COVID-19 and financial institution stability: stress testing the Eastern Caribbean currency union

PurposeThis paper aims to simulate the potential impact of increasing non-performing loans (NPLs) on capital adequacy, interest income and firm value of banks and credit unions in the Eastern Caribbean Currency Union (ECCU) using stress tests. Design/methodology/approachA financial stress testing model was deployed at the levels of individual financial intermediary (FI), sectoral loan portfolio composition, individual member country, and the ECCU collectively, to investigate the impact of NPL shocks on FI stability. FindingsThe authors find that shocks impact the capital adequacy of banks less than that of credit unions, but that firm value of banks is more susceptible to increases in NPLs. Interest income responses to NPL shocks were linked to credit exposure from the tourism sector, which also reduced capital adequacy more than other economic sectors. Findings show that while the COVID-19 pandemic occasioned some increase in NPLs, the magnitude of impact was significantly mitigated by pro-stability policies including loan repayment moratoria and restructuring, guidance on the distribution of profits and deleveraging by financial institutions leading up to 2020. Originality/valueThe paper is among the first to use stress testing on the Caribbean in response to the COVID-19 pandemic. Past studies which have used stress test models in the region have not explicitly investigated the impact of credit shocks on risk-weighted assets or interest income as done herein, nor do they include credit unions in the modeling. The results offer novel evaluations as well as implications for FIs in other developing economies, especially those that share a comparable financial and economic architecture.

Competencies, Training Needs, and Turnover Among Rural Compared With Urban Local Public Health Practitioners: 2021 Public Health Workforce Interests and Needs Survey.

Objectives. To compare rural versus urban local public health workforce competencies and training needs, COVID-19 impact, and turnover risk. Methods. Using the 2021 Public Health Workforce Interest and Needs Survey, we examined the association between local public health agency rural versus urban location in the United States (n = 29 751) and individual local public health staff reports of skill proficiencies, training needs, turnover risk, experiences of bullying due to work as a public health professional, and posttraumatic stress disorder symptoms attributable to COVID-19. Results. Rural staff had higher odds than urban staff of reporting proficiencies in community engagement, cross-sectoral partnerships, and systems and strategic thinking as well as training needs in data-based decision-making and in diversity, equity, and inclusion. Rural staff were also more likely than urban staff to report leaving because of stress, experiences of bullying, and avoiding situations that made them think about COVID-19. Conclusions. Our findings demonstrate that rural staff have unique competencies and training needs but also experience significant stress. Public Health Implications. Our findings provide the opportunity to accurately target rural workforce development trainings and illustrate the need to address reported stress and experiences of bullying. (Am J Public Health. 2023;113(6):689-699. https://doi.org/10.2105/AJPH.2023.307273).

Echocardiographic assessment of left ventricular structure and function in hypertensive disorders of pregnancy at six months and two years postpartum

