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2.
Journal of General Internal Medicine ; 37:S318-S319, 2022.
Article in English | EMBASE | ID: covidwho-1995752

ABSTRACT

BACKGROUND: Reports of silent hypoxia in patients with Covid-19 have raised concerns that patients monitored at home should receive pulse oximeters to objectively measure oxygen saturation rather than relying on subjective dyspnea as an indicator of clinical deterioration. METHODS: In this pragmatic randomized control trial, patients with suspected or confirmed Covid-19 were randomly assigned (1:1) to receive a text message based remote monitoring program (“Covid Watch”) or the program supplemented with SpO2 monitoring using a home pulse oximeter (“COVID Watch + Pulse Oximetry”). Covid Watch is a an automated 14-day text program that enquires about patients' symptoms of dyspnea. The primary outcome was days alive and out of hospital (DAOH) at 30 days. RESULTS: A total of 1056 patients (611 Covid-19 positive) were assigned to receive automated remote monitoring of both peripheral oxygen saturation (SpO2) levels and self-reported symptoms of dyspnea and 1041 (606 Covid-19 positive) to receive symptom monitoring alone. Among Covid-19 patients, the addition of SpO2 monitoring provided no significant difference in mean DAOH at 30 days (29.38 vs 29.46;difference -0.08;95% CI, -0.37 to 0.21). Patients in the intervention arm were more likely to use more clinical resources such as telephone calls and telemedicine visits. These finding were consistent across subgroups defined by race, age, and clinical status. CONCLUSIONS: SpO2 monitoring added no clinical value to subjective assessments of dyspnea in an automated text-message remote monitoring program of Covid-19 patients, while simultaneously increasing utilization of clinical resources. These findings reveal that home pulse oximetry may be ineffective and inefficient in supporting the management of Covid-19 patients in outpatient settings relative to remotely monitoring symptoms of dyspnea alone.

3.
Journal of the American College of Cardiology ; 79(9):1835-1835, 2022.
Article in English | Web of Science | ID: covidwho-1849416
4.
PubMed; 2021.
Preprint in English | PubMed | ID: ppcovidwho-333792

ABSTRACT

Patients with COVID-19 present with a wide variety of clinical manifestations. Thromboembolic events constitute a significant cause of morbidity and mortality in patients infected with SARS-CoV-2. Severe COVID-19 has been associated with hyperinflammation and pre-existing cardiovascular disease. Platelets are important mediators and sensors of inflammation and are directly affected by cardiovascular stressors. In this report, we found that platelets from severely ill, hospitalized COVID-19 patients exhibit higher basal levels of activation measured by P-selectin surface expression, and have a poor functional reserve upon in vitro stimulation. Correlating clinical features to the ability of plasma from COVID-19 patients to stimulate control platelets identified ferritin as a pivotal clinical marker associated with platelet hyperactivation. The COVID-19 plasma-mediated effect on control platelets was highest for patients that subsequently developed inpatient thrombotic events. Proteomic analysis of plasma from COVID-19 patients identified key mediators of inflammation and cardiovascular disease that positively correlated with in vitro platelet activation. Mechanistically, blocking the signaling of the FcgammaRIIa-Syk and C5a-C5aR pathways on platelets, using antibody-mediated neutralization, IgG depletion or the Syk inhibitor fostamatinib, reversed this hyperactivity driven by COVID-19 plasma and prevented platelet aggregation in endothelial microfluidic chamber conditions, thus identifying these potentially actionable pathways as central for platelet activation and/or vascular complications in COVID-19 patients. In conclusion, we reveal a key role of platelet-mediated immunothrombosis in COVID-19 and identify distinct, clinically relevant, targetable signaling pathways that mediate this effect. These studies have implications for the role of platelet hyperactivation in complications associated with SARS-CoV-2 infection. Cover illustration: ONE-SENTENCE SUMMARY: The FcgammaRIIA and C5a-C5aR pathways mediate platelet hyperactivation in COVID-19.

