Impact of improving infection control and antibiotic stewardship practices on nosocomial infections and antimicrobial resistance in an oncology centre from India

Background: Improving basic infection control (IC) practices, diagnostics and anti-microbial stewardship (AMS) are key tools to handle antimicrobial resistance (AMR). Material(s) and Method(s): This is a retrospective study done over 6 years (2016-2021) in an oncology centre in North India with many on-going interventions to improve IC practices, diagnostics and AMS. This study looked into AMR patterns from clinical isolates, rates of hospital acquired infections (HAI) and clinical outcomes. Result(s): Over all, 98,915 samples were sent for culture from 158,191 admitted patients. Most commonly isolated organism was E. coli (n = 6951;30.1%) followed by Klebsiella pneumoniae (n = 5801;25.1%) and Pseudomonas aeroginosa (n = 3041;13.1%). VRE (Vancomycin resistant Enterococcus) rates fell down from 43.5% in Jan-June 2016 to 12.2% in July-Dec 2021, same was seen in CR (carbapenem resistant) Pseudomonas (23.0%-20.6%, CR Acinetobacter (66.6%-17.02%) and CR E. coli (21.6%-19.4%) over the same study period. Rate of isolation of Candida spp. from non-sterile sites also showed reduction (1.68 per 100 patients to 0.65 per 100 patients). Incidence of health care associated infections also fell from 2.3 to 1.19 per 1000 line days for CLABSI, 2.28 to 1.88 per 1000 catheter days for CAUTI. There was no change in overall mortality rates across the study period. Conclusion(s): This study emphasizes the point that improving compliance to standard IC recommendations and improving diagnostics can help in reducing the burden of antimicrobial resistance.Copyright © 2023 Indian Association of Medical Microbiologists

Health, Economics and Politics

This paper tracks the progression of, and the government's response to, the COVID-19 pandemic in four South Asian countries -Ban-gladesh, India, Pakistan and Sri Lanka- between February 2020 and May 2021. We look at the daily reported COVID-19 cases and deaths per million population. The data shows clear patterns of two or more waves of the pandemic in South Asia. We consider COVID-19 testing, vaccination coverage, non-pharmaceutical interventions and the COVID-19 economic stimulus. Sri Lanka performs the best, Bangladesh has low reported cases and deaths, but that is perhaps because of low testing;Pakistan has the lowest vaccination coverage;India has been hit worst by the second wave and is doing mediocre in terms of testing and vaccination. In terms of the impact of the pandemic on lives lost, Sri Lanka is the best and India the worst performer.

Optimum e-Healthcare Resource Provisioning using Network Slicing Approach for Future 5G Networks

The modernization of advanced healthcare infrastructure in the early 21st century is still failing to cope up as the whole world is struggling to get rid of the deadly disease named COVID-19. The scarcity of clinical resources is one of the most fundamental as well as critical reasons behind this calamity. The entire healthcare system faces severe challenges to re-stabilize the system. Digitization of technology which is primarily driven by the next-generation communication networks has given an exclusive paradigm shift to resolving the issues. 5th generation of mobile communication-(5G) introduces classical techniques which play crucial roles in e-healthcare transformations. Software-Defined Networking(SDN), Network Function Virtualization (NFV), Network Slicing (NS), and the concept of programmable networks introduce URLLC communication and time-critical service delivery in a resource-restricted environment. Leveraging the concept of programmable slicing approach, in this work, we have framed a flexible e-healthcare slicing model for dedicated and optimized resource provisioning. We have introduced a vSDN server that can significantly balance the healthcare slice and classify the complex medical databases into simplified segments for quick data processing, management, and orchestration. Considering the reformation of global healthcare customization, our proposed approach will play a vital role in the field of the e-healthcare domain.