Purpose: Hypertensive disorders of pregnancy (HDP) are associated with longer term postpartum cardiovascular sequelae, including double the risk of ischaemic heart disease and cardiovascular mortality (1). Transthoracic echocardiograms (TTE) were performed in women with pregnancies complicated by gestational hypertension and pre-eclampsia, or uncomplicated pregnancy, at six months and two years postpartum. The aim was to longitudinally assess cardiac structure and function in women with HDP and compare this to women who had a normotensive pregnancy. The six-month results have been previously reported, we now present the two-year data. Method(s): A prospective cohort study was conducted in a pre-specified subgroup of 126 patients within a single, tertiary referral centre as part of the P4 (Post Partum, Physiology, Psychology, and Paediatric Follow Up) study (2). 74 (59%) women had a normotensive pregnancy, and 52 (41%) had a pregnancy complicated by HDP. Women with pre-existing hypertension were excluded from the study. The mean patient age at time of six-month postpartum TTE was 32 years (range 22-47 years). TTEs were performed by blinded experienced sonographers and reported by a single blinded imaging cardiologist. Result(s): Six months postpartum. 126 women underwent TTE at six months postpartum. Although all results fell within normal ranges, compared to women with a normotensive pregnancy, those with HDP had increased left ventricle (LV) wall thickness, higher relative wall thickness, and increased LV mass. E/A ratio was lower, and E/E' ratios higher in the group with pregnancy complicated by HDP, indicating a trend towards poorer diastolic function (2,3). Two years postpartum. 35 women completed a two year postpartum TTE (18 normotensive, 17 HDP). Measurements fell within normal ranges in both groups of women. At two years postpartum, women with HDP had larger BSA (1.9 vs 1.71 2 p=0.003), larger LV internal diastolic diameter (48.4 vs 45.5mm p=0.017) and increased inter-ventricular septum thickness (8.5 vs 7.7mm p=0.007) compared to those with normotensive pregnancy. LV mass was greater in women with HDP (98.1 vs 81.5g), as was LA volume indexed (25.4 vs 23.4 cm3/m3), however these differences did not reach significance (p=0.053 and 0.196 respectively). Compared to normotensive women, those with HDP had higher septal (8.7 vs 7.3 p=0.014) and lateral (6.6 vs 5.4 p=0.017) E/E' ratios, indicating a trend towards diastolic dysfunction. Conclusion(s): Despite measurements falling within normal ranges, our results indicate that women with HDP have changes in cardiac structure and function that persist out to two years postpartum. Limitations exist due to incomplete follow up, leading to small sample size;this was partially due to restrictions on service provision in the context of the COVID-19 pandemic. (Table Presented).

Evaluation of a pharmacist-led drive-up anticoagulation clinic during the coronavirus 2019 pandemic

Background: The University of Kentucky HealthCare Anticoagulation Clinic at the Gill Heart and Vascular Institute in Lexington, Kentucky, designed and implemented a drive-up clinic for warfarin management with the goal to minimize person-to-person exposure during the coronavirus disease 2019 (COVID-19) pandemic. Objective: The purpose of this study was to evaluate the effect on warfarin management in a pharmacist-led anticoagulation service when transitioned from an in-person clinic to a drive-up clinic during the COVID-19 pandemic. Methods: This is a retrospective observational cohort study of 68 patients seen in the University of Kentucky HealthCare Anticoagulation Clinic on warfarin therapy for any indication. Patients were included if they had scheduled visits at least 3 times in the period 6 months before, during, and after the initiation of the drive-up clinic. The primary outcome is the difference in time in therapeutic range (TTR) before and during the drive-up clinic. Results: The difference between the mean TTR in period 1 (69.1% ± 23.2%) and period 2 (69.6% ± 19.2%) was not statistically significant (P = 0.882). The mean TTR in period 3 (70.5% ± 20.8%) did not differ in statistical significance from either period 1 (P = 0.688) or period 2 (P = 0.746). Safety outcomes including reported bleeding events and emergency department visits or hospital admissions for bleeding or thrombotic events were consistently low across each period. Conclusion: The results of this study illustrate that a drive-up clinic for warfarin management may be a reasonable alternative approach to providing care for outpatient anticoagulant management and may support nontraditional clinic models for long-term management of anticoagulation and other chronic disease states.

Evaluation of a pharmacist-led drive-up anticoagulation clinic during the coronavirus 2019 pandemic

