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Introduction: We work in a large, tertiary Teaching Hospital Critical Care unit. As such we have a sizeable and diverse workforce from multiple professional backgrounds. We noted both anecdotally, and from the formal process of Exit Interviews that the changes imposed by the Covid-19 pandemic were impacting on team relationships. Physical barriers enforced by social distancing, as well as the burden of increased patient numbers and changes to job roles had driven apart nursing and medical teams. Critical care appeals to many staff because of the MDT and the chance to work with highly qualified, ambitious colleagues with varying skill sets. Nurturing this positive working relationship between different teams requires a commitment from all to share the burden of increased pressures wherever possible. Objective(s): The aims for this project are to identify specific areas within the working relationship between the medical team and the nursing team that can be improved. More than this, we want to open wider conversation about how teams can work more collaboratively for the benefit of the working environment, staff mental health and ultimately the patient. Method(s): We created an e-survey with input from the critical care matrons and psychologists before distributing amongst nursing staff. Questions focused on communication, practical support and the general working relationship. Each section contained MCQ's and white space questions to allow us to collect both quantitative and qualitative data. Following collection of responses we identified common themes that could be addressed and created an eye-catching poster with specific suggestions for the medical team. Result(s): Communication: Common themes were more presence on the unit with more regular walk-rounds and that STAT medications are often prescribed but not communicated to the nurse at the bedside and are therefore delayed. Practical support: Common suggestions were helping with repositioning patients and relieving breaks. Others included, pulling blood gases, printing off blood request forms and working in pairs for lines so that the nurse doesn't have to be engaged. Working relationship: suggestions mainly focused around introducing ourselves and level of training as well as social integration of the two teams. A few said that improving the communication and assisting with tasks would feed into improving the relationship. A few also said that the survey itself was a good start. Discussion(s): The survey generated many useful suggestions as well as demonstrating an open and receptive attitude. Responses were used to create a poster that gives clear and practical advice to the medical team. This method is easily reproducible and we believe that we have already seen positive changes that have been widely well received. We plan also to send a follow up survey once changes have become ingrained into the culture of the workforce. Acknowledgements Matthew Powell Jane Atkins Nathan Shearman Helen Horton.
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Background: Substance use is an understudied aspect of cystic fibrosis (CF) care. Even casual use of drugs or alcohol may reduce compliance with complicated treatment plans, worsen existing conditions associated with CF, or cause potential drug interactions. To understand the need for mitigation mechanisms for risky substance use in a CF population, we studied the prevalence of substance use in our adult CF clinic population to characterize relationships between substance use and health status. Method(s): In our large academic CF center, we performed a retrospective chart ion of 420 patients over a 6-year period (2015-2021). Clinical staff annually administer the Drug Abuse Screening Test (DAST-10), Alcohol Use Disorders Identification Test (AUDIT), Patient Health Questionnaire (PHQ-9), and General Anxiety Disorder (GAD-7) to assess drug use, alcohol use, depression, and anxiety symptoms, respectively. Demographic characteristics, lung function (percentage predicted forced expiratory volume in 1 second (FEV1pp)), and anxiety and depression symptom screening scores were recorded. Because substance use can change over time, we counted each assessment date as an independent observation (n = 1434). The chi-square test (Table 1) was conducted in R/RStudio [1] to assess for associations between self-reported substance use and symptoms of depression and anxiety. Because of insufficient data, aggregate datawere used to describe the presence (PHQ-9 