A descriptive study of older medical cannabis users in medical cannabis clinics

Introduction: There is a dearth of information on older users (65+ years) of medical cannabis, who may face unique challenges due to altered metabolism with aging, concurrent medication use, and risk of adverse effects. This observational study aimed to describe a large cohort of older medical cannabis users in Canada. Method(s): From Oct 2014 to Oct 2020, a commercial medical cannabis provider based in Canada collected anonymized data for research purposes from patient volunteers. Data included demographic, social, and health details (at intake) and cannabis products, self-perceived changes in symptoms and change in medications (at follow-up, variable duration). Cannabis products were categorized as cannabidiol (CBD) only, tetrahydocannabinol (THC) only or mixed CBD/THC. Of the mixed, formulations could be in 1:1 ratios (CBD+/THC+), predominantly CBD (CBD+/THC-) or predominantly THC (CBD-/THC+). Result(s): In total, 9766 subjects in the older cohort (65+ years old) completed the entire questionnaire (mean age (SD) = 73.6 (6.8) y, 60% female). They represented 23.1% of the total dataset (N = 42,267, mean (SD) =51.5 (16.8) y). The proportion of adults in the older cohort tended to increase over time (pre-2018: 17.6%;2018: 26.7%;2019: 31.2%;2020: 22.7%, when the overall intake decreased from 8869 to 5644). Among the older cohort, 15.5% were previous cannabis users and 67.7% were referred for chronic pain (mainly arthritis, chronic pain, lower back pain). Concomitant analgesic use was common (over-the-counter analgesics: 44.5%;opioids: 28.3%;NSAIDs: 24.5%). 7.9% of the sample (compared to 19.9% in the whole sample) were referred for psychiatric disorders, though 21.4% indicated antidepressant use and 12.3% indicated benzodiazepine use. Another 7% were referred for neurological disorders. Follow-up data were captured in visits (11,992) from 4698 older patients, averaging 2.5 visits per patient. The type of medical cannabis used changed over time, with increasing use of cannabis oil compared to herbal cannabis. In 2020, of 2478 visits, 78.9% use was cannabis oil and 6.7% was herbal forms (pre-2018: 57.6% vs 36.2%). The composition of cannabis oil demonstrated a preference for cannabinoid oil (CBD+) over tetrahydrocannabinol (THC+) in 6043 visits: 45.2% were using CBD+ preparations, only 3.2% were using THC+ preparations, and for CBD/THC combinations, CBD predominated (CBD+/THC-: 30.5%;CBD+/THC+: 16.8%;CBD-/THC+: 4.3%). Adverse-effects (7062 visits) included dry mouth (15.8%), drowsiness (8.6%), dizziness (4%) and hallucinations (0.6%). Patients reported improved pain, sleep and mood over time, though 15-20% reported no improvement or worsening. Medication use was mostly unchanged, though 40% of opioid users reported requiring reduced dosages. Conclusion(s): These data were drawn from a large convenience sample. The data suggest an increasing proportion of older users of medical cannabis, though COVID-19 may have affected recent use. Female users comprised a higher proportion, and cannabis oil containing CBD was preferred. Systematic studies of effectiveness and safety in older users of cannabinoids are needed given its increasing use. Funding(s): No funding was received for this work.Copyright © 2021

Erratum: Evaluation of intra- and inter-lab variability in quantifying SARS-CoV-2 in a state-wide wastewater monitoring network (Environmental Science: Water Research and Technology (2023) DOI: 10.1039/D2EW00737A)

The affiliation of author Zuzana Bohrer was incorrect in the original manuscript. It should appear as given here. The Royal Society of Chemistry apologises for these errors and any consequent inconvenience to authors and readers. © 2023 The Royal Society of Chemistry.

