A novel negative pressure isolation device reduces aerosol exposure: A randomized controlled trial

Background and aim The COVID-19 pandemic has led to a proliferation of intubation barriers designed to protect healthcare workers from infection. We developed the Suction-Assisted Local Aerosol Containment Chamber (SLACC) and tested it in the operating room. The primary objectives were to determine the ease and safety of airway management with SLACC, and to measure its efficacy of aerosol containment to determine if it significantly reduces exposure to health care workers. Methods In this randomized clinical trial, adult patients scheduled to undergo elective surgery with general endotracheal anesthesia were screened and informed consent obtained from those willing to participate. Patients were randomized to airway management either with or without the SLACC device. Patients inhaled nebulized saline before and during anesthesia induction to simulate the size and concentration of particles seen with severe symptomatic SARS-CoV-2 infection. Results 79 patients were enrolled and randomized. Particle number concentration (PNC) at the patients' and healthcare workers' locations were measured and compared between the SLACC vs. control groups during airway management. Ease and success of tracheal intubation were recorded for each patient. All intubations were successful and time to intubation was similar between the two groups. Healthcare workers were exposed to significantly lower particle number concentrations (#/cm3) during airway management when SLACC was utilized vs. control. The particle count outside SLACC was reduced by 97% compared to that inside the device. Conclusions The SLACC device does not interfere with airway management and significantly reduces healthcare worker exposure to aerosolized particles during airway management.

Readiness of Health Care Professionals in Singapore to Teach Online and Their Technology-Related Teaching Needs: Quantitative Cross-sectional Pilot Study.

BACKGROUND: With the increasing acceptance of face-to-face classes transitioning to web-based learning due to COVID-19, there is an increasing need to have educators trained and equipped to teach online. The ability to teach in-person may not necessarily mean that one is ready teach in a web-based environment. OBJECTIVE: The objective of our study was to investigate the readiness of health care professionals in Singapore to teach online and their technology-related teaching needs. METHODS: This was a quantitative cross-sectional pilot study conducted among health care administrative staff and professionals in medicine, nursing, allied health, and dentistry. Participants were recruited via an open invitation email to all staff members of Singapore's largest group of health care institutions. Data were collected using a web-based questionnaire. Differences in the readiness of the professionals to teach online were analyzed using analysis of variance, and a 1-sided independent sample t test was performed to analyze the differences between respondents younger than 40 years and those older than 41 years. RESULTS: A total of 169 responses was analyzed. Full-time academic faculty members scored the highest for readiness to teach online (2.97), followed by nursing professionals (2.91), medicine professionals (2.88), administrative staff members (2.83), and allied health professionals (2.76). However, there was no statistically significant difference (P=.77) among all the respondents in their readiness to teach online. There was an agreement among all professionals in their need for software tools to teach; in particular, there was a significant difference in the software needs among the professionals for streaming videos (P=.01). There was no statistically significant difference in the readiness to teach online between those younger than 40 years and those older than 41 years (P=.48). CONCLUSIONS: Our study shows that there are still some gaps in terms of readiness to teach online among health care professionals. Our findings can be used by policy makers and faculty developers to identify opportunities for development among their educators so that they are ready to teach online with the appropriate software tools.

REALITI-A Study: Real-World Oral Corticosteroid-Sparing Effect of Mepolizumab in Severe Asthma.

BACKGROUND: Patients with severe asthma may require maintenance oral corticosteroids (mOCS) for disease control as well as systemic corticosteroid (SCS) bursts for clinically significant exacerbations. However, mOCS and SCS use are associated with adverse effects, which increases patient disease burden. OBJECTIVE: To assess the real-world corticosteroid-sparing effect of mepolizumab in patients with severe asthma. METHODS: REALITI-A was a 24-month international, prospective, observational cohort study involving 84 centers across Europe, Canada, and the United States, with a 1-year pre-post mepolizumab treatment preplanned interim analysis. A total of 822 adults with a clinical diagnosis of asthma and a physician decision to initiate mepolizumab treatment (100 mg subcutaneously) were included. End points included daily mOCS dose at baseline (penultimate 28 days of pretreatment) and 1 year after treatment; percent reduction from baseline in mOCS dose; patients discontinuing mOCS 1 year after treatment; and the rate of clinically significant exacerbations (those requiring OCS for 3 days or more [or parenteral administration], emergency room visit, and/or hospital admission) before and after treatment. RESULTS: A total of 319 patients received mOCS at baseline (median [interquartile range]: 10.0 [5.0-15.0] mg/d). At 1 year after treatment, median mOCS dose was reduced by 75% (2.5 [0.0-5.0] mg/d); 64% of patients had a reduction in mOCS dose of 50% or greater compared with baseline and 43% discontinued mOCS. Clinically significant exacerbations decreased between pretreatment and posttreatment (rate ratio [95% confidence interval] 0.29 [0.26-0.32]; P < .001). CONCLUSION: This 1-year analysis demonstrates that real-world mepolizumab treatment is clinically effective in patients with severe asthma, providing disease control while reducing the need for mOCS and SCS bursts.

