Caesarean section in critically unwell peri-partum patients with COVID-19: A tertiary centre's experience

Introduction: The COVID-19 pandemic has required clinical teams to function with an unprecedented amount of uncertainty, balancing complex risks and benefits in a highly fluid environment. This is especially the case when considering the delivery of a pregnant woman critically unwell with COVID-19. This is one maternal critical care team's reflections on establishing best practice and a shared mental model when undertaking a Caesarean section in critically unwell patients with COVID-19. Objective(s): We describe our experience of balancing the risks and streamlining the process of this high-risk intervention. Method(s): We used our standard clinical governance forums across four specialties (Obstetrics, Intensive care, Anaesthetics and Neonatology) to identify key challenges and learning points. We developed a working group to combine our learning and develop a shared mental model across the involved teams. Result(s): 1. The decision to deliver must be multidisciplinary involving Obstetrics, Intensive care, Anaesthetics, Neonatology and the patient according to their capacity to participate. The existing structure of twice daily ITU ward rounds could be leveraged as a 'pause' moment to consider the need for imminent delivery and review the risk-benefit balance of continued enhanced pharmacological thromboprophylaxis. 2. We identified a range of scenarios that our teams might be exposed to: 3. Perimortem Caesarean section 4. Critically unwell - unsafe to move to theatre 5. Critically unwell - safe to move to theatre 6. Recreating an obstetric theatre in the ICU Advantages Avoids moving a critically unstable patient, although our experience is increasing moving patients for ECMO. Some forms of maximal non-invasive therapy such as High Flow Nasal Oxygen may require interruption to move to theatre with resultant risk of harm or be difficult to continue in transport mode through a bulky ICU ventilator e.g. CPAP Disadvantages Significant logistics and coordination burden: multiple items of specialist equipment needing to be brought to the ICU. Human factors burden: performing a caesarean section in an unfamiliar environment is a significant increase in cognitive load for participating teams. Environmental factors: ICU side rooms may offer limited space vs the need to control the space if performed on an open unit. Delivering a Neonate into a COVID bubble. Conclusion(s): Developing a shared mental model across the key teams involved in delivering an emergency caesarean section in this cohort of critically unwell patients has enabled our group to own a common understanding of the key decisions and risks involved. We recommend a patient centred MDT decision making model, with a structure for regular reassessment by senior members of the teams involved. In most circumstances the human factors and logistical burden of recreating an operating theatre in the ICU outweighs the risk of transport to theatre. Pre-defined checklists and action cards mitigate the cognitive and logistical burden when multiple teams do perform an operative delivery in ICU. Action cards highlight key aspects of routine obstetric care to be replicated in the ICU environment.

SARS-CoV-2 INFECTION AMONG PERSONS WHO INJECT DRUGS AND THEIR PARTNERS IN KENYA

Background: Despite increased social vulnerability and barriers to care, there has been a paucity of data on SARS-CoV-2 incidence among key populations in sub-Saharan Africa. We seek to characterize active infections and define transmission dynamics of SARS-CoV-2 among people who inject drugs (PWID) and their sexual and injecting partners from Nairobi and the coastal region in Kenya. Method(s): This was a nested cross-sectional study of SARS-CoV-2 infection from April to July 2021 within a cohort study of assisted partner services for PWID in Kenya. A total of 1000 PWID and their partners (500 living with and 500 living without HIV) were recruited for SARS-CoV-2 antibody testing, of whom 440 were randomly selected to provide self-collected nasal swabs for real-time PCR testing. Whole genome sequencing (WGS) was completed on a limited subset of samples (N=23) with cycle threshold values 32.0. Phylogenetic tree construction and analysis was performed using the Nextstrain pipeline and compared with publicly available SARS-CoV-2 sequences from GenBank. Result(s): A total of 438 (99.5%) participants provided samples for SARS-CoV-2 PCR testing. Median age was 37 (IQR 32-42);128 (29.2%) were female;and 222 (50.7%) were living with HIV. The overall prevalence of SARS-CoV-2 infection identified by RT-PCR was 86 (19.6%). In univariate analyses, there was no increased relative risk of SARSCoV- 2 infection related to positive HIV status, frequenting an injection den, methadone treatment, unstable housing, report of any high-risk exposure, or having a sexual or injecting partner diagnosed with COVID-19 or who died from COVID-19 or flu-like illness. Eight samples were successfully sequenced via WGS and classified as WHO variants of concern: 3 Delta, 3 Alpha, and 2 Beta. Seven were classified into clades predominantly circulating in Kenya during 2021. Notably, two sequences were identical and matched identically to another Kenyan sequence, which is consistent with, though not indictive of, a transmission linkage. Conclusion(s): Overall, the risk of SARS-CoV-2 infection in this population of PWID and their partners was not significantly associated with risk factors related to injection drug use. At a genomic level, the SARS-CoV-2 strains in this study were consistent with contemporary Kenyan lineages circulating during the time and not unique to PWID. Prevention efforts, therefore, must also focus on marginalized groups for control given the substantial amount of mixing that likely occurs between populations.

