CORONA (COre ultRasOund of covid in iNtensive care and Acute medicine) study: National service evaluation of lung and heart ultrasound in intensive care patients with suspected or proven COVID-19.

Background: Combined Lung Ultrasound (LUS) and Focused UltraSound for Intensive Care heart (FUSIC Heart - formerly Focused Intensive Care Echocardiography, FICE) can aid diagnosis, risk stratification and management in COVID-19. However, data on its application and results are limited to small studies in varying countries and hospitals. This United Kingdom (UK) national service evaluation study assessed how combined LUS and FUSIC Heart were used in COVID-19 Intensive Care Unit (ICU) patients during the first wave of the pandemic. Method: Twelve trusts across the UK registered for this prospective study. LUS and FUSIC Heart data were obtained, using a standardised data set including scoring of abnormalities, between 1st February 2020 to 30th July 2020. The scans were performed by intensivists with FUSIC Lung and Heart competency as a minimum standard. Data was anonymised locally prior to transfer to a central database. Results: 372 studies were performed on 265 patients. There was a small but significant relationship between LUS score >8 and 30-day mortality (OR 1.8). Progression of score was associated with an increase in 30-day mortality (OR 1.2). 30-day mortality was increased in patients with right ventricular (RV) dysfunction (49.4% vs 29.2%). Severity of LUS score correlated with RV dysfunction (p < 0.05). Change in management occurred in 65% of patients following a combined scan. Conclusions: In COVID-19 patients, there is an association between lung ultrasound score severity, RV dysfunction and mortality identifiable by combined LUS and FUSIC Heart. The use of 12-point LUS scanning resulted in similar risk score to 6-point imaging in the majority of cases. Our findings suggest that serial combined LUS and FUSIC Heart on COVID-19 ICU patients may aid in clinical decision making and prognostication.

COVID-19 booster vaccination during pregnancy enhances maternal binding and neutralizing antibody responses and transplacental antibody transfer to the newborn.

The immune response to COVID-19 booster vaccinations during pregnancy for mothers and their newborns and the functional response of vaccine-induced antibodies against Omicron variants are not well characterized. We conducted a prospective, multicenter cohort study of participants vaccinated during pregnancy with primary or booster mRNA COVID-19 vaccines from July 2021 to January 2022 at 9 academic sites. We determined SARS-CoV-2 binding and live virus and pseudovirus neutralizing antibody (nAb) titers pre- and post-vaccination, and at delivery for both maternal and infant participants. Immune responses to ancestral and Omicron BA.1 SARS-CoV-2 strains were compared between primary and booster vaccine recipients in maternal sera at delivery and in cord blood, after adjusting for days since last vaccination. A total of 240 participants received either Pfizer or Moderna mRNA vaccine during pregnancy (primary 2-dose series: 167; booster dose: 73). Booster vaccination resulted in significantly higher binding and nAb titers, including to the Omicron BA.1 variant, in maternal serum at delivery and in cord blood compared to a primary 2-dose series (range 0.44-0.88 log10 higher, p < 0.0001 for all comparisons). Live virus nAb to Omicron BA.1 were present at delivery in 9 % (GMT ID50 12.7) of Pfizer and 22 % (GMT ID50 14.7) of Moderna primary series recipients, and in 73 % (GMT ID50 60.2) of mRNA boosted participants (p < 0.0001), although titers were significantly lower than to the D614G strain. Transplacental antibody transfer was efficient for all regimens with median transfer ratio range: 1.55-1.77 for IgG, 1.00-1.78 for live virus nAb and 1.79-2.36 for pseudovirus nAb. COVID-19 mRNA vaccination during pregnancy elicited robust immune responses in mothers and efficient transplacental antibody transfer to the newborn. A booster dose during pregnancy significantly increased maternal and cord blood binding and neutralizing antibody levels, including against Omicron BA.1. Findings support the use of a booster dose of COVID-19 vaccine during pregnancy.

Vaccine Breakthrough Cases in South Dakota: Impact of SARS-CoV-2 Variants in a Rural State.

