Wedge Video: Supporting Remote Participants in a Mixed-Mode Videoconference Meeting

As global COVID-19 pandemic response has moved from full lockdowns and partial lockdowns in most parts of the world to a post-COVID era, an interesting new phenomenon that has emerged is the increased prevalence of hybrid meetings with a mixture of online and in-person attendees. The opportunity for remote participants to observe the responses and interactions of others in the meeting is generally accepted as being limited. An experimental prototype system, called Wedge Video, has been constructed as an attempt to improve the experience of remote participants in hybrid in-person/remote meetings. Wedge Video uses standard screen and camera equipment with existing video conferencing software (Zoom). An evaluation of the prototype system was conducted based on three simple games that each required players to interact rapidly and with some use of body language or gaze direction. Encouraging results led to the examination of the geometry of screen and camera placement in detail. A system that has a somewhat 'virtual reality' feeling to it has now been developed. The remote user is given a view of the in-person part of the meeting with participants at the same scale and location as they would be if the remote user were at the table themselves. Similarly, the local participants see the remote person in place at their table, at a realistic scale and with close to accurate gaze direction. A very preliminary evaluation of these concepts has been promising.

The Social Construction of Leadership Power

What is called into being as "leadership” is what is intelligible as leadership through norms and "truths” at the time. It is not just based on the intent or characteristics of the leader, but on how subjects of the "truths” of the leader are constituted and hence conduct themselves. Leadership and context are connected and hence socially constructed. In fact, traditional, views of "universal” leadership traits as possessed by the leader do not help us explain or understand what has happened in Australia during the last 2 years of the pandemic, seen by most as a crisis in leadership. Having presided over closed international borders and a majority of closed internal borders and lockdowns for most of 2020/2021 the federal government provided heavily interventionist wages support for most businesses and workers in that time. Given the closure of international borders, and the priority given to suppression of the virus, the coordinated test, trace, and isolate practices delivered in each state were largely effective. With 90% of people double-dose vaccinated across the country in November 2021 and 9 days into the Omicron variant, the international borders and most state borders opened completely or with exemptions available. The Prime Minister "declared his aspiration to get the government out of people's lives… [becoming] a government in name only… " (Felk, 2022). Infections, and deaths skyrocketed and the test, trace, and isolate regime broke down in most places with long queues and people waiting for days for results. The new pushing through and moving forward "truths” were a major change in how leadership of the pandemic was now presented. By understanding leadership as deploying techniques of governmentality, how most people are asked to reconstitute themselves as "responsible” individuals who now valued their freedoms above social obligations of protecting others from the virus can be examined. In the new narratives of "leadership, " deaths are less important than hospitalizations and managing health systems. The resurgence of the priority of the economy shows a swing from one extreme of zero-suppression of the virus to the other, described by some as the "let it rip” strategy with one of the highest rises in daily cases and deaths in the world. The health/freedom/economy paradox remains and it is uncertain if the government can "strike the most effective response to it” (Grattan, 2022). By understanding leadership as techniques of governmentality where narratives attempt to tell "truths” for a period of time that constitute people in certain ways according to rationalities of governing, how construction of compliance or not and "leadership” or not through norms of intelligibility happens can be apprehended and therefore imagine something better. "Living with Covid” might be a better balance between more distanced pushing through, moving forward, and taking individual responsibility alongside social obligations and restrictions on freedoms that prioritizes living in addition to the economy. © The Author(s), under exclusive licence to Springer Nature Switzerland AG 2022.

What Is the Optimal Pk/Pd Target for Beta-Lactam Therapy of Infective Endocarditis? A Systematic Review

Aim: To elucidate the factors that influence beta-lactam pharmacokinetic (PK) and pharmacodynamic (PD) variability in infective endocarditis (IE) and to examine optimal PK/PD target parameters for therapy. Background(s): Beta-lactam antibiotics are the mainstay of therapy for most bacterial causes of IE. Traditionally considered as agents with a broad therapeutic index there has been increasing recognition that standard doses may be subtherapeutic or toxic in critically ill patients. Optimising therapy for efficacy requires an established PK/PD target associated with clinical and microbiological cure. Method(s): Clinical and laboratory in vivo animal or human studies examining PK and/or PD of beta-lactam antibiotics in IE were eligible. Ovid MEDLINE, Embase and Cochrane Central Registry were searched using defined terms. Two authors reviewed s and full texts using Covidence software. Result(s): 62 articles were selected for review and synthesis. We identified 45 animal studies investigating the broad categories of beta-lactam diffusion into vegetations, PK/PD determinants of outcome, mode of antibiotic delivery and synergistic impact of agents. 17 human case studies/series totalling 347 participants reported antibiotic serum concentrations and clinical outcomes. Findings generally supported the importance of time-dependent killing for beta-lactams but heterogeneous data limited the determination of an optimal PK/PD target for IE treatment. Conclusion(s): Beta-lactam PK and PD in endocarditis is variable and specific to the particular antibiotic-organism combination. Timedependent killing is important, consistent with non-endocarditis studies, but there is little agreement on optimal drug exposure. Clinical studies examining various PK/PD targets in endocarditis patients are required to further inform drug selection and dosing.Copyright © 2023 Southern Society for Clinical Investigation.

