Real-World effectiveness of voxelotor for the treatment of sickle cell disease

Introduction: Voxelotor is a first-in- class sickle haemoglobin polymerisation inhibitor that targets the pathophysiology of sickle cell disease (SCD). Studies have shown that voxelotor increases haemoglobin and reduces markers of haemolysis. Emerging evidence suggests that voxelotor may improve the clinical symptoms of SCD, lower vaso-occlusive crisis (VOC) rates, and reduce transfusion needs. Objective(s): To examine the real-world impact of voxelotor on transfusion, VOC, and hospitalisation rates among patients with SCD. Method(s): Medical and pharmacy claims data for patients >=4 years with SCD who started voxelotor between November 2019 and March 2022 were obtained from the Symphony Health database. Patients with >=1 year of data before the index date (date of first voxelotor claim) were included. Annualised study outcomes were calculated for patients with >=1 occurrence of the corresponding event in the 3-month preindex period. Outcomes from a 90-day lookback were reported for the total and paediatric (aged 4 to <18 years) populations. Result(s): Of 4023 eligible patients from the Symphony Health database included in the analysis, 596 were <18 years. Compared with the 3-month preindex period, significantly lower annualised rates of transfusions, VOCs, and hospitalizations, and lower annualised mean number of inpatient days, were observed in the total population and paediatric subgroup over the 3-month postindex period. For the total population, the annualised event rates declined by 50.6% for transfusions (n = 248), 23.1% for VOCs (n = 1368), 35.5% for VOC-related hospitalizations (n = 757), and 39.4% for all-cause hospitalizations (n = 928). The annualised mean number of inpatient days declined by 29.6% for VOC-related hospitalizations (n = 757) and by 22.9% for all-cause hospitalizations (n = 928). For paediatric patients, the annualised event rates declined by 79.6% for transfusions (n = 18), 42.4% for VOCs (n = 157), 56.8% for VOC-related hospitalizations (n = 81), and 51.5% for all-cause hospitalizations (n = 106). The annualised mean number of inpatient days declined by 54.1% for VOC-related hospitalizations (n = 81) and by 45.8% for all-cause hospitalizations (n = 106). Conclusion(s): Treatment with voxelotor may provide a clinical benefit to patients with SCD by reducing the frequencies of transfusions, VOCs, and hospitalizations and decreasing inpatient days. Greater reductions were observed in the paediatric subgroup, potentially due to the smaller sample size, historically greater treatment compliance in paediatric patients, or younger patients having accumulated fewer SCD-related complications, enabling a greater clinical response. Limitations include the study's non-randomized design, reliance on claims data, and changes in healthcare use during the COVID-19 pandemic confounding the data.

Safety and Feasibility of Conversion from Venoarterial to Venovenous Extracorporeal Membrane Oxygenation in Pediatric Patients

Introduction: Children requiring venoarterial (VA) extracorporeal membrane oxygenation for long durations may have increased risk of complications compared to venovenous (VV) ECMO. The purpose of this study was to evaluate the feasibility and safety of conversion from VA to VV ECMO. Method(s): This is a retrospective review of all children requiring VA ECMO who underwent conversion to VV ECMO at a single institution, from 2015- 2022. Indications for and methods of conversion were examined as well as adverse events including re-operation, ischemic complications, renal failure, and mortality. Descriptive statistics were calculated. Result(s): Of 422 pediatric patients on initial VA ECMO, only three children (0.7%) underwent conversion from VA to VV support, ages 10-19: for hypoxic respiratory failure due to COVID19, for cardiac dysfunction following orthotopic heart transplant, and for sepsis with associated left ventricular dysfunction. The indications for conversion were bleeding from cannulation site (n=2, 66%) and an anticipated prolonged ECMO run (n=1, 33%). For all three patients, the method of conversion was cutdown with femoral arterial repair followed by placement of additional jugular venous cannulas (n=2, 66%) or insertion of a singular jugular bicaval venous cannula with removal of the femoral cannulas (n=1, 33%). The median time on VA ECMO prior to conversion was 8 days (range 4-54 days). All 3 patients were managed with renal replacement therapy with 1 patient (33%) progressing to long term dialysis. There were no significant ischemic limb complications although one (33%) patient developed a femoral artery pseudoaneurysm that required re-operation. Two of the three patients (66%) were able to be decannulated at a median of 23.5 days (range 8-39 days) following conversion to VV ECMO and survived to discharge. The other patient was unable to be decannulated after successful conversion and care was withdrawn. Conclusion(s): Based on this small pilot study, conversion to VV ECMO from initial femoral VA ECMO cannulation is safe and feasible. Indications for conversion include coagulopathy and need for extended ECMO run after recovery of cardiac function.

