Out-of-hospital Cardiac Arrest Before and During the COVID-19 Pandemic in the South Bronx

BackgroundOut-of-hospital cardiac arrest (OHCA) is a major health challenge; the impact of the COVID-19 pandemic on OHCA in the South Bronx is unknown. The aim of this study was to determine differences between return of spontaneous circulation(ROSC), witnessed arrest, bystander CPR and survival to discharge, prior to and during the COVID-19 pandemic to improve ROSC and survival. MethodsSingle-center retrospective study of non-traumatic OHCA adult patients admitted to Lincoln Medical Center between 8/2019 to 6/2021, 3/2020 being the first established date of the COVID-19 pandemic in New York City. International Classification of Diseases (ICD) coding was used to identify cardiac arrests and collect information. Statistical analysis was performed using IBM-SPSS. ResultsROSC time pre COVID-19 was 26 minutes, during the COVID-19 pandemic it was 25 minutes 54 seconds. A significant difference in witnessed arrests in the pre COVID-19 period compared to the COVID-19 period (86% vs 55% p = 0.03). Bystander CPR occurred 36% of the time in the pre COVID-19 period contrasting to 19% during. Prior to the COVID-19 pandemic the overall survival to discharge in OHCA ROSC cases was 28.5% comparing to 29% during the pandemic. ROSC was 18 minutes among survivors during the pandemic, compared to 21 minutes in survivors prior to COVID (p = 0.2). ConclusionThere was a non-significant difference in ROSC, bystander CPR and survival to discharge in non-traumatic OHCA prior to and during the COVID-19 pandemic in the South Bronx. There was a significant difference in witnessed vs unwitnessed OHCA prior to and during the COVID-19 pandemic.

Combination of Baricitinib plus Remdesivir and Dexamethasone improves time to recovery and mortality among hospitalized patients with severe COVID-19 infection

BackgroundThere seems to be a gap in the therapeutic options for severe Covid-19 pneumonia. Though the beneficial effect of combination treatment with baricitnib and remdesivir in accelerating clinical status improvement is described, the impact of the triple therapy with baricitinib + remdesivir/dexamethasone is not known. MethodsA retrospective observational study comparing the effect of baricitinib plus standard treatment (remdesivir and dexamethasone) with standard therapy in patients requiring [≥] 5 L/min O2 was conducted. The primary outcome was to compared time to recovery in both groups, and the secondary outcomes was to determine mortality rate at discharge. ResultsOf 457 patients hospitalized during the study period, 51 patients received standard treatment while 88 patients received baricitinib plus standard treatment. In baricitinib group, the rate ratio of recovery was 1.28 (95%CI 0.84-1.94, p=0.24) with a reduction in median time to recovery of 3 days compared to standard treatment group. Subgroup analysis based on Ordinal Scale showed reduction in median time to recovery by 4 and 2 days with rate ratio of recovery of 2.95 (1.03-8.42, p =0.04) and 1.80 (1.09-2.98, p=0.02) in Ordinal Scale 5 and 6 respectively. No benefit was found in the Ordinal Scale 7 subgroup. An overall decrease in rate (15.9% vs 31.4% p=0.03) a likelihood (OR 0.41, 95%CI 0.18-0.94, p=0.03) of mortality was observed in the baricitinib group. Bacteremia and thrombosis were noted in the Baricitinib group, but comparable with the Standard of care group. ConclusionBaricitinib with standard therapy reduced time to recovery and offer mortality benefit in patients with severe COVID-19 pneumonia."

A Randomized Placebo-Controlled Trial of Sarilumab in Hospitalized Patients with Covid-19