Guidance for Administering Biologics for Severe Asthma and Allergic Conditions

Asthma is a common respiratory disorder in Canada for which biologics may be prescribed for poorly controlled illness. Treatment with biologics, however, is sometimes inappropriately discontinued due to misconceptions regarding their potential immunologic effects, and concerns surrounding their continued use in severe asthma during the COVID-19 pandemic continue to propagate. Biologics can still be administered in a majority of health and treatment conditions. With regard to cardiac-related issues such as hypertension or cardiovascular disease (CVD), there is no solid evidence that suggests biologics should be withheld, as the benefits of treatment outweigh the risks. Asthmatic patients on biologic treatment should also continue treatment if they have, or are currently being treated for, a respiratory infection, including COVID-19. Evidence also indicates the importance of maintaining asthma control to reduce the risk of severe COVID-19 infection. Biologic treatment can be administered in severe asthmatic patients with bronchiectasis, though further evidence is needed to better understand the benefits. Biologic treatment should be continued postsurgery to reduce postoperative respiratory complications, as well as throughout the course of pregnancy. Regarding concerns over vaccine administration, nearly all vaccines can be given without interruption of biologic treatment in patients with severe asthma or allergic conditions. Appropriate screening for respiratory illnesses, such as COVID-19, continues to be warranted in clinical practices to reduce the risk of transmission. As recommendations from public health and regulatory agencies have been lacking, this guidance document addresses the administration of biologics in different health circumstances and respiratory illness screening during the COVID-19 pandemic.

Implementation of the Vascular Surgery Board virtual certifying examination.

OBJECTIVE: The onset of the COVID-19 (coronavirus disease 2019) pandemic mandated postponement of the in-person Vascular Surgery Board 2020 certifying examination (CE). Vascular surgery virtual CEs (VVCEs) were developed for the scheduled 2020 CEs (rescheduled to January 2021) and 2021 CEs (rescheduled to July 2021) to avoid postponing the certification testing. In the present study, we have reported the development, implementation, and outcomes of the first two VVCEs. METHODS: The VVCE was similar to the in-person format (three 30-minutes sessions, two examiners, four questions) but required a proctor and a host. In contrast to the general surgery VCEs, the VVCE also incorporated images. The candidates and examiners were instructed on the format, and technology checks were performed before the VVCE. The candidates were given the opportunity to invalidate their examination for technology-related reasons immediately after the examination. Postexamination surveys were administered to all the participants. RESULTS: The VVCEs were completed by 356 of 357 candidates (99.7%). The pass rates for the January 2021 and July 2021 examinations were 97.6% (first time, 99.4%; retake, 70%) and 94.7% (first time, 94.6%; retake, 100%), respectively. The pass rates were not significantly different from the 2019 in-person CE (χ2 = 2.30; P = .13; and χ2 = 0.01; P = .91, for the January 2021 and July 2021 examinations, respectively). None of the candidates had invalidated their examination. The candidates (162 of 356; 46%), examiners (64 of 118; 54%), proctors (25 of 27; 93%), and hosts (8 of 9; 89%) completing the survey were very satisfied with the examination (Likert score 4 or 5: candidates, 92.6%; noncandidates, 96.9%) and found the technology domains (Zoom, audio, video, viewing images) to be very good (Likert score 4 or 5), with candidate and other responder scores of 73% to 84% and >94%, respectively. Significantly more of the candidates had favored a future VVCE compared with the examiners (87% vs 32%; χ2 = 67.1; P < .001). The free text responses from all responders had commented favorably on the organization and implementation of the examination. However, some candidates had expressed concerns about image sizes, and some examiners had expressed concern about the time constraints for the question format. The candidates appreciated the convenience of an at-home examination, especially the avoidance of travel costs. CONCLUSIONS: The two Vascular Surgery Board VCEs were shown to be psychometrically sound and were overwhelmingly successful, demonstrating that image-based virtual examinations are feasible and could become the standard for the future.

