Socioeconomic Factors Associated with Delay of Minimally Invasive Benign Gynecologic Surgery and Impact of the COVID-19 Pandemic

Objective: The effects of demographic and socioeconomic characteristics on delay of minimally invasive gynecologic surgery (MIGS) before and during the COVID-19 pandemic were studied. The primary outcome was interval between first MIGS appointment and date of surgery. Materials and Methods: This retrospective cohort study used electronic medical record data of a historical cohort who had benign MIGS in 2014-2016 (n = 370) and a cohort in 2020 during the COVID pandemic (n = 249). Included procedures were laparoscopic hysterectomy, myomectomy, adnexal surgery, or endometriosis excision. Patient demographics (race, ethnicity, age, marital status, language, insurance, and socioeconomic factors) were evaluated for associations with surgery delay (> 90 days from initial consultation to operating room date). Results: Median time to surgery was 21 days faster during the pandemic. In the historical cohort, 61% patients waited >90 days, and in the pandemic cohort, 47% patients waited >90 days. In the pandemic cohort, race and primary language were new factors associated with surgery delays. During the pandemic, a greater proportion of patients having surgery delays were Black or other races, compared to White, and a greater proportion did not speak English. After adjusting for referral indications, in multivariable logistic regression, patients who reported Other race had 3 times the odds of surgery delay, compared to White patients. Black patients had higher odds of surgery delay, although this estimate was less precise. Patients with a non-English primary language had >4 times the odds of surgery delay. Ethnicity, insurance and employment status, median household income, neighborhood segregation, and distance to hospital were not associated with surgery delay. Telemedicine accounted for 71% of visits in the pandemic cohort and was associated with a significant decrease in surgery delays with a median wait time of 87 days for patients seen via telemedicine, compared to 101 days for patients seen in-person. A higher proportion of patients using telemedicine were White and spoke English. Hispanic/Latino ethnicity, non-English primary language, and unemployment were associated with in-person versus telemedicine visits. Visit type was not correlated with insurance status, median household income, neighborhood segregation, and distance from the hospital. A risk score was calculated to summarize the estimated effect of intersectionality of multiple identities;multiple minority characteristics were correlated with surgery delays. Time to benign MIGS decreased from historical baselines during the pandemic, indicating improved access to surgical care. This benefit did not apply equally. Disproportionately, White patients who spoke English had no delays and used telemedicine;racial minority patients who did not speak English had greater odds of surgery delays and in-person appointments. Conclusions: Telemedicine can improve access to both MIGS care and surgical outcomes;additional strategies are needed to ensure that all patients receive care advances equitably. (J GYNECOL SURG 20XX:000)

SARS-CoV-2 Illness Severity and Early Hospitalization Outcomes in a Multicenter Prospective Cohort Study Among Veterans

Background. Over 600,000 SARS-CoV-2 infections and 20,000 deaths have occurred among users of the Veterans Health Administration, the US's largest integrated health care system. We explored early outcomes of SARS-COV-2 infection in Veterans. Methods. An ongoing, prospective longitudinal cohort study of Veterans ages >= 18 enrolled 1,826 participants (29.0% inpatient;49.1% vaccinated;68.3% SARS-CoV-2-positive;85.0% male, mean age = 57.1 years) seeking inpatient or outpatient care after SARS-CoV-2 testing at 15 Department of Veterans Affairs medical centers in July 2020 to February 13, 2022. Using multivariable regression, we estimated relationships of baseline demographic characteristics, COVID-19 vaccination, and clinical history to illness severity and cumulative length of hospital stay within 60 days of study entry. Illness severity was defined by a Veterans Affairs adaptation of the WHO COVID-19 severity scale and included 4 levels (mild, moderate, severe, or death). We derived the Charlson co-morbidity index (CCI) and other baseline characteristics from electronic health data and study questionnaires, and reported qualitative SARS-CoV-2 IgG responses using inpatients' study-collected blood specimens. Results. High CCI scores (>= 5) occurred in 47 (42.7%) vaccinated SARS-CoV-2-positive inpatients and 47 (21.2%) unvaccinated. Severe illness occurred in 17 (15.5%) vaccinated inpatients, 37 (16.7%) unvaccinated inpatients, 4 (0.9%) vaccinated outpatients, and 3 (0.7%) unvaccinated outpatients. Eleven (10%) of 110 vaccinated SARS-CoV-2-positive inpatients died, as did 15 (6.8%) of the 222 unvaccinated. In SARS-CoV-2-positive inpatients, a one-step higher CCI was associated with more severe illness (aOR 1.10, 95%CI 1.01-1.20) and more hospitalization days (aIRR 1.06, 95% CI 1.03-1.10), adjusting for vaccination status. Respectively, 93% of vaccinated and 63% of unvaccinated SARS-CoV-2 positive inpatients with baseline antibody results had an anti-spike IgG response. Conclusion. In an ongoing longitudinal cohort study of COVID-19 in US Veterans, comorbidity burden was higher among vaccinated than unvaccinated inpatients and was associated with more severe illness and hospitalization days, independent of vaccination status.

