Hybrid Learning: A Boon or Bane

The context of higher education is changing. The emerge of social, technical, and intellectual forces has pushed higher education to the point of a significant transformation (Garrison & Vaughn, 2008). Technology enhanced learning have raised concerns about the quality of education and learning environment. For the traditional classroom-based teaching and learning, the breakthrough came during the emerge of Covid-19 pandemic. Online learning, once a separated learning system, was fully integrated into teaching and learning to continue providing education amidst the lockdown. Post the reopening of higher education institutions, hybrid learning was widely implemented in almost all universities across the world, to accommodate students' diverse range of learning needs in the post pandemic era. This case study is intended to gain insights regarding the learning experiences, challenges, and benefits in hybrid learning from both the lecturers' and students' perspective. Based from the gathered qualitative data, results show that both students and lecturers have mixed reviews regarding hybrid learning experience. One of the main findings is that hybrid learning creates a more flexible, engaging learning environment compared to traditional face-To-face learning. Lecturers generally feel that hybrid learning has several pedagogical and technological challenges. However, issues concerning quality of lecture delivery and academic malpractice during online assessments has found to be a concern among lecturers and students. In overall, lecturers and students feel that hybrid learning needs to be evaluated from time to time to address the drawback for continuous improvement towards better quality of learning. © 2023 IEEE.

Impact of the COVID-19 Pandemic on Healthcare-Associated Infections (HAI) by Race and Ethnicity in a Large Network of Community Hospitals: A Call to Action

Background. Inequities in healthcare among racial and ethnic minorities are globally recognized. The focus has centered on access to healthcare, equitable treatment, and optimizing outcomes. However, there has been relatively little investigation into potential racial and ethnic disparities in HAI. Methods. We performed a retrospective cohort analysis of select HAI prospectively-collected by a network of community hospitals in the southeastern US, including central line-associated bloodstream infection (CLABSI), catheterassociated urinary tract infection (CAUTI), and laboratory-identified Clostridioides difficile infection (CDI). Outcomes were stratified by race/ethnicity as captured in the electronic medical record. We defined the pre-pandemic period from 1/1/2019 to 2/29/2020 and the pandemic period from 3/1/2020 to 6/30/2021. Outcomes were reported by race/ethnicity as a proportion of the total events. Relative rates were compared using Poisson regression. Results. Overall, relatively few facilities consistently collect race/ethnicity information in surveillance databases within this hospital network (< 40%). Among 21 reporting hospitals, a greater proportion of CLABSI occurred in Black patients relative toWhite patients in both study periods (pre-pandemic, 49% vs 38%;during pandemic, 47% vs 31%;respectively, Figure 1a), while a higher proportion of CAUTI and CDI occurred in White patients (Figures 1b-c). Black patients had a 30% higher likelihood of CLABSI than White patients in the pre-COVID period (RR, 1.30;95% CI, 0.83-2.05), which was not statistically significant (Table 1). However, this risk significantly increased to 51% after the start of the pandemic (RR, 1.51;95% CI, 1.02-2.24). Similar trends were not observed in other HAI (Tables 2-3). Conclusion. We found differences in HAI rates by race/ethnicity in a network of community hospitals. Black patients had higher likelihood of CLABSI, and this likelihood increased during the pandemic. Patient safety events, including HAI, may differ across racial and ethnic groups and negatively impact health outcomes. (Figure Presented).

Understanding the Impact of COVID-19 Pandemic on Central Line-Associated Bloodstream Infections (CLABSIs): Expanding Analysis to the Microbiologic Level