COVID-19-Positive Testing in Minnesota High School Fall and Winter Sports: A Guide for Sports Risk.

OBJECTIVE: To assess the effectiveness of coronavirus disease 2019 (COVID-19) prevention strategies used during sports participation. DESIGN: To analyze prospective reports of student-athletes with COVID-19-positive tests to assess prevention strategies and risk factors by sports and seasons. SETTING: Minnesota high schools. PARTICIPANTS: Fall 2020 (August 24-October 30) and winter 2021 (January 2-March 12) student-athletes. ASSESSMENT OF RISK FACTORS: Sports, indoor location, mask use, physical distancing, and season. MAIN OUTCOME MEASURES: COVID-19-positive test rates. METHODS: Self-selected schools voluntarily reported, in 2-week intervals, the number of student-athletes with COVID-19-positive tests in each sport and the number of athletes participating in each sport during the fall and winter sports seasons. The positive testing rates per 100 000 athletes were calculated for participants in each sport and compared by sports type and risk variables. RESULTS: The high school age community-positive testing rate was 1298 per 100 000 students in the fall and 2396 in the winter. The student-athlete positive testing rate was 1500 per 100 000 athletes during the fall and 2800 during the winter (χ2 = 1.98, df = 1, P = 0.350). Positive tests per 100 000 athletes ranged from 197 (girls alpine skiing) to 4151 (wrestling). The incidence rates comparing indoor with outdoor sports (P = 0.001) and close-contact with physically distanced sports (P = 0.023) were significantly different, but the incidence rates comparing indoor masked with unmasked sports (P = ns) were not different. CONCLUSION: Athletes competing in outdoor individual sports have less risk of a COVID-19-positive test compared with age-matched individuals in the community and indoor sports participants either wearing or not wearing masks during competition. Unmasked athletes in close proximity have the highest positive test rates, and unenforced masking is not associated with lower positive testing rates. More study is needed to understand mask effectiveness.

Medical student education through flipped learning and virtual rotations in radiation oncology during the COVID-19 pandemic: a cross sectional research.

BACKGROUND: The COVID-19 pandemic has stripped many medical students worldwide of their right to quality education. In response, we developed hybrid courses involving aspects of both online and in-person teaching for radiation oncology medical student clerkship. METHODS: We entitled students to customize their own rotation schedule using Google Forms and developed a flipped learning online class, which consisted of at least one video clip on basic knowledge of radiation oncology per day (yonsei-radonc.com). Students were instructed to watch online videos before the next day's discussion session. Required components of the medical education program (e.g., target drawing, site visits to treatment facilities) were also prepared and conducted in accordance with the appropriate level of social distancing measures. Finally, we conducted questionnaire surveys after the completion of the week-long course and clerkship. RESULTS: From March to June 2020, 110 fourth-year medical students undertook a clinical module in our 1-week radiation oncology program course. Each day, students completed the flipped learning prior to meeting with the educator and then participated in the online discussion session and conference. All activities were well performed as scheduled. Students' motivation was high, as was their overall satisfaction with the course. The students were satisfied with the online contents, flipped learning strategy, and instructors. CONCLUSIONS: We successfully integrated open and virtual educational platforms to improve access to and satisfaction with student clerkship. In the future "new normal," minimized face-to-face learning interactions, such as flipped learning, should be actively utilized for medical and other students' education.

Pharmacy preparedness in handling COVID-19 pandemic: a sharing experience from a Malaysian tertiary hospital.

This commentary shares the experience of a hospital pharmacy department in providing healthcare services during the COVID-19 outbreak in Malaysia. During this pandemic, the medication delivery system is redesigned to minimize contact among patients and the health care providers. Also, the remote medication monitoring system was implemented to deliver pharmaceutical care for inpatients. Communication technology was used to assist the pharmacist in medication counseling. QR codes to access videos demonstrating the use of devices were made available for patients. Pharmacists were also tasked with the procurement of personal protective equipment and medications needed requiring special approval from the Ministry of Health.

Factors influencing medical student choices in the integrated vascular surgery match: Implications for future post-pandemic residency matches.

