Evaluating fomite risk of brown paper bags storing personal protective equipment exposed to SARS-CoV-2: A quasi-experimental study.

INTRODUCTION: Literature is lacking on the safety of storing contaminated PPE in paper bags for reuse, potentially increasing exposure to frontline healthcare workers (HCW) and patients. The aim of this study is to evaluate the effectiveness of paper bags as a barrier for fomite transmission of SARS-CoV-2 by storing face masks, respirators, and face shields. METHODS: This quasi-experimental study evaluated the presence of SARS-CoV-2 on the interior and exterior surfaces of paper bags containing PPE that had aerosolized exposures in clinical and simulated settings. Between May and October 2020, 30 unique PPE items were collected from COVID-19 units at two urban hospitals. Exposed PPE, worn by either an infected patient or HCW during a SARS-CoV-2 aerosolizing event, were placed into an unused paper bag. Samples were tested at 30-minute and 12-hour intervals. RESULTS: A total of 177 swabs were processed from 30 PPE samples. We found a 6.8% positivity rate among all samples across both collection sites. Highest positivity rates were associated with ventilator disconnection and exposure to respiratory droplets from coughing. Positivity rates differed between hospital units. Total positivity rates were similar between 30-minute (6.7%) and 12-hour (6.9%) sample testing time intervals. Control samples exposed to inactivated SARS-CoV-2 droplets had higher total viral counts than samples exposed to nebulized aerosols. CONCLUSIONS: Data suggests paper bags are not a significant fomite risk for SARS-CoV-2 transmission. However, controls demonstrated a risk with droplet exposure. Data can inform guidelines for storing and re-using PPE in situations of limited supplies during future pandemics.

Intermittent complete heart block with ventricular standstill after Pfizer COVID-19 booster vaccination: A case report.

As the COVID-19 pandemic continues around the globe, vaccines are undoubtedly central to the fight to control the spread of the virus. However, as with any therapy, these vaccines are not without side effects. Documented cardiac complications of COVID-19 vaccination include myocarditis, pericarditis, and cardiac conduction abnormalities. Here, we report a novel case of intermittent complete heart block with ventricular standstill occurring within 24 hours of administration of a Pfizer-BioNTech COVID-19 booster vaccine. The patient presented to the emergency department (ED) via ambulance for evaluation of syncope. On arrival, the patient lost pulses as a result of intermittent complete heart block with ventricular standstill. He required cardiopulmonary resuscitation (CPR) with intubation, transcutaneous pacing, and subsequent transvenous pacing in the ED. After stabilization and extensive workup, the patient was diagnosed with lymphocytic myocarditis and complete heart block that is suspected to be secondary to COVID-19 booster vaccination. Ultimately, the patient's complete heart block resolved spontaneously, and he was discharged home with ambulatory rhythm monitoring.

Global Oral Anticoagulation Use Varies by Region in Patients With Recent Diagnosis of Atrial Fibrillation: The GLORIA-AF Phase III Registry.

Background Effective stroke prevention with oral anticoagulants (OAC) is recommended for some patients with atrial fibrillation (AF). We aimed to describe OAC use by geographical region and type of site in patients with recent-onset AF enrolled in a large global registry. Methods and Results Eligible participants were recruited into GLORIA-AF (Global Registry on Long-Term Oral Antithrombotic Treatment in Patients With Atrial Fibrillation), a prospective observational cohort study from 2014 to 2016 in 4 international regions: North America, Europe, Asia, and Latin America. Cumulative incidence functions were generated for direct OACs (DOAC), vitamin K antagonists, and antiplatelet drugs considering competing risks, stratified by region and type of site. Time-to-treatment initiation after AF diagnosis was analyzed with Fine-Gray subdistribution hazard models. A total of 21 237 patients eligible for analysis were identified. By 30 days after AF diagnosis, 40%, 16%, and 8.6% of patients had DOAC, vitamin K antagonists, and antiplatelet drugs initiated, respectively. Earlier initiation of DOACs was observed in Europe, with Asia and Latin America having lower hazard rates of DOAC time-to-treatment initiation than Europe (hazard ratio [HR], 0.66; 95% CI, 0.62-0.70 and HR, 0.79; 95% CI, 0.73-0.85, respectively). DOAC initiation was highest in community hospitals, vitamin K antagonists in outpatient health care centers/anticoagulation clinics, and antiplatelet drugs in primary care clinics. Conclusions Important geographic variability exists with the use of OACs for patients with AF. Differences in the time-to-treatment initiation of OAC by type of site suggests suboptimal implementation of guideline recommendations and could result in less benefit and more harm. Optimizing OAC use for patients with AF may improve outcomes and reduce health care costs. Registration URL: http://www.clinicaltrials.gov; Unique identifiers: NCT01468701, NCT01671007.

