Impact of Crystalloid Administration on Patients Receiving Haploidentical Allogeneic Stem Cell Transplant (Haplo SCT) with Post Transplant Cytoxan Prophylaxis (PtCy): a Quality Improvement Initiative

Background: Crystalloid fluid administration has traditionally played an important role in prevention of hemorrhagic cystitis with high dose cyclophosphamide. Cryopreservation of stem cells in the era of the COVID pandemic has further led to an increase in crystalloid use. Excess fluid administration over a short duration could lead to volume overload, respiratory failure and impact overall survival. Method(s): A retrospective chart review was conducted on patients receiving PtCy following Haplo SCT at UVA Medical Center from September 2016 through August 2022. Internal BMT quality audit in June 2021 identified increased rate of ICU transfers and respiratory failure amongst patient receiving PtCy due to fluid overload. Hence our PtCy hydration was reduced, with IV fluid administration decreasing from 200 mL/ hr over 62 hours to 100 mL/hr over 12 hours. Urine output parameters placed to administer Cytoxan were also removed. We present our quality improvement project demonstrating outcomes pre and post intervention. Result(s): All demographic patient and transplant-related data was collected during the period of hospitalization for Haplo SCT [Table 1]. Pre-intervention spanned 9/2016-8/2021. Our analysis identified higher than expected rates of respiratory (Table Presented) failure prompting intervention on 8/2021. Post-intervention spanned 8/2021-8/2022. Pre-intervention, 45% of patients receiving Haplo SCT developed respiratory failure (defined as a new hypoxia) in the 30 day post-transplant period. Of these, 93% had volume overload. Mechanical ventilation was required in 21%. Complication rates included ICU transfer - 30%, AKI - 39%, and renal replacement therapy - 18%. Three percent (1 pt) developed hemorrhagic cystitis requiring bladder irrigation. Median LOS was 31.0 days. Post-intervention, average IV crystalloid received was reduced by about 15L. Median diuretic use reduced by 40%. No instances of respiratory failure, mechanical ventilation, ICU transfer, AKI or renal replacement therapy occurred in this group. Median LOS was 26.5 days. There were no cases of hemorrhagic cystitis. Please refer Figure 1. (Figure Presented) (Figure Presented) Conclusion(s): This single center quality improvement initiative shows that reducing IV crystalloid administration with PtCy is associated with a reduction in respiratory failure and other adverse clinical outcomes, without observed increase in hemorrhagic cystitis. Larger multi-center studies are needed to validate this finding.Copyright © 2023 American Society for Transplantation and Cellular Therapy

Impact of the pandemic on critical care staff safety climate assessed using safety attitudes questionnaire (SAQ) in all hospitals within the East of England

Introduction: As part of the last two peer review processes the East of England Critical Care Network have undertaken SAQ [1] involving staff in the 18 hospitals in the region. The questionnaire is divided into 7 scales and allows a wide assessment of safety culture which has been associated with improved outcomes and reduced adverse incidents [2]. The two surveys straddle the Covid-19 pandemic which has had a recognised impact on staff welfare. We postulated that this is likely to be identifiable within the survey and wished to understand the effect on different staff groups and levels of experience. Method(s): The survey was distributed using an online platform and analysed in R. Result(s): 1647 questionnaires were completed in 2019 (753) and 2022 (894). Demographic data was collected for role (nursing, medical, AHP, support) and critical care experience (short: < 4 years medium: 4-10 years, long: > 10 years). For all staff Climate scores fell significantly in all scales except stress recognition, most noticeably in job satisfaction and working conditions. This was also the case within the nursing subgroup;however, it was not seen in medical staff (though there was a less pronounced trend). AHPs reported a marked reduction in job satisfaction. Support staff also demonstrated big reductions in all scales including teamworking and safety climate. The fall in job satisfaction and working condition scales were also most profound in staff with 4-10 year's critical care experience. Conclusion(s): The pressures of the pandemic have had a lasting effect on most staff groups, particularly in job satisfaction and working conditions. This appears to have particularly impacted nursing and support staff. Those of moderate experience may have been the staff most directly involved with increased patient care and expectations to undertake managerial roles with reduced training. The impact of this appears to be ongoing despite efforts to support staff well-being.

