Virtual care: a design research discovery and strategic futures model for the Canadian healthcare system

The COVID 19 pandemic necessitated a rapid implementation of virtual care within the Canadian healthcare system generating previously unimagined levels of virtual care uptake and accessibility. The transition to virtual care provided benefits for both patients and providers including a reduction in cost, time saved, and greater protection from infection. However, to date, the system in the Canadian province of Ontario has focussed on ‘replacing’ discrete in-person ‘moments’ of care with digital interactions such as phone and video visits. This design research study contributes to the health design community by incorporating a strategic futures approach to existing discussions surrounding virtual care. Collecting, analyzing and adding patient and primary care provider voices through this design research study provides new insights into virtual care experiential gaps and highlights opportunities for virtual care within primary care modalities. As a result of this new data, and through consultation with stakeholders, a roadmap for future virtual care possibilities in Ontario was developed answering noted needs of patients and providers by extending digital health interactions across a broader spectrum of synchronous and asynchronous care modalities and folding in an amalgam of digital, virtual, and in person connection for patient care experiences. [ FROM AUTHOR]

A Dual Adjuvant System for Intranasal Boosting of Local and Systemic Immunity for Influenza Vaccination.

Systemically vaccinated individuals against COVID-19 and influenza may continue to support viral replication and shedding in the upper airways, contributing to the spread of infections. Thus, a vaccine regimen that enhances mucosal immunity in the respiratory mucosa is needed to prevent a pandemic. Intranasal/pulmonary (IN) vaccines can promote mucosal immunity by promoting IgA secretion at the infection site. Here, we demonstrate that an intramuscular (IM) priming-IN boosting regimen with an inactivated influenza A virus adjuvanted with the liposomal dual TLR4/7 adjuvant (Fos47) enhances systemic and local/mucosal immunity. The IN boosting with Fos47 (IN-Fos47) enhanced antigen-specific IgA secretion in the upper and lower respiratory tracts compared to the IM boosting with Fos47 (IM-Fos47). The secreted IgA induced by IN-Fos47 was also cross-reactive to multiple influenza virus strains. Antigen-specific tissue-resident memory T cells in the lung were increased after IN boosting with Fos47, indicating that IN-Fos47 established tissue-resident T cells. Furthermore, IN-Fos47 induced systemic cross-reactive IgG antibody titers comparable to those of IM-Fos47. Neither local nor systemic reactogenicity or adverse effects were observed after IN delivery of Fos47. Collectively, these results indicate that the IM/IN regimen with Fos47 is safe and provides both local and systemic anti-influenza immune responses.

Preventing spread of aerosolized infectious particles during medical procedures: A lab-based analysis of an inexpensive plastic enclosure.

Severe viral respiratory diseases, such as SARS-CoV-2, are transmitted through aerosol particles produced by coughing, talking, and breathing. Medical procedures including tracheal intubation, extubation, dental work, and any procedure involving close contact with a patient's airways can increase exposure to infectious aerosol particles. This presents a significant risk for viral exposure of nearby healthcare workers during and following patient care. Previous studies have examined the effectiveness of plastic enclosures for trapping aerosol particles and protecting health-care workers. However, many of these enclosures are expensive or are burdensome for healthcare workers to work with. In this study, a low-cost plastic enclosure was designed to reduce aerosol spread and viral transmission during medical procedures, while also alleviating issues found in the design and use of other medical enclosures to contain aerosols. This enclosure is fabricated from clear polycarbonate for maximum visibility. A large single-side cutout provides health care providers with ease of access to the patient with a separate cutout for equipment access. A survey of medical providers in a local hospital network demonstrated their approval of the enclosure's ease of use and design. The enclosure with appropriate plastic covers reduced total escaped particle number concentrations (diameter > 0.01 µm) by over 93% at 8 cm away from all openings. Concentration decay experiments indicated that the enclosure without active suction should be left on the patient for 15-20 minutes following a tracheal manipulation to allow sufficient time for >90% of aerosol particles to settle upon interior surfaces. This decreases to 5 minutes when 30 LPM suction is applied. This enclosure is an inexpensive, easily implemented additional layer of protection that can be used to help contain infectious or otherwise potentially hazardous aerosol particles while providing access into the enclosure.