OBJECTIVE: Integrated vascular surgery residency is among the most competitive specialties, but little is known about the applicant perspective. The coronavirus disease 2019 outbreak impacted the 2021 integrated vascular surgery residency match because of travel restrictions. We sought to better understand pre-pandemic applicant recruitment strategies, logistics of away rotations, and the residency interview process to identify areas for improvement in the application process. METHODS: An anonymous survey was sent to matched students in 2020, inquiring about motivations for pursuing vascular surgery (VS), logistic of away rotations and interviews, and factors influencing students' rank lists. RESULTS: Seventy of the 73 matched students completed the survey (95.9% response rate). The median age was 27 (range, 25-41); 32.9% were female, 91.4% were U.S. medical students, and 77.1% were from institutions with a VS training program. Factors most strongly influencing the decision to choose VS as a career were interest in open vascular procedures, endovascular procedures, perceived job satisfaction, emerging technologies, and influence of a mentor. The prospect of the job market, future salary, and competitiveness of the application process had the least impact. Of the matched students, 82.9% completed an away rotation (median, 2; range, 1-4), with 51.7% of students paying a total cost of more than $2500. Fifty percent of students matched either at their home institution or where they had performed an away rotation. Students reported application submissions to a median of 50 programs (range, 1-70) and interviewed at 17 (range, 1-28), with 40% of students paying a total of more than $4000 for interview costs. The most significant factors affecting students' rank lists included program culture, open aortic surgical volume, geography, and complex endovascular procedure volume. Tours of facilities, resident salary, and male/female distribution had the least importance. CONCLUSIONS: Successfully matched applicants in 2020 prioritized operative case volume and program collegiality when ranking programs. Despite their high cost, away rotations played an important role in the Match, suggesting that time spent at potential institutions allowed ideal assessment of factors for students. The high average number of away rotations and in-person interviews performed in 2019-2020 was limited for the 2021 Match due to coronavirus disease 2019 restrictions. Programs will have to continue developing creative alternatives or additions to away rotations and the application processes to assure continued success in future post-pandemic Match cycles.

Discovering the Value of Anatomy Laboratory Education During the COVID-19 Pandemic from The Perspective of Three Medical Schools’ Experience

The SARS-CoV-2 (COVID-19) outbreak adversely affected medical school education and drastically reduced in-person learning, specifically affecting gross anatomy laboratory dissection. Depending on the academic calendar schedule, some schools were interrupted in the middle of anatomy teaching while others had more lead time to prepare but schools suddenly faced an imposed demand for a transition to distance learning. SUNY Downstate had its anatomy education interrupted due to the Covid-19 shut down. To gap the previous laboratory experience of students and complete the semester anatomy curriculum, a series of dissected abdominal videos were created and distributed to all first-year medical students (n=208). The video-based curriculum and the current student experience taking anatomy without cadaveric dissections were assessed via pre/post-tests and a five-question survey. A paired single tailed t-test comparing student responses (n=164) in the pre- versus post-test was statistically significant (P < 0.002) while 92% of students (n=136) reported that their previous time dissecting prepared them to learn through videos without the benefit of hands-on dissection. Icahn School of Medicine adopted digital Grant's Dissector utilizing their accompanying narrated videos. Faculty voiced over the narration, however, permitting emphasis of material, directing pacing of course, and tying content to lecture and physical exams. Complete anatomy was used to augment the experience, with 3D virtual dissections and enhance the visualization of the structures, however the videos remained as the driver of content delivery. Weill Cornell Medicine created, and customized anatomy prosected material videotaping the show and tell sessions integrating powerpoint slides to tie in lecture content and clinical correlates. Results from all three schools highlight the technical success of implementing an anatomy video-based curriculum in response to COVID-19. Survey findings describe a unique cohort of students who were compelled to participate in a video-based curriculum after having learned anatomy in a donor body laboratory environment and student performance on summative exams in general equaled or exceeded scores from previous years. Overall, anatomy education through videos, digital platforms, and apps can offer a reliable stop-gap solution in the absence of traditional cadaveric dissection in a short-term, provisional model. However, the experience of learning anatomy from a human body in laboratory is irreplaceable and the future now seems to point to a combination of these modalities, and others, such as virtual reality or augmented reality, yet to be adapted and customized to our educational settings.

COVID-19 and heat waves: New challenges for healthcare systems.