Management of Acquired von Willebrand Syndrome During Prolonged VV-ECMO

Acquired von Willebrand syndrome (AVWS) contributes to bleeding during extracorporeal membrane oxygenation (ECMO) support. Although it is recognized that AVWS rapidly resolves after ECMO decannulation, this approach may often be clinically unsuitable. In such cases, optimal AVWS management during ECMO support is not well established. We report our approach to managing AVWS in a patient on veno-venous (VV) ECMO for 59 days. A 19-year-old male developed hypoxemic respiratory failure from SARS-CoV-2 pneumonia. Following intubation, he progressed to VV-ECMO support for refractory hypoxemia and was started on bivalirudin for systemic anticoagulation. Two days later, he developed refractory gastrointestinal and oro-nasopharyngeal bleeding despite blood product transfusions and discontinuing bivalirudin. He was started on pantoprazole along with infusions of octreotide and aminocaproic acid. Upper endoscopy on ECMO day 5 revealed an ulcerative bleeding vessel in the duodenum that was clipped. Recurrent mucosal bleeding precluded resumption of systemic anticoagulation. On ECMO day 23, AVWS was diagnosed based on elevated von Willebrand factor (VWF) activity (207%, normal 55-189%) and antigen (234%, normal 50-210%) levels with abnormally low VWF high-molecular-weight multimers. Factor VIII complex was administered twice over the following week. Between doses, the ECMO circuit was exchanged to empirically mitigate suspected shear-related VWF consumption from the fibrin burden, and a repeat endoscopy controlled additional intestinal bleeding with local hemostatic agents. He received 36 units of red blood cells, 2 units of platelets, 2 units of plasma, and 7 pooled units of cryoprecipitate over 31 days leading into these combined interventions. In the 28 days afterwards, he received 3 units of red blood cells, 3.5 pooled units of cryoprecipitate, and no additional platelets or plasma. Our patient was maintained off systemic anticoagulation for 54 of 59 days of VV-ECMO support without any thrombotic complications occurring. With no subsequent clinical evidence of bleeding, repeat VWF testing was done two months post-decannulation and showed near-normal VWF activity (54%) and normal multimer distribution. Our patient rehabilitated well without any neurologic deficits and on discharge was requiring supplemental oxygen with sleep and strenuous activity. Avoiding systemic anticoagulation, repleting VWF, maintaining circuit integrity, and providing local hemostasis, when possible, may be a safe and effective management strategy of AVWS on ECMO support when decannulation is not a viable option.

Impact of Covid-19 Induced Program Adaptations on Hiv Suppression in Three Countries

