Digital health innovations for non-communicable disease management during the COVID-19 pandemic: a rapid scoping review

ObjectiveTo identify and summarise the digital health interventions (DHIs) implemented for non-communicable disease (NCD) management for COVID-19. DesignRapid scoping review. Three reviewers jointly screened titles-s and full texts. One reviewer screened all excluded records. Data were mapped to WHO DHI Classification and narratively summarised. Data sourcesPubMed, CENTRAL, CINAHL, EMBASE. Eligibility criteria for selecting studiesPeer-reviewed primary research published between 1 November 2019 and 19 September 2021 on DHI for NCD management during the COVID-19 pandemic. Reviews, editorials, letters, commentaries, opinions, conference s and grey literature were excluded. ResultsEighty-three studies drawn from 5275 records were included. A majority of the studies were quantitative in design. Forty per cent of the DHIs were implemented in the Americas. Nearly half of these DHIs targeted mental health conditions. A majority of the interventions were delivered remotely and via telephones. Zoom (26.5%), email (17%) and WhatsApp (7.5%) were the top three platforms for care delivery. Telemedicine, targeted client interventions, personal health tracking and on-demand information services for clients were the most frequently implemented interventions. Details regarding associated costs, sustainability, scalability and data governance of the DHI implementations were not described in the majority of the studies. ConclusionWhile DHIs supported NCD management during the COVID-19 pandemic, their implementation has not been equitable across geographies or NCDs. While offering promise towards supporting the continuum of care during care delivery disruptions, DHIs need to be embedded into healthcare delivery settings towards strengthening health systems rather than standalone parallel efforts to overcome system level challenges.

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).

Current practice of otolaryngologists during COVID-19 pandemic

Objectives: The aim of the study was to determine current methods implemented by the otorhinolaryngologists in their outpatient practice, their mental wellbeing and recommend safe clinical practice based on current literature. Materials and Methods: Qualitative questionnaire study was conducted on otorhinolaryngologists working in various setups. The questionnaire had four parts including demographics, current ENT practice and precautions, mental wellbeing based on Coronavirus Anxiety Scale, and the COVID infection status. Results: Stress related to COVID did not affect the practice hours and consultation duration (P = 0.94). Nearly, 96% of the participants diligently followed hand hygiene and 87.4% stressed on the need of screening the patients before consultation. Although none of the participants had dysfunctional anxiety (score >9) on coronavirus anxiety scale, participants who had elders at home showed increased stress levels during the pandemic (P = 0.027). Participants with comorbidities did not show any elevated stress levels (P = 0.06). Endoscopic procedures (71.65%) and digital palpation of the oral cavity (42.3%) were the most stressful outpatient department procedures experienced by the participants. Although prophylactic medications were taken by 56.8% of participants, there was no association observed between comorbidities and prophylaxis (P = 0.57). Conclusion: The study highlights that otorhinolaryngologists are taking adequate precautions during the pandemic and the risk factors for anxiety were less due to a better understanding of coronavirus infection. © 2022 Wolters Kluwer Medknow Publications. All rights reserved.

Treatment-Resistant Pemphigoid Following SARS-Cov-2 Vaccination

As the SARS-CoV-2 vaccinated population increases, there have been many reports of vaccine-induced cutaneous reactions but scarce information on vaccine-induced autoimmune bullous disease. Vaccinations have been associated with the unmasking or development of autoimmune bullous disease;however, there is little data on SARS-CoV-2, specifically. We report a rare case of new-onset pemphigoid in a 70-year-old male following the second dose of the mRNA-1273 vaccine. The patient’s disease has been refractory to treatment, thus the underlying pathophysiology in vaccine-induced pemphigoid is likely unique, and further investigation into this pathophysiology is warranted. © 2022 THE AUTHORS.

CLEARED Global consortium results highlight regional variation and need for equity in inpatient outcomes in hospitalized patients with Chronic Liver Disease

