Disparities in Telemedicine Literacy and Access in the United States.

BACKGROUND: Because of the expansion of telehealth services through the 2020 Coronavirus Aid, Relief, and Economic Security (CARES) Act, the potential of telemedicine in plastic surgery has gained visibility. This study aims to identify populations who may have limited access to telemedicine. METHODS: The authors created a telemedicine literacy index (TLI) using a multivariate regression model and data from the US Census and Pew Research Institute survey. A multivariate regression model was created using backwards elimination, with TLI as the dependent variable and demographics as independent variables. The resulting regression coefficients were applied to data from the 2018 US Census at the county level to create a county-specific technological literacy index (cTLI). Significance was set at P < 0.05. RESULTS: On multivariable analysis, the following factors were found to be significantly associated with telemedicine literacy: age, sex, race, employment status, income level, marital status, educational attainment, and urban or rural classification. Counties in the lowest tertile had significantly lower median annual income levels ($43,613 versus $60,418; P < 0.001) and lower proportion of the population with at least a bachelor's degree (16.7% versus 26%; P < 0.001). Rural areas were approximately three times more likely to be in the lowest cTLI compared with urban areas ( P < 0.001). Additional associations with low cTLI were Black race ( P = 0.045), widowed marital status ( P < 0.001), less than high school education ( P = 0.005), and presence of a disability ( P = 0.01). CONCLUSIONS: These results highlight disadvantaged groups at risk of being underserved with telehealth. Using these findings, key stakeholders may be able to target these communities for interventions to increase telemedicine literacy and access.

Profile of Cardiac Involvement in Children After Exposure to COVID-19.

OBJECTIVE: To evaluate the incidence and pattern of cardiac involvement in children post-COVID (coronavirus disease) infection in a tertiary care referral hospital in India. METHODS: A prospective observational study was conducted including all consecutive children with suspected MIS-C referred to the cardiology services. RESULTS: Of the 111 children with mean (SD) age was 3.5 (3.6) years, 95.4% had cardiac involvement. Abnormalities detected were coronary vasculopathy, pericardial effusion, valvular regurgitation, ventricular dysfunction, diastolic flow reversal in aorta, pulmonary hypertension, bradycardia and intra-cardiac thrombus. The survival rate post treatment was 99%. Early and short-term follow-up data was available in 95% and 70%, respectively. Cardiac parameters improved in majority. CONCLUSION: Cardiac involvement post COVID-19 is often a silent entity and may be missed unless specifically evaluated for. Early echocardiography aided prompt diagnosis, triaging, and treatment, and helps in favorable outcomes.

COVID-19 Pandemic Lockdown: A Cloud with a Silver Lining for the Road Traffic Accidents Pandemic.

Context: Effects of coronavirus disease 2019 (COVID-19) pandemic lockdown on road traffic accidents (RTAs) in Chhattisgarh, India. Background: Most neurosurgical emergencies are from brain and spine trauma. RTA is the leading cause of such injuries. While the nationwide lockdown was an extreme measure to control the COVID pandemic, it influenced the overall road traffic dynamics and neurotrauma. Objective: This study aims to assess the impact of the lockdown on neurotrauma. Methods and Materials: This retrospective study included all patients with brain and spine injuries who were admitted between January 17th and May 31st, 2020. The study population was divided into prelockdown (PL) and lockdown (L) groups. Results: Of the 668 patients, 436 were placed in the PL and 232 in the L group. The mean ages were 36.34 (SD = 17.96) and 35.98 (SD = 16.93), respectively. Male to female ratios were 82.3:17.7 in the PL group and 79.7:20.3 for the L group. RTA-related injuries were significantly lower during the lockdown period (n = 335 PL vs. 162 L [P = 0.048]). During the lockdown, there were more mild injuries (25.91% PL vs. 36.63% L) and less severe injuries (33.25% PL vs. 18.96% L [P = 0.0002]). Mortality was significantly less (P = 0.029) during the lockdown (n = 48 L vs. 124 PL). The proportion of RTA-related neurotrauma cases increased (33.33% L1, 57.14% L2, 73.13% L3, and 80.39% L4) with each phase of lockdown (L1-L4). Conclusions: During the lockdown period, the number of trauma cases had decreased, with a significant decrease in RTA-related admissions, along with their severity and mortality. The number of trauma cases and their severity increased gradually with each phase of lockdown.

