Technology acceptance in the post-COVID multigenerational retail workforce: The relationship between employee development programs and job satisfaction

In the post-pandemic business environment, small and medium-sized enterprises have experienced historic voluntary employee turnover. One potential contributor to this phenomenon is job satisfaction. Small and medium-sized enterprises serve as the main driver of the global economy, representing 90% of all firms and 70% of the jobs worldwide. This study investigated the relationship between employee development and job satisfaction in the post-pandemic business environment and identified if technology acceptance in the multigenerational workforce moderates the relationship. The study was conducted using a quantitative non-experimental design. Retail workers of SMEs in the state of Florida were surveyed using instruments to measure employee development, technology acceptance, and job satisfaction. The study found that (a) employee development remains a driver of job satisfaction in the post-COVID-19 business environment, and (b) technology acceptance in the multigenerational workforce does not moderate the relationship between the variables. The study's overall findings offer practitioners of SMEs fresh insights into the impact of the rapid deployment of advanced technology on the post-COVID-19 business environment and its implications on job satisfaction in the multigenerational workforce. (PsycInfo Database Record (c) 2023 APA, all rights reserved)

The Feasibility and Impact of a Computer-Aided Genetics Education Module in an Obstetrics Clinic: A Randomized Controlled Trial

BackgroundRapid advances in prenatal genetic testing highlight the need for technology-based tools to assist in informed decision-making.PurposeThis study evaluates the feasibility, acceptability, and efficacy of a Computer-Aided Genetics Education Module (CAGEM) as an e-counseling tool and decision aid in a busy obstetric clinic among a socially disadvantaged patient population.MethodsA randomized controlled trial with patients randomized (1:1) to receive the intervention in addition to standard of care or standard of care only. Participants responded to pre- and posttest questionnaires.ResultsAlthough limited in recruitment by the COVID-19 pandemic, this tool scored 81.0% acceptability and 91.0% feasibility among 88 participants. No statistically significant difference was detected between the overall improvement in knowledge scores and the total posttest knowledge scores among the intervention and control groups. However, the intervention group scored significantly higher on the posttest questions regarding NIPT interpretation (61.7 +/- 49.1 vs 80.9 +/- 39.8, p = .049), Down syndrome (78.7 +/- 41.4 vs 93.6 +/- 24.7, p = .016), and inheritance of recessive conditions (59.6 +/- 49.6 vs 91.4 +/- 28.2, p < .001). The intervention group also showed a greater improvement in knowledge scores for inheritance of recessive conditions (31.9 +/- 8.1 vs 0 +/- 7.8, p = .006) and a protective effect in knowledge scores for Down syndrome (0 +/- 6.1 vs -17.1 +/- 6.0, p =.049).DiscussionCAGEM may be a feasible and acceptable e-counseling tool and decision aid, especially when compared to standard of care prenatal counseling. Although overall knowledge did not show significant improvement, CAGEM showed promise in enhancing knowledge acquisition for certain genetic education topics, showing that technology-based tools may be beneficial in informed consent. Future iterations may be revised to improve clarity, especially around invasive testing methods, race congruency, and insurance coverage.Translation to Health Education Practice: This study's method creates a model for Health Educators to design and evaluate technology-based tools for improving informed decision-making around prenatal genetic testing. Tools like CAGEM may be utilized to improve patient education prior to prenatal appointments and thus serve as an adjunct to provider counseling. Specifically, CAGEM addresses multiple NCHEC Responsibilities and Competencies including #1.1.2, 1.3.2, 1.3.4, 4.2.9, and 6.4.3.

Global Collaboration to Provide Drug Interaction Guidance for Nirmatrelvir/Ritonavir