Assessing the Impact of COVID-19 on the Health of Native Hawaiian/Pacific Islander People in the United States, 2021.

OBJECTIVES: Minimal research has assessed COVID-19's unique impact on the Native Hawaiian/Pacific Islander (NH/PI) population-an Indigenous-colonized racial group with social and health disparities that increase their risk for COVID-19 morbidity and mortality. To address this gap, we explored the scope of COVID-19 outcomes, vaccination status, and health in diverse NH/PI communities. METHODS: NH/PI staff at partner organizations collected survey data from April through November 2021 from 319 community-dwelling NH/PI adults in 5 states with large NH/PI populations: Arkansas, California, Oregon, Utah, and Washington. Data were analyzed with descriptive statistics, Pearson χ2 tests, independent and paired t tests, and linear and logistic regression analyses. RESULTS: During the COVID-19 pandemic, 30% of survey participants had contracted COVID-19, 16% had a close family member who died of the disease, and 64% reported COVID-19 vaccine uptake. Thirty percent reported fair/poor health, 21% currently smoked cigarettes, and 58% reported obesity. Survey participants reported heightened COVID-19-related psychosocial distress (mean score = 4.9 on 10-point scale), which was more likely when health outcomes (general health, sleep, obesity) were poor or a family member had died of COVID-19. Logistic regression indicated that age, experiencing COVID-19 distress, and past-year use of influenza vaccines were associated with higher odds of COVID-19 vaccine uptake (1.06, 1.18, and 7.58 times, respectively). CONCLUSIONS: Our empirical findings highlight the acute and understudied negative impact of COVID-19 on NH/PI communities in the United States and suggest new avenues for improving NH/PI community health, vaccination, and recovery from COVID-19.