6.
Antimicrobial Resistance and Infection Control ; 10(SUPPL 1), 2021.
Article in English | EMBASE | ID: covidwho-1448340

ABSTRACT

Introduction: The World Health Organization recommends improving hand hygiene (HH) practices of the general public as one aspect of controlling the transmission of novel coronaviruses and influenza virus epidemics or pandemics. Objectives: To systematically review the evidence on the effectiveness of HH interventions for preventing transmission or acquisition of viral infections in the community. Methods: PubMed, MEDLINE, CINAHL and Web of Science databases were searched for empirical studies published between 2002-May 2020, on HH in the general public and acquisition or transmission of novel coronavirus infections or influenza. Study selection, data extraction and quality assessment were conducted by one reviewer, with all decisions checked by another. We conducted a sub-set analysis of intervention studies included in this review, by calculating the effect estimates. Results: The review identified four intervention studies, all of which used cluster randomised designs evaluating the effectiveness of HH education paired with provision of HH products or hand washing with soap and water (HW) against influenza transmission or acquisition amongst the populations of schoolchildren (n = 2) or the general public (n = 2). Three indicated a protective effect of HH interventions (Figure);yet, this effect was significant for only one school-based intervention, which consisted of the provision of HH education and performing HW twice a day (OR: 0.64;95% CI 0.51, 0.80). However, the risk of bias of this study was assessed as unclear;whereas the remaining three studies were assessed as high risk. Conclusion: There is some limited evidence demonstrating that hand hygiene interventions were effective in preventing influenza in school children. Thus, whilst provision of HH education to school children will be beneficial from a public health perspective, it's impact on influenza transmission is unclear. Research is needed to evaluate the effectiveness of HH interventions for prevention of respiratory infections, including SARS-CoV-2, amongst more diverse groups of the general public populations.

7.
Tech Coloproctol ; 25(11): 1267-1268, 2021 Nov.
Article in English | MEDLINE | ID: covidwho-1427284
11.
J Hosp Infect ; 116: 37-46, 2021 Oct.
Article in English | MEDLINE | ID: covidwho-1360078

ABSTRACT

BACKGROUND: The risk of transmission of SARS-CoV-2 from aerosols generated by medical procedures is a cause for concern. AIM: To evaluate the evidence for aerosol production and transmission of respiratory infection associated with procedures that involve airway suctioning or induce coughing/sneezing. METHODS: The review was informed by PRISMA guidelines. Searches were conducted in PubMed for studies published between January 1st, 2003 and October 6th, 2020. Included studies examined whether nasogastric tube insertion, lung function tests, nasendoscopy, dysphagia assessment, or suctioning for airway clearance result in aerosol generation or transmission of SARS-CoV-2, SARS-CoV, MERS, or influenza. Risk of bias assessment focused on robustness of measurement, control for confounding, and applicability to clinical practice. FINDINGS: Eighteen primary studies and two systematic reviews were included. Three epidemiological studies found no association between nasogastric tube insertion and acquisition of respiratory infections. One simulation study found low/very low production of aerosols associated with pulmonary lung function tests. Seven simulation studies of endoscopic sinus surgery suggested significant increases in aerosols but findings were inconsistent; two clinical studies found airborne particles associated with the use of microdebriders/drills. Some simulation studies did not use robust measures to detect particles and are difficult to equate to clinical conditions. CONCLUSION: There was an absence of evidence to suggest that the procedures included in the review were associated with an increased risk of transmission of respiratory infection. In order to better target precautions to mitigate risk, more research is required to determine the characteristics of medical procedures and patients that increase the risk of transmission of SARS-CoV-2.


