Post-Acute Care Preparedness in a COVID-19 World

Coronavirus disease 2019 (COVID-19) has led to a surge of patients requiring post-acute care. In order to support federal, state and corporate planning, we offer a four-stage regionally oriented approach to achieving optimal systemwide resource allocation across a region's post-acute service settings and providers over time. In the first stage, the post-acute care system must, to the extent possible, help relieve acute hospitals of non-COVID-19 patients to create as much inpatient capacity as possible over the surge period. In the second stage after the initial surge as subsided, post-acute providers must protect vulnerable populations from COVID-19, prepare treat-in-place protocols for non-COVID-19 admissions, and create and formalize COVID-19 specific settings. In the third stage after a vaccine has been developed or an effective prophylactic option is available, post-acute care providers must assist with distribution and administration of vaccinations and prophylaxis, develop strategies to deliver non-COVID-19 related medical care, and begin to transition to the post-COVID-19 landscape. In the final stage, we must create health advisory bodies to review post-acute sector's response, identify opportunities to improve performance going forward, and develop a pandemic response plan for post-acute care providers. J Am Geriatr Soc 68:1150–1154, 2020.     

Impact of the COVID-19 Pandemic on the Management and End-of-life Care of Unresectable Pancreatic Cancer

Objective The coronavirus disease (COVID-19) pandemic has altered the delivery of medical care. The present study evaluated the impact of COVID-19 on the outcomes of unresectable pancreatic cancer (PC) patients who received end-of-life care. Methods We retrospectively compared the management of PC patients during the COVID-19 pandemic (from April 2020 to March 2021) to the preceding year, which was unaffected by the pandemic (from April 2019 to March 2020), based on a prospectively maintained institutional database. Results A total of 178 patients were included in the COVID-19-exposed group and 201 patients were included in the COVID-19-unexposed group. The median overall survival was similar between the groups (exposed vs. unexposed: 12.6 vs. 11.9 months, p=0.174). Treatment regimens and relative dose intensities and the progression-free survival of GnP (gemcitabine in combination with nab-paclitaxel) and mFOLFIRINOX as first- and second-line chemotherapy did not differ significantly between the two groups. Only 9.0% of patients died at home in the COVID-19-unexposed group, compared to 32.0% in the COVID-19-exposed group (p＜0.001). A multivariate analysis revealed that death during the COVID-19 exposed period was independently associated with home death (odds ratio: 4.536, 95% confidence interval: 2.527-8.140, p＜0.001). Conclusions While the COVID-19 pandemic did not seem to influence chemotherapeutic treatment for PC patients at our institution, it had a large impact on end-of-life care. These findings may promote discussion about end-of-life care in Japan.     

Factors Associated with Severe COVID-19 and Post-Acute COVID-19 Syndrome in a Cohort of People Living with HIV on Antiretroviral Treatment and with Undetectable HIV RNA

