The environmental impact of surgical telemedicine: life cycle assessment of virtual vs. in-person preoperative evaluations for benign foregut disease.

BACKGROUND: Health care accounts for almost 10% of the United States' greenhouse gas emissions, accounting for a loss of 470,000 disability-adjusted life years based on the health effects of climate change. Telemedicine has the potential to decrease health care's carbon footprint by reducing patient travel and clinic-related emissions. At our institution, telemedicine visits for evaluation of benign foregut disease were implemented for patient care during the COVID-19 pandemic. We aimed to estimate the environmental impact of telemedicine usage for these clinic encounters. METHODS: We used life cycle assessment (LCA) to compare greenhouse gas (GHG) emissions for an in-person and a telemedicine visit. For in-person visits, travel distances to clinic were retrospectively assessed from 2020 visits as a representative sample, and prospective data were gathered on materials and processes related to in-person clinic visits. Prospective data on the length of telemedicine encounters were collected and environmental impact was calculated for equipment and internet usage. Upper and lower bounds scenarios for emissions were generated for each type of visit. RESULTS: For in-person visits, 145 patient travel distances were recorded with a median [IQR] distance travel distance of 29.5 [13.7, 85.1] miles resulting in 38.22-39.61 carbon dioxide equivalents (kgCO2-eq) emitted. For telemedicine visits, the mean (SD) visit time was 40.6 (17.1) min. Telemedicine GHG emissions ranged from 2.26 to 2.99 kgCO2-eq depending on the device used. An in-person visit resulted in 25 times more GHG emissions compared to a telemedicine visit (p < 0.001). CONCLUSION: Telemedicine has the potential to decrease health care's carbon footprint. Policy changes to facilitate telemedicine use are needed, as well as increased awareness of potential disparities of and barriers to telemedicine use. Moving toward telemedicine preoperative evaluations in appropriate surgical populations is a purposeful step toward actively addressing our role in health care's large carbon footprint.

Secondary Prevention of Stroke or Transient Ischaemic Attack: An Investigation of Patient Experience of a Novel Dietetic Service

Introduction: Patients who have had a stroke or transient ischaemic attack (TIA) are at high risk of recurrent events. Around 90% of strokes are associated with ten modifiable risk factors. The prevalence of modifiable risk factors is high, with 89% of stroke clinic patients at Guy's and St. Thomas' Hospital having at least one. This study aimed to explore the patient experience of a novel virtual dietetic secondary prevention service, between November and December 2020, developed in response to the COVID-19 pandemic. Method(s): A questionnaire was developed to explore patients' experience of receiving virtual consultation with the Specialist Stroke Dietitian for the secondary stroke or TIA prevention. The questionnaire, informed by a literature review, was piloted with dietitians and patients. The Questionnaire was used to develop a topic guide for structured in-depth telephone interviews. Patients (n=8) who completed a telephone consultation with the Stroke Dietitian were invited to participate in a structured telephone interview with the researcher. The Framework method was used for thematic analysis. Result(s): Six patients aged 30-69 years discussed their experience of secondary prevention dietetic consultations. Thematic analysis suggests that new knowledge obtained, nutrition education provided, and the Dietitian's interpersonal communication style were key factors that improved confidence, facilitated behaviour change and contributed to a positive patient experience. Participants expressed a preference for telephone appointments rather than face-to-face or video. Conclusion(s): Exploration of patient experience is central to the design of novel clinical services. Our pilot questionnaire can be modified for use in future stroke service development.

Impact of the COVID-19 pandemic on essential workers in Europe: Subset analysis of a global online survey

