The COVID-19 Pandemic and Adult Cardiac Transplantation: Impact, Interventions, and Implications.

In this review, we provide a comprehensive overview of the impact of the COVID-19 pandemic on adult heart transplantation. We highlight the decline in the number of adult transplantations performed throughout the pandemic as a consequence of restrictions imposed on individual programs and hospitals. There were challenges to maintaining cardiac transplant activity at multiple levels, including organ donation in intensive care units, logistical difficulties with organ procurement, and rapidly changing resource considerations at health system and jurisdictional levels. We also review the impact of COVID-19 on cardiac transplant recipients. Despite the high rates of morbidity and mortality observed during the initial phases of the pandemic among heart transplant patients infected with COVID-19, the availability of effective vaccines, pre-exposure prophylaxis, and specific antiviral therapies have drastically improved outcomes over time. Vaccines have proven to be safe and effective in reducing infections and illness severity, but specific considerations in the immunocompromised solid organ transplant population apply, including the need for additional booster doses to achieve sufficient immunisation. We further outline the strong rationale for vaccination before transplantation wherever possible. Finally, the COVID-19 response created a number of barriers to safe and efficient post-transplantation care. Given the need for frequent evaluation and monitoring, especially in the first several months after cardiac transplantation, the pandemic provided the impetus to improve virtual care delivery and explore noninvasive rejection surveillance through gene expression profiling. We hope that lessons learned will allow us to prepare and pivot effectively during future pandemics and health care emergencies.

Opposing views: associations of political polarization, political party affiliation, and social trust with COVID-19 vaccination intent and receipt.

INTRODUCTION: Political polarization has increased in the USA within recent years. Studies have shown Republicans are less likely to accept COVID-19 vaccinations than Democrats; however, little is known regarding the association between COVID-19 vaccination acceptance and political polarization. METHODS: We used data from a nationally-representative survey of 1427 participants conducted between 9 February 2021 and 17 February 2021. We estimated multivariate-adjusted odds ratios for COVID-19 vaccination intent and receipt according to perceived political polarization (measured as the perceived size of the ideological gap between Democrats and Republicans), political party affiliation, and social trust, controlling for demographic and socioeconomic factors. RESULTS: Among participants perceiving high levels of polarization, Republicans (versus Democrats) reported a 90% lower odds of vaccination intent (OR = 0.10 [0.05, 0.19], P < 0.001). Participants with high (versus low) social trust and low perceived polarization had a 2-folder higher vaccination intent (OR = 2.39 [1.34, 4.21], P = 0.003); this association was substantially weaker in the high perceived polarization group. CONCLUSIONS: High perceived levels of political polarization appear to magnify the decrease in the odds of receiving the COVID-19 vaccine and the intent to get vaccinated among Republicans versus Democrats. Political polarization may further attenuate the protective associations of high social capital with vaccination.

What Matters Most: A Needs Assessment of Older Adults

Introduction With aging, comes a myriad of new experiences and adversities. One theme that continuously presents itself, especially in mental health clinics, is loneliness and isolation. The lack of social connections and the hinderance it plays only became more apparent during the COVID-19 pandemic and prompted the idea of creating a psychotherapeutic intervention to help combat these experiences in older adults. Group interventions foster social connections while reducing cost and the limited access to clinicians;the overall aim of this project was to conduct a program evaluation of an innovative, rotating psychological wellness group for older adults. In keeping with this, a needs assessment of what matters most in older adults was performed. Methods This pilot program includes a psychological wellness group offering for older adults with 6 modules covering a collection of topics that support optimal psychological wellness and promote health and resilience (i.e. digital tools and mobile apps, value-based behavioral activation to improve your mood, eating for a healthy brain, introduction to mindfulness, improving your sleep and strategies for managing anxiety) that are be held weekly, ranging in duration from 2-6 weeks, over the next 6 months. Participants were referred from outpatient psychiatry clinics, geriatric medicine providers in medical center, and local community organizations servicing older adults. To be included, patients had to be 65+ years old, English speaking, open to group treatment, and without a diagnosis of dementia. Once participants were triaged and selected, a questionnaire was sent that addressed multiple aspects of their past medical history as well as their goals of care, prompting patients to identify what matters most to them in the domains of functionality, enjoyment, and connectivity as well as an open text question allowing them to expand on which three matter the most above all. Results Older adults (N=21) were enrolled in the psychological wellness group, including 6 males and 15 females. Seven of the participants lived alone and 3 were caregivers. Survey results indicated that older adults greatly prioritize maintaining cognitive status as their greatest health priority. The perceived importance of maintaining social connectivity via relationships with family and friends was rated equally if not higher than physical functionality. The following representative direct patient quotes encapsulate this sentiment well with "[I] just can't seem to connect. I spend most of my days alone trying to make meaningful connection.” "Spend time with family and friends (personal connections, they are important to me).” Relatedly, patients who indicated that mental cognition was not one of their most important health goals tended to respond positively to priorities centered around personal independence, such as travel, preserved sensory function, and ability to complete iADLs. However, ability to care for self and others was globally the least important priority. Conclusions Insights in the health priorities of older adults may allow for a better understanding of their treatment goals, allowing for greater alignment in the therapeutic alliance. Of the neurocognitive domains, social cognition is not routinely tested;this preliminary data underscores the importance of this domain to older adults. Future work includes collecting additional surveys to create datasets large enough for cluster analysis and predictive modeling, which may be informative for directing targeted modules in expected areas of need and in initial intake triage. This research was funded by Psychiatry Innovator Grants Program- Grant #1266204-705-KAVGS Department of Psychiatry and Behavioral Sciences, Stanford University (PI: Cassidy-Eagle).