Subject(s)
Aerosols , COVID-19 , Aerosols/adverse effects , Air Microbiology , COVID-19/transmission , Humans , Respiratory Physiological Phenomena , SARS-CoV-2
12.
Economic and Social Review ; 52(2):193-216, 2021.
Article in English | Web of Science | ID: covidwho-1321139

ABSTRACT

With the onset of the COVID-19 pandemic, and the introduction of rolling public health restrictions, conditions in Ireland's labour market deteriorated significantly. In response to the widespread impacts on businesses and workers, the Irish Government, as part of a broader suite of policy measures, introduced the Pandemic Unemployment Payment (PUP) in March 2020. Though the lens of the PUP, this paper explores the impact of the COVID-19 pandemic on Ireland's labour market and its implications for post-COVID recovery and policy. In particular, this analysis examines the demographics of impacted workers over time, rates of payment relative to pre-pandemic earnings and the potential scale of the post-COVID labour market challenge, via an exploration of long-term recipients.

13.
American Journal of Respiratory and Critical Care Medicine ; 203(9), 2021.
Article in English | EMBASE | ID: covidwho-1277460

ABSTRACT

Rationale: Respiratory viruses are commonly detected pathogens in pulmonary sepsis. Prior studies have demonstrated that patients with respiratory viral infections may have transient lymphocytopenia and thrombocytopenia. Leukocyte parameters including lymphocyte to monocyte ratio (LMR) and neutrophil to lymphocyte ratio (NLR) have been reported as screening tools for viral infections. Platelet counts and dynamics have been described as quantitative traits for ARDS risk and mortality. Therefore, we hypothesized that early hematologic parameters including lymphocyte count, monocyte count, platelet count, NLR, and LMR may distinguish viral from bacterial pulmonary sepsis. Methods: We enrolled 1,158 critically ill patients with pulmonary sepsis from 2009 to 2020 and measured lymphocyte count, monocyte count, platelet count, NLR, and LMR on ICU admission and at 24-hrs. Respiratory viruses were detected via PCR panel on nasopharyngeal swabs. Pulmonary sepsis was adjudicated by a physician panel. APACHE III scores were collected during the first 24-hrs. Shock was assessed by vasopressor use or mean arterial pressure <65mmHg despite 30cc/kg fluid resuscitation. ARDS was defined per Berlin criteria. We assessed mortality at 30 days. We used multivariable linear regression to test the association between each of the laboratory studies and a positive respiratory pathogen panel (RVP) adjusting for APACHE III score, age, sex, malignancy, and race. We used multivariable logistic regression to assess for associations between a positive RVP and outcomes. Results: The incidence of respiratory virus detection was 33.9%. The incidence of ARDS and mortality were 52.7% and 49.0%, respectively. The most commonly detected pathogens were SARS-CoV-2 and rhinovirus (Table 1). Lower platelet counts at 24-hrs were significantly associated with respiratory virus detection (β-41.59 × 109/L [95%CI-79.03,-4.15], p=0.03), whereas admission platelet counts were not significantly associated (β-22.38 × 109/L [95%CI-63.26, 20.49], p=0.32). The significant association at 24-hrs was also present on sensitivity analyses excluding patients with SARS-CoV-2. There were no statistically significant differences between the populations with respect to lymphocyte count, monocyte count, NLR, LMR, ARDS, shock, and mortality. Conclusion: Lower early platelet counts were identified in patients with viral pulmonary sepsis. Although LMR and NLR have been reported as screening tools for viral infections in non-critically ill populations, we did not detect significant associations between lymphocyte count, monocyte count, NLR or LMR and viral detection in pulmonary sepsis. Our findings suggest that platelet counts in combination with other validated parameters may warrant further investigation for the early discrimination of viral versus bacterial pulmonary sepsis.

14.
American Journal of Respiratory and Critical Care Medicine ; 203(9), 2021.
Article in English | EMBASE | ID: covidwho-1277376