Utility of COVID-19 antigen testing in the emergency department.

BACKGROUND: The BinaxNOW coronavirus disease 2019 (COVID-19) Ag Card test (Abbott Diagnostics Scarborough, Inc.) is a lateral flow immunochromatographic point-of-care test for the qualitative detection of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) nucleocapsid protein antigen. It provides results from nasal swabs in 15 minutes. Our purpose was to determine its sensitivity and specificity for a COVID-19 diagnosis. METHODS: Eligible patients had symptoms of COVID-19 or suspected exposure. After consent, 2 nasal swabs were collected; 1 was tested using the Abbott RealTime SARS-CoV-2 (ie, the gold standard polymerase chain reaction test) and the second run on the BinaxNOW point of care platform by emergency department staff. RESULTS: From July 20 to October 28, 2020, 767 patients were enrolled, of which 735 had evaluable samples. Their mean (SD) age was 46.8 (16.6) years, and 422 (57.4%) were women. A total of 623 (84.8%) patients had COVID-19 symptoms, most commonly shortness of breath (n = 404; 55.0%), cough (n = 314; 42.7%), and fever (n = 253; 34.4%). Although 460 (62.6%) had symptoms ≤7 days, the mean (SD) time since symptom onset was 8.1 (14.0) days. Positive tests occurred in 173 (23.5%) and 141 (19.2%) with the gold standard versus BinaxNOW test, respectively. Those with symptoms >2 weeks had a positive test rate roughly half of those with earlier presentations. In patients with symptoms ≤7 days, the sensitivity, specificity, and negative and positive predictive values for the BinaxNOW test were 84.6%, 98.5%, 94.9%, and 95.2%, respectively. CONCLUSIONS: The BinaxNOW point-of-care test has good sensitivity and excellent specificity for the detection of COVID-19. We recommend using the BinasNOW for patients with symptoms up to 2 weeks.

Predictors of Acute Atrial Fibrillation and Flutter Hospitalization across 7 U.S. Emergency Departments: A Prospective Study.

INTRODUCTION: International rates of hospitalization for atrial fibrillation and flutter (AFF) from the emergency department (ED) vary widely without clear evidence to guide the identification of high-risk patients requiring inpatient management. We sought to determine (1) variation in hospital admission and (2) modifiable factors associated with hospitalization of AFF patients within a U.S. integrated health system. METHODS: This multicenter prospective observational study of health plan members with symptomatic AFF was conducted using convenience sampling in 7 urban community EDs from 05/2011 to 08/2012. Prospective data collection included presenting symptoms, characteristics of atrial dysrhythmia, ED physician impression of hemodynamic instability, comorbid diagnoses, ED management, and ED discharge rhythm. All centers had full-time on-call cardiology consultation available. Additional variables were extracted from the electronic health record. We identified factors associated with hospitalization and included predictors in a multivariate Poisson Generalized Estimating Equations regression model to estimate adjusted relative risks while accounting for clustering by physician. RESULTS: Among 1,942 eligible AFF patients, 1,074 (55.3%) were discharged home and 868 (44.7%) were hospitalized. Hospitalization rates ranged from 37.4% to 60.4% across medical centers. After adjustment, modifiable factors associated with increased hospital admission from the ED included non-sinus rhythm at ED discharge, no attempted cardioversion, and heart rate reduction. DISCUSSION: Within an integrated health system, we found significant variation in AFF hospitalization rates and identified several modifiable factors associated with hospital admission. Standardizing treatment goals that specifically address best practices for ED rate reduction and rhythm control may reduce hospitalizations.

Assessing effective mask use by the public in two countries: an observational study.