Background: Nirmatrelvir/ritonavir (NMV/r), a preferred antiviral for high-risk outpatients with COVID-19, is associated with major drug-drug interactions (DDIs). Given the lack of DDI data with short course ritonavir (RTV), initial NMV/r product information was extrapolated from chronic, full dose RTV use. In Jan 2022, DDI experts from the University of Liverpool (UoL), NIH COVID-19 Guidelines Panel, and Ontario Science Table (OST) contributors established a global collaboration to address DDI challenges limiting NMV/r use in real-life settings. We report how safe, pragmatic, and consistent resources were developed to support NMV/r prescribing, and the utilization of these resources globally. Method(s): The 3 teams met monthly to discuss DDIs, review NMV/r DDI literature, and achieve consensus on recommendations. Additional experts were invited as needed. Metrics from the UoL DDI checker guided review of most searched DDIs overall and by severity. 2022 usage metrics for each DDI guide were collected. Differences in recommendations between initial DDI guides and product information were compared. Result(s): In 2022, 12 meetings were convened. Each team's DDI guide was revised and expanded (Table 1). To factor in the lower RTV dose and shorter treatment duration, some recommendations differed from product information. Drug categories that required the most discussion and revision included: anticoagulants (ACs), immunosuppressants, calcium channel blockers. NMV/r accounted for 85% of queries on the UoL site. NMV/r DDI guidance was the most viewed page of the NIH guidelines and among the OST ID/clinical care Science Briefs. Top searched drugs on the UoL site with serious DDIs were certain ACs and statins. Utilization of DDI guides was not limited to in-country resources: 51% and 7% of UoL queries came from the USA and Canada, respectively. NIH users followed links to the UoL and OST sites 161,478 and 37,619 times, respectively. Conclusion(s): Significant efforts have been made by the 3 teams to provide upto-date, complementary DDI guidance. Usage metrics confirm the demand for DDI guidance during the pandemic. Cross-utilization of the DDI guides confirms the need for consistency. DDI recommendations were more permissive than initial product information, expanding clinicians' ability to prescribe NMV/r. DDI guidance for ACs and immunosuppressants was particularly challenging. During drug development, complex interactions likely to be encountered in target populations should be addressed.

Religiosity, Mental Health and Substance Use among Black and Hispanic Adults during the First Six Months of the COVID-19 Pandemic in New York City.

The purpose of this study was to investigate the association between personal religiosity, mental health, and substance use outcomes among Black and Hispanic adults during the first six months of the COVID-19 outbreak in New York City (NYC). Phone interviews were conducted with 441 adults to obtain information on all variables. Participants self-reported race/ethnicity as Black/African American (n = 108) or Hispanic (n = 333). Logistic regression were used to examine associations between religiosity, mental health, and substance use. There was a significant inverse association of religiosity and substance use. Religious people had a lower prevalence of drinking alcohol (49.0%) compared to non-religious people (67.1%). Religious people also had substantially lower prevalence of cannabis or other drug use (9.1%) in comparison to non-religious people (31%). After adjusting for age, sex, race/ethnicity, and household income, the association of religiosity with alcohol use and with cannabis/other drug use remained statistically significant. Despite restricted access to in-person religious activities and congregational supports, the findings suggest that religiosity itself may be helpful from a public health perspective, independent of serving as a conduit for other social services.

Assimilation of aircraft observations over the Indian monsoon region: Investigation of the effects of COVID-19 on a reanalysis

Since March 2020, the COVID-19 pandemic has significantly reduced the availability of global aircraft-based observations (ABOs), which has been restored later in 2021. This study focuses on the impact of ABOs on a regional reanalysis. Indian Monsoon Data Assimilation and Analysis (IMDAA) is a regional reanalysis for a period from 1979 to 2020 (originally up to 2018) over India and surrounding regions produced at the National Centre for Medium Range Weather Forecasting (NCMRWF), India, in collaboration with the UK Met Office. A comparison of the impact of ABOs on other conventional and satellite observations assimilated in the NCMRWF global model and IMDAA during 2019 and 2020 revealed the importance of ABOs, particularly in IMDAA, since it did not assimilate the latest satellite data as the IMDAA system was frozen in October 2016. A data denial experiment that removes all the ABOs from the IMDAA assimilation system for a period from March to November 2019 is designed. The results from the IMDAA reanalysis run, which assimilates ABOs during the same period, are compared with the data denial experiment. Assimilation of ABOs strengthened the upper tropospheric circulation, the Tropical Easterly Jet (TEJ), during the Indian summer monsoon compared to the data denial experiment. Analysis of the features of two cyclones that developed over the North Indian Ocean during the study period revealed that ABO assimilation played a key role in simulating the track and intensity of these cyclones when they were in the ‘severe' category. Since the sample is small, more cyclone cases need to be analysed to consolidate the result. © 2023 Royal Meteorological Society.