Case Studies in the Treatment of Asian Scroll Paintings

Works of art in the diverse Asian collections at the National Gallery of Australia (NGA) are regularly requested for display. These collections are routinely condition checked and, where appropriate, interventive treatments undertaken. Storage, in particular, has been continually improved. With the closure of the NGA during the initial Covid lockdown in March 2020, and the subsequent decreased demand to prepare works for exhibition, loan and travelling exhibitions, there was an opportunity to investigate Asian works in the NGA Study Collection, with the objective of identifying those excluded from display because of condition. The time available meant that the NGA Paper Conservation team could examine and treat a number of Asian scroll paintings in this collection. The focus of this paper is three Japanese paintings and two Chinese paintings, all on silk supports, with various degraded paper and fabric mounts and backings. After initially viewing the works with Curatorial colleagues, treatment expectations were discussed and established. Background research was undertaken, in terms of generic style and period, together with limited analysis on supports and pigments in order to inform treatment. While further Curatorial research is ongoing, it was possible to agree appropriate potential mounting styles and materials, allowing treatments to progress. © The Australian Institute for the Conservation of Cultural Materials 2022.

COVID-19 infection and maternal morbidity in critical care units in Scotland: a national cohort study.

BACKGROUND: Previous research has shown that, in comparison with non-pregnant women of reproductive age, pregnant women with COVID-19 are more likely to be admitted to critical care, receive invasive ventilation, and die. At present there are limited data in relation to outcomes and healthcare utilisation following hospital discharge of pregnant and recently pregnant women admitted to critical care. METHODS: A national cohort study of pregnant and recently pregnant women who were admitted to critical care in Scotland with confirmed or suspected COVID-19. We examined hospital outcomes as well as hospital re-admission rates. RESULTS: Between March 2020 and March 2022, 75 pregnant or recently pregnant women with laboratory-confirmed COVID-19 were admitted to 24 Intensive Care Units across Scotland. Almost two thirds (n=49, 65%) were from the most deprived socio-economic areas. Complete 90-day acute hospital re-admission data were available for 74 (99%) patients. Nine (12%) women required an emergency non-obstetric hospital re-admission within 90 days. Less than 5% of the cohort had received any form of vaccination. CONCLUSIONS: This national cohort study has demonstrated that pregnant or recently pregnant women admitted to critical care with COVID-19 were more likely to reside in areas of socio-economic deprivation, and fewer than 5% of the cohort had received any form of vaccination. More targeted public health campaigning across the socio-economic gradient is urgently required.

