Immune resilience despite inflammatory stress promotes longevity and favorable health outcomes including resistance to infection.

Some people remain healthier throughout life than others but the underlying reasons are poorly understood. Here we hypothesize this advantage is attributable in part to optimal immune resilience (IR), defined as the capacity to preserve and/or rapidly restore immune functions that promote disease resistance (immunocompetence) and control inflammation in infectious diseases as well as other causes of inflammatory stress. We gauge IR levels with two distinct peripheral blood metrics that quantify the balance between (i) CD8+ and CD4+ T-cell levels and (ii) gene expression signatures tracking longevity-associated immunocompetence and mortality-associated inflammation. Profiles of IR metrics in ~48,500 individuals collectively indicate that some persons resist degradation of IR both during aging and when challenged with varied inflammatory stressors. With this resistance, preservation of optimal IR tracked (i) a lower risk of HIV acquisition, AIDS development, symptomatic influenza infection, and recurrent skin cancer; (ii) survival during COVID-19 and sepsis; and (iii) longevity. IR degradation is potentially reversible by decreasing inflammatory stress. Overall, we show that optimal IR is a trait observed across the age spectrum, more common in females, and aligned with a specific immunocompetence-inflammation balance linked to favorable immunity-dependent health outcomes. IR metrics and mechanisms have utility both as biomarkers for measuring immune health and for improving health outcomes.

Our New Reality: A Needs Assessment for Telemedicine Goals of Care Training in Undergraduate Medical Education (QI418)

Outcomes 1. Evaluate the need for a formal telemedicine goals of care curriculum for undergraduate medical learners 2. Emphasize the importance of adapting the current curriculum to meet the new telemedicine goals of care communication need 3. Understand use of the P-T-SPIKEES framework for facilitating telemedicine goals of care conversations Background Many providers have no formal telemedicine training, let alone training specific to delivering goals of care (GOCs) in a virtual platform. Given the demand for using such platforms to deliver patient care and the need for virtual GOC communication due to the COVID-19 global pandemic, medical education needs to swiftly adjust to these skills of the future. Thus, a needs assessment was conducted to determine 4th-year undergraduate medical learner (UML) training and self-confidence in telemedicine and GOC communication. Aim Statement Evaluate the need for a formal telemedicine GOC curriculum for undergraduate medical learners. Methods 4th-year UMLs from a single institution were surveyed to determine current exposure to telemedicine and GOC communication training. Responses were gathered from 18 to 22 March 2021 and analyzed. Results Of the 165 learners surveyed, 26 (15.7%) identified as having prior informal or on-the-job telemedicine training. 69 (41.8%) reported some prior GOC training. Learners self-evaluated their ability to conduct telemedicine GOC patient encounters as follows: 3 (1.8%) extremely competent, 31 (18.8%) somewhat competent, 69 (41.8%) neither competent nor incompetent, 49 (29.7%) somewhat incompetent, and 13 (7.9%) extremely incompetent. Because most learners do not identify as at least competent in performing telemedicine GOC conversations and the majority have had no formal training, a curriculum was developed using a P-T-SPIKEES framework to provide specific telemedicine-focused GOC communication skills to facilitate these virtual conversations. Conclusions and Implications Most 4th-year UMLs are not confident in their ability to conduct telemedicine GOC conversations, a skill that will continue to be greatly needed. Future studies should focus on the effects of a formal telemedicine GOC curriculum on learner ability and perceived competency.

Early Documentation of Life-Sustaining Treatment Orders Prior to Diagnosis of COVID-19 in Nursing Home Residents

Coronavirus disease 2019 (COVID-19) has had a devastating impact on older adult nursing home residents (NHR). NHRs comprise greater than one-third of COVID-19 U.S. deaths, emphasizing the importance of engaging in end-of-life discussions. At South Texas Veterans Health Care System (STVHCS), we implemented early documentation of patient’s Life-Sustaining Treatment (LST) or end-of-life goals-of-care preferences prior COVID-19 infection. We now aim to examine the association between early LST documentation (prior to COVID-19 diagnosis) and hospital admissions for COVID-19 by conducting a retrospective cohort study of Veteran NHRs at STVHCS from March 2020-January 2021. Inclusion criteria were NHRs with COVID-19 diagnosis, LST documentation, and clear timing of whether the LST documentation occurred before or after COVID-19 diagnosis. Logistic regression was used to determine the likelihood of hospitalization by whether LST was documented before or after COVID-19 diagnosis. 208 NHRs were diagnosed with COVID-19 and 160 (76.9%) had LST documentation. Of these, 148 were included in the analysis: 84 (56.8%) had a completed LST note prior to diagnosis and 64 (43.2%) after diagnosis. The hospitalization rate was 46% for those with LST prior to diagnosis compared to 78% in those with LST after diagnosis (OR = 0.24, 95% CI: 0.12-0.50, P<0.001), showing that early LST documentation was associated with 76% lower likelihood of hospitalization. Early interventions for LST documentation can reduce hospitalization in high-risk populations. These findings may have implications for reducing unnecessary hospitalizations, diminishing healthcare costs, and resolving ethical dilemmas related to potential resource allocation during a pandemic.