Introduction: This study aims to explore how essential workers in Europe differed from the rest of the population in terms of their experiences of social life, access to services, mental well-being, and perceived benefits of the lockdown. Methods: This study used a descriptive analysis to evaluate the overall experiences of the essential workers in Europe. Data analyzed in this study is part of a larger global online cross-sectional survey conducted during April to November 2020 involving post-secondary staff, students and the general population (remote workers). Data of 19,794 participants are included in the current study, and analysis is based on a comparison of participants who self-identified as essential workers, with those who did not using the chi-square test. Results: Mean age was 34.5 years (SD =13.0) for essential workers and 30.2 years (SD =12.4) for the general population (remote workers). While 13.6% of all respondents were essential workers, the proportion was more among older ages (30 and above), females, and those who lived in suburbs. Overall, 46.8% of participants reported increased levels of stress during week 1-2 (51% of essential workers and 46.1% of the other participants, p<0.001). More essential workers reported their social life being great than the rest of the population (25.3% vs. 16.4%, p<0.001), and COVID-19 symptoms (13.6 vs 10.5%, p<0.001). In addition, fewer reported having troubled relationships (16.3% vs. 18.6%, p<0.001) or being able to do sufficient exercise (35.7% vs. 40.5%, p<0.001) than the general population (remote workers). Take-home message: The important role of essential workers during the pandemic cannot be overstated, yet their contributions, especially non-healthcare essential workers, have not been fully appreciated. © 2022 Parvin EFTEKHAR et al.

Impact of COVID-19 on Infants Followed After Discharge from the Neonatal Intensive Care Unit via a Telemedicine Model

Background: While the prevalence of SARS-CoV-2 has remained low among newborns, there is increasing evidence that the COVID-19 pandemic impacted healthcare for families with infants in the neonatal intensive care unit (NICU). However, little is known about the impact of COVID-19 on families with infants discharged from the NICU. During the initial pandemic shutdown, our Neonatal Follow-Up Program (NFP) transitioned to a virtual platform and implemented a survey about new/worsened obstacles families might be facing due to the pandemic as standard of care. We aimed to: 1) evaluate for patient-level differences in virtual neonatal follow-up visit rates;and 2) characterize the social impact of the pandemic on families followed via a large, urban NFP. Methods: All infants scheduled for NFP visits during our telemedicine epoch (March 13, 2020- July 31, 2020) were eligible for inclusion. We compared the family demographics and medical history of infants whose televisits occurred to those for whom televisits did not occur as scheduled. Secondly, we conducted a descriptive analysis of caregiver responses to the pandemic-specific challenges survey. Given the known disproportionate impact of SARS-CoV-2 on communities of color, we also assessed for differences in responses by self-identified race. Data was manually extracted by three coders from the electronic medical record who showed high interrater agreement. Results: After excluding visits cancelled by the provider team, we found 499 clinic encounters for 678 scheduled visits during the study period (i.e. a show-rate of 73.6%). When comparing patients who completed their virtual visit to those who did not, we found no differences in infants' sex, birthweight or gestational age at birth, nor in their reliance on medical technology at discharge. (Table 1). There were also no differences by caregiver self-reported race/ethnicity, but infants whose visits did not occur were more often covered by public insurance. (Table 1). In addition, 43.9% of caregivers reported that their employment had changed since the onset of the shutdown and 6.1% reported housing changes. (Table 2). Eight percent of families endorsed having trouble accessing at least one basic infant necessity (i.e. formula, diapers or medical supplies) due to cost issues and 10% of families endorsed having trouble accessing such necessities due to availability. Non-Hispanic Black caregivers reported this challenge and other infant food-related challenges more often than non-Hispanic White caregivers. Conclusion: We found socioeconomic disparities with respect to virtual follow-up visit rates after discharge from the NICU during the initial COVID-19 shutdown. In addition to navigating the discharge of their infant, families also reported pandemic-enhanced stressors related to difficulty accessing basic infant needs as well as employment and housing changes. Our study highlights the importance of proactive strategies to screen for and mitigate the unique economic vulnerabilities of families discharged from the NICU even beyond the pandemic. (Table Presented).

Early warning signal reliability varies with COVID-19 waves.

Early warning signals (EWSs) aim to predict changes in complex systems from phenomenological signals in time series data. These signals have recently been shown to precede the emergence of disease outbreaks, offering hope that policymakers can make predictive rather than reactive management decisions. Here, using a novel, sequential analysis in combination with daily COVID-19 case data across 24 countries, we suggest that composite EWSs consisting of variance, autocorrelation and skewness can predict nonlinear case increases, but that the predictive ability of these tools varies between waves based upon the degree of critical slowing down present. Our work suggests that in highly monitored disease time series such as COVID-19, EWSs offer the opportunity for policymakers to improve the accuracy of urgent intervention decisions but best characterize hypothesized critical transitions.