IMPLEMENTATION OF A NARRATIVE MEDICINE CURRICULUM FOR INTERNAL MEDICINE RESIDENTS

SETTING AND PARTICIPANTS: The initial narrative medicine sessions were held virtually over Zoom during the 2020-2021 academic year due to COVID-19. Sessions were held in person during the 2021-2022 academic year. Each session included 8-16 internal medicine residents. Residents participated in a single session during their ambulatory block. DESCRIPTION: Narrative medicine has been integrated into medical training with increased depth and frequency to enhance competencies such as observation, reflection, and self-care among trainees. The narrative medicine sessions in this pilot curriculum consisted of one-hour interactive workshops. The workshops began with a brief introduction to the field of narrative medicine, followed by a discussion of a short literary text. After reading and discussing the text, participants were asked to complete a brief writing exercise designed to elicit a personal narrative, and responses were then shared with the larger group. EVALUATION: Following the workshop, participants (N=100) completed a retrospective pre- and post- survey assessing the impacts of this intervention on several different variables. Descriptive statistics were used to evaluate pre- and post-workshop differences. Participants also completed open-ended questions assessing what they learned from the session and what they could apply to their future practice, and key themes were extracted. The survey was administered through a HIPAA-compliant online platform, and no personally identifiable data were collected. Participants' interest in learning about the field of narrative medicine increased significantly after the workshop compared to prior (p<0.01). After the workshop, participants noted significantly higher levels of confidence in their ability to listen to patient stories, analyze short pieces of literature, and engage in reflective writing (p<0.01). They also expressed significantly greater agreement with the notions that engaging in literary analysis and reflective writing could improve patient care, reduce provider burnout, and improve connectedness to one's colleagues (p<0.01). Analysis of open-ended questions demonstrated that participants found the sessions to be engaging and worthwhile, and that many skills could be applied to their future practice. DISCUSSION / REFLECTION / LESSONS LEARNED: The results of this pilot study suggest that incorporating a brief narrative medicine curriculum into an internal medicine residency program is both feasible and valuable. A single, one-hour session was easily integrated into a pre-existing ambulatory block;participation fostered meaningful reflection, development of observational skills, and connection with colleagues. The session was positively received, and participants were able to appreciate the ways in which narrative medicine could enhance their own medical practice. Future directions include expanding the curriculum over all 3 years of residency and integrating it into existing curricula that address issues such as Social Determinants of Health and Equality, Diversity, and Inclusion.

Sleep telemedicine in Germany: a developed model

Telemedicine has advanced and grown enormously during the last 10 years. Due to the Sars-CoV2 pandemia the pace of digitalizing diagnostics and therapy in the field of sleep medicine has accelerated. In Germany the main fields of sleep telemedicine are the group of sleep disordered breathing and the group of insomnias. Although there are several initiatives which aim an inventing digital sleep technologies as telemedical recording of relevant data for the diagnostics of obstructive apnea syndrome or digital applications for the treatment of insomnia coordinated approaches are being developed. The German Sleep Society aims on coordinating all initiatives with several approaches. Here the main focus is the standard which a needed for quality aspects. Another aspect is to transform the German health system, which is divided into the public and the private health insurance system, into a more flexible and digital friendly one accepting that sleep medicine is one of the best example to implement digital techniques for telemedicine. The German state of the art in the field of sleep telemedicine will be reflected to open the chance for other countries to have a deeper insight in the challenges and shortcomings for implementing sleep telemedicine in a highly sophisticated health care system.

Nurses’ Experience in COVID-19 Patient Care

Purpose: This study aimed to explore nurses’ experience in caring for COVID-19 patients. Methods: A total of 10 nurses working in a COVID-19 ward of a public hospital in South Korea were recruited using purposeful sampling. Individual telephone interviews were conducted and then transcribed verbatim. Data were analyzed using qualitative content analysis. Results: Two categories of nurses’ experience in caring for COVID-19 patients emerged;“unstable psychological status” and “adaptation and self-esteem”. “Shortage of staff due to the increase in infected people”, “poor environment due to the urgent construction of a COVID-19 ward”, “unstable operating system”, and “excessive demands and verbal abuse from patients” were “obstacles”, while “cooperation and consideration between colleagues” and “interest and support from the manager” were found to be “sources to boost morale” for nurses in caring for COVID-19 patients. Conclusion: This study can be fundamental data for a deeper understanding of the experiences and challenges faced by frontline nurses caring for COVID-19 patients. It is necessary to provide psychological support for nurses and establish a well-structured nursing care system in order to fight a pandemic such as COVID-19. © 2022 Korean Academy of Nursing Administration

Law Enforcement’s Evolving Mission to Protect Children: A Multi-disciplinary Perspective Years Later