BACKGROUND: Emergence of the SARS-CoV-2 Delta variant raised concern for greater transmissibility and severity of illness compared to the Alpha variant. Our objective was to compare SARS-CoV-2 vaccine breakthrough cases in South Dakota during the time periods where the Alpha and Delta variants of SARS-CoV-2 predominated. METHODS: Data were obtained from the South Dakota Department of Health's electronic disease surveillance system and South Dakota's Health Information Exchange. SARS-CoV-2 cases were matched with the immunization system data to verify vaccination status of vaccine breakthrough cases (VBC). The Alpha variant time-period (ATP) was defined as April 15-May 10, 2021 and the Delta variant time-period (DTP) as July 18-31, 2021. Case rates, demographics, risk factors, symptomology, and outcomes were compared for VBC during these periods. RESULTS: A total of 155 VBC were reported during the ATP and 153 during the DTP. The rate of SARS-CoV-2 VBC was 1.88 times higher for the DTP than the ATP. VBC during the ATP were more likely to present with no symptoms and during the DTP were more likely to present with subjective fever, cough, headache, loss or altered smell/taste, congestion, or postnasal drip. The average hospital length of stay was 6 days for the ATP and 4 days for the DTP. A total of 5 deaths were reported during the ATP compared to 1 death during the DTP. The non-statistically significant relation of the ATP and the DTP for hospital length of stay and number of deaths indicated a similar severity of disease. CONCLUSIONS: In fully vaccinated South Dakotans, the SARS-CoV-2 Delta variant was shown to cause 1.88 times higher breakthrough cases but resulted in similar severity of illness compared to the Alpha variant.

Goals of Care Conversations in Long-Term Care during the First Wave of the COVID-19 Pandemic.

Goals of care discussions typically focus on decision maker preference and underemphasize prognosis and outcomes related to frailty, resulting in poorly informed decisions. Our objective was to determine whether navigated care planning with nursing home residents or their decision makers changed care plans during the first wave of the COVID-19 pandemic. The MED-LTC virtual consultation service, led by internal medicine specialists, conducted care planning conversations that balanced information-giving/physician guidance with resident autonomy. Consultation included (1) the assessment of co-morbidities, frailty, health trajectory, and capacity; (2) in-depth discussion with decision makers about health status and expected outcomes; and (3) co-development of a care plan. Non-parametric tests and logistic regression determined the significance and factors associated with a change in care plan. Sixty-three residents received virtual consultations to review care goals. Consultation resulted in less aggressive care decisions for 52 residents (83%), while 10 (16%) remained the same. One resident escalated their care plan after a mistaken diagnosis of dementia was corrected. Pre-consultation, 50 residents would have accepted intubation compared to 9 post-consultation. The de-escalation of care plans was associated with dementia, COVID-19 positive status, and advanced frailty. We conclude that during the COVID-19 pandemic, a specialist-led consultation service for frail nursing home residents significantly influenced decisions towards less aggressive care.

Cost comparison between spinal versus general anesthesia for hip and knee arthroplasty: an incremental cost study Comparaison des coûts entre la rachianesthésie et l’anesthésie générale pour l’arthroplastie de la hanche et du genou : une étude de coût incrémentielle

Purpose Wait list times for total joint arthroplasties have been growing, particularly in the aftermath of the COVID-19 pandemic. Increasing operating room (OR) efficiency by reducing OR time and associated costs while maintaining quality allows the greatest number of patients to receive care. Methods We used propensity score matching to compare parallel processing with spinal anesthesia in a block room vs general anesthesia in a retrospective cohort of adult patients undergoing primary total hip arthroplasty (THA) and total knee arthroplasty (TKA). We compared perioperative costs, hospital costs, OR time intervals, and complications between the groups with nonparametric tests using an intention-to-treat approach. Results After matching, we included 636 patients (315 TKA;321 THA). Median [interquartile range (IQR)] perioperative costs were CAD 7,417 [6,521–8,109], and hospital costs were CAD 10,293 [9,344–11,304]. Perioperative costs were not significantly different between groups (pseudo-median difference [MD], CAD −47 (95% confidence interval [CI], −214 to −130;P = 0.60);nor were total hospital costs (MD, CAD −78;95% CI, −340 to 178;P = 0.57). Anesthesia-controlled time and total intraoperative time were significantly shorter for spinal anesthesia (MD, 14.6 min;95% CI, 13.4 to 15.9;P < 0.001;MD, 15.9;95% CI, 11.0 to 20.9;P < 0.001, respectively). There were no significant differences in complications. Conclusion Spinal anesthesia in the context of a dedicated block room reduced both anesthesia-controlled time and total OR time. This did not translate into a reduction in incremental cost in the spinal anesthesia group. Supplementary Information The online version contains supplementary material available at 10.1007/s12630-022-02303-3.

Cost comparison between spinal versus general anesthesia for hip and knee arthroplasty: an incremental cost study.