BACKGROUNDSarilumab (anti-interleukin-6 receptor- monoclonal antibody) may attenuate the inflammatory response in Covid-19. METHODSWe performed an adaptive, phase 2/3, randomized, double-blind, placebo-controlled trial of intravenous sarilumab 200 mg or 400 mg in adults hospitalized with Covid-19. The phase 3 primary analysis population (cohort 1) was patients with critical Covid-19 receiving mechanical ventilation (MV) randomized to sarilumab 400 mg or placebo. The primary end point for phase 3 was the proportion of patients with [≥]1-point improvement in clinical status from baseline to day 22. RESULTSFour-hundred fifty-seven (457) and 1365 patients were randomized and treated in phases 2 and 3, respectively. Among phase 3 critical patients receiving MV (n=289; 34.3% on corticosteroids), the proportion with [≥]1-point improvement in clinical status (alive not receiving MV) at day 22 was 43.2% in sarilumab 400 mg and 35.5% in placebo (risk difference [RD] +7.5%; 95% confidence interval [CI], -7.4 to 21.3; P=0.3261), representing a relative risk improvement of 21.7%. Day 29 all-cause mortality was 36.4% in sarilumab 400 mg versus 41.9% in placebo (RD -5.5%; 95% CI, -20.2 to 8.7; relative risk reduction 13.3%). In post hoc analyses pooling phase 2 and 3 critical patients receiving MV, the hazard ratio (HR) for death in sarilumab 400 mg compared with placebo was 0.76 (95% CI, 0.51 to 1.13) overall, improving to 0.49 (95% CI, 0.25 to 0.94) in patients receiving corticosteroids at baseline. CONCLUSIONIn hospitalized patients with Covid-19 receiving MV, numerical benefits with sarilumab did not achieve statistical significance, but benefit may be greater in patients receiving corticosteroids. A larger study is required to confirm this observed numerical benefit. (ClinicalTrials.gov number, NCT04315298)

Comparison of clinical course and outcomes of critically ill patients with SARS-CoV2 infection managed in traditional ICU and "Flex" ICU during the surge of the pandemic in the Bronx.

BACKGROUNDAs part of the response to increase critical care capacity during the unprecedented surge of COVID-19 infections, NYC Health + Hospital systems identified and resourced areas in the hospital that could deliver critical care as "Flex" ICUs to complement the traditional ICUs to manage the rapid influx of critically ill patients. OBJECTIVEComparison of clinical features and outcomes of mechanically ventilated COVID-19 patients admitted to the traditional and "Flex" ICUs during the surge of the pandemic METHODSRetrospective comparative cohort study of patients with confirmed SARS-CoV-2 infection on mechanical ventilation admitted to traditional ICU and Flex ICU. Univariate and multivariate analysis to detect factors associated with death from COVID-19 patients in mechanical ventilation were performed with the Cox proportional hazards regression model RESULTSOut of the 312 patients on mechanical ventilation, 111 were admitted to the traditional ICU and 201 to the Flex ICU. The mortality rate was higher in the Flex ICU compared with the traditional ICU, but the adjusted risk model was not significantly associated with increased mortality CONCLUSION"Flex" ICUs played a crucial role in the management of critically ill patients during the pandemic. Mortality risk of patients in the "Flex" ICUs were comparable to traditional ICUs in the adjusted analysis. While there is enough evidence for Intensivist managed ICUs to have better outcomes, our study demonstrates the feasibility of non-intensivist led Flex" ICUs during a crisis.

High Initial Titres of Anti-Spike Antibodies following SARS-CoV-2 Infection is Associated with Faster Decay Rates at Four Months Follow-Up

BackgroundDynamics of humoral immune responses to SARS-CoV-2 antigens following infection suggests an initial decay of antibody followed by subsequent stabilization. We aim to understand the longitudinal humoral responses to SARS-CoV-2 nucleocapsid (N) protein and spike (S) protein and to evaluate their correlation to clinical symptoms among healthcare workers (HCW). MethodsIn this cross-sectional longitudinal cohort study done in two phases over four months, HCW underwent serial qualitative serology testing for anti-N antibody, quantitative MSH-ELISA to detect Receptor Binding Domain and full-length S reactive antibodies and completed online surveys about COVID-19 related symptoms and healthcare/community exposure. ResultsAnti-N antibody positivity was 27% and anti-S positivity was 28% in Phase 1. In Phase 2 anti-S titres were higher in symptomatic than in asymptomatic positive subjects in Phase 1. Marginally higher titers were seen in asymptomatic compared to the symptomatic positive subgroup in Phase 2. A positive correlation was noted between age, number and duration of symptoms, and Phase 1 anti-S antibody titre. A strong correlation was observed between Phase 1 titers and decay of anti-S antibody titres between the two phases. Significant correlation with rate of decay was also noted with fever, GI symptoms, and total number and duration of COVID-19 symptoms. ConclusionsHigher initial anti-S antibody titres were associated with larger number and longer duration of symptoms as well as faster decay during the two time points. Key PointsO_ST_ABSQuestionC_ST_ABSWhat is the decay rate of neutralizing antibodies among SARS-CoV-2 infected healthcare workers? FindingsIn this cohort study that included 178 healthcare workers, over a 4-month period following the COVID-19 pandemic, participants had an initial rise in anti-nucleocapsid (N) and anti-spike (S) antibodies, which was followed by decay and stabilization of the titres. Significant correlation with rate of decay was noted with the symptomatic participants. MeaningA strong correlation is observed in the decay of anti-S antibody titres based on symptomology, thus eluding to the fact that continued recommendations for infection protection and COVID-19 vaccine campaigns are necessary.