Genotype-Specific Detection of Ferret Coronavirus by Conventional and Real-Time Reverse Transcription Polymerase Chain Reaction

Ferret coronavirus is associated with two disease presentations in ferrets, namely, epizootic catarrhal enteritis and a feline infectious peritonitis (FIP)-like systemic disease. In this chapter, we describe conventional and real-time one-step reverse transcription polymerase chain reaction assays that are routinely used in our laboratory to detect either genotype 1 or genotype 2 ferret coronavirus in clinical specimens. These assays were designed based upon the conserved spike gene sequence difference found between three strains of ferret systemic coronavirus and three strains of ferret enteric coronavirus. Recent literature evidence indicates that pathotype is not associated with a specific genotype, and therefore, it is important to test for both genotypes either in enteric or systemic disease. Copyright © 2016 Springer Science+Business Media New York.

SARS-CoV-2 ANTIBODY CORRELATES among PWID LIVING with and WITHOUT HIV in KENYA

Background: In sub-Saharan Africa many persons who inject drugs (PWID) are living with undiagnosed or untreated HIV and experience high levels of poverty, housing instability, and co morbid conditions that contribute to worse outcomes from SARS-CoV-2. We sought to determine SARS-CoV-2 antibody prevalence and risk factors for PWID and their sexual and injecting partners in Kenya. Identifying the burden of infection in marginalized populations like PWID may contribute to controlling the pandemic in LMIC Methods: In a nested cross-sectional study, we recruited PWID living with HIV and their injecting and/or sexual partners in Nairobi, Kilifi, and Mombasa counties at needle and syringe programs (NSP). Blood samples were collected from consenting participants at enrollment to determine SARS-CoV-2 antibodies using a Platellia BioRad SARS-CoV-2 total antibody enzyme-linked immunosorbent assay. Baseline data was collected on HIV status, antiretroviral therapy (ART) and methadone adherence. Logistic regression was used to identify factors associated with antibody positivity Results: In total,1000 participants were enrolled in the study between April and July 2021, of whom 323 (32.3%) were women and 677 (67.7%) were men. Median age of participants was 36 years (Interquartile range [IQR]: 30, 42). SARS-CoV-2 positivity was reported in 309 (30.9%) of the participants. Of the participants who tested positive for SARS-CoV-2 antibodies, 39.5% did not report any symptoms at any time during the last 3 months. Men were significantly less likely than women to have SARS-CoV-2 antibodies (Odds ratio [OR] 0.70, 95% confidence interval [CI] 0.52, 0.94;p<0.016). Participants from the Coast region had lower odds of SARS-CoV-2 antibody positivity compared to the Nairobi region (OR 0.72, 95% CI, 0.54, 0.95;p<0.019) and participants who had a sexual or injecting partner diagnosed with COVID-19 were more likely to have SARS-CoV-2 antibodies detected (OR 2.12, 95% CI 1.02, 4.39;p<0.042). Living with HIV was not significantly associated with presence of SARS-CoV-2 antibodies Conclusion: SARS-CoV-2 antibody was detected in 30.9% of participants in this cohort of PWID and their partners, suggesting high transmission rates within this key population. SARS-CoV-2 seroprevalence was similar for people living with and without HIV;no increase in risk was found for those living with HIV. This cohort represents an at-risk population that should be considered for COVID-19 vaccination, surveillance and other targeted public health measures.

Modeling of Waiting Lists for Chronic Heart Failure in the Wake of the COVID-19 Pandemic

The Covid-19 pandemic has disrupted access to health services globally for patients with non-Covid-19 conditions. We consider the condition of heart failure and describe a discrete event simulation model built to describe the impact of the pandemic and associated societal lockdowns on access to diagnosis procedures. The number of patients diagnosed with heart failure fell during the pandemic and in the UK, the number of GP referrals for diagnostic tests in November 2020 were at 20% of their pre-pandemic levels. While the numbers in the system have fallen clinicians believe that this is not reflective of a change in need, suggesting that many patients are delaying accessing care during pandemic peaks. While the effect of this is uncertain, it is thought that this could have a significant impact on patient survival. Initial results reproduce the observed increase in the number of patients waiting. © 2021 IEEE.

