Is Orthrus the Next Top-Dog COVID Variant?

 The Omicron subvariant XBB.1.5

opens in a new tab or window -- aka "Krakenopens in a new tab or window" -- has climbed to more than 66% of new COVID-19 cases in the U.S., but a relatively new Omicron subvariant named after a two-headed dog may be nipping at its tentacles.

Over the last several weeks, CH.1.1 -- deemed "Orthrusopens in a new tab or window" after a monster canine in Greek mythology -- accounted for less than 2%opens in a new tab or window of new COVID cases in the U.S. as of January, per the CDC. However, Orthrus has a mutation, L452Ropens in a new tab or window,opens in a new tab or window previously seen in the highly pathogenic Delta variant, and highly transmissible BA.4 and BA.5 variants, according to researchers from the Ohio State University in Columbus.

In a BioRxiv

opens in a new tab or window preprint, Shan-Lu Liu, MD, PhD, and colleagues said Orthrus emerged in Southeast Asia in November 2022, and now accounts for about a quarter of cases in the U.K. and New Zealand. At other times in the pandemic, the U.K. has served as a bellwether of what could hit the U.S. in terms of new variants and potential surges.

They also explained that Orthrus, along with another new variant, CA.3.1, possess a "consistently stronger neutralization resistance than XBB, XBB.1, and XBB.1.5, which is astonishing and warrants continuous monitoring and further investigations." Liu's group called for continuing current vaccination strategies, or the investigation of new ones, and the ongoing surveillance of emerging variants.

The February 2023 COVID epidemiological updateopens in a new tab or window from the World Health Organization (WHO) lists Orthrus among the top three most prevalent variants in Europe, clocking in at 12.3%, slightly behind BQ.1 at 13% and BQ.1.1 at 31.3%.

"WHO is currently prioritizing the tracking of four Omicron descendent lineages," the agency stated. "These variants are included on the basis of signals of an increase in prevalence or signs of growth rate advantage in some countries relative to other circulating variants, and additional amino acid changes that are known or suspected to confer fitness advantage."

During the second week of January, there were 3,473 (13.9%) sequences of BA.2.75, from which Orthrus is descended. That included BA.2.75.2 at 35 sequences (<1%), and then Orthrus, at 1,672 sequences (6.7%), according to WHO.

Recent CDC dataopens in a new tab or window show U.S. COVID cases, hospitalizations, and deaths trending down as of Feb. 1. Weekly cases were at 280,911, with weekly hospitalizations at 3,459, and weekly deaths at 3,452.

Liu and colleagues pointed out that "our study highlights the continued waning of 3-dose mRNA booster efficacy against newly emerging Omicron subvariants. This effect can be partially saved by administration of a bivalent booster, though escape by some subvariants, particularly CH.1.1 and CA.3.1, is still prominent."

Currently authorized bivalent COVID-19 boosters demonstrated similar protectionopens in a new tab or window against symptomatic illness from the XBB/XBB.1.5 Omicron subvariants as from BA.5-related subvariants, according to a recent CDC study.

Disclosures

The authors disclosed support from the National Cancer Institute, the Glenn Barber Fellowship from the Ohio State University College of Veterinary Medicine, the Robert J. Anthony Fund for Cardiovascular Research, the JB Cardiovascular Research Fund, and the NIH.

Primary Source

BioRxiv

Source Reference: opens in a new tab or windowQu P, et al "Extraordinary evasion of neutralizing antibody response by Omicron XBB.1.5, CH.1.1 and CA.3.1 Variants" BioRxiv 2023; DOI: 10.1101/2023.01.16.524244.

https://www.medpagetoday.com/special-reports/features/103002

New York's Plan for Mentally Ill Homeless People 'Not the Solution'

 Kim Hopper, PhD, an adjunct professor at Columbia Law School in New York City, discusses the systemic shortfalls of New York City Mayor Eric Adams' involuntary removal initiative

opens in a new tab or window to get homeless New Yorkers with mental illness off the streets and subways. Hopper is also a medical anthropologist who served as president of the National Coalition for the Homeless and teaches in the Bard Prison Initiative.

