Pandemic Poverty Governance: Neoliberalism under Crisis

Prevailing theories of poverty governance emphasize how political and economic constraints associated with urban neoliberalism have led to the retraction of protective welfare commitments and an increased criminalization of poverty. While research on this "disciplinary turn" has been generative, it tells us little about countervailing trends or how institutional responses to poverty change over time. Addressing these gaps, this article offers a case study of the emergence and acceptance by the business community of a supportive Housing First and harm reduction initiative called JustCARE-a distinct technique of poverty governance not readily explicable within existing theoretical frameworks. By situating JustCARE within a wider strategic action field of poverty governance, we reveal the macro-, meso-, and micro-level dynamics that together facilitated its inception, growth, and eventual embrace by members of the formerly hostile business establishment. Specifically, we underscore how two exogenous shocks (COVID-19 and the Black Lives Matter [BLM] uprisings) enabled a well-positioned advocacy organization to articulate and implement a non-punitive homelessness response alternative. We conclude that field-based scholarship centering "theoretically deviant" cases can reveal how the contradictions and failures of neoliberal poverty management can generate unique opportunities for meaningful institutional change.

The impact of COVID-19 on the performance of the Rapid Access Lung Clinic: The Cork/Kerry experience

Background: The COVID-19 pandemic has contributed to lower hospital admissions and higher mortalities associated with chronic conditions such as cancer and cardiovascular diseases. The Rapid Access Lung Clinic (RALC), established in 2009 for immediate assessment of individuals at risk of lung cancer, has experienced reduced functioning particularly during the pandemic peaks in Ireland. Therefore, we undertook a retrospective chart review of the 2019-2021 referrals and attendances at the Cork University Hospital (CUH) RALC to determine the impact of COVID-19 on this pathway. Methods: The medical charts of patients referred to CUH RALC from 03/2019 to 02/2020 (period I), and from 03/ 2020 to 02/2021 (period II), were reviewed after ethical approval was obtained. Clinicodemographic characteristics including age, sex, and hometown were extracted. Average time to acquire the first CT scan, consultation at RALC, and receiving a diagnosis of cancer were calculated using the date of referral and compared between periods I and II using the t-test. Frequency and the stages of cancer diagnosis in periods I and II were compared using a Chi-squared test. Progression-free and overall survivals were measured from diagnosis date until 09/2020 for period I and 09/2021 for period II. Results: Of the 1192 medical charts reviewed;687 patients in period I and 505 patients in period II were referred to RALC;indicating a 26.5% reduction in the number of referrals during the first year of the pandemic. Average monthly referrals (p = 0.008) and reviews (p = 0.017) were significantly lower in period II compared to period I and corresponded with the COVID-19 peaks in 04/2020 and 01/2021 in Ireland. However, no significant difference was seen in the length of time from referral to review at RALC (p = 0.11). There were 33% fewer post-referral CT scans performed (p = 0.032) and shorter wait times from referral to CT scan in period II (p = 0.001). The frequency of cancers detected did not differ between periods I and II. While there was no difference in the wait times from referral to diagnosis between periods, patients ultimately diagnosed with lung cancer in period II received surgery sooner than patients in period I (p = 0.024). Progression-free and overall survivals for patients diagnosed with lung cancer were comparable between periods I and II. Conclusions: Contrary to our hypothesis, we have shown that the COVID-19 pandemic had minimal impact on the performance of RALC. Shorter wait times for CT scan and surgery during the pandemic account for fewer hospital referrals and availability of CT scanner. Fewer referrals to RALC in period II may relate to the fewer patients attending their general practitioner (GP) and/or GPs raising the thresholds for referrals to RALC during the pandemic. Ultimately, a national evaluation will be required to fully determine the impact of this pandemic on lung cancer diagnosis, management, and outcomes in Ireland.

Optimising outpatient care after paediatric burns: The development of a chatbot to identify complications and provide clinical advice