Dipeptidyl Peptidase-1 Inhibition in Patients Hospitalized with COVID-19: a Multicentre Randomized Double-Blind Placebo Controlled Trial

Background: Neutrophil serine proteases (NSPs) are involved in the pathogenesis of COVID19 and are increased in severe and fatal infection. We investigated whether treatment with Brensocatib, an inhibitor of dipeptidyl peptidase-1, an enzyme responsible for the activation of NSPs, would improve outcomes in hospitalized patients with COVID19. Method(s): In a randomized, double-blind, placebo-controlled trial, 406 hospitalized patients with COVID19 with at least one risk factor for severe disease were randomized 1:1 to once-daily Brensocatib 25mg (n=192) or placebo (n=214) for 28 days. Primary outcome was the 7-point World Health Organisation Clinical Status scale at day 29. Secondary outcomes included time to clinical improvement, national early warning score, new oxygen and ventilation use, neutrophil elastase activity in blood and mortality. Finding(s): Brensocatib treatment was associated with worse clinical status at day 29 (adjusted odds ratio 0 72, 95%CI 0 57-0 92) compared to placebo. The adjusted hazard ratio (aHR) for time to clinical improvement was 0 87 (95%CI 0 76-1 00) and time to hospital discharge was 0 98 (95%CI 0 84-1 13). During the 28-day follow-up period, 23 (11%) and 29 (15%) patients died in the placebo and Brensocatib treated groups respectively). Oxygen and new ventilation use were greater in the Brensocatib treated patients. Neutrophil elastase activity in blood was significantly reduced in the Brensocatib group from baseline to day 29. Prespecified subgroup analyses of the primary outcome supported the primary results.

An effective Approach for Pneumonia Detection using Convolution Vision Transformer

Early detection of pneumonia in patients through effective medical imaging may enable timely remedial measures and reduce the severity of the infection. There is an increase in cases among new-borns, teenagers and also people with health issues in recent years. The COVID-19 pandemic also revealed the major impact pneumonia had on the lungs and the consequences of delayed detection. The presence of the infection in the lungs is examined through images of Chest X-ray, however, for an early diagnosis of the infection, this paper proposes an automated model as a more effective alternative. Convolutional Vision Transformer (CVT) which gives an accuracy of 97.13%, and is a robust combination of Convolution and Vision Transformer (ViT), is suggested in this paper as a potential model to detect pneumonia early in patients. © 2022 IEEE.

Effect of Higher-Dose Ivermectin for 6 Days vs Placebo on Time to Sustained Recovery in Outpatients With COVID-19: A Randomized Clinical Trial.

Importance: It is unknown whether ivermectin, with a maximum targeted dose of 600 µg/kg, shortens symptom duration or prevents hospitalization among outpatients with mild to moderate COVID-19. Objective: To evaluate the effectiveness of ivermectin at a maximum targeted dose of 600 µg/kg daily for 6 days, compared with placebo, for the treatment of early mild to moderate COVID-19. Design, Setting, and Participants: The ongoing Accelerating COVID-19 Therapeutic Interventions and Vaccines 6 (ACTIV-6) platform randomized clinical trial was designed to evaluate repurposed therapies among outpatients with mild to moderate COVID-19. A total of 1206 participants older than 30 years with confirmed COVID-19 experiencing at least 2 symptoms of acute infection for less than or equal to 7 days were enrolled at 93 sites in the US from February 16, 2022, through July 22, 2022, with follow-up data through November 10, 2022. Interventions: Participants were randomly assigned to receive ivermectin, with a maximum targeted dose of 600 µg/kg (n = 602) daily, or placebo (n = 604) for 6 days. Main Outcomes and Measures: The primary outcome was time to sustained recovery, defined as at least 3 consecutive days without symptoms. The 7 secondary outcomes included a composite of hospitalization, death, or urgent/emergent care utilization by day 28. Results: Among 1206 randomized participants who received study medication or placebo, the median (IQR) age was 48 (38-58) years, 713 (59.1%) were women, and 1008 (83.5%) reported receiving at least 2 SARS-CoV-2 vaccine doses. The median (IQR) time to sustained recovery was 11 (11-12) days in the ivermectin group and 11 (11-12) days in the placebo group. The hazard ratio (posterior probability of benefit) for improvement in time to recovery was 1.02 (95% credible interval, 0.92-1.13; P = .68). Among those receiving ivermectin, 34 (5.7%) were hospitalized, died, or had urgent or emergency care visits compared with 36 (6.0%) receiving placebo (hazard ratio, 1.0 [95% credible interval, 0.6-1.5]; P = .53). In the ivermectin group, 1 participant died and 4 were hospitalized (0.8%); 2 participants (0.3%) were hospitalized in the placebo group and there were no deaths. Adverse events were uncommon in both groups. Conclusions and Relevance: Among outpatients with mild to moderate COVID-19, treatment with ivermectin, with a maximum targeted dose of 600 µg/kg daily for 6 days, compared with placebo did not improve time to sustained recovery. These findings do not support the use of ivermectin in patients with mild to moderate COVID-19. Trial Registration: ClinicalTrials.gov Identifier: NCT04885530.