The following is a transcript of his remarks:

I'm not sure I know what it would really take from the inside of the bureaucracy at the city and state level to mount what would be a durable, long-term commitment to addressing not just the emerging needs or the emergent needs on the street, but the long-term need for supportive and affordable housing. That's what has been missing from the equation ever since the start.

What we've had are a number of, I think, remarkably promising small-scale efforts at providing exactly that for exactly this population, and they have an enviable track record of almost unblemished success even over the long haul. In 5-year follow-ups, we've had 85% retention rates, which is sort of unheard of in mental health research.

I think the most remarkable one is the one that began in the early 1990s and became known as Housing First. It asked a really simple question: what would happen if in doing street outreach, instead of threatening people with coercive placement elsewhere, we offered them a chance to say, "What would it help me to get from you?" And when they asked that question in 1990, remarkably enough, in a randomized controlled trial, the people said, "I need a place to live."

These were seriously mentally ill people, often with long-standing substance use problems. And they said, "I really could use a place of my own." And over the next decade or so, that program rehoused voluntarily over 500 New Yorkers from the street directly, often, again, with long-standing issues of psychiatric disability or substance abuse problems.

The key has always been that once people had a place of their own that was affordable, secure, and regularly visited by case managers, once that was in place, it didn't take long for them to develop a stake in holding onto it.

I mean, mistakes were made. Sometimes people brought their friends from the street into their apartment and it didn't go very well. They had to be resettled and the landlord reassured that this was not going to happen again. But the beauty of the program was its security. Once you had a place, you were a member of Pathways to Housing forever.

It was just remarkable what a difference it made. You actually see it in the shelter statistics in the early 90s in New York City, you actually see a decline in the numbers of people there and in Westchester County from the shelter population, because they weren't simply circulating through that system and the hospital system and the jails and the detox facilities, they were actually leaving that circuit for a place of their own.

New problems arise like, now what do I do for a social life? But that's a different kind of problem than being paraded as the public enemy number one on the streets and subways of New York City.

Bringing those up to scale is not something any public authority has taken on in a serious way, and that's what we need. It probably can't be done at a city level alone, even at a state level alone. I mean, we've just seen the effects over the summer of erratic political moves in the American South suddenly overwhelming the shelter systems in the American Northeast. It's not something that can be done, I think, on a local level, but pretending to be able to do it on a local level is a real disservice. That's the read I have or the feeling I have when faced with the mayor's most recent initiative.

It's not that the hospital doesn't have a stake in this, because the clinical work they're doing is undone by the homelessness that follows discharge if they have no place to go. It's not that the hospitals aren't trying hard or the social workers aren't putting the effort in, it's just that the resources aren't there.

You see this not simply with respect to mental health, but you see it in clinical interventions all over the country. Internally, clinicians are weighing the option of going ahead with a procedure contingent upon this person having some place to go after they can be discharged. Homeless people are really low on the eligibility scale judged by that rubric. They just don't have that option, and you can't conjure it up out of thin air as a discharge plan if the actual resources aren't there.

The stock of housing isn't there, and unless we tackle that really fundamental issue of resource scarcity, we're just tinkering around the edges and imaginatively developing workarounds that manage to get our guy placed when somebody else is going to be pushed back. It's a terribly demoralizing place to be as a clinician.

https://www.medpagetoday.com/publichealthpolicy/publichealth/103008

Wide Variation in Organ Procurement Performance

 Addressing the wide variation in the performance of organ procurement organizations (OPOs), particularly at individual hospitals, could help to increase the organ supply, according to a retrospective cross-sectional study.

Of 931 potential organ donors identified at 13 hospitals covered by two OPOs, only 242 donors, or 26%, actually had organs recovered, reported Seth Karp, MD, of Vanderbilt University Medical Center in Nashville, Tennessee, and colleagues.