AI Book Club: An Innovative Professional Development Model for AI Education

This paper describes an AI Book Club as an innovative 20-hour professional development (PD) model designed to prepare teachers with AI content knowledge and an understanding of the ethical issues posed by bias in AI that are foundational to developing AI-literate citizens. The design of the intervention was motivated by a desire to manage the cognitive load of AI learning by spreading the PD program over several weeks and a desire to form and maintain a community of teachers interested in AI education during the COVID-19 pandemic. Each week participants spent an hour independently reading selections from an AI book, reviewing AI activities, and viewing videos of other educators teaching the activities, then met online for 1 hour to discuss the materials and brainstorm how they might adapt the materials for their classrooms. The participants in the AI Book Club were 37 middle school educators from 3 US school districts and 5 youth-serving organizations. The teachers are from STEM disciplines as well as Social Studies and Art. Eighty-nine percent were from underrepresented groups in STEM and CS. In this paper we describe the design of the AI Book Club, its implementation, and preliminary findings on teachers' impressions of the AI Book Club as a form of PD, thoughts about teaching AI in classrooms, and interest in continuing the book club model in the upcoming year. We conclude with recommendations for others interested in implementing a book club PD format for AI learning. © 2022 Owner/Author.

Covid-19, Child & Adolescent Mental Health Services (CAMHS) and Crises

Despite low rates of Covid-19 infection and mortality, children and adolescents have experienced disproportionate restrictions on their personal, social and academic life. Among youth in Ireland, reports of increased attendances by primary care counselling services have been mirrored by increased presentations to emergency departments and specialist mental health services, most notably self-harm and eating disorders. Following an immediate post lock down reduction, emergency department presentations by children for acute mental health care and referrals to child and adolescent mental health services (CAMHS) showed a sustained increase throughout 2020. Urgent action is needed to invest in CAMHS post pandemic to prevent any further increase in psychiatric illness among youth. We all share this collective responsibility to insist of government commitment to our youth.

Diagnostic accuracy of the Abbott ID NOW SARS-CoV-2 rapid test for the triage of acute medical admissions.

BACKGROUND: Decisions to isolate patients at risk of having coronavirus disease 2019 (COVID-19) in the emergency department (ED) must be rapid and accurate to ensure prompt treatment and maintain patient flow whilst minimising nosocomial spread. Reverse transcription polymerase chain reaction (RT-PCR) assays are too slow to achieve this, and near-patient testing is being used increasingly to facilitate triage. The ID NOW severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) assay is an isothermal nucleic acid amplification near-patient test which targets the RNA-dependent RNA-polymerase gene. AIM: To assess the diagnostic performance of ID NOW as a COVID-19 triage tool for medical admissions from the ED of a large acute hospital. METHODS: All adult acute medical admissions from the ED between 31st March and 31st July 2021 with valid ID NOW and RT-PCR results were included. The diagnostic accuracy of ID NOW [sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV)] was calculated against the laboratory reference standard. Discrepant results were explored further using cycle threshold values and clinical data. FINDINGS: Two percent (124/6050) of medical admissions were SARS-CoV-2 positive on RT-PCR. Compared with PCR, ID NOW had sensitivity and specificity of 83.1% [95% confidence interval (CI) 75.4-88.7] and 99.5% (95% CI 99.3-99.6), respectively. PPV and NPV were 76.9% (95% CI 69.0-83.2) and 99.6% (95% CI 99.5-99.8), respectively. The median time from arrival in the ED to ID NOW result was 59 min. CONCLUSION: ID NOW provides a rapid and reliable adjunct for the safe triage of patients with COVID-19, and can work effectively when integrated into an ED triage algorithm.