SARS-CoV-2 can produce both severe clinical conditions and long-term sequelae, but data describing post-acute COVID-19 syndrome (PACS) are lacking for people living with HIV (PLWH). We aimed at assessing the prevalence and factors associated with severe COVID-19 and PACS in our cohort. We included all unvaccinated adult PLWH on antiretroviral treatment and plasma HIV-RNA < 40 cp/mL since at least six months before SARS-CoV-2 infection at the Infectious and Tropical Diseases Unit of Padua (Italy), from 20 February 2020 to 31 March 2021. COVID-19 severity was defined by WHO criteria; PACS was defined as the persistence of symptoms or development of sequelae beyond four weeks from SARS-CoV-2 infection. Demographic and clinical variables were collected, and data were analyzed by non-parametric tests. 123 subjects meeting the inclusion criteria among 1800 (6.8%) PLWH in care at the Infectious and Tropical diseases Unit in Padua were diagnosed with SARS-CoV-2 infection/COVID-19 during the study period. The median age was 51 years (40–58), 79.7% were males, and 77.2% of Caucasian ethnicity. The median CD4+ T-cell count and length of HIV infection were 560 cells/mmc (444–780) and 11 years, respectively. Of the patients, 35.0% had asymptomatic SARS-CoV-2 infection, 48% developed mild COVID-19, 17.1% presented moderate or severe COVID-19 requiring hospitalization and 4.1% died. Polypharmacy was the single independent factor associated with severe COVID-19. As for PACS, among 75 patients who survived SARS-CoV-2 symptomatic infection, 20 (26.7%) reported PACS at a median follow-up of six months: asthenia (80.0%), shortness of breath (50.0%) and recurrent headache (25.0%) were the three most common complaints. Only the severity of the COVID-19 episode predicted PACS after adjusting for relevant demographic and clinical variables. In our study, PLWH with sustained viral suppression and good immunological response showed that the risk of hospital admission for COVID-19 was low, even though the severity of the disease was associated with high mortality. In addition, the likelihood of developing severe COVID-19 and PACS was mainly driven by similar risk factors to those faced by the general population, such as polypharmacy and the severity of SARS-CoV-2 infection.     

Hypertension and COVID-19: Potential use of beta-blockers and a call for randomized evidence

Hypertension is one of the most common morbidities in COVID-19. Previous studies demonstrated that hypertension increases composite poor outcomes in patients with COVID-19. Beta-blockers is widely used as one of the most common antihypertensive agents. Beta-blockers may hold potential benefits in COVID-19 treatment, with current evidence of the potential mechanism of beta-blockers remains scarce. However, several mechanisms were suggested, including decreasing RAAS pathway activity and lowering the ACE2 levels, reducing cytokine storms, and may be beneficial in reducing mortality in ARDS related COVID-19. Further large-scale randomized clinical trials should be conducted before a definite recommendation can be drawn.     

Interventions to Ensure the Continuum of Care for Hypertension During the COVID-19 Pandemic in Five Indian States—India Hypertension Control Initiative

Background:Hypertension is the leading risk factor for cardiovascular disease in India, but less than 10% of the estimated people with hypertension have blood pressure under control. The India Hypertension Control Initiative (IHCI) was implemented to strengthen hypertension management and control in public sector health facilities. Since late March 2020, lockdown due to the COVID-19 pandemic limited healthcare access and disrupted the provision of essential health services. IHCI quickly implemented adaptive interventions to improve access to medications.Objectives:To estimate the availability of antihypertensive drugs in peripheral public sector facilities during the lockdown and the proportion of patients who received drugs through community drug distribution, i.e., through Health and Wellness Centers (HWCs)/Sub-Centers (SCs), the most peripheral public sector health facilities for primary care, and home delivery.Methods:We collected data from 29 IHCI districts of 5 states (Kerala, Madhya Pradesh, Maharashtra, Punjab, and Telangana) during April–May 2020. The population included individuals diagnosed with hypertension and enrolled under IHCI in all public sector primary care health facilities. We contacted a convenience sample of more than one-third of the functional HWC/SC and analyzed the proportion of facilities and patients who received drugs. We also contacted a convenience sample of patients telephonically to estimate their self-reported availability of drugs.Conclusion:Of the 4245 HWC/SC, more than one-third were contacted telephonically, and 85–88% had received antihypertensive medications for community-level distribution. Among 721,675 patients registered until March 2020, 38.4% had received drug refills through HWC/SC or home delivery by frontline workers during the lockdown. We demonstrated the feasibility of community-level drug distribution for patients with hypertension during the COVID-19 lockdown in India. The adaptive strategy of community-based drug distribution through HWC/SC and home delivery appears feasible and may help improve access to hypertension care during the COVID-19 pandemic and beyond.     

COVID-19 vaccine acceptance among people living with HIV: A systematic review and meta-analysis

Objective

To assess coronavirus disease 2019 (COVID-19) vaccine acceptance among people living with HIV (PLHIV) worldwide.