OBJECTIVES: During the COVID-19 pandemic wearing a mask in public has been recommended in some settings and mandated in others. How often this advice is followed, how well, and whether it inadvertently leads to more disease transmission opportunities due to a combination of improper use and physical distancing lapses is unknown. DESIGN: Cross-sectional observational study performed in June-August 2020. SETTING: Eleven outdoor and indoor public settings (some with mandated mask use, some without) each in Toronto, Ontario, and in Portland, Oregon. PARTICIPANTS: All passers-by in the study settings. OUTCOME MEASURES: Mask use, incorrect mask use, and number of breaches (ie, coming within 2 m of someone else where both parties were not properly masked). RESULTS: We observed 36 808 persons, the majority of whom were estimated to be aged 31-65 years (49%). Two-thirds (66.7%) were wearing a mask and 13.6% of mask-wearers wore them incorrectly. Mandatory mask-use settings were overwhelmingly associated with mask use (adjusted OR 79.2; 95% CI 47.4 to 135.1). Younger age, male sex, Torontonians, and public transit or airport settings (vs in a store) were associated with lower adjusted odds of wearing a mask. Mandatory mask-use settings were associated with lower adjusted odds of mask error (OR 0.30; 95% CI 0.14 to 0.73), along with female sex and Portland subjects. Subjects aged 81+ years (vs 31-65 years) and those on public transit and at the airport (vs stores) had higher odds of mask errors. Mask-wearers had a large reduction in adjusted mean number of breaches (rate ratio (RR) 0.19; 95% CI 0.17 to 0.20). The 81+ age group had the largest association with breaches (RR 7.77; 95% CI 5.32 to 11.34). CONCLUSIONS: Mandatory mask use was associated with a large increase in mask-wearing. Despite 14% of them wearing their masks incorrectly, mask users had a large reduction in the mean number of breaches (disease transmission opportunities). The elderly and transit users may warrant public health interventions aimed at improving mask use.

Early Convalescent Plasma for High-Risk Outpatients with Covid-19.

BACKGROUND: Early administration of convalescent plasma obtained from blood donors who have recovered from coronavirus disease 2019 (Covid-19) may prevent disease progression in acutely ill, high-risk patients with Covid-19. METHODS: In this randomized, multicenter, single-blind trial, we assigned patients who were being treated in an emergency department for Covid-19 symptoms to receive either one unit of convalescent plasma with a high titer of antibodies against severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) or placebo. All the patients were either 50 years of age or older or had one or more risk factors for disease progression. In addition, all the patients presented to the emergency department within 7 days after symptom onset and were in stable condition for outpatient management. The primary outcome was disease progression within 15 days after randomization, which was a composite of hospital admission for any reason, seeking emergency or urgent care, or death without hospitalization. Secondary outcomes included the worst severity of illness on an 8-category ordinal scale, hospital-free days within 30 days after randomization, and death from any cause. RESULTS: A total of 511 patients were enrolled in the trial (257 in the convalescent-plasma group and 254 in the placebo group). The median age of the patients was 54 years; the median symptom duration was 4 days. In the donor plasma samples, the median titer of SARS-CoV-2 neutralizing antibodies was 1:641. Disease progression occurred in 77 patients (30.0%) in the convalescent-plasma group and in 81 patients (31.9%) in the placebo group (risk difference, 1.9 percentage points; 95% credible interval, -6.0 to 9.8; posterior probability of superiority of convalescent plasma, 0.68). Five patients in the plasma group and 1 patient in the placebo group died. Outcomes regarding worst illness severity and hospital-free days were similar in the two groups. CONCLUSIONS: The administration of Covid-19 convalescent plasma to high-risk outpatients within 1 week after the onset of symptoms of Covid-19 did not prevent disease progression. (SIREN-C3PO ClinicalTrials.gov number, NCT04355767.).

An international survey of healthcare workers use of personal protective equipment during the early stages of the COVID-19 pandemic.

