Virtual-Reality Simulation Can Teach VATS Lobectomy to Lobectomy-Naive Trainees Within 4 Weeks: A Cross-Over Study

Objective: The aim of the cross-over study was to evaluate skill acquisition in lobectomy-naive surgical trainees completing a 4-week program to learn VATS lobectomy on a virtual reality surgical simulator (LapSim). Method(s): Lobectomynaive surgical trainees (year 1 and 2 postgraduation) were enrolled during the COVID pandemic from March to June 2021 for a 4-week course on basic VATS skills and right upper lobectomy. They were divided into 2 groups. Both groups completed an initial assessment, Group 1 completed the course first, then both groups completed a second assessment. Then Group 2 completed the course, and both groups completed a final assessment. Skill acquisition was assessed using instrument movement, procedure time, and blood loss for both the trained operation and an untrained operation (left lower lobectomy). Result(s): 16 trainees were enrolled, 10 completed the training program. There was no difference in baseline assessment. After Group 1 completed the training, they outperformed Group 2 in all metrics but this did not reach statistical significance. After training Group 2 at week 8, there was no longer difference in performance from Group 1. After completing the training program, the entire cohort showed a significant improvement in basic VATS tasks as well as lobectomies. There was statistically significant improvement in both right upper lobectomy instrument movement (P=0.002) and time (P=0.009) and left lower lobectomy time (P=0.047). Conclusion(s): This study showed that VATS simulation training on LapSim allowed junior trainees to learn advanced VATS resection during a pandemic and within 4 weeks. The acquired skills is transferrable to untrained operations. (Table Presented).

Optimal Hospital Care Scheduling During the SARS-CoV-2 Pandemic

The COVID-19 pandemic has seen dramatic demand surges for hospital care that have placed a severe strain on health systems worldwide. As a result, policy makers are faced with the challenge of managing scarce hospital capacity to reduce the backlog of non-COVID patients while maintaining the ability to respond to any potential future increases in demand for COVID care. In this paper, we propose a nationwide prioritization scheme that models each individual patient as a dynamic program whose states encode the patient's health and treatment condition, whose actions describe the available treatment options, whose transition probabilities characterize the stochastic evolution of the patient's health, and whose rewards encode the contribution to the overall objectives of the health system. The individual patients' dynamic programs are coupled through constraints on the available resources, such as hospital beds, doctors, and nurses. We show that the overall problem can be modeled as a grouped weakly coupled dynamic program for which we determine near-optimal solutions through a fluid approximation. Our case study for the National Health Service in England shows how years of life can be gained by prioritizing specific disease types over COVID patients, such as injury and poisoning, diseases of the respiratory system, diseases of the circulatory system, diseases of the digestive system, and cancer.

E-service-learning is equally effective as traditional service-learning in enhancing student developmental outcomes

The adoption of online learning has been accelerated by COVID-19, including experiential learning such as service-learning (SL). This study compares the student developmental outcomes between the traditional face-to-face and e-service-learning (E-SL) to reveal the effectiveness of E-SL and its good practices. A self-reporting measurement instrument was used to collect and compare the developmental outcomes perceived by students before and after SL experience between the traditional SL and E-SL cohorts of a course with the same setting, including instructor, curriculum, and assessment criteria. Qualitative research methodology is adopted to analyse students' learning artefacts to reveal possible reasons for the differences identified in student developmental outcomes, and good practices derived in E-SL. Results indicate that both traditional SL and E-SL cohorts show significant enhancement in student developmental outcomes after participating in SL. Although there are no significant differences between the two cohorts, E-SL seems to slightly outperform traditional SL in enhancing student developmental outcomes. Qualitative analysis indicates that good practices, such as stakeholders' commitment and students' constant reflection, could be the reasons why the challenges posed by the online environment in E-SL is turned into learning opportunities to students. © 2023 Informa UK Limited, trading as Taylor & Francis Group.

The Efficacy, Safety, And Cost Savings Of High Dose IV Diuretics For Heart Failure Patients In An Outpatient Setting With Limited Hospital Bed Space Due To Covid-19

