Difficult Conversations Workshop for Trainees in Paediatrics

Aims Effective communication skills are vital for Paediatricians to allow them to establish and develop relationships with children and their families. Whilst there is a significant emphasis on communication skills in the RCPCH curriculum, many trainees receive little dedicated communication skills teaching or feedback during Paediatric training. In addition, COVID undoubtedly had an impact on trainees' experiences and their exposure to difficult conversations. We planned a communication skills workshop involving simulated difficult conversations with actors, aimed at doctors working in General Paediatrics. The workshop aimed to offer the opportunity to practise challenging conversations and manage conflict in a supportive environment. Methods We successfully applied for COVID recovery funding to run a full day workshop for communication skills in Paediatrics. Paediatric and GP trainees working in general paediatrics were surveyed using an anonymous online platform about areas of communication they feared most. We used the areas identified to develop communication scenarios that addressed key capabilities in the RCPCH Progress curriculum. These included raising safeguarding concerns with a family, talking to a family when their child has died, exploring mental health concerns with a young person and dealing with conflict. These are common scenarios that trainees may have missed out on due to redeployment or change in work patterns. The workshop, held in October 2021, involved face-to-face simulated communication scenarios with actors for Paediatric and GP trainees currently working in general paediatrics. Each trainee led a simulated communication scenario with an actor and received a full debrief and feedback with experienced faculty. Scenarios were recorded to create a learning tool to use within the trust as examples of good practice. Trainees completed anonymous feedback online immediately after the session. Results Eight doctors attended, consisting of 2 GP trainees, 4 junior Paediatric trainees (ST2-3), 1 Paediatric ST4 trainee and 1 senior clinical fellow. All attendees rated the session as 5/5 overall on a Likert scale. The average rating for relevance to their work was 4.86/5. All felt the session had improved their communication skills (71% of trainees by 'a lot' and 29% of trainees by 'a little'). 100% would recommend the session to colleagues. Specific comments included * 'The environment felt like a safe space to debrief and discuss situations openly in a non-judgemental manner. Having professional actors involved was invaluable to get the most realistic feel to the scenarios.' * 'The faculty were really supportive, the scenarios were very realistic, the atmosphere was non-judgmental and the actors were amazing.' Conclusion Our workshop allowed trainees to experience difficult conversations relevant to their training. By basing the scenarios on trainees' suggestions, we ensured we targeted their identified learning needs. Using professional actors with experienced faculty allowed trainees to develop vital skills in a safe and realistic environment. Feedback was overwhelmingly positive, and we are planning to run another similar workshop in early 2022. We hope to develop a bank of scenarios that can be used to develop and hone the skills that Paediatricians of the future need to communicate effectively with children, young people and their families.

Prevention and early treatment of the long-term physical effects of COVID-19 in adults: design of a randomised controlled trial of resistance exercise-CISCO-21.

BACKGROUND: Coronavirus disease-19 (COVID-19) infection causes persistent health problems such as breathlessness, chest pain and fatigue, and therapies for the prevention and early treatment of post-COVID-19 syndromes are needed. Accordingly, we are investigating the effect of a resistance exercise intervention on exercise capacity and health status following COVID-19 infection. METHODS: A two-arm randomised, controlled clinical trial including 220 adults with a diagnosis of COVID-19 in the preceding 6 months. Participants will be classified according to clinical presentation: Group A, not hospitalised due to COVID but persisting symptoms for at least 4 weeks leading to medical review; Group B, discharged after an admission for COVID and with persistent symptoms for at least 4 weeks; or Group C, convalescing in hospital after an admission for COVID. Participants will be randomised to usual care or usual care plus a personalised and pragmatic resistance exercise intervention for 12 weeks. The primary outcome is the incremental shuttle walks test (ISWT) 3 months after randomisation with secondary outcomes including spirometry, grip strength, short performance physical battery (SPPB), frailty status, contacts with healthcare professionals, hospitalisation and questionnaires assessing health-related quality of life, physical activity, fatigue and dyspnoea. DISCUSSION: Ethical approval has been granted by the National Health Service (NHS) West of Scotland Research Ethics Committee (REC) (reference: GN20CA537) and recruitment is ongoing. Trial findings will be disseminated through patient and public forums, scientific conferences and journals. TRIAL REGISTRATION: ClinicialTrials.gov NCT04900961 . Prospectively registered on 25 May 2021.