CLI120-001 PHASE1B DOSE ESCALATION STUDY OF RVU120 IN PATIENTS WITH AML OR HIGH RISK MDS SAFETY AND EFFICACY DATA UPDATE

Background: CDK8 and its paralog CDK19 have central roles in maintenance of cancer cell viability and undifferentiated state for a variety of tumor types. (Dannappel et al. 2019;Rzymski et al. 2015;Philip et al. 2018). RVU120 (SEL120), a novel CDK8/CDK19 kinase inhibitor with significant efficacy in preclinical AML models, has shown clinical efficacy in a currently ongoing phase Ib trial in patients with relapsed/refractory (R/R) AML or HR-MDS (NCT04021368). This paper provides update with new available data on disease evaluation from ongoing patients and further enrolment into next cohort level 85 mg. Aims: The primary objective of the study is to determine preliminary safety profile, dose limiting toxicities (DLTs), maximum tolerated dose (MTD) and the recommended phase 2 dose of RVU120 as a single agent. Secondary objectives include PK, antileukemic activity and exploratory PD characterization. Methods: The study comprises at least 7 dose escalating cohorts. The first 3 cohorts followed an accelerated scheme, 1 patient enrolled/cohort from 10 to 50 mg dose levels, from cohort 4 (75 mg) to 7 (100 mg) doses onwards a 3+3 design is followed. Data from each cohort is evaluated by a data review committee (DRC). RVU120 is administered orally every other day, for a total of 7 doses, in a 3-week treatment cycle until disease progression/unacceptable toxicity. Adverse events are graded according to NCI-CTCAE v.5.0. DLTs are assessed at completion of C1. Disease evaluation is performed according to Dohner 2017 and Cheson 2006 response criteria for AML and MDS respectively. PK parameters are calculated by non-compartmental analysis. Pharmacodynamic (PD) activity is assessed by flow cytometry measure of pSTAT5 Ser725 levels, that are highly dependent on the activity of CDK8 and CDK19 in AML/MDS cells. Results: At data cut off of 23rd Feb22, 13 pts have been enrolled, median age 73 years and median 2 previous lines of therapy, ECOG PS 2 in 4 pts, 1 in 7, 0 in 2. No DLTs were observed, all 14 Serious Adverse Events, including 1 COVID19 death and 1 pancreatitis, were not related to study drug (G1 fever, G2 Upper Respiratory Infection, G3: pseudomonas sepsis;urinary tract infection;febrile neutropenia;lung infection, pain, hemoptysis, pleural effusion, G5 pneumonitis, death NOS, pancreatitis). Cohort 1 pt, 10 mg dose level, and cohort 2 pt, 25 mg, showed stable (SD) and progressive disease (PD) respectively at the end of C1. Cohort 3 pt, an 81 YO male HR-MDS, escalated from 50 to 75 mg dose from C7, is SD at C24D13 with Erythroid Hematological Improvement on C5, C7, C10, C18. Cohort 4, 75 mg dose pt, a 62 YO male with AML DNMT3A pos, relapsing after Ven/Dec, achieved CRi at the end of C1 and CR in C7, and progressed at the end of C8. Two out of the remaining 4 pts treated at 75 mg reached SD (1 still ongoing at C3D15 and another died on C3D20 while on SD), 1 pt died of COVID-19 pneumonitis on C1D18, 1 pt with AML secondary to MPN was SD at C2 and progressed on C4. Two pt were treated at 110 mg (cohort 5), 1 not evaluable died for pancreatitis and 1 was SD at the end of C1. 2 pt entered cohort 6, 85 mg, and will be evaluable at the end of March 2022. Summary/Conclusion: Preliminary results from the first 6 cohorts have shown a favorable safety and a predictable PK profile of RVU120. Meaningful PD activity and clinical efficacy were observed at 50 and 75 mg doses. Enrollment is currently ongoing at 85 mg cohort.

Native Hawaiian/Pacific Islander alcohol, tobacco and other drug use, mental health and treatment need in the United States during COVID-19.

INTRODUCTION: Before COVID-19, Native Hawaiians/Pacific Islanders (NH/PI) endured a heavy burden of alcohol, tobacco and other drug (ATOD) use in prior US data. Responding to reports that many NH/PI communities experienced severe COVID-19 disparities that could exacerbate their ATOD burden, we partnered with NH/PI communities to assess the substance use patterns and treatment needs of diverse NH/PIs during COVID-19. METHODS: Collaborating with NH/PI community organisations across five states with large NH/PI populations, we conducted a large-scale investigation of NH/PI ATOD use, mental health and treatment need during COVID-19. Between April and November 2021, NH/PI-heritage research staff from our community partners collected data involving 306 NH/PI adults using several community-based recruitment methods (e-mail, telephone, in-person) and two survey approaches: online and paper-and-pencil. Multivariate regressions were conducted to examine potential predictors of NH/PI alcohol use disorder and need for behavioural health treatment. RESULTS: During COVID-19, 47% and 22% of NH/PI adults reported current alcohol and cigarette use, while 35% reported lifetime illicit substance use (e.g., cannabis, opioid). Depression and anxiety were high, and alcohol use disorder, major depression and generalised anxiety disorder prevalence were 27%, 27% and 19%, respectively. One-third of participants reported past-year treatment need with lifetime illicit substance use, COVID-19 distress and major depression respectively associating with 3.0, 1.2, and 5.3 times greater adjusted odds for needing treatment. CONCLUSIONS: NH/PI adults reported heavy ATOD use, depression, anxiety and treatment need during COVID-19. Targeted research and treatment services may be warranted to mitigate COVID-19's negative behavioural health impact on NH/PI communities.