Each discipline responsible for providing safety and protection to child victims of violence has a vested interest in developing and maintaining best practice methods for responding to child maltreatment and exploitation. The steady progression of collaborative efforts in investigating, prosecuting and providing necessary services to victims, families and the greater community has led to the realization of the need for functioning and integrated partnerships. This chapter addresses two themes. We begin with a fresh look at some of the advances and emerging practices that have occurred over the last several years. For example, we discuss the adaptations made in the use of technology due to conditions imposed by the COVID19 world-wide pandemic, changes in legislation made to reflect the evolution of practices in the field, and highlights representing adoption worldwide of modern practice in communities where historically efforts to standardize the investigative process have been stalled. © 2022, The Author(s), under exclusive license to Springer Nature Switzerland AG.

Schlafstörungen und Erschöpfungssyndrom bei Long-COVID-Syndrom: Fallbasierte Erfahrungen aus der neurologischen/schlafmedizinischen Rehabilitation Sleep disorders and fatigue syndrome in long COVID syndrome: case-based experiences from neurological/sleep medicine rehabilitation

Schlafstörungen und ein klinisch signifikantes Erschöpfungssyndrom werden für das Long-COVID-Syndrom regelhaft beschrieben. Die pathophysiologischen Zusammenhänge sind weitergehend unbekannt. Die klinische Präsentation ist unterschiedlich und muss individuell betrachtet werden. Anhand von vier Fallbeispielen wird dargestellt, welche Symptome ein Long-COVID-Syndrom ausmachen und welche Therapieoptionen zur Verfügung stehen. Eine multimodale individualisierte Rehabilitation scheint geeignet, Betroffene wieder an die prämorbide Leistungsfähigkeit heranzuführen und eine erhebliche Reduktion von insomnischen Beschwerden zu erreichen.

[Sleep disorders and fatigue syndrome in long COVID syndrome: case-based experiences from neurological/sleep medicine rehabilitation]. / Schlafstörungen und Erschöpfungssyndrom bei Long-COVID-Syndrom: Fallbasierte Erfahrungen aus der neurologischen/schlafmedizinischen Rehabilitation.

Sleep disturbances and clinically significant fatigue syndrome are regularly described for long COVID syndrome. The pathophysiological correlations remain unknown. The clinical presentation is variable and must be considered individually. Four case studies will be used to illustrate the symptoms that constitute long COVID syndrome and the treatment options available. Multimodal individualized rehabilitation seems to be suitable to return those affected to their premorbid performance and to achieve a considerable reduction in insomniac complaints.

TELEREHABILITATION INNOVATION IN RESPONSE TO COVID-19

The State of the Science Symposium is held multiple times per year to enhance the knowledge and skills of individuals working in the fields such as rehabilitation medicine, engineering, and public health. The Symposium has continually focused on the health and well-being of active-duty military members, reserve/guard components, veterans, and their families. With the onset of the COVID-19 pandemic and the social distancing protocols adopted to combat viral spread, the State of the Science Symposium was moved to an online platform to minimize risk. In December 2020, the symposium invited professionals to discuss necessary changes in their fields of practice in light of the pandemic protocols, and how telehealth has expanded to encompass multiple disciplines. It is concluded that the adoption of telemedicine as a standard of care wherever appropriate will benefit all parties involved, even after restrictions on gatherings and interpersonal contact are eased.

The plasma-lyte 148 versus saline (PLUS) statistical analysis plan: A multicentre, randomised controlled trial of the effect of intensive care fluid therapy on mortality

Background and objective: The Plasma-Lyte 148 versus Saline (PLUS) study is a prospective, multicentre, parallel-group, concealed, blinded, randomised controlled trial comparing the effect of Plasma-Lyte 148 versus 0.9% sodium chloride (saline) for fluid resuscitation and other fluid therapy on 90-day mortality among critically ill adults requiring fluid resuscitation. The original target for recruitment was 8800 participants, which was reduced to 5000 participants following the onset of the coronavirus disease 2019 (COVID-19) pandemic in 2020. This article describes the statistical analysis plan for the PLUS study. Methods: The statistical analysis plan was developed by the study statistician, chief investigator, and project manager, and was approved by the Management Committee before unblinding. The plan describes in detail the analysis of baseline characteristics, process measures, and outcomes, including covariate adjustments, subgroup analyses, missing data handling, and sensitivity analyses. Results and conclusions: A statistical analysis plan for the PLUS study was developed. This pre-specified plan accords with high quality standards of internal validity and should minimise future analysis bias. © 2021, College of Intensive Care Medicine. All rights reserved.