Associations of Race/Ethnicity and Socioeconomic Factors with Vaccination Among US Adults During the COVID-19 Pandemic, January to March 2021.

To date, there has been limited data available to understand the associations between race/ethnicity and socioeconomic and related characteristics with novel coronavirus disease (COVID-19) vaccination in the United States. We leveraged the large, nationally-representative cross-sectional surveys of the U.S. Household Pulse Survey between January and March 2021 with relatively complete race/ethnicity and socioeconomic data to examine national trends in levels of COVID-19 vaccine initiation and intention in adults aged 18-85 years. We further estimated the multivariable associations between race/ethnicity, education, income, and financial hardship with the adjusted prevalence odds ratios of: 1) receipt of ≥1 COVID-19 vaccine dose; and 2) among those unvaccinated, the definite intention to receive a vaccine. We observed persistent disparities in vaccine initiation for non-Hispanic Blacks, Hispanics, and non-Hispanic multiracial/other race persons, and vaccine intention for Blacks and multiracial/other race persons, compared to non-Hispanic Whites and Asians. In late March 2021, the prevalence estimates of Hispanics and Blacks receiving a vaccine were 12-percentage points and 8-percentage points lower than for Whites, respectively. Education and income exhibited dose-response relationships with vaccine initiation (P for trend≤.01 and <.001, respectively). Substantial financial hardship was linked to 35-44% lower adjusted odds of vaccination (P<.001). In this large, nationally-representative study, we found persistent racial/ethnic and socioeconomic disparities in vaccine initiation and intention, more than three months after COVID-19 vaccines first became available. Addressing these persistent racial/ethnic and socioeconomic inequities in vaccination is essential to mitigate the pandemic's higher risks of infection and adverse health outcomes in Hispanic, Black, and socioeconomically-disadvantaged communities.

Recombinant proteins of spike protein of SARS-CoV-2 with the Omicron receptor-binding domain induce production of highly Omicron-specific neutralizing antibodies.

Various vaccines have been developed to fight severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), the virus responsible for the coronavirus disease 2019 pandemic. However, new variants of SARS-CoV-2 undermine the effort to fight SARS-CoV-2. Here, we produced S proteins harboring the receptor-binding domain (RBD) of the Omicron variant in plants. Plant-produced S proteins together with adjuvant CIA09A triggered strong immune responses in mice. Antibodies in serum inhibited interaction of recombinant human angiotensin-converting enzyme 2 with RBD of the Omicron variant, but not RBD of other variants. These results suggest that antibodies induced by RBD of the Omicron variant are highly specific for the Omicron RBD, but not for that of other variants.

Pyramidal Decision Support Framework Leverages Subspecialty Expertise across Enterprise to Achieve Superior Cancer Outcomes and Personalized, Precision Care Plans.