Delayed presentations, increased complications, and worse outcomes after aneurysmal subarachnoid hemorrhage in the covid-19 era

Introduction The COVID-19 pandemic has led to excess mortality out of proportion to documented COVID-19 cases while also affecting the care of non-COVID-19 related diseases. No data exist on the effects of the COVID-19 pandemic on the care and outcomes of patients with aneurysmal subarachnoid hemorrhage (aSAH). Here we determine the impact of the COVID-19 pandemic on latency to presentation and clinical outcomes for aneurysmal subarachnoid hemorrhage. Methods We performed a retrospective cohort study of all patients presenting to a single center in Atlanta, Georgia, USA with aSAH between 2012 and 2020. COVID-19 was first reported in Georgia on March 2, 2020. All patients presenting from March 2nd through June 30th of a given calendar year were compared from the pre-COVID-19 era (2012- 2019) to the COVID-19 era (2020). Patient characteristics, latency from ictus to presentation, and clinical outcomes were compared. Every index digital subtraction angiogram was scored for the presence of vasospasm, and all cranial imaging studies were reviewed for infarcts consistent with delayed cerebral ischemia. Results 470 patients presented with aneurysmal subarachnoid hemorrhage during the study period. 433 and 37 presented before and during the COVID-19 era, respectively. Compared to the pre-COVID-19 era patients, patients presenting during the early phase of the pandemic were more likely to delay presentation (2.3 ± 1.3 days vs. 0.9 ± 2.2 days, respectively, p<0.01). Delays to presentation were driven by low and mid-grade subarachnoid hemorrhage patients (2.8± 3.1 days vs. 1.0 ± 2.2 days, p<0.01) with no differences noted in high-grade subarachnoid hemorrhage patients. The COVID-19 era was independently associated with significantly increased rates of angiographic vasospasm on presentation (aOR 2.52, 1.01 - 6.29, p = .048), delayed cerebral ischemia (aOR 3.84, 1.74 - 8.50, p=.001), and in-hospital aneurysmal re-rupture (aOR 5.75, 1.05 - 31.54, p=.044). Presentation during the COVID-19 era was independently associated with increased in-hospital death or hospice disposition in adjusted analysis (aOR 3.05, 1.03 - 9.04, p=0.04). Conclusions In this retrospective cohort, aSAH the COVID-19 era is associated with delayed presentation and attendant increases in cerebral vasospasm, delayed cerebral ischemia, aneurysmal re-rupture, and increased in-hospital mortality/hospice disposition. These data demonstrate a novel association between the COVID-19 pandemic and aneurysmal subarachnoid hemorrhage care, highlighting increases in overall mortality in non-COVID-19 associated disease driven by the ongoing pandemic.

Delays to presentation and outcomes after aneurysmal subarachnoid hemorrhage in the Sars-CoV-2 era

INTRODUCTION: Increasing reports suggest that patients have been reluctant to present for care due to fear of contracting severe acute respiratory syndrome-coronavirus-2 (SARS-CoV-2), even in the setting of ischemic stroke or myocardial infarction. The impact of the ongoing pandemic on patients with aneurysmal subarachnoid hemorrhage (aSAH) remains unknown. METHODS: We performed a retrospective cohort study of all patients presenting to a single referral center in Atlanta, Georgia, USA with aSAH between 2012 and 2020. SARSCoV- 2 was first reported in Georgia on March 2, 2020. All patients presenting from March through June of a given calendar year were compared from the pre-SARS-CoV-2 era (2012-2019) to the SARS-CoV-2 era (2020). Patient characteristics, latency from ictus to presentation, and clinical outcomes were compared. RESULTS: A total of 472 patients presented with aSAH during the study period, with comparable distribution in the age, sex, and Hunt and Hess grade on presentation. The mean latency in days from ictus to presentation was significantly longer in 2020 when compared to the pre- SARS-CoV-2 era (2.3, + 3.0 vs. 0.9 + 2.2, respectively, p<.05). Absolute rates of discharge home or in-hospital mortality were not significantly different. In binary regression analysis, patients were more likely to present post-bleed day 2 or after (OR 3.9, 1.9-8.1, p<.05). This effect was driven by delays to presentation in low grade aSAH (OR 3.2, 1.1-9.25, p<.05) with no difference to time in presentation in highgrade aSAH (2.3, 0.25 - 21.6). The delay to presentation was persistent on multiple binary regression analysis after controlling for age and grade (aOR 3.7, 1.7-8.0, p<.05). There was a non-significant trend towards increased mortality in the SARS-CoV-2 era on multiple regression analysis (2.78, 0.95-8.16). CONCLUSIONS: Similar to patients with myocardial and cerebral infarctions, patients are presenting for care later after an aSAH. This effect is driven by low grade aSAH, as high grade aSAH patients with a more fulminant presentation are still largely presenting within the first day, similar to the pre- SARS-CoV-2 era. These data highlight the ongoing collateral damage of the SARS-CoV-2 pandemic and need for vigilant public health efforts to encourage rapid presentation for care.