ABSTRACT

Rationale: Obesity is a strong risk factor for acute kidney injury (AKI) in patients with COVID-19, but underlying mechanisms are unknown. Resistin is an immunomodulatory adipokine with elevated circulating levels in obese outpatients that could contribute to inflammatory kidney injury. We hypothesized that plasma resistin levels would be associated with AKI and BMI, and correlated with the inflammatory markers IL6 and MCP1 in hospitalized COVID-19 patients. Methods: We conducted a prospective cohort study of 134 patients admitted to the Hospital of the University of Pennsylvania with a primary diagnosis of COVID-19. Plasma samples were collected within 48 hours of admission and analyzed using the Olink Proximity Extension Assay, with biomarker levels expressed using normalized protein expression (NPX) values relative to common pooled control plasma. We tested the association of each biomarker with AKI, defined by Kidney Disease Improving Global Outcomes creatinine and dialysis criteria, using the Wilcoxon rank-sum test as well as multivariable logistic regression to adjust for confounders. Spearman's rho and correlation coefficients were calculated for the correlation of biomarker levels with each other. We used causal mediation models to investigate effects of BMI on AKI mediated by plasma resistin. Results: Of 134 patients enrolled, 43 (32.1%) developed AKI: 25 with stage 1, 5 with stage 2, and 13 with stage 3. Plasma resistin levels ranged from 5.26-13.01 NPX units and were strongly associated with AKI: odds ratio 2.13 (95% CI 1.43-3.17) per NPX unit. This association was diminished but remained significant after adjustment for age and APACHE III score (OR 1.69 (1.09-2.63)). Body mass index was higher in patients with AKI than without (median 31.4 (IQR 27.1-37.6) kg/m2 v. 28.3 (25.1-34.9) kg/m2, respectively), but the difference was not statistically significant (p=0.082). There was no significant correlation of BMI with resistin levels (rho 0.05, p=0.562), and causal mediation models failed to detect significant mediation of BMI-AKI association through resistin. Plasma IL6 and MCP1 were associated with AKI (p=0.044 and p=0.003, respectively) and correlated with resistin levels (rho=0.32, p<0.001 and rho=0.40, p<0.001, respectively). Conclusion: In patients hospitalized with COVID-19, plasma levels of the adipokine resistin were strongly associated with the development of AKI, and correlated with circulating inflammatory markers IL6 and MCP1. We did not detect a mediation effect of the obesity-AKI association by plasma resistin but had limited sample size to adequately power this analysis.

15.
American Journal of Respiratory and Critical Care Medicine ; 203(9), 2021.
Article in English | EMBASE | ID: covidwho-1277337

ABSTRACT

Rationale: To utilize high-dimensional proteomic data to identify dysregulated pathways that are associated with COVID-19 disease severity and suggest potential therapeutic targets. Methods: We enrolled 161 COVID-19 inpatients admitted at two tertiary care hospitals. Plasma samples collected within 48 hours of admission were analyzed with the Olink Proximity Extension Assay;713 unique proteins were assayed. The WHO COVID-19 ordinal severity scale at enrollment was dichotomized into moderate (levels 3-4) and severe (levels 5-7). Normalized protein expression (NPX) values were generated in relation to a common pooled control plasma on each plate. The association between NPX values and disease severity on admission was estimated with logistic regression (LR) after adjustment for age, sex, race, and select comorbidities. Ingenuity Pathway Analysis (IPA) was employed after application of the Benjamini-Hochberg procedure with a false discovery rate of 5% to all proteins for which the NPX difference was +/-0.8 between groups. Predictive models of disease severity on hospital day 7 using all proteins as potential features were fit using elastic net LR (ENLR) and gradient boosting (GBM). Performance was estimated on a held-out test set (40% of the data) with area under the receiveroperator characteristic curve (AUROC). Results: Of 161 subjects, 85 (53%) were classified as having severe COVID-19. A total of 552 proteins were differentially expressed (Figure 1), and 31 of these proteins met criteria for inclusion in pathway analysis. IPA identified the triggering receptor expressed on myeloid cells 1 (TREM-1) signaling pathway (4 members, p=3.8E-3), the tumor microenvironment (TME) pathway (5 members, p=4.1E-3), and the interleukin 17 (IL-17) signaling pathway (4 members, p=1.8E-2). Interleukin 1 receptor-like 1, a member of the TREM-1 pathway, was the protein most associated with disease severity (OR=3.18, p=1.82E-08). Tumor necrosis factor ligand superfamily member 11 (TNFSF11), a member of the IL-17 signaling pathway was the only factor whose enrichment was associated with less severe disease (OR=0.39, p=2.3E-05). ENLR and GBM predicted disease severity on day 7 with AUROC values of 0.908 (0.828, 0.968) and 0.882 (0.788, 0.957), respectively. Conclusion: We identified pathways differentially expressed between patients with severe and nonsevere COVID-19 associated with immune function and angiogenesis. Several agents currently being investigated to treat severe COVID-19 act on these dysregulated pathways, and future investigations could test whether these proteins act as enrichment markers or response indicators. Integrating protein expression with cellular immune phenotype may help explain COVID-19 pathophysiology.

