Almost two years into the Covid-19 pandemic, the question still remains: When will the pandemic end? Some believe the answer to this question lies in herd immunity. With a highly infectious disease such as Covid-19, many have argued that eradication of the virus will occur naturally once it has spread throughout the entire community, generating antibody-mediated immunity in those that recover from the disease. The reasoning is that Covid-19 will simply fade away when there are no remaining vulnerable hosts to infect. Individuals who have argued from the herd immunity perspective often advocate for the continued opening of businesses as well as loosened restrictions for mask-wearing, social distancing, and other preventative measures. These practices, they argue, serve to simply prolong the amount of time it takes to reach herd immunity. Countries like Sweden, which have remained fairly open throughout the pandemic and now reportedly have the virus “under control,”1 have been used to substantiate this argument. The availability of Covid-19 vaccines also raises the question of whether immunity gained from the shots differs from that gained from prior infection.

            Covid-19 vaccines are readily available in many high-income countries, including the United States. Many are asking: Is complete vaccine compliance necessary when, at the end of 2020, approximately 31 percent of the U.S. population had already been infected with Covid-19?2 Ostensibly, this would mean that roughly a third of Americans already had some sort of antibody-mediated immunity to the disease, and certainly more have been infected since the publication of the aforementioned study.

            Authors Bozio et al. sought to answer this exact question in a study published in November of 2021.3 They examined a number of hospitalized individuals over the age of 18 who had either previously tested positive for Covid-19 infection (via a rapid assay test or reverse PCR testing) or been fully vaccinated with an mRNA vaccine (two doses, given within the recommended timeframe) in the past 90-179 days. The primary outcome was the result of a Covid-19 test taken at the time of hospitalization. When the results were adjusted for pertinent sociodemographic and health factors, the authors found that individuals who had received the Covid-19 vaccine were less likely to test positive for Covid-19 than those who had been previously infected. Interestingly, further analysis revealed that recipients of the Moderna vaccine appeared to have improved immunity when compared to recipients of the Pfizer-BioNTech vaccine. This was consistent with a previous study published in September of 2021 which reported similar findings.4

            These accumulative results would suggest that vaccines confers greater immunity when compared to a prior history of Covid-19 infection. While there are some limits to this study – for example, children were excluded, as the U.S. only recently gave full approval for administration of the Pfizer vaccine to individuals aged five and up5 – the results were fairly conclusive. These findings support the CDC recommendation that all Americans eligible to receive the vaccine should do so, for the benefit of both personal and public health.

References

[1] Carlsson, M., & Söderberg-Nauclér, C. (2021). Indications that Stockholm has reached herd immunity, given limited restrictions, against several variants of SARS-COV-2. (preprint). https://doi.org/10.1101/2021.07.07.21260167.

2 One in three Americans Already Had COVID-19 by the End of 2020. Columbia Public Health. (2021, August 26). Retrieved from https://www.publichealth.columbia.edu/public-health-now/news/one-three-americans-already-had-covid-19-end-2020.

3 Centers for Disease Control and Prevention. (2021, November 4). Laboratory-Confirmed COVID-19 Among Adults Hospitalized with COVID-19–Like Illness with Infection-Induced or mRNA Vaccine-Induced SARS-COV-2 Immunity – Nine States, January–September 2021. Centers for Disease Control and Prevention. Retrieved from https://www.cdc.gov/mmwr/volumes/70/wr/mm7044e1.htm?s_cid=mm7044e1_w.

4 Self WH; Tenforde MW; Rhoads JP; Gaglani M; Ginde AA; Douin DJ; Olson SM; Talbot HK; Casey JD; Mohr NM; Zepeski A; McNeal T; Ghamande S; Gibbs KW; Files DC; Hager DN; Shehu A; Prekker ME; Erickson HL; Gong MN; Mohamed A; Henning DJ; Steingrub JS; Peltan ID; Brown SM; Martin ET; Mo. (2021). Comparative effectiveness of Moderna, Pfizer-BioNTech, and Janssen (Johnson & Johnson) Vaccines in Preventing COVID-19 Hospitalizations Among Adults Without Immunocompromising Conditions – United States, March-August 2021. MMWR. Morbidity and mortality weekly report. Retrieved from https://pubmed.ncbi.nlm.nih.gov/34555004/.

5 Centers for Disease Control and Prevention. (n.d.). Covid-19 Vaccines for Children and Teens. Centers for Disease Control and Prevention. Retrieved from https://www.cdc.gov/coronavirus/2019-ncov/vaccines/recommendations/children-teens.html

Atelectasis occurs when air is not able to fully expand the alveoli of the lungs. 90% of patients undergoing general anesthesia experience atelectasis (Randtke et al, 2015). This is because general anesthesia decreases muscle tone and thus functional residual capacity (FRC) — the amount of air that is left in the lungs after exhaling. Atelectasis increases the risk for hypoxemia and pneumonia and can continue into the postoperative period. Preventing and reversing atelectasis can improve patient outcomes for surgeries that require general anesthesia (Randtke et al, 2015).

There are three explanations of the physiological cause of atelectasis that are generally agreed upon. The absorption mechanism is based on oxygen balance. Often, patients undergoing anesthesia will be placed on 100% oxygen, which pushes nitrogen gas out of the lungs (nitrogen is a component of normal atmospheric air) (Randtke et al, 2015). Oxygen is absorbed by the capillary bed, leaving the alveoli with too little gas remaining inside. Since the alveoli are not supported by cartilage, only the pressure of gases against their walls, they then collapse (Randtke et al, 2015). This can also occur with a low ventilation to perfusion ratio — when the capillary beds absorb oxygen faster than the person’s breathing can provide more air. The decreased FRC with general anesthesia exacerbates this problem. It is a challenge to get the appropriate oxygen balance, as not providing enough oxygen can also lead to hypoxemia during the procedure (Randtke et al, 2015).

The compression mechanism for atelectasis occurs when the pleural pressure in the chest cavity is greater than the intrapulmonary pressure. With the reduced muscle tone that occurs under anesthesia, the weight of the chest and the patient’s organs against the diaphragm are significant contributing factors in this mechanism (Randtke et al, 2015). Inflammation and buildup of fluid in the pleural space can also contribute. The pressure can push residual air out of the lungs, further decreasing the FRC and leading to alveolar collapse (Randtke et al, 2015).