Introduction: Hospitalization is the greatest expenditure for heart failure treatment, estimated to be 8-15 billion dollars annually with the most common cost due to acute decompensation. An approach to manage this is an infusion clinic for outpatient diuresis and observation is an effective way to reduce the admission rate and improve patient outcomes. There are limited studies about high dose IV diuretics for outpatient treatment and outcomes. Bed availability during 2021 was severely limited due to COVID, and sicker patients were cared for outside of conventional hospital treatment. Hypothesis: High dose IV diuretics for heart failure patients in an infusion clinic can reduce admission rate effectively and safely. Method(s): Patient medical records were retrospectively reviewed. 83 patients with symptomatic decompensation underwent 117 treatments in 2021. They received an individualized, protocol driven bolus and infusion of IV diuretics at the clinic calculated on their baseline diuretic dosing. All but one patient was seen in follow up in 2 business days. Outcomes measured included hospital admission within 30 days, hospital days avoided, and costs saved. Adverse outcomes monitored included acute kidney injury, hypokalemia, symptomatic hypotension, and arrhythmia. Result(s): The patients had an average age of 73.6+/-12.9 years old, 64% male and 36% female. There were 80% of patients with HFpEF. The average weight gain above dry weight was 14.6 pounds. The patients had multiple comorbidities and all have chronic kidney disease stage 3 or higher. They were all on high dose diuretics. The results showed that following treatment the admission rate was 47% with 78% of those diagnosed with heart failure exacerbation. Only 1 patient was hospitalized for AKI and hypokalemia. Two patients had transient AKI at follow-up which resolved with diuretic adjustment. Estimated hospital days avoided was 372 days with a savings of 413,168 dollars based on FY21 direct cost/case. Conclusion(s): COVID-19 significantly limited the ability to provide care for patients with chronic issues in the hospital due to bed availability. Avoiding inpatient admissions on a medically complex, congested group of patients results in a significant cost saving while providing safe and effective care.Copyright © 2022

Measuring Asymptomatic Growth of COVID-19, A Powerful Mechanism for Controlling the Disease Spread

Background: Coronavirus, called as, "the worst public health crisis for a generation," is a malevolent silent killer. Objective(s): One of the main concerns is containing the disease and avoiding the second wave of the pan-demic, likely to arise because of the symptomatic patients, while ensuring the safe execution of day to day tasks. Method(s): The indirect transmission of coronavirus from asymptomatic individuals during incubation time and the identification of the people who have accidentally and unknowingly come in contact with infected but asymptomatic patients pose a significant challenge to the health care providers. Result(s): Herein, for the first time, we have introduced a quantitative index;asymptomatic growth, to indicate whether the COVID-19 community spread is under control and if economic activities can be resumed. Conclusion(s): More importantly, our system provides a feasible mechanism for improving the index to a level <1, a safety level at which normal economic activities can be conducted.Copyright © 2021 Bentham Science Publishers.

Delays in Stroke Onset to Hospital Arrival Time during COVID-19

Background and Purpose: The current coronavirus disease 2019 (COVID-19) pandemic represents a global public health crisis, disrupting emergency healthcare services. We determined whether COVID-19 has resulted in delays in stroke presentation and affected the delivery of acute stroke services in a comprehensive stroke center in Hong Kong. Method(s): We retrospectively reviewed all patients with transient ischemic attack and stroke admitted via the acute stroke pathway of Queen Mary Hospital, Hong Kong, during the first 60 days since the first diagnosed COVID-19 case in Hong Kong (COVID-19: January 23, 2020-March 24, 2020). We compared the stroke onset to hospital arrival (onset-to-door) time and timings of inpatient stroke pathways with patients admitted during the same period in 2019 (pre-COVID-19: January 23, 2019-March 24, 2019). Result(s): Seventy-three patients in COVID-19 were compared with 89 patients in pre-COVID-19. There were no significant differences in age, sex, vascular risk factors, nor stroke severity between the 2 groups (P>0.05). The median stroke onset-to-door time was =1-hour longer in COVID-19 compared with pre-COVID-19 (154 versus 95 minutes, P=0.12), and the proportion of individuals with onset-to-door time within 4.5 hours was significantly lower (55% versus 72%, P=0.024). Significantly fewer cases of transient ischemic attack presented to the hospital during COVID-19 (4% versus 16%, P=0.016), despite no increase in referrals to the transient ischemic attack clinic. Inpatient stroke pathways and treatment time metrics nevertheless did not differ between the 2 groups (P>0.05 for all comparisons). Conclusion(s): During the early containment phase of COVID-19, we noted a prolongation in stroke onset to hospital arrival time and a significant reduction in individuals arriving at the hospital within 4.5 hours and presenting with transient ischemic attack. Public education about stroke should continue to be reinforced during the COVID-19 pandemic.Copyright © 2020 Lippincott Williams and Wilkins. All rights reserved.

Clinical Reasoning: A 23-Year-Old Man With Progressive Asymmetric Weakness and Numbness.

We report a case of a 23-year-old man who presented with progressive asymmetric weakness and numbness in his distal extremities over 4 months, with initial symptoms starting days after a coronavirus 2019 (COVID-19) vaccine booster. Initial neurologic examination was notable for distal weakness of both upper and lower extremities that was more pronounced on the left, complete areflexia, and decreased distal sensation to pinprick and vibration without loss of proprioception. Nerve conduction studies demonstrated a generalized, non-length-dependent, sensorimotor, demyelinating polyneuropathy, with conduction block seen in multiple compound muscle action potentials. Sensory nerve action potentials were normal in absolute terms but had asymmetric amplitudes.Based on the patient's nerve conduction studies, he was diagnosed with a specific immune-mediated neuromuscular disorder. He was started on intravenous immunoglobulin, but within days of the first infusions experienced a rare and potentially life-threatening complication. He received appropriate treatment and was started on alternative immunotherapy, after which his symptoms improved.Our case exemplifies the features of a specific subtype of a more common immune-mediated neuromuscular diagnosis with unique elements of history, examination, and nerve conduction studies that required interpretation in the clinical context. We also discuss a rare side effect of a commonly used immunotherapy and its risk factors and comment on the likelihood that this diagnosis may be related to a preceding COVID-19 vaccine booster.