or GAD-7 >= 10) or absence (PHQ-9 or GAD-7 < 10) of symptoms of depression and anxiety. Result(s): Positive scores for risky use were defined as a DAST score of 1 or higher and an AUDIT score of 8 or hither. Eighty-three of 326 patients (25%) met criteria for risky substance use on at least one observation. Therewas a slight male predominance (54.2%) and wide age distribution (mean age 30 +/- 7, range 20-55);Thirty (36.1%) had a higher AUDIT score, 34 (40.9%) had a high DAST score, and 19 (22.9%) had high scores on both.We selected 2019 to evaluate single-year prevalence of positive screenings to avoid the impact of COVID. In 2019, 29 patients had at least one positive screening result (DAST,15/203, 7.3%;AUDIT, 24/193,12%;both,10/193, 5.2%). In the 6- year dataset, we did not find a statistically significant association between symptoms of depression and anxiety and indication of drug or alcohol use in self-reported users (355 observations). Conclusion(s): According to a 2020 national survey of healthy Americans, 20.8% have used illicit drugs at least once in the past year, and 10.2% meet criteria for alcohol use disorder [2], compared with 7.3% of patients in our 2019 data who have used drugs (n = 15) and 12% (n = 24) who indicated risky alcohol use. In this review, positive screening scores on the DAST and AUDIT were not associated with degree of symptoms of depression and anxiety, suggesting that substance use and symptoms of depression and anxiety were not temporally associated with each other. Future work will include analysis of the relationship between substance use and mental health in the larger University of North Carolina clinic population and linear regression to evaluate possible explanatory variables for substance use in this populationCopyright © 2022, European Cystic Fibrosis Society. All rights reserved
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Aims: To describe longitudinal associations between health-related quality of life (HR-QoL) scores and demographic, clinical, and health behavioral characteristics in a multisite U.S. cohort of adults in HIV care. Method(s): People with HIV (PWH) completed an electronic assessment of patient-reported outcomes (PROs) as part of routine clinical care between 2016 and 2021 including measures for HR-QoL (EQ-5D-3L), substance use (ASSIST, AUDIT/AUDIT-C), smoking, and HIV stigma, among others. We used generalized linear latent and mixed models with nonparametric random effects for the intercept term to accommodate repeated measures on individuals to examine longitudinal factors associated with HR-QoL overall and stratified by birth-sex. Result(s): PWH (n = 10,559, median age at first assessment = 49, 17.8% cis-gender women, 1.4% transgender women;68.3% non-White) completed 33,866 assessments. Lower HR-QoL scores were associated with increasing age (p <= 0.0001);identifying as female (cis or transgender) compared to cisgender male (p <= 0.0001, p = 0.005, respectively);living in the Southeast or Western US relative to Northeast (both p <= 0.0001);identifying as a sexual orientation other than gay (heterosexual p = 0.03, bisexual p = 0.009, other p <= 0.0001);higher internalized HIV stigma (p <= 0.0001);current or former smoking (both p <= 0.0001);past methamphetamine use (p = 0.015) and current cocaine/crack, methamphetamine, opioid and cannabis use (p <= 0.0001 for each except cannabis, which was p = 0.007). Higher HR-QoL scores were associated with race/ethnicities other than White (Black: p = 0.002, Hispanic: p = 0.002, other: p <= 0.0001);the COVID-19 pandemic period (March 2020-December 2021) (p <= 0.0001);and increased AUDIT/AUDIT-C score (p = 0.001). In sex stratified models men (n = 8666) had higher HR-QoL scores among non-white compared to white (Black p = 0.0006, Hispanic p = 0.007, Other p <= 0.0001);and during the COVID period (p <= 0.0001). Men had lower HR-QoL scores among heterosexual and bisexual men relative to gay (p = 0.004, p = 0.005), if they were a former smoker (p <= 0.0001), and among past or current methamphetamine users relative to nonusers (p = 0.002, p <= 0.0001). Women (n = 1893) had higher HR-QoL scores if in care longer (p = 0.005), and lower HR-QoL if in the South (p <= 0.0001), if previously used cocaine/crack (p <= 0.0001), or if currently uses marijuana (p = 0.001). Conclusion(s): Our findings describe HR-QoL and its associations among a large diverse cohort of PWH, identifying potentially modifiable factors to improve HR-QoL, such as substance use, smoking, and impact of HIV-related stigma.