Background and aims: A global study with equitable participation for cirrhosis and chronic liver disease (CLD) outcomes is needed. We initiated the Chronic Liver disease Evolution And Registry for Events and Decompensation (CLEARED) study to provide this global perspective. Aim to evaluate determinants of inpatient mortality and organ dysfunction in a multi-center worldwide study. Method: We prospectively enrolled pts with CLD/Cirrhosis >18 years without organ transplant or COVID-19 who were admitted non-electively. To maintain equity in outcome analysis, a maximum of 50 pts/site were allowed. Data for admission variables, hospital course, and inpatient outcomes (ICU, death, organ dysfunction [ODF]) were recorded. This was analyzed for death and ODs using significant variables on admission and including World Bank classification of low/middle-income countries (LMIC). A model for in-hospital mortality for all variables during the hospital course, including ODs) was analyzed. Results: 1383 pts (55 ± 13 yrs, 64% men, 39% White, 30% Asian, 10% Hispanic, 9% Black, 12% other) were enrolled from 49 centers (Fig A). 39% were from high-income while the rest were from LMICs. Admission MELDNa 23 (6–40) with history in past 6 months of hospitalizations 51%, infections 25%, HE 32%, AKI 23%, prior LVP 15%, hydrothorax 8% and HCC 4%. Leading etiologies were Alcohol 46% then NASH 23%, HCV 11% and HBV 13%. Most were on lactulose 52%, diuretics 53%, PPI 49% and statins 11%, SBP prophylaxis 16%, beta-blockers 35% and rifaximin 31%. 90% were admitted for liver-related reasons;GI bleed 30%, HE 34%, AKI 33%, electrolyte issues 30%, anasarca 24% and 25% admission infections. In-hospital course: Median LOS was 7 (1–140) days with 25% needing ICU. 15% died in hospital, 3% were transplanted, 46% developed AKI,15% grade 3–4 HE, 14% shock, 13% nosocomial infections and 13% needed ventilation. Logistic Regression: Fig B shows that liver-related/unrelated factors on admission which predicted in-hospital mortality and development of organ dysfunction with MELDNa and Infections being common among all models. Nosocomial infections and organ dysfunctions predicted mortality when all variables were considered. High-income countries had better mortality outcomes likely due to transplant and ICU availability. AUCs were >0.75 (Figure Presented) Conclusion: In this worldwide equitable experience, admission cirrhosis severity and infections are associated with inpatient outcomes, which are greater in low-income settings. Liver-related and unrelated factors and regional variations are important in defining critical care goals and outcome models in inpatients with cirrhosis.

Digital health innovations for non-communicable disease management during the COVID-19 pandemic: A rapid scoping review

Objective: To identify and summarise the digital health interventions (DHIs) implemented for non-communicable disease (NCD) management for COVID-19. Design: Rapid scoping review. Three reviewers jointly screened titles-s and full texts. One reviewer screened all excluded records. Data were mapped to WHO DHI Classification and narratively summarised. Data sources: PubMed, CENTRAL, CINAHL, EMBASE. Eligibility criteria for selecting studies: Peer-reviewed primary research published between 1 November 2019 and 19 September 2021 on DHI for NCD management during the COVID-19 pandemic. Reviews, editorials, letters, commentaries, opinions, conference s and grey literature were excluded. Results: Eighty-three studies drawn from 5275 records were included. A majority of the studies were quantitative in design. Forty per cent of the DHIs were implemented in the Americas. Nearly half of these DHIs targeted mental health conditions. A majority of the interventions were delivered remotely and via telephones. Zoom (26.5%), email (17%) and WhatsApp (7.5%) were the top three platforms for care delivery. Telemedicine, targeted client interventions, personal health tracking and on-demand information services for clients were the most frequently implemented interventions. Details regarding associated costs, sustainability, scalability and data governance of the DHI implementations were not described in the majority of the studies. Conclusion: While DHIs supported NCD management during the COVID-19 pandemic, their implementation has not been equitable across geographies or NCDs. While offering promise towards supporting the continuum of care during care delivery disruptions, DHIs need to be embedded into healthcare delivery settings towards strengthening health systems rather than standalone parallel efforts to overcome system level challenges. © Author(s) (or their employer(s)) 2022. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.

Trends in admission rates for alcohol-associated hepatitis in a single tertiary care center surrounding the COVID-19 pandemic

Background: In the United States, national trends in alcohol use are rising at an alarming rate. With an increasing prevalence of high-risk drinking and alcohol use disorder (AUD), there has been a notable increase in prevalence of alcohol-associated liver disease (ALD). The epidemiology of alcohol-associated hepatitis (AH), the most severe form of ALD, has not been clearly outlined. This is particularly relevant in the setting of the Coronavirus Disease-2019 (COVID-19) pandemic, which has led to increased overall alcohol consumption and reduced utilization of AUD treatment. Thus, we performed a cohort study of admissions for AH at our center, to evaluate trends and outcomes of hospitalization surrounding the pandemic. Methods: Patients were retrospectively identified from a single tertiary care center at the Mayo Clinic in Rochester, Minnesota, from January 1, 2019 to December 31, 2020. Advanced Text Explorer was used to search the electronic medical record for alcoholic/alcohol-associated hepatitis admissions. Each medical record was manually reviewed to determine if the patient met clinical and biochemical criteria according to the National Institute on Alcohol Abuse and Alcoholism AH Consortia of probable AH. Results: Among 96 confirmed admissions for AH, annual admission rate increased by 77% from 2019 (n=34) to 2020 (n=62). In 2019, the median age of patients was 52 and 38.2% were women. In 2020, the median age decreased to 43 (p=0.03) and 48.4% were women (p=0.34). Figure 1 shows the trend of admissions by month. During the COVID-19 pandemic in 2020, number of admissions increased in the summer, which was approximately 3 months after Minnesota instituted a stay at home order, and continued to rise until hospital capacity became severely limited due to COVID-19 cases in November 2020. Measures of liver severity on admission, including MELD and discriminant function, as well as liver-related mortality were not significantly different. Conclusion: In this single center study, there was a marked increase in admission rates for AH from 2019 to 2020, especially among younger individuals and women, with a notable increase following the stay at home order. Our findings corroborate early reports of rising hospitalizations related to increased alcohol consumption and consequent burden of AUD precipitated by the COVID-19 pandemic.