Worsening pain and quality of life for spine surgery patients during the COVID-19 pandemic: Roles of psychological distress and patient activation.

BACKGROUND: Public health measures during the COVID-19 pandemic have disrupted access to basic resources (income, food, housing, healthcare). The effects may impact patients differently based on socioeconomic status (SES), pre-existing psychological distress, and patient activation (knowledge, skills, and motivation to manage healthcare). We examined changes in access to basic resources and in pain and health-related quality of life (HRQoL) during the pandemic and determined how pre-existing psychological distress and patient activation are associated with exacerbation or mitigation of effects on pain and HRQoL. METHODS: This cross-sectional study assessed 431 patients in a longitudinal-outcomes registry who underwent or scheduled spine surgery at our institution and were surveyed about COVID-19 effects on accessing basic resources. We assessed pain (numeric rating scale) and HRQoL (PROMIS 29-Item Profile). Information on preoperative SES, psychological distress, patient activation, pain, and HRQoL was collected previously. We compared access to basic resources by SES. We compared changes from pre-COVID-19 to COVID-19 assessments of pain and HRQoL and proportions of patients reporting worsened pain and HRQoL stratified by psychological distress. We analyzed associations between patient activation and negative effects on HRQoL using multivariable linear regression. Alpha=0.05. RESULTS: Respondents reported minor disruptions in accessing basic resources (no difference by SES) but significant worsening of back (p=.027) and leg pain (p=.013) and HRQoL (physical function, fatigue, p<0.001; satisfaction with participation in social roles, p=0.048) during COVID-19. Psychological distress was associated with clinically relevant worsening of back, pain, leg pain, and physical function all, (p<0.05). High patient activation was associated with less impairment of physical function (p=0.03). CONCLUSION: Patients with pre-existing psychological distress experienced greater worsening of pain and HRQoL. High patient activation appeared to mitigate worsening of physical function. Providers should screen for psychological distress and patient activation and enhance supports to manage pain and maintain HRQoL in at-risk patients.Level of Evidence: III.

Machine Learning Techniques for the Prediction of B-Cell and T-Cell Epitopes as Potential Vaccine Targets with a Specific Focus on SARS-CoV-2 Pathogen: A Review.

The only part of an antigen (a protein molecule found on the surface of a pathogen) that is composed of epitopes specific to T and B cells is recognized by the human immune system (HIS). Identification of epitopes is considered critical for designing an epitope-based peptide vaccine (EBPV). Although there are a number of vaccine types, EBPVs have received less attention thus far. It is important to mention that EBPVs have a great deal of untapped potential for boosting vaccination safety-they are less expensive and take a short time to produce. Thus, in order to quickly contain global pandemics such as the ongoing outbreak of coronavirus disease 2019 (COVID-19) caused by the severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2), as well as epidemics and endemics, EBPVs are considered promising vaccine types. The high mutation rate of SARS-CoV-2 has posed a great challenge to public health worldwide because either the composition of existing vaccines has to be changed or a new vaccine has to be developed to protect against its different variants. In such scenarios, time being the critical factor, EBPVs can be a promising alternative. To design an effective and viable EBPV against different strains of a pathogen, it is important to identify the putative T- and B-cell epitopes. Using the wet-lab experimental approach to identify these epitopes is time-consuming and costly because the experimental screening of a vast number of potential epitope candidates is required. Fortunately, various available machine learning (ML)-based prediction methods have reduced the burden related to the epitope mapping process by decreasing the potential epitope candidate list for experimental trials. Moreover, these methods are also cost-effective, scalable, and fast. This paper presents a systematic review of various state-of-the-art and relevant ML-based methods and tools for predicting T- and B-cell epitopes. Special emphasis is placed on highlighting and analyzing various models for predicting epitopes of SARS-CoV-2, the causative agent of COVID-19. Based on the various methods and tools discussed, future research directions for epitope prediction are presented.

