Learning Management System: An Approach towards Virtual Education

With India's rapid educational growth towards virtual education, the education system has intensified. India has gone through critical condition like COVID-19. There is huge increment in the implementation of online learning management system. This helped the educational institutions to manage their education system without being physically present in the institution. This paper is presenting the challenges required by institutions to transform their manual education system into virtual/online education system. The online learning management system has enhanced the way of teaching and learning process of students. This study will tell us about how online LMS has speeding up the quality of education for the On-Campus enrolled students as well as distance learning students also. In general, LMS are built to provide the course material in a static way only. The modern LMS has the ability for the group discussion which is helping the student to achieve the qualities of team-working. © 2022 IEEE.

Depression Analysis Due to Impact of Working from Home during Covid-19 Pandemic

The corona virus [corona virus disease 2019 (COVID-19)] pandemic had adversely affected the people's lives. Work from home during this pandemic has affected various age group of people which leads to the several mental health issues such as depression. Initial indications imply that depression level is higher during COVID-19 pandemic. This research study reveals the quantitative analysis of affected people from depression by work from home during this pandemic an analytical online survey was conducted during this pandemic which contains a sample of 300 people from the different age groups they may include students, unemployed, IT sector workers, research scholars and had no prior history regarding their mental illness. Their working situation in this pandemic time of COVID-19 described their level of depression. The data of this survey show that the maximum number of depressed adults is belong from the age group of 36-40 mainly it includes working professional, unemployed and IT professionals, during this pandemic COVID-19. The adults who were working in IT sector or working professional due to this situation the interaction with the people decrease and screen time increase which results into the aggression, anxiety, mood swings and pessimistic thinking. As in case of student's depression due to less understanding and interaction with teacher in online classes which increases digital divide, dropouts, learning losses and their increase interest towards social media platforms. In our study age-based differences revealed that older age-groups were more vulnerable to stress, depression and anxiety symptoms.Copyright © 2022, Medico Legal Society. All rights reserved.

A novel PRFB decomposition for non-stationary time-series and image analysis

This work presents a novel perfect reconstruction filterbank decomposition (PRFBD) method for nonlinear and non-stationary time-series and image data representation and analysis. The Fourier decomposition method (FDM), an adaptive approach based on Fourier representation (FR), is shown to be a special case of the proposed PRFBD. In addition, adaptive Fourier–Gauss decomposition (FGD) based on FR and Gaussian filters, and adaptive Fourier–Butterworth decomposition (FBD) based on Butterworth filters are developed as the other special cases of the proposed PRFBD method. The proposed theory of PRFBD can decompose any signal (time-series, image, or other data) into a set of desired number of Fourier intrinsic band functions (FIBFs) that follow the amplitude-modulation and frequency-modulation (AM-FM) representations. A generic filterbank representation, where perfect reconstruction can be ensured for any given set of lowpass or highpass filters, is also presented. We performed an extensive analysis on both simulated and real-life data (COVID-19 pandemic, Earthquake and Gravitational waves) to demonstrate the efficacy of the proposed method. The resolution results in the time-frequency representation demonstrate that the proposed method is more promising than the state-of-the-art approaches. © 2023 Elsevier B.V.

Impact of Board of Director's Remuneration on Financial Performance during Covid-19: A Study of Indian Pharmaceutical Companies

This study aims to investigate the relationship between director's salary and financial performance of top 10 BSE Listed companies for the period of 3 years i.e. 2019-2021. Remuneration of director pays a vital role for the interest group of companies moreover it impacts the company's financial performance. Financial performance of the company is being judged by various financial ratio i.e. NPR, DE, ROCE, CR, ROA. Secondary data have been collected from the official website of the company. E views have been used to investigate the correlation between Directors remuneration and Financial performance. Our study indicates that director's remuneration has significant impact on financial performance. Copyright © 2022 Wolters Kluwer Medknow Publications. All rights reserved.