Proposal from the World Association of Social Psychiatry (WASP)

Covid-19 pandemic has been an unprecedented crisis seen by the humanity in the last two years with a magnitude no less than the two world wars. Globally, more than 260 million cases have been reported and more than 5 million deaths have been attributed to Covid-19 till the end of November 2021. Despite introduction of the vaccine nearly a year ago, though there has been a big hope of controlling the pandemic, there have been repeated rises in infections due to the mutations in virus, like the coming of Delta, Delta plus and Omicron variants, which are increasingly infectious. There have already been two waves of the pandemic with the second wave being very lethal in India. The pandemic had both direct as well as indirect effects on mental health of the population across allover the world. Many countries had to resort to lockdowns to control the spread of infection, which had serious economic consequences, adding to the mental and social distress. Other infection control measures like quarantine and social isolation, and inability of the persons with existing mental illnesses to access treatment further added to the problem. Introduction of vaccine brought some hope, but it has been a great challenge to cover such a huge population with vaccine alongwith dealing with vaccine hesitancy. This symposium being proposed by the World Association of Social Psychiatry. The symposium will assess the current situation with focus on psychosocial aspects, social psychiatry approach used to deal with the mental health issues, challenges ahead and the lessons learnt to deal with any future challenges of similar nature.

How did the COVID-19 lockdown impact patients with dual diagnoses?

Purpose: Individuals with dual diagnoses might experience significant clinical and social vulnerabilities during the pandemic and lockdown. This study aims to compare medication adherence, substance use, clinical stability and overall functioning before and during lockdown periods. Design/methodology/approach: This was a cross-sectional survey among patients registered in dual diagnosis clinic of an addiction psychiatry center in Northern India between March 2019 and February 2020. This study approached 250 patients for telephonic interviews. This study assessed adherence to medications with the brief adherence rating scale (BARS). Global functioning was measured by global assessment of functioning. Clinical interviews assessed substance use and the clinical status of psychiatric disorders. Findings: One hundred fifty patients were recruited. The mean age of the sample was 35.8 years. The sample had a slight preponderance of alcohol dependence. Depressive disorder was the largest category of psychiatric diagnosis. Compared to prelockdown period, during the lockdown, there were an increased number of days of nonadherence (X2 17.61, p < 0.05), proportion of patients underdosing (X2 8.96, p = 0.003) and lower BARS scores (t = 10.52, df = 144, p < 0.0001). More patients were abstinent from substances during the lockdown (X2 49.02, p < 0.0001). Clinical stability of psychiatric disorders did not differ during the two-time points, but overall functioning decreased during the lockdown (t = 2.118, p = 0.036). This study observed a small positive correlation (r = 0.2, p = 0.02) between functioning and adherence levels. Originality/value: Lockdown was associated with poor medication adherence, change in substance use patterns and functional impairment. In the future, treatment programs and policies must take preemptive steps to minimize the effects of restrictions. © 2022, Emerald Publishing Limited.

Telemedicine Mediated Service Delivery for Substance Use Disorders

Telemedicine in addiction service delivery- Dr. D Basu For around last two decades, telepsychiatry has been practiced in India to reach the unreached population with variable degree of success. COVID-19 pandemic limited healthcare access due to travel and face to face consultation restrictions. It warranted an urgent and widespread expansion of telepsychiatry practice, and application of the same in management of patients using substance. In spite of the advantage of increased access, there are some inherent limitations in the form of inability to perform detailed physical examination and restriction of medication prescriptions. Dr. Basu will discuss the opportunities and challenges in telemedicine-based service delivery for substance use disorders. Telemedicine and Opioid substitution treatment (OST)- Dr. A. Ghosh Opioid substitution treatment (OST) was significantly affected during pandemic, as there was a strict requirement of face-to-face consultation. Only United States shifted the buprenorphine-naloxone assisted OST induction through teleconsultation. Many other countries including India has allowed preliminary assessment for OST through teleconsultation, but induction and dispensing were essentially through in person consultation. The dispensing of OST has been mechanized in some other countries. Dr. Ghosh will review the adaptations and challenges in OST delivery during the pandemic. Telemedicine mediated service delivery in the Drug Deaddiction & Treatment Centre (DDTC), PGIMER, Chandigarh- Dr. T. Mahintamani In DDTC, PGIMER, a synchronous, stepwise (telephonic, video, and in-person consultation) direct-care model has been adopted for provision of teleconsultation. A psychiatrist with post-graduate qualification performs initial assessment through telephonic or video-consultation. The prescriptions are sent through WhatsApp platform. If there is a felt need for in-person care, the patient is called in the OPD. Whenever required the feedback of consultant is sought after. Patients were found to experience stronger therapeutic relationship and physician empathy with in person consultation. Difficulty in telephonic registration, privacy and connectivity issues were commonly faced by the service users. Dr. Mahintamani will discuss the experience from DDTC, PGI, Chandigarh.

