Adapting learning materials for the digital age: Teacher education during emergency remote learning

Pivoting to emergency remote learning (ERL) during the COVID-19 pandemic highlighted the ingenuity and perseverance of teacher educators. As a hallmark of the shift to ERL, teacher educators provided authentic and meaningful science learning experiences for students and teachers despite facing incredible struggles. This chapter focuses on the affordances and challenges of developing, disseminating, and reimagining online classroom materials, resources, and experiential learning. The three sections of this chapter include creative solutions to utilize physical resources through repurposing household items and distributing science kits, adapting physical resources to the digital world, and capitalizing on existing online infrastructure such as live animal cameras and videos. The examples shared in this chapter are intended to provide teacher educators inspiration and pathways to implement engaging and high-quality virtual science learning experiences for in-service and pre-service teachers, with the intention that such practices be leveraged during ERL and beyond. © 2023, IGI Global.

Child neurology telemedicine: Analyzing 14 820 patient encounters during the first year of the COVID-19 pandemic

Aim: To determine the long-term impact of telemedicine in child neurology care during the COVID-19 pandemic and with the reopening of outpatient clinics. Method(s): We performed an observational cohort study of 34 837 in-person visits and 14 820 telemedicine outpatient visits across 26 399 individuals. We assessed differences in care across visit types, time-period observed, time between follow-ups, patient portal activation rates, and demographic factors. Result(s): We observed a higher proportion of telemedicine for epilepsy (International Classification of Diseases, 10th Revision G40: odds ratio [OR] 1.4, 95% confidence interval [CI] 1.3-1.5) and a lower proportion for movement disorders (G25: OR 0.7, 95% CI 0.6-0.8;R25: OR 0.7, 95% CI 0.6-0.9) relative to in-person visits. Infants were more likely to be seen in-person after reopening clinics than by telemedicine (OR 1.6, 95% CI 1.5-1.8) as were individuals with neuromuscular disorders (OR 1.6, 95% CI 1.5-1.7). Self-reported racial and ethnic minority populations and those with highest social vulnerability had lower telemedicine participation rates (OR 0.8, 95% CI 0.8-0.8;OR 0.7, 95% CI 0.7-0.8). Interpretation(s): Telemedicine continued to be utilized even once in-person clinics were available. Pediatric epilepsy care can often be performed using telemedicine while young patients with neuromuscular disorders often require in-person assessment. Prominent barriers for socially vulnerable families and racial and ethnic minorities persist.Copyright © 2022 Mac Keith Press.

CEFAZOLIN-INDUCED COAGULOPATHY

SESSION TITLE: Critical Thinking SESSION TYPE: Case Reports PRESENTED ON: 10/19/2022 09:15 am - 10:15 am INTRODUCTION: Cephalosporins have been known to cause hypo-prothrombinemia and prothrombin prolongation (1). The proposed mechanism of this coagulopathy is secondary to a N-methylthiotetrazole side chain interfering with vitamin-k metabolism (1). Current literature supporting the association between cefazolin and hypo-prothombinemia have only been reported through case reports. As cefazolin is a commonly used antibiotic, it is important that healthcare professionals are aware of its potential bleeding risk. We present a case of a 72 year old female with cefazolin-induced hypo-prothrombinemia. CASE PRESENTATION: A malnourished 72-year old female with a past medical history of recent methicillin-susceptible Staphyloccocus aureus (MSSA) bacteremia and COVID-19 pneumonia presented to the emergency department from a skilled nursing facility (SNF) due to shortness of breath. The patient was previously discharged to SNF to complete a 14 day course of IV cefazolin due to her MSSA bacteremia. On admission, vital signs were significant for a respiratory rate of 22 and a pulse oximetry reading of 78% on room air. Laboratory findings were significant for an elevated prothrombin time of >100 seconds, an INR >15, and a D-dimer of 42,344 ng/mlL. A computed tomography angiography (CTA) of the chest revealed a small segmental pulmonary embolus in the right lower lobe of the lung. The patient was started on a heparin drip, placed on a non-rebreather mask, and admitted to the ICU for closer monitoring. Infectious disease was consulted and cefazolin was discontinued. Due to the patient's risk of bleeding her heparin drip was stopped. It was decided not to reverse the patient's coagulopathy with vitamin K as there were no signs of an acute bleed in the setting of an acute pulmonary embolus. The patient was started on nafcillin in place of cefazolin. Four days after discontinuation of cefazolin, the patient's INR had trended down from >15 to 1.6 and she was started on Lovenox 1mg/kg for the treatment of her acute PE. DISCUSSION: Due to the timing of the discontinuation of cefazolin and the correction of the hypo-prothrombinemia, a clear association between the two can be made. It has been proposed that cefazolin's side chain, heterocyclic thiol, 2-methyl-1,3,4-thiadiazole-5-thiol (MTD), causes a similar reaction that other cephalosporins have on the metabolism of Vitamin K (2). This altered Vitamin K metabolism was also likely exacerbated due to the patient's malnourishment and likely depleted vitamin k reserves (2). CONCLUSIONS: Although rare, this case demonstrates the need for clinicians to be aware of the potential bleeding risk associated with cephalosporins and cefazolin in particular. In the future, routine monitoring of PT/INR levels may be recommended when initiating cephalosporins. Reference #1: Park GH, Kim S, Kim MS, Yu YM, Kim GH, Lee JS, Lee E. The Association Between Cephalosporin and Hypoprothrombinemia: A Systematic Review and Meta-Analysis. Int J Environ Res Public Health. 2019 Oct 16;16(20):3937 Reference #2: Shearer, M. J., Bechtold, H., Andrassy, K., Koderisch, J., McCarthy, P. T., Trenk, D., Jähnchen, E., & Ritz, E. (1988). Mechanism of cephalosporin-induced hypoprothrombinemia: relation to cephalosporin side chain, vitamin K metabolism, and vitamin K status. Journal of clinical pharmacology, 28(1), 88–95 DISCLOSURES: no disclosure on file for John Abernathy;No relevant relationships by Ethan Goldberg No relevant relationships by Renee Miu No relevant relationships by Luis Osorio no disclosure on file for Satesh Saroop;no disclosure on file for Oliver Sevilla;no disclosure on file for Kristen Zubel;