Background: The pandemic response measures have had significant global economic and health impacts with transient reductions in HIV clinic attendance and self-reported anti-retroviral therapy (ART) adherence reported in prior studies. Since viral suppression (VS) is an indication of ART adherence and effective service delivery, we assessed VS in the context of the COVID-19 pandemic in 3 African countries Methods: Since 2013, the African Cohort Study (AFRICOS) has enrolled individuals 18 years or older with and without HIV, in an approximate 5:1 ratio, at 12 clinics across 5 HIV care programs in Tanzania Uganda, Kenya, and Nigeria. For people living with HIV (PLWH), ART history was extracted from medical records and viral load was assessed at each visit. This assesses VS (< 1000 c/ml) before and during the COVID-19 pandemic (categorized into 4 surges and a consolidated non-surge period;defined in Table 1) among PLWH. Tanzania was excluded due to inadequate pandemic data. Logistic regression with generalized estimating equations, clustered by participant, was used to estimate odds ratios (ORs) and 95% confidence intervals (CI) comparing VS before and during COVID-19. Models are adjusted for age, sex, and program. Result(s): Of the 1741 study participants, 368 are from Uganda, 1156 are from Kenya, and 217 are from Nigeria;730 are males, 1011 are females, and 147 are under the age of 30. PLWH were less likely to be virally suppressed during the first surge period (OR 0.85, CI 0.46-1.56), but VS significantly increased during the second surge period (OR 1.95, CI 1.23-3.04) compared to the pre-COVID period. The third and fourth surge periods also saw a higher VS (table 1). Females are more likely to be virally suppressed than males (OR 1.58, CI 1.09- 2.29) and PLWH ages 40-49 have higher VS (OR 2.43, CI 1.32-4.48) compared to PLWH under. PLWH at the AFRICOS sites in Kenya and Nigeria show lower VS than the Ugandan cohort (ORs 0.46, CI 0.26-0.79 and OR 0.32, CI 0.17-0.60 respectively). Conclusion(s): The initial drop in VS may be attributed to reduced clinic access due to lockdowns. Many HIV programs supported by the President's Emergency Plan for AIDS Relief (PEPFAR) adapted their strategies to serve PLWH by scaling up community ART dispensing and multi-month dispensing (MMD) of ART for stable clients, which could have led to increased VS during the other surge periods.

Scaling Supply to Meet Behavioral Health Demand in New York State Nursing Homes

Nursing home residents' need for behavioral health services is ever-increasing, and the Covid-19 pandemic exacerbated problems in behavioral health involving: (1) access, (2) quality of care, (3) care continuity, and (4) staff education. This case study describes a novel behavioral health program developed at the University of Rochester (UR) to optimize limited clinical resources and address unmet behavioral health needs of New York State's long-term care residents. To deliver effective behavioral health services in nursing homes, UR's behavioral health program has four components: onsite psychiatric nurse support, telepsychiatry, telepsychotherapy, and telementoring. Prior to the Covid-19 pandemic, this behavioral health program provided services to 29 nursing homes. Over 2 years (2017 to 2019), antipsychotic use among long-stay residents in these homes decreased by 37%. During the Covid-19 pandemic, the program's services expanded to 53 nursing homes. In contrast to increasing antipsychotic use at the national and state levels, long-stay resident antipsychotic use among program nursing homes decreased. With demonstrated success in improving access and outcomes at lower cost, the New York State Office of Mental Health has funded the program's expansion to nursing homes across the state. © 2022 NEJM Catalyst Innovations in Care Delivery. All right reserved.

Effectiveness of Dolutegravir in People on Rifampin-Based Tuberculosis Treatment

Background: Tenofovir-lamivudine-dolutegravir (TLD) is the WHO-preferred first-line regimen for people with HIV, but drug-drug interactions between dolutegravir (DTG) and rifampin (RIF) require an additional 50mg DTG (TLD+50) in people receiving tuberculosis (TB)/HIV co-treatment. RIF is a key drug in TB treatment, but is a potent inducer of metabolizing enzymes and efflux transporters, which can markedly lower drug concentrations. There are limited data on the effectiveness of TLD+50 in people with TB/HIV from program settings. Method(s): We conducted a prospective, observational study at 12 sites in 6 countries (Haiti, Kenya, Malawi, South Africa, Uganda, Zimbabwe). Participants received concomitant TLD+50 and RIF-based TB treatment provided as standard of care by HIV and TB treatment programs. Primary outcome was HIV-1 RNA <1000 copies/mL (cpm) at end of TB treatment. New DTG resistance mutations were defined as those present at end of TB treatment but not present at start. Result(s): From 11/2019-6/2021, we enrolled 91 participants with TB/HIV, including 75 ART-naive participants (82%) starting TLD+50 after a median of 15 days on TB treatment, 10 ART-naive participants (11%) starting TLD+50 and RIF together, 5 (5%) starting TB treatment and changing to TLD+50 after a median of 3.3y on TLD, and 1 (1%) starting RIF and TLD+50 after changing from EFV/3TC/TDF. Median age was 37y (IQR 32-43), 35% were female, 100% cis-gender, median CD4 count was 120 cells/mm3 (IQR 50-295), 87% had HIV-1 RNA >1000 copies/mL. Two participants died during TB treatment (week 4 disseminated TB, week 12 suspected COVID-19), 1 interrupted TLD+50 due to jaundice;and 1 discontinued TB treatment due to drug-induced liver injury. Among 89 surviving participants, 6 were lost to follow-up and a further 10 had no HIV-1 RNA result due to missed or remote visits. Primary virologic outcome was therefore assessed in 73 (80%), of whom 69 (95%, Wald 95% CI 89-100%) had HIV-1 RNA <=1000 cpm;68 (93%) had HIV-1 RNA <200 cpm. No sex specific differences in viral suppression were observed. No DTG resistance mutations were detected among 4 participants with HIV-1 RNA >1000 cpm. Conclusion(s): Concomitant RIF-containing TB treatment and TLD+50 was welltolerated and achieved excellent viral suppression in a cohort of predominantly ART-naive people with TB/HIV. These multi-country data from program settings support feasibility and effectiveness of current treatment approaches for TB/ HIV co-infection.