Laboratory parameters associated with prolonged hospital length of stay in COVID-19 patients in Johannesburg, South Africa

Background. Coronavirus disease (COVID-19) has imposed unprecedented stressors on South Africa (SA)'s healthcare system. Superimposed on the country's quadruple burden of disease, pandemic-related care further exposes existing inequities. Some of these inequities are specific to hospital-based inpatient services, such as the geographical maldistribution of hospital beds, lack of oxygen supplies and assisted ventilation, and scarcity of trained healthcare workers. Certain high-risk groups, such as individuals with cardiometabolic comorbidity, are likely to develop severe COVID-19 disease requiring hospitalisation with potential for a prolonged length of stay (LoS). It may be helpful for health authorities to identify those at risk for prolonged LoS to facilitate appropriate health systems planning. Objectives. To identify hospital admission laboratory parameters associated with a hospital stay >14 days in patients with COVID-19 pneumonia. Methods. A retrospective observational study design was used. Laboratory data were obtained from an SA private laboratory for 642 inpatients with suspected or confirmed COVID-19 pneumonia, comprising 7 months of admission laboratory data from six private hospitals in Johannesburg, Gauteng Province. Results. Of 642 hospital admissions for pneumonia, 497 were confirmed to have COVID-19 infection (reverse transcription-polymerase chain reaction test positive). In the COVID-19-positive group, hospital LoS was prolonged in 35.4% of admissions. Univariate analysis demonstrated an association with the following risk factors for prolonged LoS: older age;male sex;high serum creatinine, sodium (Na), chloride, potassium and urea levels and low estimated glomerular filtration rate;raised white blood cell count, lymphopenia, neutrophilia and an elevated neutrophil-to-lymphocyte ratio (NLR);and elevated levels of D-dimers, interleukin-6 (IL-6), and procalcitonin (PCT). The strongest univariate associations (relative risk (RR) ≥2.0) with a hospital stay >14 days were high Na levels, NRL >18, high PCT levels and IL-6 >40 pg/mL. On multivariable analysis, the following factors remained significantly associated with prolonged LoS: older age (RR 1.015 per year of age;95% confidence interval (CI) 1.005 - 1.024);hypernatraemia (RR 1.80;95% CI 1.25 - 2.60);hyperkalaemia (RR 1.61;95% CI 1.18 - 2.20);and neutrophilia (RR 1.47;95% CI 1.15 - 1.88). Conclusions. COVID-19 pandemic preparedness requires hospital-based inpatient care to be prioritised in resource-limited settings, and availability of beds and prompt admissions are essential to ensure good clinical outcomes. In this study of COVID-19 patients admitted with pneumonia, multivariable analysis showed older age, hypernatraemia, hyperkalaemia and neutrophilia to be associated with LoS >14 days. This may assist with healthcare systems planning. © 2022 South African Medical Association. All rights reserved.