Age and Racial Disparities in Telemedicine Utilization in an Academic Orthopedic Surgery Department.

Introduction: The COVID-19 pandemic has highlighted significant racial and age-related health disparities. In response to pandemic-related restrictions, orthopedic surgery departments have expanded telemedicine use. We analyzed data from a tertiary care institute during the pandemic to understand potential racial and age-based disparities in access to care and telemedicine utilization. Materials and Methods: Data on patient race and age, and numbers of telemedicine visits, in-person office visits, and types of telemedicine were extracted for time periods during and preceding the pandemic. We calculated odds ratios for visit occurrence and type across race and age groups. Results: Patients ages 27-54 were 1.3 (95% confidence interval [CI] 1.1-1.4, p < 0.01) and 1.2 (95% CI 1.0-1.3, p < 0.05) times more likely to be seen than patients <27 during the pandemic, versus the 2019 and 2020 controls. Patients 54-82 were 1.3 (95% CI 1.1-1.5, p < 0.001) times more likely to be seen than patients <27 during the pandemic versus the 2019 control. Patients 27-54, 54-82, and 82+, respectively, were 3.3 (95% CI 2.6-4.2, p < 1e-20), 3.5 (95% CI 2.8-4.4, p < 1e-24), and 1.9 (95% CI 1.1-3.4, p < 0.05) times more likely to be seen by telemedicine than patients <27. Among pandemic telemedicine appointments, Black patients were 1.5 (95% CI 1.2-1.9, p < 1e-3) times more likely to be seen by audio-only telemedicine than White patients, as compared with video telemedicine. Conclusions: Telemedicine access barriers must be reduced to ensure that disparities during the pandemic do not persist.

Ensemble Machine Learning Model to Predict SARS-CoV-2 T-Cell Epitopes as Potential Vaccine Targets.

An ongoing outbreak of coronavirus disease 2019 (COVID-19), caused by a single-stranded RNA virus called severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), has caused a worldwide pandemic that continues to date. Vaccination has proven to be the most effective technique, by far, for the treatment of COVID-19 and to combat the outbreak. Among all vaccine types, epitope-based peptide vaccines have received less attention and hold a large untapped potential for boosting vaccine safety and immunogenicity. Peptides used in such vaccine technology are chemically synthesized based on the amino acid sequences of antigenic proteins (T-cell epitopes) of the target pathogen. Using wet-lab experiments to identify antigenic proteins is very difficult, expensive, and time-consuming. We hereby propose an ensemble machine learning (ML) model for the prediction of T-cell epitopes (also known as immune relevant determinants or antigenic determinants) against SARS-CoV-2, utilizing physicochemical properties of amino acids. To train the model, we retrieved the experimentally determined SARS-CoV-2 T-cell epitopes from Immune Epitope Database and Analysis Resource (IEDB) repository. The model so developed achieved accuracy, AUC (Area under the ROC curve), Gini, specificity, sensitivity, F-score, and precision of 98.20%, 0.991, 0.994, 0.971, 0.982, 0.990, and 0.981, respectively, using a test set consisting of SARS-CoV-2 peptides (T-cell epitopes and non-epitopes) obtained from IEDB. The average accuracy of 97.98% was recorded in repeated 5-fold cross validation. Its comparison with 05 robust machine learning classifiers and existing T-cell epitope prediction techniques, such as NetMHC and CTLpred, suggest the proposed work as a better model. The predicted epitopes from the current model could possess a high probability to act as potential peptide vaccine candidates subjected to in vitro and in vivo scientific assessments. The model developed would help scientific community working in vaccine development save time to screen the active T-cell epitope candidates of SARS-CoV-2 against the inactive ones.

