Online palliative care curriculum: contextual adaptation for Nigerian healthcare workers.

OBJECTIVES: This study reports on a yearlong sequence of three periodic, virtual trainings in primary palliative care for healthcare professionals across Nigeria. Our overall objective was to determine the impact of the full course on participants' attitudes, knowledge, skills and plans to implement and deliver palliative care in their local contexts. METHODS: The curriculum for this programme was codeveloped by a team of USA and Nigerian palliative care professionals and delivered via three 3-day virtual sessions. Daily surveys, knowledge tests and end-of-training surveys were administered to participants electronically. Demographics, knowledge scores, confidence levels and self-reported achievement were analysed using descriptive statistics. RESULTS: Pretraining and post-training knowledge scores showed significant improvement with average gains of 10.3 percentage points in training 1 (p<0.001) to 11.7 percentage points in training 2 (p=0.01). More than three-quarters of participants improved their test scores. Most participants (89.4%-100%) agreed that they had achieved the daily learning objectives across all trainings. Nearly 100% of participants reported that they felt more empowered as healthcare workers, more confident in their decision-making and more comfortable communicating with patients and other healthcare workers about palliative care. CONCLUSIONS: Healthcare workers in Nigeria demonstrated increased knowledge and confidence in providing palliative care as a result of an adapted virtual training programme. Further research is needed to (1) demonstrate feasibility for online trainings in similar resource-limited settings and (2) evaluate impact on patient-centred outcomes.

Prevalence and Risk Factors for Renal Insufficiency among Adults Living with HIV in Tanzania: Results from a Cross-Sectional Study in 2020-2021.

With improved survival, adults living with HIV (ALHIV) are increasingly likely to experience age-related and HIV-related comorbidities, including renal insufficiency. Other risk factors for renal insufficiency (high blood pressure (BP), obesity, diabetes, and dyslipidemia) are also growing more common among ALHIV. To determine the prevalence of renal insufficiency (defined as an eGFR < 60 mL/min/1.73 m2) and factors associated with reduced eGFR, we conducted a cross-sectional study at six HIV clinics in Dar-es-Salaam, Tanzania. We applied multivariable (MV) ordinal logistic regression models to identify factors associated with reduced eGFR and examined the interaction of age with BP levels. Among the 450 ALHIV on ART analyzed [26% males; median age 43 (IQR: 18-72) years; 89% on tenofovir-containing ART; 88% HIV viral load ≤50 copies/mL], 34 (7.5%) had renal insufficiency. Prevalence was higher among males (12%) vs. females (6%), p = 0.03; ALHIV ≥50 (21%) vs. <50 years (2.5%), p < 0.001; those with high [≥130/80 mmHg (15%)] vs. normal [<120/80 mmHg (4%)] BP, p < 0.01 and those with dyslipidemia (10%) vs. those without (4.5%), p < 0.03. After adjusting for covariates, age (in years) was the only covariate with a statistically significant association with reduced eGFR (OR = 1.09 (1.07-1.12), p < 0.001). No significant interaction between age and BP was found. Interventions to increase routine screening for renal insufficiency, especially among older ALHIV, and improve BP control are critical to reducing kidney disease-related morbidity and mortality.

Generalized and COVID related anxiety as risk factors for health outcomes among adolescents with HIV during COVID-19 in Tanzania.