Gamma-Glutamyltransferase at the Time of Listing May Predict Irreversible Severe Cholangiopathy After Lung Transplantation for COVID19-ARDS

Lung transplantation (LTx) can be considered for selected patients suffering from COVID19 ARDS or fibrosis. Besides the lung, the virus also affects the liver and cholangiopathy with progressive biliary liver failure has been described in a substantial rate of COVID19 ARDS survivors. Despite an increasing number of LTx performed worldwide for post-COVID19 ARDS, rates of cholangiopathic liver dysfunction and factors predicting this detrimental late complication are unknown. This retrospective analysis included all LTx performed for post-COVID ARDS or post-COVID fibrosis in our institution between May 2020 and October 2021. Clinical parameters available at the time of listing were compared between LTx recipients who developed irreversible cholangiopathy leading to death or consideration for liver transplantation ('cholangiopathy' group) and patients who had no or only transient liver dysfunction ('control' group). Severe elevation of LFPs was defined as greater than 5 times the upper limit of normal (ULN) of bilirubin, ASAT, ALAT, GGT and AP, respectively. A total of 23 patients were included in the analysis. While 14 (60.9%) showed no or only transient liver dysfunction post-transplant, 9 (39.1%) developed persistent cholangiopathy after LTx. In 4 of these cases, this ultimately led to death, while 2 patients had to be put on the liver transplant wait list. Median time between COVID disease onset and Tx listing (p=0.603) was similar in both study groups. Recipient BMI, previous comorbidities and SOFA score at Tx listing were comparable. Levels of AP, ASAT, ALAT and bilirubin were similar in both groups, however, GGT at the time of listing seemed to predict a later development of cholangiopathy (median 510 vs 211.5 U/L;p=0.062). Moreover, patients with a GGT > 5xULN had a 12 times higher likelihood for the development of post-transplant cholangiopathy compared to those with lower GGT values (OR 95% CI: 0.010 - 0.590). Since severe cholangiopathy is associated with a high mortality after LTx, liver function should be thoroughly assessed in all post-COVID ARDS/fibrosis LTx candidates. In this preliminary observation, we found that GGT at the time of listing was the only parameter which appeared to predict this late complication. Further large-scale studies are required to confirm our findings. [ FROM AUTHOR] Copyright of Journal of Heart & Lung Transplantation is the property of Elsevier B.V. and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use. This may be abridged. No warranty is given about the accuracy of the copy. Users should refer to the original published version of the material for the full . (Copyright applies to all s.)

Lactobacillus crispatus DSM25988 as novel bioactive agent to co-aggregate Streptococcus pyogenes and to exclude it by binding to human cells.

Streptococcus pyogenes, a group A streptococcus, is the major bacterial pathogen responsible for acute bacterial infection of the human oropharynx and the causative agent of scarlet fever. Estimates of the global burden of S. pyogenes related diseases revealed 616 million cases of pharyngitis, and at least 517,000 deaths due to severe invasive diseases and sequelae. Here we describe Lactobacillus crispatus DSM25988 that was identified among hundreds of Lactobacillus strains (referring to all organisms that were classified as Lactobacillaceae until 2020) showing ability to prevent adhesion of S. pyogenes to Detroit 562 cells, and to exhibit a masking and co-aggregating effect on S. pyogenes in vitro. L. crispatus DSM25988 also inhibits invasion of cultured human epithelial pharyngeal cells by S. pyogenes. Competitive binding to fibronectin might be involved in the inhibition process. Antiviral activity of the L. crispatus DSM25988 cells were identified in an in vitro cell model demonstrating that L. crispatus effectively excludes viruses from epithelial cells using SARS-CoV2 proteins as a model. This finding points to the potential of DSM25988 to protect cells from virus infection. Biological activity is retained in heat treated cells. The heat-treated Lactobacillus strain was further developed into functional throat lozenges, wherein its biological activity is stably maintained in the formulation. Lozenges containing L. crispatus DSM25988 underwent testing in an uncontrolled, prospective user study in 44 subjects with symptoms of sore throat for a period of up to 14 days. The study data shows promising safety and efficacy of the medical device when used against symptoms of sore throat like scratchy feeling, hoarse voice and swallowing pain.

Benralizumab for corticosteroid-refractory DRESS in two COVID-19 patients

Drug rash with eosinophilia and systemic symptoms (DRESS) is a rare severe drug hypersensitivity reaction. Treatment of DRESS currently consists of systemic corticosteroids. Here, we report benralizumab (Fasenra®) as a treatment for corticosteroid-refractory DRESS occurring in two severely ill COVID-19 patients. Both patients received high-dose intravenous corticosteroids for 4-6 days, but cutaneous symptoms, eosinophilia and signs of related organ damage were deteriorating. Based on its successful use in PDGFRA-independent hypereosinophilia, we decided to treat our patients with benralizumab. The patients showed clinical improvement and a rapid substantial drop in eosinophils. Targeted high-throughput serum proteomics prior vs. after treatment revealed a significant reduction mostly in eosinophil- and T cell response-related proteins (a.e. IL-5, CD8, TNF and PD-L1), thus pointing towards an impact of benralizumab on the (drug-directed) T cell response in DRESS.

