Transvenous lead extraction on uninterrupted anticoagulation: A safe approach?

INTRODUCTION: Current guidelines advocate reviewing peri-procedural anticoagulation on individual case basis for transvenous lead extraction (TLE). We investigated the safety of TLE on uninterrupted warfarin with therapeutic INR. METHODS: Retrospective registry of consecutive patients undergoing TLE on uninterrupted warfarin (Warfarin Group) across two centres. Age and sex matched controls not on anticoagulation (No-Warfarin Group) and undergoing TLE over the same time-period were included. Both groups were compared over one-year. RESULTS: 121 TLEs over 18-months. 22 patients on uninterrupted anticoagulation were compared to 22 controls. Groups were well matched for baseline demographics other than INR. Warfarin group had mean INR of 2.2 ± 0.6 (range 2-3.5). Primary end point was procedural safety and efficacy. Amongst cases, 43/45 (96%) leads were removed in their entirety compared to 37/40 (93%) in controls (p = 0.66). In the cases, these included 44% defibrillator, 47% pace-sense and 9% CS leads of average duration 7yrs. There was no reported tamponade, haemothorax or procedural mortality in either group. One patient amongst cases required inotropic support while two patients amongst controls had device-site haematomas. No significant difference reported in Hb drop post-procedure or overall complication rate between the groups (p = 0.11,0.32). Cox regression showed a significant association between procedural success and device infection, number of leads extracted, serum creatinine (p = 0.03, 0.04, 0.02). Over a 1-year follow-up, there was lead displacement in one case and one control had infection of the re-implanted device. CONCLUSION: TLE can be carried out safely in anticoagulated patients with therapeutic INRs. Larger multicentre studies are required to confirm these findings.

Pilot program for test-based SARS-CoV-2 screening and environmental monitoring in an urban public school district

ImportanceScalable programs for school-based SARS-CoV-2 testing and surveillance are needed to guide in-person learning practices and inform risk assessments in K-12 settings. ObjectivesTo characterize SARS-CoV-2 infections in staff and students in an urban public school setting and evaluate test-based strategies to support ongoing risk assessment and mitigation for K-12 in-person learning. Design, Setting, and ParticipantsThe pilot program engaged three schools for weekly saliva PCR testing of staff and students participating in in-person learning over a 5-week period. Wastewater, air, and surface samples were collected weekly and tested for SARS-CoV-2 RNA to determine surrogacy for case detection and interrogate transmission risk of in-building activities. Main Outcomes and MeasuresSARS-CoV-2 detection in saliva and environmental samples and risk factors for SARS-CoV-2 infection. Results2,885 supervised self-collected saliva samples were tested from 773 asymptomatic staff and students during November and December, 2020. 46 cases (22 students, 24 staff) were detected, representing a 5.8- and 2.5-fold increase in case detection rates among students and staff, respectively, compared to conventional reporting mechanisms. SARS-CoV-2 RNA was detected in wastewater samples from all pilot schools, as well as in air samples collected from two choir rooms. Sequencing of 21 viral genomes in saliva specimens demonstrated minimal clustering associated with one school. Geographic analysis of SARS-CoV-2 cases reported district-wide demonstrated higher community risk in zip codes proximal to the pilot schools. Conclusions and RelevanceWeekly screening of asymptomatic staff and students by saliva PCR testing dramatically increased SARS-CoV-2 case detection in an urban public-school setting, exceeding infection rates reported at the county level. Experiences differed among schools, and virus sequencing and geographic analyses suggest a dynamic interplay of school-based and community-derived transmission risk. Environmental testing for SARS-CoV-2 RNA in air and surface samples enabled real-time risk assessment of in-school activities and allowed for interventions in choir classes. Wastewater testing demonstrated the utility of school building-level SARS-CoV-2 surveillance. Collectively, these findings provide insight into the performance and community value of test-based SARS-CoV-2 screening and surveillance strategies in the K-12 educational setting. KEY POINTSO_ST_ABSQuestionC_ST_ABSDo test-based programs reduce SARS-CoV-2 risk in K-12 schools? FindingsWeekly school-based saliva PCR testing at three urban public schools doubled case detection among staff and students over symptom-based strategies, exceeding county-level case rates. SARS-CoV-2 was detected in school wastewater samples each week, as well as air and surface samples related to choir classrooms. MeaningRoutine SARS-CoV-2 testing removes infected staff and students from school who are not identified through conventional case detection. With rigorous infection control and environmental monitoring, this helps mitigate risk during school operations. Furthermore, screening in K-12 schools may provide insight into disease burdens of undertested communities.

A Novel Approach to Data Driven Pandemic Recovery: The Pandemic Recovery Acceleration Model

A data driven approach to guide the global, regional and local pandemic recovery planning is key to the safety, efficacy and sustainability of all pandemic recovery efforts. The Pandemic Recovery Acceleration Model (PRAM) analytic tool was developed and implemented state wide in Nebraska to allow health officials, public officials, industry leaders and community leaders to capture a real time snapshot of how the COVID-19 pandemic is affecting their local community, a region or the state and use this novel lens to aid in making key mitigation and recovery decisions. This is done by using six commonly available metrics that are monitored daily across the state describing the pandemic impact: number of new cases, percent positive tests, deaths, occupied hospital beds, occupied intensive care beds and utilized ventilators, all directly related to confirmed COVID-19 patients. Nebraska is separated into six Health Care Coalitions based on geography, public health and medical care systems. The PRAM aggregates the data for each of these geographic regions based on disease prevalence acceleration and health care resource utilization acceleration, producing real time analysis of the acceleration of change for each metric individually and also combined into a single weighted index, the PRAM Recovery Index. These indices are then shared daily with the state leadership, coalition leaders and public health directors and also tracked over time, aiding in real time regional and statewide decisions of resource allocation and the extent of use of comprehensive non-pharmacologic interventions.