SAFETY OF 30-ML/KG IV FLUID ADMINISTRATION PER SEP-1 TO ADULT PATIENTS IN THE ED MEETING CRITERIA FOR SEPTIC SHOCK BEFORE KNOWN COVID-19 STATUS

SESSION TITLE: Outcomes Across COVID-19 SESSION TYPE: Rapid Fire Original Inv PRESENTED ON: 10/19/2022 11:15 am - 12:15 pm PURPOSE: ED clinicians play a critical role in the early detection and management of septic shock. Intravenous fluid (IVF) resuscitation is a central component of the recommended treatment for septic shock (SEP-1), but experts have expressed concerns that excessive fluid administration to patients with COVID-19 could lead to poor clinical outcomes due to the development of ARDS like lung physiology. COVID-19 status is often unknown in the first several hours after ED arrival and withholding adequate IVF resuscitation to patients with septic shock is known to be harmful. Our objective was to evaluate whether adult ED patients meeting criteria for septic shock (≥2 SIRS + initial lactate ≥4 or Mean Arterial Pressure (MAP) <65) who receive 30ml/kg of IV fluids in the ED have poor clinical outcomes, if they are later found to have COVID-19, compared to adult ED patients with non-COVID-19 septic shock. METHODS: In this retrospective cohort study we analyzed EHR of adult patients who visited any of 3 EDs within a single academic health system in Rhode Island. We included patients who had a discharge diagnosis of septic shock and presented to the ED between February 15 -September 30, 2020. The exposure was the receipt of 30ml/kg of IVF and outcomes were intensive care unit (ICU) admission, ventilator receipt, and inpatient mortality. We used multivariate logistic regression and adjusted for fluid volume, age, receipt of antibiotics, and Charlson Comorbidity Index. RESULTS: Of 278 patients with septic shock, 39 (14%) were COVID positive. 15 (38%) COVID positive patients received 30ml/kg IVF per SEP-1 bundle compared to 163 (68%) of COVID negative patients. The overall inpatient mortality rate of COVID positive septic shock patients (n=25, 64%) was three times higher as compared to COVID negative septic shock patients (n=51, 21%). Receipt of 30ml/kg IVF in the ED did not increase the odds of ICU admission [AOR 0.46 (0.07-3.26), p = 0.43], receipt of ventilator [AOR 0.40 (0.07-2.28), p=0.30], or inpatient mortality [AOR 0.15 (0.020-1.10), p=0.06] in patients who were COVID positive. However, in COVID negative patients, receipt of 30ml/kg IVF in the ED significantly reduced the odds of ICU admission [AOR 0.50 (0.27-0.93), p=0.029], receipt of ventilator [AOR 0.41 (0.22-0.74), p=0.003] and inpatient mortality [AOR 0.44 (0.22-0.87), p=0.018]. CONCLUSIONS: Optimal and timely fluid resuscitation per the SEP-1 bundle reduces the odds of unfavorable clinical outcomes in patients with septic shock who test negative for COVID-19, while causing no increased odds of harm to patients with COVID-19 and septic shock. Replication of our work in a post-vaccination cohort and during waves with different variants is advisable as the clinical outcomes may vary. CLINICAL IMPLICATIONS: Early fluid resuscitation in patients diagnosed with septic shock in the ED appears to be a safe strategy even in patients that are later diagnosed with COVID-19. DISCLOSURES: No relevant relationships by Natalie Davoodi No relevant relationships by Elizabeth Goldberg No relevant relationships by Richa Nahar