LivR Well, a 28-day, community-based liver optimization program for patients with acute-on-chronic liver failure: A feasibility study

Background and Aim: Acute-on-chronic liver failure (ACLF) is a global health care challenge, with a 28-day mortality rate of 33.9% and 30-day readmission rate of 37%.1,2 Management of ACLF is often complicated by multiorgan involvement, need for intensive care support, sarcopenia/frailty, and lack of universally accepted diagnostic criteria.3,4 Health care resource utilization is high. Our aims were to assess the safety, efficacy, acceptability, and cost of LivR Well, a new model of intensive, multidisciplinary ambulatory care for patients with ACLF. Method(s): We conducted a prospective, single-arm, mixed-methods study at Monash Health, a large Victorian tertiary network. Adult patients were enrolled from the inpatient ward, emergency department, or outpatient clinic in the first 28 days after a formal diagnosis of ACLF. ACLF was defined using Asian Pacific Association for the Study of the Liver criteria (an acute hepatic insult manifesting as jaundice and coagulopathy, complicated by ascites and/or encephalopathy within 4 weeks).5 Study criteria and the LivR Well intervention are shown in Figure 1. Patients were admitted to hospital in the home and received nursing visits up to 3 times a week and a weekly clinic medical review. Patients accessed physiotherapy, pharmacy, dietetics, social work, addiction medicine, and neuropsychiatry if appropriate. Blood test results were monitored weekly, and patients were followed up for 12 weeks. Health-related quality of life (HRQoL) was measured using EQ-5D and the Chronic Liver Disease Questionnaire (CLDQ) at baseline and Week 6. A qualitative substudy was undertaken to assess acceptability, with interviews performed between Weeks 6 and 12. The primary outcome was safety. Secondary outcomes were readmission, liver disease severity, HRQoL, symptom burden (CLDQ), acceptability, and health care resource utilization. Result(s): Fifty-nine patients (median age, 51 years [IQR, 45-59];66% male) were enrolled between March 2021 and April 2022. Forty-four patients completed the 28-day program, with two deaths (at Days 16 and 27), one drop-out due to COVID-19 requiring isolation, eight patients discharged due to failure to attend, and four patients who remain active in the program. There were no reported adverse events. Alcohol misuse was the most frequent liver disease etiology (73%). There was a significant reduction in median Model for End-Stage Liver Disease-Sodium (MELDNa) score from 16 at baseline (IQR, 12-21) to 15 at Day 28 (IQR, 11-18;P < 0.001). Sarcopenia prevalence decreased from baseline to Day 28 but did not reach statistical significance (27% vs 19%, P = 0.48). HRQoL significantly improved from a median baseline CLDQ score of 4.34 (IQR, 3.37-5.08) to 4.75 (IQR, 3.97-5.81;P = 0.02), with specific improvement in the domains of activity (P = 0.04), fatigue (P = 0.02), and worry (P = 0.001). The qualitative study highlighted universal themes of high acceptability, improved health literacy/insight, and increased autonomy. The median self-reported health perception using a visual analog scale significantly improved from 64% (IQR, 42-77%) to 72% (IQR, 50-80%;P = 0.05). The 28-day mortality rate was 3%, and the 30-day readmission rate was 14%. The median LivRWell program cost was A$4947. The total 6-month median direct health care cost for each LivR Well patient improved from a median of A$30 913 before LivR Well (IQR, $11 201-$61 464) to $784 after LivR Well (IQR, $0-$18 117;P < 0.001). The total direct health care cost for this cohort was reduced by 71%, from $1.16 million before to $335 000 after LivR Well, largely driven by a 40% reduction in 30-day readmission. Conclusion(s): LivR Well is a world-first multidisciplinary ambulatory care program for patients with ACLF. Our feasibility study supported the safety, potential efficacy, and cost-effectiveness of such an intervention, with lower than expected 30-admission, 28-day mortality, and total health care cost for this complex cohort. There was a small, but significant improvement in MELD-Na score, HRQoL, and self-rep rted health perception. We are further evaluating the clinical and economic impact of LivR Well as part of a randomized controlled trial comparing it with standard ambulatory care.