The third mechanism is related to abnormalities in surfactant. Surfactant is produced by specific cells in the alveoli and reduces surface tension, making it easier for the lungs to expand (Randtke et al, 2015). Reduced surfactant makes it more difficult for alveoli to stay open in the first place,  re-inflate once collapsed and stabilized once reopened. General anesthesia may have some impact on surfactant abnormalities but more research is needed to clarify its role in atelectasis in this context (Randtke et al, 2015).

As shown in a recent meta-analysis regarding prevention and treatment pathways of postoperative pulmonary complications, there is not a lot of high-quality data currently available (Odor et al, 2020). With the lower quality data that is available, interventions found to have a significant effect include postoperative continuous positive airway pressure (CPAP), mucolytic medications (specifically ambroxol) and respiratory physiotherapy (a series of muscle training and breathing exercises practiced before and after the surgery). There is moderate quality data for intraoperative lung protective ventilation, defined as using reduced tidal volumes (<8 mL/kg), positive end expiratory pressure of at least 5 cm H2O and intermittent recruitment maneuvers (high pressure applied for a short period of time to inflate the lungs more fully) (Odor et al, 2020). It is also important to look at prevention in specific patient populations, such as in pediatric patients. One newer study suggests that use of CPAP during induction and emergence in children decreases the risk of intraoperative atelectasis, as well as the risk of residual atelectasis in the postoperative period (Acosta et al, 2021). Another recent study suggests that high-flow nasal cannula oxygen in the postoperative period reduces residual atelectasis (Lee et al, 2021). Overall, more high-quality comparative research on the effectiveness of different prevention methods is needed for all patient populations.

References

Acosta CM, Lopez Vargas MP, Oropel F, et al. Prevention of atelectasis by continuous positive airway pressure in anaesthetised children: A randomised controlled study. Eur J Anaesthesiol. 2021;38(1):41-48. doi:10.1097/EJA.0000000000001351

Lee J-H, Ji S-H, Jang Y-E, Kim E-H, Kim J-T, Kim H-S. Application of a High-Flow Nasal Cannula for Prevention of Postextubation Atelectasis in Children Undergoing Surgery: A Randomized Controlled Trial. Anesthesia & Analgesia. 2020;133(2):474-482. doi:10.1213/ane.0000000000005285

Odor PM, Bampoe S, Gilhooly D, Creagh-Brown B, Moonesinghe SR. Perioperative interventions for prevention of postoperative pulmonary complications: systematic review and meta-analysis. BMJ. 2020;368:m540. doi:10.1136/bmj.m540

Randtke MA, Andrews BP, Mach WJ. Pathophysiology and Prevention of Intraoperative Atelectasis: A Review of the Literature. J Perianesth Nurs. 2015;30(6):516-527. doi:10.1016/j.jopan.2014.03.012

Across the United States in 2019, over 1 in 10 households were defined as being food-insecure. Food-insecure households are, according to U.S. Department of Agriculture (USDA), “uncertain of having, or unable to acquire, at some time during the year, enough food to meet the needs of all their members because they had insufficient money or other resources for food.” These food-insecure households include 5.3 million U.S. households with “very low food security,” which disrupts eating patterns and leads to food intake levels below those considered adequate.1

While rates of food insecurity have significantly declined since they spiked to nearly 15 percent of households following the 2008 stock market crash,1 preliminary data shows that the COVID-19 pandemic has dramatically worsened food insecurity, which was already considered one of “the nation’s leading health and nutrition issues.”2 Feeding America, a national anti-hunger nonprofit, estimates that 1 in 8 people may experience food insecurity in 2021, with those most impacted by the pandemic at greater risk. Notably, racial disparities in food security that existed before the COVID-19 pandemic remain severe, with 1 in 5 Black individuals in the U.S. projected to experience food insecurity in 2021 (nearly double the rate among white individuals).3

The health complications associated with food insecurity are well-documented. Among children, these include anemia, key nutrient deficiencies, behavioral problems such as aggression, and mental health challenges such as depression and suicidal ideation.2 Many of these issues persist for adults, who are also more likely to develop chronic conditions, like diabetes, chronic heart disease, chronic obstructive pulmonary disease (COPD), hypertension, and hyperlipidemia.2,4 A study from the USDA on working-age U.S. adults found that food security status is more strongly correlated with chronic disease than income, which was only associated with hepatitis, arthritis, and COPD out of 10 chronic diseases significantly associated with food insecurity.5

How food insecurity may cause many chronic conditions remains under-researched. One exception is type 2 diabetes, which is reportedly twice as common in food-insecure individuals than others. Food scarcity may trigger peripheral insulin resistance, increases in cortisol, and accumulation of central adiposity (belly fat), which are all conditions associated with diabetes. Obesity, which some studies have found to be associated with food insecurity, may also play a role in making individuals vulnerable to diabetes and other chronic conditions.2

These findings are indicative of the essential tie between food insecurity and an inability to access nutritious food, which together impact overall health. In general, the cost of a diet rich in healthy foods — including fruits and vegetables, fish, and nuts — is greater than one reliant on highly processed foods, including meats and refined grains, according to a Harvard School of Public Health meta-analysis of 27 studies.6 A USDA study likewise found that foods high in saturated fat and/or added sugars are overall less expensive, per calorie.7 The authors of the Harvard study estimate that a “healthy” diet costs on average $1.50 more per day, which amounts to $550 per year and is an appreciable investment for low-income individuals.6

Making healthier foods more accessible, the authors write, would require a reversal of many decades of policies that have created “a complex network of farming, storage, transportation, processing, manufacturing and marketing capabilities” that have generated an economy for highly processed, low-priced foods.6 While the federal government has historically invested in food initiatives for low-income people, notably the Supplemental Nutrition Assistance Program (SNAP), there has been little innovation in these programs over the past four decades, in spite of a dramatic increase in diet-related illnesses such as obesity and type 2 diabetes.8 SNAP benefits are based on a 1970s metric that represents the minimal amount of money needed to purchase a nutritious diet, and therefore do not align with modern dietary recommendations and economic circumstances. Before the pandemic, SNAP benefits averaged less than $1.40 per meal.9