Aim: More than 6000 children require specialist care from one of fourteen regional burns services in England and Wales each year. Families often have to travel long distances and may not have access to specialist care with restricted services due to Covid-19. This quality improvement project aimed to: 1) Determine national practice in paediatric burn follow up 2) Investigate whether chatbots have been used in outpatient settings 3) Develop a novel application (a chatbot) that patients and parents can interact with for advice and reassurance following paediatric burns. Method: We conducted a national service evaluation of children's burns services in England and Wales. We then conducted a PRISMA compliant systematic review up to September 2020 to identify studies reporting chatbot use to deliver outpatient care. A chatbot was then developed using Dialogflow to identify complications and provide advice to families. Results: Across England and Wales, 11 children's burns services reported outpatient practice: six services follow up all children at three months, three have variable follow-up and two discharge all patients. Our systematic review identified 10 studies reporting chatbot use although none were used following burns. A frame-based system-focused chatbot was developed in conjunction with expert burns surgeons and patient representatives. Conclusions: Chatbots are effective and acceptable alternatives for inperson follow up. We demonstrate national variation in the provision of outpatient paediatric burn care and have developed a chatbot that can address clinical concerns and provide reassurance to patients and family members. Future studies will determine the acceptability and safety of this chatbot.

Post COVID-19 reactive arthritis

Case report-IntroductionWe present what we believe to be the first reported case of post COVID-19 reactive arthritis, in a previously medically well 16-year-old with no past or family history of inflammatory arthritis.Case report-Case descriptionOur patient was a previously medically fit 16-year-old of Caucasian origin who tested positive for COVID-19 in late March 2020. She developed with a 4-day illness with fever, cough, and myalgia from which she made a full and uncomplicated recovery.Ten days later she developed a new erythematous itchy rash on her legs, trunk, and face and a progressive polyarthralgia affecting her MCPs, wrists, shoulders, hips, and knees. The rash typically lasted for 2 days at one site and was non-scarring. This was associated with a low-grade fever. There were no associated mouth ulcers, photosensitivity, alopecia, Raynaud's, GI disturbance or respiratory symptoms. She had no relevant family history of autoimmunity, psoriasis or inflammatory bowel disease or travel history and had been prescribed no new medications.On examination, she had an erythematous rash on the face in a non malar distribution. She had multiple tender joints without definite synovitis. Cardiovascular, respiratory, gastroenterology and neurological examinations were unremarkable.Investigations revealed a normal full blood count and CRP<1 with normal liver and renal function tests. Her urinalysis was unremarkable. Immunology was negative for ANA, ANCA and rheumatoid factor. Immunoglobulins were normal. Two weeks later her symptoms were fully resolved.Case report-DiscussionCoronaviruses are single-stranded RNA viruses with nearly 30 strains recognised to infect humans. They induce both an innate and adaptive immune system response. It is hypothesised that a dysregulated innate system response, leading to a prolonged adaptive response triggers damaging inflammation and a potential cytokine storm. This is associated with poor outcome during primary viral infection. Variations in this immune response, with different underlying HLA genotypes could lead to other post infectious immune mediated phenomena, such as Paediatric Multisystem Inflammatory Syndrome-Temporally associated with COVID-19.There is a European registry collating data about patients with known rheumatic diseases who are admitted with COVID-19. There is emerging data regarding Paediatric Inflammatory Multisystem Syndrome-Temporally associated with SARS-CoV-2 (PIMS-TS). There is a growing suggestion that a subgroup of patients is developing a COVID-19 associated post viral fatigue syndrome. We suggest that a registry to collect information on de novo autoimmune diseases presenting post COVID-19 is also commenced.Case report-Key learning pointsCOVID-19 infection is associated with a wide variety of sequalae, including rheumatological ones.Classic post viral Reactive arthritis has been seen. A registry to collect information on de novo autoimmune presentations would be highly informative.

How COVID-19 influenced UK Burns Services: A national multicentred audit

Introduction: COVID-19 has affected national guidelines and availability of resources, resulting in different approaches to treating burns. This project aimed to identify changes to burns management in the UK during the 'first wave' of COVID-19, and how the lessons learned can be applied to the current 'second wave'. Methods: Between 11th July-15th September, 18 burns services across the UK completed a MDT survey and contributed data on service evaluation. The MDT survey captured perspectives of multiple stakeholders and included changes to burns services, disruptions to supply chain, and service improvements resulting from COVID-19. Service evaluation data was collected retrospectively and prospectively on patients who received inpatient/outpatient treatment during COVID-19. Patients in the retrospective cohort were first seen by burns services between 6th-30th April (coinciding with the UK's COVID-19 peak), and the prospective cohort were first seen between 30th April-15th September. Each cohort consisted of 10-20 patients per burns service. Service evaluation covered key areas of burns aetiology, referral pathway changes, patient presentation delays to tertiary services, patient management decisions, and outpatient dressing clinic management. Data from the MDT survey and the service evaluation were analysed by descriptive statistics and thematic analysis. Results: The changes to burns services include delays in burn referrals, increase in conservative management, and increased use of telemedicine. Conclusion: Across the UK, safe and effective burns care continued to be delivered despite difficulties from the pandemic. We hope the learning points identified in this study will be of use during the 'second wave' of the pandemic.

