between 4/3/21 and 26/7/21. Results: No deaths were recorded in this cohort of 248 patients between 29/1/20 and 26/7/21. In line with national guidance, all patients in this cohort were advised that the diagnosis of SAID managed with single-line biologic therapy was not an indication for shielding and that they should continue their biologic therapy unless otherwise instructed by a medical professional. Survey responses were received from 195 patients (195/248, 78.6%). Biologic therapy was as follows: anakinra (129/195, 66.2%), canakinumab (55/195, 28.2%), tocilizumab (8/195, 4.1%), etanercept (3/195, 1.5%), adalimumab (co-prescribed with anakinra) (1/195, 0.5%). Among survey respondents, 32 cases of suspected COVID-19 infection were reported, of which 15 were confirmed on testing (15/195, 7.7%). Two patients on anakinra were hospitalised due to dehydration. No patient required supplemental oxygen, mechanical ventilation or intensive care admission. Biologic therapy continued uninterrupted in all patients managed in the outpatient setting and was temporailty discontinued in the two hospitalised patients by the admitting team. Three patients with suspected or confirmed COVID-19 infection reported new symptoms that persisted for more than twelve weeks. 164/195 (84.1%) respondents had received the first vaccine dose and 79/195 (40.5%) had received two doses. 162/164 (98.8%) patients continued biologic therapy uninterrupted around the time of vaccination. Of the 243 vaccine doses administered, 138 (56.8%) were the Oxford Astra-Zeneca vaccine and 105 (43.2%) were the Pfizer-BioNTech vaccine. Following vaccination, no serious adverse events were reported and no patient required hospital admission. Side effects were reported following 130/243 (53.5%) doses and symptoms reported by patients to be in keeping with a flare of the underlying SAID were reported following 40/243 (16.5%). Side effects had fully resolved by 72 hours following 92.2% of doses (224/243). No cases of COVID-19 were reported following administration of both vaccine doses and only one early case was reported after the first dose, with symptom onset within five days of vaccine administration. Median follow up following vaccination was 10.5 weeks following the first dose and 6.0 weeks following the second. Conclusion: This study shows COVID-19 infection rates broadly in line with that of the UK general population among patients with SAID on biologics and demonstrates no significant concerns regarding outcomes of infection in these patients. We also present the largest series of patients with SAID or on IL-1/6 biologics to have received an adenoviral vector or mRNA vaccine and observe no significant early safety concerns. Whilst longer follow-up is needed to establish the efficacy of vaccination in these patients, these findings will support patients and their clinicians to make informed decisions around continuation of biologic therapy and vaccination during the ongoing COVID-19 pandemic.
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COVID-19 has heavily impacted our lives. To date, the ongoing pandemic continues to cause dramatic societal changes and raises shared sentiments of uncertainty for our future. As such, however, COVID-19 provides opportunities to explore futures through speculative research. Here, we gamify the story completion method (SCM) to explore futures post-COVID and ask 37 participants to play a day in the life of Sal in a post-COVID future. The game asks participants to describe what Sal sees, hears, or does throughout a day based on multiple story stems. Our analysis reveals narratives of post-COVID futures as business as usual, back to basics, or everyday chaos. Notably, these narratives raise concerns about privacy loss and increased militarization, but also envision futures post-COVID that reclaim stronger bond with nature and family. We discuss the lessons learned from gamifying the SCM and the temporal implications of performing speculative research during evolving dramatic events. © 2021 ACM.
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OBJECTIVES: As the pathophysiology of COVID-19 emerges, this paper describes dysphagia as a sequela of the disease, including its diagnosis and management, hypothesised causes, symptomatology in relation to viral progression, and concurrent variables such as intubation, tracheostomy and delirium, at a tertiary UK hospital. RESULTS: During the first wave of the COVID-19 pandemic, 208 out of 736 patients (28.9 per cent) admitted to our institution with SARS-CoV-2 were referred for swallow assessment. Of the 208 patients, 102 were admitted to the intensive treatment unit for mechanical ventilation support, of which 82 were tracheostomised. The majority of patients regained near normal swallow function prior to discharge, regardless of intubation duration or tracheostomy status. CONCLUSION: Dysphagia is prevalent in patients admitted either to the intensive treatment unit or the ward with COVID-19 related respiratory issues. This paper describes the crucial role of intensive swallow rehabilitation to manage dysphagia associated with this disease, including therapeutic respiratory weaning for those with a tracheostomy.