The need for improving nutritional health and equity across the country is clear. Greater government coordination across federal agencies and programs, especially within the National Institutes of Health, can strengthen government research and programs.8 Beyond taxation of less healthy foods and subsidies for more nutritious options, greater governmental coordination can fuel projects to revolutionize the production, transportation and marketing of healthier foods, increasing their availability while reducing their prices.6

References 

  1. Coleman-Jensen A, Rabbitt MP, Gregory CA, Singh A. Household Food Security in the United States in 2019. U.S. Department of Agriculture. Published 2020. https://www.ers.usda.gov/publications/pub-details/?pubid=99281 
  1. Gundersen C, Ziliak JP. Food insecurity and health outcomes. Health Aff (Millwood). 2015;34(11):1830-1839. 
  1. Hake M, Dewey A, Engelhard E, et al. The Impact of the Coronavirus on Food Insecurity. Feeding America. Published 2021. https://www.feedingamerica.org/sites/default/files/2021-03/National%20Projections%20Brief_3.9.2021_0.pdf 
  1. Sun Y, Liu B, Rong S, et al. Food insecurity is associated with cardiovascular and all-cause mortality among adults in the United States. J Am Heart Assoc. 2020;9(19):e014629. 
  1. Gregory CA, Coleman-Jensen A. Food Insecurity, Chronic Disease, and Health Among Working-Age Adults. U.S. Department of Agriculture. Published 2017. https://www.ers.usda.gov/publications/pub-details/?pubid=84466 
  1. Rao M, Afshin A, Singh G, Mozaffarian D. Do healthier foods and diet patterns cost more than less healthy options? A systematic review and meta-analysis. BMJ Open. 2013;3(12):e004277. 
  1. Carlson A, Frazao E. Are healthy foods really more expensive? It depends on how you measure the price. SSRN Electron J. Published online 2012. doi:10.2139/ssrn.2199553 
  1. Fleischhacker SE, Woteki CE, Coates PM, et al. Strengthening national nutrition research: rationale and options for a new coordinated federal research effort and authority. Am J Clin Nutr. 2020;112(3):721-769. 
  1. Carlson S, Keith-Jennings B, Llobrera J. Modernizing SNAP Benefits Would Help Millions Better Afford Healthy Food. Center on Budget and Policy Priorities. Published 2021. https://www.cbpp.org/research/food-assistance/modernizing-snap-benefits-would-help-millions-better-afford-healthy-food 

Sleep allows the body and mind to recharge; without it, the human brain cannot function properly, and the body becomes more susceptible to disease. Sleep apnea involves brief stoppages in breathing that cause a person to wake repeatedly, which over time can increase risk of cardiovascular disease, depression, high blood pressure, and type 2 diabetes (O’Connor, 2019). For those with the condition, nightly sleep becomes a noisy struggle to breathe rather than a period of restoration. The most common type of sleep apnea is known as obstructive sleep apnea (OSA), which increases the risk of complications during surgery, and despite decades of research, there are no approved medications to treat the condition (Brody, 2019). However, in June of 2021, a team of researchers at Flinders University in Australia found promising results for a potential treatment. Their research, first published in the Journal of Physiology, found that a two-drug combination can reduce sleep apnea by at least 30% (Lim et al., 2021).

There are currently only a few therapies for sleep apnea patients. Continuous positive airway pressure (CPAP) therapy works to prevent a person’s airway from collapsing during sleep (Schein, 2014). CPAP machines, which are comprised of a mask, tube, and motor, use mild air pressure to keep the mask wearer’s airways open. While the CPAP therapy approach works for many, the most common side effects include nasal congestion or runny nose, feelings of claustrophobia, and difficulty falling asleep (Bakalar, 2021). Variable and bi-level positive airway pressure (VPAP and BPAP) therapies work similarly.

An alternative approach is a mandibular repositioning device; these are oral appliances designed to keep the airway open by bringing the wearer’s jaw forward or holding their tongue in place (Marques et al., 2019). However, these devices can be expensive, cause jaw pain, and are less reliable than PAP machines (Bakalar, 2021). Surgery is the last resort for sleep apnea: in the most common of these procedures, surgeons remove obstructive tissues that block the airway (Brody, 2019). Cheaper, over-the-counter approaches like nasal decongestant and breathing strips rarely work for diagnosed sleep apnea.

Researchers at Flinders University found that a combination of two medications – butylbromide and reboxetine – kept pharyngeal muscles active during sleep in people with sleep apnea, allowing for improvement in airway collapsibility and more regular and steady breathing (Lim et al., 2021). Butylbromide is an antispasmodic drug, while reboxetine is most often used to treat depression. While the medications had previously been shown to improve upper airway function during sleep for healthy individuals, its effect on sleep apnea severity was unknown until the Flinders researchers completed their study (Flinders Newsdesk, 2021). Out of fifteen original volunteers, twelve otherwise healthy individuals with OSA completed a double-blind, randomized, placebo-controlled trial (Lim et al., 2021). The research team observed participants for two nights. Each participant received either the two-drug combination or placebo immediately prior to sleep; using nasal masks, pneumotachographs (devices that record the rate of airflow), epiglottic pressure sensors, and more, researchers captured data to create estimates of OSA severity between the two groups. “Almost everyone we studied had some improvement in sleep apnea,” said Professor Danny Eckert, lead researcher and Director of Adelaide Institute for Sleep Health at Flinders (Flinders Newsdesk, 2021). “People’s oxygen intake improved. Their number of breathing stoppages was a third or more less.”

The research team will next look at the long-term effects of this drug combination and similar medications. For now, the findings of the recent study bode well for future developments in pharmacological treatment for OSA.