For each hospital, the ratio of actual donors to potential donors varied widely, from 0.0 to 0.51. Of the two OPOs analyzed, one recovered 14% of possible donors, while the other recovered 48% (rate ratio [RR] 2.77, 95% CI 2.56-2.99, P<0.001), they noted in JAMA Surgeryopens in a new tab or window.

Of note, hospitals where transplants are performed (two of the 13) had a higher probability of donor recovery compared with non-transplant hospitals (OR 5.0, 95% CI 3.09-8.45, P<0.001).

"There are many, many donors out there that are not being picked up by the system," Karp told MedPage Today, "and it's due to a failure of regulation at the government level, and due to a failure of the performance of the OPO organizations."

The vast difference in performance between just the two OPOs (there are 58 total in the U.S.) -- 237.5% -- means that 206 additional potential donors could have been available if the first OPO had performed similarly to the second one, noted Robert M. Cannon, MD, MS, and Jayme E. Locke, MD, MPH, both of the University of Alabama at Birmingham Heersink School of Medicine, in an accompanying editorialopens in a new tab or window.

"This gap between only 2 OPOs is of similar magnitude to the performance gap seen in all U.S. transplant centers," they wrote.

Karp and colleagues said that there is little understanding of the causes of variation among OPO procurement rates, "in part because relevant data are difficult to obtain. ... Some argue that blame lies with the failure of hospitals to refer ventilated patients to OPOs or with center acceptance practices."

According to Cannon and Locke, "the cold truth is that we have no good understanding of why some OPOs are better than others, or even what an acceptable level of OPO performance should be because the environment in which OPOs operate is so completely obscure."

For this study, Karp and team chose two donor service areas with two OPOs whose historic observed-to-expected donor metrics were the same, but who differed using a new metric, CMS CALC, which was implemented in 2022. The metrics historically used by OPOs, accessed through the Scientific Registry of Transplant Recipients, showed that the two OPOs had equivalent performances. This disparity in the performance-measuring metrics, the authors wrote, "suggests that historical performance metrics failed to find an actual difference in performance."

The newer metric considers death data from the National Center for Health Statistics, and "is an objective, independently reported measure" that captures the ratio of actual-to-potential donors more realistically, the authors added. The older metric was self-reported by OPOs and criticized for excluding certain potential donors and failing to capture

opens in a new tab or window actual OPO performance.

Although thousands of patients languish on donor lists each year, Karp said that it's a misconception that there aren't enough organs to go around. "It's not that people just don't want to donate. That's just simply not true," he noted. The problem, instead, is with the organ procurement system.

He suggested that OPOs that perform better build meaningful relationships with hospitals in order to coordinate a time-sensitive donation with a donor's family -- something that often involves in-person meetings and delicate conversations.

Co-author Malay B. Shah, MD, of the University of Kentucky in Lexington, noticed that organs he recovered for transplants were only coming from certain hospitals in his area. "People don't just die at the University of Kentucky, right? They die at other hospitals that have very robust services," he told MedPage Today. "Why do we not do donors [there]?"

Metrics that hold OPOs accountable for their ability to do this effectively make the disparities less obscure -- but they must be available publicly, Shah added. "We all need to be transparent about the work we're doing and and use it to improve."

In this study, Karp and colleagues reviewed 2,008 medical records for decedents from 2017-2018 as a sample of nearly 9,000 deaths.

Inpatient deaths were excluded as potential donors if they met certain medical criteria that would typically disqualify organ donation, such as multi-organ failure or cardiac arrest without return of spontaneous circulation.

The authors said it is possible that they over-counted the number of potential donors, but tried to control for this by using conservative criteria. In addition, bias could have been introduced by using only hospitals that could provide medical records. Furthermore, because their analysis included only two OPOs, their results may not be generalizable to others.

Disclosures

This study received support from the National Institute of Diabetes and Digestive and Kidney Diseases.

Karp and Shah reported no conflicts of interest.

