The positive impact of the COVID 19 pandemic on organ utilisation in liver transplantation

Background: As the world recovers from the aftermath of devastating waves of an outbreak, the ongoing Coronavirus disease 2019 pandemic has presented a unique perspective to the transplantation community of ''organ utilisation'' in liver transplantation, a poorly defined term and ongoing hurdle in this field. To this end, we report the key metrics of transplantation activity from a high-volume liver transplantation centre in the United Kingdom over the past two years. Method(s): Between March 2019 and February 2021, details of donor liver offers received by our centre from National Health Service Blood & Transplant, and of transplantation were reviewed. Differences in the activity before and after the outbreak of the pandemic, including short term post-transplant survival, have been reported. Result(s): The pandemic year at our centre witnessed a higher utilisation of Donation after Cardiac Death livers (80.4% vs. 58.3%, p = 0.016) with preserved United Kingdom donor liver indices and median donor age (2.12 vs. 2.02, p = 0.638;55 vs. 57 years, p = 0.541) when compared to the pre-pandemic year. The 1- year patient survival rates for recipients in both the periods were comparable. The pandemic year, that was associated with increased utilisation of Donation after Cardiac Death livers, had an ischaemic cholangiopathy rate of 6%. Conclusion(s): The pressures imposed by the pandemic led to increased utilisation of specific donor livers to meet patient needs and minimise the risk of death on the waiting list, with apparently preserved early post-transplant survival. Optimum organ utilisation is a balancing act between risk and benefit for the potential recipient, and technologies like machine perfusion may allow surgeons to increase utilisation without compromising patient outcomes.Copyright © 2022

In search of ethical pandemic technology.

The duration of the pandemic over the last two years has witnessed the steering of multiple technological interventions by governments. These interventions - ranging from contact tracing applications to vaccine certificates - have been developed in the specific context of the pandemic, and were meant to address its unique requirements. This family of technological interventions may be termed "pandemic technology" - having diverse uses such as preventing the transmission of Covid-19, and aiding the relaxation of pandemic-induced restrictions. We propose a four-rung ethical paradigm for the deployment of such technology. We call it the STEP model and its four pillars consist of (i) sunset clauses, (ii) trust, (iii) equity, and (iv) privacy preservation.

COVID-19 pandemic: the impact on Canada's intensive care units

The COVID-19 pandemic has exposed the precarious demand-capacity balance in Canadian hospitals, including critical care where there is an urgent need for trained health care professionals to dramatically increase ICU capacity. The impact of the pandemic on ICUs varied significantly across the country with provinces that implemented public health measures later and relaxed them sooner being impacted more severely. Pediatric ICUs routinely admitted adult patients. Non-ICU areas were converted to ICUs and staff were redeployed from other essential service areas. Faced with a lack of critical care capacity, triage plans for ICU admission were developed and nearly implemented in some provinces. Twenty eight percent of patients in Canadian ICUs who required mechanical ventilation died. Surviving patients have required prolonged ICU admission, hospitalization and extensive ongoing rehabilitation. Family members of patients were not permitted to visit, resulting in additional psychological stresses to patients, families, and healthcare teams. ICU professionals also experienced extreme psychological stresses from caring for such large numbers of critically ill patients, often in sub-standard conditions. This resulted in large numbers of health workers leaving their professions. This pandemic is not yet over, and it is likely that new pandemics will follow. A review and recommendations for the future are provided. © 2022 Gibney et al.

Pandemic Disruptions to Access to Higher Education in South Africa: A Dream Deferred?