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Most physical therapists would agree that physical rehabilitation is difficult to perform remotely. Consequently, the global COVID-19 pandemic has forced many physical therapists and their clients to adapt to telehealth, especially with video conferencing. In this article, we ask: How has telehealth for physical rehabilitation evolved with the global pandemic and what are the largest technological needs, treatment methodologies, and patient barriers? With the increased widespread use of telehealth for physical therapy, we present a qualitative study towards examining the shortcomings of current physical therapy mediums and how to steer future virtual reality technologies to promote remote patient evaluation and rehabilitation. We interviewed 130 physical rehabilitation professionals across the United States through video conferencing during the COVID19 pandemic from July—August 2020. Interviews lasted 30–45 min using a semi-structured template developed from an initial pilot of 20 interviews to examine potential barriers, facilitators, and technological needs. Our findings suggest that physical therapists utilizing existing telehealth solutions have lost their ability to feel their patients’ injuries, easily assess range of motion and strength, and freely move about to examine their movements when using telehealth. This makes it difficult to fully evaluate a patient and many feel that they are more of a “life coach” giving advice to a patient rather than a traditional in-person rehabilitation session. The most common solutions that emerged during the interviews include: immersive technologies which allow physical therapists and clients 1) to remotely walk around each other in 3D, 2) enable evidence-based measures, 3) automate documentation, and 4) provider clinical practice operation through the cloud. We conclude with a discussion on opportunities for immersive virtual reality towards telehealth for physical rehabilitation. Copyright © 2022 Elor, Conde, Powell, Robbins, Chen and Kurniawan.
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Objectives: Obesity is an epidemic in gynecologic oncology, leading to an increased risk of surgical complications and poor cancer outcomes. Cognitive-behavioral therapy (CBT) is an effective weight loss strategy. We aimed to determine whether group CBT is an effective weight loss tool when offered in an outpatient gynecologic oncology setting. Methods: We established a CBT-based weight management intervention for gynecologic oncology patients at an NCI-designated cancer center. The intervention was a 12-week group-based weight loss program offered to patients from the gynecologic oncology clinic with body mass indices (BMI) between 25-50 kg/m2. Sessions were free of charge, led by a psychologist and dietitian, and transitioned from in-person to tele-visits due to the COVID-19 pandemic. The program combined nutritional education, lifestyle changes, and CBT approaches, with 12 weekly group visits followed by three monthly individual follow-up visits. Each participant was given a goal weight loss of 7% total body weight (TBW). Retrospective data were collected from patients enrolled in the intervention from September 2019 through March 2021. Paired t-tests were performed to compare the pre-program and ending weights for all participants. Weight loss data were tested for normality using the Shapiro-Wilk test. Results: A total of 29 patients were enrolled in four cohorts during the study timeframe. Fifty-nine percent of participants were White, 38% were Black. The mean age among participants was 56 years, and the mean BMI was 41 kg/m2. Most participants had a history of endometrial hyperplasia or malignancy (58%) and had stage I disease (59%). Among the participants, 22 (76%) completed the program. The average weight loss among all participants during the 12-week program was 5.6 pounds (CI: -8.9- -2.1, p = 0.002), equivalent to an average 2% change in TBW. Among the 22 participants who completed the program, the average weight loss was 7.4 pounds (CI: -11.1- -3.8, p <0.001), equivalent to an average 3% change in TBW. Weight loss was sustained at the 6-month mark, with an average change in TBW of 2-3% when comparing weight at 6 months to pre-program weight. Conclusions: This CBT-based weight loss intervention was feasible and acceptable to gynecologic oncology patients. While the average weight loss fell short of the goal of 7% TBW, the 2-3% change in TBW achieved on average with this intervention was stable over six months. Additionally, retention within the intervention was high and maintained during COVID-19 with tele-visits. Given that weight loss plateaued when transitioning from weekly to monthly sessions, our findings suggest that longer, more intensive treatment may be needed to promote sustainable weight loss among gynecologic oncology patients. Collaboration between psychologists, oncology dietitians, and gynecologic oncologists, with continued support for psychologists and dieticians at cancer centers, is critical to the success of such programs. CBT is a feasible behavioral intervention to add further multidisciplinary efforts to tackle the complexity of obesity in cancer survivors. [Formula presented]