Evaluation of intra- and inter-lab variability in quantifying SARS-CoV-2 in a state-wide wastewater monitoring network

In December 2019, SARS-CoV-2, the virus that causes coronavirus disease 2019, was first reported and subsequently triggered a global pandemic. Wastewater monitoring, a strategy for quantifying viral gene concentrations from wastewater influents within a community, has served as an early warning and management tool for the spread of SARS-CoV-2 in a community. Ohio built a collaborative statewide wastewater monitoring network that is supported by eight labs (university, government, and commercial laboratories) with unique sample processing workflows. Consequently, we sought to characterize the variability in wastewater monitoring results for network labs. Across seven trials between October 2020 and November 2021, eight participating labs successfully quantified two SARS-CoV-2 RNA targets and human fecal indicator virus targets in wastewater sample aliquots with reproducible results, although recovery efficiencies of spiked surrogates ranged from 3 to 75%. When SARS-CoV-2 gene fragment concentrations were adjusted for recovery efficiency and flow, the proportion of variance between laboratories was minimized, serving as the best model to account for between-lab variance. Another adjustment factor (alone and in different combinations with the above factors) considered to account for sample and measurement variability includes fecal marker normalization. Genetic quantification variability can be attributed to many factors, including the methods, individual samples, and water quality parameters. In addition, statistically significant correlations were observed between SARS-CoV-2 RNA and COVID-19 case numbers, supporting the notion that wastewater surveillance continues to serve as an effective monitoring tool. This study serves as a real-time example of multi-laboratory collaboration for public health preparedness for infectious diseases. © 2023 The Royal Society of Chemistry

Temperature screening and detection of Covid-19 in school-aged children: A retrospective cohort study assessing the efficacy of temperature screening in schools

In July 2020, Corinth School District was the first in Mississippi to return to the classroom setting. Coronavirus disease 2019 (Covid-19) protocols were developed to maintain the safety of students. These included mandatory masking, seating charts, desk spacing, sanitizing protocols, lunch within classrooms, alteration of extracurriculars, cancellation of assemblies, and quarantine policies. Temperature screenings were also performed. Students registering as febrile would undergo Covid-19 testing. To evaluate the efficacy of temperature scanning as a surveillance method for Covid-19 in the school setting, deidentified data was obtained from the Corinth School District. Overall incidence and grade level incidence of Covid-19 were calculated in children attending school from July 27, 2020 to September 25, 2020. Data were examined for a correlation between documented fevers and Covid-19 positivity. Reports provided by the school district were investigated for positive test groupings signifying a school-related outbreak. Of 28 children with fevers at school, zero tested positive for Covid-19. Twenty-six children tested positive for Covid-19;none were febrile at school. The incidence of Covid-19 in our population during the study period was 1.03%. Incidence in elementary students was 0.34%, 0.93% in middle school, and 2.51% in high school students. There were no school outbreaks during the study period. Both relative risk and odds ratio were calculated as equal to zero (0.00). Temperature scanning is not a sensitive screening method for Covid-19 in school children.Copyright © 2023 Policy Studies Organization.

Rethinking the university: a case study

Purpose: This study aims to describe and illuminate the ways in which Kwantlen Polytechnic University (KPU) – an urban, undergraduate institution with a strong focus on teaching, learning and related research and scholarship, and a substantial international student population – adapted to pandemic conditions in 2020 in an effort to meet community and pedagogical priorities, institutional/legal responsibilities and strategic goals. Design/methodology/approach: Three institutional leaders at KPU draw together their respective insights and experiences, reflecting on how governance, pedagogy and operations were impacted by COVID-19. Findings: After two years of continuous operation during the COVID-19 pandemic, and with the strong support of its learners and the faculty, KPU has undergone significant pedagogical and technological shifts to become a multi-modal university for study, teaching and administration. Research limitations/implications: This is a "practitioner paper” with a practical focus on institutional leadership and adaptation in a period of rapid adjustment. It is more of an accounting and reflection piece than a critical analysis. Practical implications: It offers post-secondary leaders' insights into ways in which institutional values and community needs inform policy-making, operations and innovation in education. Social implications: KPU's domestic and international student constituencies are complex and required unconventional post-secondary strategies regarding faculty autonomy and growth, de-colonization and inclusion. Originality/value: KPU has a distinctive mandate in British Columbia and its commitment to experiential learning – typically associated with hands-on education – presented unusual challenges for delivery. While research-and-teaching universities were tested by COVID-19, their tests were largely alike. KPU's experience illustrates what practical- and teaching-focused institutions confronted. © 2022, Emerald Publishing Limited.