Behavioral insights for minimizing loneliness during the COVID-19 pandemic

Social distancing is a necessary policy with an unfortunate name. Although maintaining geographical, or physical, distance from one another is important for slowing the spread of COVID-19, people should strive to maintain social connections even while physically apart. That is because the lack of connection and the attendant loneliness that can result from physical distancing are not benign: loneliness can impair well-being and harm health. In this article, we review evidence demonstrating the ill effects of loneliness and summarize actions that psychological science suggests can enhance social connection during the COVID-19 pandemic despite physical distancing. We also discuss ways that governments, nonprofit organizations, and for-profit organizations can help motivate people to adopt these actions. Efforts to mitigate the medical risks of COVID-19 should not have to exacerbate the public health problem of loneliness. © 2020, Brookings Institution Press. All rights reserved.

The Effect of Ebola Virus Disease on Maternal and Child Health Services and Child Mortality in Sierra Leone, 2014–2015: Implications for COVID-19

WATERLIT Abstract: During Sierra Leone's 2014–2015 Ebola virus disease (EVD) epidemic, early reports warned of health system collapse and potential effects on other-cause mortality. These same warnings are reverberating during the COVID-19 pandemic. Consideration of the impacts of EVD on maternal and child health services from facility data can be instructive during COVID-19. We surveyed all peripheral healthcare units (PHUs) in Sierra Leone in October 2014 and March 2015 to assess closures, staffing, amenities, medicines, supplies, and service utilization during May 2014–January 2015 and October 2013–January 2014. We report PHU characteristics and service utilization changes for equivalent 4-month periods during the epidemic and the prior year. We present utilization changes by district and service type, and model excess child mortality. PHU closures (−8%) and staff attrition (−3%) were limited, but many facilities lacked amenities, medicines, and supplies. Utilization of preventive and scheduled services fell more than individualized, clinical care interventions, aside from malaria treatment which declined significantly. Ebola virus disease intensity in districts was weakly associated with utilization, aside from two districts that were severely affected. Modeling suggests utilization declines resulted in 6,782 excess under-five deaths (an increase of 21%) between 2014 and 2015. Ebola virus disease negatively affected service provision, but utilization declined relatively more, particularly for preventive and scheduled interventions. Although these findings are specific to Sierra Leone's EVD epidemic, they illustrate the magnitude of possible effects in other settings due to COVID-19–induced service disruptions, where collateral impacts on child mortality from other preventable causes may far outweigh COVID-19 mortality

Optimizing outcomes for COVID-19 coagulopathy through thromboelastography and platelet mapping

INTRODUCTION: COVID-19 coagulopathy is described most frequently as a hypercoagualable state, often leading to empiric anti-coagulant therapy. However, COVID-19 can present with either thrombotic and/or hemorrhagic complications secondary to a platelet function diathesis or factor dysfunction. We hypothesized that thromboelastography with platelet mapping (TEG-PM) would more accurately characterize an individual's COVID-19 coagulopathic state and that TEG-guided medical therapy would reduce complications and improve outcomes. METHODS: Prospective, longitudinal chart reviews of 65 COVID-19 patients with TEG-PM data were performed at an 800-bed tertiary care hospital. Clinician-initiated TEG-PM was drawn on admission and q48-72 hrs whenever possible. Patients were divided into 2 groups depending on whether their coagulopathy ultimately resolved: 1) resolved/non-coagulopathic state (NC-TEG) or 2) persistent coagulopathic condition, either hyper- or hypo-coagulable (C-TEG). Outcomes included thrombotic/hemorrhagic complications, pulmonary failure, acute kidney injury (AKI) and non-survival. Standard therapy was provided independently by attending clinicians, including the option of using pre-existing TEG-guided treatment algorithms. RESULTS: D-dimer, CRP and ferritin, while significantly elevated in the sickest patients, could not differentiate coagulopathic from non-coagulopathic patients. Platelet hyperactivity (MA-AA/ADP >50min), with or without thrombocytosis, was associated with thrombotic/ischemic complications. Hemorrhagic complications (cerebrovascular, hemoptysis) were observed with elevated R (>8min) and decreased factor activity. C-TEG patients had nearly a 40-fold increased risk for mechanical ventilation (p=0.0002), 2.7 for AKI (p=0.0027), 33.7 dialysis (p=0.0152) and 13.3-fold increased risk of death (p<0.0001) with 12/16 (75%) C-TEG patients dying compared to 1 (2%) NC-TEG patient (<0.0001). TEG-PM guided anti-platelet treatment decreased mortality 73% (p=0.0108). In contrast, indiscriminate anti-coagulation (antifactor therapy: heparin/enoxaparin) resulted in 3.6-fold increased risk of death (p=0.0218). CONCLUSIONS: Proper characterization of coagulopathic patients with TEG-PM and TEG-tailored therapy (guided by algorithm) may decrease complications and improve outcomes for COVID-19 patients.