Heat waves and Covid-19 overlap, as this pandemic continues into summer 2021. Using a narrative review, we identified overlapping risk groups and propose coping strategies. The high-risk groups for heat-related health problems as well as for high-risk COVID-19 groups overlap considerably (elderly with pre-existing health conditions). Health care facilities will again be challenged by Covid-19 during heat waves. Health care personnel are also at risk of developing heat related health problems during hot periods due to the use of personal protective equipment to shield themselves from SARS-CoV-2 and must therefore be protected from excessive heat periods. Some existing recommendations for heat health protection contradict recommendations for COVID-19 protection. This paper provides a preliminary overview of possible strategies and interventions to tackle these ambiguities. The existing recommendations for protection against heat-related illnesses need revisions to determine whether they include essential aspects of infection control and occupational safety and how they may be supplemented.

Facing the Coronavirus Pandemic: An Integrated Continuing Education Program in Taiwan.

This study aimed to identify knowledge gaps regarding coronavirus disease 2019 (COVID-19) and develop an integrated educational program for healthcare workers. First, we designed and validated ten multiple-choice questions to identify knowledge gaps among healthcare workers. Within one month of the online test and curriculum offering, 5533 staff had completed the test, with a completion rate of 84.97%. There were 2618 healthcare workers who answered the pre-test 100% correctly. Those who did not answer the pre-test 100% correctly took multiple tests after learning through the online teaching materials. Eventually, 5214 staff passed the test (pre-test or post-test with 100% correct answers). The result showed that all staff had a low correct rate for personal protective equipment (PPE) use recommendations. The Infection Control Center conducted training sessions for hospital staff on how to wear protective clothing. Information on the selection and use of PPE for infection prevention was provided, and participants were allowed time to practice and familiarize themselves with the correct way to wear PPE. Moreover, the Department of Education and Research continued updating the online learning materials based on the most important updated peer-reviewed published articles. The attending teaching physicians helped to search, translate, and take notes on articles in the local language (traditional Chinese) for other colleagues to read easily. We expect to increase learning opportunities for healthcare workers, even during uncertain times such as the current coronavirus pandemic through (1) the hospital-wide course announcements, (2) the continuous placement of test questions and learning files on the digital learning platform, (3) the placement of journal highlights in cloud folders, and (4) the use of the digital learning platform on mobile phones accessible outside the hospital.

Time series analysis and mechanistic modelling of heterogeneity and sero-reversion in antibody responses to mild SARS­CoV-2 infection.

BACKGROUND: SARS-CoV-2 serology is used to identify prior infection at individual and at population level. Extended longitudinal studies with multi-timepoint sampling to evaluate dynamic changes in antibody levels are required to identify the time horizon in which these applications of serology are valid, and to explore the longevity of protective humoral immunity. METHODS: Healthcare workers were recruited to a prospective cohort study from the first SARS-CoV-2 epidemic peak in London, undergoing weekly symptom screen, viral PCR and blood sampling over 16-21 weeks. Serological analysis (n =12,990) was performed using semi-quantitative Euroimmun IgG to viral spike S1 domain and Roche total antibody to viral nucleocapsid protein (NP) assays. Comparisons were made to pseudovirus neutralizing antibody measurements. FINDINGS: A total of 157/729 (21.5%) participants developed positive SARS-CoV-2 serology by one or other assay, of whom 31.0% were asymptomatic and there were no deaths. Peak Euroimmun anti-S1 and Roche anti-NP measurements correlated (r = 0.57, p<0.0001) but only anti-S1 measurements correlated with near-contemporary pseudovirus neutralising antibody titres (measured at 16-18 weeks, r = 0.57, p<0.0001). By 21 weeks' follow-up, 31/143 (21.7%) anti-S1 and 6/150 (4.0%) anti-NP measurements reverted to negative. Mathematical modelling revealed faster clearance of anti-S1 compared to anti-NP (median half-life of 2.5 weeks versus 4.0 weeks), earlier transition to lower levels of antibody production (median of 8 versus 13 weeks), and greater reductions in relative antibody production rate after the transition (median of 35% versus 50%). INTERPRETATION: Mild SARS-CoV-2 infection is associated with heterogeneous serological responses in Euroimmun anti-S1 and Roche anti-NP assays. Anti-S1 responses showed faster rates of clearance, more rapid transition from high to low level production rate and greater reduction in production rate after this transition. In mild infection, anti-S1 serology alone may underestimate incident infections. The mechanisms that underpin faster clearance and lower rates of sustained anti-S1 production may impact on the longevity of humoral immunity. FUNDING: Charitable donations via Barts Charity, Wellcome Trust, NIHR.