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Background: We provide care for the rural, low-income, and underserved population of Oroville. The community has a vaccination rate of 50% and booster rate of over 20% in the 3rd year of the ongoing global SARS-CoV-2 pandemic in 2022. During this period, a subset of our cancer patients benefited from the use of immune checkpoint inhibitors. Methods: This is a cross-sectional observational study of the effectiveness of a mRNA-based vaccine in medical care workers compared to patients with systemic malignancies treated with immunomodulation of PD-1 and CTLA-4 inhibitors. The study was approved by the hospital IRB. We evaluated the total anti-Spike protein antibody titer using a commercial semi-quantitative assay, Labcorp Test #164090. All subjects received 3 doses of the mRNA vaccine. We excluded anyone who was administered therapeutic monoclonal antibodies (mAb) or had a recent infection within 120 days. Results: Subjects with systemic malignancies were significantly older, p = 0.0001 by t-test: median age: 76, range: 64-82, compared to health care workers: median age: 52, range: 21-75. Accrual had to be prematurely stopped upon the arrival of Omicron wave in the community. Out of the seven subjects treated with immunomodulation, six received nivolumab, including two in combination with ipilimumab. One subject received pembrolizumab. Six of the subjects had metastatic disease: one was treated adjuvantly for locally advanced esophageal adenocarcinoma. The rest had NSCLC and one case of urothelioma. We divided the groups to those who had the highest titer of antibody versus everybody else and found a similar distribution in both groups using the Chi2 test. The vast majority of the healthcare workers, 24/27 or 89%, had above the upper limit antibody titer. Patients with systemic malignancy, 5/7 or 71%, had above the upper limit antibody titer p = N.S. Conclusions: Three doses of the mRNA vaccine provided high titers irrespective of frailty or age. We hypothesize that immunomodulation could favorably affect vaccination response.
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Background Anticipated severe illness at the start of the COVID-19 pandemic bought increased endorsement, awareness and provision of advance care planning in adults with serious illness. Place of death is often considered a surrogate quality indicator for end-of-life care. Aim To examine the impact of advance care planning on place of death for patients who died during the COVID-19 pandemic with a Coordinate My Care (CMC) record, the Electronic Palliative Care Coordination System currently commissioned in London. Methods Retrospective non-interventional cohort analysis of CMC records for patients aged over 18 who died between 20/03/20 and 05/03/21 with recorded place of death. Patient demographics, socio-economic position and advance care planning related factors associated with achieving preferred place of death were explored using logistic regression. Results 11,913 records were included. 76.9% patients died in their preference place of death (57.7% Home, 31.4% Care Home, 7.5% Hospice, 3.3% Hospital, 0.1% Other). A higher likelihood of dying in the preferred place was associated with a 'Not for resuscitation' (DNACPR) status (OR=1.55, 95% CI 1.23 to 1.95), a Ceiling of Treatment for 'Symptomatic Treatment' (when compared to 'Full active treatment', OR=3.55, 95% CI 2.78 to 4.53), discussions with family regarding resuscitation recommendations (OR=1.53, 95% CI 1.34 to 1.74) and at least 2 non-urgent care record views in the 30days before death (OR=1.27, 95% CI 1.23 to 1.43). Patients from areas of lower socio-economic position had a decreased likelihood of dying in their preferred place (OR= 0.65, 95% CI 0.54 to 0.79). Conclusion Components of Advance care planning carry potential to significantly influence place of death, even in times of crisis and when controlling for socio-economic and demographic determinants. Effective advance care planning is fundamental to achieving patient-centred, high-quality end-oflife care and factors relating to it must be considered in ongoing research on end-of-life outcomes.
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This chapter brings together the literatures on learning and policy transfer with material on crisis learning in order to assess policy transfer in the COVID-19 pandemic in the UK. The policy transfer literature focuses on ‘normal’ times, but there is little on policy transfer in a crisis, with its constituent elements of threat, uncertainty and urgency. Conversely, it is broadly argued that lesson-drawing is one of the most underdeveloped aspects of crisis management. The literature distinguishes learning across crises and learning within a crisis, or inter-crisis and inter-crisis management, and between ‘routine’ and ‘non-routine’ or ‘less routine’ crises. While there is some literature on inter-crisis learning from Pandemics, the material on intra-learning during Pandemics is limited. The main aim of the chapter is to explore the UK response to COVID-19 with respect to the crisis and lesson-drawing literatures. The material is primarily drawn from ‘scientific’ and ‘political’, and analysed by Interpretative Content Analysis. It is concluded given the difficulty of learning in the urgency, uncertainty and threat of a crisis situation, it is hardly surprising that in the case of COVID-19, high complexity and limited fungibility intra-crisis policy transfer from the past and from abroad was limited. © 2021, The Author(s), under exclusive license to Springer Nature Switzerland AG.