Rethinking the university: a case study

PurposeThis study aims to describe and illuminate the ways in which Kwantlen Polytechnic University (KPU) - an urban, undergraduate institution with a strong focus on teaching, learning and related research and scholarship, and a substantial international student population - adapted to pandemic conditions in 2020 in an effort to meet community and pedagogical priorities, institutional/legal responsibilities and strategic goals. Design/methodology/approachThree institutional leaders at KPU draw together their respective insights and experiences, reflecting on how governance, pedagogy and operations were impacted by COVID-19. FindingsAfter two years of continuous operation during the COVID-19 pandemic, and with the strong support of its learners and the faculty, KPU has undergone significant pedagogical and technological shifts to become a multi-modal university for study, teaching and administration. Research limitations/implicationsThis is a "practitioner paper" with a practical focus on institutional leadership and adaptation in a period of rapid adjustment. It is more of an accounting and reflection piece than a critical analysis. Practical implicationsIt offers post-secondary leaders' insights into ways in which institutional values and community needs inform policy-making, operations and innovation in education. Social implicationsKPU's domestic and international student constituencies are complex and required unconventional post-secondary strategies regarding faculty autonomy and growth, de-colonization and inclusion. Originality/valueKPU has a distinctive mandate in British Columbia and its commitment to experiential learning - typically associated with hands-on education - presented unusual challenges for delivery. While research-and-teaching universities were tested by COVID-19, their tests were largely alike. KPU's experience illustrates what practical- and teaching-focused institutions confronted.

Hospital COVID-19 Burden Impact on Inpatient Antibiotic Use Rates

Background. COVID-19 shifted antibiotic stewardship program resources and changed antibiotic use (AU). Shifts in patient populations with COVID surges, including pauses to surgical procedures, and dynamic practice changes makes temporal associations difficult to interpret. Our analysis aimed to address the impact of COVID on AU after adjusting for other practice shifts. Methods. We performed a longitudinal analysis of AU data from 30 Southeast US hospitals. Three pandemic phases (1: 3/20-6/20;2: 7/20-10/20;3: 11/20-2/21) were compared to baseline (1/2018-1/2020). AU (days of therapy (DOT)/1000 patient days (PD)) was collected for all antimicrobial agents and specific subgroups: broad spectrum (NHSN group for hospital-onset infections), CAP (ceftriaxone, azithromycin, levofloxacin, moxifloxacin, and doxycycline), and antifungal. Monthly COVID burden was defined as all PD attributed to a COVID admission. We fit negative binomial GEE models to AU including phase and interaction terms between COVID burden and phase to test the hypothesis that AU changes during the phases were related to COVID burden. Models included adjustment for Charlson comorbidity, surgical volume, time since 12/2017 and seasonality. Results. Observed AU rates by subgroup varied over time;peaks were observed for different subgroups during distinct pandemic phases (Figure). Compared to baseline, we observed a significant increase in overall, broad spectrum, and CAP groups during phase 1 (Table). In phase 2, overall and CAP AU was significantly higher than baseline, but in phase 3, AU was similar to baseline. These phase changes were separate from effects of COVID burden, except in phase 1 where we observed significant effects on antifungal (increased) and CAP (decreased) AU (Table). Conclusion. Changes in hospital AU observed during early phases of the COVID pandemic appeared unrelated to COVID burden and may have been due to indirect pandemic effects (e.g., case mix, healthcare resource shifts). By pandemic phase 3, these disruptive effects were not as apparent, potentially related to shifts in non-COVID patient populations or ASP resources, availability of COVID treatments, or increased learning, diagnostic certainty, and provider comfort with avoiding antibacterials in patients with suspected COVID over time. (Figure Presented).