Pre-operative electronic checklists as a systematic method to improve patient care

Aims: The COVID-19 pandemic has resulted in major changes in pre-operative assessment, as consultations became conducted over The telephone, and pre-operative tests carried out a few days before Surgery to coincide with The COVID testing visit. This increased The chances for preoperative tests to be missed. A recent audit in our unit revealed missed investigations just before surgery. A checklist was introduced to identify issues early and help reduce avoidable delays. Method(s): An audit was performed for completeness of preoperative preparations. A pre-operative checklist was created to include pre-operative investigation reports, routine laboratory results, proof of COVID-19 swabs and vaccination records, correct details on The theatre lists, signed consent forms with clearly visible patient marking. The checklist was launched and The team, including doctors and nurses, were educated on its value in improving patient care. Result(s): The implementation of electronic pre-operative checklists resulted in an immediate improvement of care, with preliminary results showing issues with a potential of causing delays being promptly identified and addressed. Late identification of issues could not be entirely avoided;however, this was discussed with team members, further education was provided, and data collection continues, to ensure good practice is sustained. Conclusion(s): COVID-19 has reduced The time for hospital visit and face to face interactions, but this created The opportunity for missed tests and processes leading to delays and cancellation of surgery. The checklist in our case has proven useful in identifying issues early and promptly managing potential delays in patient care.

Safety of Inactivated and mRNA COVID-19 Vaccination among Patients Treated for Hypothyroidism: a Population-based Cohort Study

Background: Thyroiditis and Graves’ disease have been reported after COVID-19 vaccination. Patients with hypothyroidism due to various etiologies may be at risk of thyroid-specific outcomes. We aimed to evaluate the risks of thyroid-specific outcomes and adverse events after COVID-19 vaccination among patients treated for hypothyroidism. Methods: In this population-based cohort from Hong Kong Hospital Authority electronic health records with Department of Health vaccination records linkage, levothyroxine users were categorized into unvaccinated, vaccinated with BNT162b2 (mRNA vaccine) or CoronaVac (inactivated vaccine) between 23 February and 9 September 2021. Propensity score (PS) weighting with inverse probability of treatment weighting (IPTW) was applied to balance the baseline characteristics among the three groups, which included age, sex, history of COVID-19, health care utilization, comorbidities, baseline thyroid-stimulating hormone (TSH) level (within the 6 months before the index date), and recent use of medications including anti-hypertensive, anti-diabetic and lipid-lowering agents. Study outcomes were dosage reduction or escalation in levothyroxine, emergency department visit, unscheduled hospitalization, adverse events of special interest (AESI) according to World Health Organization's Global Advisory Committee on Vaccine Safety, and all-cause mortality. Results: In total, 47,086 levothyroxine users were identified (BNT162b2: n=12,310;CoronaVac: n=11,353;unvaccinated: n=23,423). After PS weighting, all baseline characteristics had standardised differences of less than 0.2, implying a balance of covariates among the three groups. COVID-19 vaccination was not associated with increased risks of levothyroxine dosage reduction (BNT162b2: HR=0.971, 95% CI 0.892–1. 058;CoronaVac: HR=0.968, 95% CI 0.904–1. 037) or escalation (BNT162b2: HR=0.779, 95% CI 0.519–1.169;CoronaVac: HR=0.715, 95% CI 0.481–1. 062). Besides, COVID-19 vaccination was not associated with a higher risk of emergency department visits (BNT162b2: HR=0.944, 95% CI 0.700-1.273;CoronaVac: HR=0.851, 95% CI 0.647-1.120) or unscheduled hospitalization (BNT162b2: HR=0.905, 95% CI 0.539-1.520;CoronaVac: HR=0.735, 95% CI 0.448-1.207). There were two (0. 016%) deaths and six (0. 062%) AESI recorded for BNT162b2 recipients, and one (0. 009%) and three (0. 035%) for CoronaVac recipients, respectively. Sensitivity analyses were performed by stratifying the groups according to age, sex and pre-vaccination thyroid status. The results were largely consistent with the main analysis. Conclusion: BNT162b2 or CoronaVac vaccination is not associated with unstable thyroid status or an increased risk of adverse outcomes among patients treated for hypothyroidism. These reassuring data should encourage them to get vaccinated against COVID-19 for protection from potentially worse COVID-19-related outcomes.Presentation: No date and time listed

Disparities in Telehealth use During the COVID-19 Pandemic.