Characteristics and outcomes of COVID-19 patients with COPD from the United States, South Korea, and Europe

Background: Characterization studies of COVID-19 patients with chronic obstructive pulmonary disease (COPD) are limited in size and scope. The aim of the study is to provide a large-scale characterization of COVID-19 patients with COPD. Methods: We included thirteen databases contributing data from January-June 2020 from North America (US), Europe and Asia. We defined two cohorts of patients with COVID-19 namely a ‘diagnosed' and ‘hospitalized' cohort. We followed patients from COVID-19 index date to 30 days or death. We performed descriptive analysis and reported the frequency of characteristics and outcomes among COPD patients with COVID-19. Results: The study included 934,778 patients in the diagnosed COVID-19 cohort and 177,201 in the hospitalized COVID-19 cohort. Observed COPD prevalence in the diagnosed cohort ranged from 3.8% (95%CI 3.5-4.1%) in French data to 22.7% (95%CI 22.4-23.0) in US data, and from 1.9% (95%CI 1.6-2.2) in South Korean to 44.0% (95%CI 43.1-45.0) in US data, in the hospitalized cohorts. COPD patients in the hospitalized cohort had greater comorbidity than those in the diagnosed cohort, including hypertension, heart disease, diabetes and obesity. Mortality was higher in COPD patients in the hospitalized cohort and ranged from 7.6% (95%CI 6.9-8.4) to 32.2% (95%CI 28.0-36.7) across databases. ARDS, acute renal failure, cardiac arrhythmia and sepsis were the most common outcomes among hospitalized COPD patients. Conclusion: COPD patients with COVID-19 have high levels of COVID-19-associated comorbidities and poor COVID-19 outcomes. Further research is required to identify patients with COPD at high risk of worse outcomes. Copyright: © 2023 Moreno-Martos D et al.

Does perceived behavioral control mediate customers' innovativeness and continuance intention of e-money? The moderating role of perceived risk and e-security

Purpose: With the emergence of coronavirus disease 2019 (COVID-19), the usage of e-money has been reinforced to reach the next level. Therefore, this study aims to examine the mediating role of perceived behavioral control (PBC) on the nexus of customers' innovativeness and continuance intention of electronic money (e-money). This study also explores the moderating roles of perceived risk (PR) and electronic security (e-security) in relationships. Design/methodology/approach: The authors employed a structured questionnaire for data collection and the partial least squares structural equation modeling (PLS-SEM) for empirical estimations. Findings: The authors' findings reveal that customers' innovativeness promotes continuance intention of using e-money and demonstrate that PBC partially mediates the relation between customers' innovativeness and continuance intention of using e-money. The empirical findings also reveal that PR negatively moderates the relationship between customers' innovativeness and continuance intention and the relationship between customers' innovativeness and PBC. The empirical findings also exhibit that perceived e-security enhances the degree of the relationship between customers' innovativeness and continuance intention and the relationship between customers' innovativeness and PBC. Practical implications: The findings shed light on an important factor that increases the likelihood of repeat e-money usage and has direct managerial implications for customer experience and risk concerns. Hence, the findings imply that e-money service providers should run a promotional advertisement highlighting what additional features are included or offered and how these could be beneficial for the customers. Furthermore, e-money service providers should provide some tutorial videos in order to increase innovative customers' control over e-money services as well as highlight how risk and security are protected. Originality/value: This paper integrates three key theories: the diffusion of innovation (DOI) theory, the theory of planned behavior (TPB) and the PR theory in post-adoption behavior of e-money usage. The current study also attempts to fill a literature gap by examining the moderating role of PR and e-security, which could be useful within the relationship between customers' innovativeness, PBC and customers' continued intentions of e-money usage. © 2022, Emerald Publishing Limited.