Adapting to the Times: Evaluating the Efficacy of Telehealth on Hcv Outcomes in a Safety-Net Population

Background: The Grady Liver Clinic (GLC) is a primary care-based hepatitis C (HCV) clinic that provides comprehensive care for an urban, primarily African American, underserved patient population at Grady Health System. At the onset of the COVID-19 pandemic, GLC pivoted to using a telehealth model for HCV treatment. With telehealth, treatment visits were conducted via telephone or video and HCV medications could be couriered to patients' residences. We aim to compare outcomes of the HCV telehealth treatment model to traditional, in-person treatment. Method(s): We performed a retrospective chart review of all patients who initiated HCV treatment at GLC from 03/2019-02/ 2020 (Pre-Pandemic) and 03/2020-02/ 2021 (Pandemic). The latter cohort was stratified into three types of visits: in-person only, telehealth only, and hybrid (mixture of in-person and telehealth). We compared demographic data and HCV treatment outcomes between groups. Result(s): Patients in pre-pandemic and pandemic cohorts were similar genders, ages, ethnicities, and used similar payor sources. The average number of days from referral to treatment initiation differed between cohorts (52 days vs 92 days) as did the treatment duration (84 vs 56 days). The rate of sustained virologic response (SVR12) was similar between cohorts, with SVR12 obtained in 59% of the pre-pandemic cohort that started treatment (96% of those who completed testing for SVR12) vs 61% of the pandemic cohort that started treatment (95% of those who completed testing for SVR12). A substantial proportion of patients in both groups did not follow-up for SVR12 testing. Importantly, there were similar rates of SVR12 in the pandemic in-person, telehealth, and hybrid subgroups (Figure 1, attached). Conclusion(s): Our results show that virtual delivery of healthcare is as effective as traditional in-person clinic visits for HCV treatment. Our data supports continued use of telehealth to improve access to HCV treatment for a vulnerable patient population who face chronic barriers to healthcare access. (Figure Presented).

Lessons learned from automated screening of COVID-19 preprints : Tracey Weissgerber

Preprints occupied the spotlight early in the pandemic, as scientists, the media and the public sought information on the evolving pandemic. While some in the scientific community embraced this shift, others were concerned about the quality of these papers, which had not yet undergone peer review. Furthermore, the flood of COVID-19 preprints quickly overwhelmed the scientific community's ability to monitor and assess new preprints. Automated screening tools that detect beneficial practices, or common problems, in preprints are one potential solution to this problem. These tools could potentially provide individualized feedback, allowing authors to improve their manuscripts prior to publication in a peer-reviewed journal. We have combined many tools into a single pipeline, called ScreenIT. ScreenIT assess factors such as open data and open code, blinding, randomization, power calculations, limitations sections, and data visualization problems. Since June 2020, we have used ScreenIT to screen and post daily reports on more than 23,000 new COVID-19 preprints deposited on bioRxiv and medRxiv. Results show that practices such as sharing data and code are relatively uncommon. Sample size calculations, blinding and randomization are rarely reported and most papers do not report the sex of participants, animals or samples. This work demonstrates the feasibility of using automated tools to rapidly screen many preprints in real time, and provide authors and readers with rapid feedback. However, this approach has important limitations. Automated screening tools can make mistakes. Tools can't always determine whether an item is relevant to a particular manuscript. Further studies are needed to determine whether feedback from automated tools is effective in encouraging authors to improve reporting.