CHILDREN AND GUN VIOLENCE DURING THE PANDEMIC

Objectives: Nationwide, adolescents and young adults are at highest risk for death and injury by gunshot wound. Black youth are at the highest risk of gunshot wound as a result of assault, and American Indian/Alaskan Native youth are at highest risk for gunshot wound as a result of a suicide attempt. There is evidence that youth-involved gun violence has increased during the pandemic. This session will explore the history of youth-involved gun violence, changes in gun violence during the COVID-19 pandemic, and therapeutic considerations about gun violence. Methods: This session will be organized around themes of “dysregulation”—how gun violence affects the lives of youth and how we respond to it as child and adolescent psychiatrists. For the theme of community dysregulation, Renuka Patel, MBBS, and Jennifer Zaspel, MD, will explore the history and epidemiology of youth-involved gun violence and look at changes during the pandemic. Alison M. Duncan, MD, will describe hospital and community response programs to promote recovery from gun violence and prevent future victimization. For the theme of individual dysregulation, Eva Ihle, MD, PhD, and Dr. Patel will present case vignettes and a literature review that will explore emotional and behavioral dysregulation before gun violence occurs (coping through affiliation and risk-taking behavior) and afterward (the sequelae of PTSD, a sense of foreshortened future, anger, and hopelessness). Inpatient acute rehabilitation and outpatient programs to promote posttraumatic growth and resilience in gunshot wound survivors will be discussed. Results: After this Clinical Perspectives session, participants will be able to: 1) discuss epidemiological changes in gun violence involving children and adolescents during the COVID-19 pandemic;2) recognize acute clinical needs for children and adolescents who are hospitalized for gunshot wounds;3) discuss gun safety with families;and 4) identify community supports and rehab resources for children and adolescents in postacute recovery from gun violence. Conclusions: Youth-involved gun violence has increased since the start of the COVID-19 pandemic. Gun violence is something that child and adolescent psychiatrists can address in the clinic, in the hospital, in their communities, and in politics. Terry Lee, MD, will discuss the roles that child and adolescent psychiatrists can take to reduce these tragic outcomes in our youth. Jeanette Scheid, MD, will discuss child maltreatment exposure and gun violence. AGG, EPI, PUP

Challenges on the interaction of models and policy for pandemic control.

The COVID-19 pandemic has seen infectious disease modelling at the forefront of government decision-making. Models have been widely used throughout the pandemic to estimate pathogen spread and explore the potential impact of different intervention strategies. Infectious disease modellers and policymakers have worked effectively together, but there are many avenues for progress on this interface. In this paper, we identify and discuss seven broad challenges on the interaction of models and policy for pandemic control. We then conclude with suggestions and recommendations for the future.

Early warning signals predict emergence of COVID-19 waves (preprint)

Early warning signals (EWSs) aim to predict changes in complex systems from phenomenological signals in time series data. These signals have recently been shown to precede the initial emergence of disease outbreaks, offering hope that policy makers can make predictive rather than reactive management decisions. Here, using daily COVID-19 case data in combination with a novel, sequential analysis, we show that composite EWSs consisting of variance, autocorrelation, and return rate not only pre-empt the initial emergence of COVID-19 in the UK by 14 to 29 days, but also the following wave six months later. We also predict there is a high likelihood of a third wave as of the data available on 9th June 2021. Our work suggests that in highly monitored disease time series such as COVID-19, EWSs offer the opportunity for policy makers to improve the accuracy of time critical decisions based solely upon surveillance data.