Methods

We searched MEDLINE, PSYINFO, CINHAL, Scopus and EMBASE databases and other sources including free Google search and subject-specific journals from January 2020 to September 2021. The study population included adults (aged 18+ years) living with HIV and evaluated for COVID-19 vaccine acceptance. A random effect meta-analysis model was used to estimate the pooled COVID-19 vaccine acceptance rate. Subgroup analyses were performed, and factors associated with COVID-19 vaccine hesitancy underwent narrative analysis. Of 558 initial records, 14 studies were eligible for review.

Results

The overall pooled COVID-19 vaccine acceptance rate among adult PLHIV was 62% (95% confidence interval [CI], 56%–69%). In subgroup analysis, the estimated pooled COVID-19 vaccine acceptance rate was higher in high-income countries: 63% (95% CI, 55%–70%) versus 62% (95% CI, 54%–71%) in low- and middle-income countries, and in studies conducted in 2022 (66% [95% CI, 58%–75%]) than in studies conducted in 2021 (57% [95% CI, 47%–68%]). Reasons for lower COVID-19 vaccine acceptance included higher monthly income, being non-homosexual, history of chronic disease, COVID-19-related medical mistrust, not knowing anyone who died of COVID-19, believing oneself to be immune to COVID-19, general vaccine refusal, negative attitude to the vaccine, concerns about efficacy, safety and side effects, distrust in common sources of vaccine-related information and using social media as a source of information on COVID-19.

Conclusion

Among PLHIV, acceptance of COVID-19 vaccine is generally low. A greater emphasis on collaborative efforts between all concerned bodies is needed to boost vaccine acceptance in this population.     

Impact of COVID-19 Lockdown on the Nasopharyngeal Microbiota of Children and Adults Self-Confined at Home

The increased incidence of COVID-19 cases and deaths in Spain in March 2020 led to the declaration by the Spanish government of a state of emergency imposing strict confinement measures on the population. The objective of this study was to characterize the nasopharyngeal microbiota of children and adults and its relation to SARS-CoV-2 infection and COVID-19 severity during the pandemic lockdown in Spain. This cross-sectional study included family households located in metropolitan Barcelona, Spain, with one adult with a previous confirmed COVID-19 episode and one or more exposed co-habiting child contacts. Nasopharyngeal swabs were used to determine SARS-CoV-2 infection status, characterize the nasopharyngeal microbiota and determine common respiratory DNA/RNA viral co-infections. A total of 173 adult cases and 470 exposed children were included. Overall, a predominance of Corynebacterium and Dolosigranulum and a limited abundance of common pathobionts including Haemophilus and Streptococcus were found both among adults and children. Children with current SARS-CoV-2 infection presented higher bacterial richness and increased Fusobacterium, Streptococcus and Prevotella abundance than non-infected children. Among adults, persistent SARS-CoV-2 RNA was associated with an increased abundance of an unclassified member of the Actinomycetales order. COVID-19 severity was associated with increased Staphylococcus and reduced Dolosigranulum abundance. The stringent COVID-19 lockdown in Spain had a significant impact on the nasopharyngeal microbiota of children, reflected in the limited abundance of common respiratory pathobionts and the predominance of Corynebacterium, regardless of SARS-CoV-2 detection. COVID-19 severity in adults was associated with decreased nasopharynx levels of healthy commensal bacteria.     

Initiating HIV Care: Attitudes and Perceptions of HIV Positive Crack Cocaine Users

There is limited data on the initiation and use of HIV care services by HIV-positive crack cocaine users. We analyzed data from a study of 286 recently infected HIV-positive persons recruited from 4 U.S. cities. Participants completed an Audio Computer Assisted Self Interview (A-CASI) regarding HIV care knowledge, attitudes, beliefs and practices related to the initiation of HIV care. In multiple logistic regression analysis, higher scores on an assessment of knowledge, attitudes and beliefs regarding HIV care, and Hispanic race were positively associated with initiating HIV primary care. Crack cocaine use in the past 30 days and male gender were negatively associated with initiating care. Injection drug use was not associated with initiation of care. Targeted interventions for crack cocaine users, including drug treatment, may be required to provide optimal HIV primary care use in this population.     