A co-author reported personal fees from Life Connection of Ohio and the Arkansas Regional Organ Recovery Agency unrelated to this work.

Cannon reported no conflicts of interest.

Locke reported consulting fees from Sanofi and grants from United Therapeutics and Hansa.

Primary Source

JAMA Surgery

Source Reference: opens in a new tab or windowJohnson W, et al "Variability in organ procurement organization performance by individual hospital in the United States" JAMA Surg 2023; DOI: 10.1001/jamasurg.2022.7853.

Secondary Source

JAMA Surgery

Source Reference: opens in a new tab or windowCannon RM, Locke JE "It is time for the light to shine on organ procurement organizations" JAMA Surg 2023; DOI: 10.1001/ jamasurg.2022.7857.

https://www.medpagetoday.com/transplantation/transplantation/103011

Theft of Controlled Substances in Long-Term Care Homes

 Eilon Caspi https://orcid.org/0000-0001-8043-3233, Wei-Lin Xue, and Pi-Ju Liu https://orcid.org/0000-0002-8762-5120View all authors and affiliations

OnlineFirst

https://doi.org/10.1177/07334648231153731

Abstract

The theft of controlled substances has been studied in the community and healthcare settings including hospitals, pharmacies, hospice, and pain clinics. However, research on these thefts in long-term care homes has yet to be published. This exploratory study makes first steps toward bridging this gap. Using 107 Minnesota Department of Health’s investigation reports substantiated as “drug diversion” between 2013 and 2021 in assisted living residences and nursing homes, we found that 11,328.5 tablets were stolen from 368 residents (97.5% were controlled substances), with over 30 tablets stolen per resident. We also identified the types of medications stolen, duration of theft, extent to which nurses stole the medications or were those initially suspecting thefts, and the role of surveillance cameras in confirming allegations. The findings could raise awareness to this form of elder mistreatment in long-term care homes and call for action to address it.

https://journals.sagepub.com/doi/10.1177/07334648231153731

Metabolic side effects in schizophrenia during mid- to long-term treatment with antipsychotics

 Angelika Burschinski, Johannes Schneider-Thoma, Virginia Chiocchia, Kristina Schestag, Dongfang Wang, Spyridon Siafis, Irene Bighelli, Hui Wu, Wulf-Peter Hansen, Josef Priller, John M. Davis … See all authors 

https://doi.org/10.1002/wps.21036

Abstract

Metabolic side effects of antipsychotic drugs can have serious health consequences and may increase mortality. Although persons with schizophrenia often take these drugs for a long time, their mid- to long-term metabolic effects have been studied little so far. This study aimed to evaluate the mid- to long-term metabolic side effects of 31 antipsychotics in persons with schizophrenia by applying a random-effects Bayesian network meta-analysis. We searched the Cochrane Schizophrenia Group's Study-Based Register of Trials (up to April 27, 2020) and PubMed (up to June 14, 2021). We included published and unpublished, open and blinded randomized controlled trials with a study duration >13 weeks which compared any antipsychotic in any form of administration with another antipsychotic or with placebo in participants diagnosed with schizophrenia. The primary outcome was weight gain measured in kilograms. Secondary outcomes included “number of participants with weight gain”, fasting glucose, total cholesterol, low-density lipoprotein cholesterol, high-density lipoprotein cholesterol, and triglycerides. We identified 137 eligible trials (with 35,007 participants) on 31 antipsychotics, with a median follow-up of 45 weeks. Chlorpromazine produced the most weight gain (mean difference to placebo: 5.13 kg, 95% credible interval, CrI: 1.98 to 8.30), followed by clozapine (4.21 kg, 95% CrI: 3.03 to 5.42), olanzapine (3.82 kg, 95% CrI: 3.15 to 4.50), and zotepine (3.87 kg, 95% CrI: 2.14 to 5.58). The findings did not substantially change in sensitivity and network meta-regression analyses, although enriched design, drug company sponsorship, and the use of observed case instead of intention-to-treat data modified the mean difference in weight gain to some extent. Antipsychotics with more weight gain were often also among the drugs with worse outcome in fasting glucose and lipid parameters. The confidence in the evidence ranged from low to moderate. In conclusion, antipsychotic drugs differ in their propensity to induce metabolic side effects in mid- to long-term treatment. Given that schizophrenia is often a chronic disorder, these findings should be given more consideration than short-term data in drug choice.