Approach to the Patient With Thyrotoxicosis Using Telemedicine.

CONTEXT: The potential for endocrine care via telemedicine has been recognized since the early 2000s when clinical outcome data demonstrated improvements in glycemic control with telemedicine. The widespread use of telemedicine during the COVID-19 pandemic has pushed telemedicine beyond diabetes care and into clinical areas with a paucity of published data. The evaluation and treatment of thyrotoxicosis heavily relies on laboratory assessment and imaging with physical exam playing a role to help differentiate the etiology and assess the severity of thyrotoxicosis. CASE DESCRIPTION: We describe a patient presenting for evaluation of new thyrotoxicosis via telemedicine, and describe modifications to consider for thorough, safe evaluation via telemedicine. CONCLUSION: Telemedicine may be an ideal way to assess and treat patients with thyrotoxicosis who are not able to physically attend a visit with an endocrinologist but still have access to a laboratory for blood draws. Potential challenges include access to imaging and high-volume surgeons if needed. Clinical and economic outcomes of telemedicine care of thyrotoxicosis should be studied so that standards of care for endocrine telemedicine can be established.

Initial Impact of COVID-19 on Radiology Practices: An ACR/RBMA Survey.

PURPOSE: The coronavirus disease 2019 (COVID-19) pandemic affected radiology practices in many ways. The aim of this survey was to estimate declines in imaging volumes and financial impact across different practice settings during April 2020. METHODS: The survey, comprising 48 questions, was conducted among members of the ACR and the Radiology Business Management Association during May 2020. Survey questions focused on practice demographics, volumes, financials, personnel and staff adjustments, and anticipation of recovery. RESULTS: During April 2020, nearly all radiology practices reported substantial (56.4%-63.7%) declines in imaging volumes, with outpatient imaging volumes most severely affected. Mean gross charges declined by 50.1% to 54.8% and collections declined by 46.4% to 53.9%. Percentage reductions did not correlate with practice size. The majority of respondents believed that volumes would recover but not entirely (62%-88%) and anticipated a short-term recovery, with a surge likely in the short term due to postponement of elective imaging (52%-64%). About 16% of respondents reported that radiologists in their practices tested positive for COVID-19. More than half (52.3%) reported that availability of personal protective equipment had become an issue or was inadequate. A majority (62.3%) reported that their practices had existing remote reading or teleradiology capabilities in place before the pandemic, and 22.3% developed such capabilities in response to the pandemic. CONCLUSIONS: Radiology practices across different settings experienced substantial declines in imaging volumes and collections during the initial wave of the COVID-19 pandemic in April 2020. Most are actively engaged in both short- and long-term operational adjustments.

Characteristics of COVID-19 Community Practice Declines in Noninvasive Diagnostic Imaging Professional Work.