COVID-19 vaccination hesitancy in Kazakhstan : Gaukhar Mergenova

Background COVID-19 vaccine hesitancy is a major problem worldwide that impedes vaccine uptake. We explored factors associated with vaccine hesitancy in Kazakhstan. Methods We conducted a cross-sectional face-to-face survey of 991 adults in Kazakhstan in July 2021, using quota sampling of respondents over 18 years old reflecting the distribution of gender, age, residence type, and geographical regions of Kazakhstan, according to the 2020 census. Results Over two third (68.4%) of the sample was vaccine hesitant;22.11% - received a vaccine (18.6%-Sputnik V, 2%-Hayat-Vax, 0.9%-QazCovid and 0.6%- CoronaVac). We used logistic regression to explore factors that were associated with vaccine hesitancy, adjusting age, education, employment, type of residence, self-reported COVID-19. The odds of not being vaccine hesitant were higher among those who had a higher perception that the COVID-19 vaccine was important for health OR = 2.66 (95%CI:2.24,3.17), higher belief in vaccine safety/effectiveness OR = 3.16 (95%CI:2.57,3.89), higher trust in government/health providers OR = 3.32 (95%CI:2.72,4.05), higher trust in official sources of information OR = 1.16 (95%CI:1.12,1.21), higher adherence to preventive measures OR = 1.05 (95%CI:1.03,1.08), knew someone diagnosed with COVID-19 OR = 1.36 (95%CI:1.01,1.82), or who died of COVID-19 OR = 1.47 (95%CI:1.04,2.08), had been ever tested for COVID-19 OR = 1.75 (95%CI:1.30,2.35), had ever received flu vaccine OR = 2.16 (95%CI:1.62,2.88), among health professionals OR = 2.76 (95%CI:1.38,5.51), and who had lower vaccine conspiracy beliefs OR = 0.48 (95% CI:0.40,0.58). Conclusions Vaccine accepting individuals held positive beliefs about the COVID-19 vaccine, had greater trust in government/official sources of information/health care workers, had greater exposure to COVID-19. Interventions aimed at reducing vaccine hesitancy need to address sources people find credible and may need to target individuals who have had limited exposure to the risks of COVID-19. Key messages • Strategies to increase trust in government/ health care workers and official sources of information can be an effective approach to reduce COVID-19 vaccination hesitancy. • Interventions to reduce COVID-19 vaccination hesitancy should target individuals who have had limited exposure to the risks of COVID-19.

Exploring the Electronic Course Reserves Management and Reading List Tool Leganto through the Lenses of Academic Librarians and Instructors

Reading resources are essential for teaching and learning. Today’s students and instructors are used to the Learning Management System (LMS) for teaching and learning. Within the general LMS trend, a variety of electronic course reserves tools have emerged. One particular tool is Leganto which has been increasingly widely deployed, particularly in the wake of COVID-19. This article adopts the Educause reporting model of teaching and learning technologies best practices of “7 things You Should Know About.” The article also presents the authors’ institutional case of adoption, implementation, and data analytics results at Purdue University. © 2022 The Author(s). Published with license by Taylor & Francis Group, LLC.

EARLY GAS EXCHANGE PARAMETERS NOT ASSOCIATED WITH SURVIVAL IN COVID-19-ASSOCIATED ARDS PATIENTS REQUIRING PROLONGED VENOVENOUS EXTRACORPOREAL MEMBRANE OXYGENATION