The COVID-19 pandemic and associated prevention strategies caused widespread interruptions to care and treatment for people living with HIV. Adolescents living with HIV (AWHIV) were particularly vulnerable to poor mental and physical health during COVID-19. We assessed the burden of generalized and COVID-19-related anxiety and associations with adherence to HIV care and treatment and viral load suppression (VLS) among AWHIV during the peak of the COVID-19 pandemic in Tanzania. Methods: This cross-sectional study was conducted among AWHIV aged 15-19 years attending 10 clinics in Dar es Salaam from April 2022-February 2023. Study participants completed a self-administered questionnaire including Generalized Anxiety Disorder (GAD), COVID-19-related anxiety, and other psychosocial and physical health and support measures. HIV visit adherence, viral load and sociodemographic data were abstracted from patient health records.Analysis:: Multivariable (MV) quasibinomial and logistic regression models examined associations of Generalized and COVID-19-related anxiety with visit adherence and HIV virologic suppression (HIV VL < 50 copies/mL). Data were analyzed using R software. Results: 658 AWHIV (52% male) were included in this analysis. Most (86%) had been on antiretroviral treatment (ART) for at least four years, 55% attended at least 75% of their scheduled clinic visits, and 78% were HIV virologically suppressed. The median GAD and COVID-19-related anxiety scores were 2 (IQR: 0-5, and 26 (IQR: 13-43; respectively. Only 2% scored moderate-severe generalized anxiety (score 10-21). We found no significant associations between COVID-19-related anxiety or GAD and visit adherence. Higher GAD was inversely associated with VLS (adjusted odds ratio (AOR): 0.89 (95% CI 0.81, 0.98)). Female gender and higher quality of physical life were significantly associated with VLS. Conclusion: Low levels of generalized and COVID-19 related anxiety were reported among Tanzanian AWHIV. Integrating screening and management of generalized anxiety screening into HIV care for AWHIV could improve VLS among this population.

Integration of individualized and population-level molecular epidemiology data to model COVID-19 outcomes.

Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) variants with enhanced transmissibility and immune escape have emerged periodically throughout the coronavirus disease 2019 (COVID-19) pandemic, but the impact of these variants on disease severity has remained unclear. In this single-center, retrospective cohort study, we examined the association between SARS-CoV-2 clade and patient outcome over a two-year period in Chicago, Illinois. Between March 2020 and March 2022, 14,252 residual diagnostic specimens were collected from SARS-CoV-2-positive inpatients and outpatients alongside linked clinical and demographic metadata, of which 2,114 were processed for viral whole-genome sequencing. When controlling for patient demographics and vaccination status, several viral clades were associated with risk for hospitalization, but this association was negated by the inclusion of population-level confounders, including case count, sampling bias, and shifting standards of care. These data highlight the importance of integrating non-virological factors into disease severity and outcome models for the accurate assessment of patient risk.

The impact of a blended multidisciplinary training for the management of obstetric haemorrhage in Mbeya, Tanzania.

Background: The Maternal Mortality Rate (MMR) in Tanzania is 78 times higher than that of the UK. Obstetric haemorrhage accounts for two-thirds of these deaths in Mbeya, Tanzania. A lack of healthcare providers' (HCPs') competencies has been the key attribute. This study measured the impact on HCP's competencies from a blended training programme on obstetric haemorrhage. Methods: A "before and after" cohort study was undertaken with HCPs in 4 hospitals in the Mbeya region of Tanzania between August 2021 and April 2022. A multidisciplinary cohort of 34 HCPs (doctors, nurses, midwives, anaesthetists and radiologists) were enrolled on a blended face-to-face and virtual training course. The training was delivered by a multidisciplinary team (MDT) from London, UK, assisted by local multidisciplinary trainers from Mbeya, Tanzania and covered anaesthetic, obstetrics, haematology and sonographic use. Results: There were 33 HCP in the cohort of trainees where 30/33 (90.9%) of HCPs improved their Anaesthesia skills with a mean score improvement of 26% i.e., 0.26 (-0.009 -0.50), 23 HCPs (69.7%) improved obstetric skills 18% i.e., 0.18 (-0.16 to 0.50), 19 (57.6%), (57.6%) improved competences in Haematology 15%.i.e., 0.15 (-0.33 to 0.87), 20 out of 29 HCPs with ultrasound access (68.8%) improved Sonographic skills 13%.i.e., 0.13 (-0.31 to 0.54). All 33 HCPs (100%) presented a combined change with the mean score improvement of difference of 25% i.e., 0.25 (0.05-0.66). The deaths attributed to obstetric haemorrhage, the mortality rate declined from 76/100,000 to 21/100,000 live births. Actual number of deaths due to obstetric haemorrhage declined from 8 before training to 3 after the completion of the training. Conclusion: This comprehensive blended training on anaesthetic surgical, haematological, and sonographic management of obstetric haemorrhage delivers a significant positive impact on the detection, management and outcomes of obstetric haemorrhage.