DISSEMINATED INVASIVE ASPERGILLUS MASQUERADING AS AMIODARONE-INDUCED THYROTOXICOSIS

SESSION TITLE: Rare Pulmonary Infections SESSION TYPE: Rapid Fire Case Reports PRESENTED ON: 10/18/2022 01:35 pm - 02:35 pm INTRODUCTION: Aspergillus is a group of opportunistic endemic fungal species that causes pathology within the respiratory tract and sinuses of individuals with predisposing factors, such as immunosuppression. While less frequently discussed, aspergillosis thyroiditis represents the most common fungal thyroiditis. We present a case of this condition that was misdiagnosed as amiodarone induced thyrotoxicosis. CASE PRESENTATION: A 54-year-old male was evaluated in outpatient pulmonary clinic after a chest CT revealed new upper lobe mass-like pleural based infiltrates with accompanying symptoms of dyspnea on exertion and fevers. His medical history was significant for orthotopic heart transplant 6 months ago due to a combination of non-ischemic cardiomyopathy with further decompensation from COVID-19 infection. After transplant, he was diagnosed with thyrotoxicosis secondary to amiodarone that was being treated with prednisone and methimazole. Given the concern for infection on imaging, he was admitted to the hospital and underwent urgent bronchoscopic evaluation. During the procedure, he was noted to have severe extrinsic tracheal compression. His neck imaging was consistent with a nodular goiter. The BAL revealed Aspergillosis fumigatus and he was subsequently treated with isavuconazium. Given the compression on the trachea and persistent dyspnea, the decision was to pursue total thyroidectomy. Surgery occurred 2 months after treatment was initiated for the Aspergillosis and with improvement on serial chest CTs. Pathologic examination of the thyroid tissue revealed extensive invasive aspergillus with abscesses involving both lobes. DISCUSSION: Aspergillus infection leading to disseminated disease typically occurs in individuals that have a compromised immune system such as seen in malignancy, solid organ transplant, chronic steroid use, and poorly controlled diabetes mellitus. Recently, it has been cited that up to 15% of hospitalized COVID-19 patients requiring intensive care develop aspergillus infection. After initial aspergillosis infection has been established, the thyroid gland is a site for dissemination due to its rich vascular supply. In addition, due to the angioinvasive properties of the pathogen, the fungus can breakdown tissue planes and easily travel from its site of origin. Thereby a primary infection in the respiratory tract can lead to dissemination to the neck structures due to its proximity. When thyroid invasion occurs, the common complaints are neck pain and swelling. Thyroid laboratory findings encompass the full spectrum including hyperthyroidism, hypothyroidism, and euthyroid. Given these non-specific findings, clinicians need to be conscious of this disease entity. CONCLUSIONS: In patients with immunocompromising conditions, findings of neck pain, swelling, and abnormal thyroid laboratory values should broaden the differential for clinicians to include aspergillosis thyroiditis. Reference #1: Alvi, Madiha M et al. "Aspergillus thyroiditis: a complication of respiratory tract infection in an immunocompromised patient.” Case reports in endocrinology vol. 2013 (2013): 741041. doi:10.1155/2013/741041 Reference #2: Marui, Suemi, et al. "Suppurative thyroiditis due to aspergillosis: a case report.” Journal of Medical Case Reports 8.1 (2014): 1-3. Reference #3: Kuehn, Bridget M. "Aspergillosis Is Common Among COVID-19 Patients in the ICU.” JAMA 326.16 (2021): 1573-1573. DISCLOSURES: No relevant relationships by A. Whitney Brown, value=Honoraria Removed 04/03/2022 by A. Whitney Brown No relevant relationships by A. Whitney Brown, value=Honoraria Removed 04/03/2022 by A. Whitney Brown No relevant relationships by A. Whitney Brown, value=Consulting fee Removed 04/03/2022 by A. Whitney Brown No relevant relationships by Kristen Bussa Advisory Committee Member relationship with Boehringer Ingelheim Please note: 2019-2021 Added 04/03/2022 by Christopher King, value=Consulting f e Advisory Committee Member relationship with Actelion Please note: 2019-2022 Added 04/03/2022 by Christopher King, value=Consulting fee Advisory Committee Member relationship with United Therapeutics Please note: 2019-2022 Added 04/03/2022 by Christopher King, value=Consulting fee Speaker/Speaker's Bureau relationship with Actelion Please note: 2019-2022 Added 04/03/2022 by Christopher King, value=Consulting fee Speaker/Speaker's Bureau relationship with United Therapeutics Please note: 2020-22 Added 04/03/2022 by Christopher King, value=Consulting fee No relevant relationships by Haresh Mani No relevant relationships by Mary Beth Maydosz No relevant relationships by Alan Nyquist No relevant relationships by Anju Singhal No relevant relationships by Amy Thatcher