References 

Bakalar, Nicholas. (2021, May 31). For Sleep Apnea, a Mouth Guard May be a Good Alternative to CPAP. The New York Times. https://www.nytimes.com/2021/05/31/well/mind/sleep-apnea-treatment-mouth-guard.html 

Brody, Jane E. (2019, May 27). Sleep Apnea Can Have Deadly Consequences. The New York Times. https://www.nytimes.com/2019/05/27/well/mind/sleep-apnea-can-have-deadly-consequences.html 

Flinders Newsdesk. (2021, July 7). Drug combo cuts severity of sleep apnoea. Flinders University. https://news.flinders.edu.au/blog/2021/07/07/drug-combo-cuts-severity-of-sleep-apnoea/ 

Lim, R., Messineo, L., Grunstein, R.R., Carberry, J.C. and Eckert, D.J. (2021), The noradrenergic agent reboxetine plus the antimuscarinic hyoscine butylbromide reduces sleep apnoea severity: a double-blind, placebo-controlled, randomised crossover trial. J Physiol. https://doi.org/10.1113/JP281912 

Marques, M., Genta, P.R., Azarbarzin, A., Taranto-Montemurro, L., Messineo, L., Hess, L.B., Demko, G., White, D.P., Sands, S.A. and Wellman, A. (2019), Structure and severity of pharyngeal obstruction determine oral appliance efficacy in sleep apnoea. J Physiol, 597: 5399-5410. https://doi.org/10.1113/JP278164 

O’Connor, Anahad. (2019, April 10). A Guide to Sleep Apnea. The New York Timeshttps://www.nytimes.com/guides/well/sleep-apnea-guide 

Schein, A. S., Kerkhoff, A. C., Coronel, C. C., Plentz, R. D., & Sbruzzi, G. (2014). Continuous positive airway pressure reduces blood pressure in patients with obstructive sleep apnea; a systematic review and meta-analysis with 1000 patients. Journal of Hypertension, 32(9), 1762–1773. https://doi.org/10.1097/HJH.0000000000000250 

An accurate estimation of the timing of labor is important for several clinical decisions, including determination of preterm birth and necessary treatment regimens [1]. Currently, gestational age and due date is approximated based on information about the last menstrual cycle and assumes a gestational length of 40 weeks [1,2]. Ultrasound imaging in early pregnancy can also be used to determine gestational age and estimated date of delivery [1]. Although these approaches are useful in managing pregnancy, neither method is an accurate predictor of when labor will begin, since most pregnancies deviate from the standard of 40 weeks of gestational duration [2]. To advance clinical decision-making, efforts have been made to better predict the actual onset of labor using predictive biomarkers measured by blood tests [2].

During pregnancy, the maternal circulatory system connects with the fetal circulatory system through the placenta, carrying a variety of compounds such a steroid hormones, micronutrients, and nucleic acids [1]. The maintenance of pregnancy relies on finely tuned adaptions to the concentrations of these biomarkers, which can be easily detected in maternal blood using high-content metabolomic, proteomic, and single-cell cytometric technologies [2].

A 2019 study funded by the University Hospitals of Leicester yielded results that support the idea that it may be possible to predict the onset of labor from a single blood test [3]. The researchers monitored the plasma concentrations of N-arachidonylethanolamine (AEA), N-acylethanolamines (NAE), N-oleoylethanolamide (OEA), and N-palmitoylethanolamide (PEA) in 217 pregnant patients [3]. In line with previous studies that had shown that plasma AEA concentrations increase in the third trimester and peak in labor, they found that women at risk for pre-term labor also had an elevated plasma AEA concentration [3]. The data suggested that a single AEA measurement taken from a blood sample can predict the gestational age of delivery and the remaining duration of pregnancy with better accuracy compared to conventional methods [3].

Similarly, a 2021 study by Stanford University sought to determine the dynamic changes in the maternal metabolome, proteome, and immunome preceding the day of labor [2]. The analysis of the results revealed a marked transition from pregnancy maintenance to pre-labor physiology starting 2 to 4 weeks before labor onset [2]. Endocrine and inflammatory changes were pronounced during late pregnancy, with steroid hormone metabolites being among the most informative biomarkers [2]. A decline in progesterone levels was linked to the progression to labor [2]. Moreover, the surge in steroid hormone metabolites weeks before labor coincided with changes in plasma protein concentrations and immune cell responses [2]. A sharp increase in the concentration of IL-4, an IL-33 antagonist, was found to play a prominent regulatory role during the pre-labor phase [2]. In mice, IL-33 has been shown to have a role in pregnancy maintenance [2].

The non-invasive nature of maternal blood tests offers great promise as a way to predict labor onset [3]. Research continues to determine the best biomarkers for estimating the timing of labor and has the potential to transform the management of pregnancy, especially in relation to pre-term birth [1-3].

References

  1. Liang, L., Rasmussen, M., Piening, B. etc. (2020). Metabolic dynamics and prediction of gestational age and time to delivery in pregnant women. Cell181(7), 1680-1692. doi:10.1016/j.cell.2020.05.002
  2. Stelzer, I., Ghaemi, M., Han, X. etc. (2021). Integrated trajectories of the maternal metabolome, proteome, and immunome predict labor onset. Science Translational Medicine13(592). doi:10.1126/scitranslmed.abd9898
  3. Bachkangi, P., Taylor, A., Bari, M. etc. (2019). Prediction of preterm labour from a single blood test: The role of the endocannabinoid system in predicting preterm birth in high-risk women. European Journal of Obstetrics & Gynecology and Reproductive Biology243, 1-6. doi:10.1016/j.ejogrb.2019.09.029

Distal radius fractures, or breaks in the radius bone of the arm close to the wrist, are among the most common types of bone fractures. Many of these fractures, particularly if they are displaced (i.e., if the bone fragments on either side of the break are not aligned), require surgery, known as distal radius repair, to ensure proper setting and healing of the radius.1 There are several options for anesthesia during radius repair—most notably general anesthesia, local anesthesia, and peripheral nerve blocking (a specific type of local anesthesia)—and recent studies have begun to evaluate the benefits and drawbacks of each approach, particularly with regard to pain control, postoperative functional outcomes, and length of stay.