SoftHealth: Softwarized 5G-Driven Network Slicing for Real-time e-Healthcare Applications using ML

The recent years have whiteness the substandard situations of the modern healthcare system due to a fatal pandemic called COVID19. The rapid advancements of modern technology have disseminated the superficial benefits of medical infrastructure, but significant improvements are still extremely necessary over the massive e-healthcare system (mHS). Considering the fact of limited resources and unlimited demands, a highly stable end-to-end optimization model is required. Healthcare also struggles with real-time communication. The next-generation communication networks (e.g 5G and beyond) proficiently influence the network resource distribution for URLLC. In this work, we have envisioned a novel on-demand e-Healthcare dynamic network slice architecture that uses the ML algorithms at the edge server for real-time classification and access of the offloaded data from the central controller (vSDN-Control layer to Data plane layer). The comparative analysis over the datasets of patients consisting of special index parameters shows that our proposed model allows the end-user more efficient data accessibility over the conventional approaches. We have studied the model over the multi-classification ML models (kNN, DT and RF) and we have found an average improvement of 10% to 15% of average data offloading time efficiency from the local machines from the edge servers. This approach can be further extended as the QoS improvement of the healthcare data traffic over the dynamic network slice instances. We have kept the model simple but standard in nature. © 2022 IEEE.

A Grounded Theory Analysis of COVID-19 Information and Resources Relayed Through University Webpages: Implications for a More Inclusive Community

This qualitative study investigates web pages documenting COVID-19 responses from 28 universities across the United States. Using grounded theory methodology, we inductively developed a model of universities' response to the pandemic. Four types of strategies were identified from the data and a theoretical model was developed describing (a) causal conditions that underlie the strategies for response to the pandemic, (b) the context that influenced the strategies adopted by the universities, (c) intervening conditions due to the pandemic that influenced strategy development, and (d) potential recommendations to make universities' responses more inclusive. This research has implications for improving the experience of the communities a university serves, including faculty development, especially for newer faculty who are joining the universities remotely and interacting with new colleagues only through the virtual mediums. Finally, this paper will be of use to engineering educators and administrators as they seek to improve inclusion and belonging within faculty at universities. © American Society for Engineering Education, 2021

Decreased severity of disease during the first global omicron variant covid-19 outbreak in a large hospital in tshwane, south africa.

INTRODUCTION: The coronavirus disease 2019 (COVID-19) first reported in Wuhan, China in December 2019 is a global pandemic that is threatening the health and wellbeing of people worldwide. To date there have been more than 274 million reported cases and 5.3 million deaths. The Omicron variant first documented in the City of Tshwane, Gauteng Province, South Africa on 9 November 2021 led to exponential increases in cases and a sharp rise in hospital admissions. The clinical profile of patients admitted at a large hospital in Tshwane is compared with previous waves. METHODS: 466 hospital COVID-19 admissions since 14 November 2021 were compared to 3962 admissions since 4 May 2020, prior to the Omicron outbreak. Ninety-eight patient records at peak bed occupancy during the outbreak were reviewed for primary indication for admission, clinical severity, oxygen supplementation level, vaccination and prior COVID-19 infection. Provincial and city-wide daily cases and reported deaths, hospital admissions and excess deaths data were sourced from the National Institute for Communicable Diseases, the National Department of Health and the South African Medical Research Council. RESULTS: For the Omicron and previous waves, deaths and ICU admissions were 4.5% vs 21.3% (p<0.00001), and 1% vs 4.3% (p<0.00001) respectively; length of stay was 4.0 days vs 8.8 days; and mean age was 39 years vs 49,8 years. Admissions in the Omicron wave peaked and declined rapidly with peak bed occupancy at 51% of the highest previous peak during the Delta wave. Sixty two (63%) patients in COVID-19 wards had incidental COVID-19 following a positive SARS-CoV-2 PCR test . Only one third (36) had COVID-19 pneumonia, of which 72% had mild to moderate disease. The remaining 28% required high care or ICU admission. Fewer than half (45%) of patients in COVID-19 wards required oxygen supplementation compared to 99.5% in the first wave. The death rate in the face of an exponential increase in cases during the Omicron wave at the city and provincial levels shows a decoupling of cases and deaths compared to previous waves, corroborating the clinical findings of decreased severity of disease seen in patients admitted to the Steve Biko Academic Hospital. CONCLUSION: There was decreased severity of COVID-19 disease in the Omicron-driven fourth wave in the City of Tshwane, its first global epicentre.