The COVID-19 pandemic and the shift to emergency remote teaching (ERT) and online learning highlighted issues of social justice, pedagogical inclusion and epistemic access in higher education. The research underlying this article analyses the complexities of access to learning and the effects of the shift to ERT and online learning on the social justice agenda in South Africa, using the case study of the University of Johannesburg.The article uses the conceptual frameworks of epistemic access, equity and inclusive pedagogy from the theories of Fraser (2008), Mbembe (2016) and Mgqwashu (2016). Pedagogic continuity and inclusion (Motala and Menon 2020;Menon and Motala 2021), hard-won by many institutions during the pandemic, will need to be sustained and secured as the world adapts to a "new normal" in higher education and other spheres of life.Czerniewicz et al. (2020, 957) refer to the maxim "Anytime, anyplace, anywhere" characterising ERT as a "brutal underestimation of the complexities and entanglement of different inequalities and structural arrangements". Fataar (2020), Czerniewicz et al. (2020) and Hodges et al. (2020) advocate an alternative pedagogy that is "trauma-informed" and offers parity with the pedagogies that prevailed pre-pandemic.The article concludes that the pre-existing conditions of deep inequality and inequities, and a highly differentiated higher education system with uneven pedagogical practices, were exacerbated by the pandemic. While we acknowledge the achievement of avoiding the loss of the academic year during the pandemic, we argue that it is important to learn lessons from the initial implementation of ERT and the fractures that it highlights in higher education. Heading into an uncertain future, the sector needs explicit equity-driven approaches to ensure pedagogical inclusion beyond physical and epistemic access.

Pedagogical continuities in teaching and learning during COVID-19: Holding up the bridge

2020 and 2021 in higher education were characterised by pandemic-related disruptions to conventional modes of teaching and learning. These prompted discussions about pedagogic shifts, academic continuity and the future of teaching and learning. Debates on the 'future-focused' university have raised questions about system-level and resourcing issues, teaching and learning practices and new ecologies of e-learning. This paper engages with these debates to better understand the continuities and discontinuities in the new pedagogies and how these affect what universities may do differently going forward. The pandemic prompted exploration of hybrid models of teaching and learning, with radical changes to traditional face-to-face teaching. The theoretical framework of the paper synthesises the concepts of pedagogical continuity and social justice to analyse the research findings. The research is based on data collected from interviews with 15 senior academic leaders at the University of Johannesburg (UJ) about how they negotiated pedagogy during the transition to emergency remote teaching (ERT) and online teaching and learning. The findings indicate that academic staff were able to draw significant gains in the transition to ERT that may offer new opportunities and possibilities for learning in an uncertain future. © 2022 by the authors.

Heart Lung Health Monitor: Remote At-Home Patient Surveillance for Pandemic Management

The COVID-19 pandemic has brought about an unprecedented shift towards Telehealth since physicians are overwhelmed by the huge patient load in hospitals. This has forced policy makers to advise home quarantine for mild and moderate COVID patients. Additionally, even non-COVID patients with diabetes and cardiovascular or pulmonary diseases who do not need hospitalization are currently being monitored at home for any changes in their severity that may require a home to hospital transfer. Our research team has developed an Internet of Medical Things wearable Heart Lung Health monitor for patients with cardiovascular and pulmonary risk factors so as to enable hospitals to remotely track patient health status. Our system consists of a credit-card sized wearable 3-lead ECG device interfaced with smartphone that analyzes ECG and extracts heart and respiratory parameters, and transmits these to a dashboard for remote monitoring. We present the architecture, device, respiratory rate extraction algorithm, and its validation on 50 patients. Encouraged by these results we are readying deployment of our system for home monitoring of at-risk patients.

REWOC: Remote Early Warning of Out-of-ICU Crashes in COVID Care Areas using IoT Device

COVID-19 pandemic has challenged the capabilities of hospital healthcare delivery systems worldwide. Among patients admitted in hospitals, sudden severity deterioration leading to out-of-ICU ward crashes are observed in many care areas. During the current pandemic, the major gap in the timely identification of COVID patient deterioration is due to the isolation precautions precluding continuous patient monitoring in wards. To address this challenge, we developed and deployed a wearable IoT integrated system called Remote Early Warning of Out-of-ICU Crashes (REWOC in short), which consists of wearable devices at the patient end and early warning score integrated dashboards for physicians and nurses to monitor patients remotely. We describe the architecture and design of REWOC as well as our deployment experience of REWOC on COVID patients in a large hospital in India. To our knowledge, this is one of the first reports of a real-world deployment using wearable devices for monitoring out-of-ICU ward crashes among COVID patients. © 2021 IEEE.