PURPOSE: Wait list times for total joint arthroplasties have been growing, particularly in the aftermath of the COVID-19 pandemic. Increasing operating room (OR) efficiency by reducing OR time and associated costs while maintaining quality allows the greatest number of patients to receive care. METHODS: We used propensity score matching to compare parallel processing with spinal anesthesia in a block room vs general anesthesia in a retrospective cohort of adult patients undergoing primary total hip arthroplasty (THA) and total knee arthroplasty (TKA). We compared perioperative costs, hospital costs, OR time intervals, and complications between the groups with nonparametric tests using an intention-to-treat approach. RESULTS: After matching, we included 636 patients (315 TKA; 321 THA). Median [interquartile range (IQR)] perioperative costs were CAD 7,417 [6,521-8,109], and hospital costs were CAD 10,293 [9,344-11,304]. Perioperative costs were not significantly different between groups (pseudo-median difference [MD], CAD -47 (95% confidence interval [CI], -214 to -130; P = 0.60); nor were total hospital costs (MD, CAD -78; 95% CI, -340 to 178; P = 0.57). Anesthesia-controlled time and total intraoperative time were significantly shorter for spinal anesthesia (MD, 14.6 min; 95% CI, 13.4 to 15.9; P < 0.001; MD, 15.9; 95% CI, 11.0 to 20.9; P < 0.001, respectively). There were no significant differences in complications. CONCLUSION: Spinal anesthesia in the context of a dedicated block room reduced both anesthesia-controlled time and total OR time. This did not translate into a reduction in incremental cost in the spinal anesthesia group.

RéSUMé: OBJECTIF: Les temps d'attente pour les arthroplasties articulaires totales ont augmenté, en particulier à la suite de la pandémie de COVID-19. Une augmentation de l'efficacité de la salle d'opération (SOP) fondée sur une réduction du temps en salle d'opération et des coûts associés, tout en maintenant la qualité, permettrait à un plus grand nombre de patients de recevoir des soins. MéTHODE: Nous avons utilisé l'appariement par score de propension pour comparer en parallèle des traitements par rachianesthésie dans une salle de bloc vs par anesthésie générale dans une cohorte rétrospective de patients adultes bénéficiant d'une arthroplastie totale de la hanche (ATH) et d'une arthroplastie totale du genou (ATG) primaires. Nous avons comparé les coûts périopératoires, les coûts hospitaliers, les intervalles de temps en SOP et les complications entre les groupes avec des tests non paramétriques en utilisant une approche d'intention de traiter. RéSULTATS: Après appariement, nous avons inclus 636 patients (315 ATG; 321 ATH). Les coûts périopératoires médians [écart interquartile (ÉIQ)] étaient de 7417 $ CA [6521 ­ 8109] et les coûts hospitaliers de 10 293 $ CA [9344 ­ 11 304]. Les coûts périopératoires n'étaient pas significativement différents entre les groupes (différence pseudomédiane [DM], −47 $ CA (intervalle de confiance à 95 % [IC], −214 à −130; P = 0,60), pas plus que les coûts hospitaliers totaux (DM, −78 $ CA; IC 95 %, −340 à 178; P = 0,57). Le temps sous anesthésie et le temps peropératoire total étaient significativement plus courts pour la rachianesthésie (DM, 14,6 min; IC 95 %, 13,4 à 15,9; P < 0,001; DM, 15,9; IC 95 %, 11,0 à 20,9; P < 0,001, respectivement). Aucune différence significative n'a été observée dans les complications. CONCLUSION: La rachianesthésie dans un contexte de salle de bloc dédiée a réduit à la fois le temps sous anesthésie et le temps total de SOP. Cela ne s'est pas traduit par une réduction du coût différentiel dans le groupe recevant une rachianesthésie.

Multi-site observational maternal and infant COVID-19 vaccine study (MOMI-vax): a study protocol.