COVID-19 in SOUTH ASIA: HEALTH, ECONOMICS and POLITICS

This paper tracks the progression of, and the government’s response to, the COVID-19 pandemic in four South Asian countries —Bangladesh, India, Pakistan and Sri Lanka— between February 2020 and May 2021. We look at the daily reported COVID-19 cases and deaths per million population. The data shows clear patterns of two or more waves of the pandemic in South Asia. We consider COVID-19 testing, vaccination coverage, non-pharmaceutical interventions and the COVID-19 economic stimulus. Sri Lanka performs the best, Bangladesh has low reported cases and deaths, but that is perhaps because of low testing;Pakistan has the lowest vaccination coverage;India has been hit worst by the second wave and is doing mediocre in terms of testing and vaccination. In terms of the impact of the pandemic on lives lost, Sri Lanka is the best and India the worst performer. 2022 Universidad Nacional Autónoma de México, Facultad de Economía.

Hematological parameters in covid-19 illness: Emphasis on platelet indices as a marker of severity of disease

Aims&Objectives: To study the hematological parameters and platele tindices and correlate with the severity of disease in COVID-19 positive patients. Patients/Materials & Methods: A record based study conducted in a tertiary care centre included 125 COVID-19 positive patients diagnosed by either RT-PCR orrapidantigentest. The clinical data was retrieved from the case records and the cases were categorized as mild, moderate, severe and critical based on the consensus guidelines. Hematological parameters studied were hemoglobin, RBC indices, total leucocyte count, neutrophil lymphocyte ratio (NLR), platelet count, platelet indices (plateletcrit, platelet distribution width, mean platelet volume and platelet large cell ratio) and D-dimer. Each of the parameters were correlated with these verity of the disease and statistical analysis was done using IBMSPSS software. Results: The mean age was 53.3 years (range: 3-96 years) with male preponderance observed in 62.3% of cases. of the 125 cases, 57 patients were categorized as mild disease, 42 moderate, 16 severe and 10 with critical illness. Cases with severe and critical COVID-19 illness were associated with eosinopenia and neutrophillymphocyte ratio more than 3.3 (p value of both<0.05). Platelet count was normal in 69% cases. of the 39 patients with thrombocytopenia, as many as 59% had mild reduction (1.0-1.5 lakh/cumm). Among the various platelet parameters plateletcrit (PCT) was significantly lower in mild COVID illness in comparision with moderate to critical disease (p<0.05) while mean platelet volume and platelet distribution width was higher in severe and critical COVID illness (p value<0.05). PLCR did not show any statistical significance. Elevation of d-dimerlevels positively correlated with the severity of the disease. Patients with mild COVID-19 illness had mean D-dimer level of 0.86 Âμg/dl while patients with critical illness had 4.01 Âμg/ dl. Discussion & Conclusion: In addition to the known hematologic paratmeters implicated in COVID-19 illness such as NLR, eosinopenia and D-dimer, platelet parameters (MPV, PDW and PCT) can also be used as biomarkers that indicate the severity of the disease.

The effect of lockdown regulations on SARS-CoV-2 infectivity in Gauteng Province, South Africa.