Evaluation of treatment delays in hepatopancreatico-biliary surgery during the first COVID-19 wave.

INTRODUCTION: The COVID-19 pandemic has caused oncological services worldwide to face unprecedented challenges resulting in treatment disruption for surgical patients. Hepatopancreatico-biliary (HPB) cancers are characterised by rapid disease progression. This study aims to assess delays in receiving surgery for this patient cohort during the first COVID-19 wave. METHODS: Patients undergoing surgery between April and July 2020 (COVID period) were compared with a control group from the preceding year. Delay in receiving surgery was defined as more than 50 days between referral and surgery date. Statistical analysis was carried out to evaluate predictors of delay and short-term outcomes. RESULTS: During the COVID-19 and pre-COVID-19 periods, 94 and 115 patients underwent surgery, respectively. No patients contracted COVID-19 postoperatively. Some 118 patients waited more than 50 days for surgery versus 91 who received surgery within 50 days from referral. Independent predictors for surgical delay were undergoing surgery in the COVID-19 era (odds ratio (OR) 2.2, 95% confidence interval (CI) 1.2-4.1; p=0.015), referral pathway (OR 35.1, 95% CI 4.2-296; p=0.001) and presenting pathology (OR 8.3, 95% CI 1.2-56.1; p=0.03). Short-term outcomes were comparable between groups. CONCLUSIONS: Patient referral pathway and presenting pathology may contribute to delays in undergoing HPB cancer surgery during COVID-19 outbreaks. It is hoped that a better understanding of these factors will aid in designing shifts in healthcare policy during future pandemic outbreaks.

Stage migration: The impact of COVID-19 on the management of hepatocellular carcinoma;A uk centre experience

Background: The COVID 19 Pandemic has been an unprecedented global health crisis. We undertook a retrospective observational study to evaluate its impact on the management of hepatocellular cancer (HCC) in a large tertiary referral service in the UK offering all treatment modalities: liver transplantation and resection through to locoregional, systemic therapy and specialist palliative care. HCC in adults is often diagnosed in advanced stages as symptoms are only apparent later in the disease, and recent reviews have highlighted more patients presenting later with decompensation and a backlog of deferred care1. This study reviews outcomes pre and post the first wave of the Pandemic, including disease presentation, time to treatment and loss to follow up. Methods: Retrospective study of consecutive new referrals to a tertiary treatment centre. These included patients discussed between Dec 2019-Feb 2020 ('pre-COVID';total referrals n=98 with 66 newly diagnosed HCC), and July-Sept 2020 ('post 1st wave COVID';total referrals n=81 with 51 newly diagnosed HCC). NHS Providers had been asked to maintain access to essential cancer treatment throughout the Pandemic with easing of lockdown on 11 May 2020. Patients were longitudinally followed up and analysed using electronic medical records. Descriptive results were expressed as median with IQR for continuous data and as frequency (%) for categorical data. Baseline characteristics of patients were compared between the two cohorts using the Mann-Whitney U test for continuous data, and χ2 test for qualitative data. Results: As shown in Table 1, post 1st wave there has been a reduction in total number of referrals. Median age, sex and aetiology were similar between groups. Differences were noted in patient characteristics of the 'post 1st wave' cohort with a greater proportion presenting with Child Pugh C (19% vs 4%, p=0.037) and BCLC stage D (25.5% vs 12% p=0.019). Among the group of patients presenting during the Pandemic none had a diagnosis of COVID 19 infection. While there were no significant differences in loss to follow up or the decision to treatment time interval (excluding transplant) between 2019 & 2020 (p=0.672), 3 patients in 2020 had treatment cancellations due to capacity. Conclusion: After the 1st wave there has been a reduction in external referrals and an increase in number of patients presenting with advanced chronic liver disease and untreatable HCC. Whilst these are likely to represent the effects of major service reconfiguration during the Pandemic at both a 1° and 2° care level our study suggests we need to better understand medium to longterm impact. We note local efforts to preserve cancer care avoided treatment delays post 1st wave but further analysis is underway to assess impact of the second wave on quality of care received and mortality.