Some studies have identified better clinical outcomes for distal radius repair with local, rather than general, anesthesia. For instance, Egol et al. collected data from 187 patients and found that patients who received local anesthesia had improved wrist and finger range of motion compared with patients who received general anesthesia and also showed higher functional scores (as measured by Disabilities of the Arm, Shoulder and Hand) at 3- and 6-month follow-ups.2 In contrast, Rundgren et al. found using a single-center randomized clinical trial of 88 patients that, while local anesthesia appeared to significantly reduce early patterns of postoperative pain and opioid consumption after radius repair, neither total opioid consumption nor longer-term functional outcomes differed significantly between the local and general anesthesia groups.3

Peripheral nerve blocking, a type of local anesthesia, has also recently been employed in comparison studies with general anesthesia to examine its effects on outcomes following distal radius repair. For example, Galos et al. conducted a randomized controlled study of 36 patients to answer four questions: (1) whether patients receiving general anesthesia or brachial plexus blockade (a type of peripheral nerve blockade administered through a single infraclavicular shot) had worse pain scores at various time points, (2) whether there was a difference in operating suite time and recovery room time between the two groups, (3) whether either group experienced higher postoperative narcotic use, and (4) whether either group displayed higher functional assessment scores 6 and 12 weeks after surgery. The researchers found that patients who received general anesthesia had worse pain 2 hours postoperatively, while patients who received a brachial plexus blockade reported worse pain 12 hours postoperatively, suggesting that “rebound pain” ought to be taken into consideration when employing peripheral nerve blocking. Both time in the recovery room and overall amount of narcotics consumed was higher for patients who received general anesthesia, but functional scores did not differ between the two groups.4

In addition, Johnson et al. found this past year, based on a review of 80 patients, that patients who were treated with peripheral nerve blocking reported a significant decrease in postoperative pain at discharge as well as decreased length of stay. These researchers reported one minor complication with peripheral nerve blocking: a short-lived skin irritation at the site of injection.5

References 

(1)  Distal Radius Fracture (Wrist Fracture) | Johns Hopkins Medicine https://www.hopkinsmedicine.org/health/conditions-and-diseases/distal-radius-fracture-wrist-fracture

(2)  Egol, K. A.; Soojian, M. G.; Walsh, M.; Katz, J.; Rosenberg, A. D.; Paksima, N. Regional Anesthesia Improves Outcome After Distal Radius Fracture Fixation Over General Anesthesia. Journal of Orthopaedic Trauma 201226 (9), 545–549. https://doi.org/10.1097/BOT.0b013e318238becb. 

(3)  Rundgren, J.; Mellstrand Navarro, C.; Ponzer, S.; Regberg, A.; Serenius, S.; Enocson, A. Regional or General Anesthesia in the Surgical Treatment of Distal Radial Fractures: A Randomized Clinical Trial. The Journal of Bone and Joint Surgery 2019101 (13), 1168–1176. https://doi.org/10.2106/JBJS.18.00984. 

(4)  Galos, D. K.; Taormina, D. P.; Crespo, A.; Ding, D. Y.; Sapienza, A.; Jain, S.; Tejwani, N. C. Does Brachial Plexus Blockade Result in Improved Pain Scores After Distal Radius Fracture Fixation? A Randomized Trial. Clinical Orthopaedics & Related Research 2016474 (5), 1247–1254. https://doi.org/10.1007/s11999-016-4735-1. 

(5)  Johnson, P.; Hustedt, J.; Matiski, T.; Childers, R.; Lederman, E. Improvement in Postoperative Pain Control and Length of Stay With Peripheral Nerve Block Prior to Distal Radius Repair. Orthopedics 202043 (6). https://doi.org/10.3928/01477447-20200721-14. 

COVID-19, like many viral diseases, continues to impact patients’ health even after they have resolved their initial infections. Symptoms manifest across different organ systems with varying levels of severity. A literature review published March 22, 2021 in Nature Medicine by Nalbandian et al. surveyed the current research on post-acute COVID-19 disease. Across different studies of post-acute sequelae of SARS-CoV-2 infection (PASC), researchers observed pulmonary, cardiovascular, neuropsychiatric, hematologic, renal, endocrine, gastrointestinal, and dermatologic conditions, underscoring the complex, heterogeneous nature of the syndrome.1

In a prospective cohort study of 1,733 Chinese patients observed at six months from the onset of COVID-19 symptoms, Huang et al. found that a majority of the patients (76 percent) reported at least one PASC symptom. Fatigue or muscular weakness were the most commonly reported symptom (63 percent), in line with other studies.2 Chronic fatigue has been observed after numerous other acute infections, like SARS coronavirus.3 In one analysis, nearly all (97 percent) of a cohort of 29 patients admitted to a rehabilitation center after overcoming severe COVID-19 still experienced gait speed deficits at discharge from the rehabilitation center.4

Pulmonary complications are notably prevalent as well, with over one-fifth (23 percent) of participants in the study by Huang et al. experiencing dyspnea.2 In smaller studies conducted over shorter follow-up periods, this number was as high as 40 percent. Other observed symptoms include cough and persistent oxygen requirements. Those who had more severe acute COVID-19, including patients who required a high-flow nasal cannula or mechanical ventilation, may be at risk for serious long-term complications like pulmonary fibrosis and pneumonia.1

Neuropsychiatric complications continue to impact the quality of life and daily activities of a significant number of COVID-19 survivors. In the study by Huang et al., 23 percent of individuals experienced anxiety or depression and 26 percent had sleep difficulties.2 In a small United Kingdom study, 30 percent of hospitalized COVID-19 patients had symptoms of PTSD. In all of the studies summarized by Nalbandian et al., loss of taste and smell was experienced by over 10 percent of study participants. Cognitive impairment has widely been noted as well, with many suffering from “brain fog” (difficulties with concentration, memory, executive function and more).1

Beyond impacting individuals’ wellbeing, cognitive and physical fatigue associated with post-acute COVID-19 will alter productivity and the economy. Chronic fatigue symptoms bear resemblance to myalgic encephalomyelitis/chronic fatigue syndrome (ME/CFS), which currently poses an estimated financial burden of between $17 and $24 billion in the U.S. each year. Experts propose that even if only 25 million Americans contract COVID-19 by the end of 2021 and only 10 percent subsequently suffer from an illness meeting the ME/CFS definition, the number of Americans suffering from ME/CFS would at least double over one year. Globally, they estimate that the number of people suffering from ME/CFS would increase to 110 million during 2021.3

Pulmonary complications will also pose economic consequences. While only one year of data is available thus far on the healthcare costs associated with COVID-19, the Kaiser Family Foundation studied these figures to estimate that the annual cost of treating COVID-19 cases only for uninsured Americans might range from $13.9 billion to $41.8 billion.5 It is also necessary to consider healthcare costs for managing conditions that can be exacerbated by lasting damage from a previous COVID-19 infection, such as pneumonia. Before the pandemic, roughly 1.5 million people were hospitalized for pneumonia each year in the U.S., at an average cost of $20,000 per stay.