BACKGROUND: On 26 March 2020, the South African (SA) government initiated a 21-day national level 5 lockdown which was subsequently eased off and downgraded to level 4 on 1 May and to level 3 on 1 June. The effect of lockdown measures on SARS-CoV-2 infectivity is currently uncertain. In this article, we analyse the effects of the lockdown measures on the SARS-CoV-2 epidemic in one of the epicentres in SA. OBJECTIVES: To measure the effects of lockdown measures introduced in SA on SARS-CoV-2 attack rates (ARs, the percentage of individuals who tested positive in a specified time period) in Gauteng Province during a 4-month period (March - June 2020). METHODS: In this retrospective cohort study, we used a comprehensive database from an independent pathology laboratory in Gauteng. We analysed trends of positivity rates of reverse transcription polymerase chain reaction tests done during the 4-month period. The ARs are reported over time (unweighted and age-weighted 14-day moving averages) by age groups, gender, and different regions/districts in Gauteng. RESULTS: A total of 162 528 tests were performed at a private laboratory between 5 March and 30 June 2020, of which 20 574 were positive (overall AR 12.7%). These positive tests constituted 44.8% of all positive cases in the province (20 574/45 944). Sixty-two percent of all tests were done in June during lockdown level 3. There was an exponential increase in the AR in June (18.3%) when lockdown was eased to level 3, in comparison with 4.2% (March), 2.2% (April) and 3.3% (May). The increase in June was seen in all the age groups, although it was more pronounced in the 21 - 60 years age groups than the younger (0 - 20 years) and older (>60 years) age groups. The AR was significantly higher in males (13.2%) compared with females (12.1%) (χ2 test, p<0.0001). CONCLUSIONS: The findings of this study testify to the rapid increase in ARs resulting from easing of the lockdown regulations, especially to level 3 in June. Of concern is the upward trend in the AR across all age groups, especially <20 years (15.9%), which was not reported in other parts of the world. Population age dynamics should therefore be considered when taking future decisions about lockdown regulations.

Evaluation of Course Strategies: Face-to-Face vs. Online

Asynchronous, online courses are being designed from face-to-face (F2F) versions to provide the flexibility to scale-up enrollment [3]. To support student success in large-enrollment online classes, it is important to design online courses with strategies that enhance student engagement, which impacts achievement due to the changes in the learning environment[1]. F2F course strategies that are known to engage students may not work for online formats, and engaging online students can be difficult as students often feel isolated and detached [2]. There are a limited number of studies that report on or compare course strategies for online students. Strategies that support student success in online course offerings are valuable for student engagement, especially for upper-level programming intensive courses in computer science (CS)[4]. We present an approach to redesigning the F2F version of a Web-based Application Design and Development course and developing its online offering. We incorporated 17 course strategies in both the F2F and online formats including, course structure/sequence, course book, online class discussion, study group discussion, and weekly activity. We conducted an IRB approved study to examine: How valuable do students find the course strategies to be for their engagement (dependent variable) in F2F and online formats (independent variables) of an upper-level on-campus undergraduate CS course? We utilized an experimental research design to conduct this study in a doctoral university with high research activity located in the south-eastern US during its Aug-Dec 2019 semester. There were 103 online students and 72 F2F students who were taught by the same instructor. To answer the above research question, we asked students in an end-of-semester survey to evaluate each of the 17 course strategies in terms of their engagement with the course and/or course topics using a 5-point Likert scale that ranged from "not valuable"to "very valuable". The mean and standard deviation (SD) value of five example course strategies are shown in Table ~\reftab:course-strategies for the students who completed the survey and consented to participate in the study. Independent t-tests were conducted to compare how the course strategies supported engagement in the F2F and online formats, and we found significant differences between course formats for some of the course strategies despite having no significant difference in terms of student learning. We found empirical evidence that students' perceived some course strategies, including course structure/sequence to be more valuable in the online format, while study group discussion to be more useful in the F2F format. Also, some strategies including weekly activity were useful in both the formats. Our results show how course strategies supporting student engagement can inform online, F2F, and hybrid courses design in CS, especially as the COVID-19 pandemic will continue to require online or hybrid instruction. Future work will consider analysis on student learning and engagement. Additionally, we will examine course strategies to create a stronger community in the online space, and to improve online engagement. © 2020 Owner/Author.