The coronavirus 2019 pandemic led to rapid expansion of outpatient telemedicine. We sought to characterize patient factors influencing outpatient teleneurology utilization at an urban safety-net hospital. We reviewed all neurology televisits scheduled between June 15, 2020 to April 15, 2021. We used the chi-squared test and multivariate logistic regression to characterize patient demographic factors associated with televisit completion and video use. Of 8875 scheduled televisit encounters, 7530 were completed successfully, 44% via video. Non-English speaking patients, Black patients, Latinx patients, and those with a zip code-linked annual income less than $50,000 were less likely to successfully complete a scheduled televisit. The same demographic groups other than Latinx ethnicity were also less likely to use the video option. Our study found unequal telehealth utilization based on patients' demographic factors. Currently declining telemedicine reimbursement rates asymmetrically affect audio-only visits, which may limit telehealth access for vulnerable patient populations.

Disparate healthcare access and telehealth-based hybrid consultations during the COVID-19 pandemic.

BACKGROUND: The coronavirus disease-2019 pandemic led to rapid expansion of telehealth services. This was speculated to improve healthcare access among underserved populations, including individuals unable to take time off work or arrange transportation. OBJECTIVE: We completed a quality improvement project to evaluate the feasibility of hybrid consultations that combined televisits and abbreviated in-person visits for neuromuscular referrals. METHODS: Using a censoring date of August 5, 2021, we reviewed all outpatient neuromuscular consultations from August 5, 2020 to February 5, 2021. For both hybrid and traditional in-person consultations, we reviewed no-show rates, completion rates of ordered diagnostic workup, and billing codes. For hybrid consultations only, we also reviewed intervals between initial televisit and subsequent examination and rates of video-enhanced versus audio-only televisits. RESULTS: During the study period, we completed 153 hybrid and 59 in-person new-patient consultations (no-show rates 9% and 27% respectively.) For hybrid consultations, 77% and 73% of laboratory and imaging studies were completed respectively, compared to 89% and 91% for in-person consultations. For hybrid visits, average RVUs (a marker for reimbursement) per consultation depended on whether audio-only televisits were billed as telephone calls or E/M visits per insurance payer rules, while video-enhanced televisits were uniformly billed as E/M visits. This resulted in average RVUs between 2.09 and 2.26, compared to 2.30 for in-person consultations. CONCLUSIONS: Telehealth-based hybrid neuromuscular consultations are feasible with minor caveats. However, the future of telehealth may be restricted by decreasing reimbursement rates particularly for audio-only televisits, limiting its potential to improve healthcare access.

SEVERE IRON DEFICIENCY ANAEMIA SECONDARY TO UTERINE FIBROIDS CAUSING CEREBRAL VENOUS SINUS THROMBOSIS

Background and aims: Cerebral venous sinus thrombosis (CVST) is a rare cause of stroke, contributing to less than 1%. We report an unusual case of severe iron deficiency anaemia (IDA) causing CVST in a young woman with menorrhagia. Methods: Case report: A 40-year-old female with underlying anaemia presented with headache, right leg numbness and expressive dysphasia. She experienced massive menstrual bleeding prior to the symptoms onset on background of uterine fibroids. There was no history of contraceptive pills consumption, massive blood transfusion, COVID-19 infection or vaccination. Systemic review was unremarkable. Results: Blood investigations revealed haemoglobin of 4.5g/dl, MCV 52.3fL, platelet 657x1////////09/L and low ferritin level. Coagulation profile, connective tissue disease, thrombophilia screening, serum homocysteine and HIV test were normal. Computed tomography (CT) of the head showed left temporoparietal lobe infarct and left dural venous sinus thrombosis. CT venography revealed CVST within the distal left transverse sinus and the vein of Labbe. Pelvic ultrasound showed multiple uterine fibroids. She was warfarinised and had iron and red cell transfusion. She agreed to take progesterone-only pill and interval hysterectomy after gynaecological review. Discussion: CVST in association with IDA is rare in adults and is more prevalent in men. In IDA, hypercoagulability and venous stasis play a vital role in thrombus formation. One study found that IDA in women caused arachidonic acid-induced platelet dysfunction causing menorrhagia which is reversible with iron repletion. Conclusion: IDA is a rare cause of CVST but should be considered in the context of relevant history and blood tests.

Statewide Efficacy Assessment of Insect Growth Regulators Against Aedes albopictus (Diptera: Culicidae) in Sabah, Malaysia: An Alternative Control Strategy?