PURPOSE: The operational and financial impact of the widespread coronavirus disease 2019 (COVID-19) curtailment of imaging services on radiology practices is unknown. We aimed to characterize recent COVID-19-related community practice noninvasive diagnostic imaging professional work declines. METHODS: Using imaging metadata from nine community radiology practices across the United States between January 2019 and May 2020, we mapped work relative value unit (wRVU)-weighted stand-alone noninvasive diagnostic imaging service codes to both modality and body region. Weekly 2020 versus 2019 wRVU changes were analyzed by modality, body region, and site of service. Practice share χ2 testing was performed. RESULTS: Aggregate weekly wRVUs ranged from a high of 120,450 (February 2020) to a low of 55,188 (April 2020). During that -52% wRVU nadir, outpatient declines were greatest (-66%). All practices followed similar aggregate trends in the distribution of wRVUs between each 2020 versus 2019 week (P = .96-.98). As a percentage of total all-practice wRVUs, declines in CT (20,046 of 63,992; 31%) and radiography and fluoroscopy (19,196; 30%) were greatest. By body region, declines in abdomen and pelvis (16,203; 25%) and breast (12,032; 19%) imaging were greatest. Mammography (-17%) and abdominal and pelvic CT (-14%) accounted for the largest shares of total all-practice wRVU reductions. Across modality-region groups, declines were far greatest for mammography (-92%). CONCLUSIONS: Substantial COVID-19-related diagnostic imaging work declines were similar across community practices and disproportionately impacted mammography. Decline patterns could facilitate pandemic second wave planning. Overall implications for practice workflows, practice finances, patient access, and payment policy are manifold.

Increase in Pediatric Perforated Appendicitis in the New York City Metropolitan Region at the Epicenter of the COVID-19 Outbreak.

OBJECTIVE: The aim of the study was to determine whether perforated appendicitis rates in children were influenced by the Coronavirus disease 2019 (COVID-19) surge. BACKGROUND: Disruption of care pathways during a public health crisis may prevent children from obtaining prompt assessment for surgical conditions. Progression of appendicitis to perforation is influenced by timeliness of presentation. In the context of state-mandated controls and public wariness of hospitals, we investigated the impact of the COVID-19 outbreak on perforated appendicitis in children. STUDY DESIGN: We conducted an analysis of all children presenting to 3 hospital sites with acute appendicitis between March 1 and May 7, 2020, corresponding with the peak COVID-19 outbreak in the New York City region. Control variables were collected from the same institutions for the preceding 5 years. The primary outcome measure was appendiceal perforation. RESULTS: Fifty-five children presented with acute appendicitis over 10 weeks. Compared to a 5-year control cohort of 1291 patients, we observed a higher perforation rate (45% vs 27%, odds ratio 2.23, 95% confidence interval 1.29-3.85, P = 0.005) and longer mean duration of symptoms in children with perforations (71 ±â€Š39 vs 47 ±â€Š27 h, P = 0.001) during the COVID-19 period. There were no differences in perforation rates (55% vs 59%, P = 0.99) or median length of stay (1.0 vs 3.0 days, P = 0.58) among children screening positive or negative for SARS-CoV-2. CONCLUSIONS: Children in the epicenter of the COVID-19 outbreak demonstrated higher rates of perforated appendicitis compared to historical controls. Preoperative detection of SARS-CoV-2 was not associated with inferior outcomes. Although children likely avoid much of the morbidity directly linked to COVID-19, disruption to local healthcare delivery systems may negatively impact other aspects of pediatric surgical disease.

A simple, effective enclosure with disposable coverings for inexpensive containment of aerosolized COVID viruses during tracheal intubation and extubation (preprint)