The neurological consequences of contracting covid-19

Since the first confirmed case in Wuhan, China on December 31, 2019, the novel coronavirus (SARS-CoV-2) has spread quickly, infecting 165 million people as of May 2021. Since this first detection, research has indicated that people contracting the virus may suffer neurological and mental disorders and deficits, in addition to the respiratory and other organ challenges caused by COVID-19. Specifically, early evidence suggests that COVID-19 has both mild (e.g., loss of smell (anosmia), loss of taste (ageusia), latent blinks (hete-rophila), headaches, dizziness, confusion) and more severe outcomes (e.g., cognitive impairments, seizures, delirium, psychosis, strokes). Longer-term neurological challenges or damage may also occur. This knowledge should inform clinical guidelines, assessment, and public health planning while more systematic research using biological, clinical, and longitudinal methods provides further insights.

MyCOVIDrisk: User Experience Study Of COVID-19 Risk Assessment and Mitigation Application

Background: MyCOVIDRisk app is a free, publicly available COVID-19 risk estimation and mitigation tool. The MyCOVIDRisk app has since been accessed almost 1.3 million times since launch, demonstrating the acceptability of a free and simple web-based mobile application to estimate risk of COVID-19 transmission. Little is known about how mobile apps influence assessments of risk. User experience (“UX”) studies are a key strategy for examining usability and influence of digital technology. Study Objectives: Our primary objectives were to (1) describe how the app informs interpretation of COVID-19 risk, (2) describe motivations for use and patterns of use, (3) to inform future app design. Methods: This UX study consisted of two parts. Part 1 focused on new users’ experiences, particularly navigation of the user interface across various operating systems and devices. Part 2 focused on repeat users’ experiences, particularly how they interpreted risk, what motivated their use of the app, and whether it modified behavior. Participants were recruited remotely via social media advertisements on Facebook, Instagram, and Twitter. To reach existing users, Part 2 additionally included emailing MyCOVIDRisk users who previously sent unsolicited feedback on the app. Study participants were entered into raffles to win one of two $50 Amazon gift codes. For Part 1, users completed a series of tasks during a semi-structured 30-minute video interview using the app while sharing first impressions, likes, and dislikes. Live notes taken tracked common user errors, points of confusion, and other insights. Part 2 consisted of 40-minute semi-structured video interviews with repeat users. Participants shared their personal pandemic experiences, related health decisionmaking processes, and their experience with the MyCOVIDRisk app. Interviews were audio recorded, transcribed, and analyzed to find common themes and subthemes. Results: Recruitment continued until thematic saturation was reached. Part 1 and Part 2 included 8 and 5 unique participants, respectively. Participants varied in terms of background (age range: 21-73 years), geography, prior use of the app, and goals of usage. Key use cases were as a teaching tool, source of authority and objectivity, and resource for personal decisionmaking (Fig 1). Nearly all pointed to simplicity and ease of use as key design strengths. Repeat users highlighted the interactive nature and ability to change parameters, eg, “when it [MyCOVIDRisk App] came out, I used it you know like a hundred times-like what if I do this or what if I do that? Like almost like a video game!” Challenges included difficulty in estimating number of people present and percent that would be masked, and desire for more complex activities than the prepopulated options. Users nearly unanimously suggested integration of vaccine status as an input parameter. Other common recommendations included more customization options (eg, ability to change font size), having more information when hovering over icons, and options to send inputs and risk score results to others or to print them for documentation. Conclusion: This UX testing of a COVID-19 risk assessment and mitigation app confirmed key principles for design: clear imagery, interactivity, and interpretable science. Future work should incorporate new data in real-time and improve customizability. [Formula presented] Figure 1. Primary cases for MyCOVIDRisk app based on interview responses from repeat users.