Online Examination System with Measures for Prevention of Cheating along with Rapid Assessment and Automatic Grading

The requirement for remote examination had emerged along with remote learning during the COVID-19 pandemic as the unprecedented situation had brought the world to halt. The pandemic had forced many educational institutions to move towards the online mode of assessment to assess the caliber of the students. This paper focuses on the ways that an online examination system can be prepared and can be used for conducting exams remotely in a secure way. It also emphasizes on various test cases that are essential for an efficient and useful examination system that can benefit both students and faculty by saving them time and effort. Due to the challenges in the existing mode of online assessment such as the use of digital forms that are usually used for conducting surveys, scanning and uploading answer sheets using phone with poor camera quality, the problem of engaging in the different kinds of misconduct, it was important to understand the user requirements at an examiner and examinee level and prepare a web application that addresses them and makes it convenient to conduct and attempt. We propose different methodologies that can be implemented in a Python based web application with the help of JavaScript such as switching the browser window to full-screen in order to restrict access to other applications, limited exits from full-screen, easy management of examiner and candidate data along with visualization of exam data that help to better understand and draw quick conclusions at the time of exam. It is also focused on the continuously evolving distance education system and finding the best software solution possible for online examinations. Additionally, an automated grading system may help to reduce human error and declare results easily reducing fatigue. © 2022 IEEE.

Purulent Pericardial Effusion with a Swinging Heart Post-Sars-Cov-2 Infection: A Case Report

Background Acute bacterial pericarditis is rare and can decompensate quickly to cardiac tamponade and cardiac arrest. Targeted antibiotic therapy, pericardiocentesis, and pericardiotomy are the cornerstones of management. Case 51-year-old male presented with 2-weeks of progressive chest pain, cough, and fatigue. A month prior he tested positive for COVID-19. On exam he was tachycardiac, tachypneic, and normotensive. JVD and peripheral edema were present. Labs revealed elevated WBC, BNP, HS-troponin, and ESR/CRP. Blood cultures were positive for methicillin susceptible Staphylococcus aureus (MSSA). Echo showed a large pericardial effusion with a swinging heart. ECG showed diffuse ST elevations and PR depression. He was not clinically in tamponade but shortly after became bradycardic and had a PEA arrest. Emergent bedside pericardiocentesis was performed, and after 9-minutes of ACLS, ROSC was attained. Pericardial fluid grew MSSA. Decision-making Vancomycin and cefepime were started and tapered to cefazolin to cover MSSA bacteremia and pericarditis. Repeat blood cultures were negative. A month after discharge he had no cardiac symptoms and echo showed minimal pericardial fluid. Conclusion In patients with COVID-19 and pericardial effusion, bacterial pericarditis can be secondary to contiguous spread from lung parenchyma or myopericarditis with superimposed infection, or due to primary pericarditis. This is the second reported case of spontaneous purulent pericarditis with MSSA. [Formula presented]Copyright © 2023 American College of Cardiology Foundation

Surgery for urologic cancers after SARS-CoV-2 infection: Adverse outcomes and optimal delay