Markers of coagulation and hemostatic activation identify COVID-19 patients at high risk for thrombotic events

Introduction: COVID-19 has been associated with venous and arterial thrombotic complications. The objective of our study was to determine whether markers of coagulation and hemostatic activation (MOCHA) on admission could identify COVID-19 patients at risk for thrombotic events. Methods: COVID-19 patients admitted to a tertiary academic healthcare system from April 3, 2020 to July 31, 2020 underwent admission testing of MOCHA profile parameters (plasma d-dimer, prothrombin fragment 1.2, thrombin-antithrombin complex, and fibrin monomer). For this analysis we excluded patients on outpatient anticoagulation therapy preceding admission. Prespecified endpoints monitored during hospitalization included deep vein thrombosis, pulmonary embolism, myocardial infarction, ischemic stroke and access line thrombosis. Results: During the study period, 276 patients were included in the analysis cohort (mean age 59 ± 6.3 years, 47% female, 83% non-white race). Arterial and venous thrombotic events occurred in 43 (16%) patients (see Table). Each coagulation marker was independently associated with the composite endpoint (p<0.05). Admission MOCHA with ≥ 2 abnormalities was associated with the composite endpoint (OR 3.1, 95% CI 1.2-8.3), ICU admission (OR 3.2, 95% CI 1.8-5.5) and intubation (OR 2.8, 95% CI 1.5-5.5). Admission MOCHA with < 2 abnormalities (26% of the cohort) had sensitivity of 88% and a negative predictive value of 93% for an in-hospital endpoint. Conclusion: Admission MOCHA with ≥ 2 abnormalities identified COVID-19 patients at risk for a thrombotic event, ICU admission and intubation while < 2 abnormalities identified a subgroup of patients who were at low risk for thrombotic events. Our results suggest that an admission MOCHA profile can be useful to risk stratify COVID-19 patients. Further studies are needed to determine whether an admission MOCHA profile can guide anticoagulation therapy and improve overall clinical outcomes.(Figure Presented).

Reproduction as a Means of Evaluating Policy Models: A Case Study of a COVID-19 Simulation (preprint)

This article proposes (and demonstrates the effectiveness of) a new strategy for assessing the results of epidemic models which we designate reproduction. The strategy is to build an independent model that uses (as far as possible) only the published information about the model to be assessed. In the example presented here, the independent model also follows a different modelling approach (agent-based modelling) to the model being assessed (the London School of Hygiene and Tropical Medicine compartmental model which has been influential in COVID lockdown policy). The argument runs that if the policy prescriptions of the two models match then this independently supports them (and reduces the chance that they are artefacts of assumptions, modelling approach or programming bugs). If, on the other hand, they do not match then either the model being assessed is not provided with sufficient information to be relied on or (perhaps) there is something wrong with it. In addition to justifying the approach, describing the two models and demonstrating the success of the approach, the article also discusses additional benefits of the reproduction strategy independent of whether match between policy prescriptions is actually achieved.

A Fast and Accessible Method for the Isolation of RNA, DNA, and Protein To Facilitate the Detection of SARS-CoV-2.

Management of the coronavirus disease 2019 (COVID-19) pandemic requires widespread testing for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). A main limitation for widespread SARS-CoV-2 testing is the global shortage of essential supplies, among them RNA extraction kits. The need for commercial RNA extraction kits places a bottleneck on tests that detect SARS-CoV-2 genetic material, including PCR-based reference tests. Here, we propose an alternative method we call PEARL (precipitation-enhanced analyte retrieval) that addresses this limitation. PEARL uses a lysis solution that disrupts cell membranes and viral envelopes while simultaneously providing conditions suitable for alcohol-based precipitation of RNA, DNA, and proteins. PEARL is a fast, low-cost, and simple method that uses common laboratory reagents and offers performance comparable to that of commercial RNA extraction kits. PEARL offers an alternative method to isolate host and pathogen nucleic acids and proteins to streamline the detection of DNA and RNA viruses, including SARS-CoV-2.

Lessons Learned by Converting a First-Year Physical Chemistry Unit into an Online Course in 2 Weeks

The disruptions of the COVID-19 pandemic caused academic staff from around the world to convert to online methods of teaching. At the University of Western Australia, this transition was implemented half way through semester one. This commentary provides an overview of the changes made for a physical chemistry first year unit. We provide analysis into the lessons that we learned having gone through the process and how we can use this experience to improve the unit in the future.