The novelty of COVID-19 and the limited opportunities to observe its ongoing impacts mean that much is unknown about the prevalence and characteristics of post-acute conditions. Hypotheses about their causes abound: the effects of hospitalization, acute respiratory distress syndrome, and the impact of the hyperinflammatory response associated with COVID-19 may all play roles. Other important factors are confounding health disparities, social determinants of health, and the psychosocial impact of the pandemic.6

In December, Congress promised $1.15 billion over four years for the National Institutes of Health to fund research on the prolonged health consequences of COVID-19.7 Moreover, over 30 U.S. hospitals and health systems have already established clinics solely devoted to post-COVID-19 research and care.8 The long-term effects of COVID-19 remain unclear, and health systems, researchers, and clinicians are still in the initial stages of learning about how to best care for patients.

References 

  1. Nalbandian A, Sehgal K, Gupta A, et al. Post-acute COVID-19 syndrome. Nat Med. 2021;27(4):601-615. 
  1. Huang C, Huang L, Wang Y, et al. 6-month consequences of COVID-19 in patients discharged from hospital: a cohort study. Lancet. 2021;397(10270):220-232. 
  1. Komaroff AL, Bateman L. Will COVID-19 lead to myalgic encephalomyelitis/chronic fatigue syndrome? Front Med (Lausanne). 2020;7:606824. 
  1. Olezene CS, Hansen E, Steere HK, et al. Functional outcomes in the inpatient rehabilitation setting following severe COVID-19 infection. PLoS One. 2021;16(3):e0248824. 
  1. Dovere E-I. Vaccine refusal will come at a cost—for all of us. Atl Mon. Published online April 10, 2021. https://www.theatlantic.com/politics/archive/2021/04/vaccine-refusal-hesitancy-economic-costs/618528/ 
  1. Bhadelia, N. “Post Acute Sequelae of SARS-CoV-2 (PAS-C)” Lecture presented at MassCPR Scientific Symposium: COVID-19 Diagnostic Testing and Clinical Management; March 30, 2021; https://www.youtube.com/watch?v=5RX2IM4Srgc.  
  1. NIH launches new initiative to study “Long COVID.” NIH. Published February 23, 2021. https://www.nih.gov/about-nih/who-we-are/nih-director/statements/nih-launches-new-initiative-study-long-covid 
  1. Carbajal E. 30 hospitals, health systems that have launched post-COVID-19 clinics. Beckers Hospital Review. https://www.beckershospitalreview.com/patient-safety-outcomes/13-hospitals-health-systems-that-have-launched-post-covid-19-clinics.html

The field of outpatient services has grown rapidly over the last several years, spurred by changes to reimbursements for inpatient procedures from health plan providers. One result of this is an increasing number of hybrid surgery centers — facilities that operate as both an office-based laboratory (OBL) and an ambulatory surgical center (ASC). Usually, a hybrid suite contains the imaging equipment typical of an OBL, as well as the equipment and sterilization standards necessary for surgical and non-surgical interventions [1]. While hybrid surgery centers can offer advantages to both patients and healthcare providers that a traditional hospital setting cannot, the transition to this structure may prove difficult. OBL-ASC facilities are complex structures that have many financial, legal, and practical hurdles.  

The flexibility of hybrid suites is advantageous to medical organizations and patients alike. The ability to transition from office to OR can improve patient outcomes in the event of an emergency during a routine procedure [2]. It also allows for non-surgical and surgical procedures to be performed consecutively or simultaneously, thus reducing the number of hospital admissions and shortening the length of stay for patients, which saves money and increases efficiency [3]. Hybrid centers have the potential to guide the standard for medical treatment toward a more integrated approach [4]. Improving patient outcomes and satisfaction is also beneficial for medical providers as the industry shifts toward value-based care [5]. Structurally, the hybrid center is less bureaucratic than the traditional hospital and allows physicians to increase their income through equity ownership [6].  

Despite these prospective benefits, there are many logistical obstacles to instituting a hybrid surgery center. Legal regulations can make it difficult to build a hybrid suite or convert existing offices. Under federal law, in order for an OBL and ASC to operate within the same facility, they must maintain different hours of operation and keep medical records separate. Certain states also restrict the proliferation of outpatient clinics based on need and access [7]. The performance of hybrid procedures must be accommodated not only by new facilities but by new, interdisciplinary working dynamics. Optimizing the design of hybrid centers will require repeated study of the workflow in these environments, and improved collaboration between medical professionals [7].  

Despite the difficulties of establishing hybrid surgery centers, these facilities are growing rapidly and encompass a large share of healthcare services in the country. This trend is the result of a confluence of factors. Many insurance providers no longer cover routine procedures when performed in a hospital because of the higher costs associated with inpatient procedures [8]. Patients, too, object to high costs and have demanded alternatives, pressuring the industry to embrace hybrid centers [5]. The most recent development accelerating the shift, however, is more urgent than market forces. In order to minimize exposure and free up hospital resources for COVID-19 patients, pressure for outpatient centers to increase their caseload has grown. While the pandemic is ongoing, outpatient facilities, including hybrid centers, are easing the strain on hospitals by providing care that would otherwise have been delayed [9].       

References 

[1] Bazzi, May, et al. “The Drama in the Hybrid OR: Video Observations of Work Processes and Staff Collaboration During Endovascular Aortic Repair.” Journal of Multidisciplinary Healthcare, vol. 12, 2019, pp. 453-464, doi: 10.2147/JMDH.S197727.   

[2] “Hybrid Surgical Procedures.” Hybrid Operating Rooms & Hybrid Cath Labs, J.M. Keckler Medical Co., hybridoperatingroom.com/hybrid-surgical-procedures/. 

[3] Bazzi, May, et al. “Team Composition and Staff Roles in a Hybrid Operating Room: A Prospective Study Using Video Observations.” Nursing Open, 2019, doi: 10.1002/nop2.327.   

[4] Davidson, Michael J. and Tsuyoshi Kaneko. “Use of the Hybrid Operating Room in Cardiovascular Medicine.” Circulation, vol. 130, no. 11, 2014, pp. 910-917, doi: 10.1161/CIRCULATIONAHA.114.006510

[5] Derek Long, David McMillan, et al.| CPA, ASA | Apr 1, 2019. “HOPDs vs. ASC: Understanding Payment Differences.” 1 Apr. 2019, https://www.hfma.org/topics/hfm/2019/ april/hopds-vs–asc–understanding-payment-differences.html. 