COURSE AND OUTCOMES OF COVID-19 INFECTIONS IN LUNG TRANSPLANT RECIPIENTS

SESSION TITLE: COVID-19 Infections: Issues During and After Hospitalization SESSION TYPE: Original Investigations PRESENTED ON: 10/17/2022 01:30 pm - 02:30 pm PURPOSE: It has been established that recipients of solid organ transplants have worse outcomes compared to the general population from COVID-19 infections. We sought to determine the course and outcomes of lung transplant recipients (LTR) with COVID-19 infections based on vaccination status and treatments. METHODS: We performed a retrospective study of all LTR from Inova Fairfax Hospital with COVID-19 infections. Infection was confirmed based on symptoms and testing from an urgent care, hospital, or home kit. Patients with presumed but unconfirmed COVID-19 infections were excluded. The study timeframe was the two-year period: 3/1/2020 - 2/28/2022. Data collected included patient demographics, transplant type, immunosuppression, immunization status, episodes of rejection, donor derived cell-free DNA (dd-cfDNA) values (where available), spirometric data, outpatient/inpatient treatments, hospitalization data, and outcomes including death, infections, and other complications. The severity of illness was based on the 8-point ordinal scale. RESULTS: There were 45 LTR who tested positive during the study period;22 male and 23 female, average age of 57 and mean time from transplant of 4 years. 11 of the patients were unvaccinated (UV), 2 partially vaccinated (PV), 11 vaccinated non-boosted (VNB), and 21 vaccinated and boosted (VB). In total, 34 (76%) LTR required hospitalization. Of those hospitalized: 7 UV, 1 PV, 11 VNB, and 15 FV. In addition, 7 of those hospitalized required intubation with only 1/7 surviving to discharge. Overall, 8/45 (17.8%) patients died from COVID-19: 3 UV, 1PV, 1 VNB, 3VB. Infectious complications included 3 cases of PCP, 1 empyema, and 1 reactivation of CMV. For individuals who had spirometry at least 2 weeks after diagnosis (n =25), FVC decreased in 17 LTR by an average of 0.17 L, the FEV1 decreased in 14 LTR by an average of 0.14 L. On repeat spirometry testing (n=14), FVC further decreased in 9 LTR by 0.25 L and the FEV1 further decreased in 7 LTR by 0.13 L. CONCLUSIONS: A large proportion of LTR with COVID-19 infections require hospitalization (76%) with a high associated mortality rate and a sustained lung function decline seen in many who survive. The high mortality was independent of vaccination status, likely reflecting the inability of LTR to mount an immune response. A high index of suspicion and monitoring for superimposed infections, especially PCP, appears prudent. The sustained decline in lung function raises the notion of COVID-19 as a precipitating factor for chronic lung allograft dysfunction (CLAD). CLINICAL IMPLICATIONS: LTR who contract COVID-19 infection represent a high-risk population, even in those fully vaccinated, with potential for hospitalization, death, loss of lung function, and infectious complications. In this population, new algorithms for immunosuppression, monitoring and treatments may help to improve outcomes. DISCLOSURES: No relevant relationships by Shambhu Aryal No relevant relationships by A. Whitney Brown, value=Honoraria Removed 04/03/2022 by A. Whitney Brown No relevant relationships by A. Whitney Brown, value=Honoraria Removed 04/03/2022 by A. Whitney Brown No relevant relationships by A. Whitney Brown, value=Consulting fee Removed 04/03/2022 by A. Whitney Brown No relevant relationships by Jessica Chun No