Background: The University of Kentucky HealthCare Anticoagulation Clinic at the Gill Heart and Vascular Institute in Lexington, Kentucky, designed and implemented a drive-up clinic for warfarin management with the goal to minimize person-to-person exposure during the coronavirus disease 2019 (COVID-19) pandemic. Objective(s): The purpose of this study was to evaluate the effect on warfarin management in a pharmacist-led anticoagulation service when transitioned from an in-person clinic to a drive-up clinic during the COVID-19 pandemic. Method(s): This is a retrospective observational cohort study of 68 patients seen in the University of Kentucky HealthCare Anticoagulation Clinic on warfarin therapy for any indication. Patients were included if they had scheduled visits at least 3 times in the period 6 months before, during, and after the initiation of the drive-up clinic. The primary outcome is the difference in time in therapeutic range (TTR) before and during the drive-up clinic. Result(s): The difference between the mean TTR in period 1 (69.1% +/- 23.2%) and period 2 (69.6% +/- 19.2%) was not statistically significant (P = 0.882). The mean TTR in period 3 (70.5% +/- 20.8%) did not differ in statistical significance from either period 1 (P = 0.688) or period 2 (P = 0.746). Safety outcomes including reported bleeding events and emergency department visits or hospital admissions for bleeding or thrombotic events were consistently low across each period. Conclusion(s): The results of this study illustrate that a drive-up clinic for warfarin management may be a reasonable alternative approach to providing care for outpatient anticoagulant management and may support nontraditional clinic models for long-term management of anticoagulation and other chronic disease states. Copyright © 2022 American Pharmacists Association

A Case of Beriberi After MIS-C

Introduction: As of June 2021, 4 million children have tested positive for COVID-19 in the US. In contrast to adults, children are often hospitalized with gastrointestinal symptoms including persistent vomiting. Pancreatitis has also been seen in MISC, which can lead to malnutrition. Most physician learn about thiamine deficiency and Wernicke Encephalopathy in patients with severe alcoholism or in low-income settings. We cared for a child with Wernicke Encephalopathy due to subacute malnutrition and weight loss after pancreatitis secondary to MISC in the US. Case Description: A 13-year-old female presented to Levine Children's Hospital with weight loss. She was diagnosed with COVID on 1/23/21 with 1 week of URI symptoms, with baseline weight 165 pounds (BMI 31.1). She was seen in an Emergency Department (ED) on 3/1/21 for vomiting with lipase 350u/L;she received fluids and was discharged. She represented on 3/7/21 with persistent symptoms weighing 135.5 pounds (BMI 25.6) with lipase 790u/L. She was discharged after three days with a diagnosis of post-COVID pancreatitis and lipase 600u/L. After discharge, she continued losing weight despite ondansetron. She followed up with GI on 3/15, weighing 130 pounds (BMI 24.5). An abdominal MRI and endoscopy were normal. She was started on omeprazole and cyproheptadine. She presented to Levine Children's Hospital on 3/24/21 for a second opinion. Upon admission, her serum lipase was 895u/L and she weighed 115 pounds (BMI 21.7). She was started on dextrose-containing fluids and developed seizures on 3/27/21. MRI brain was normal. Ophthalmology noted bilateral abducens nerve palsy. She developed worsening mental status and respiratory failure, so was intubated. A repeat MRI brain revealed posterior reversible encephalopathy syndrome and findings specific for Wernicke Encephalopathy. Thiamine level was low, and empiric thiamine was initiated. She was started on feeds and clinically improved. She was then extubated and showed improvements in her motor function and ability to follow commands. She transferred to inpatient rehab and continues to make progress. Discussion: Identification of the degree of malnutrition for this patient was difficult to obtain due to non-communicating EMRs. This limited the providers' ability to accurately quantify the degree of weight loss and the potential for Thiamine deficiency. The combination of limited body storage and short half-life can result in total depletion of thiamine stores within 2 weeks leading to altered mental status. Unfortunately, stigmatization of obesity in children has been well documented and malnutrition may be overlooked due to a normal BMI. Conclusion: Obtaining growth charts for patients presenting with weight loss is important as they provide objective data and help prevent obesity bias. If a child has a history of weight loss and develops altered mental status, vitamin B deficiencies should be considered in the differential. Pancreatitis associated with MIS-C can cause significant malnutrition leading to Wernicke Encephalopathy.