Interviews With Emergency Physicians on Telehealth During COVID-19 and its Role in Caring for Older Americans

Study Objectives: To explore United States (US)-based emergency medicine (EM) physicians’ perspectives with providing telehealth during the COVID-19 pandemic, with a particular focus on meeting the needs of older (>64 years old) EM patients who may have unique challenges with technology use and increased vulnerability to COVID-19. Methods: We used purposive sampling through social media and listservs to recruit emergency physicians, from all geographic regions and practice settings, who cared for older patients during the pandemic. We conducted 30-minute semi-structured interviews and offered incentives for participation. Initial interview questions elicited general experiences with telehealth during the pandemic, while later questions focused on special considerations for older patients. Interviews were recorded, transcribed and de-identified. We created a codebook a priori, double-coded the interview transcripts, and used framework matrix analyses to identify themes and subthemes. Results: We interviewed from July to November 2020. Participating physicians (n=15;academic 10/15, community 5/15) practiced in all US regions. Practice locations included metro (7/15), suburban (6/15), and rural areas (2/15). Physicians reported using telehealth in the outpatient setting and within the emergency department (ED), especially during personal protective equipment (PPE) shortages. Several themes emerged: (1) telehealth as a public health tool, (2) its suitability for EM patients, (3) special considerations for older patients, and (4) the future of telehealth. Physicians noted that telehealth was a valuable public health tool, providing access to accurate, timely information about COVID-19. This assistance was considered integral given changing guidance on testing, hospital capacity concerns necessitating thoughtful triage, and limited availability of PPE. Physicians noted that telehealth improved access to care for EM patients who lived in rural communities, had mental health concerns or mobility challenges, or received home hospital care. Most expressed that telehealth was suitable for low acuity EM complaints, but those with chest or abdominal pain, as well as critical patients, required in-person care to facilitate rapid diagnosis, testing, and interventions. They considered virtual care convenient, efficient and useful for establishing rapport with older patients and caregivers (including for end-of-life conversations). Emergency physicians indicated that telehealth would be beneficial in the future as a complementary method of care rather than a complete replacement of in-person ED visits if reimbursement policies and multi-state licensure concerns were addressed. Conclusions: Emergency physicians indicated that telehealth should be integrated into health care delivery as a complementary tool to traditional in-person EM care as it was integral to providing public health information, in addition to low acuity complaint diagnosis and treatment. Although technological barriers existed, many older adults could access and benefit from virtual care.

The Lancet's COVID-19 Commission Mental Health Task Force

Since the first confirmed case in Wuhan, China on December 31, 2019, the novel coronavirus (SARS-CoV-2) has spread quickly, infecting 165 million people as of May 2021. Since this first detection, research has indicated that people contracting the virus may suffer neurological and mental disorders and deficits, in addition to the respiratory and other organ challenges caused by COVID-19. Specifically, early evidence suggests that COVID-19 has both mild (e.g., loss of smell (anosmia), loss of taste (ageusia), latent blinks (heterophila), headaches, dizziness, confusion) and more severe outcomes (e.g., cognitive impairments, seizures, delirium, psychosis, strokes). Longer-term neurological challenges or damage may also occur. This knowledge should inform clinical guidelines, assessment, and public health planning while more systematic research using biological, clinical, and longitudinal methods provides further insights.

The association of lung ultrasound images with COVID-19 infection in an emergency room cohort.

Lung ultrasound could facilitate the triage of patients with suspected COVID-19 infection admitted to the emergency room. We developed a predictive model for COVID-19 diagnosis based on lung ultrasound and clinical features. We used ultrasound to image the lung bilaterally at two anterior sites, one and two hands below each clavicle, and a posterolateral site that was the posterior transverse continuation from the lower anterior site. We studied 100 patients, 31 of whom had a COVID-19 positive reverse transcriptase polymerase chain reaction. A positive test was independently associated with: quick sequential organ failure assessment score ≥1; ≥3 B-lines at the upper site; consolidation and thickened pleura at the lower site; and thickened pleura line at the posterolateral site. The model discrimination was an area (95%CI) under the receiver operating characteristic curve of 0.82 (0.75-0.90). The characteristics (95%CI) of the model's diagnostic threshold, applied to the population from which it was derived, were: sensitivity, 97% (83-100%); specificity, 62% (50-74%); positive predictive value, 54% (41-98%); and negative predictive value, 98% (88-99%). This model may facilitate triage of patients with suspected COVID-19 infection admitted to the emergency room.