The efficacy of three groups of insect growth regulators, namely juvenile hormone mimics (methoprene and pyriproxyfen), chitin synthesis inhibitors (diflubenzuron and novaluron), and molting disruptor (cyromazine) was evaluated for the first time, against Aedes albopictus Skuse (Diptera: Culicidae) larvae from 14 districts in Sabah, Malaysia. The results showed that all field populations of Ae. albopictus were susceptible towards methoprene, pyriproxyfen, diflubenzuron, novaluron, and cyromazine, with resistance ratio values ranging from 0.50-0.90, 0.60-1.00, 0.67-1.17, 0.71-1.29, and 0.74-1.07, respectively. Overall, the efficacy assessment of insect growth regulators in this study showed promising outcomes and they could be further explored as an alternative to conventional insecticides.

Impact of the COVID-19 Pandemic on in-Person Visit Rates Among Patients with Hematologic Malignancies in the United States

Background/objectives: The COVID-19 pandemic led to a dramatic reduction of in-person medical care in the general population;however, impacts have not been well-characterized for patients with hematologic malignancies. This study assessed the impact of COVID-19 on healthcare delivery for patients with hematologic malignancies with documented active treatment. Methods: Patients from the nationwide Flatiron Health electronic health record (EHR)-derived de-identified database with confirmed diagnosis of AML, DLBCL, FL, MCL, CLL or MM, and age ≥ 18 years at initial diagnosis were included. To be included in the study, documented receipt of at least one systemic, non-maintenance line of therapy between March 1, 2016 - February 28, 2021 was required. Patients were categorized into treatment types within lines of therapy: Oral therapy (OralTx);outpatient infusions (OutPtTx);and inpatient infusions, including hematopoietic transplants and CAR-T cell therapy (InPtTx). Monthly visit rates were calculated as the number of visits (telemedicine or in-person [in-clinic treatment administration, vitals, and/or labs]) per active patient per 30-day standardized month. Only visits occurring within a line of therapy were included (i.e. during active therapy, excluding surveillance). Telemedicine was only available for ion during the pandemic period. We used time-series forecasting methods on pre-pandemic monthly visit rate data (March 2016 - February 2020) to estimate projected counterfactual visit rates between March 2020 - February 2021 (expected in-person visit rates if the pandemic had not occurred) for all diseases combined, each disease, and each treatment type. Differences between projected and actual monthly visit rates during the pandemic period were considered statistically significant and related to the pandemic if the actual visit rate was outside of the 95% prediction interval (PI) surrounding the projected estimate. Results: A total of 22,559 patients were included in this analysis (6,241 OralTx, 14,501 OutPtTx, 7,675 InPtTx): 4,069 AML, 3,641 DLBCL, 2,004 FL, 1,899 MCL, 4,574 CLL and 6,701 MM. There was a gradual downward trend in in-person visit rates across all diseases over the study period (March 2016 - February 2021, Figure) and general visit frequencies were lower for OralTx and higher for OutPtTx and InPtTx overall. For all diseases combined, early pandemic months (March - May 2020) saw an 18% (95% PI 8.9% - 25%) reduction in in-person visit rates averaged across OralTx and OutPtTx, with the projected rate being 1.5 (95% PI 1.3 - 1.6) visits per patient per month, compared to an actual rate of 1.2. Reductions in the in-person visit rates were significant for all 3 treatment types for MM, for OralTx for CLL, and for OutPtTx for MCL and CLL. Telemedicine visit rates were greatest for patients who received OralTx, followed by OutPtTx, then InPtTx, with greater use in the early pandemic months and subsequent decrease in later months. All in-person visit rates increased close to predicted rates in the later half of the pandemic period. Conclusions: In treatment of hematologic malignancies, overall documented in-person visit rates for patients on OralTx and OutPtTx significantly decreased during early pandemic months, but returned close to the projected rates later in the pandemic. There were no significant reductions in the overall in-person visit rate for patients on InPtTx. Variability in these trends by disease type was observed, with significant reductions in in-person visits impacting MM, CLL, and MCL. Figure. Visit rates over time according to treatment category [Formula presented] Disclosures: Lau: Roche: Current equity holder in publicly-traded company;Flatiron Health Inc: Current Employment. Wang: Roche: Current equity holder in publicly-traded company;Flatiron Health: Current Employment. Davidoff: AbbVie: Other: Family member consultancy;Amgen: Consultancy. Huntington: Bayer: Honoraria;Thyme Inc: Consultancy;Novartis: Consultancy;Flatiron Health Inc.: Consultancy;Genentech: Consultancy;eaGen: Consultancy;Servier: Consultancy;AstraZeneca: Consultancy, Honoraria;TG Therapeutics: Research Funding;DTRM Biopharm: Research Funding;AbbVie: Consultancy;Pharmacyclics: Consultancy, Honoraria;Celgene: Consultancy, Research Funding. Calip: Pfizer: Research Funding;Roche: Current equity holder in publicly-traded company;Flatiron Health Inc: Current Employment. Shah: AstraZeneca: Research Funding;Seattle Genetics: Research Funding;Epizyme: Research Funding. Stephens: CSL Behring: Consultancy;TG Therapeutics: Membership on an entity's Board of Directors or advisory committees;AstraZeneca: Consultancy;Celgene: Consultancy;JUNO: Research Funding;Mingsight: Research Funding;Abbvie: Consultancy;Arqule: Research Funding;Adaptive: Membership on an entity's Board of Directors or advisory committees;Novartis: Research Funding;Epizyme: Membership on an entity's Board of Directors or advisory committees;Beigene: Membership on an entity's Board of Directors or advisory committees;Innate Pharma: Membership on an entity's Board of Directors or advisory committees;Karyopharm: Membership on an entity's Board of Directors or advisory committees, Research Funding. Miksad: Flatiron Health Inc: Current Employment, Current holder of individual stocks in a privately-held company;Roche: Current equity holder in publicly-traded company. Parikh: GNS Healthcare: Current holder of individual stocks in a privately-held company;Onc.AI: Current holder of individual stocks in a privately-held company;Humana: Honoraria, Research Funding;Nanology: Honoraria;Thyme Care: Honoraria;Flatiron Health Inc: Honoraria. Takvorian: Pfizer: Research Funding;Genentech: Consultancy. Neparidze: GlaxoSmithKline: Research Funding;Janssen: Research Funding;Eidos Therapeutics: Membership on an entity's Board of Directors or advisory committees. Seymour: Flatiron Health Inc: Current Employment;Janssen: Membership on an entity's Board of Directors or advisory committees;Roche: Current equity holder in publicly-traded company;Karyopharm: Honoraria, Membership on an entity's Board of Directors or advisory committees;Pharmacyclics: Membership on an entity's Board of Directors or advisory committees.