Functional capacity in cirrhosis is predicted by additive impact of covert hepatic encephalopathy and frailty in a multi-center outpatient cohort

Background: Daily functional capacity is a major determinant of outcomes in patients with chronic medical conditions. Given that it can be affected by disease-specific factors as well as physical and cognitive impairment, it may be of increasing relevance in patients with cirrhosis given the changing demographics and increasing co-existing conditions including HE and physical frailty. An integrated multi-site approach combining cirrhosis-related factors, comorbidities, cognitive function, and frailty metrics is needed. Aim: To determine the integrated effect of frailty and CHE on functional capacity in outpatients with cirrhosis. Methods: NACSELD-3 (North American Consortium for the Study of End-Stage Liver Disease) is a new cohort of outpatients with cirrhosis recruited from 11 centers across North America. We enrolled pts able to consent, without HIV/illicit drug use or current alcohol misuse. Demographics, cirrhosis severity/history, comorbidities, medications were recorded. DASI (Duke Activity Status Index, Low=worse), studies that assess functional capacity, Liver frailty index instruments (LFI, high=worse) & EncephalApp Stroop (High time=worse) were administered. Norms were used to classify pts as having CHE on EncephalApp & frailty on LFI. Pts divided into having none, either or both CHE & frailty. Regression analyses were performed for DASI using all clinical variables collected. Results: Demographics: 220 patients (61.7±10.6 yrs, 74% men, 76% White, 6% Latinx) were enrolled;EncephalApp & LFI were complete in 182 pts (redgreen color blindness, logistic issues or COVID restrictions) Cirrhosis details: Major etiologies were 37% alcohol, 26% NAFLD, 17% HCV and 10% HCV+alcohol. Mean MELD was 13.9±8.5, 36% had prior HE, and 19% had difficult to control ascites. Mean Charlson comorbidity index was 5.1±2.2 Cognition, frailty and DASI: EncephalApp total was 184.2±55.6 seconds and 148 (64%) pts had CHE. Mean LFI score was 3.89±0.63 and 37 (16%) were deemed frail. 49 (27%) had neither CHE nor frailty, 104 (58%) had either CHE or Frailty , and 26 (15%) had both (Fig A). EncephalApp & LFI were positively correlated (r=0.36, p<0.001) and both were correlated with DASI (EncephalApp r=-0.33, LFI r=-0.27, both p<0.001). DASI was lower with both CHE & Frailty (Fig B). Regression: Variables associated with lower DASI (poor capacity) were higher MELD score (T-value -2.1, p=0.03), higher CCI (T-value -3.6, p<0.0001) and being frail+CHE versus either or none (T-value -2.6, p=0.01). No interaction between LFI and EncephalApp was seen. Conclusion: In this multi-center experience combined frailty and covert hepatic encephalopathy and cirrhosis-unrelated comorbidities significantly add to MELD score in predicting functional capacity in outpatients with cirrhosis.

Decision-to-delivery interval and neonatal outcomes for category-1 caesarean sections during the COVID-19 pandemic.

General anaesthesia is known to achieve the shortest decision-to-delivery interval for category-1 caesarean section. We investigated whether the COVID-19 pandemic affected the decision-to delivery interval and influenced neonatal outcomes in patients who underwent category-1 caesarean section. Records of 562 patients who underwent emergency caesarean section between 1 April 2019 and 1 July 2019 in seven UK hospitals (pre-COVID-19 group) were compared with 577 emergency caesarean sections performed during the same period during the COVID-19 pandemic (1 April 2020-1 July 2020) (post-COVID-19 group). Primary outcome measures were: decision-to-delivery interval; number of caesarean sections achieving decision-to-delivery interval < 30 min; and a composite of adverse neonatal outcomes (Apgar 5-min score < 7, umbilical arterial pH < 7.10, neonatal intensive care unit admission and stillbirth). The use of general anaesthesia decreased significantly between the pre- and post-COVID-19 groups (risk ratio 0.48 (95%CI 0.37-0.62); p < 0.0001). Compared with the pre-COVID-19 group, the post-COVID-19 group had an increase in median (IQR [range]) decision-to-delivery interval (26 (18-32 [4-124]) min vs. 27 (20-33 [3-102]) min; p = 0.043) and a decrease in the number of caesarean sections meeting the decision-to-delivery interval target of < 30 min (374/562 (66.5%) vs. 349/577 (60.5%); p = 0.02). The incidence of adverse neonatal outcomes was similar in the pre- and post-COVID-19 groups (140/568 (24.6%) vs. 140/583 (24.0%), respectively; p = 0.85). The small increase in decision-to-delivery interval observed during the COVID-19 pandemic did not adversely affect neonatal outcomes.