Lessons from a pandemic: An audit of acute medical oncology admissions during SARS-CoV-2 outbreak

Background: In December 2019 a cluster of pneumonias, later identified as SARS-CoV-2 (CoV), were reported in China. The first case in Ireland was reported February 29th 2020. The first community acquired case in Ireland was reported March 5th. The World Health Organisation declared CoV a pandemic March 11th. Lockdown measures were implemented in Ireland March 27th. Cork University Hospital is a large acute hospital and a tertiary referral center for cancer care. We undertook an audit of unscheduled medical oncology admissions over a 3 month period with a view to assess the impact of CoV on the centre. Method(s): From 1st February to 30th April we audited unscheduled medical oncology admissions. Parameters included presenting time, location and complaint, CoV status and average length of hospital stay (aLOS). Data was organised into 3 phases: four week period prior to a confirmed case of CoV in Ireland (phase I), four week period from confirmed case to lockdown implementation (phase 2) and four week period during lockdown (phase 3). After the outbreak of CoV we developed a separate medical oncology assessment facility (AOS) with an admission pathway. A hospital CoV pathway (CoVp) for potential CoV cases was also implemented. Result(s): A total of 162 medical oncology patients had unscheduled admissions during this period. Over half (57%) were receiving anticancer systemic treatment. The most common presenting complaints were pain (21%), pyrexia (17%) and dyspnoea (14%). The underlying diagnosis was cancer-related in 51%, treatment-related toxicity in 10% and non-cancer related in 39%. One patient was CoV positive. Unscheduled hospital admissions, source of admission and aLOS are outlined in the Table. [Formula presented]. Conclusion(s): A reduction in aLOS and ED admissions was paralleled by increasing use of alternative pathways. Processes which facilitate urgent assessment of oncology patients in specialized units avoid ED attendance and accelerate discharge planning in the care of cancer patients in the face of a pandemic and beyond. Legal entity responsible for the study: The authors. Funding(s): Has not received any funding. Disclosure: All authors have declared no conflicts of interest.Copyright © 2020

A Soft Landing for Developing Countries and Non-Discrimination in Digital Trade: Possible Lessons from Asian Countries

The article suggests the implementation of certain legal devices to enable developing countries to achieve policy flexibility to take advantage of the opportunities presented by the expansion of digital trade while balancing some of the risks which this may present to consumers in the sphere of privacy as well as threats to governments in the form of national security. These include a 'renegotiation clause' as well as the familiar classification of 'special and differential treatment' for developing or least-developed countries.

Acute stroke presentations during the course of the COVID-19 pandemic

Background: Decline in presentations of acute stroke during the early period of COVID-19 pandemic have been reported. We aimed to investigate the stroke presentations during the subsequent months as the pandemic evolved into a second wave. Methods: Data was obtained from a health system with 19 emergency departments (EDs) in northeast Ohio in the United States. Baseline period from January 1 to February 29, 2020, was compared with the individual months during COVID-19 period from March through July. Variables included were numbers of daily stroke alerts across the EDs, thrombolysis, thrombectomy, time to presentation, stroke severity, time from door-to-needle in thrombolysis, and door-to puncture in thrombectomy. The time periods were compared using nonparametric statistics and Poisson regression with month, weekend, and daily COVID cases as independent variables. Results: A total of 2264 stroke alerts from EDs were analyzed between January 1 to July 31, 2020. Total daily stroke alerts decreased from a median of 10 (interquartile range [IQR]:10-13) in January and February to 9 (IQR:6-11, p=0.001) in March, 8(IQR:7-10, p=0.0001) in April, 10 (IQR:8-11, p=0.04) in May, and returned similar to baseline in June (12, IQR:10-13, p=0.5) and July (13, IQR:11-14,p=0.1). In Poisson regression, stroke alert numbers showed no significant association with daily COVID-19 counts, but significant association with months, with rate ratios of 0.74 (95%CI 0.64-0.85) for March, 0.71 (95%CI 0.61-0.82) for April, and 0.86 (95%CI 0.75-0.98) for May, but not with June and July. Time to presentation and stroke severity were unchanged throughout the study period. Thrombolysis volume decreased in March and May but thrombectomy volume was unchanged. Conclusion: We observed a decrease in stroke presentations across emergency departments by about 30% during the early period of COVID-19 pandemic, followed by return to baseline frequency despite a second wave of COVID-19 cases.