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Background/aims: Mortality forecasts associated with COVID-19 pandemic stressed a need to prepare adults with advanced disease for possible severe illness and engage with Advance Care Planning (ACP). We aimed to examine ACP engagement and activity during the COVID-19 pandemic. Methods: A retrospective non-interventional cohort study, comparing the creation, content and use of Coordinate My Care (CMC) records that include an ACP component, in London, prior to and during the onset of COVID-19. Records for people aged 18+, created and published in prepandemic period (2018-2019) and 'wave 1' (W1) of COVID-19 (20/03/20- 04/07/20) were extracted. Demographics, ACP-related content and the use of CMC records created were analysed and compared using standard descriptive statistics. Results: 56,343 records were included, 35,108 from the pre-pandemic period and 21,235 records from W1. The average records created each week rose by 296.9% (P<0.005) in W1. There were fewer records in W1 for those aged 80 years (60.8% vs 64.9% pre-pandemic, P<0.005) and who had WHO performance status of 4 (34.8% vs 44.2% pre pandemic, P<0.005). More people who created records during W1 had an estimated prognosis of at least a year (73.3% vs 53.0% pre-pandemic, P<0.005), were “For Resuscitation” (38.2% vs 29.8% pre-pandemic, P<0.005) and had a Ceiling of Treatment of “Full Active Treatment” (32.4% vs 25.7%, P<0.005). More people in W1 listed hospital as their preferred place of care (PPC) and preferred place of death (PPD) (PPC: 13.3% vs 5.8% pre-pandemic, P<0.005. PPD: 14.0% vs 7.9%, P<0.005). Average monthly non-urgent and urgent record views rose by 320.3% (P=0.02) and 154.3% (P=0.01) in W1. Conclusions: A large uptake in engagement with ACP is demonstrated during the 1st wave of the pandemic. An increase in use among younger, more independent patients with longer prognoses, with a higher preference for hospital care creating records in W1 compared to before the pandemic, suggests heightened awareness and provision of ACP at this time.
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Background/aims: At the beginning on the COVID-19 pandemic, advance care planning (ACP) was widely encouraged and endorsed for adults with serious illness to ensure their treatment and care preferences would be honoured, including location of death, often considered a surrogate quality indicator for end-of-life care. Coordinate My Care (CMC) represents the UK's largest Electronic Palliative Care Coordination System that comprises an ACP component. We aimed to examine the impact of ACP on place of death for people who died during the COVID-19 pandemic with a CMC record. Methods: Retrospective cohort analysis of CMC records for people aged over 18 who died between 20/03/20 and 05/03/21 with recorded place of death. Socio-demographic, clinical and ACP-related factors associated with achieving preferred place of death (PPD) were examined using logistic regression. Results: 11,913 records were included. 76.9% patients died in their preferred place location of death (57.7% Home, 31.4% Care Home, 7.5% Hospice, 3.3% Hospital, 0.1% Other). An increased likelihood of dying in PPD was associated with a 'Not for resuscitation' (DNACPR) status (OR=1.55, 95% CI 1.23 to 1.95), a Ceiling of Treatment for Symptomatic Treatment (when compared to Full active treatment, OR=3.55, 95% CI 2.78 to 4.53), documented family discussions regarding resuscitation recommendations (OR=1.53, 95% CI 1.34 to 1.74) and 2+ non-urgent care record views in the 30 days before death (OR=1.27, 95% CI 1.23 to 1.43). People from materially deprived areas had a decreased likelihood of dying in their PPD (OR= 0.65, 95% CI 0.54 to 0.79). Conclusions: Modifiable elements of ACP significantly influence place of death, even when controlling for socio-economic and demographic determinants. In times of crisis, effective ACP is central to delivering high quality end-of-life care;ACP related factors must be considered in ongoing research on end-of-life outcomes.