The Liminal Leisure of Disadvantaged Young People in the UK Before and During the COVID-19 Pandemic

The global COVID-19 pandemic has created, exposed and exacerbated inequalities and differences around access to—and experiences and representations of—the physical and virtual spaces of young people’s leisure cultures and practices. Drawing on longstanding themes of continuity and change in youth leisure scholarship, this paper contributes to our understandings of ‘liminal leisure’ as experienced by some young people in the UK before and during the COVID-19 pandemic. To do this, we place primary pre-pandemic research on disadvantaged young people’s leisure spaces and practices in dialogue with secondary data on lockdown and post-lockdown leisure. Subsequently, we argue that existing and emergent forms of youth ‘leisure liminality’ are best understood through the lens of intersectional disadvantages. Specifically, pre-existing intersectional disadvantages are being compounded by disruptions to youth leisure, as the upheaval of the pandemic continues to be differentially experienced. To understand this process, we deploy the concept of liminal leisure spaces used by Swaine et al Leisure Studies 37:4,440-451, (2018) in their ethnography of Khat-chewing among young British Somali urban youth ‘on the margins’. Similarly, our focus is on young people’s management and negotiation of substance use ‘risks’, harms and pleasures when in ‘private-in-public’ leisure spaces. We note that the UK government responses to the pandemic, such as national and regional lockdowns, meant that the leisure liminality of disadvantaged young people pre-pandemic became the experience of young people more generally, with for example the closure of night-time economies (NTEs). Yet despite some temporary convergence, intersectionally disadvantaged young people ‘at leisure’ have been subject to a particularly problematic confluence of criminalisation, exclusion and stigmatisation in COVID-19 times, which will most likely continue into the post-pandemic future. © 2021, The Author(s).

Safety and effectiveness of an integrated, telehealth-led supported discharge service for Covid-19

Introduction and ObjectivesThe Covid-19 pandemic has driven forward a number of remote monitoring schemes (virtual wards) across the country to support the early discharge of patients with covid-19. Technology can assist clinical teams to deliver comprehensive care in the community. In this study we aim to evaluate the safety and effectiveness of an innovative, telehealth-led virtual ward for Covid-19.MethodsPatients discharged from hospital respiratory wards with a diagnosis of Covid-19 and deemed at risk of readmission (or requiring home oxygen weaning) were eligible for referral. Monitoring equipment (thermometers and digital pulse oximeters) was provided and patients were on-boarded into a telehealth platform prior to discharge. Smartphones and tablets were supplied by the service if required. A Covid-19 digital clinical question set and triaging algorithm was developed locally. Patients were instructed to complete it daily remotely during follow-up and to enter their observations three times daily. Clinical data fed into a dashboard reviewed daily by the community respiratory specialist team who would contact and assess patients submitting symptoms of concern. Monitoring lasted for up to 14 days, and escalation processes to the acute Trust were in place for those patients showing evidence of deterioration.Results218 patients were monitored between December 2020 and May 2021, 29 for oxygen weaning. 41% were female, mean age 57 years old (minimum 21, maximum 89). Average oxygen weaning time was 11 days, with 319 days of hospital bed days saved by the oxygen weaning service and an estimated £127,600 cost saving to the system. Only 10 patients (4.9%) were readmitted after 14 days (versus 9% in usual care from hospital Covid-19 wards). Four patients (1.8%) died in hospital after a readmission. 83% of patients felt ‘very supported’ by the service and 73% expressed that it had ‘fully’ improved their confidence. Average score of satisfaction with the service, measured by a self-reported questionnaire, was 9.9/10.ConclusionsA telehealth-assisted remote monitoring service for Covid-19 is a safe way to provide specialist care at home and can reduce hospital readmissions whilst improving patient experience.