The effect of the COVID-19 lockdown on the epidemiology of hip fractures in the elderly: a multicentre cohort study.

INTRODUCTION: The COVID-19 pandemic presented extraordinary challenges to the UK healthcare system. This study aimed to assess the impact of the COVID-19 lockdown on the epidemiology, treatment pathways and 30-day mortality rates of hip fractures. Outcomes of COVID-19 positive patients were compared against those who tested negative. METHODS: An observational, retrospective, multicentre study was conducted across six hospitals in the South East of England. Data were retrieved from the National Hip Fracture Database and electronic medical records. Data was collected for the strictest UK lockdown period (period B=23 March 2020-11 May 2020), and the corresponding period in 2019 (period A). RESULTS: A total of 386 patients were admitted during period A, whereas 381 were admitted during period B. Despite the suspension of the 'Best Practice Tariff' during period B, time to surgery, time to orthogeriatric assessment, and 30-day mortality were similar between period A and B. The length of inpatient stay was significantly shorter during period B (11.5 days vs 17.0 days, p<0.001). Comparison of COVID-19 positive and negative patients during period B demonstrated that a positive test was associated with a significantly higher rate of 30-day mortality (53.6% vs 6.7%), surgical delay >36h (46.4% vs 30.8%, p=0.049), and increased length of inpatient stay (15.8 vs 11.7 days, p=0.015). CONCLUSIONS: The COVID-19 lockdown did not alter the epidemiology of hip fractures. A substantially higher mortality rate was observed among patients with a COVID-19 positive test. These findings should be taken into consideration by the healthcare policymakers while formulating contingency plans for a potential 'second wave'.

Correction to: Thirty-day mortality following surgical management of hip fractures during the COVID-19 pandemic: findings from a prospective multi-centre UK study.

The published online version contains mistake, as the Fig. 1 legend should read "Kaplan-Meier survival curve for 30-day survival for 2020 cohort COVID-19 positive vs COVID-19 negative" whilst the Fig. 2 legend should read "Kaplan-Meier survival curve for 30-day survival 2020 COVID-19 negative group vs 2019 cohort".

Thirty-day mortality following surgical management of hip fractures during the COVID-19 pandemic: findings from a prospective multi-centre UK study.

PURPOSE: Thirty-day mortality of patients with hip fracture is well researched and predictive; validated scoring tools have been developed (Nottingham Hip Fracture Score, NHFS). COVID-19 has significantly greater mortality in the elderly and comorbid patients which includes hip fracture patients. Non-operative treatment is not appropriate due to significantly higher mortality, and therefore, these patients are often exposed to COVID-19 in the peri-operative period. What is unclear is the effect of concomitant COVID-19 infection in these patients. METHODS: A multicentre prospective study across ten sites in the United Kingdom (responsible for 7% of hip fracture patients per annum in the UK). Demographic and background information were collected by independent chart review. Data on surgical factors included American Society of Anesthesiologists (ASA) score, time to theatre, Nottingham Hip fracture score (NHFS) and classification of fracture were also collected between 1st March 2020 and 30th April 2020 with a matched cohort from the same period in 2019. RESULTS: Actual and expected 30-day mortality was found to be significantly higher than expected for 2020 COVID-19 positive patients (RR 3.00 95% CI 1.57-5.75, p < 0.001), with 30 observed deaths compared against the 10 expected from NHFS risk stratification. CONCLUSION: COVID-19 infection appears to be an independent risk factor for increased mortality in hip fracture patients. Whilst non-operative management of these fractures is not suggested due to the documented increased risks and mortality, this study provides evidence to the emerging literature of the severity of COVID-19 infection in surgical patients and the potential impact of COVID-19 on elective surgical patients in the peri-operative period.