SESSION TITLE: ECMO and ARDS in COVID-19 Infections SESSION TYPE: Rapid Fire Original Inv PRESENTED ON: 10/17/2022 12:15 pm - 1:15 pm PURPOSE: Veno-venous extracorporeal membrane oxygenation (VV-ECMO) is an important salvage therapy for patients with severe COVID-19 associated acute respiratory distress syndrome (ARDS). Whether gas exchange after initiation of ECMO predicts survival remains unknown. The present study aims to investigate if gas exchange parameters are associated with survival during ECMO support of COVID-19 associated ARDS. METHODS: We retrospectively evaluated all ARDS patients initiated on VV-ECMO according to ELSO guidelines between 2018 and 2021 at a tertiary academic medical center. ECMO sweep and ventilator fraction of inspire oxygen (FiO2) were catalogued every eight hours for all patients and compared between COVID-19 survivors and non-survivors at Days 0, 7, 14, 21, and 28 of ECMO using the Mann-Whitney U test. Cohort characteristics were compared between patients with and without COVID-19 using the chi-squared test for categorical comparisons and the Mann-Whitney U test for comparison of non-parametric continuous variables. Statistical significance was considered as p<0.05 for all tests. RESULTS: Forty-two ARDS patients were initiated on VV-ECMO during the study period, including 30 patients with COVID-19. Mortality was similar between patients with and without COVID-19 (43.3% vs 41.7%, p=0.92). ECMO duration (31 [33.5] vs 9.5 [7.0] days, p=0.002), median sweep (7.0 [4.5] vs 4.3 [4.0], p< 0.001), and median ventilator FiO2 (0.55 [0.50] vs 0.45 [25], p < 0.001) were significantly increased in patients with COVID-19 compared to those without. Among COVID-19 patients, median sweep did not differ between survivors and non-survivors at Day 0 (3.5 [1.0] vs 4.0 [1.0], p=0.20), Day 7 (6.0 [3.0] vs 7.5 [2.3], p=0.38), Day 14 (6.0 [2.5] vs 8.0 [3.3], p=0.14), Day 21 (8.0 [3.5] vs 9.0 [3.0], p= 0.97), or Day 28 (7.5 [3.5] vs 8.0 [3.0], p=0.74). Median ventilator FiO2 was significantly lower in COVID-19 survivors compared to non-survivors at Day 28 (0.50 [0.16] vs 0.81 [0.40], p=0.03), but not at Day 0 (0.75 [0.52] vs 0.60 [0.25], p= 0.98), Day 7 (0.90 [0.50] vs 1 [0.45], p = 0.54), Day 14 (0.90 [0.50] vs 1 [0.08], p=0.08), or Day 21 (0.80 [0.10] vs 0.90 [0.40], p=0.62). CONCLUSIONS: Survival was similar between ARDS patients with and without COVID-19 despite significantly increased ECMO duration and gas exchange support in patients with COVID-19. Early gas exchange parameters after initiation of ECMO were not associated with survival in patients with COVID-19. At Day 28 of ECMO, COVID-19 survivors had significantly lower ventilator FiO2 requirements compared to non-survivors. CLINICAL IMPLICATIONS: Gas exchange parameters did not discriminate survivors from non-survivors until day 28 of ECMO in patients with COVID-19 associated ARDS. Given the need for increased gas exchange support and duration of ECMO therapy in this population, gas exchange parameters prior day 28 of ECMO may not be suitable markers for prognostication. DISCLOSURES: No relevant relationships by Andrew Davis No relevant relationships by Malcolm DeCamp No relevant relationships by Hilary Faust No relevant relationships by James Maloney No relevant relationships by Daniel McCarthy No relevant relationships by Michael Peliska

The Gap Between Breast and Bottle, What Are the Disparities in a Large Community Hospital in Southern West Virginia?

Background: Exclusive breastfeeding is recognized as the ideal feeding method for infants. Newborns receiving formula inhospital are at higher risk for early breastfeeding cessation. Among infants born in 2017, CDC Breastfeeding Report Card, 2020, reported the rate of breastfed infants receiving formula before two days of age as 15% in West Virginia (WV). We aimed to determine factors associated with in-hospital formula supplementation of breastfed newborns at a large community hospital in Southern WV. We hypothesized that disparities exist in supporting women to exclusively breastfeed. Methods: We retrospectively reviewed 500 randomly selected charts of infants born 09/01/2019-09/1/2020. Full-term infants with a recorded maternal decision to exclusively breastfeed were included. Exclusion criteria were prematurity, NICU admission, maternal diabetes, and infant hypoglycemia. Factors associated with formula supplementation were compared between mothers exclusively breastfeeding and those who were not at the time of discharge. Results: Of the reviewed charts, 70% of birth mothers desired to exclusively breastfeed. 211 infants met all inclusion criteria. 70% were delivered via vaginal delivery;52% were induced. Of the included newborns, 41% were supplemented with formula. 32% of mothers met with lactation consultants prior to formula supplementation. Top reasons for formula supplementation were mother request (45%) and newborn difficulty latching (22%). Median time of first supplementation was 20.0 hours (range:0.5-54). 12% of the supplementation occurred within 6 hours and 96.5% within 2 days of age. Rates of formula supplementation did not increase during the nurses' night shift or at nurses' shift change. Exclusive breastfeeding at discharge was associated with higher education level (p=0.002), tobacco abstinence (p=0.03), prior births (p=0.04), and increased maternal age (p=0.02);with every 1 year increase in maternal age, there was 7% decrease in supplementation. No statistically significant associations were present between exclusive breastfeeding at discharge meeting with a hospital lactation consultant, maternal race, marital status, induction need, or neonatal characteristics (p>0.05). When controlling for confounders of maternal age, marital status, tobacco use, and lactation consultation, Cesarean delivery (odd ratio: 2.0,1.03-4.2, 95% confidence interval), primiparity (2.6, 1.4-4.8), and not completing high school (12.5, 1.6-96.5) predicted formula supplementation. Exclusive breastfeeding discharge rates remained relatively steady over the 12 month study period, including during the COVID-19 pandemic. Conclusion: At our center, formula supplementation rate of 41% in the first two days of age appears higher than the state's rate using the CDC report card. Mother request and newborn difficulty latching are the top reasons for formula supplementation. Median age of supplementation was 20 hours. Lactation consultations were not universal and disparities existed for breastfeeding mothers supplementing with formula. Addressing maternal disparities is essential to enhance newborn health equity. Our study's findings will be used to develop prenatal and postnatal interventions to maximize hospital breastfeeding support and minimize formula supplementation.