https://onlinelibrary.wiley.com/doi/10.1002/wps.21036

Cardiac Monitoring Continues to Flag Unsuspected Afib in Broader Population

 Long-term monitoring improved the detection of atrial fibrillation (Afib) after a large artery or small vessel stroke, a randomized trial showed.

Among survivors of strokes attributed to small vessel occlusion or large artery atherosclerosis in the STROKE AF trial, Afib was detected in 21.7% of those who underwent insertable cardiac monitoring (ICM) versus 2.4% of those who received standard care over 3 years (HR 10.0, 95% CI 4.0-25.2, P<0.001), reported Lee Schwamm, MD, of Massachusetts General Hospital in Boston, during the American Stroke Association's International Stroke Conferenceopens in a new tab or window.

While there were similar rates of recurrent stroke between the study groups (17.0% vs 14.1%, respectively; HR 1.10, 95% CI 0.67-1.78, P=0.71), Schwamm said this clinical event analysis was underpowered and explained that only three out of the 34 patients with recurrent stroke in the ICM arm had Afib detected prior to the recurrent stroke, and only one of those three was on oral anticoagulant therapy at the time of recurrent stroke.

"There were similar recurrent stroke rates in both arms by the end of the study, but these were rarely in patients with Afib and this population has a substantial risk factor burden for recurrent atherosclerotic stroke," he said.

Schwamm pointed out that suspicion of Afib based on patient symptom self-report is unreliable: 88% of Afib episodes recorded via ICM were asymptomatic.

"Fibrillation is common in these patients. Relying on routine monitoring strategies is not sufficient and neither is placing a 30-day continuous monitor on the patient. Even if fibrillation is ruled out in the first 30 days, most of the cases are missed -- because, as we found, more than 80% of the episodes are first detected more than 30 days after the stroke," Schwamm said in a press release.

This report of STROKE AF extends findings from 12 months

opens in a new tab or window, when Afib detection was 12.1% with ICM versus 1.8% with usual care (HR 7.7, 95% CI 2.7-21.9) in a patient population not typically considered for Afib detection and management. The trial was underpowered for clinical endpoints at that time.

Three years into the study, the burden of Afib detected by ICM was clinically relevant, Schwamm said, as over two-thirds of people with Afib detected by ICM had at least one episode lasting more than 1 hour. "This degree of Afib would be considered a sufficient indication by many physicians to treat with anticoagulation for secondary prevention of cardioembolic stroke," he noted.

Insertable cardiac monitors are used frequently in clinical practice to identify post-stroke Afib in patients with cryptogenic stroke. This is based on the CRYSTAL AF studyopens in a new tab or window that found that long-term ICM detected significantly more occult Afib at 12 months following cryptogenic stroke.

STROKE AF is important for expanding well beyond CRYSTAL-AF to include patients with known vascular disease that could explain the cause of stroke, commented Andrea Russo, MD, of Cooper Medical School of Rowan University in Camden, New Jersey, who was not involved with the trial.

"Even this group demonstrated the benefit of prolonged monitoring with an implantable loop recorder in increasing the yield of detection of Afib during follow-up compared with usual care. These patients had risk factors for Afib (which are similar to risk factors for [stroke]) and Afib was more likely to be detected with the implantable monitor, which could be a future risk for recurrent stroke. This highlights the importance of prolonged monitoring for Afib," she told MedPage Today.

Nevertheless, long-term monitoring for the detection of Afib is currently not recommended for survivors of stroke due to presumed small vessel occlusion or large artery atherosclerosis and is not frequently performed, according to Schwamm.