Systemic hyperinflammation as a driver of maculopapular drug exanthema in severely ill COVID-19 patients?

Coronavirus disease 2019 (COVID-19) has been associated with cutaneous findings, some being the result of drug hypersensitivity reactions Here, we utilize imaging mass cytometry (IMC) to characterize the cutaneous immune response in maculopapular drug rashes (MDR), including those associated with COVID-19 infection (COVID MDR). For comparison skin from healthy controls and patients with drug rash with eosinophilia and systemic symptoms (DRESS) was analyzed. Results demonstrated that COVID MDR are characterized by a more prominent infiltration of cytotoxic CD8+ T cells and highly activated, phenotypically shifted monocyte/macrophage (Mo/Mac) clusters in comparison to MDR and DRESS. RNA sequencing transcriptome of the affected skin also demonstrated a more robust cytotoxic response in lesional COVID MDR skin Serum proteomic profiling of COVID MDR patients revealed up-regulation of various inflammatory mediators (IL-4, IL-5, IL-8, IL-18, IL-6, TNF and IFN-γ), eosinophil and Mo/Mac -attracting chemokines MCP-2, MCP- 3, MCP-4 and CCL11. Analyses of cytokine networks demonstrated a relatively milder cytokine storm in DRESS compared to COVID MDR while MDR did not exhibit such features. Our results suggest that a massive systemic cytokine storm promotes activation of Mo/Mac and cytotoxic CD8+ T cells, which impacts MDR development in severely ill COVID-19 patients.

International Experience with Lung Transplantation for COVID-19 Associated Acute Respiratory Distress Syndrome

Purpose The COVID-19 pandemic has infected millions of people across the world and caused several thousands of deaths. Given advances in extracorporeal life support technology, ECMO for COVID-19 acute respiratory distress syndrome (ARDS) has proven to be successful in sustaining life, however, has left a significant number of patients fully depended on devices and incapable of being weaned. Lung transplantation, as a well-established therapy for end-stage lung disease, has been considered for some patients with COVID-19 ARDS in the absence of lung recovery and the presence of findings suggestive of end-stage lung disease. Methods This is an International collaborative effort to assess the role of lung transplantation in COVID-19 ARDS. There is worldwide representation with centers from US (3), Europe (2) and Asia (1). Patients with COVID-19 ARDS supported on ECMO and/or mechanical ventilation who were deemed unweanable and developed features of end-stage lung disease were evaluated for lung transplantation. We followed ISHLT conventional recipient selection criteria recommendations and a 2 negative COVID-19 PCRs from bronchoalveaolar lavage or viral culture depending on medical urgency. Endpoints We will present demographics, intraoperative challenges, primary graft dysfunction, postoperative complications, survival and functional outcomes of patients with COVID-19 ARDS who underwent lung transplantation. Additionally, referral patterns, reasons for listing denial and waitlist outcomes will be presented. So far, this collaborative group has transplanted 17 patients. There have been no deaths on the waitlist, there was one post-transplant mortality at day 61. Ten patients have been discharged from the hospital and are doing well. Six patients are recovering well however less than 30 days post-transplantation and remain admitted.

"Five-early" model: The magic weapon against covid-19

Background: COVID-19(2019 novel coronavirus disease)has brought tremendous pressure to the prevention and control of the national epidemic due to its concealed onset, strong infectivity and fast transmission speed. Methods: In this retrospective study, 226 patients diagnosed with 2019 novel coronavirus pneumonia (NCP) in the Chongqing University Three Gorges Hospital were included. The patients' clinical data, including general information, initial symptoms at the onset, time of disease diagnosis, time to treatment in hospital, time of nucleic acid conversion to negative, disease classification, total time of hospitalization were collected. The clinical data of the mild and severe patients were compared. Results: Fever, cough, sore throat, poor appetite andfatigue were the main symptoms of the diagnosed patients. The time of diagnosis was significantly shorter in the mild patients (4.96 ± 4.10 days) than severe patients (7.63 ± 9.17 days) (P=0.004). Mild patients had shorter time to treatment in hospital (6.09 ± 4.47 vs. 8.71 ± 9.04 days) and less time of nucleic acid conversion to negative (7.58 ± 2.51 vs. 11.6 ± 4.67 days) compared to the severe patients. Conclusion: The above results can be used as a quantitative basis for the “five-early"(early detection, early screening, early diagnosis, early isolation treatment, and early recovery) model. The government, the masses, and the hospitals' joint prevention and optimization of the "five-early" model will provide important scientific reference for further prevention and control of the epidemics. © 2020, Iranian Journal of Public Health. All rights reserved.