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This article assesses, using a framework derived from lesson-drawing, policy transfer and crisis research, the lessons offered by the media from abroad and from the past in the UK COVID-19 pandemic. The lesson-drawing literature focuses on a series of steps and questions associated with the 'fungibility' of lessons, and the crisis literature, with its constituent elements of threat, uncertainty and between 'routine' and 'non-routine' or 'less routine' crises. The article utilises the LexisNexis Database' in order to provide a content analysis of newspaper coverage of lessons offered, giving analysis in 'real time' of the source of potential lessons (e.g. past pandemics or other nations), and the type of lessons (e.g. copying or instruments). Its analysis highlights the complexity of lesson-drawing in 'real time' in a period of considerable uncertainty, where knowledge is contested, and is subject to change over time.
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Background. mRNA vaccines for coronavirus disease 2019 (COVID-19) illicit strong humoral and cellular responses and have high efficacy for preventing and reducing the risk of severe illness from COVID-19. Since solid organ transplant (SOT) recipients were excluded from the phase 3 trials, the efficacy of the COVID-19 vaccine remains unknown. Understanding the serological responses to COVID vaccines among SOT recipients is essential to better understand vaccine protection for this vulnerable population. Methods. In this prospective cohort study, a subset of SOT recipients who were part of our center's larger antibody study were enrolled prior to receipt of two doses of the BNT162b2 (Pfizer, Inc) vaccine for high resolution immunophenotyping. To date, plasma has been collected for 10 participants on the day of their first dose (baseline), day of their second dose, and 28 days post second dose. 23 healthy participants planning to receive either BNT162b2 or mRNA-1273 (ModernaTX, Inc) were also enrolled, providing plasma at the same timepoints. Ultrasensitive single-molecule array (Simoa) assays were used to detect SARS-CoV-2 Spike (S), S1, receptor-binding domain (RBD) and Nucleocapsid (N) IgG antibodies. Results. Participant demographics and SOT recipient characteristics are summarized in Table 1. Low titers of anti-N IgG at all timepoints indicate no natural infection with COVID-19 during the study (Fig 1A). There were significantly lower magnitudes for anti-S (p< 0.0001), anti-S1 (p< 0.0001), and anti-RBD (p< 0.0001) IgG titers on the day of dose 2 and day 28 post second dose for SOT recipients compared to healthy controls (Fig 1B,C,D). Using the internally validated threshold of anti-S IgG >1.07 based on pre-pandemic controls, only 50% of the SOT sub-cohort responded to vaccine after series completion (Fig 2). There was a positive trend between months from transplant and anti-S IgG titer (Fig 3). Black error bars denote median and 95% CI. The dotted line on panel B denotes an internally validated cutoff of 1.07;anti-S IgG titers greater than 1.07 denote a positive response. SOT recipients further out from transplant tend to have a higher anti-S IgG response. The dotted line denotes an internally validated cutoff, with anti-S IgG titers greater than 1.07 indicating a positive response. Conclusion. SOT recipients had a significantly decreased humoral response to mRNA COVID-19 vaccines compared to the healthy cohort, with those further out from transplant more likely to respond. Further research is needed to evaluate T-cell responses and clinical efficacy to maximize the SARS-CoV-2 vaccine response among SOT recipients.