COVID-19 pandemic: Impact on doctors in training

Background: The COVID 19 pandemic is a healthcare crisis leading to unprecedented impact upon healthcare services, notable morbidity and mortality of the public and healthcare professionals, significant psychological effects, and economic repercussions. Junior doctors and those in training are at the forefront of medical care for these patients. We present survey results outlining the concerns of doctors in training. Methods: A questionnaire was developed and delivered via Survey Monkey relevant to doctors in training during the COVID-19 pandemic. The Perceived Stress Scale was incorporated to gauge participant stress in the weeks leading up to the expected surge of COVID-19 patients. Ethical approval was obtained. Results: A total of 285 participants engaged with the survey but 197 (69%) completed all answers. Almost 86% of respondents had been trained in donning and doffing personal protective equipment (PPE) and nearly 85% felt significantly confident in the process. Overall, most respondents felt somewhat prepared (60%) or well prepared (20%) to treat COVID-19 patients. However, 42% of respondents worried that their hospital would struggle, or could not cope at all, with COVID-19 patients. Nearly 91% of respondents were concerned that their hospital might run out of PPE. When asked to report their concerns, family health (86%), personal health (72%) and social life (47%) topped the list. According to the Perceived Stress Scale, the majority of respondents (62%) had moderate stress. Conclusions: This survey is the first known effort to gauge the concerns of doctors in training in Ireland with regard to the COVID-19 pandemic. Our results show that most junior doctors were trained and relatively confident in donning and doffing PPE and managing COVID-19 patients. However, significant percentage of doctors in training worried that their hospital might run out of PPE and would struggle with COVID-19 patients. They reported concerns regarding their personal and family health as well as impact on social life. A significant finding was that a majority of junior doctors had moderate stress at baseline. A follow-up survey to gauge the stress of doctors in training after the surge of COVID-19 patients is planned. Legal entity responsible for the study: The authors. Funding: Has not received any funding. Disclosure: D. Collins: Honoraria (self): Pfizer;Honoraria (self), Travel/Accommodation/Expenses: Genmab;Honoraria (self), Travel/Accommodation/Expenses: Astra Zeneca;Honoraria (self): Eli Lilly;Honoraria (self), Travel/Accommodation/Expenses: Roche;Advisory/Consultancy, Travel/Accommodation/Expenses: MSD;Advisory/Consultancy: Seattle Genetics. All other authors have declared no conflicts of interest.

Airborne transmission of severe acute respiratory syndrome coronavirus-2 to healthcare workers: a narrative review.

Healthcare workers are at risk of infection during the severe acute respiratory syndrome coronavirus-2 pandemic. International guidance suggests direct droplet transmission is likely and airborne transmission occurs only with aerosol-generating procedures. Recommendations determining infection control measures to ensure healthcare worker safety follow these presumptions. Three mechanisms have been described for the production of smaller sized respiratory particles ('aerosols') that, if inhaled, can deposit in the distal airways. These include: laryngeal activity such as talking and coughing; high velocity gas flow; and cyclical opening and closure of terminal airways. Sneezing and coughing are effective aerosol generators, but all forms of expiration produce particles across a range of sizes. The 5-µm diameter threshold used to differentiate droplet from airborne is an over-simplification of multiple complex, poorly understood biological and physical variables. The evidence defining aerosol-generating procedures comes largely from low-quality case and cohort studies where the exact mode of transmission is unknown as aerosol production was never quantified. We propose that transmission is associated with time in proximity to severe acute respiratory syndrome coronavirus-1 patients with respiratory symptoms, rather than the procedures per se. There is no proven relation between any aerosol-generating procedure with airborne viral content with the exception of bronchoscopy and suctioning. The mechanism for severe acute respiratory syndrome coronavirus-2 transmission is unknown but the evidence suggestive of airborne spread is growing. We speculate that infected patients who cough, have high work of breathing, increased closing capacity and altered respiratory tract lining fluid will be significant producers of pathogenic aerosols. We suggest several aerosol-generating procedures may in fact result in less pathogen aerosolisation than a dyspnoeic and coughing patient. Healthcare workers should appraise the current evidence regarding transmission and apply this to the local infection prevalence. Measures to mitigate airborne transmission should be employed at times of risk. However, the mechanisms and risk factors for transmission are largely unconfirmed. Whilst awaiting robust evidence, a precautionary approach should be considered to assure healthcare worker safety.