The complexity of cancer care requires integrated and continuous support to deliver appropriate care. An expert network with complementary expertise and the capability of multidisciplinary care is an integral part of contemporary oncology care. Appropriate infrastructure is necessary to empower this network to deliver personalized precision care to their patients. Providing decision support as cancer care becomes exponentially more complex with new diagnostic and therapeutic choices remains challenging. City of Hope has developed a Pyramidal Decision Support Framework to address these challenges, which were exacerbated by the COVID pandemic, health plan restrictions, and growing geographic site diversity. Optimizing efficient and targeted decision support backed by multidisciplinary cancer expertise can improve individual patient treatment plans to achieve improved care and survival wherever patients are treated.

Gastrointestinal Manifestations of Coronavirus Disease 2019 Across the United States: A Multicenter Cohort Study.

Background and Aims: Gastrointestinal (GI) symptoms occur among patients diagnosed with coronavirus disease 2019 (COVID-19), and there is clear evidence that SARS-CoV-2, the causative pathogen, infects the GI tract. In this large, multicenter cohort study, we evaluated variations in gastrointestinal and hepatic manifestations of COVID-19 throughout the United States (US). Methods: Patients hospitalized with a positive COVID-19 test prior to October 2020 were identified at 7 US academic centers. Demographics, presenting symptoms, laboratory data, and hospitalization outcomes were abstracted. Descriptive and regression analyses were used to evaluate GI manifestations and their potential predictors. Results: Among 2031 hospitalized patients with COVID-19, GI symptoms were present in 18.9%; diarrhea was the most common (15.2%), followed by nausea and/or vomiting (12.6%) and abdominal pain (6.0%). GI symptoms were less common in the Western cohort (16.0%) than the Northeastern (25.6%) and Midwestern (26.7%) cohorts. Compared to nonintensive care unit (ICU) patients, ICU patients had a higher prevalence of abnormal aspartate aminotransferase (58.1% vs 37.3%; P < .01), alanine aminotransferase (37.5% vs 29.3%; P = .01), and total bilirubin (12.7% vs 9.0%; P < .01). ICU patients also had a higher mortality rate (22.7% vs 4.7%; P < .01). Chronic liver disease was associated with the development of GI symptoms. Abnormal aspartate aminotransferase or alanine aminotransferase was associated with an increased risk of ICU admission. Conclusion: We present the largest multicenter cohort of patients with COVID-19 across the United States. GI manifestations were common among patients hospitalized with COVID-19, although there was significant variability in prevalence and predictors across the United States.

The mental health burden of racial and ethnic minorities during the COVID-19 pandemic.

Racial/ethnic minorities have been disproportionately impacted by COVID-19. The effects of COVID-19 on the long-term mental health of minorities remains unclear. To evaluate differences in odds of screening positive for depression and anxiety among various racial and ethnic groups during the latter phase of the COVID-19 pandemic, we performed a cross-sectional analysis of 691,473 participants nested within the prospective smartphone-based COVID Symptom Study in the United States (U.S.) and United Kingdom (U.K). from February 23, 2021 to June 9, 2021. In the U.S. (n=57,187), compared to White participants, the multivariable odds ratios (ORs) for screening positive for depression were 1·16 (95% CI: 1·02 to 1·31) for Black, 1·23 (1·11 to 1·36) for Hispanic, and 1·15 (1·02 to 1·30) for Asian participants, and 1·34 (1·13 to 1·59) for participants reporting more than one race/other even after accounting for personal factors such as prior history of a mental health disorder, COVID-19 infection status, and surrounding lockdown stringency. Rates of screening positive for anxiety were comparable. In the U.K. (n=643,286), racial/ethnic minorities had similarly elevated rates of positive screening for depression and anxiety. These disparities were not fully explained by changes in leisure time activities. Racial/ethnic minorities bore a disproportionate mental health burden during the COVID-19 pandemic. These differences will need to be considered as health care systems transition from prioritizing infection control to mitigating long-term consequences.

The balancing role of distribution speed against varying efficacy levels of COVID-19 vaccines under variants.