OBJECTIVE: Little is known regarding the specific ways personal protective equipment (PPE) has been used and reused during the coronavirus disease 2019 (COVID-19) pandemic. The objective of this study was to evaluate the patterns of PPE use and the impact of PPE availability on the attitudes and well-being of an international population of healthcare workers. METHODS: This was an online, cross-sectional survey of healthcare workers. The survey was disseminated internationally using social media, specialty society list-serves, and email augmented by snowball sampling to healthcare workers who provided direct care to patients with suspected or confirmed COVID-19. The survey was conducted between April 13 and May 1, 2020. The primary outcome was self-reported PPE use during aerosol-generating medical procedures. Other outcomes included PPE use during care for respiratory patients in general, PPE reuse, PPE decontamination, and healthcare worker impressions related to their work and the pandemic. RESULTS: A total of 2227 healthcare workers from 23 countries completed the survey. The N95 was the most common respirator among the 1451 respondents who performed aerosol-generating procedures (n = 1050, 72.3%). Overall, 1783 (80.1%) of providers reported general reuse of PPE, which was similar across US regions but less common in Canada, Italy, and Spain. The most commonly reused item of PPE was the N95 respirator, with the majority of respondents who reused PPE reporting N95 reuse (n = 1157, 64.9%). Of the 1050 individuals who wore an N95 mask while performing an aerosol-generating medical procedure, 756 (72%) reported re-using an N95, and 344 (45.5%) reported reuse for >3 days. Qualitative results identified several common themes, including (1) lack of availability of PPE, (2) fear and anxiety as a result of inadequate PPE, (3) potential exposure to family members, and (4) concerns regarding workload and pay. CONCLUSIONS: This international survey of healthcare workers found that N95 respirators were commonly used to care for patients with respiratory symptoms with and without aerosol-generating medical procedures. Healthcare workers reported an unprecedented need to reuse PPE that was designed for single-use, specifically the N95 respirator. The reuse of PPE increased the perceived risk for COVID-19 infection and harmed mental health.

Practice Gap in Atrial Fibrillation Oral Anticoagulation Prescribing at Emergency Department Home Discharge.

INTRODUCTION: Current U.S. cardiology guidelines recommend oral anticoagulation (OAC) to reduce stroke risk in selected patients with atrial fibrillation (AF), but no formal AF OAC recommendations exist to guide emergency medicine clinicians in the acute care setting. We sought to characterize emergency department (ED) OAC prescribing practices after an ED AF diagnosis. METHODS: This retrospective study included index visits for OAC-naive patients ≥18 years old who were discharged home from the ED at an urban, academic, tertiary hospital with a primary diagnosis of AF from 2012-2014. Five hypothesis-blinded, chart reviewers abstracted data from patient problem lists and medical history in the electronic health record to assess stroke (CHA2DS2-VASc) and bleeding risk (HAS-BLED). The primary outcome was the provision of an OAC prescription at discharge in OAC-naive patients with high stroke risk. Descriptive statistics and multivariable logistic regression assessed associations between OAC prescription and patient characteristics. RESULTS: We included 138 patient visits in our analysis, of whom 39.9% (n = 55) were low stroke risk (CHA2DS2-VASc = 0 in males and 1 in females), 15.9% (n = 22) were intermediate risk (CHA2DS2-VASc = 1 in males), and 44.2% (n = 61) were high risk (CHA2DS2-VASc ≥ 2). Of patients with high stroke risk and low-to-intermediate bleeding risk (n = 57), 80.7% were not prescribed an OAC at discharge. Cardiology consultation and female gender, but not stroke risk (CHA2DS2-VASc score), were predictors of an ED provider prescribing an OAC to an OAC-naive AF patient at ED discharge. CONCLUSION: The majority of OAC-eligible patients were discharged home without an OAC prescription. In OAC-naive patients discharged home from the ED, cardiology consultation and female gender were associated with OAC prescription. Our findings suggest that access to expert opinion may improve provider comfort with OAC prescribing and highlight the need for improved guidelines specific to ED-management of AF.

Peripartum Cardiomyopathy: A Review.

PURPOSE OF REVIEW: Peripartum cardiomyopathy (PPCM) is an important condition with high morbidity and mortality worldwide. Patients with PPCM are at risk of developing life-long cardiac disease, requiring regular management and medical intervention. This article conducts a review of recent literature and gives insight into this disease. RECENT FINDINGS: There is promising research in the fields of vascular, hormonal and genetics. A number of genetic markers are being analyzed; including TTNC1, TTN and STAT3. Mutations to these genes have been found to be prevalent in PPCM. These combined with the secretion of placental angiogenic factors potentially create imbalance in angiogenesis as the primary etiology. SUMMARY: Current biomarkers do not differentiate between PPCM and other variants of heart failure. Women with PPCM are more likely to have a cesarean section, have hypertensive disease, at greater risk of major adverse cardiac events and to have lifelong morbidity.