Background. Increases in central line-associated bloodstream infection (CLABSI) rates have been reported in association with the COVID-19 pandemic, particularly among Candida species and coagulase-negative Staphylococcal species (CoNS). We sought to further validate the impact of the COVID-19 pandemic on CLABSI trends and perform a microbiologic analysis. Methods. This is an IRB-approved retrospective analysis of CLABSIs across a network of 38 community hospitals in southeastern United States. CLABSI rates were compared between pre-pandemic (1/1/2018-3/30/2020) and pandemic periods (4/1/2020-12/31/2021). Regression models were developed to evaluate CLABSI incidence over time. Likelihood ratio tests were used to compare models that were exclusively time-dependent to segmented regression models that also accounted for the COVID-19 pandemic. Results. A total of 1,167 CLABSIs over 1,345,062 central line days were analyzed (Table 1). The mean monthly CLABSI rate per hospital increased from 0.63 to 1.01 per 1,000 central line days (p< 0.001) in the pandemic period (Table 1). CLABSIs secondary to Candida (0.16 to 0.33, p< 0.001), CoNS (0.09 to 0.22, p< 0.001), and Enterococcal species (0.06 to 0.18, p=0.001) increased, while Escherichia coli CLABSIs decreased (0.04 to 0.01, p< 0.001). Upon regression modeling, the COVID-19 pandemic was associated with increases in monthly CLABSI rates by Candida and Enterococcus species (Figure 1). In contrast, the changes in CoNS and Escherichia coli CLABSI rates were better explained by exclusively timedependent models (Figure 1;Table 2). Non-sustained changes in Staphylococcus aureus and Klebsiella pneumoniae CLABSI rates were also noted (Table 2). Gray areas denote COVID-19 pandemic period. Statistically significant level changes in CLABSI rates were observed among Candida and Enterococcus spp. (RR=1.92, CI 1.16-3.20 and 2.42, CI 1.09-5.38). Staphylococcus aureus CLABSI rates had a non-sustained but significant increase at the onset of COVID-19 (RR 2.20, CI 1.16-4.20). CoNS and E. coli rate changes occurred independent of COVID-19 (see Table 2). Conclusion. The COVID-19 pandemic was associated with substantial increases in CLABSIs, driven in part by Candida and Enterococcus species across this network of hospitals. However, the observed increase in CoNS CLABSIs and decrease in Escherichia coli CLABSIs appear to have occurred independently of COVID-19, which only became apparent upon regression analysis. Interpretation of pre-post statistics without assessment of pre-existing trends should be done cautiously. Additional analyses may help elucidate other factors influencing these CLABSI trends by organism.

Comparison of Trends in Hospital-Onset Bloodstream Infections (HOBSIs) and Central Line Associated Bloodstream Infections (CLABSIs) across a Three-Hospital Health System in the COVID Era

Background. Hospital-onset bloodstream infection (HOBSI) incidence has been proposed as a complementary quality metric to central line-associated bloodstream infection (CLABSI) surveillance. Several recent studies have detailed increases in median HOBSI and CLABSI rates during the COVID-19 pandemic. We sought to understand trends in HOBSI and CLABSI rates at a single health system in the context of COVID-19. Methods. We conducted a retrospective analysis of HOBSIs and CLABSIs at a three-hospital health system from 2017 to 2021 (Figure 1). We compared counts, denominators, and demographic data for HOBSIs and CLABSIs between the prepandemic (1/1/2017-3/30/2020) and pandemic period (4/1/2020-12/31/2021) (Table 1). We applied Poisson or negative binomial regression models to estimate the monthly change in incidence of HO-BSI and CLABSI rates over the study period. Figure 1: Definitions applied for hospital-onset bloodstream infections (HO-BSIs) and central line-associated bloodstream infections (CLABSIs). Potentially contaminated blood cultures were identified by microbiology laboratory technicians as any set of blood culture in which a single bottle was positive for organisms typically considered as skin contaminants. Uncertain cases undergo secondary review by senior lab technicians. Table 1: Count, denominator, and device utilization ratio data for hospital-onset bloodstream infections (HO-BSIs) and central line-associated bloodstream infections (CLABSIs) Note that central line utilization increased upon regression analysis (p<0.001). Results. The median monthly HOBSI rate per 1,000 patient days increased from 1.0 in the pre-pandemic to 1.3 (p< 0.01) in the pandemic period, whereas the median monthly CLABSI rate per central line days was stable (1.01 to 0.88;p=0.1;Table 2). Our regression analysis found that monthly rates of HO-BSIs increased throughout the study, but the increase was not associated with the onset of the COVID-19 pandemic based on comparisons of model fit (Figure 2;Table 3). Despite an increase in central line utilization, regression modelling found no changes in monthly CLABSIs rates with respect to time and the COVID-19 pandemic. Incidence of HOBSIs and CLABSIs by common nosocomial organisms generally increased over this time period, though time to infection onset remained unchanged in our studied population (Table 2). Conclusion. HOBSIs rates did not correlate with CLABSI incidence across a three-hospital health system from 2017 and 2021, as rates of HOBSI increased but CLABSI rates remained flat. Our observed increase in HOBSI rates did not correlate with the onset of the COVID-19 pandemic, and caution should be used in modeling the effects of COVID-19 without time-trended analysis. Further evaluation is needed to understand the etiology, epidemiology, and preventability of HO-BSI.