Trends in dental insurance claims in the United States in the context of the COVID-19 pandemic: A 3-year perspective (2019-2022).

OBJECTIVES: We showed in a previous analysis the patterns of disruption for private dental insurance claims in the United States caused by the SARS-CoV-2 pandemic in 2020. The present report examines trends during 2020 and 2021, that is, contrasting perspectives during 2019 with the acute phase of the pandemic in 2020, and 2021. METHODS: Private dental insurance paid claims from a data warehouse were obtained, encompassing a 5% random sample of records between January 2019 and December 2021 for child and adult insureds who filed a claim in 2019, 2020, and 2021. We classified claims into one of four categories based on the likelihood of being associated with urgent/emergency care. RESULTS: The precipitous reduction in dental care claims in March-June 2020 recovered to almost pre-pandemic levels by the fall of 2020. However, a downward decline in private dental insurance claims started in the late fall of 2020 and continued through 2021. Differential impacts in dental care categories-in terms of urgency of care-were evident 2021, closely resembling previous trends in 2020. CONCLUSIONS: Dental care claims from the first year of the 2020 SARS-CoV-2 pandemic were contrasted with perspectives in 2021. A downward trend in demand/availability changes in dental care insurance claims set in for 2021, perhaps linked to perceptions of the overall economic situation. Such downward trend has continued overall, even after considering seasonal changes and the acceleration of the pandemic during the Delta, Omicron, and other variants.

A dermatologic assessment of 101 mpox (monkeypox) cases from 13 countries during the 2022 outbreak: Skin lesion morphology, clinical course, and scarring.

BACKGROUND: In the 2022 mpox (monkeypox) outbreak, 79,000 global cases have been reported. Yet, limited dermatologic data have been published regarding lesion morphology and progression. OBJECTIVE: The objective of this study was to characterize skin lesion morphology, symptomatology, and outcomes of mpox infection over time. METHODS: The American Academy of Dermatology/International League of Dermatological Societies Dermatology COVID-19, Mpox, and Emerging Infections Registry captured deidentified patient cases of mpox entered by health care professionals. RESULTS: From August 4 to November 13, 2022, 101 cases from 13 countries were entered, primarily by dermatologists (92%). Thirty-nine percent had fewer than 5 lesions. In 54% of cases, skin lesions were the first sign of infection. In the first 1-5 days of infection, papules (36%), vesicles (17%), and pustules (20%) predominated. By days 6-10, pustules (36%) were most common, followed by erosions/ulcers (27%) and crusts/scabs (24%). Crusts/scabs were the predominant morphology after day 11. Ten cases of morbilliform rash were reported. Scarring occurred in 13% of the cases. LIMITATIONS: Registry-reported data cannot address incidence. There is a potential reporting bias from the predilection to report cases with greater clinical severity. DISCUSSION: These findings highlight differences in skin findings compared to historical outbreaks, notably the presence of skin lesions prior to systemic symptoms and low overall lesion counts. Scarring emerged as a major possible sequela.

Procalcitonin and D-dimer levels at baseline, but not CRP, were informative of COVID-19 hospitalization outcomes

Background. The WHO estimates 512 million cases of COVID-19 and 6.2 million deaths globally as of May 4th, 2022. In Michigan (MI), the first case was diagnosed March 10th, 2020. We describe here outcomes of COVID-19 patients cared for in a large tertiary hospital in 2020 spanning two surges based on baseline lab values for C-reactive protein (CRP), Procalcitonin (PC), and D-Dimer (DD). Methods. After IRB approval, adult patients diagnosed via PCR with COVID-19 during the two surges in 2020 and admitted to Beaumont Hospital, Royal Oak, an 1,131 beds tertiary care referral center in MI, were reviewed. Demographic, clinical and laboratory characteristics were obtained from the EMR. ICD-10 classification diagnoses were utilized to identify comorbidities, and patient BMIs were based on the admission values in the EMR. Outcomes were defined as death during current admission, transfer to nursing home or other facility, or discharge home. Using a tree-based model and the combined levels of the three labs we defined a hierarchy of four lab levels, each progressively having increased risk of death. We then analyzed the outcome for the four levels, adjusting for time period (surge), age, sex, race, BMI and comorbidities. Data was analyzed using SAS statistical software version 9.4 (SAS Institute). Results. A total of 2197 patients were identified from March through December 2020, of whom 1118 had CRP, PC and DDavailable at baseline. The mean age was 66.7 years (SD 16.1) for the cohort in first surge (March-June), and 66.4 (15.6) in the latter surge (July-December, Table1). More patients had a PC of >0.5 in the first surge (25.7%) than the second (13.2%). After adjusting for all other factors, the hierarchical lab levels are significantly associated with outcomes. Of note, baseline CRP value was not informative. Compared to the 2nd level (Table 2), the lowest level (PC < 0.1) has significantly lower odds of death [OR=0.37, 95% CI (0.19, 0.73)], while the highest level, (DD >1000 and PC >= 0.26) has significantly higher odds of death [OR=3.01, 95% CI (1.59, 5.72)]. Conclusion. Baseline PC and DD, but not CRP, were informative in determining risk of death and can assist clinicians determine possible outcomes during COVID-19 hospitalization.