Virtual pulmonary rehabilitation programme – A new era of working

Keywords: Digital;Improvement;Respiratory Purpose: In March 2020, all clinics and group sessions were suspended due to the COVID-19 pandemic and most of our respiratory clients were shielding. During our initial contact with these clients, they reported being less active than they were pre-lockdown. Reduced physical activity is directly related to quality of life (QoL). So, it became important for our team to look into innovative ways to engage with our clients. The aim was to find an effective alternative way for clients to participate in our Pulmonary Rehabilitation (PR) while the restrictions were in place. Methods: This service evaluation used a mixed method approach to investigate the effectiveness of Virtual PR (VPR). Both quantitative and qualitative data were collected during the initial assessment (IA) and post assessment (PA) for comparison. Informal feedbacks were collected from clients and staff during the VPR group sessions. Quantitative data: 1. COPD Assessment Tool (CAT), measures the impact of condition on client's health. 2. Patient Health Questionnaire (PHQ-9) for depression. 3. Generalised Anxiety Disorder (GAD-7) for anxiety. 4. Exercise Tolerance test (ET) Qualitative data: 1. Medical Research Council dyspnoea scale (MRC) 2. Client satisfactory survey during PA. Results: Of the 52 digitally enabled clients that were offered VPR, 88% completed the programme. 4% dropped out and the remaining 8% were expelled due to medical reasons. 11% of those who completed were housebound either due to their condition or lack of transport. 93% of the clients attended ten or more of the allocated 12 sessions. At the end of VPR, 13% of clients reported an improvement in MRC, and 65% of the clients had attained minimally important difference in ET. During IA, 86% reported to have medium to high impact on CAT. 43% of those clients had dropped to a lower impact level during post assessment. Initially, 63% reported to have psychological symptoms in at least one or both of the questionnaires (PHQ-9, GAD-7). Of these 29 clients who reported symptoms, 62% showed improvement at the end. 95% have said that VPR has motivated them to be active, 41% would have preferred face to face (F2F) sessions for the social aspects of the group, but all participants agreed that VPR was a good alternative. 95% of clients rated 8 or above for the quality of the sessions. During informal interviews, clients said VPR has saved them travel time and reduced dependency on family for transport. Staff reported lack of exercise equipment had an impact on the progress when compared to F2F. Conclusion(s): VPR as a digital solution has a positive effect on both physiological and psychological symptoms, thus improving QoL. Also, proved to be cost, time and clinically effective way to rehabilitate housebound clients. VPR is a good alternative to F2F sessions, but further work needs to be done to enable clients in digital and data poverty to uptake VPR to ensure fair access. Impact: VPR has been imbedded into our pathway and will be offered based on clinical decision and clients’ choice. Referral form will be revised to reflect the optional digital pathway. Funding acknowledgements: So far, this project has been funded at team level for the virtual platform licence. Funding has been secured for digital devices and data through the organisation (NELFT NHS trust) for a project on, ‘VPR for clients in digital/data poverty’.

Can Family Medicine's Counterculture History Help Shape an Anti-Racist Future?

Family medicine prides itself on community engagement and has embraced its counterculture roots. After the racial and social reckoning of 2020, including the COVID-19 pandemic and the Black Lives Matters movement, family medicine, as a specialty, must embrace anti-racism as a core value to meet community needs. This article reflects on the foundational tenets of family medicine's origin. It highlights the current disparities regarding professional representation while offering equitable, intentional, and collaborative approaches to move toward and achieve anti-racism within the specialty, medical education, and the community.

Arq Ajib - a wonder Unani formulation for inhibiting SARS-CoV-2 spike glycoprotein and main protease - an in silico approach.