Extrusion and characterization of recycled polyethylene terephthalate (rPET) filaments compounded with chain extender and impact modifiers for material-extrusion additive manufacturing.

The continuous growth of annual production and consumption of polyethylene terephthalate (PET) is coined with increasing waste that leaks into the environment, landfills and oceans as microplastics and nano plastics fragments. Upcycling the recycled PET to make a feedstock for the fast-growing material-extrusion additive manufacturing (MEX-AM) technology can contribute to the solution and supports the concept of sustainable materials. In this work, extrudable filaments comprising recycled polyethylene terephthalate (rPET) with low-cost additives, such as pyromellitic dianhydride (PMDA) as a chain extender, styrene-ethylene-butylene-styrene terpolymer functionalized with maleic anhydride (SEBS-g-MA), a thermal modifier and toughening agent, ethylene-ethyl acrylate-glycidyl methacrylate terpolymer (E-EA-GMA), a functional reactive elastomeric impact modifier and ethylene-ethyl-acrylate (EEA), a non-reactive elastomeric impact modifier, have been fabricated using the twin-screw extruder. The optimum extrusion process parameters for producing uniform filaments of different rPET compounded formulations have been identified, this includes the extrusion die temperature of 280 °C and the screw speed of 150 ± 3 rpm. The compounded filaments are then printed into standard ASTM test specimens for thermal characterization and mechanical characterization, including glass transition and melting temperatures, crystallinity and crystallization temperature, tensile strength, tensile modulus, ductility, flexural strength, and Izod impact energy. Furthermore, the melt flow index for the filaments was measured. More significantly, the experimental data showed that compounding rPET with such additives in the reactive twin-screw extrusion process results in uniform filaments that display advantageous thermal and mechanical properties and can be used as a feedstock in the MEX-AM technology. This study suggests that compounding the recycled PET pellets with low-cost additives while extruding them into filaments for MEX-AM offers excellent potential to make high-value-added customized products from a sustainable polymer feedstock, such as prototyping, tooling, testing components or end-use internal components for small machines and cars.

Stress and safety of maternal and newborn healthcare workers early in the COVID-19 pandemic: a repeat cross-sectional analysis from a global online survey from March 2020 to March 2021.

OBJECTIVES: This study aims to characterise the physical and psychological well-being of maternal and newborn healthcare workers (MNHCWs) during the COVID-19 pandemic. DESIGN: Observational repeated cross-sectional study. SETTING: An online questionnaire was distributed to MNHCWs around the globe in three separate rounds from March 2020 to March 2021. PARTICIPANTS: Total samples of N=1357 (round 1) and N=420 (round 3) primarily consisted of doctors, midwives and nurses in maternal and newborn specialties. Samples represented all WHO regions, with 33% (round 1) and 42% (round 3) from low- or middle-income countries (LMICs). PRIMARY AND SECONDARY OUTCOME MEASURES: Responses from rounds 1 (March-June 2020) and 3 (December 2020-March 2021) were analysed to measure self-reported levels of relative stress and workplace protection from COVID-19, while associated factors were determined through multivariable ordinal logistic regression. RESULTS: In round 1, 90% of MNHCWs reported increased stress levels and 45% reported insufficient personal protective equipment (PPE) access. Nurses and physicians were less likely to report increased stress than midwives at the pandemic onset. Factors associated with increased stress included being female, being from an LMIC and insufficient PPE. In round 3, 75% reported similar or increased stress while 10% reported insufficient PPE. In both rounds, over 50% of MNHCWs felt relatively or completely unprotected from COVID-19 in the workplace. Those from LMICs were more likely to report feeling unprotected, while receiving organisational information that valued safety was associated with better feelings of protection in the workplace. CONCLUSIONS: Among our international sample of MNHCWs, we observed high rates of self-reported stress increase at the start of the pandemic with persistence or increase up to a year later. High rates of feeling unprotected persisted even as PPE became more available. These results may inform interventions needed to support and protect MNHCWs during this and future pandemics.

A Multicenter Retrospective Cohort Study to Characterize Patients Hospitalized With Multisystem Inflammatory Syndrome in Adults and Coronavirus Disease 2019 in the United States, 2020-2021.