Racial Disparities in Telemedicine Uptake during the COVID-19 Pandemic Among Patients with Hematologic Malignancies in the United States

Background/objectives: The COVID-19 pandemic impacted healthcare visit trends, propelling healthcare systems to reduce in-person visits and hospital admissions and increasingly rely on telemedicine;whether there are differences in these trends across racial groups is unknown. This study investigated potential racial disparities in visits during the pandemic for patients with documented active treatment for hematologic malignancies. Methods: We used the nationwide Flatiron Health electronic health record (EHR)-derived de-identified database to select patients with confirmed diagnosis of AML, DLBCL, FL, MCL, CLL or MM, at least 18 years old at initial diagnosis, and documented race in the EHR as Black/African American or White were included. Patients were categorized into treatment types within lines of therapy: Orals (orals + outpatient infusions with orals) vs. Inpatient treatments (chemotherapy, hematopoietic transplants & CAR-T cell therapy). Monthly visit rates were calculated as the number of visits (telemedicine or in-person [in-clinic treatment administration, vitals, and/or labs]) per active patient per 30-day standardized month, except for months in which the patient was considered not active (e.g. no documented therapy, surveillance). We used time-series forecasting methods on pre-pandemic monthly visit rate data (March 2016 - February 2020) to estimate projected counterfactual monthly visit rates (expected rates if the pandemic did not occur) between March 2020 - February 2021 for all diseases combined, for each disease, each treatment type, and each race. Differences between projected and actual monthly visit rates during the pandemic period were considered significant and related due to the pandemic if the actual visit rate was outside of the 95% prediction interval (PI) surrounding the projected estimate. We used cross-correlation analysis to test for significant differences in visit rates between Black and White patients. Results: The analysis included 17,621 patients (2,225 Black, 15,396 White): 3,041 AML, 2,715 DLBCL, 1,558 FL, 1,511 MCL, 3,813 CLL and 5,244 MM (1,166 Black, 4078 White). Across all diseases and treatment categories, Black patients had no significant reductions in in-person visit rates throughout the pandemic period compared to the projected rates. There was, however, an 18% statistically significant reduction (95% PI 9.9% - 25%) in in-person visit rates for White patients on orals during early pandemic months (March - May 2020) from a projected visit rate of 2.0 (95% PI 1.8 - 2.2) visits per patient per month to an actual visit rate of 1.61. There was no significant reduction in in-person visit rates for White patients on inpatient treatments. Telemedicine uptake was significantly higher for White patients compared with Black patients for all diseases combined across all treatment categories (Figure A & B) (t = 9.5, p < 0.01), AML inpatient treatments (t = 2.4, p = 0.04), MM orals (Figure C) (t = 6.0, p < 0.01) and MM inpatient treatments (Figure D) (t = 2.3, p = 0.04). Conclusions: A tradeoff in reductions in in-person visits and uptake of telemedicine use was observed overall. White patients had significantly higher telemedicine uptake compared with Black patients for both oral and inpatient treatments. In-person visit rates for Black patients were unchanged regardless of treatment category. These in-person visit rates reflect documented telemedicine use disparities, which requires further study into possible compound causes, including economic and societal factors. Figure. Trends over time in telemedicine visit rates for White patients (blue line) and Black patients (black line) [Formula presented] Disclosures: Neparidze: Eidos Therapeutics: Membership on an entity's Board of Directors or advisory committees;GlaxoSmithKline: Research Funding;Janssen: Research Funding. Lau: Flatiron Health Inc: Current Employment;Roche: Current equity holder in publicly-traded company. Wang: Flatiron Health: Current Employment;Roche: Current equity holder in publicly-traded company. Davidoff: Amgen: Consultancy;AbbVie: Other: Family member consultancy. Huntington: Bayer: Honoraria;Servier: Consultancy;Pharmacyclics: Consultancy, Honoraria;Thyme Inc: Consultancy;Genentech: Consultancy;AbbVie: Consultancy;SeaGen: Consultancy;Celgene: Consultancy, Research Funding;Flatiron Health Inc.: Consultancy;DTRM Biopharm: Research Funding;TG Therapeutics: Research Funding;AstraZeneca: Consultancy, Honoraria;Novartis: Consultancy. Calip: Flatiron Health Inc: Current Employment;Roche: Current equity holder in publicly-traded company;Pfizer: Research Funding. Shah: AstraZeneca: Research Funding;Seattle Genetics: Research Funding;Epizyme: Research Funding. Stephens: Adaptive: Membership on an entity's Board of Directors or advisory committees;Celgene: Consultancy;Abbvie: Consultancy;CSL Behring: Consultancy;Novartis: Research Funding;Karyopharm: Membership on an entity's Board of Directors or advisory committees, Research Funding;JUNO: Research Funding;Mingsight: Research Funding;AstraZeneca: Consultancy;Innate Pharma: Membership on an entity's Board of Directors or advisory committees;Beigene: Membership on an entity's Board of Directors or advisory committees;TG Therapeutics: Membership on an entity's Board of Directors or advisory committees;Epizyme: Membership on an entity's Board of Directors or advisory committees;Arqule: Research Funding. Miksad: Flatiron Health Inc: Current Employment, Current holder of individual stocks in a privately-held company;Roche: Current equity holder in publicly-traded company. Parikh: Onc.AI: Current holder of individual stocks in a privately-held company;Humana: Honoraria, Research Funding;Flatiron Health Inc: Honoraria;Thyme Care: Honoraria;Nanology: Honoraria;GNS Healthcare: Current holder of individual stocks in a privately-held company. Takvorian: Genentech: Consultancy;Pfizer: Research Funding. Seymour: Janssen: Membership on an entity's Board of Directors or advisory committees;Roche: Current equity holder in publicly-traded company;Pharmacyclics: Membership on an entity's Board of Directors or advisory committees;Flatiron Health Inc: Current Employment;Karyopharm: Honoraria, Membership on an entity's Board of Directors or advisory committees.