During a pandemic, vaccination plays an important role in reducing the infection spread or adverse outcomes such as hospitalizations and deaths. However, a vaccine's overall public health impact depends not only on its initial efficacy, but also its efficacy against emerging variants and ease and speed of distribution. For example, mutations in SARS-CoV-2 raised concerns about diminishing vaccine effectiveness against COVID-19 caused by particular variants. Furthermore, due to supply-chain challenges, the accessibility and distribution of the vaccines have been hindered in many regions, especially in low-income countries, while the second or third wave of the COVID-19 pandemic has occurred due to the variants. Hence, we evaluated the interactions between the speed of distribution and efficacy against infection of multiple vaccines when variants emerge by utilizing a Susceptible-Infected-Recovered-Deceased model and assessing the level of infection attack rate. Our results show that speed is a key factor to a successful immunization strategy to control the pandemic even when the emerging variants may reduce the efficacy of a vaccine. Understanding the interactions between speed and efficacy and distributing vaccines that are available as quickly as possible are crucial to eradicate the pandemic before new variants spread.

Impact of medical school responses during the COVID-19 pandemic on student satisfaction: a nationwide survey of US medical students.

PURPOSE: Medical schools have faced various challenges in preparing their clinical students for the frontlines of a pandemic. This study investigated medical students' satisfaction with their institutions during the coronavirus disease 2019 (COVID-19) pandemic with the intention of guiding educators in future public health crises. METHODS: In this cross-sectional study surveying students in clinical rotations, the primary outcome was overall satisfaction regarding medical schools' responses to the pandemic, and the four secondary outcomes were school communication, exposure to COVID-19, availability of personal protective equipment, and access to COVID-19 testing. RESULTS: The survey was distributed to ten medical schools, of which 430 students responded for a response rate of 13.0%. While most students were satisfied (61.9%, n=266) with their schools' response, more than one in five (21.9%, n=94) were dissatisfied. Among the four secondary outcomes, communication with students was most predictive of overall satisfaction. CONCLUSION: In future crises, schools can best improve student satisfaction by prioritizing timely communication.

A Rare Case of Fat Embolism Syndrome Masquerading as COVID-19 Pneumonia.

In the wake of the novel coronavirus disease 2019 (COVID-19) pandemic and its associated mortality and virulence, a high clinical suspicion must be maintained for all patients presenting with respiratory failure. However, there are well-known disease processes that may have a similar presentation. We present a case of a 25-year-old male who suffered a right tibia fracture after a motor vehicle collision. He had acute hypoxic respiratory failure within 24 hours of admission, requiring mechanical ventilation. His condition significantly improved with airway pressure release mode of ventilation and proning. Although his chest CT demonstrated characteristic findings of COVID-19, he subsequently tested negative. The differential included aspiration pneumonia and fat embolism syndrome from the lower extremity fracture. Fat embolism syndrome can very closely mimic COVID-19. The rapid onset and improvement of symptoms coupled with serial negative COVID-19 testing may aid in the diagnosis.

Resource allocation for different types of vaccines against COVID-19: Tradeoffs and synergies between efficacy and reach.

OBJECTIVE: Vaccine shortage and supply-chain challenges have caused limited access by many resource-limited countries during the COVID-19 pandemic. One of the primary decisions for a vaccine-ordering decision-maker is how to allocate the limited resources between different types of vaccines effectively. We studied the tradeoff between efficacy and reach of the two vaccine types that become available at different times. METHODS: We extended a Susceptible-Infected-Recovered-Deceased (SIR-D) model with vaccination, ran extensive simulations with different settings, and compared the level of infection attack rate (IAR) under different reach ratios between two vaccine types under different resource allocation decisions. RESULTS: We found that when there were limited resources, allocating resources to a vaccine with high efficacy that became available earlier than a vaccine with lower efficacy did not always lead to a lower IAR, particularly if the former could vaccinate less than 42.5% of the population (with the selected study parameters) who could have received the latter. Sensitivity analyses showed that this result stayed robust under different study parameters. CONCLUSIONS: Our results showed that a vaccine with lower resource requirements (wider reach) can significantly contribute to reducing IAR, even if it becomes available later in the pandemic, compared to a higher efficacy vaccine that becomes available earlier but requires more resources. Limited resource in vaccine distribution is significant challenge in many parts of the world that needs to be addressed to improve the global access to life-saving vaccines. Understanding the tradeoffs between efficacy and reach is critical for resource allocation decisions between different vaccine types for improving health outcomes.

Financial hardship and social assistance as determinants of mental health and food and housing insecurity during the COVID-19 pandemic in the United States.