Hospital in Home COVID-19 Monitoring: A Novel Approach to Keeping a Watchful Eye on Older Adults

Older adults suffering from severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) are at increased risk of death and hospitalization-related complications. The coronavirus disease 2019 (COVID-19) pandemic has forced adaptations in Telehealth, allowing COVID-19 patients to be managed at home. Traditionally, Hospital in Home (HIH) patients have better clinical outcomes and lower mortality compared to similar hospitalized patients. However, effectiveness of HIH for COVID-19 older adults remains unknown. This study examines the effect of age on rates of hospital readmission and overall mortality for patients enrolled in HIH after initial COVID-19 hospital discharge. A HIH COVID-19 monitoring program was developed to facilitate earlier hospital discharge and monitoring. Retrospective data between March 2020 and January 2021 were analyzed. Of the 402 subjects (age:26-99;mean:61.8), 13 (6.1%) subjects <65 years old vs 19 (10%) subjects □65 years old were readmitted to the hospital at least once. Two (0.94%) subjects <65 years old and 12 (6.3%) subjects □65 years old died. Older adults were 1.719 times more likely to be re-hospitalized (p=0.005) and 7.153 times more likely to die (p=0.017) compared to younger adults. Age remains a significant predictor of hospital readmission and mortality in subjects previously hospitalized for COVID-19 even when followed by monitoring programs like HIH. Further studies are needed to determine the best way to reduce hospital readmission and mortality rates for older adults after initial COVID-19 hospital discharge.

Immunologic resilience and COVID-19 survival advantage.

BACKGROUND: The risk of severe coronavirus disease 2019 (COVID-19) varies significantly among persons of similar age and is higher in males. Age-independent, sex-biased differences in susceptibility to severe COVID-19 may be ascribable to deficits in a sexually dimorphic protective attribute that we termed immunologic resilience (IR). OBJECTIVE: We sought to examine whether deficits in IR that antedate or are induced by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection independently predict COVID-19 mortality. METHODS: IR levels were quantified with 2 novel metrics: immune health grades (IHG-I [best] to IHG-IV) to gauge CD8+ and CD4+ T-cell count equilibrium, and blood gene expression signatures. IR metrics were examined in a prospective COVID-19 cohort (n = 522); primary outcome was 30-day mortality. Associations of IR metrics with outcomes in non-COVID-19 cohorts (n = 13,461) provided the framework for linking pre-COVID-19 IR status to IR during COVID-19, as well as to COVID-19 outcomes. RESULTS: IHG-I, tracking high-grade equilibrium between CD8+ and CD4+ T-cell counts, was the most common grade (73%) among healthy adults, particularly in females. SARS-CoV-2 infection was associated with underrepresentation of IHG-I (21%) versus overrepresentation (77%) of IHG-II or IHG-IV, especially in males versus females (P < .01). Presentation with IHG-I was associated with 88% lower mortality, after controlling for age and sex; reduced risk of hospitalization and respiratory failure; lower plasma IL-6 levels; rapid clearance of nasopharyngeal SARS-CoV-2 burden; and gene expression signatures correlating with survival that signify immunocompetence and controlled inflammation. In non-COVID-19 cohorts, IR-preserving metrics were associated with resistance to progressive influenza or HIV infection, as well as lower 9-year mortality in the Framingham Heart Study, especially in females. CONCLUSIONS: Preservation of immunocompetence with controlled inflammation during antigenic challenges is a hallmark of IR and associates with longevity and AIDS resistance. Independent of age, a male-biased proclivity to degrade IR before and/or during SARS-CoV-2 infection predisposes to severe COVID-19.