Management of a Pregnant Patient with ARDS Due to COVID-19: A Case Report

Introduction: In the obstetric population, ARDS due to COVID- 19 has been found to have worse outcome. Treatment of severe COVID-19 has been a real challenge world over. This case report is aimed at giving an insight to the management of COVID-19 in a pregnant patient. Case report: A 36-year-old primi with 33 weeks and 2 days of gestation was admitted with fever, cough, and shortness of breath for 4 days. The patient was found to be positive for COVID. The patient was initially admitted in the wards. In view of worsening oxygenation patient was shifted to the ICU. The patient was initiated on high flow nasal cannula with FiO2 100%, but maintained saturation of 82-84% with that. Hence, patient was intubated and initiated on mechanical ventilation. Post intubation patient maintained a saturation of 86-88% with 100% FiO2. Within half an hour of intubation, fetal bradycardia was noted. The patient was taken up for an emergency Caesarian section. At birth, the child did not cry and received two cycles of CPR and positive pressure ventilation and was shifted to the NICU. The baby was extubated after days. Postpartum the mother required 70% FiO2 to maintain 90% saturation which further improved upon proning. The Pplat and inturn the driving pressure improved upon Cesarian section. Patient required one more round of proning on D5 of ICU stay. During the course of hospitalization, the patient had one episode of septic shock and 2 episodes of urosepsis. This was treated appropriately with antibiotics. Bedside sonography revealed right-sided Hydro Uretero Nephrosis which was tackled with DJ stenting. On day 11 of ICU stay, patient was tracheostomised. By the end of 1 month, the mother was decannulated and discharged. Discussion: Pregnancy especially in the final trimester causes changes like reduced functional residual capacity and compliance. Airway edema in pregnancy complicates intubation making it difficult. Proning though not contraindicated may be difficult to achieve in pregnant patients. In our patient, we could prone the patient postpartum with ease. Though Caesarian section was done in view of fetal distress. But postpartum it was easier to ventilate the patient and oxygenation showed steady improvement. AJOG also suggests that a Caesarian section may be considered after 34 weeks in a critically ill COVID-19 patient. We also had the luxury of a neonatal ICU and the neonate could be saved though the mother's well-being was our priority. Pregnancy and gestational diabetes mellitus and receiving steroids made the patient susceptible to multiple infections which we handled by source control and antibiotics. Conclusion: Though the pandemic is on the decline this case report is an attempt to throw light on the management of the critically ill pregnant patient with ARDS. Cesarean section may aid in the management of the pregnant patient with severe ARDS.

Impact of COVID-19 on survival among kidney transplant patients in a tertiary care centre in North Kerala - a longitudinal study

Background: In this study we wanted to measure the prevalence of Covid-19 disease among patients of renal transplant. The secondary outcome was to determine the demographic, clinical profile, and functional parameters of renal function and co morbidities associated with outcome in Covid-19 disease and to determine the predictors of mortality in patients who are post kidney transplant.

Novel SARS-CoV-2 variants induce higher toxicity in cardiovascular cells

Objective: SARS-CoV-2 causes the coronavirus disease 2019 (COVID-19) and has spawned a global health crisis. Virus infection can lead to elevated markers of cardiac injury and inflammation associated with a higher risk of mortality. However, it is so far unclear whether cardiovascular damage is caused by direct virus infection or is mainly secondary due to inflammation. Recently, additional novel SARS-CoV-2 variants have emerged accounting for more than 70% of all cases in Germany. To what extend these variants differ from the original strain in their pathology remains to be elucidated. Here, we investigated the effect of the novel SARS-CoV-2 variants on cardiovascular cells. Results: To study whether cardiovascular cells are permissive for SARSCoV-2, we inoculated human iPS-derived cardiomyocytes and endothelial cells from five different origins, including umbilical vein endothelial cells, coronary artery endothelial cells (HCAEC), cardiac and lung microvascular endothelial cells, or pulmonary arterial cells, in vitro with SARS-CoV-2 isolates (G614 (original strain), B.1.1.7 (British variant), B.1.351 (South African variant) and P.1 (Brazilian variant)). While the original virus strain infected iPS-cardiomyocytes and induced cell toxicity 96h post infection (290±10 cells vs. 130±10 cells;p=0.00045), preliminary data suggest a more severe infection by the novel variants. To what extend the response to the novel variants differ from the original strain is currently investigated by phosphoproteom analysis. Of the five endothelial cells studied, only human coronary artery EC took up the original virus strain, without showing viral replication and cell toxicity. Spike protein was only detected in the perinuclear region and was co-localized with calnexin-positive endosomes, which was accompanied by elevated ER-stress marker genes, such as EDEM1 (1.5±0.2-fold change;p=0.04). Infection with the novel SARS-CoV-2 variants resulted in significant higher levels of viral spike compared to the current strain. Surprisingly, viral up-take was also seen in other endothelial cell types (e.g. HUVEC). Although no viral replication was observed (850±158 viral RNA copies at day 0 vs. 197±43 viral RNA copies at day 3;p=0.01), the British SARS-CoV-2 variant B.1.1.7 reduced endothelial cell numbers (0.63±0.03-fold change;p=0.0001). Conclusion: Endothelial cells and cardiomyocytes showed a distinct response to SARS-CoV-2. Whereas cardiomyocytes were permissively infected, endothelial cells took up the virus, but were resistant to viral replication. However, both cell types showed signs of increased toxicity induced by the British SARS-CoV-2 variant. These data suggest that cardiac complications observed in COVID-19 patients might at least in part be based on direct infection of cardiovascular cells. The more severe cytotoxic effects of the novel variants implicate that patients infected with the new variants should be even more closely monitored.