Operating a medical intensive liver unit during a pandemic

Background: The novel COVID-19 pandemic created an unprecedented strain on healthcare systems, particularly on intensive care services. Balancing demand for intensive care unit beds with increased patient acuity challenged facility's abilities to provide access to care for patients with advanced liver disease. We report the development of unique practices designed to maintain clinical operations of our Medical Intensive Liver Unit (MILU). Methods: Consecutive patients admitted to the MILU at a United States quaternary care LT center between 08/27/2018 and 12/31/2020 were enrolled in a prospective registry and followed from admission to hospital discharge, LT or death. In March 2020, the MILU was geographically relocated to accommodate the COVID-19 pandemic surge and to protect the at-risk patients with liver disease. To facilitate this transition, new protocols were developed to rapidly train nursing and support staff and to adjust ICU throughput. Procedures were implemented to facilitate virtual models of clinical care and communication. Clinical working groups were assembled to re-design protocols encompassing acute liver failure, acute kidney injury, nutrition optimization, sepsis pathways, and perioperative management. Results: In 2020, 373 patients were admitted to the MILU, accounting for 408 hospital admissions and 472 MILU admissions. Of these patients, 124 patients (30.3%) died in-hospital. 279 patients (74.5%) were cirrhotic, and 26 patients (6.9%) were admitted for acute liver failure. The most common etiology of liver disease in patients with cirrhosis was alcohol-related liver disease (42.6%), increased from 2019 (33.3%). Average MELD-Na score was 30.1, increased from 2019 (27.2). 48 (12.9%) of these patients underwent LT in 2020, 35 (72.9%) of whom were transplanted during the same hospitalization as their MILU admission, and 22 (45.8%) directly from MILU. Conclusion: Data previously presented supports the MILU as a promising sub-specialty model for the improved intensive care of patients with advanced liver disease. The COVID-19 pandemic presented both logistical and clinical challenges for the delivery of care to this vulnerable patient population. Our experience mirrors national trends in increased severity of illness for hospitalized hepatology patients during the pandemic. Collaborative efforts in ensuring adherence to novel protocols and maintained communication within a multi-disciplinary team resulted in successful optimization strategies for bridging higher acuity patients to LT.

COVID-19 Diagnosis from Chest X-Ray Images Using Convolutional Neural Networks and Effects of Data Poisoning

At the end of 2019, a new type of virus called SARS-CoV-2 began spreading resulting in a global pandemic. As of June 2021, almost 175 million people were affected worldwide. Symptom-wise, it is very difficult to diagnose if a person has Covid or just a viral infection. But, taking a close look at chest X-Rays is extremely helpful in the diagnostic process. The proposed methodology in this paper helps in classification of chest X-Ray images into 3 categories: ‘Covid’, ‘Viral’ and ‘Normal’. The dataset was created by integrating 3 pre-existing evergrowing datasets and the ResNet-18 model was adopted to train it. The experimental results show that the classification of the chest X-Ray images was done with an accuracy of 0.9648. An adversarial machine learning approach was employed to poison the train data after which the classification accuracy dropped to 0.8711. © 2021, Springer Nature Switzerland AG.