BACKGROUND: The diagnosis of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2)-associated multisystem inflammatory syndrome in adults (MIS-A) requires distinguishing it from acute coronavirus disease 2019 (COVID-19) and may affect clinical management. METHODS: In this retrospective cohort study, we applied the US Centers for Disease Control and Prevention case definition to identify adults hospitalized with MIS-A at 6 academic medical centers from 1 March 2020 to 31 December 2021. Patients MIS-A were matched by age group, sex, site, and admission date at a 1:2 ratio to patients hospitalized with acute symptomatic COVID-19. Conditional logistic regression was used to compare demographic characteristics, presenting symptoms, laboratory and imaging results, treatments administered, and outcomes between cohorts. RESULTS: Through medical record review of 10 223 patients hospitalized with SARS-CoV-2-associated illness, we identified 53 MIS-A cases. Compared with 106 matched patients with COVID-19, those with MIS-A were more likely to be non-Hispanic black and less likely to be non-Hispanic white. They more likely had laboratory-confirmed COVID-19 ≥14 days before hospitalization, more likely had positive in-hospital SARS-CoV-2 serologic testing, and more often presented with gastrointestinal symptoms and chest pain. They were less likely to have underlying medical conditions and to present with cough and dyspnea. On admission, patients with MIS-A had higher neutrophil-to-lymphocyte ratio and higher levels of C-reactive protein, ferritin, procalcitonin, and D-dimer than patients with COVID-19. They also had longer hospitalization and more likely required intensive care admission, invasive mechanical ventilation, and vasopressors. The mortality rate was 6% in both cohorts. CONCLUSIONS: Compared with patients with acute symptomatic COVID-19, adults with MIS-A more often manifest certain symptoms and laboratory findings early during hospitalization. These features may facilitate diagnosis and management.

Clinical evaluation of the Diagnostic Analyzer for Selective Hybridization (DASH): A point-of-care PCR test for rapid detection of SARS-CoV-2 infection.

BACKGROUND: An ideal test for COVID-19 would combine the sensitivity of laboratory-based PCR with the speed and ease of use of point-of-care (POC) or home-based rapid antigen testing. We evaluated clinical performance of the Diagnostic Analyzer for Selective Hybridization (DASH) SARS-CoV-2 POC rapid PCR test. METHODS: We conducted a cross-sectional study of adults with and without symptoms of COVID-19 at four clinical sites where we collected two bilateral anterior nasal swabs and information on COVID-19 symptoms, vaccination, and exposure. One swab was tested with the DASH SARS-CoV-2 POC PCR and the second in a central laboratory using Cepheid Xpert Xpress SARS-CoV-2 PCR. We assessed test concordance and calculated sensitivity, specificity, negative and positive predictive values using Xpert as the "gold standard". RESULTS: We enrolled 315 and analyzed 313 participants with median age 42 years; 65% were female, 62% symptomatic, 75% had received ≥2 doses of mRNA COVID-19 vaccine, and 16% currently SARS-CoV-2 positive. There were concordant results for 307 tests indicating an overall agreement for DASH of 0.98 [95% CI 0.96, 0.99] compared to Xpert. DASH performed at 0.96 [95% CI 0.86, 1.00] sensitivity and 0.98 [95% CI 0.96, 1.00] specificity, with a positive predictive value of 0.85 [95% CI 0.73, 0.96] and negative predictive value of 0.996 [95% CI 0.99, 1.00]. The six discordant tests between DASH and Xpert all had high Ct values (>30) on the respective positive assay. DASH and Xpert Ct values were highly correlated (R = 0.89 [95% CI 0.81, 0.94]). CONCLUSIONS: DASH POC SARS-CoV-2 PCR was accurate, easy to use, and provided fast results (approximately 15 minutes) in real-life clinical settings with an overall performance similar to an EUA-approved laboratory-based PCR.

Clinical evaluation of the Diagnostic Analyzer for Selective Hybridization (DASH): a point-of-care PCR test for rapid detection of SARS-CoV-2 infection.