Brief Report: The major genetic risk factor for severe COVID-19 is associated with protection against HIV

There are genetic risk factors that influence the outcome of COVID-19 [COVID-19 Host Genetics Initiative, Nature 600, 472–477 (2021)]. The major genetic risk factor for severe COIVD-19 resides on chromosome 3 and is inherited from Neandertals [H. Zeberg, S. Pääbo, Nature 587, 610–612 (2020)]. The risk-associated DNA segment modulates the expression of several chemokine receptors, among them CCR5, a coreceptor for HIV which is down-regulated in carriers of the COVID-19 risk haplotype. Here I show that carriers of the risk variant have an ∼27% lower risk of HIV infection.     

Hypertension is a clinically important risk factor for critical illness and mortality in COVID-19: A meta-analysis

AimsAs reported, hypertension may play an important role in adverse outcomes of coronavirus disease-2019 (COVID-19), but it still had many confounding factors. The aim of this study was to explore whether hypertension is an independent risk factor for critical COVID-19 and mortality.Data synthesisThe Medline, PubMed, Embase, and Web of Science databases were systematically searched until November 2020. Combined odds ratios (ORs) with their 95% confidence interval (CIs) were calculated by using random-effect models, and the effect of covariates was analyzed using the subgroup analysis and meta-regression analysis. A total of 24 observational studies with 99,918 COVID-19 patients were included in the meta-analysis. The proportions of hypertension in critical COVID-19 were 37% (95% CI: 0.27 ?0.47) when compared with 18% (95% CI: 0.14 ?0.23) of noncritical COVID-19 patients, in those who died were 46% (95%CI: 0.37 ?0.55) when compared with 22% (95% CI: 0.16 ?0.28) of survivors. Pooled results based on the adjusted OR showed that patients with hypertension had a 1.82-fold higher risk for critical COVID-19 (aOR: 1.82; 95% CI: 1.19 ? 2.77; P = 0.005) and a 2.17-fold higher risk for COVID-19 mortality (aOR: 2.17; 95% CI: 1.67 ? 2.82; P < 0.001). Subgroup analysis results showed that male patients had a higher risk of developing to the critical condition than female patients (OR: 3.04; 95%CI: 2.06 ? 4.49; P < 0.001) and age >60 years was associated with a significantly increased risk of COVID-19 mortality (OR: 3.12; 95% CI: 1.93 ? 5.05; P < 0.001). Meta-regression analysis results also showed that age (Coef. = 2.3×10^?2, P = 0.048) had a significant influence on the association between hypertension and COVID-19 mortality.ConclusionsEvidence from this meta-analysis suggested that hypertension was independently associated with a significantly increased risk of critical COVID-19 and inhospital mortality of COVID-19.     

COVID-19 hospitalization outcomes in adults by HIV status; a nation-wide register-based study

Objectives

To assess the outcome of patients hospitalized with COVID-19 by HIV status and risk factors for severe COVID-19 in people living with HIV (PWH), we performed a nationwide cohort study using register data.

Methods

All people aged ≥18 years hospitalized with a primary COVID-19 diagnosis (U07.1 or U07.2) in Sweden between February 2020 and October 2021 were included. The primary outcome was severe COVID-19 [intensive care unit (ICU) admission or 90-day mortality]. Secondary outcomes were days in hospital and ICU, complications in hospital, and risk factors for severe COVID-19 in PWH. Regression analyses were performed to assess severe COVID-19 by HIV status and risk factors.