Assessing mortality difference across COVID-19 intubation strategies

Rationale: The optimal timing of invasive mechanical ventilation (IMV) among patients with COVID-19 related acute respiratory failure (ARF) is unknown. Use of high flow nasal cannula (HFNC) support could potentially avoid the need for IMV and related risks. However, patients failing HFNC may be at increased risk for peri-intubation complications such as cardiac arrest. At NewYork-Presbyterian Weill Cornell Medical Center (NYP-WCMC) and Lower Manhattan Hospital (LMH), an early IMV strategy prior to March 26th 2020. We subsequently switched to a prolonged observation strategy, supporting patients with non-invasive devices including HFNC. In this study, we compared in-hospital mortality in patients with ARF managed with early IMV strategy versus a prolonged observation strategy. Methods: This is a retrospective cohort study using the Weill Cornell COVID-19 Registry, which included 1869 patients admitted with a COVID-19 positive PCR test up until May 15, 2020. Patients at risk for intubation due to ARF, defined by requiring > 6 liters/min nasal cannula, were included. Patients who met ARF criteria prior to March 26, 2020 were in the early IMV strategy group, and those who met criteria on or after March 26, 2020 were in the prolonged observation strategy group. In-hospital mortality with intubation strategy as the main exposure was modelled with cox proportional hazards regression. Confounders included age, sex, BMI, comorbidities, severity of illness (SOFA) and hospital strain (difference between daily admissions and discharges). Both SOFA and hospital strain were calculated for each patient on the day that they developed ARF for modelling purposes. Results: We identified 774 patients at risk for intubation due to ARF (table), 141 were in the early IMV group and 633 were in the prolonged observation strategy group. Death occurred in 33.3% of patients in the early IMV group compared to 34.8% in the prolonged observation group. Patients in the early IMV group had a longer length of stay among survivors (27.2 ± 26.1 days vs 21.6 ± 22.8 days, p = .0213). Age-adjusted hazard ratio for death comparing early IMV versus prolonged observation was 1.35 (95% CI 0.86-2.12, which decreases to 0.87 (95% CI 0.52-1.45) after adjusting for confounders. Conclusion: In this retrospective observational study with a modest sized sample, early IMV strategy was not associated with excess mortality compared to prolonged observation. In resource constrained settings, prolonged observation with HFNC support is a reasonable hospital-level strategy in patients with ARF.

Respiratory disease, and treatment / thematic poster session a novel approach to medical monitoring during the sars-cov-2 pandemic supporting the activ 4b outpatient anticoagulation trial

Rationale The ACTIV 4B (OWS/NHLBI supported) clinical trial addresses the use of anti-platelet and anticoagulant agents in symptomatic COVID-19 positive non-hospitalized patients with regards to safety and prevention of macro- and micro-thrombotic events using a composite outcome (symptomatic DVT/PE, arterial thromboembolism, MI, CVA, hospitalization for CV/pulmonary events, mortality). Concerns regarding SARS-CoV- 2 transmission risk to research staff and overburdened institutional environments create challenges for standard event monitoring. In addition, safety or outcome events often occur at other institutions rather than the enrollment site. Therefore, research methodology was adapted to effectively evaluate and categorize safety events using a remote low touch approach. Methods Trial over can be found at NCT04498273. Potential adverse events identified through patient electronic data capture survey or call center assessments are handled remotely by central clinical study staff. If an event is identified as a possible endpoint or SAE by the central study staff the electronic data collection (EDC) system notifies the central medical monitoring team, and the enrolling site coordinator if patient enrolled from an acute care setting, that additional source documents are necessary. The medical coordinator works with the site coordinator, or will reach out independently to treating institutions to obtain necessary source documents. Based on a review of clinical data from the EDC and all available source documents, final arbitration of seriousness, relatedness and expectedness is be made by the study's Medical Monitor, and appropriate study entities (NIH, FDA, IRB, study leadership, pharmaceutical co.) are notified.Results The process as described has been successfully and effectively implemented in >50 patients with anticipation of 7000 patient eventual enrollment. Events have been captured, source documentation has been procured and events have been reported as per established protocol processes. Conclusion We have effectively implemented a medical safety event monitoring methodology in a “low touch” study design to assess events in the complex COVID-19 outpatient space. Elements of our system can be effectively replicated in other COVID and non-COVID clinical trials. .