DELAYED DECLINE: A CASE OF DELAYED POST-HYPOXIC LEUKOENCEPHALOPATHY

CASE: A 44 year old female with history of depression and recent suicide attempt presents with one week of cognitive and functional decline. One month prior to presentation, patient attempted suicide with opioids requiring intubation for respiratory depression and stroke sequelae. She was discharged from this stay after 12 days having returned to mental and functional baseline. Two weeks later, she demonstrated decreased focus and concentration, progressing to decreased mobility and akinesis, eventually presenting to our hospital. Admission metabolic and toxic workup was negative. CT head redemonstrated findings of previously known stroke. MRI demonstrated new increased T2 Flair of the parietal lobes and the cerebral white matter. LP was without evidence of infection or inflammation. Encephalitis panel and autoimmune workup were negative. Neurology consult suggested delayed post-hypoxic leukoencephalopathy as a possible diagnosis, given clinical course of improvement and subsequent decline, along with akinetic mutism and deep cortical white matter flair abnormalities. After failed trial of lorazepam, she was started on amantadine and her cognitive and functional status improved slowly. IMPACT/DISCUSSION: Delayed post-hypoxic leukoencephalopathy (DPHL) is a rare syndrome characterized by biphasic time course with initial recovery and subsequent cognitive and functional decline. DPHL can follow any event of prolonged cerebral hypoxia most frequently CO poisoning. It can occur with more common causes of hypoxia including overdose, cardiac arrest, and seizures;recent case reports have reported DPHL following severe covid infection. The clinical course involves a hypoxic event followed by a return to functional baseline typically lasting 7-21 days, after which progressive physical and mental decline occur. Signs include neuropsychiatric symptoms like amnesia and disorientation, as well as parkinsonism or akinetic mutism (1). The mechanism of DPHL is unclear. One possible mechanisms involves diffuse demyelination. The half life of myelin basic proteins is approximately 20 days, the length of the lucid interval. Hypoxia may abruptly halt the myelination process but symptoms may not emerge until a critical threshold of loss was achieved. Evaluation of DPHL involves considering other causes of encephalopathy, such as infection, substance use, stroke, catatonia, and toxins. In the absence of other causes, diagnosis of DPHL is based on characteristic time course following hypoxic event, symptoms, and MRI findings of diffuse T2 hyperintensity of cerebral white matter are pathognomonic (1). Treatment of DPHL is generally supportive. Limited evidence suggests amantadine may be of benefit. CONCLUSION: Physicians should consider DPHL in patients who have experienced cerebral hypoxia and present with the characteristic time course and imaging findings.