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Background. Allogeneic stem cell transplant (SCT) recipients are at an increased risk of poor outcomes from COVID-19. While the mRNA-1273 (Moderna) and BNT162b2 (Pfizer) COVID-19 mRNA vaccines are highly immunogenic in the general population, the immune response in SCT recipients is poorly understood. We characterized the immunogenicity and reactogenicity of COVID-19 mRNA vaccines in a cohort of SCT patients. Methods. We performed a prospective cohort study of 16 allogeneic SCT patients and 23 healthy controls. Blood samples for both cohorts were collected prior to first vaccination (baseline), at the time of second vaccination, and approximately 28 days post-second vaccination. Anti-Spike (S), anti-S1, anti-receptor binding domain (RBD), and anti-Nucleocapsid (N) IgG levels were measured quantitatively from plasma using a multiplexed single molecule array (Simoa) immunoassay. Reactogenicity was captured for the SCT cohort via a self-reported post-vaccination diary for 7 days after each dose. Results. Demographics and SCT recipients' characteristics are shown in Table 1. In the SCT cohort, we observed a significantly lower anti-S (p< 0.0001), S1 (p< 0.0001), and RBD (p< 0.0001) IgG responses as compared to healthy controls, both at the time of dose 2 and 28 days post-vaccine series (Fig 1). Overall, 62.5% of SCT recipients were responders after vaccine series completion, as compared to 100% of healthy controls (Fig 2). While no patients had a reported history of COVID-19 diagnosis, 2 patients in the SCT cohort had elevated anti-S IgG levels and 1 showed elevated anti-N at baseline. 10/16 participants in the SCT cohort completed at least one post-vaccination diary. Local and systemic reactions were reported by 67% and 22% of participants, respectively, after dose 1, and 63% and 50% after dose 2 (Figure 3). All reported events were mild. Anti-Spike (A), anti-S1 (B), anti-RBD (C), and anti-nucleocapsid (D) IgG titers were measured at baseline, time of second dose, and approximately 28 days after second vaccination. IgG levels were measured quantitatively using multiplexed single molecule array (Simoa) immunoassays, and are reported as Normalized Average Enzymes per Bead (AEB). Allogeneic stem cell transplant recipients (mauve) showed significantly lower anti-S, S1, and RBD IgG responses as compared to healthy controls (mint). Low titers of anti-N IgG demonstrates no history of COVID-19 natural infection during the course of the study. 10 allogeneic stem cell transplant recipients completed at least one diary for 7 days after vaccination. Reactions after dose 1 are shown in light blue, and reactions after dose 2 are shown in dark blue. Local reactions (A) were reported by 67% (6/9) of participants after dose 1, and 63% (5/8) after dose 2. Systemic reactions (B) were reported by 22% (2/9) of participants after dose 1, and 50% (4/8) after dose 2. All reported events were mild (Grade 1). Conclusion. Among SCT recipients, mRNA COVID-19 vaccines were well-tolerated but less immunogenic than in healthy controls. Further study is warranted to better understand heterogeneous characteristics that may affect the immune response in order to optimize COVID-19 vaccination strategies for SCT recipients. Figure 2: Response Rate to COVID-19 Vaccination An internally validated threshold for responders was established using pre-pandemic sera from healthy adults. A positive antibody response was was defined as individuals with anti-Spike IgG levels above the 1.07 Normalized AEB threshold.
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Background. Patients with lymphoid malignancies are at high risk of severe COVID-19 disease and were not included in the phase 3 mRNA vaccine trials. Many patients with lymphoid malignancies receive immunosuppressive therapies, including B-cell depleting agents, that may negatively impact humoral response to vaccination. Methods. We recruited patients with lymphoid malignancies and healthy participants who planned to receive two doses of SARS-CoV-2 mRNA vaccine (BNT162b2 or mRNA-1273). Blood was drawn at baseline, prior to second dose of vaccine, and 28 days after last vaccination. Disease characteristics and therapies were extracted from patients' electronic medical record. An ultrasensitive, single molecule array (Simoa) assay detected anti-Spike (S), anti-S1, anti-receptor binding domain (RBD), and anti-Nucleocapsid (N) IgG from plasma at each timepoint. Results. 23 healthy participants and 37 patients with lymphoid malignancies were enrolled (Table 1). Low titers of anti-N (Fig 1A) demonstrate no prior exposure or acquisition of COVID-19 before vaccination or during the study. 37.8% of the lymphoid malignancy cohort responded to the vaccine, using an internally validated AEB cutoff of 1.07. A significantly higher magnitude of anti-S (p< 0.0001), anti-S1 (p< 0.0001) and anti-RBD (p< 0.0001) are present in the healthy as compared to lymphoid malignancy cohort at the second dose and day 28 post-series (Fig 1B, Fig 1C and Fig 1D). Anti-S IgG titers were compared between the healthy cohort, treatment naI&Die;ve, and treatment experienced groups (Fig 2). The treatment naI&Die;ve cohort had high titers by series completion which were not significantly different from the healthy cohort (p=0.2259), although the treatment experienced group had significantly decreased titers (p< 0.0001). Of the 20 patients who had received CD20 therapy, there was no clear correlation of anti-S IgG response with time from CD20 therapy, although most patients who received CD20 therapies within 12 months from the vaccine had no response (Figure 3). Conclusion. The vaccine-induced immune response was poor among treatment-experienced patients with lymphoid malignancies, especially among those who received CD20 therapies within 12 months.