Mucormycosis: A deadly black fungus infection among COVID-19 patients in India.

After first phase of Covid-19, the second wave affects a lot to the Indians with mysterious fungal infection known as Mucormycosis. Here, we reviewed clinical pathogenesis, signs, symptoms and treatment against black fungus. The conclusion revealed that use of immunosuppressant to combat Covid-19 also increases the risk to get infected with mucormycosis. Patients with hyperglycemia, ketoacidosis, solid organ or bone marrow transplantion, liver cirrhosis, neutropenia are more susceptible to get attacked by Mucormycosis moulds. Early diagnosis, removal of predisposing factors, timely antifungal therapy with surgical removal of all infected tissues and adjunctive therapies are four major factors to eradicate Mucormycosis.

Considering opportunistic parasitic infections in COVID-19 policies and recommendations.

The COVID-19 pandemic has led to a significant increase in the immunosuppressed population worldwide due to the disease pathology and extensive use of corticosteroids. This has subsequently increased the risk of opportunistic parasitic infections such as Toxoplasma gondii, Strongyloides stercoralis and other parasites in these patients. The reactivation of such parasites may remain unnoticed due to overlapping symptoms, the difficulty of diagnosis and lack of guidelines for opportunistic parasitic infections in COVID-19 management. Therefore, recommendations for systematic screening of high-risk patients in endemic regions and active research and surveillance to estimate the impact of these infections are required in COVID-19 policy guidelines.

The Impact of the COVID-19 Pandemic on Elective Inpatient Surgical Admissions: Evidence From Maryland.

BACKGROUND: The COVID-19 pandemic led to large-scale cancellation and deferral of elective surgeries. We quantified volume declines, and subsequent recoveries, across all hospitals in Maryland. MATERIALS AND METHODS: Data on elective inpatient surgical volumes were assembled from the Maryland Health Service Cost Review Commission for years 2019-2020. The data covered all hospitals in the state. We compared the volume of elective inpatient surgeries in the second (Q2) and fourth quarters (Q4) of 2020 to those same quarters in 2019. Analysis was stratified by patient, hospital, and service characteristics. RESULTS: Surgical volumes were 55.8% lower in 2020 Q2 than in 2019 Q2. Differences were largest for orthopedic surgeries (74.3% decline), those on Medicare (61.4%), and in urban hospitals (57.3%). By 2020 Q4, volumes for most service lines were within 15% of volumes in 2019 Q4. Orthopedic surgery remained most affected (44.5% below levels in 2019 Q4) and Plastic Surgery (21.9% lower). CONCLUSIONS: COVID-19 led to large volume declines across hospitals in Maryland followed by a partial recovery. We observed large variability, particularly across service lines. These results can help contextualize case-specific experiences and inform research studying potential health effects of these delays and cancellations.

Worsening pain and quality of life for spine surgery patients during the COVID-19 pandemic: roles of psychological distress and patient activation