Preadmission use of DPP4i reduced risk of hyperinflammatory syndrome, in-hospital death or invasive mechanical ventilation in COVID-19 patients with type 2 diabetes: A territory-wide retrospective cohort study

OBJECTIVE: T2DM patients with COVID-19 were associated with increased risk of hyperinflammation and hence poor prognosis. Inconclusive evidence suggested that dipeptidyl peptidase-4 inhibitors (DPP4i) may have anti-inflammatory effect and preventing SARS-CoV-2 viral entry. This territory-wide retrospective cohort study evaluated the clinical outcomes associated with the pre-admission use of DPP4i for T2DM patients with COVID-19. METHODS: Patients with T2DM admitted with COVID-19 between 21st January 2020 and 31st January 2021 in Hong Kong were observed from date of admission until the date of in-hospital death, hospital discharge or data cut-off date (30th April 2021). Exposure was defined as receiving DPP4i treatment from 90 days prior admission to the day before admission for COVID-19. The primary outcome was the incidence rate of hyperinflammatory syndrome. Multivariable logistic regression models weighted by inverse probability of treatment weighting using the propensity score were performed to estimate odds ratios (OR) and their 95% confidence intervals (CI) of event outcomes for exposure versus nonexposure. RESULTS: Out of 1214 eligible patients at a median follow-up of 16 days with 30,035 person-days, 107 patients received DPP4i prior to COVID-19 hospitalization. Preadmission use of DPP4i was associated with a lower risk of hyperinflammatory syndrome (OR = 0.56, 95%CI 0.45 to 0.69, P < 0.001), composite outcome of in-hospital death or the need of invasive mechanical ventilation (OR = 0.71, 95%CI 0.54 to 0.93, P = 0.013) and reduced length of hospital stay among survivors (-4.82 days, 95%CI -6.80 to -2.84, P < 0.001). Moreover, DPP4i users incurred significantly lower cumulative healthcare costs from day-7 (US$7,877 vs US$10,246, P < 0.001) to day-90 (US$26,310 vs US$39,482, P < 0.001) than control. CONCLUSION: Our study may have shed light regarding hyperinflammatory dynamics in mild-to-moderate COVID-19 patients with T2DM, which may be informative to these patient cohorts and associated clinicians. However, prospective studies are necessary to further elucidate the potential role of DPP4i in the pathophysiology of T2DM and COVID-19.