OBJECTIVES: The current pandemic caused by Severe Acute Respiratory Syndrome Corona-Virus 2 (SARS-CoV-2) has become a global health menace with significant morbidity and mortality besides huge socioeconomic implications. Despite the approval of few vaccines for the prevention of the disease, the discovery of safe and effective countermeasures especially from natural sources is of paramount importance, as the number of cases continues escalating. Arq Ajib has long been used for various diseases and its ingredients have been reported for antiviral, antimicrobial, antipyretic, anti-inflammatory, antioxidant activities. The present study investigates the inhibitory effect of phytocompound of Arq Ajib on potential drug targets of SARS-CoV-2. METHODS: The structures of phytocompounds present in Arq Ajib were retrieved from PubChem database and some were illustrated using Marvin Sketch. SARS-CoV-2 S glycoprotein (PDB ID: 6LZG) and 3CLpro (PDB ID: 7BQY) were selected as the target protein. Dock Prep module in UCSF Chimera software was used for receptor structure processing. AutoDock Vina was used to calculate the binding affinities between the protein and ligands and to predict most promising compounds with best scores. RESULTS: Molecular docking results predicted that the phytocompounds of Arq Ajib had good binding affinity and interaction with S glycoprotein and 3CLpro. Quercetin and Isorhoifolin from Mentha arvensis were identified as promising candidates with the potential to interact with 3CLpro and spike glycoprotein and inhibit the viral replication and its entry into the host. CONCLUSIONS: Arq Ajib may prove valuable for developing novel therapeutic candidate for COVID-19; however, it has to be substantiated further with in-vitro and in-vivo studies.

Surgery in the era of COVID-19: implications for laparoscopy and natural-orifice endoscopic surgery: a narrative review

Controversy exists regarding the use of minimally invasive surgery (MIS) during the corona virus disease 2019 (COVID-19) pandemic. Several surgical societies have issued recommendations regarding precaution measures during MIS, nonetheless these recommendations were conflicting with respect to the use of laparoscopy with little or no inference to natural-orifice endoscopic surgery. A comprehensive literature search was performed to explore the available evidence pertinent to the novel coronavirus 2 (SARS-CoV-2) transmission dynamics in MIS, and benefits of MIS procedures in patients with transmissible viral diseases. According to the current evidence, SARS-CoV-2 has a multi-route transmission, including fecal-oral transmission. Evidence on airborne transmission in the operative setting are however limited. In addition to nasopharyngeal screening, it would seem prudent to perform routine fecal testing for SARS-CoV-2 in patients undergoing positive-pressure transanal minimally invasive procedures. This is particularly relevant to regions with high level of epidemicity. In patients with confirmed SARS-CoV-2 infection, conventional laparoscopic and robotic approaches, and atmospheric transanal surgery with high volume smoke evacuation may be safer alternatives. Considering the high rates of postoperative pulmonary complications and mortality associated with SARS-CoV-2 infection, use of laparoscopy is advised in suspected or confirmed COVID-19 patients who require abdominal surgery, particularly older patients and those with comorbidities. Laparoscopy may decrease the probability of postoperative disease exacerbation, and provide earlier recovery, less morbidity and mortality, and shorter hospital stay with subsequent decreased risk of in-hospital secondary transmission. High index of suspicion in postoperative patients with fever or respiratory symptoms is necessary to timely diagnose COVID-19. Chest computed tomography scan has a higher sensitivity compared to real-time PCR and can potentially be used to assist in the diagnosis, particularly in elderly patients.

A Design and Dissemination Studio: Building a Scholarly Community of Practice in Rural Health Professions Education and Training.

The Collaborative for Rural Primary Care Research, Education, and Practice (Rural PREP) has adapted a process, originally developed for cancer research, to engage community members in a research Design and Dissemination Studio in rural health professions education, enlarging a scholarly community of practice in preparing a future rural health workforce.

For us, COVID-19 is personal

We are colleagues and friends working together in busy emergency departments in Washington DC. As Black physicians working in urban America, we do not find the recent deluge of news reports chronicling the disproportionate effect that the coronavirus disease (COVID-19) pandemic is having on the disenfranchised and minority populations in our country shocking. We have long been witness to and are in a constant state of alarm over the legal, medical, educational, social and economic inequities faced by the most vulnerable residents of this country.