Background: Perioperative SARS-CoV-2 infection has been associated with increased adverse outcomes. Research conducted early in the COVID-19 pandemic suggested an 8 week delay after SARSCoV-2 infection prior to undergoing surgery. The aim of this study is to determine if prior COVID-19 infection is an independent risk factor for adverse outcomes following surgery for urologic cancers. A secondary objective was to determine the optimal duration to delay surgery, specifically cystectomy, prostatectomy, or nephrectomy, after COVID-19 infection. Method(s): Data from the National COVID Cohort Collaborative (N3C) data enclave was used to conduct this retrospective cross-sectional study. Patients with cancer diagnoses that underwent surgery for urologic cancers after January 2020 were included in the analyses. Urologic surgeries were queried using standard SNOMED concepts corresponding to cystectomy, nephrectomy, and prostatectomy. Patients were assessed for adverse postoperative events that were defined using standard SNOMED clinical concepts. COVID-19 positive patients were identified via the N3C Knowledge Store using positive lab measurement or a positive SARS-CoV-2 diagnosis. Analyses were conducted in the N3C data enclave. Result(s): The study cohort included 38,974 total patients with 15,216, 14,778, and 8,980, undergoing cystectomy, prostatectomy, and nephrectomy, respectively. 2,807 had a history of COVID-19 infection greater than 20 days prior to surgery. Prior history of COVID-19 was independently associated with adverse outcomes for cystectomy (OR 1.21 [1.03-1.43], p<0.05) and nephrectomy (OR 1.27 [1.06-1.52], p<0.05), but not prostatectomy (OR 1.14 [0.95-1.36]). Multivariable regression assessing time to surgery and risk for any adverse events, did not reveal significant benefit to waiting greater than 20 days after COVID-19 infection to operate. Conclusion(s): Patients with known prior COVID-19 infection who underwent surgical treatment of urologic cancers experienced increased risk of adverse surgical outcomes. Among this group, those who delayed surgery greater than 20 days after infection did not demonstrate decreased risk of these negative outcomes across the procedures studied. Optimal surgical delay in the treatment of urologic cancers after COVID-19 infection does not appear to be greater than 20 days.

Realtime Risk Monitoring System using Convolutional Neural Network for COVID19 Pandemic

The COVID19 pandemic has significantly changed the lifestyle of billions of people across the globe. It has greatly affected almost all sectors of business, industry and public life. As per the WHO's guidelines, wearing a face mask has become the new compulsory and precautionary measures for everyone. Currently, all the public and private service providers will expect their stakeholders to wear face mask in an appropriate way to avail any services. Therefore, detection of face mask at public places is a crucial task to help the society to overcome current pandemic. This paper presents a unique approach to not only detect face mask but also calculate the risk of getting infected by COVID-19 using machine learning algorithms. The proposed model detects the various faces present in an input video, identifies if it has a mask present or not. If the mask is not detected, the model calculates the risk of human being getting infected based on their age. Finally, the model generates the output and provides analysis based on the real time data it has processed. As a real-time surveillance system, the model can also classify a face when a person is moving in the live video. The proposed method attained a highest accuracy of 99.57 % against standard datasets under study. The authors experimented and explored various Convolutional Neural Network models like DenseNet, MobileNet_V2, Inception_V3 and YOLO_V4 find the best model, detecting the presence of masks accurately without causing over-fitting. © 2022 IEEE.

A Retrospective Single Centre Analysis of the Incidence of Hospital Admission for Acute Coronary Syndrome During the COVID-19 Pandemic