BACKGROUND: Pregnant women were excluded from investigational trials of COVID-19 vaccines. Limited data are available to inform pregnant and postpartum women on their decisions to receive a COVID-19 vaccine. METHODS: The goal of this observational, prospective cohort study is to evaluate the immunogenicity and safety of various Emergency Use Authorization (EUA) or licensed COVID-19 vaccines administered to pregnant or lactating women and describe the transplacental antibody transfer and kinetics of antibodies in mothers and infants. The study is adaptive, allowing additional groups to be added as new vaccines or vaccine regimens are authorized. Up to 20 clinical research institutions in the United States (U.S.) will be included. Approximately 200 pregnant women and 65 postpartum women will be enrolled per EUA or licensed COVID-19 vaccine formulation in the U.S. This study will include pregnant and postpartum women of all ages with and without chronic medical conditions. Their infants will be enrolled and followed beginning at birth in the pregnant cohort and beginning at the earliest possible time point in the postpartum cohort. Blood samples will be collected for immunogenicity outcomes and pregnancy and birth outcomes assessed among women and infants. Primary analyses will be descriptive and done by vaccine type and/or platform. DISCUSSION: Given the long-standing and legitimate challenges of enrolling pregnant individuals into clinical trials early in the vaccine development pipeline, this study protocol describes our current study and provides a template to inform the collection of data for pregnant individuals receiving COVID-19 or other vaccines. TRIAL REGISTRATION: NCT05031468 .

Neurocognitive Profiles in Patients With Persisting Cognitive Symptoms Associated With COVID-19.

OBJECTIVE: A subset of individuals with coronavirus disease 2019 (COVID-19) appears to develop persisting cognitive and medical symptoms. Research in the acute stages of illness, generally utilizing cognitive screening measures or case reports, suggests presence of deficits in attention and executive function. This observational study investigated cognitive functioning among individuals with persistent cognitive complaints about 5.5 months after COVID-19 infection. METHODS: Patients with polymerase chain reaction confirmed COVID-19 and persistent cognitive complaints underwent comprehensive in-person neuropsychological evaluations. Patients with prior neurological disorders were excluded. When diagnosed, 40% required hospitalization, 15% were in an intensive care unit, 10% needed mechanical ventilation, and 10% experienced delirium. RESULTS: This sample was predominately women (90%), White non-Hispanic (70%), with average education of 15 years. Mild cognitive deficits were seen on tests involving attention and processing speed or executive function. Seventy percent of patients were diagnosed with a mood disorder prior to COVID-19 infection. At the time of testing, 35%-40% endorsed moderate to severe mood symptoms and 85% noted significant fatigue as measured by the Fatigue Severity Scale. CONCLUSIONS: The pattern of cognitive deficits, although mild, is consistent with prior research at the acute stage of the illness. These findings suggest that psychological factors and other persisting symptoms (e.g., sleep, fatigue) may play a significant role in subjective cognitive complaints in patients with persisting complaints post COVID-19 who did not require intensive treatment. These patients would likely benefit from resources to manage persisting or new mood symptoms and compensatory strategies for the cognitive inefficiencies they experience.

The Utility of a Novel Definition of Health Care Regions in the United States in the Era of COVID-19: A Validation of the Pittsburgh Atlas Using Pneumonia Admissions.

STUDY OBJECTIVE: The COVID-19 pandemic in the United States has underscored the need to understand health care in a regional context. However, there are multiple definitions of health care regions available for conducting geospatial analyses. In this study, we compare the novel Pittsburgh Atlas, which defined regions for emergency care, with the existing definitions of regions, counties, and the Dartmouth Atlas, with respect to nonemergent acute medical conditions using pneumonia admissions. METHODS: We identified patients hospitalized with a primary diagnosis of pneumonia or a primary admitting diagnosis of sepsis with a secondary diagnosis of pneumonia in the Agency for Healthcare Research and Quality's State Inpatient Databases. We calculated the percentage of region concordant care, the localization index, and market share for 3 definitions of health care regions (the Pittsburgh Atlas, Dartmouth Atlas, and counties). We used logistic regression identified predictors of region concordant care. RESULTS: We identified 1,582,287 patients who met the inclusion criteria. We found that the Pittsburgh Atlas and Dartmouth Atlas definitions of regions performed similarly with respect to both localization index (92.0 [interquartile range 87.9 to 95.7] versus 90.3 [interquartile range 81.4 to 94.5]) and market share (8.5 [interquartile range 5.1 to 13.6] versus 9.4 [interquartile range 6.7 to 14.1]). Both atlases outperformed the localization index (67.5 [interquartile range 49.9 to 83.9]) and market share (20.0% [interquartile range 11.4 to 31.4]) of the counties. Within a given referral region, the demographic factors, including age, sex, race/ethnicity, insurance status, and the level of severity, affected concordance rates between residential and hospital regions. CONCLUSION: Because the Pittsburgh Atlas also has the benefit of respecting state and county boundaries, the use of this definition may have improved policy applicability without sacrificing accuracy in defining health care regions for acute medical conditions.