[6] Tim van Biesen and Todd Johnson | Healthcare Private Equity Advisers | Sept 23, 2019. “Ambulatory Surgery Center Growth Accelerates: Is Medtech Ready?” Bain & Company, 23 Sept. 2019, https://www.bain.com/insights/ambulatory-surgery-center-growth-accelerates-is- medtech-ready/. 

[7] Cilek, Jacob A. and Jason S. Greis. 12 Business and Legal Considerations for Developing a ‘Hybrid’ Office-Based Laboratory–Ambulatory Surgery Center. McGuire Woods, Sept. 2019, https://media.mcguirewoods.com/publications/2019/OBL-ASC-Hybrid-Article-12-Considerations.pdf. 

[8] Karen Blum | Office of Johns Hopkins Physicians | Apr 25, 2018. “Shifting Low-Risk Procedures to Ambulatory Surgery Centers.” BestPractice News, 25 Apr. 2018, https://www. hopkinsmedicine.org/office-of-johns-hopkins-physicians/best-practice-news/shifting-low-risk-procedures-to-ambulatory-surgery-centers. 

[9] Jacqueline LaPointe | Revcycle Intelligence | Mar 17, 2020. “Hospitals Delay, Shift Surgeries to Outpatient Due to COVID-19.” Revcycle Intelligence, 17 Mar. 2020, https://revcycleintelligen ce.com/news/hospitals-delay-shift-surgeries-to-outpatient-due-to-covid-19.

Anemia is a condition that results in low red blood cell count and hemoglobin deficiency, decreasing the blood’s capacity to carry oxygen [1]. The World Health Organization specifies that hemoglobin concentrations of less than 12.0g/dl in non-pregnant women and 13.0g/dl in men could be considered anemic [2]. There are a number of potentially serious consequences of anemia, including increased cardiac output, which can lead to damage to the heart’s muscular tissue [3]. Perioperative anemia is not uncommon and can make surgery and recovery significantly more complicated. Furthermore, anemia in surgical patients is associated with higher morbidity and mortality rates [4].  

In order to improve the survival and recovery outcomes for anemic surgical patients, the condition must first be diagnosed and treated appropriately. Unfortunately, perioperative anemia often does not receive the attention it warrants until hemoglobin levels become low enough for blood transfusion [5]. A study by Beattie et al. found that transfusion rates were three times higher for anemic patients than their non-anemic counterparts. [2]. When transfusions are required, the risk of complications such as ischemic stroke and myocardial infarction rises significantly, and transfusions are associated with higher morbidity rates among surgical patients [6].  

As anemia has gained attention in the medical community, a number of recommendations and strategies for preventing morbidities associated with anemia in surgical patients have been released. In 2005, an interdisciplinary panel of medical professionals advised that elective surgery patients have their hemoglobin levels tested at least thirty days before surgery and that unexplained anemia should always be considered as an effect of a condition that requires pre-surgical attention [7]. The American Society of Anesthesiology advises that the necessity for blood transfusion is usually indicated at a hemoglobin level of <6g/dl, but that ischemia, bleeding, and other risks should be weighed alongside it [6]. More recently, researchers created an automated system for iron-deficiency anemia screening, which they found to improve diagnosis over clinical procedures [4].  

Concerns regarding morbidity rates for anemic patients extend to all members of the surgical team, including anesthesia providers. The anesthesia provider should review vital signs and patient data and evaluate whether red blood cell transfusion is worth the risk to the patient. Because anemia is associated with poorer outcomes, care providers must carefully weigh the decision to administer a transfusion [1]. Several medical associations have issued guidelines for evaluating the necessity of transfusion. These guidelines include considerations of hemoglobin levels as well as various health factors. Current trends indicate that physicians’ ability to identify and treat anemia is developing rapidly, improving outcomes for surgical patients with anemia. 

References 

[1] Klick, John C., and Edwin G. Avery. “Anesthetic Considerations for the Patient With Anemia and Coagulation Disorders.” Anesthesiology, edited by David E. Longnecker et al, McGraw-Hill, 2012, pp. 196-216.   

[2] Beattie, Scott W., et al. “Risk Associated With Preoperative Anemia in Noncardiac Surgery: A Single-Center Cohort Study.” Anesthesiology, vol. 110, 2009, doi: 10.1097/ALN.0b013e318 19878d3. 

[3] “Anemia Compensation.” Open Anesthesia, 26 Feb., https://www.openanesthesia.org/anemia _compensation/

[4] Okocha, Obianuju, et al. “An Effective and Efficient Testing Protocol for Diagnosing Iron-Deficiency Anemia Preoperatively.” Anesthesiology, vol. 133, 2020, 109-118, doi: 10.1097/ALN.0000000000003263. 

[5] Warner, Matthew A., et al. “Perioperative Anemia: Prevention, Diagnosis, and Management Throughout the Spectrum of Perioperative Care.” Anesthesia & Analgesia, vol. 130, no. 5, 2020, 1364-1380, doi: 10.1213/ANE.0000000000004727. 

[6] Shander, Aryeh et al., “Anesthesia for Patients With Anemia.” Anesthesiology Clinics, vol. 34, no. 4, 2016, 711-730, doi: 10.1016/j.anclin.2016.06.007. 

[7] Goodnough, Laurence T., et al. “Detection, Evaluation, and Management of Anemia in the Elective Surgical Patient.” Anesthesia & Analgesia, vol. 101, no. 6, 2005, 1858-1861, doi: 10.1213/01.ANE.0000184124.29397.EB. 

The SARS-CoV-2 VUI 202012/01 variant sits poised to become the dominant coronavirus variant in the U.S. as early as March.1 Scientists first sequenced the variant, also known as B.1.1.7, in the U.K. in September 2020.2 It quickly garnered scientific and public attention as experts hypothesized that B.1.1.7’s fast spread contributed to the case spike in England. Recent research – yet to undergo peer review – estimates that B.1.1.7’s transmissibility exceeds that of prior variants by 50-75%.3,4 As of January 12, 2021, B.1.1.7 has appeared already in at least 33 countries.2 A key question is how available vaccines affect this SARS-CoV-2 variant.