Quality Delivered: How a Pandemic Fostered Innovation and Creative Solutions in Clinical Education

Background: Clinical education placements for students enrolled in healthcare programs were abruptly upended in March 2020 due to COVID-19. Programs were faced with decisions of how to mitigate substantive challenges due to an unforeseen pandemic within timeframes that would align with curricular sequences and graduation dates. Schools quickly modified curriculum formats, implemented alternative teaching and learning instruction and developed safety protocols to protect students, clinical faculty, and patients. Purpose: The aim of this study explored the strategies employed by one physical therapy school's clinical education team, which resulted in successful completion of clinical course requirements and on-time graduation. Method: Data was collected on a single cohort of eighty (n=80) students who experienced changes in the timing, location, and/or progression of their clinical experiences due to COVID-19 related complications. The use of innovative clinically-oriented teaching strategies including web-based patient case simulation, virtual grand rounds, and other creative learning activities effectively supported student engagement both in and outside of clinical settings. Alternative learning strategies provided students the opportunity to progress through the clinical education curriculum, meet educational objectives, and satisfy the standard requirements by the Commission on Accreditation in Physical Therapy Education (CAPTE). Performance on the Clinical Performance Instrument (CPI) for the cohort of students affected by COVID-19 was compared to a cohort from 2019 who were not affected by COVID-19 related issues. Results: Analysis using Mann Whitney U statistics showed there were no significant differences in performance on the CPI between the groups (p=0.874). Conclusion: Looking forward, there is an opportunity for schools to build on what was learned during the pandemic and apply those strategies to other non-pandemic related situations with successful outcomes. Innovative teaching and learning strategies can help to bridge the gap of time out of clinic for any student who may experience an interruption in clinical education due to injury, illness, or other situation, and can provide a way for students to progress successfully through their physical therapy education.

Capacity Building in Sub-Saharan Africa as Part of the INTENSE-TBM Project During the COVID-19 Pandemic.

Tuberculous meningitis (TBM) is the most severe and disabling form of tuberculosis (TB), with at least 100,000 cases per year and a mortality rate of up to 50% in individuals co-infected with human immunodeficiency virus type 1 (HIV-1). To evaluate the efficacy and safety of an intensified anti-tubercular regimen and an anti-inflammatory treatment, the INTENSE-TBM project includes a phase III randomised clinical trial (TBM-RCT) in four countries in sub-Saharan Africa (SSA). Within this framework, we designed a comprehensive capacity-building work package ensuring all centres had, or would acquire, the ability to conduct the TBM-RCT and developing a network of skilled researchers, clinical centres and microbiology laboratories. Here, we describe these activities, identify strengths/challenges and share tools adaptable to other projects, particularly in low- and lower-middle income countries with heterogeneous settings and during the coronavirus disease 2019 (COVID-19) pandemic. Despite major challenges, TBM-RCT initiation was achieved in all sites, promoting enhanced local healthcare systems and encouraging further clinical research in SSA. In terms of certified trainings, the achievement levels were 95% (124/131) for good clinical practice, 91% (39/43) for good clinical laboratory practice and 91% (48/53) for infection prevention and control. Platform-based research, developed as part of capacity-building activities for specific projects, may be a valuable tool in fighting future infectious diseases and in developing high-level research in Africa.

The INTENSE-TBM project aimed to design a comprehensive work-package on capacity building, ensuring all centres would acquire the ability to conduct a phase III randomised clinical trial on TBM in sub-Saharan Africa, to reduce tuberculous meningitis mortality and morbidity in patients with/without HIV-1 co-infection. Therefore, the INTENSE-TBM project is an example of how an international clinical research consortium can provide opportunities to enhance local capacity building and promote centres without previous experience in clinical research. This article provides practical approaches for implementing effective capacity-building programmes. We highlight how to overcome limitations imposed by the COVID-19 pandemic to successfully complete clinics, laboratory set-ups and personnel training, so as to optimise resources and empower African institutions on a local level. At the same time, our experience shows how capacity-building programmes can deliver long-lasting impact that extends beyond the original aims of the project (e.g. HIV and TB), and support local health systems in fighting other infectious disease (e.g. COVID-19). Research projects in low- and lower-middle income countries with heterogeneous settings could stand to benefit the most.