Managing cancer care during the covid-19 pandemic-experience at a cancer department in a tertiary hospital in antigua and Barbuda

The emergence of corona virus disease 2019 (COVID-19) has caused a global public health emergency and the pandemic has forced the healthcare givers to organise their work differently to provide the same level of care to their patients. Meticulous planning and implementation of robust infection control, proper triage of patients, patient education and awareness and establishment of good command structure has become the norm. In this article we illustrate how the COVID-19 pandemic has affected the oncology department in a tertiary centre in the Caribbean country of Antigua & Barbuda. We describe the changes in treatment decisions for outpatient and inpatient services along with a look at the ethical considerations and the well-being of the oncology team.

A Fast and Accessible Method for the Isolation of RNA, DNA, and Protein to Facilitate the Detection of SARS-CoV-2 (preprint)

Management of the COVID-19 pandemic requires widespread SARS-CoV-2 testing. A main limitation for widespread SARS-CoV-2 testing is the global shortage of essential supplies, among these, RNA extraction kits. The need for commercial RNA extraction kits places a bottleneck on tests that detect SARS-CoV-2 genetic material, including PCR-based reference tests. Here we propose an alternative method we call PEARL (Precipitation Enhanced Analyte RetrievaL) that addresses this limitation. PEARL uses a lysis solution that disrupts cell membranes and viral envelopes while simultaneously providing conditions suitable for alcohol-based precipitation of RNA, DNA, and proteins. PEARL is a fast, low-cost, and simple method that uses common laboratory reagents and offers comparable performance to commercial RNA extraction kits. PEARL offers an alternative method to isolate host and pathogen nucleic acids and proteins to streamline the detection of DNA and RNA viruses, including SARS-CoV-2.

Geographical Accessibility to Glucose-6-Phosphate Dioxygenase Deficiency Point-of-Care Testing for Antenatal Care in Ghana.

BACKGROUND: Glucose-6-Phosphate Dehydrogenase (G6PD) deficiency screening test is essential for malaria treatment, control, and elimination programs. G6PD deficient individuals are at high risk of severe hemolysis when given anti-malarial drugs such as primaquine, quinine, other sulphonamide-containing medicines, and chloroquine, which has recently been shown to be potent for the treatment of coronavirus disease (COVID-19). We evaluated the geographical accessibility to POC testing for G6PD deficiency in Ghana, a malaria-endemic country. METHODS: We obtained the geographic information of 100 randomly sampled clinics previously included in a cross-sectional survey. We also obtained the geolocated data of all public hospitals providing G6PD deficiency testing services in the region. Using ArcGIS 10.5, we quantified geographical access to G6PD deficiency screening test and identified clinics as well as visualize locations with poor access for targeted improvement. The travel time was estimated using an assumed speed of 20 km per hour. FINDINGS: Of the 100 clinics, 58% were Community-based Health Planning and Services facilities, and 42% were sub-district health centers. The majority (92%) were Ghana Health Service facilities, and the remaining 8% were Christian Health Association of Ghana facilities. Access to G6PD deficiency screening test was varied across the districts, and G6PD deficiency screening test was available in all eight public hospitals. This implies that the health facility-to-population ratio for G6PD deficiency testing service was approximately 1:159,210 (8/1,273,677) population. The spatial analysis quantified the current mean distance to a G6PD deficiency testing service from all locations in the region to be 34 ± 14 km, and travel time (68 ± 27 min). The estimated mean distance from a clinic to a district hospital for G6PD deficiency testing services was 15 ± 11 km, and travel time (46 ± 33 min). CONCLUSION: Access to POC testing for G6PD deficiency in Ghana was poor. Given the challenges associated with G6PD deficiency, it would be essential to improve access to G6PD deficiency POC testing to facilitate administration of sulphadoxine-pyrimethamine to pregnant women, full implementation of the malaria control program in Ghana, and treatment of COVID-19 patients with chloroquine in malaria-endemic countries. To enable the World Health Organization include appropriate G6PD POC diagnostic tests in its list of essential in-vitro diagnostics for use in resource-limited settings, we recommend a wider evaluation of available POC diagnostic tests for G6PD deficiency, particularly in malaria-endemic countries.