Clinical outcomes associated with early in-hospital use of metformin, dipeptidyl peptidase-4 inhibitor or insulin in COVID-19 patients with type 2 diabetes: A territory-wide retrospective observational study

OBJECTIVE: Type 2 diabetes mellitus (T2DM) is associated with worse outcomes for patients with COVID-19. Commonly used glucose-lowering medications, metformin, dipeptidyl peptidase-4 inhibitor (DPP4i), or insulin, were found to impact the level of inflammatory and cytokine, therefore potentially influence the clinical outcomes in SARS-CoV-2 infected patients. Concerns remain on the early in-hospital use of these medications. This territory-wide retrospective observational study evaluated clinical improvement, virality, acidosis, hypoglycemia, hyperinflammation status, composite clinical outcomes associated with use of metformin, DPP4i, or insulin for hospitalized T2DM patients with COVID-19 infection. METHODS: Baseline covariate between the two groups were balanced by multiple imputation followed by inverse probability of treatment weighting for propensity score. Multivariable cox proportional hazard models were performed to estimate hazard ratios (HR) and their 95% confidence intervals (CI) of time-to-event outcomes. Exposure was defined as receiving glucose-lowering drug class within 3 days of admission. RESULTS: After propensity-score weighting, baseline characteristics were generally balanced. Metformin users (n = 609) were associated with quicker time to clinical improvement (HR = 1.41, 95%CI 1.19 to 1.65, P < 0.001), hospital discharge (HR = 1.43, 95%CI 1.20 to 1.69, P < 0.001) and recovery (HR = 2.09, 95%CI 1.42 to 3.06, P < 0.001), shorter hospital length of stay among survivors (-6.45 days, 95%CI -8.34 to -4.56, P < 0.001), reduced costs from 30-days onward, lower risk of composite outcome (HR = 0.41, 95%CI 0.23 to 0.74, P = 0.003) and macrophage activation (HR = 0.64, 95%CI 0.47 to 0.87, P < 0.004) when compared to non-metformin users. Shorter hospital length of stay was also observed in DPP4i users (n = 144) compared with non-DPP4i users (-5.32 days, 95%CI to 7.30 to -3.34, P < 0.001). Insulin users (n = 414) have greater risk of hypoglycemia during admission (HR = 2.61, 95%CI 1.23 to 5.53, P = 0.013) when compared to non-insulin users. CONCLUSION: Metformin and DPP4i have exhibited association with improved clinical outcomes while insulin has proved to be associated with increased risk of hypoglycemia for in hospitalized T2DM patients with COVID-19.

What Really Matters: Experiences of Emergency Remote Teaching in University Teaching and Learning During the COVID-19 Pandemic

The COVID-19 pandemic and related lock downs have accelerated the need for online and remote teaching within university settings. However, due to the abrupt nature of the pandemic, many academic staff were not prepared for this forced transition. This study aimed to understand how the pandemic affected academics at a New Zealand university, with regards to their transition to emergency remote teaching. Specifically, it explores the challenges as well as benefits academics experienced during this transition. Recommendations for future online learning are also made. Academic staff (N = 67) at a New Zealand University completed an anonymous online survey. Quantitative data were analyzed statistically using descriptive and inferential statistics, while qualitative data were analyzed thematically. Major challenges experienced included miscommunication from the university, concerns about student access to technology, finding a quiet space to work, lack of digital competence skills, too much screen-time, managing work hours, and work/life balance. Benefits included enhanced flexibility, enhanced teacher creativity, increasing autonomy of learners, and reduced commute time. Looking forward, academic staff desired future teaching to include blended learning and virtual immersion. New strategies of working remotely are being explored to facilitate teaching and learning while catering to the preferences and skills of both educators and students. Our findings honor the considerable agility of academic staff who sought to sustain and enhance excellence in remote education. At an institutional level our findings point to the need for staff to be supported by their institutions as they further refine their work within new-found spaces.

Combating the coronavirus disease 2019 pandemic in the HONG KONG hospital authority paediatric infectious disease centre

Since the coronavirus disease 2019 (COVID-19) outbreak in late December 2019, and escalation of the public hospital infectious disease outbreak response level to the highest "emergency" level three days after two COVID-19 cases were diagnosed on 22 January 2020, all public hospitals implemented a series of isolation policies, rescheduled clinical services and mobilised resources to support frontline clinical staff. This article reviewed these multi-level policies adopted in the Department of Paediatrics and Adolescent Medicine, Princess Margaret Hospital, which have ensured that the healthcare system was not overwhelmed and frontline staff was not over-stressed and infected.