Impact of COVID-19 Lockdown Restrictions: Ambient NO2 and Asthma Hospital Admissions

Aim The World Health Organization (WHO) declared the COVID-19 pandemic a global health emergency. Many countries of the world, including Ireland, closed their borders and imposed nationwide lockdown. During this period, all major anthropogenic transport activities, which contribute to atmospheric pollution, were restricted. The current study examines the impact of the transport restrictions on ambient nitrogen dioxide (NO2) concentrations and hospital admissions for asthma across Ireland. Methods This is a retrospective population-based cohort study. National ambient air quality monitoring network data were analysed to investigation variations in NO2 concentrations. Asthma hospital admissions data were collected from the HSE Hospital In-patient Enquiry (HIPE) for Cork, Dublin, and Meath. Results During the period of transport restrictions, there were reductions in the annual mean NO2 for Cork, Dublin and Meath (i.e. 12µg/m3 to 11µg/m3 (p = 1);25µg/m3 to 17µg/m3 (p < 0.001);and 23µg/m3 to 21µg/m3 (p = 1)). Reductions in asthma hospital admissions were also observed. Among the 8,471 patient episodes included in this study, the mean [SD] age at admission was 47.2[22.9] years;61% were female (n=5,134);mean [SD] length of stay was 4.9[10.9] days. Conclusion The findings of this study provide an opportunity to explore the impact of NO2 emissions for Cork, Dublin and Meath on asthma hospital admissions, in order to improve air quality modelling and policy development of management of asthma.

COVID-19 transport restrictions in Ireland: impact on air quality and respiratory hospital admissions.

AIM: Exposure to poor air quality is a well-established factor for exacerbation of respiratory system diseases (RSDs); whether air pollutants are a cause of the development of RSD, however, remains unclear. This study aimed to examine the relationship between COVID-19 transport restrictions and hospital admissions because of RSD in Dublin city and county for 2020. STUDY DESIGN: This was a retrospective population-based cohort. METHODS: Admission data were collected from the Health Service Executive Hospital In-patient Enquiry. Daily count of hospital admissions with Dublin city and county address with primary diagnosis of RSD was performed. The daily air nitrogen dioxide (NO2) data were obtained from the Environmental Protection Agency (EPA). RESULTS: During the period of transport restrictions, there was a reduction in the annual mean NO2 from 25 µg/m3 to 17 µg/m3 (P < 0.001), and decreases in hospital admissions for RSD were observed. Among the 9934 patient episodes included in this study, the mean age at admission was 61.5 years, 57.8% were female (n = 5744), and mean (standard deviation) length of stay was 7.5 (13.52) days. CONCLUSION: This study, using routinely gathered data, suggests that decreases in ambient NO2 as related to COVID-19 transport restrictions were significantly associated with lower asthma and chronic obstructive pulmonary disease admissions.

Health Equity Beyond Data: Health Care Worker Perceptions of Race, Ethnicity, and Language Data Collection in Electronic Health Records.

BACKGROUND: Recent research and policy initiatives propose addressing the social determinants of health within clinical settings. One such strategy is the expansion of routine data collection on patient Race, Ethnicity, and Language (REAL) within electronic health records (EHRs). Although previous research has examined the general views of providers and patients on REAL data, few studies consider health care workers' perceptions of this data collection directly at the point of care, including how workers understand REAL data in relation to health equity. OBJECTIVE: This qualitative study examines a large integrated delivery system's implementation of REAL data collection, focusing on health care workers' understanding of REAL and its impact on data's integration within EHRs. RESULTS: Providers, staff, and administrators expressed apprehension over REAL data collection due to the following: (1) disagreement over data's significance, including the expected purpose of collecting REAL items; (2) perceived barriers to data retrieval, such as the lack of standardization across providers and national tensions over race and immigration; and (3) uncertainty regarding data's use (clinical decision making vs. system research) and dissemination (with whom the data may be shared; eg, public agencies, other providers, and insurers). CONCLUSION: Emerging racial disparities associated with COVID-19 highlight the high stakes of REAL data collection. However, numerous barriers to health equity remain. Health care workers need greater institutional support for REAL data and related EHR initiatives. Despite data collection's central importance to policy objectives of disparity reduction, data mandates alone may be insufficient for achieving health equity.

Rhabdomyolysis in SARS-CoV-2 infection

Introduction: Acute kidney injury (AKI) is a common complication of SARSCoV- 2 infection. Multiple mechanisms have been proposed including acute tubular necrosis (ATN) due to shock, cytokine release syndrome, hypoxia or vascular injury and thrombosis. Direct viral injury to tubular epithelial cells and podocytes has also been described. Rhabdomyolysis has been reported in infection with SARS-CoV, Respiratory Syncytial Virus and Influenza A. Although mild CK elevation was reported in cohorts of patients with COVID-19 and there is a single case report of late onset rhabdomyolysis, overt rhabdomyolysis on presentation has not been described. To our knowledge this is the first patient who presented with signs and symptoms of severe rhabdomyolysis and AKI that was likely secondary to SARS-CoV-2 infection. Case Description: A 51 year-old male with hypertension and diabetes, presented with 2 days of diffuse myalgia and mild dry cough without shortness of breath. He denied trauma, new medications, changes in diet, strenuous exercise or illicit drug use. Physical exam notable for fever and mild tachypnea, but no hypoxia. Lungs were clear and all muscles groups were soft and non-tender. Polymerase chain reaction was positive for SARS-CoV-2. Serum creatinine was 2.4 mg/dL (baseline 1.3 mg/dL), Urinalysis showed 3+ blood, 2+protein and 1-2 RBC per high power field. Initial serum creatinine kinase was 340,000 U/L and peaked at 464,000 U/L on day 4. Serum and urine myoglobin levels were elevated at 15,175 mg/L and >5000 mcg/L respectively on day 5. He received isotonic intravascular (IV) fluids but developed oliguria on day 2, requiring diuresis to maintain urine output. BUN and creatinine increased to 130 and 19 mg/dL respectively by day 8 and hemodialysis was initiated. Renal clearance and urine output then slowly improved, and dialysis was discontinued by day 15. Discussion: Myalgia and fatigue are common symptoms of COVID-19 infection. In addition, dipstick hematuria is reported in up to 10% of patients. Thus diagnosis of rhabdomyolysis and myoglobinuria requires a high index of suspicion. Early consideration and timely diagnosis of rhabdomyolysis and the treatment of myoglobinuria with intravenous fluids is critically important to prevent ATN. However, administration of IV fluids may be challenging in COVID-19 patients at risk of hypoxia and acute respiratory distress syndrome.