Hepatitis c screening and diagnosis in a canadian provincial correctional system during the COVID-19 pandemic

Background: Increased hepatitis C virus (HCV) testing among people in prison (PIP) is key for HCV elimination efforts to be successful. Efforts to improve health care in all British Columbia (BC) Provincial Correctional Centres (PCCs) have been made in recent years, beginning with the transfer of health services from BC Corrections to BC Provincial Health Services Authority (PHSA) in 2017. However, the state of emergency declared in BC in early 2020 in response to the COVID-19 pandemic may have undermined these efforts. This study aims to examine patterns in HCV screening and diagnosis in all 10 BC PCCs before and during the COVID-19 pandemic. Methods: Data from the BC Sexually Transmitted and Blood-Borne Infections Data Mart, which contains laboratory data accounting for >95% of all anti-HCV and >99% of all HCV RNA and genotype tests performed in BC, were used for this study. The number of anti-HCV, HCV RNA and HCV genotype tests that were ordered from BC PCCs between April 1 2011 and March 31 2021 was determined for quarterly periods. New HCV diagnoses were defined as the number of 1st-time HCV-positive test episodes (anti-HCV, RNA or genotype) among HCV tests ordered from BC PCCs. Total intake numbers were provided by BC Corrections per calendar year. Results: The number of HCV antibody, RNA, and genotype tests ordered from BC PCCs in the 1st quarter of 2020 had increased by 412% (n=486), 530% (n=252) and 827% (n=139) respectively (Figure 1), compared to the 1st quarter of 2017 (prior to the transfer of health services to PHSA). Following the beginning of the COVID-19 pandemic, the number of HCV antibody, RNA, and genotype tests ordered from BC PCCs in the 2nd quarter of 2020 had decreased by 66% (n=165), 67% (n=83) and 68% (n=44), respectively (Figure 1), compared to the 1st quarter of 2020. The total number of HCV tests as a proportion of intakes to BC PCCs in 2019 was 17% (2518/15303), which increased to 23% (2112/9283) in 2020. Conclusion: The transfer of health services in BC PCCs to PHSA led to increased volume of HCV screening, with concomitant increases in new HCV diagnoses among PIP in BC from 4th quarter 2017 onwards. The COVID-19 pandemic led to health care challenges in prisons in BC (including the suspension of non-urgent HCV testing in the entire province for several weeks), and at the same time, the number of HCV tests and new diagnoses decreased. This may have been partly due to reduced intakes to BC PCCs over 2020, as the total number of HCV tests ordered as a proportion of intakes increased in 2020, compared to the previous year. Those people diverted away from the correctional system due to decarceration efforts triggered by COVID-19 may have missed out on HCV screening during 2020, therefore further efforts to increase HCV screening in correctional settings and the community will be needed.

Environmental effects of stratospheric ozone depletion, UV radiation, and interactions with climate change: UNEP Environmental Effects Assessment Panel, Update 2020.

This assessment by the Environmental Effects Assessment Panel (EEAP) of the United Nations Environment Programme (UNEP) provides the latest scientific update since our most recent comprehensive assessment (Photochemical and Photobiological Sciences, 2019, 18, 595-828). The interactive effects between the stratospheric ozone layer, solar ultraviolet (UV) radiation, and climate change are presented within the framework of the Montreal Protocol and the United Nations Sustainable Development Goals. We address how these global environmental changes affect the atmosphere and air quality; human health; terrestrial and aquatic ecosystems; biogeochemical cycles; and materials used in outdoor construction, solar energy technologies, and fabrics. In many cases, there is a growing influence from changes in seasonality and extreme events due to climate change. Additionally, we assess the transmission and environmental effects of the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), which is responsible for the COVID-19 pandemic, in the context of linkages with solar UV radiation and the Montreal Protocol.