B.1.1.7 differs from SARS-CoV-2 by 23 mutations in its genetic blueprint.2 Six of the mutations do not cause any change in the amino acid sequence. Eight changes, however, affect the spike protein of the virus. The spike protein plays a key role in receptor recognition and cell membrane fusion; it is this protein that locks onto compounds in the human body to enable infection. Currently, the N501Y mutation is of primary interest to scientists. This mutation – the change of an asparagine to a tyrosine – alters the receptor binding domain of the spike protein.2,5 Scientists hypothesize that this mutation allows the virus to attach more strongly to cells, which, in turn, increases its transmissibility. It is critical to understand whether this SARS-CoV-2 variant is different enough as to affect the efficacy of available vaccines.

Current vaccines target these spike proteins to impede the virus’s ability to latch onto host cells.2 A person’s immune response to the vaccine produces antibodies that bind to various locations on the spike protein in order to neutralize the virus. Experts fear, however, that certain mutations to the spike protein may destroy or impair the sites where antibodies bind.6 Fortunately, the N501Y mutation’s location makes it such that the mutation likely does not significantly affect antibody binding sites.6,7  

Currently, the CDC reports that “there is no evidence to suggest that the variant [B.1.1.7] has any impact on the severity of disease or vaccine efficacy.”8 In a January 7 preprint, scientists at Pfizer and the University of Texas Medical Branch at Galveston concluded that the N501Y mutation did not affect the Pfizer vaccine-generated antibodies’ ability to latch on to the virus.9 In this study, researchers examined whether the sera of Phase 3 trial participants neutralized the B.1.1.7 variant as well as they neutralized the non-B.1.1.7 virus.10 The results suggest the N501Y mutation does not confer Pfizer vaccine resistance because the same quantity of serum successfully neutralized both the original and the mutated virus. Likewise, the Moderna vaccine appears to confer immunity that recognizes B.1.1.7. Early laboratory tests looked at blood samples from eight people and two primates who received the two Moderna vaccine doses. The scientists observed no decrease in neutralization capacity in the serum against B.1.1.7.11 In addition, Novavax reports its vaccine efficacy as 85.6% protective against B.1.1.7 in Phase 3 UK clinical trials.12  

Neither Oxford-AstraZeneca nor Johnson & Johnson have yet released data that specifically examines their vaccines’ efficacy against B.1.1.7. Oxford-AstraZeneca scientists currently have an analysis underway that examines the vaccine’s neutralization capacity against the variant; they expect to report the results within two weeks.13 Moreover, recently released data from Johnson & Johnson claim 66% vaccine efficacy against COVID-19 infection and 85% efficacy against severe cases; unfortunately, the data does not speak explicitly to the vaccine’s efficacy against B.1.1.7.14 However, the study spanned multiple continents and concluded relatively recently, which makes it likely that some participants were exposed to B.1.1.7.  

At present, scientists seem optimistic that current vaccines will confer some level of protection against the B.1.1.7 SARS-CoV-2 variant. As new variants arise, however, the current vaccines will continue to be tested. 

References 

1. Branswell, H. Coronavirus variant could become dominant strain by March, CDC warns. STAT News https://www.statnews.com/2021/01/15/covid19-b117-variant-cdc/ (2021). 

2. Cohut, M. & Hewnigs-Martin, Y. New coronavirus variant: What we know so far. https://www.medicalnewstoday.com/articles/covid-19-what-do-we-know-about-the-new-coronavirus-variant (2021). 

3. Davies, N. G. et al. Estimated transmissibility and severity of novel SARS-CoV-2 Variant of Concern 202012/01 in England. medRxiv (2020) doi:10.1101/2020.12.24.20248822. 

4. Volz, E. et al. Transmission of SARS-CoV-2 Lineage B.1.1.7 in England: Insights from linking epidemiological and genetic data. medRxiv (2021) doi:10.1101/2020.12.30.20249034. 

5. Rathnasinghe, R. et al. The N501Y mutation in SARS-CoV-2 spike leads to morbidity in obese and aged mice and is neutralized by convalescent and post-vaccination human sera. medRxiv (2021) doi:10.1101/2021.01.19.21249592. 

6. Moore, J. P. & Offit, P. A. SARS-CoV-2 Vaccines and the Growing Threat of Viral Variants. JAMA (2021) doi:10.1001/jama.2021.1114. 

7. Starr, T. N. et al. Deep Mutational Scanning of SARS-CoV-2 Receptor Binding Domain Reveals Constraints on Folding and ACE2 Binding. Cell 182, 1295-1310.e20 (2020) doi: 10.1016/j.cell.2020.08.012. 

8. CDC. Emerging SARS-CoV-2 Variants. Centers for Disease Control and Prevention https://www.cdc.gov/coronavirus/2019-ncov/more/science-and-research/scientific-brief-emerging-variants.html (2020). 

9. Xie, X. et al. Neutralization of N501Y mutant SARS-CoV-2 by BNT162b2 vaccine-elicited sera. bioRxiv (2021) doi:10.1101/2021.01.07.425740. 

10. Pfizer. An In Vitro Study Shows Pfizer-BioNTech COVID-19 Vaccine Elicits Antibodies that Neutralize SARS-COV-2 with a Mutation Associated with Rapid Transmission. News | Pfizer https://www.pfizer.com/news/press-release/press-release-detail/vitro-study-shows-pfizer-biontech-covid-19-vaccine-elicits (2021). 

11. Wu, K. et al. mRNA-1273 vaccine induces neutralizing antibodies against spike mutants from global SARS-CoV-2 variants. bioRxiv (2021) doi:10.1101/2021.01.25.427948. 

12. Novavax, Inc. Novavax COVID-19 Vaccine Demonstrates 89.3% Efficacy in UK Phase 3 Trial. 3 https://ir.novavax.com/node/15506/pdf (2021). 

13. Rivas, K. AstraZeneca expects COVID-19 vaccine data on UK variant within 2 weeks. Fox News https://www.foxnews.com/health/astrazeneca-expects-covid-19-vaccine-data-uk-variant-within-2-weeks (2021). 

14. Johnson & Johnson. Johnson & Johnson Announces Single-Shot Janssen COVID-19 Vaccine Candidate Met Primary Endpoints in Interim Analysis of its Phase 3 ENSEMBLE Trial. https://www.jnj.com/johnson-johnson-announces-single-shot-janssen-covid-19-vaccine-candidate-met-primary-endpoints-in-interim-analysis-of-its-phase-3-ensemble-trial (2021).