Early detection of SARS-CoV-2 and other infections in solid organ transplant recipients and household members using wearable devices

Purpose: Wearable devices that measure physiological parameters have shown utility for detecting infections such as influenza and recently COVID-19 up to 10 days before clinical symptoms appear. Combining symptom data with wearable biosensor data has proven to increase discrimination between COVID-19 and non-COVID-19 infection compared to using symptom data alone (AUC 0.80 vs. 0.71, p<0.01). Here we study the utility of wearable devices in early detection of SARS-Cov2 and related infections in pediatric solid organ transplant recipients. Early remote detection of infections may guide treatment responses to improve clinical outcomes such as rates of hospitalization. Methods: This is an ongoing prospective cohort study of pediatric solid organ transplant recipients and their non-transplanted household members. We are currently remotely recruiting all participants from multicenter sites and heart, liver and lung transplant patients from a single transplant center. We continuously monitor heart rate (HR), body temperature, oxygen saturation, blood pressure, sleep and respiratory patterns, and electro-dermal activity. We use MyPHD, a HIPAA compliant information architecture that supports EHR integration, for remote patient recruitment, secure data collection, and analyses. We apply two real-time algorithms to the data to identify changes that are associated with COVID-19. The algorithms are based on Resting Heart-Rate-Difference (RHR-Diff) and identify periods of elevated HR based on outlier interval detection, calculating standardized residuals for each HR observation compared to a baseline of clinically validated “healthy days” for each patient. Results: Continuous real-time physiological monitoring of transplant patients may provide syndromic surveillance and inform healthcare management. The primary outcome is time to infection diagnoses, with a particular emphasis on SARS-CoV2 and common post-transplant infections (Influenza, EBV, CMV, and BK virus). The secondary outcomes are to optimize our algorithms for the pediatric transplant setting and to monitor for other complications including cardiometabolic complications and eGFR decline. Conclusions: The potential impact of this study include algorithm-guided early detection of infection signatures coupled with provider clinical-decision-support and return-of-results to manage transplant patient care.

Patient Characteristics Associated with Delays to Benign Gynecologic Surgery: Impact of the COVID-19 Pandemic

Study Objective To examine how demographic and socioeconomic characteristics impact timing of minimally invasive gynecologic surgery (MIGS) before and during the COVID-19 pandemic. Design Retrospective cohort study using electronic medical record data. Primary outcome was interval between referral to MIGS and date of surgery. Setting Tertiary-level MIGS division in the southeast US. Patients or Participants Historical cohort undergoing surgery with MIGS 2014-2016 (n=377) and cohort in 2020 referred during the pandemic (n=191). Interventions Laparoscopic hysterectomy, myomectomy, adnexal surgery, or excision of endometriosis. Measurements and Main Results Patient demographics (race, age, marital status, language, insurance, and socioeconomic factors) were evaluated for significant associations with surgical delay. Patients with fibroids and abnormal uterine bleeding had a shorter interval to surgery (median 95 days, range 66-133) compared to patients with chronic pelvic pain (median 127 days, range 73-274). Our model adjusting for surgical indication revealed that single patients were 2.13 times as likely to wait >90 days (95% CI 1.35-3.36) compared to partnered patients prior to the pandemic. Additionally, those in the lowest quartile of median household income (<$42,572 vs > $75,020;OR 2.42, 95% CI 1.32, 4.46) and those from zip codes with the highest proportion of population in poverty (≥ 0.20 vs <0.07;OR 1.93, 95% CI 1.04, 3.6) were more likely to wait > 90 days. However, all of these differences disappeared during the pandemic. There were no differences in time to surgery by race, ethnicity, language, population density, markers of education by zip code, or insurance before or during the pandemic. Conclusion Historically, race and socioeconomic factors are associated with decreased access to MIGS and vulnerable populations were disproportionately affected by the COVID-19 pandemic. Despite this, we found decreased time to surgery at our institution, and previous socioeconomic disparities associated with scheduling delays were improved during the pandemic, suggesting improved equitable access to tertiary-level MIGS.