Qualification of COVID-19 convalescent plasma donations by SARS-CoV-2 antibody testing utilizing a wide-dynamic range Antigen-Sandwich S1-antigen immunoassay and reflex neutralizing antibody testing

Background/Case Studies: The efficacy of COVID-19 convalescent plasma (CCP) to treat COVID-19 is hypothesized to be associated with the concentration of neutralizing antibodies (nAb) to SARS-CoV-2. While high capacity, automated serologic assays to detect binding antibodies (bAb) have been developed, complex nAb assays are not easily adaptable to high-throughput testing. We sought to determine the effectiveness of using surrogate bAb signalto- cutoff ratio (S/CO) in predicting nAb titers using a pseudovirus reporter viral neutralization (RVPN) assay. Study Design/Methods: CCP donor serum collected by 3 large US blood collectors was tested with a bAb assay (Ortho Diagnostic VITROS® Anti-SARS-CoV-2 Total, CoV2T) and a nAb RVPN assay. Although EUA approved as a qualitative assay, CoV2T reports a semi-quantitative S/CO. The RVPN assay uses a pseudovirus construct with native S-protein and target cell lines overexpressing ACE2 receptor and TMPRSS2 protease. Serially diluted serum is mixed with SARS-CoV-2 pseudovirus to assess inhibition of viral entry in culture and reported as titers resulting in 50% neutralization of virus infectivity (NT50) by nonlinear regression analysis. CoV2T prediction effectiveness at several S/CO thresholds was evaluated for various RVPN nAb NT50 titers using receiver operating characteristic analysis. Results/Findings: 753 CCP donations were tested with median CoV2T S/CO of 71.2 (range 0.1-919) and median NT50 of 527.5 (range <40 to >10,240). The prevalence of CCP donors with NT50 over various target n-Ab titers were 86% >80, 76% >160, and 45% >640. Increasing CoV2T reactivity threshold reduces sensitivity to predict the target NT50 titer while specificity to identify those below nAb threshold increases for all targeted NT50s (Table 1). As the targeted NT50 is increased from >80 to >640, the positive predictive value falls dramatically while the negative predictive value increases, thus S/CO thresholds are less able to predict donors who have the target NT50 titer but more able to predict those donors who do not meet it. Conclusions: The selection of targeted nAb titer for clinical use will significantly impact availability of CCP for transfusion. Product release with CoV2T assay S/CO thresholds must balance the risk of releasing products below minimum target nAb titer and the cost of false negatives (CCP units below the threshold with adequate nAb titers). A two-step testing scheme may be optimal, with nAb testing performed on CoV2T reactive samples with S/CO values below the release threshold.

[Management of diagnostic procedures and treatment of sleep related breathing disorders in the context of the coronavirus pandemic]. / Diagnostik und Therapie schlafbezogener Atmungsstörungen im Zusammenhang mit der Corona­Pandemie: Deutsche Gesellschaft für Pneumologie und Beatmungsmedizin e. V. (DGP), Deutsche Gesellschaft für Schlafforschung und Schlafmedizin (DGSM).

When providing sleep medical services special aspects must be taken into account in the context of the coronavirus pandemic. Despite all prevention, due to the high number of unrecognized cases, SARS-CoV2 contacts in the sleep laboratory must be expected and appropriate precautions are necessary. Nevertheless, the continuation or resumption of sleep medical services under the appropriate hygiene measures is strongly recommended to avoid medical and psychosocial complications. There is no evidence for a deterioration of COVID-19 through CPAP therapy. In principle, the application of positive pressure therapy via various mask systems can be accompanied by the formation of infectious aerosols. In the case of confirmed infection with SARS-CoV2, a pre-existing PAP therapy should be continued in an outpatient setting in accordance with the local guidelines for home isolation, since discontinuation of PAP therapy is associated with additional cardiopulmonary complications due to the untreated sleep-related breathing disorder. According to the current state of knowledge inhalation therapy, nasal high-flow (NHF), and PAP therapy can be carried out without increased risk of infection for health care workers (HCW) as long as appropriate personal protective equipment (eye protection, FFP2 or FFP-3 mask, gown) is being used.This position paper of the German Society for Pneumology and Respiratory Medicine (DGP) and the German Society for Sleep Medicine (DGSM) offers detailed recommendations for the implementation of sleep medicine diagnostics and therapy in the context of the coronavirus pandemic.

Erratum zu: SARS-CoV-2/COVID-19 und neuromuskuläre Erkrankungen

Erratum zu: DGNeurologie 2020 https://doi. Die ursprünglich publizierte Online-Version des Beitrags ent-hielt einen fehlerhaften Interessenkonflikt. Dies wurde im Ori-ginalbeitrag berichtigt. Bitte beachten Sie die korrigierte Version. Wir bitten, den Fehler zu entschuldigen. Die Online-Version des Originalartikels ist unter https://doi.org/10.

Disease X ver1.0: COVID-19

The SARS-Cov2 has presented the world with a novel pandemic challenge requiring a rapid response. This article provides a May 2020 snapshot from Professor Paul Young, who is part of a group working with urgency on Australia's leading COVID-19 candidate vaccine.