16.
American Journal of Respiratory and Critical Care Medicine ; 203(9), 2021.
Article in English | EMBASE | ID: covidwho-1277046

ABSTRACT

RATIONALE: Currently, there are over 20,000 COVID-19 positive patients requiring intensive care unit (ICU) care in the United States (US). Even prior to the pandemic, up to 30% of family members of ICU patients experience post-traumatic stress disorder and up to 50% sustain potentially prolonged anxiety and/or depression. Although family bedside engagement improves both short-and long-term outcomes for patients and their families, nationwide social distancing recommendations have curtailed hospital visitation, potentially heightening the risk of stress-related disorders in these family members. The goal of this analysis is to explore the experiences of physically distanced family members of COVID-19 ICU patients in order to inform future best practices. Methods: This qualitative analysis is part of a multisite, observational, mixed-methods study of 12 US hospitals. Qualitative interviews were conducted with 75 participants from five sites;14 interviews were analyzed in this preliminary analysis. Adult family members of COVID-19 positive patients admitted to the ICU from March-June 2020 were interviewed three months post-discharge. After sequential screening by site coordinators, participants were contacted by the qualitative team until all interviews (10-15 per site) were completed. Qualitative interviews explored the illness stories, communication perceptions, and explored stressors. Thematic analysis was applied to the verbatim transcripts of the phone interviews. Four coders utilized an iteratively-developed codebook to analyze transcripts using a round-robin method with two analysts per transcript. Discrepant codes were adjudicated by a third analyst to attend to inter-rater reliability. Results: Five preliminary themes and seven subthemes emerged (Table 1). Positive communication experiences were more common than negative ones. Communication themes were: 1) Participants were reassured by proactive and frequent communication, leaving them feeling informed and included in care;and 2) Mixed feelings were expressed about the value of video-conferencing technology. Themes from the emotional and stress experiences were: 3) Profound sadness and distress resulted from isolation from patients, clinicians, and supportive family;4) Stress was amplified by external factors;and 5) Positive experiences centered upon appreciation for healthcare workers and gratitude for compassionate care. Conclusion: Incorporating the voices of family members during the COVID-19 pandemic establishes a foundation to inform family-centered, best practice guidelines to support the unique needs of family members who are physically distant from their critically ill and dying loved ones.

17.
British Journal of Surgery ; 108(SUPPL 2):ii30, 2021.
Article in English | EMBASE | ID: covidwho-1254493

ABSTRACT

Introduction: Anecdotal evidence suggest a direct impact of the SARSCOV- 2-pandemic on presentation and severity of major trauma. Method: This observational study from a UK Major Trauma Centre matched a cohort of patients admitted during a 10-week period of the SARS-CoV-2-pandemic (09/03/2020 to 18/05/2020) to a historical cohort admitted during a similar time period in 2019 (11/03/2019 to 20/05/ 2019). Demographic differences, injury method and severity were compared using Fisher's and Chi-squared tests. Multivariable logistic regression examined the associated factors predicting 30-day mortality. Results: Of 642 patients, 405 and 237 were in the 2019 and 2020 cohorts respectively. 1.69%(4/237) of the 2020 cohort tested SARS-CoV-2 positive. There was a 41.5% decrease in trauma admissions in 2020. The 2020 cohort was older (median 46 vs.40 years), more comorbid and frailer (p<0.0015). There was a significant difference in injury method with a decrease in vehicle related trauma, but an increase in falls. There was a 2-fold increased risk ofmortality in the 2020 cohort that in adjustedmodels, was explained by higher injury severity and frailty. Positive SARS-CoV-2 status was not associated with increasedmortality onmultivariable analysis. Conclusions: Patients admitted during the SARS-CoV-2-pandemic were older, frailer, more co-morbid and had an increased risk of mortality.