Considerations for COVID-19 vaccination in pregnancy

Pregnant women are at greater risk of severe COVID-19 than non-pregnant women. Despite limited safety data on use of COVID-19 vaccines in pregnancy, many international societies have recommended their use when pregnant women are at particularly high risk of acquiring COVID-19, or have suggested that vaccines should not be withheld from pregnant women where no other contraindications to COVID-19 vaccination exist. A number of vaccines, including those against influenza, tetanus and pertussis, have been shown to reduce both maternal and infant morbidity and mortality when used antenatally. We explore the role of COVID-19 vaccination in the setting of pregnancy, discuss the limited data available, and summarise current international guidelines.

Early experience with focused telemedicine implementation in an academic colorectal surgery practice

Purpose/Background: With advances in technology there has been increased interest in and application of telemedicine in clinical practice. The need to continue providing care to patients during the COVID-19 pandemic facilitated telemedicine's rapid adoption. We evaluated the integration of telemedicine into an academic colorectal surgery practice. Methods/Interventions: All patients seen in a single center academic colorectal surgery practice from March 31, 2020 to August 31, 2020 were evaluated, and patients who were seen via telemedicine were evaluated for demographic information, diagnosis and disease history, and outcome of telemedicine visit. All physicians who provided care during this time period were asked to complete a survey regarding their experience providing telemedicine visits. Results/Outcome(s): A total of 231 telemedicine visits were performed by four providers, comprising 20% of all clinic visits during the study period. Patients were 47.6% male and 90.9% white. Most (85.7%) were established patient visits and 49 (21.2%) patients were seen for postoperative visits. Diagnoses evaluated by telemedicine included benign anorectal disease (9.1%), malignant anal disease (2.6%), inflammatory bowel disease (22.9%), benign colorectal disease (20.3%), and colorectal cancer (38.5 %). Of the 55 procedures planned during these visits, 41 (74.5%) were performed (Table). None of the four providers reported providing telemedicine visits prior to the COVID-19 pandemic, though all felt able to provide adequate care via telemedicine and were planning to continue providing telemedicine care in the future. They reported seeing the same or fewer total patients while providing telemedicine and reported comfort with evaluating a variety of pathologies, with all four reporting that they saw established colorectal cancer and inflammatory bowel disease patients as well as postoperative visits. Three out of four providers, however, reported that 50% or more of the patients that they saw via telemedicine would need an in-person evaluation. Conclusions/Discussion: During the COVID-19 pandemic telemedicine visits were rapidly and successfully integrated into this colorectal surgery practice. These were most successfully used to facilitate care for already established patients, particularly in the long-term care of colorectal cancer and inflammatory bowel disease patients, as well in the immediate postoperative period. This represents an exciting advancement in the clinical care of patients, though ongoing study remains to be done in how best to provide access this technology and full clinical care for colorectal surgery patients.

Will the coronavirus slow open access - And is the answer different for books and journals?

We got to talking about life, the pandemic and everything and became intrigued about the different state of play around open access (OA) for books and journals and how it all might evolve. We had been surprised to hear speculation that OA might slow down even further as a result of Covid-19. However, this was not what we were seeing from our perspectives working with journals and learned society publishers (Alicia), and working with books and small university presses (Frances). So, we decided to collaborate on a short article to explore this and in the process have clarified our own thinking. We share it with Insights readers as an opinion piece. © 2020 Alicia Wise and Frances Pinter.

Obstetrics and gynaecology forum - COVID-19 in pregnancy : update on the disease and its management

At the time of writing (24th August 2020), it has been over 5 months since the first case of COVID-19 was diagnosed in South Africa. Since then over 600,000 cases have been diagnosed in South Africa, of which over 13,000 have unfortunately resulted in death. The previous edition of the O+G Forum, three months ago (issue 2, 2020), included an editorial about South Africa's initial response to the COVID-19 pandemic, as well as an overview of management of obstetric patients with COVID-19. Since then the course of the pandemic has evolved and the scientific literature has been dominated by publications relating to various aspects of the pandemic and its management.