BOLSTERING SOCIAL CONNECTEDNESS DURING COVID-19: COMMUNICATION BETWEEN ESSENTIAL CONTACTS AND OLDER ADULTS

Social isolation may increase morbidity and mortality, particularly for aging adults. Research suggests that COVID-19 has significantly disrupted social networks, exacerbating isolation and risk. However, the extent of disruption and its implications for older adults and their essential contacts (ECs) is unknown. ECs, those who provide support/engagement to older adults, play a significant role in networks and help shape communication patterns. Understanding the effects of COVID-19 on social connectedness between ECs and older adults is vital to promoting their well-being. The purpose of this study was to investigate ECs' patterns of communication with adults aged 60+ during the COVID-19 pandemic , considering preferences, needs, and barriers. Self-identified ECs (N=546, Aged 19+, MAge=44.3±14.2) completed a Qualtrics survey via Amazon Mechanical Turk. Participants were ECs for community-dwelling (CDECs=57.3%) and institutionalized adults (IECs=42.7%). In addition to likert-style questions, the survey included free-response sections, examining communication quality, frequency, and method. Content analysis was conducted independently by two reviewers, using inductive coding. Qualitative results revealed distanced communication was widely utilized. Audiovisual/video communication was more frequently noted as desirable by IECs (32.8%) than CDECs (11.85%). Further, preference for audiovisual communication negatively correlated to expression of COVID-19-related barriers (IECs=12.5%, CDECs=7.7%, (r(546)= -.128, p=.01). Comparisons suggested that IECs reported absence of in-person contact with older adults more frequently than CDECs (recent contact=Never: 51% and 13.4% respectively). This may support the utility of video-communication to meaningfully supplement connectedness in the absence of in-person contact. The experiences described can reveal avenues for loneliness interventions and may guide future technology innovations.

Low Serum Albumin at Admission Is Associated with Mortality among Inpatients with Cirrhosis: A Multi-National Experience

Background: MELD and Child-Pugh scores have traditionally been used as prognostic indicators in patients with cirrhosis. Albumin infusions in outpatients have been associated with improved outcomes, but not in transplant waitlisted patients or inpatients. This aim of this study was to assess whether low serum albumin (sAlb) on admission alone is a poor prognostic indicator among cirrhotic inpatients from a new multi-national cohort. Method(s): The CLEARED study is a global study that enrolled consecutive non-electively admitted inpatients without organ transplant or COVID-19 from 6 continents. Admission demographics, medical history, laboratory data, inpatient course, death/hospice transfer and mortality at 30 days post-discharge were recorded. Patients were divided into 3 groups: sAlb <28gm/L(A), sAlb >=28 but <35gm/L (B), and sAlb>=35gm/L (C) were compared. Multi-variable logistic regression was performed using inpatient mortality and overall 30-day mortality as outcomes. Result(s): 2429 patients were enrolled from 21 countries worldwide. The distribution was A:49%, B:39%, C:12%. Gp A patients were significantly younger (54yrs vs. 57yrs vs 58yrs p<0.0001) but with similar gender distribution, and higher MELD-Na score of 25 vs. 20 vs. 17 (p<0.0001). Gp A patients were more likely to have alcohol as etiology of cirrhosis (49% vs. 45% vs 38%, p=0.004), and were more likely to have either infection (27% vs. 18% vs. 13%, p<0.0001), HE (39% vs. 33% vs. 23%, p=0.005) or fluid related issues as a reason for admission (p<0.0001). More patients in Gp A received albumin infusion during their hospital stay (120gm vs. 100gm vs. 100gm p=0.0004), mostly for the indications of AKI (47% vs. 49% vs. 47%, p=0.79) and performance of large volume paracentesis (44% vs. 42% vs. 41%, p=0.80), followed by bacterial peritonitis indication (22% vs. 17% vs. 11%, p=0.01). Group A patients had longer hospital stays (9 days vs. 8 days vs. 7 days (p<0.001), but similar ICU transfer (23% vs. 22% vs. 20%, p=0.55). group A patients were more likely to die while inpatients (19% vs. 11% vs. 5%, p<0.0001), or by 30 days post-discharge (29% vs. 20% vs. 9%, p<0.0001). Table shows the admission variables associated with a poor outcome. Conclusion(s): Hypoalbuminemia is extremely common among admitted cirrhotic patients, with sAlb of <28gm/L occurring in almost half. Together with MELD-Na score and infection at admission, a low sAlb is associated with a poor outcome in these patients. Future studies will need to validate these findings and to assess whether albumin infusions will improve the outcome of these patients. (Figure Presented).