18.
PubMed; 2021.
Preprint in English | PubMed | ID: ppcovidwho-7509

ABSTRACT

Cancer patients have increased morbidity and mortality from Coronavirus Disease 2019 (COVID-19), but the underlying immune mechanisms are unknown. In a cohort of 100 cancer patients hospitalized for COVID-19 at the University of Pennsylvania Health System, we found that patients with hematologic cancers had a significantly higher mortality relative to patients with solid cancers after accounting for confounders including ECOG performance status and active cancer status. We performed flow cytometric and serologic analyses of 106 cancer patients and 113 non-cancer controls from two additional cohorts at Penn and Memorial Sloan Kettering Cancer Center. Patients with solid cancers exhibited an immune phenotype similar to non-cancer patients during acute COVID-19 whereas patients with hematologic cancers had significant impairment of B cells and SARS-CoV-2-specific antibody responses. High dimensional analysis of flow cytometric data revealed 5 distinct immune phenotypes. An immune phenotype characterized by CD8 T cell depletion was associated with a high viral load and the highest mortality of 71%, among all cancer patients. In contrast, despite impaired B cell responses, patients with hematologic cancers and preserved CD8 T cells had a lower viral load and mortality. These data highlight the importance of CD8 T cells in acute COVID-19, particularly in the setting of impaired humoral immunity. Further, depletion of B cells with anti-CD20 therapy resulted in almost complete abrogation of SARS-CoV-2-specific IgG and IgM antibodies, but was not associated with increased mortality compared to other hematologic cancers, when adequate CD8 T cells were present. Finally, higher CD8 T cell counts were associated with improved overall survival in patients with hematologic cancers. Thus, CD8 T cells likely compensate for deficient humoral immunity and influence clinical recovery of COVID-19. These observations have important implications for cancer and COVID-19-directed treatments, immunosuppressive therapies, and for understanding the role of B and T cells in acute COVID-19.

19.
Tech Coloproctol ; 25(5): 505-520, 2021 05.
Article in English | MEDLINE | ID: covidwho-1051360

ABSTRACT

BACKGROUND: Coronavirus disease (COVID-19) has caused global disruption to health care. Non-urgent elective surgical cases have been cancelled, outpatient clinics have reduced and there has been a reduction in the number of patients presenting as an emergency. These factors will drastically affect the training opportunities of surgical trainees. The aim of this systematic review is to describe the impact of COVID-19 on surgical training globally. METHODS: The review was performed in line with Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines and registered with the Open Science Framework (OSF). Medline, EMBASE, PubMed and the Cochrane Central Register of Controlled Trials were searched. RESULTS: The searches identified 499 articles, 29 of which were included in the review. This contained data from more than 20 countries with 5260 trainees and 339 programme directors. Redeployment to non-surgical roles varied across studies from 6% to 35.1%. According to all of the studies, operative experience has been reduced. Knowledge learning had been switched to online platforms across 17 of the studies and 7 reported trainees had increased time to devote to educational/academic activities. All of the studies reporting on mental health report negative associations with increased stress, ranging from 54.9% to 91.6% of trainees. CONCLUSIONS: The impact of COVID-19 on surgical trainees has been experienced globally and across all specialities. Negative effects are not limited to operative and clinical experience, but also the mental health and wellbeing of trainees. Delivery of surgical training will need to move away from traditional models of learning to ensure trainees are competent and well supported.


Subject(s)
COVID-19 , Humans , SARS-CoV-2
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