Patient Characteristics Associated with Access to Minimally Invasive Gynecologic Surgery: Changes during the COVID-19 Pandemic

Study Objective To evaluate patient characteristics that affect access to minimally invasive gynecologic surgery (MIGS) and identify changes during the COVID-19 pandemic. Design Retrospective cohort study of patients referred to MIGS in 2014-2016 compared to 2020. Demographic and appointment information was abstracted from the electronic medical record. Primary outcome was interval between referral and first appointment. Setting Academic, tertiary-care MIGS division. Patients or Participants Historical cohort referred to MIGS 2014-2016 (n=1082) and cohort referred during the pandemic (n=770). Interventions N/A. Measurements and Main Results Demographic characteristics (race, age, language, insurance, employment, socioeconomic factors by census tract) were evaluated for associations with a longer referral interval. Being unemployed and living in an area with lower income, less population density (rural), or less education were associated with referral interval >30 days in 2014-2016 (p<0.05). In 2020, only unemployment was associated with referral interval >30 days and new risk factors were: primary language Spanish versus English (OR 2.92, 95% CI: 1.45-5.88) and public insurance versus commercial (OR 1.48, 95% CI: 1.00-2.18). Average referral intervals were significantly shorter in 2020 versus 2014-2016 (p<0.01). The odds of waiting >30 days increased by 7% with the addition of one demographic risk factor (95% CI: 1.02-1.11) and 22% for three risk factors (95% CI:1.07-1.38) in 2014-2016 whereas there was no significant association identified in 2020 for one (OR 1.02, 95% CI: 0.97-1.07) or three risk factors (OR 1.05, 95% CI: 0.91-1.22). Telemedicine appointments had a shorter referral interval versus in-person appointments (p<0.01). Hispanic and unemployed patients were less likely to have telemedicine appointments (p<0.01). Conclusion Time from referral to first appointment at a tertiary-care MIGS practice during the COVID-19 pandemic was faster than in 2014-2016. Differences in the prevalence of socioeconomic and demographic factors suggest that telemedicine improved access to care for most patients and decreased access disparities for many vulnerable populations, but not for Spanish-speaking, publicly-insured, or unemployed patients.

Rapid review of decision-making for place of care and death in older people: Lessons for COVID-19

IntroductionThe coronavirus pandemic (COVID-19) has affected the functioning and capacity of healthcare systems worldwide. COVID-19 has also disproportionately affected older adults, including those living with dementia. In the context of COVID-19, decision-making surrounding place of care and place of death in this population involves significant new challenges.ObjectivesTo explore key factors that influence place of care and place of death decisions in older adults. A secondary aim was to investigate key factors that influence the process and outcome of these decisions in older adults. To apply findings from current evidence to the context of COVID-19.MethodsRapid review of reviews, undertaken using WHO guidance for rapid reviews. Ten papers were included for full data extraction. These papers were published between 2005-2020. Data extracted was synthesised using narrative synthesis, with thematic analysis and tabulation.ResultsPapers included discussed actual place of death, as well as preferred. Results were divided into papers that explored the process of decision-making, and those that explored decision-making outcomes. Factors such as caregiver capacity, the availability of multidisciplinary teams, cultural appropriateness of care packages and advanced care planning were found to be key.ConclusionsThe process and outcomes of decision-making for older people are affected by many factors – all of which have the potential to influence both patients and caregivers experience of illness and dying. Within the context of COVID-19, such decisions may have to be made rapidly and be reflexive to changing needs of systems and of families and patients.

Rapid development of a decision-aid for people with dementia and their families during COVID-19

IntroductionCOVID-19 as a pandemic has disproportionately affected older adults, including those with dementia. The effects on health and social care systems has necessitated a rapid-response approach to care planning and decision-making in this population, with reflexivity and responsiveness to changing individual and system needs at its core. In light of this, a decision-making tool to help families of persons with dementia was developed using a combination of qualitative data and evidence synthesis.ObjectivesTo develop a decision-aid using a combination of assessment and evidence-gathering methods for families of persons with dementia.MethodsSemi-structured interviews with helpline staff from national end-of-life and supportive care organisations formed the basis of the tool design. Co-design with people living with dementia, current and former carers and experts in general practice and social care shaped the next stage. Simultaneously, a rapid review of current evidence on making decisions with older people at the end of life was undertaken.ResultsOutput from interviews covered many topics, including trust, agency and confusion in making decisions in the context of COVID-19. The rapid review of existing evidence highlighted the need to consider both process and outcome elements of decision-making.ConclusionsCombining different sources and forms of evidence was efficient and valuable in creating a novel decision-making tool for persons with dementia and their families within the context of COVID-19. The decision-aid covered care planning, caregiver support systems, access to information and contingency considerations. Upon publication, the tool was adopted by NHS England and other leading healthcare organisations.DisclosureNo significant relationships.