Background: SARS-CoV-2 (COVID-19) is a severe respiratory virus that can be transmitted through aerosol particles produced by coughing, talking, and breathing. Medical procedures used to treat severe cases such as tracheal intubation, extubation, and tracheal suctioning produce infectious aerosol particles. This presents significant risk for viral exposure of nearby healthcare workers during and following tracheal operations. This study looks at an enclosure to limit exposure for medical personnel to these particles. Methods: A low-cost plastic enclosure was designed to reduce aerosol spread and viral transmission during intubation and extubation procedures. The enclosure consists of clear polycarbonate for maximum visibility. Large side cutouts provide health care providers with ease of access to the patient. Aerosol particle instruments measured the aerosol containment efficacy after applying various types of plastic coverings to seal the side openings. The use of negative pressure was also tested. Results: The enclosure with 2 layers of plastic coverings sealing the side openings reduced total escaped particle number concentrations (diameter > 10 nm) by over 93% at 3 inches away from all openings. Concentration decay experiments indicated that the enclosure without active suction should be left on the patient for 15-20 minutes following a tracheal manipulation to allow sufficient time for >90% of aerosol particles to settle upon interior surfaces. This decreases to 5 minutes when 30 LPM suction is applied. Conclusions: This enclosure is an inexpensive, easily implemented additional layer of protection that can be used to reduce the risk of SARS-CoV-2 aerosol transmission between patients and healthcare workers.

Preparing for Peer Review in a Pandemic: Certified Public Accountant

[...]published or in-house checklists that were intended for use in internal quality control inspections conducted in 2019 are obsolete in these respects, and will most likely be updated or supplemented as necessary to cover these areas, and will apply to the next peer review even if it will not be conducted until after 2020. Planning and Conducting a Remote Audit away from the Client's Premises * Appropriate supervision of staff auditors working at home * The authenticity and reliability of copies or scans obtained of selected client records, related fraud risk, and the degree of professional skepticism exercised * The reliability of any alternative procedures employed when preferred audit evidence (such as direct confirmation) is not readily available due to business closures or staff reductions * The inability to observe the timely taking of physical inventories and directly observe slow-moving or obsolete items * The inability to observe (or test) key internal controls functioning in real time or the client's failure to maintain such controls and failure to adjust the audit scope appropriately for all or part of audit period as a result of reductions in effectiveness or other changes in the client's internal controls policies and procedures, such as staff reductions or reassignments of tasks, and the consequential inability to continue effective segregation of duties, management oversight, or other monitoring controls. Disclosure, and Other COVID-19-related Issues * Whether there was adequate disclosure of pandemic-related risks and uncertainties, including increased vulnerability to concentrations (e.g., reduced volume of business conducted with a particular customer or group of customers, or an interruption in the supply chain) or increased exposure to shortterm changes in estimates * Whether there was documented evidence of adequate consideration of conditions requiring adoption of liquidation basis reporting (ASC 205-30) apply, or uncertainties about the entity's ability to continue as a going concern (ASC 205-40) * Whether there was documented evidence of adequate consideration of the effects of COVID-19-related post-balance-sheet developments on recorded estimates * Whether there was documented evidence of use of an appropriate level of professional skepticism in considering the need for asset impairment adjustments, and whether they were made in the proper period * Whether there was documented evidence of consideration of the adequacy of provisions made in the appropriate period for the effects of loss contingencies arising from the pandemic (ASC 450). * Whether there was documented evidence of whether coverage was verified and determined to be recoverable for any material accrual of business interruption insurance proceeds that was made or proposed by the client * Whether there was documented evidence of an adequate search for significant subsequent events made by the client (up to the reporting date) and whether any significant COVID19-related findings were appropriately disclosed or recognized in the proper period * Whether there was documented evidence of adequate consideration of the relative precision and reliability of expectations used for substantive analytical procedures in light of COVID-19-related uncertainties * Whether there was documented evidence of adequate consideration of the effect of late reporting and other COVID19-related matters on compliance with loan covenants * Whether there was documented evidence of adequate consideration of the effects of any COVID-19-related lease or other contract modifications * Whether there was documented evidence of adequate consideration of the effects of the Coronavirus Aid, Relief, and Security (CARES) Act and other COVID-19-related tax guidance on the recorded income tax provision, payroll tax credits, and related disclosures;accounting and disclosures related to forgivable SBA loans and related tests of eligibility and penalties for noncompliance * Whether there was documented evidence of adequate consideration of increased fraud risk resulting from any identifiable management incentive to over- or understate the effects of COVID-19-related matters on reported financial condition or operating performance.