Differences in Mortality Rates in Inpatients with Cirrhosis Depends on the Low, Middle or High Income Country Location: Multi-National Cleared Consortium Experience

Background: Although cirrhosis is a major cause of mortality worldwide, there could be disparities in outcomes. This needs a global consortium to study disparities in inpatient cirrhosis care Aim: Define the impact of location in prediction of outcomes in inpts with cirrhosis. Method(s): CLEARED prospectively enrolled non-electively admitted cirrhosis pts without COVID from all continents. To ensure equity, we allowed only 50 pts/site. Admission details, cirrhosis history, inpatient & 30-day course were recorded. World bank classification of low/low middle income (LMI), upper middle (UMI) & High income (HI) were used. Cirrhosis details, inpatient & 30-day outcomes were compared between groups. Multi-variable regression was performed using inpatient & 30-day mortality as outcomes. Result(s): 2758 pts from 21 countries from all continents, including Africa & Australia, were included.727 were L/LMI, 1050 UMI & 981 pts were from HICs. More men & younger pts were in LMI. Cirrhosis details: More pts in HI gp had 6M hospitalizations & infections, HE & ascites while prior variceal bleeding was higher in LMI . Prior HCC & transplant listings were lower in LMI but similar in UMI/HI. Alcohol & NASH was highest in HI. Viral hepatitis & cryptogenic were highest in UMI.Admissions: Admission MELD was highest in LMI. LMI pts were admitted more for GI Bleed, HE, & DILI, while anasarca & HBV flares were higher in UMI. Higher SBP (36% vs 24% vs 21% p<0.0001) & lowest skin/soft-tissue infections were in LMI (5% vs 5% vs 10% p=0.008);rest were similar. Nosocomial infections, driven by UTI were highest in LMI & HI pts (15% vs 14% vs 11% UMI, p=0.03). Admission diuretics, PPIs, Lactulose & statins were highest & antivirals lower in HI. SBP prophylaxis & rifaximin were highest in LMI pts. Outcome(s): More LMI pts needed ICU & had more organ failures (Fig B). Discharge MELD was highest in LMI. In-hospital mortality was highest & transplant lowest in LMI. This extended to 30-day mortality & transplant in LMI patients vs HI pts.Regression: In-hospital mortality was linked with age, infections, MELD & being in a LMI/UMI vs HIC while being on a transplant list, diabetes, & SBP prophylaxis were protective (Fig C). 30-day mortality predicted by age, ascites, HCC, discharge MELD, organ failures, LMI/UMI vs HIC but rifaximin was protective(Fig D). In-hospital transplant was higher with high MELD, admission rifaximin & listed pts &lower in LMI (OR 0.26) & UMI (OR 0.22) & age. 30-day transplant was higher in those with hyponatremia, ascites & HRS, on the list & on rifaximin and lower in LMI (OR 0.24) & UMI (OR 0.59) vs HI. Conclusion(s): In a global study of inpatients with cirrhosis, there were major differences in outcomes. Not being in a high-income country significantly increased the risk of inpatient and 30-day mortality independent of demographics, medications, in-hospital course, and cirrhosis severity likely due to disparities in access to transplant, which should be accounted for in global models. (Figure Presented).

COVID-19 Pandemic: Impact on Healthcare in Missouri

Most elective and non-essential procedures and in-person visits were deferred in Missouri based on CDC and CMS recommendations in order to preserve PPE, and free up equipment, ORs, hospital beds, ICUs and ventilators for an expected surge of COVID-19 cases (as was seen in Italy and New York City), and to prevent the spread of the virus in the healthcare setting. A trip to the supermarket, hardware store, or gas station may well be riskier than going to the doctors office or an outpatient surgery center, which are much better controlled environments. By having a detailed, written COVID-19 pandemic preparedness plan in place, we have been able to bring back staff who were leery of working during these uncertain times. [...]there is a vaccine or some highly effective treatment, COVID-19 will be with us.