Recognising Bias in Studies of Diagnostic Tests Part 1: Patient Selection.

In this two-part series on sources of bias in studies of diagnostic test performance, we outline common errors and optimal conditions during three study phases: patient selection, interpretation of the index test and disease verification by a gold standard. Here in part 1, biases associated with suboptimal participant selection are discussed through the lens of partial verification bias and spectrum bias, both of which increase the proportion of participants who are the 'sickest of the sick' or the 'wellest of the well.' Especially through retrospective methodology, partial verification introduces bias by including patients who are test positive by a gold standard, since patients with a positive index test are more likely to go on to further gold standard testing. Spectrum bias is frequently introduced through case-control design, dropping of indeterminate results or convenience sampling. After reading part 1, the informed clinician should be better able to judge the quality of a diagnostic test study, its inherent limitations and whether its results could be generalisable to their practice. Part 2 will describe how interpretation of the index test and disease verification by a gold standard can contribute to diagnostic test bias.

Recognising bias in studies of diagnostic tests part 2: interpreting and verifying the index test.

Multiple pitfalls can occur with the conduct and analysis of a study of diagnostic tests, resulting in biased accuracy. Our conceptual model includes three stages: patient selection, interpretation of the index test and disease verification. In part 2, we focus on (1) Interpretation bias (or workup bias): where the classification of an indeterminate index test result can bias the accuracy of a test or how lack of blinding can bias a subjective test result, and (2) Disease verification bias: where the index test result is incorporated into the gold standard or when the gold standard is applied only to a select population as the gold standard is an invasive test. In an example with age-adjusted D-dimer for pulmonary embolism, differential verification bias was a limitation due to the use of two gold standards-CT for a high-risk population and follow-up for symptoms in a low-risk population. However, there are circumstances when certain choices in study design are unavoidable, and result in biased test characteristics. In this case, the informed reader will better judge the quality of a study by recognising the potential biases and limitations by being methodical in their approach to understanding the methods, and in turn, better apply studies of diagnostic tests into their clinical practice.

Stroke Prophylaxis for Atrial Fibrillation? To Prescribe or Not to Prescribe-A Qualitative Study on the Decisionmaking Process of Emergency Department Providers.

STUDY OBJECTIVE: Although clinical guidelines recommend oral anticoagulation for atrial fibrillation patients at high risk of stroke, emergency physicians inconsistently prescribe it to patients with newly diagnosed atrial fibrillation. We interview emergency physicians to gain insight into themes influencing prescribing of oral anticoagulation for patients discharged from the ED with new-onset atrial fibrillation. METHODS: From September 2015 to January 2017, we conducted semistructured qualitative interviews with a purposeful sampling of 18 ED attending physicians who had evaluated a patient with new-onset atrial fibrillation within the past 30 days. Interview prompts examined physicians' attitudes toward prescription of oral anticoagulation therapy and current clinical guidelines. We used a constructivist grounded theory approach to analyze data and develop a theory on prescribing practices among emergency physicians. RESULTS: Three broad domains emerged from our analyses. (1) Oral anticoagulation prescribing practice: underlying themes affecting oral anticoagulation prescribing from the ED included physician practice patterns, beliefs, and barriers (including experience, comfort, and insurance coverage), and patient factors (including comorbidities, bleeding risk, and social concerns). Ultimately, these themes indicated physician discomfort and a sense of futility in prescribing oral anticoagulation for atrial fibrillation. (2) Guideline usage for oral anticoagulation prescribing: regardless of experience, most emergency physicians did not report using clinical guidelines when treating patients. (3) Recommendations for improved prescribing: physicians recommended the development of a validated, reliable, simple, accessible, and population-specific guideline that considers patient social factors. CONCLUSION: The decision to prescribe oral anticoagulation in the ED is complex. Improving guideline adherence will require a multifaceted approach inclusive of system-level improvements, physician education, and the development of ED-specific tools and guidelines.