BACKGROUND CONTEXT The consequences of public health protection measures may include loss of income, lack of access to basic resources (including health care), and increased psychological burdens. This has led to cancellation of elective surgical cases and greater reliance on telemedicine to conduct consultations and maintain patient access to orthopedic providers. Little is currently known regarding the effects that this has on spine surgery patients and their recovery. The effects of the COVID-19 pandemic may affect individuals differently according to their access to socioeconomic resources, preexisting burden of psychological distress, and knowledge, skills, and confidence to manage their health care. Evidence suggests that the presence of psychological distress, defined as a high burden of symptoms of anxiety and/or depression, is associated with poorer postoperative outcomes than those for patients without psychological distress. Because of the effects of the pandemic, patients may need to rely more than ever on their internal strengths as they recover from spine surgery. One measure of internal strength is “patient activation,” which is a hierarchical construct that encompasses the knowledge, skills, and confidence to manage one's health care. Patient activation may mitigate the negative effects of psychological stress in patients undergoing spine surgery. PURPOSE We tested the hypotheses that patients with greater socioeconomic resources would experience less disruption of access to basic resources;those with psychological distress would experience worsening pain and HRQOL;and those with high patient activation would experience less worsening of pain and HRQOL. STUDY DESIGN/SETTING This was a prospective survey of patients presenting to an academic medical center. PATIENT SAMPLE We selected adults who had undergone or were scheduled to undergo spine surgery for cervical or lumbar spine degeneration or deformity correction at our academic center. Between May 1, 2020 and July 31, 2020, patients were asked to complete a survey regarding the effects of COVID-19 on their health, well-being, and personal life. Surveys were sent to 1,506 patients, 431 of whom (29%) completed and returned them. The mean (± standard deviation [SD]) age of the 431 respondents was 61 ± 15 years. Fifty-five percent of respondents identified as female, and most respondents were non-Hispanic (92%) and white (81%). Most reported living with a partner (71%) and were not currently employed (68%). Approximately one-fifth of respondents reported an annual household income of ≤$50,000, and 120 reported having less than a college education. Two hundred twenty-nine patients were being treated for a degenerative lumbar condition, 118 for a degenerative cervical condition, and 84 for spinal deformity. We found no significant differences between groups in terms of demographic characteristics. OUTCOME MEASURES Respondents reported on their access to basic resources and health care and on their health and wellness. Patients scored their worst back, leg, neck and arm pain during the previous week on a numeric rating scale, with 0 representing no pain and 10 representing the worst imaginable pain. Patients completed the Patient-Reported Outcome Measurement Information System 29-Item profile (PROMIS-29), version 2, which assesses HRQOL using the following domains: pain interference, Physical Function, Fatigue, Anxiety, Depression, Sleep Disturbance, and Satisfaction with Participation in Social Roles. At their preoperative visit, patients provided information on their annual income and highest level of education attained and completed assessments of psychological distress (anxiety and depression) and patient activation. Patient activation was assessed using the Patient Activation Measure. Psychological distress was assessed from PROMIS-29 domains. Methods We surveyed 431 patients who had undergone or were scheduled for surgical treatment of lumbar or cervical spine degeneration or deformity at 1 institution. The survey inquired about the effec s of COVID-19 on patients’ access to basic resources and health care and assessed pain (numeric rating scale) and HRQOL (PROMIS-29). We compared the proportions of patients who reported worsening pain and HRQOL between groups defined by presence of psychological distress and high patient activation measured before the pandemic. Alpha = 0.05. Results Respondents reported only minor disruptions in access to basic resources but significant worsening of pain and HRQOL during COVID-19. Health care access was interrupted, with 117 respondents (43%) reporting a canceled health care appointment. Respondents who had undergone spine surgery before the pandemic (N = 296) reported significantly worse outcomes between the most recent pre-pandemic and COVID-19. assessments. During COVID-19, respondents reported worsening of the following: back pain (mean increase, 0.57 ± 3.0 points;p=.027), leg pain (mean increase, 0.74 ± 3.4 points;p=.013), physical function (mean decrease, 2.4 ± 7.5 points;p<.001), fatigue (mean increase, 3.8 ± 9.6 points;p<.001) and satisfaction with participation in social roles (mean decrease, 1.9 ± 11 points;p=.048). Those with psychological distress were more likely to experience clinically relevant worsening of back pain, leg pain and physical function than those without distress (p<.01 for all outcomes). High patient activation (measured before the pandemic) was associated with less worsening of physical function (p = 0.031). Conclusions Spine surgery patients reported little disruption in access to basic resources during COVID-19. Psychological distress was associated with worsening of pain and HRQOL. High patient activation appeared to mitigate the worsening of physical function during COVID-19. Health care systems should screen for psychological distress and patient activation and, during times of disruption, enhance supports to manage pain and maintain HRQOL. FDA DEVICE/DRUG STATUS This abstract does not discuss or include any applicable devices or drugs.