Unintended Consequences of Prior Authorization

There are a number of ways that PAs could reduce burden on physicians, interfere less with patient care, save administrative costs for both sides and allow payors to focus on areas of overuse, waste and abuse of scarce healthcare resources. Development of "best practices" by physician organizations and payors working together to eliminate the need for prior authorization when such best practices are followed.2 The Missouri State Medical Association has been able to, through its advocacy on behalf of Missouri physicians and their patients, get S.B. 514 passed in 2019 and signed into law. The COVID-19 pandemic has led the Centers for Medicare and Medicaid Services to allow waivers of PAs by Medicare Advantage (MA) Plans and Medicare Part D to facilitate healthcare access for beneficiaries during the public health emergency.3 It is not clear if the MA Plans have taken advantage of this flexibility.

Who You Gonna Call?

MSMA has successfully spearheaded additional reforms to reduce lawsuit abuse: expert witness reforms that require testimony to be based on evidence widely accepted by the scientific community, updates to the collateral source rule so plaintiffs can only recover actual monetary damages instead of billed charges and increasing the standard of proof for punitive damage claims. There are many groups, including the state's trial attorneys, the hospitals, integrated healthcare systems, pharmacy benefit managers, pharmacy chains, health insurers, and many others that are in Jefferson City every day often pushing positions that are at odds with what is best for our patients. Select Legislation important for Physicians and Patients that MSMA Passed or Blocked 2010 * Insurance company prompt pay (signed into law) * Naturopath licensure and scope expansion (blocked) * Private Medicaid fraud lawsuits (blocked) * Statute of limitations expansion for medical malpractice cases and weakening of the collateral source rule (blocked) * Tiering of physicians (blocked) * Autism insurance coverage (signed into law) 2011 * Drug testing of surgeons (blocked) * Chiropractors Medicaid payment (blocked) * Allowing professional counselors to diagnose (blocked) * Board of Healing Arts civil penalties (blocked) * Implementation of concussion protocols for student athletes (signed into law) * Preemption of local tobacco laws (blocked) 2012 * Increased use of ignition interlock devices (signed into law) * Regulations on the creation and operation of HIEs (signed into law) * Lay midwife licensure (blocked) * CRNA scope expansion (blocked) * Co-pay equity between primary care physicians and physical therapists (blocked) 2013 * Prompt credentialing improvements (signed into law) * Telehealth reimbursement parity (signed into law) * Repeal of collaborative practice act (blocked) * Volunteer physician malpractice immunity (signed into law) * Updating of newborn screening requirements (signed into law) * Mandatory arbitration for claims over 30 days unpaid (blocked) 2014 * Non-physician clinicians scope expansion (blocked) * Tanning bed parental permission (signed into law) * Establishment of ECHO telehealth distance learning program (signed into law) * Statewide Medicaid managed care implementation (blocked) 2015 * Tort reform (signed into law) * Establishment of direct primary care services (blocked) * Expansion of APRN scope-of-practice (blocked) * Parental notification of immunization exemptions (signed into law) 2016 * Telehealth expansion (signed into law) * Prohibit MOC/MOL for licensure (signed into law) * Licensure not conditioned on participating in any health insurance plan (signed into law) * Step therapy reform (signed into law) * Insurance contracts gag clauses banned (signed into law) * APRN, athletic trainers, physical therapists, radiology technicians scope expansion (blocked) 2017 * Expert witness reform (signed into law) * Collateral source rule updated (signed into law) * Tort reform fix for hospital non-employees (signed into law) * Requirements for medical student mental health and wellbeing (signed into law) * APRN opioid prescriptive authority expansion (blocked) * Implementation of statewide naloxone protocol (signed into law) 2018 * Protection of prudent layperson standard in the ER (signed into law) * Prohibit pharmacy gag clauses (signed into law) * Non-physician clinicians, physical therapists, radiology technicians scope expansion (blocked) * Implementation of workers compensation fee schedule (blocked) * Increased Medicaid post-partum benefits (signed into law) 2019 * Prior authorization reform (signed into law) * Prohibit use of virtual credit cards by insurers (signed into law) * Establishment of pregnancy-associated mortality review board (signed into law) * Implementation of statewide MAT insurance coverage for opioid disorders (blocked) * Defeat of various anti-vaccination requirements for physicians (blocked) * Independent pharmacist prescribing (blocked) 2020 * Punitive damages only for intentional or malicious act (signed into law) * Prompt credentialing to pay from the date of application (signed into law) * Overpayment transparency (signed into law) * Vaping prohibitions (signed into law) * Criminal penalties for gender dysmorphia treatments (blocked)

Outcomes of acute type A aortic dissection during the COVID-19 pandemic: An analysis of the Society of Thoracic Surgeons Database.