Pandemic Leadership in Higher Education: New Horizons, Risks and Complexities

The disruption of the academic year by the COVID-19 pandemic required higher education institutions to manage and lead under untenable conditions. This article is a case study of a leadership model adopted at the University of Johannesburg (UJ) located in South Africa. It offers insights into how the leadership and governance evolved and enabled management of the crisis presented by the pandemic. This article presents the relevant theory and concepts on leadership followed by a review of the impact of COVID-19 on higher education. This is followed by an interpretation of the sequence of events as they unfolded at UJ propelled by the mandate to leave no student behind and continue with the academic year. The UJ experience was characterised by the values of social justice, equity, access and teaching excellence. This article explores the University of Johannesburg's response in relation to these values and leadership theories.

Tocilizumab therapy in 5 solid and composite tissue transplant recipients with early ARDS due to SARS-CoV-2.

There are emerging data depicting the clinical presentation of coronavirus disease 19 (COVID-19) in solid organ transplant recipients but negligible data-driven guidance on clinical management. A biphasic course has been described in some infected with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), beginning with a flu-like illness followed by an intense inflammatory response characterized by elevated c-reactive protein (CRP), interleukin 6 (IL-6), and acute respiratory distress syndrome (ARDS) associated with high mortality. The exuberant and possibly dysregulated immune response has prompted interest in therapeutic agents that target the cytokines involved, particularly IL-6. Tocilizumab is an IL-6 receptor antagonist with a record of use for a variety of rheumatologic conditions and cytokine release syndrome due to chimeric antigen receptor T-cell therapy but experience in solid organ and composite tissue transplant recipients (SOT/CTTRs) with SARS-CoV-2-related ARDS has not been previously reported in detail. We present the clinical course of 5 SOT/CTTRs with SARS-CoV-2-related ARDS that received tocilizumab with favorable short-term outcomes in 4. Responses were characterized by reductions in CRP, discontinuation of vasopressors, improved oxygenation and respiratory mechanics, and variable duration of ventilator support. Four bacterial infections occurred within 2 weeks of tocilizumab administration. We discuss safety concerns and the need for randomized comparative trials to delineate tocilizumab's clinical utility in this population.

Successful orthotopic liver transplantation in a patient with a positive SARS-CoV2 test and acute liver failure secondary to acetaminophen overdose.

SARS-CoV2, first described in December 2019, was declared a pandemic by the World Health Organization in March 2020. Various surgical and medical societies promptly published guidelines, based on expert opinion, on managing patients with COVID-19, with a consensus to postpone elective surgeries and procedures. We describe the case of an orthotopic liver transplantation (OLT) in a young female who presented with acute liver failure secondary to acetaminophen toxicity to manage abdominal pain and in the setting of a positive SARS-CoV2 test. Despite a positive test, she had no respiratory symptoms at time of presentation. The positive test was thought to be residual viral load. The patient had a very favorable outcome, likely related to multiple factors including her young age, lack of respiratory COVID-19 manifestations and plasma exchange peri-operatively. We recommend a full work-up for OLT in COVID-19 patients with uncomplicated disease according to standard of care, with careful interpretation of COVID-19 testing in patients presenting with conditions requiring urgent or emergent surgery as well as repeat testing even a few days after initial testing, as this could alter management.

Coronavirus disease 2019 in an orthotopic liver transplant recipient living with human immunodeficiency virus.

Coronavirus disease 2019 (COVID-19), mediated by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), can manifest with flu-like illness and severe pneumonia with acute respiratory distress syndrome (ARDS). Immunocompromised patients merit particular attention as altered host immunity may influence both disease severity and duration of viral shedding as is described with several other ribonucleic acid respiratory viruses. Yet immunocompromised status alone, in the absence of other comorbidities, may not necessarily predict severe illness presentations and poorer clinical outcomes as indicated by recent reports of COVID-19-infected solid organ transplant recipients and people living with human immunodeficiency virus (HIV). Such patients may even be spared the robust inflammatory response that precipitates ARDS associated with COVID-19, complicating the management of iatrogenic immunosuppression in this setting. We present a case of an orthotopic liver transplant recipient with well-controlled HIV who successfully recovered from a mild, flu-like illness attributed to SARS-CoV-2.