BACKGROUND: Rapid and accurate testing for SARS-CoV-2 is an essential tool in the medical and public health response to the COVID-19 pandemic. An ideal test for COVID-19 would combine the sensitivity of laboratory-based PCR combined with the speed and ease of use of point-of-care (POC) or home-based rapid antigen testing. METHODS: To evaluate the performance of the Diagnostic Analyzer for Selective Hybridization (DASH) SARS-CoV-2 POC PCR (sample insertion to result time of 16 minutes), we conducted a cross-sectional study of adults with and without symptoms of COVID-19 at four clinical sites. We collected two bilateral anterior nasal swabs from each participant and information on COVID-19 symptoms, vaccination, and exposure. One swab was tested with the DASH SARS-CoV-2 POC PCR and the second in a central laboratory using Cepheid Xpert Xpress SARS-CoV-2 PCR. We assessed test concordance and calculated sensitivity, specificity, negative and positive predictive values using Xpert as the "gold standard." RESULTS: We enrolled 315 and analyzed 313 participants with median age 42 years; 65% were female, 62% symptomatic, 75% had received ≥2 doses of mRNA COVID-19 vaccine, and 16% currently COVID-19 positive. There were concordant results for 307 tests indicating an overall agreement for DASH of 0.98 [95% CI 0.96, 0.99] compared to Xpert. DASH performed at 0.96 [95% CI 0.86, 1.00] sensitivity and 0.98 [95% CI 0.96, 1.00] specificity, with a positive predictive value of 0.85 [95% CI 0.73, 0.96] and negative predictive value of 0.996 [95% CI 0.99, 1.00]. The six discordant tests between DASH and Xpert all had high Ct values (>30) on the respective positive assay. DASH and Xpert Ct values were highly correlated (R=0.89 [95% CI 0.81, 0.94]). CONCLUSIONS: DASH POC SARS-CoV-2 PCR was accurate, easy to use, and provided fast results in real-life clinical settings with an overall performance similar to an EUA-approved laboratory-based PCR. Its compact design and ease of use are optimal for a variety of healthcare, and potentially community settings, including areas with lack of access to central laboratory-based PCR testing. SUMMARY: DASH is an accurate, easy to use, and fast point-of-care test with applications for diagnosis and screening of SARS-CoV-2 infection.

No difference in anti-spike antibody and surrogate viral neutralization following SARS-CoV-2 booster vaccination in persons with HIV compared to controls (CO-HIV Study).

Background: Understanding the immune response to severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) vaccination will enable accurate counseling and inform evolving vaccination strategies. Little is known about antibody response following booster vaccination in people living with HIV (PLWH). Methods: We enrolled SARS-CoV-2 vaccinated PLWH and controls without HIV in similar proportions based on age and comorbidities. Participants completed surveys on prior SARS-CoV-2 infection, vaccination, and comorbidities, and provided self-collected dried blood spots (DBS). Quantitative anti-spike IgG and surrogate viral neutralization assays targeted wild-type (WT), Delta, and Omicron variants. We also measured quantitative anti-nucleocapsid IgG. The analysis population had received full SARS-CoV-2 vaccination plus one booster dose. Bivariate analyses for continuous outcomes utilized Wilcoxon tests and multivariate analysis used linear models. Results: The analysis population comprised 140 PLWH and 75 controls with median age 58 and 55 years, males 95% and 43%, and DBS collection on 112 and 109 days after the last booster dose, respectively. Median CD4 count among PLWH was 760 cells/mm3 and 91% had an undetectable HIV-1 viral load. Considering WT, Delta, and Omicron variants, there was no significant difference in mean quantitative anti-spike IgG between PLWH (3.3, 2.9, 1.8) and controls (3.3, 2.9, 1.8), respectively (p-values=0. 771, 0.920, 0.708). Surrogate viral neutralization responses were similar in PLWH (1.0, 0.9, and 0.4) and controls (1.0, 0.9, 0.5), respectively (p-values=0.594, 0.436, 0.706). Conclusions: PLWH whose CD4 counts are well preserved and persons without HIV have similar anti-spike IgG antibody levels and viral neutralization responses after a single SARS-CoV-2 booster vaccination.