"There is still a lot that we don't yet understand about why people who have had a previous stroke have another one; however, this study contributes important information to one potential cause -- namely, unsuspected Afib -- for some of those 25% of patients with recurrent strokes," he said.

"What we need to sort out is what additional risk does Afib add, and can the use of anticoagulation reduce that risk, especially for the type of major and disabling strokes that are often associated with Afib," he added.

STROKE AF had been conducted at 33 U.S. centers from 2016 to 2019 and included nearly 500 patients ages 60 and older (or 50-59 with an additional stroke risk factor) with ischemic stroke attributed to large- or small-vessel disease, who had no prior Afib diagnosis and no contraindication to long-term oral anticoagulation.

Patients were randomized to Reveal LINQ loop recorder monitoring or usual arrhythmia detection within 10 days of the index stroke.

The overall cohort averaged 67 years, and 62% were men. Over half of patients were tobacco smokers, and the median CHA2DS2-VASc score was 5.0. There were no significant differences between groups at baseline.

For this predefined secondary analysis, trial participants with 36-month follow-up totaled 148 in the ICM arm and 146 in the control arm.

The subgroup of patients with congestive heart failure, left atrial enlargement, a body mass index >30, and a QRS >120 ms had a whopping 30% Afib detection rate over the 3 years -- suggestive of a potential high-yield population for ICM.

The STROKE AF trial was conducted open-label but had a clinical events committee to adjudicate irregular heart rhythms lasting more than 30 seconds. Schwamm noted that the Reveal LINQ only captures Afib episodes lasting at least 2 minutes.

Disclosures

The study was funded by Medtronic.

Schwamm disclosed personal relationships with Medtronic, the Massachusetts Department of Public Health, Penumbra, and Diffusion Pharma.

Russo had no disclosures.

Primary Source

International Stroke Conference

Source Reference: opens in a new tab or windowSchwamm LH, et al "3-year results from the STROKE AF randomized trial" ISC 2023.

https://www.medpagetoday.com/meetingcoverage/isc/103013

Half of Americans say they are financially worse off, highest since 2009

 Half of Americans say they are financially worse off now than they were a year ago, the highest amount since 2009, according to a Gallup survey published Wednesday.

An even greater share of lower-income respondents said they are losing ground, according to the Jan. 2-22 survey. Roughly 61% of those with household incomes below $40,000 report that their financial situation has deteriorated over the past year. Just 26% indicated that it has improved.  

By comparison, about 49% and 43% of respective middle- and high-income households said their financial situation worsened last year. 

Stubbornly high inflation has created severe financial pressures for most U.S. households, which are forced to pay more for everyday necessities like food and rent. The burden is disproportionately borne by low-income Americans, whose already-stretched paychecks are heavily impacted by price fluctuations. 

The Labor Department reported last month that the consumer price index, a broad measure of the price for everyday goods including gasoline, groceries, and rents, fell 0.1% in December but climbed 6.5% on an annual basis.

The number marked the slowest annual inflation rate since October 2021 and the slowest monthly rate since April 2020, at the height of the COVID-19 lockdowns. Still, inflation remains about three times higher than the pre-pandemic average, underscoring the persistent financial burden placed on millions of U.S. households by high prices. 

"High inflation, rising interest rates, and declining stock values in 2022 all likely took their toll on Americans’ financial situations, with half saying their situation got worse in the past year," the Gallup survey said. "Lower-income Americans, who have consistently been most likely to report that higher prices are causing them financial hardship, are particularly inclined to say they are financially worse off."

Still, despite the overall pessimism, Americans remain optimistic about their financial health in the year ahead. About 60% of respondents said they expect to be better off a year from now, while just 28% predict they will be worse off. 

"If this optimism holds and consumers act accordingly, it may help to minimize or avert an economic recession," the survey said.

https://www.foxbusiness.com/economy/half-americans-say-they-are-financially-worse-off-highest-2009