PURPOSE: There have been reported reductions of hospital presentation for acute cardiovascular conditions such as myocardial infarction and acute type A aortic dissection (ATAAD) in the United States during the COVID-19 pandemic. This study examined presentation patterns and outcomes of ATAAD in North America immediately before, and during, the COVID-19 pandemic. METHODS: The Society of Thoracic Surgeons Adult Cardiac Surgery Database (STS ACSD) was queried to identify patients presenting with ATAAD in the 12 months pre-pandemic (March 2019-February 2020), and during the early pandemic (March through June 2020). Demographics and operative characteristics were compared using χ² test and Wilcoxon Rank-sum test. The median annual case volume designated low-volume centers versus high-volume centers (>10 cases per month). Step-wise variable selection was used to create a risk set used for adjustment of all multivariable models. RESULTS: There were 5480 patients identified: 4346 pre-pandemic and 1134 during pandemic. There was significantly lower volume of median cases per month during the COVID-19 pandemic period (286 interquartile range [IQR]: 256-306 vs. 372 IQR: 291-433,p = .0152). In historically low-volume centers (<10 cases per year), there was no difference in volume between the two periods (142 IQR: 133-166 vs. 177 IQR: 139-209, p = NS). In high-volume centers, there was a decline during the pandemic (140 IQR: 123-148 vs. 212 IQR: 148-224, p = .0052). There was no difference in overall hospital-to-hospital transfers during the two time periods (54% of cases pre-pandemic, 55% during). Patient demographics, operative characteristics, malperfusion rates, and cardiac risk factors were similar between the two time periods. There was no difference in unadjusted operative mortality (19.01% pre-pandemic vs. 18.83% during, p = .9) nor major morbidity (52.42% pre-pandemic vs. 51.24% during, p = .5). Risk-adjusted multivariable models showed no difference in either operative mortality nor major morbidity between time periods. CONCLUSIONS: For patients presenting to the hospital with ATAAD during the first surge of the pandemic, operative outcomes were similar to pre-pandemic despite a 30% reduction in volume. Out-of-hospital mortality from ATAAD during the pandemic remains unknown. Further understanding these findings will inform management of ATAAD during future pandemics.

Validation of the Baveno VI criteria for the exclusion of high-risk varices in western Sydney

Background and Aim: The Baveno VI guidelines recommend that screening for high-risk varices (HRV) by endoscopy can be safely avoided in patients with compensated advanced chronic liver disease (cACLD) with a liver stiffness measurement (LSM) < 20 kPa and a platelet count > 150 x 109. We aimed to validate these criteria in a real-world cohort in western Sydney, Australia. Method(s): This retrospective study included patients with cACLD who underwent screening endoscopy for varices in the Western Sydney Local Health District. Inclusion criteria included a FibroScan no more than 12 months before screening endoscopy. Exclusion criteria were splanchnic vein thrombosis, non-cirrhotic portal hypertension, use of beta-blockers, and history of esophageal varices. Result(s): Based on the study criteria, 108 patients qualified. The main etiology of cirrhosis was hepatitis C (54.6%), with 91.7% of patients classified as Child-Pugh A. Varices were present in 38% of cases, with a 13.9% prevalence of HRV. In total, 38/108 patients (35.2%) satisfied the Baveno VI criteria. Within this group, 10.5% had varices and 2.6% had HRV, representing 6.7% of all HRV. The Baveno VI criteria had a sensitivity of 0.93, specificity of 0.4, positive predictive value of 0.2, negative predictive value of 0.97, positive likelihood ratio of 1.55, and negative likelihood ratio of 0.18. The area under the receiver operating characteristic curve for LSM and platelet count combined was 0.715 (P = 0.008) (Fig. 1). Conclusion(s): The Baveno VI criteria performed well with good accuracy in excluding HRV in a real-world Western Sydney cohort. Formal implementation of Baveno VI guidelines could have resulted 35.2% of less endoscopies. Given the resource restraints and long waiting times in the public health system, particularly in the COVID era, such strategies should be considered to improve access for essential screening procedures, while avoiding unnecessary overservicing.