BACKGROUND: While social assistance through the U.S. federal CARES Act provided expanded unemployment insurance benefits during the COVID-19 pandemic until the summer of 2020, it is unclear whether social assistance was sufficient in subsequent months to meet everyday spending needs and to curb the adverse health-related sequelae of financial hardship. METHODS: Using multivariable Poisson log-binomial regression and repeated cross-sectional Household Pulse Survey data between September and December 2020 on 91,222 working-aged U.S. adults and 28,842 adult housing renters, this study explored the associations of financial hardship with mental health outcomes and food and housing insecurity after accounting for receipt of social assistance. RESULTS: Financial hardship rose progressively from September to December 2020, and disproportionately affected Black non-Hispanic and Hispanic Americans and lower-income households. Experiencing considerable financial hardship (vs no hardship) predicted nearly 3-fold higher risks of anxiety and depressive symptoms (e.g., adjusted prevalence ratio, PR of depression = 2.75, 95% CI = 2.54-2.98, P < .001), a 23-fold higher risk of food insufficiency (PR = 22.71, 95% CI = 15.62-33.01, P < .001), and a 27-fold higher risk of a likely eviction (PR = 27.20, 95% CI = 10.63-69.59, P < .001). Across outcomes, these relationships were stronger at each successively higher level of financial hardship (all P values for linear trend <0.001), and more than offset benefits from social assistance. CONCLUSIONS: Even after accounting for social assistance receipt, working-aged adults experiencing financial hardship had markedly greater risks of anxiety and depressive symptoms, food insufficiency, and an anticipated housing eviction. These findings point to the urgent need for direct and sustained cash relief well in excess of current levels of social assistance to mitigate the pandemic's adverse impacts on the well-being of millions of Americans, including vulnerable minority and low-income populations.

Cohort profile: a migratory cohort study of US Marines who train in Australia.

PURPOSE: In 2012, US Marines and Sailors began annual deployments to Australia to participate in joint training exercises with the Australian Defence Force and other partners in the region. During their training, US service members are exposed to a variety of infectious disease threats not normally encountered by American citizens. This paper describes a cohort of US Marines and Sailors enrolled during five rotations to Australia between 2016 and 2020. PARTICIPANTS: Study participation is strictly voluntary. Group informational sessions are held prior to deployment to describe the study structure and goals, as well as the infectious disease threats that participants may encounter while in Australia. All participants provided written informed consent. Consented participants complete a pre-deployment questionnaire to collect data including basic demographic information, military occupational specialty, travel history, family history, basic health status and personal habits such as alcohol consumption. Blood is collected for serum, plasma and peripheral blood mononuclear cells (PBMC) processing. Data and specimen collection is repeated up to three times: before, during and after deployment. FINDINGS TO DATE: From the five rotations that comprised the 2016-2020 Marine Rotational Force-Darwin, we enrolled 1289 volunteers. Enrolments during this period were overwhelmingly white male under the age of 24 years. Most of the enrollees were junior enlisted and non-commissioned officers, with a smaller number of staff non-commissioned officers and commissioned officers, and minimal warrant officers. Over half of the enrollees had occupational specialty designations for infantry. FUTURE PLANS: In the future, we will screen samples for serological evidence of infection with Burkholderia pseudomallei, Coxiella burnetii, Ross River virus, SARS-CoV-2 and other operationally relevant pathogens endemic in Australia. Antigenic stimulation assays will be performed on PBMCs collected from seropositive individuals to characterise the immune response to these infections in this healthy American population.

Kynurenic acid may underlie sex-specific immune responses to COVID-19.

Coronavirus disease 2019 (COVID-19) has poorer clinical outcomes in males than in females, and immune responses underlie these sex-related differences. Because immune responses are, in part, regulated by metabolites, we examined the serum metabolomes of COVID-19 patients. In male patients, kynurenic acid (KA) and a high KA-to-kynurenine (K) ratio (KA:K) positively correlated with age and with inflammatory cytokines and chemokines and negatively correlated with T cell responses. Males that clinically deteriorated had a higher KA:K than those that stabilized. KA inhibits glutamate release, and glutamate abundance was lower in patients that clinically deteriorated and correlated with immune responses. Analysis of data from the Genotype-Tissue Expression (GTEx) project revealed that the expression of the gene encoding the enzyme that produces KA, kynurenine aminotransferase, correlated with cytokine abundance and activation of immune responses in older males. This study reveals that KA has a sex-specific link to immune responses and clinical outcomes in COVID-19, suggesting a positive feedback between metabolites and immune responses in males.