Results

Data from 64 815 hospitalized patients were collected, of whom 121 were PWH (0.18%). PWH were younger (p < 0.001), and larger proportions were men (p = 0.014) and migrants (p < 0.001). Almost all PWH had undetectable HIV-RNA (93%) and high CD4 T-cell counts (median = 560 cells/μL, interquartile range: 376–780). In an unadjusted model, PWH had statistically significant lower odds of severe COVID-19 compared with patients without HIV [odds ratio (OR) = 0.6, 95% confidence interval (CI): 0.34–0.94], but there was no significant difference after adjusting for age and comorbidity (adjusted OR = 0.7, 95% CI: 0.43–1.26). A statistically significant lower proportion of PWH (8%, 95% CI: 5–15%) died within 90 days compared with those without HIV (16%, 95% CI: 15–16%, p = 0.024). There was no statistically significant difference in days in hospital and complications during the hospital stay between PWH and patients without HIV.

Conclusions

In this nationwide study including well-treated PWH, HIV was not a risk factor in hospitalized patients for developing severe COVID-19.     

Healthcare outcomes in patients with HIV infection at a tertiary hospital during the COVID-19 pandemic

BackgroundThe COVID-19 pandemic has affected the care of patients with other diseases. Difficulty in access to healthcare during these months has been especially relevant for persons with HIV infection (PWH). This study therefore sought to ascertain the clinical outcomes and effectiveness of the measures implemented among PWH in a region with one of the highest incidence rates in Europe.MethodsRetrospective, observational, pre-post intervention study to compare the outcomes of PWH attended at a high-complexity healthcare hospital from March to October 2020 and during the same months across the period 2016–2019. The intervention consisted of home drug deliveries and preferential use of non face-to-face consultations. The effectiveness of the measures implemented was determined by reference to the number of emergency visits, hospitalisations, mortality rate, and percentage of PWH with viral load >50 copies, before and after the two pandemic waves.ResultsA total of 2760 PWH were attended from January 2016 to October 2020. During the pandemic, there was a monthly mean of 106.87 telephone consultations and 2075 home deliveries of medical drugs dispensed to ambulatory patients. No statistically significant differences were found between the rate of admission of patients with COVID-HIV co-infection and that of the remaining patients (1172.76 admissions/100,000 population vs. 1424.29, p = 0.401) or in mortality (11.54% vs. 12.96%, p = 0.939). The percentage of PWH with viral load >50 copies was similar before and after the pandemic (1.20% pre-pandemic vs. 0.51% in 2020, p = 0.078).ConclusionOur results show that the strategies implemented during the first 8 months of the pandemic prevented any deterioration in the control and follow-up parameters routinely used on PWH. Furthermore, they contribute to the debate about how telemedicine and telepharmacy can fit into future healthcare models.     

Coronavirus Disease 2019 in Geriatrics and Long-Term Care: The ABCDs of COVID-19

The pandemic of coronavirus disease of 2019 (COVID-19) is having a global impact unseen since the 1918 worldwide influenza epidemic. All aspects of life have changed dramatically for now. The group most susceptible to COVID-19 are older adults and those with chronic underlying medical disorders. The population residing in long-term care facilities generally are those who are both old and have multiple comorbidities. In this article we provide information, insights, and recommended approaches to COVID-19 in the long-term facility setting. Because the situation is fluid and changing rapidly, readers are encouraged to access frequently the resources cited in this article. J Am Geriatr Soc 68:912–917, 2020     

Proposed Use of Continuous Glucose Monitoring for Care of Critically Ill COVID-19 Patients

Coronavirus disease 2019 (COVID-19) has disproportionately affected patients with diabetes. Mounting evidence has shown that adequate inpatient glycemic control may decrease the risk of mortality. In critically ill patients, insulin drips are the most effective means of controlling blood glucose. However, resource limitations such as the availability of protective equipment and nursing time have discouraged the use of insulin drips during COVID-19. In this commentary, we review existing evidence on the importance of glycemic control in COVID-19 patients with diabetes and propose a protocol for utilizing continuous glucose monitors (CGMs) to improve glycemic control by decreasing the need for bedside management in critically ill COVID-19 patients.