Longitudinal analysis of SARS-CoV-2 seroprevalence using multiple serology platforms

Serological tests are important tools helping to determine previous infection with severe acute respiratory disease coronavirus 2 (SARS-CoV-2) and to monitor immune responses. The current tests are based on spike (S), the receptor binding domain (RBD), or the nucleoprotein (NP) as substrate. Here, we used samples from a high seroprevalence cohort of health care workers (HCWs) to perform a longitudinal analysis of the antibody responses using three distinct serological assays. 501 serum samples were tested using: a) a research-grade RBD and spike based tandem enzyme-linked immunosorbent assay (MS-RBD ELISA, MS-spike ELISA), b) a commercial RBD and spike based tandem ELISA (Kantaro-RBD, -spike), and c) a commercial NP-based chemiluminescent microparticle immunoassay (CMIA, Abbott Architect). Seroprevalence ranged around 28% during the early stage of the pandemic (a: 28.4% positives; b: 28.1%; c: 27.3%). Good correlation was observed between the MS and Kantaro RBD ELISAs and between the MS and Kantaro spike ELISAs. By contrast, modest correlations were observed between the Abbott Architect and both RBD and spike-based assays. A proportion of HCWs (n=178) were sampled again 3-5 months after the first time point. Although antibody levels declined in most of the positive individuals, the overall seroprevalence measured by RBD-spike based assays remained unchanged. However the seroprevalence of NP-reactive antibodies significantly declined. Lastly, we tested six samples of individuals who received two doses of SARS-CoV-2 mRNA vaccine and found that seroconversion was detected by the RBD-spike assays but - of course as expected - not the NP based assay. In summary, our results consolidate the strength of different serological assays to assess the magnitude and duration of antibodies to SARS-CoV-2.

Impact of Residential Neighborhood and Race/Ethnicity on Outcomes of Hospitalized Patients with COVID-19 in the Bronx

The socially vulnerable have been most affected due to the COVID-19 pandemic, similar to the aftermath of any major disaster. Racial and social minorities are experiencing a disproportionate burden of morbidity and mortality. The aim of this study was to evaluate the impact of residential location/community and race/ethnicity on outcomes of COVID-19 infection among hospitalized patients within the Bronx. This was a single center retrospective observational cohort study that included SARS-CoV2 positive adult residents of the Bronx (stratified as residents of South Bronx vs Rest of Bronx) hospitalized between March-May 2020. Data extracted from hospital electronic medical records included residential addresses, race, comorbidities, and insurance details. Comorbidity burden other clinical and laboratory details were also assessed to determine their correlation to COVID-19 severity of illness and outcomes of mortality and length of stay. As expected, the COVID-19 pandemic differentially affected outcomes in those in the more socially disadvantaged area of the South Bronx versus the rest of the Bronx borough. Residents of the South Bronx had a significantly higher comorbidity burden and had public insurance to access medical care in comparison to the remainder of the Bronx. Interestingly, for the patient population studied there was no observed difference in 30-day mortality by race/ethnicity among those infected with COVID- 19 in spite of the increased disease burden observed. This adds an interesting perspective to the current literature, and highlights the need to address the social/economic factors contributing to health access disparity to reduce the adverse impact of COVID-19 in these communities.