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Objective: The adoption of telehealth rapidly accelerated due to the global COVID19 pandemic disrupting communities and in-person healthcare practices. While telehealth had initial benefits in enhancing accessibility for remote treatment, physical rehabilitation has been heavily limited due to the loss of hands-on evaluation tools. This paper presents an immersive virtual reality (iVR) pipeline for replicating physical therapy success metrics through applied machine learning of patient observation. Methods: We demonstrate a method of training gradient boosted decision-trees for kinematic estimation to replicate mobility and strength metrics with an off-the-shelf iVR system. During a two-month study, training data was collected while a group of users completed physical rehabilitation exercises in an iVR game. Utilizing this data, we trained on iVR based motion capture data and OpenSim biomechanical simulations. Results: Our final model indicates that upper-extremity kinematics from OpenSim can be accurately predicted using the HTC Vive head-mounted display system with a Mean Absolute Error less than 0.78 degrees for joint angles and less than 2.34 Nm for joint torques. Additionally, these predictions are viable for run-time estimation, with approximately a 0.74 ms rate of prediction during exercise sessions. Conclusion: These findings suggest that iVR paired with machine learning can serve as an effective medium for collecting evidence-based patient success metrics in telehealth. Significance: Our approach can help increase the accessibility of physical rehabilitation with off-the-shelf iVR head-mounted display systems by providing therapists with metrics needed for remote evaluation. Author
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Introduction: The COVID-19 pandemic led to cancellation of all face-to-face clinics in our health board in mid-March 2020. Overnight we had to develop an alternative service for our cystic fibrosis children. We set up video clinics from end of March 2020 using Webex initially and then Attend Anywhere when this became available in July 2020. We also arranged supplies of rescue antibiotics at home and arranged to collect cough swabs from patients’ doorsteps. Objectives: To obtain feedback from parents on the cystic fibrosis service provided during COVID-19 pandemic, including virtual clinics, and to get their opinion about use of virtual cystic fibrosis clinics post COVID-19. Methods: Short questionnaire was devised and e-mailed to parents in January 2021. Results: 23 of 26 questionnaires have been returned to date. 100% were very satisfied with service provided during the COVID-19 pandemic and 78%were very satisfied, with 17% satisfied with use of virtual consultations. Mean score for ease of use of Attend Anywhere was 9.4 out of 10. 74% were very satisfied and 22% satisfied that their needs were met via virtual consultations. 39% were very satisfied, 35% satisfied with alternate virtual and face-to-face clinic appointments post-COVID-19. Concerns were raised around no clinical examination and delays in replacing physiotherapy equipment with virtual appointments. Areas suggested for improvement included the ability to do lung function at home. Conclusion: Parents were supportive of the use of virtual clinics during COVID-19 but there were mixed views with continuing virtual clinics post-COVID-19.
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The critical need for surveillance of SARS-CoV-2 variants of concern has prompted the development of methods that can track variants in wastewater. Here, we develop and present an open-source method based on allele-specific RT-qPCR (AS RT-qPCR) that detects and quantifies the B.1.1.7 variant, targeting spike protein mutations at three independent genomic loci that are highly predictive of B.1.1.7 (HV69/70del, Y144del, and A570D). Our assays can reliably detect and quantify low levels of B.1.1.7 with low cross-reactivity, and at variant proportions down to 1% in a background of mixed SARS-CoV-2. Applying our method to wastewater samples from the United States, we track the occurrence of B.1.1.7 over time in 19 communities. AS RT-qPCR results align with clinical trends, and summation of B.1.1.7 and wild-type sequences quantified by our assays matches SARS-CoV-2 levels indicated by the U.S. CDC N1 and N2 assays. This work paves the way for AS RT-qPCR as a method for rapid inexpensive surveillance of SARS-CoV-2 variants in wastewater. © 2021 The Authors. Published by American Chemical Society.