Background: The severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) has caused a pandemic due to ‘coronavirus disease 2019' (COVID-19) that has led to millions of deaths. This may have resulted in a change in the rate of admissions for other potentially life-threatening conditions such as acute coronary syndromes (ACS). Therefore, we investigated the incidence of ACS admissions during the current pandemic and compared it to a similar period the year before. Methods: This was a retrospective analysis of all patients admitted to a tertiary cardiology centre with ACS between February 2019 and the end of April 2019 (pre-COVID) that was compared with admissions between the same three months in 2020 (post-COVID). The main outcomes of interest were to evaluate any potential reduction of ACS admissions during the pandemic or change in mortality. In addition, we evaluated the rate of patients proceeding to coronary angiography (CAG). Results: During the post-COVID period, only 200 patients were admitted with ACS as compared to 331 patients during the pre-COVID period (39.6% reduction;95% confidence interval (CI): 34%-44%;p<0.01). A reduction in the percentage of patients proceeding to CAG was also noted (253 patients during the pre-COVID period compared to only 134 patients in the post-COVID period (76.4% vs 67.0%;p = 0.02)) but no associated reduction of primary percutaneous coronary intervention was noted. No increase in in-hospital mortality was noted between the pre-COVID and post-COVID groups (1.5% vs 1% respectively;p = 0.62). Conclusion: There was a significant reduction in admissions for ACS in the post-COVID period compared to a similar period prior. There was also a reduction in the overall invasive management of ACS, with less CAG performed but no associated reduction in the rate of PPCI. The in-hospital mortality rate was similar in the two groups. © 2023 Shah et al.

Optimal Procurement of COVID-19 Vaccine with Time-Dependent Holding Cost and Shortages under Cloud Fuzzy Demand Rate

COVID-19 vaccine has emerged as the most powerful weapon against the spread of the coronavirus. Therefore, the management of the vaccine inventory is undoubtedly the most influential and important task for the global distribution of the vaccine. This paper is an attempt to model the vaccine inventory system having time-varying holding costs and partially backlogged shortages. The concept of fuzzy set and cloud pentagonal fuzzy number has been incorporated to make the models more realistic and applicable. Models are solved and validated through numerical examples and graphical representation. Further, sensitivity analysis has been done to identify the most sensitive parameters of all. Finally, managerial insights and conclusions have been drawn to make the vaccine inventory system more robust. © 2023 World Scientific Publishing Company.

Comparison of Virtual Reality Platforms to Enhance Medical Education for Gynecologic Brachytherapy

Purpose: Historically, medical education relied on apprentice-based experiences requiring direct observation in patient cases. Simulation-based education has been shown to improve resident confidence but can be time intensive and difficult to coordinate. The COVID-19 pandemic demonstrated the need to develop distributed educational tools. Virtual reality (VR) platform has been shown to improve resident confidence and proficiencies. This pilot study compared educational and cost effectiveness of low-cost cardboard viewer VR (CVVR) and commercially available integrated headset VR (IHVR). Material(s) and Method(s): We created a VR video of an intracavitary brachytherapy case for treatment of cervical cancer. Radiation oncology residents from a single ACGME-accredited training program were recruited and randomized to IHVR or CVVR. Both groups were given unlimited access to their randomized technology. Each resident performed a timed intracavitary procedure on a simulator while 5 implant quality metrics were recorded. A pre- and post-simulation questionnaire assessed self-confidence, procedural knowledge, and perceived usefulness of VR technology. Result(s): There were 13 residents, including four post-graduate year (PGY)-2, three PGY-3, two PGY-4, and four PGY-5, in the study. Seven (53.8%) of residents had previously performed an intracavitary brachytherapy procedure, while six (46.2%) had no prior experience. There were six residents randomized to IHVR and seven residents randomized to CVVR. Both VR technologies improved self-perceived overall confidence, assembly skill, and comfort performing the procedure independently. There were also non-statistically significant improvements in the ability to correctly order the steps of the brachytherapy procedure on post-simulation survey compared to pre-simulation survey in both VR viewer groups. Average time required for implant (mean: CVVR - 200 seconds vs. IHVR - 235 seconds, p=0.38) and median objective proficiencies of implant quality (5/5 in both group, p=0.56) were similar. There was no difference between CVVR and IHVR as useful, enjoyable and engaging educational tool. Both groups would recommend the technology to another trainee. There were differences in the time between last usage of the VR technology with 50% of the residents in the IHVR group completing the last VR SBE more than 2 weeks before the procedure, while the majority of residents in the CVVR group (57%) completed the last VR SBE within 1 hour before the procedure. IHVR-based program would cost ~33x more than CVVR-based program based on an assessment of US-based programs. Conclusion(s): CVVR is a cost-effective alternative to a IHVR as a virtual education tool. Copyright © 2022