Decontamination of common healthcare facility surfaces contaminated with SARS-CoV-2 using peracetic acid dry fogging.

BACKGROUND: The SARS-CoV-2 pandemic has highlighted the urgent need for safe and effective surface decontamination methods, particularly in healthcare settings. AIM: To evaluate the effectiveness of peracetic acid (PAA) dry fogging in decontaminating healthcare facility surfaces experimentally contaminated with SARS-CoV-2. METHODS: Nine materials (stainless steel, latex painted wood, unsealed hardwood, melamine countertop, vinyl flooring, clear plastic, faux leather, computer keyboard button, and smartphone touch screen) were surface contaminated with >106 median tissue culture infectious dose (TCID50) of SARS-CoV-2, and allowed to dry before exposing to PAA dry fogging. FINDINGS: When fumigated with PAA dry fog for 1 h, no infectious SARS-CoV-2 virus was recovered from any of the experimentally inoculated surface types. By contrast, high titres of infectious virus were recovered from corresponding untreated drying controls of the same materials. CONCLUSION: Standard surface decontamination processes, including sprays and wipes, are laborious and frequently cannot completely decontaminate sensitive electronic equipment. The ease of use, low cost, and overall effectiveness of a PAA dry fogging suggest that it should be considered for decontaminating healthcare settings, particularly intensive care units where severely ill SARS-CoV-2 patients are cared for.

OpenSAFELY: factors associated with COVID-19-related hospital death in the linked electronic health records of 17 million adult NHS patients. (preprint)

Background Establishing who is at risk from a novel rapidly arising cause of death, and why, requires a new approach to epidemiological research with very large datasets and timely data. Working on behalf of NHS England we therefore set out to deliver a secure and pseudonymised analytics platform inside the data centre of a major primary care electronic health records vendor establishing coverage across detailed primary care records for a substantial proportion of all patients in England. The following results are preliminary. Data sources Primary care electronic health records managed by the electronic health record vendor TPP, pseudonymously linked to patient-level data from the COVID-19 Patient Notification System (CPNS) for death of hospital inpatients with confirmed COVID-19, using the new OpenSAFELY platform. Population 17,425,445 adults. Time period 1st Feb 2020 to 25th April 2020. Primary outcome Death in hospital among people with confirmed COVID-19. Methods Cohort study analysed by Cox-regression to generate hazard ratios: age and sex adjusted, and multiply adjusted for co-variates selected prospectively on the basis of clinical interest and prior findings. Results There were 5683 deaths attributed to COVID-19. In summary after full adjustment, death from COVID-19 was strongly associated with: being male (hazard ratio 1.99, 95%CI 1.88-2.10); older age and deprivation (both with a strong gradient); uncontrolled diabetes (HR 2.36 95% CI 2.18-2.56); severe asthma (HR 1.25 CI 1.08-1.44); and various other prior medical conditions. Compared to people with ethnicity recorded as white, black people were at higher risk of death, with only partial attenuation in hazard ratios from the fully adjusted model (age-sex adjusted HR 2.17 95% CI 1.84-2.57; fully adjusted HR 1.71 95% CI 1.44-2.02); with similar findings for Asian people (age-sex adjusted HR 1.95 95% CI 1.73-2.18; fully adjusted HR 1.62 95% CI 1.43-1.82). Conclusions We have quantified a range of clinical risk factors for death from COVID-19, some of which were not previously well characterised, in the largest cohort study conducted by any country to date. People from Asian and black groups are at markedly increased risk of in-hospital death from COVID-19, and contrary to some prior speculation this is only partially attributable to pre-existing clinical risk factors or deprivation; further research into the drivers of this association is therefore urgently required. Deprivation is also a major risk factor with, again, little of the excess risk explained by co-morbidity or other risk factors. The findings for clinical risk factors are concordant with policies in the UK for protecting those at highest risk. Our OpenSAFELY platform is rapidly adding further NHS patients' records; we will update and extend these results regularly. Keywords COVID-19, risk factors, ethnicity, deprivation, death, informatics.