relevant relationships by Meg Fregoso No relevant relationships by Vikramjit Khangoora Advisory Committee Member relationship with Boehringer Ingelheim Please note: 2019-2021 Added 04/03/2022 by Christopher King, value=Consulting fee Advisory Committee Member relationship with Actelion Please note: 2019-2022 Added 04/03/2022 by Christopher King, value=Consulting fee Advisory Committee Member relationship with United Therapeutics Please note: 2019-2022 Added 04/03/2022 by Christopher King, value=Consulting fee Speaker/Speaker's Bureau relationship with Actelion Please note: 2019-2022 Added 04/0 /2022 by Christopher King, value=Consulting fee Speaker/Speaker's Bureau relationship with United Therapeutics Please note: 2020-22 Added 04/03/2022 by Christopher King, value=Consulting fee Consultant relationship with Veracyte Please note: $1001 - $5000 by Steven Nathan, value=Honoraria Removed 03/29/2022 by Steven Nathan Consultant relationship with United Therapeutics Please note: $5001 - $20000 by Steven Nathan, value=Consulting fee Consultant relationship with Bellerophon Please note: $5001 - $20000 by Steven Nathan, value=Consulting fee Speaker/Speaker's Bureau relationship with Roche-Genentech Please note: $5001 - $20000 by Steven Nathan, value=Honoraria Speaker/Speaker's Bureau relationship with Boerhinger-Ingelheim Please note: $20001 - $100000 by Steven Nathan, value=Honoraria No relevant relationships by Alan Nyquist No relevant relationships by Michelle Schreffler Speaker/Speaker's Bureau relationship with United Therapeutics Please note: 2020-2022 Added 04/01/2022 by Oksana Shlobin, value=Consulting fee Speaker/Speaker's Bureau relationship with Bayer Please note: 2020-2022 Added 04/01/2022 by Oksana Shlobin, value=Honoraria Speaker/Speaker's Bureau relationship with Janssen&Janssen Please note: 2020-2022 Added 04/01/2022 by Oksana Shlobin, value=Honoraria Consultant relationship with Altavant Please note: 2020-2022 Added 04/01/2022 by Oksana Shlobin, value=Consulting fee Consultant relationship with Acceleron Please note: 2020-2022 Added 04/01/2022 by Oksana Shlobin, value=Honoraria Consultant relationship with United Therapeutics Please note: 2020-2022 Added 04/01/2022 by Oksana Shlobin, value=Honoraria No relevant relationships by Anju Singhal No relevant relationships by Christopher Thomas

Ambient Fine Particulate Matter and COVID-19 in India

We examine the correlation between COVID-19 case activity and air pollution in two cities of Delhi and Mumbai in India. Data regarding air quality index (AQI) of PM2.5 and PM10 from Delhi and Mumbai were collected between July and November 2020. Within the same time period, confirmed cases and daily deaths due to COVID-19 in these two cities were also recorded. AQI levels in Delhi were worst in November (PM2.5: 446 ± 144.6 µg/m3;PM10: 318 ± 131.7 µg/m3) and were significantly higher as compared to Mumbai (PM2.5: 130 ± 41.2 µg/m3;PM10: 86 ± 21.2 µg/m3). This correlated with greater number of cases and higher mortality in Delhi (cases: 6243;deaths: 85) relative to Mumbai (cases: 1526;deaths: 35) during the same time period. This observational study shows that air pollution is associated with poor outcomes in patients with COVID-19. There is an urgent unmet need for appropriate public health measures to decrease air pollution along with strict policy change. © 2022, The Author(s), under exclusive license to Springer Nature Singapore Pte Ltd.

Clubfoot management during COVID-19 times: An Indian scenario

The coronavirus disease 2019 (COVID-19) pandemic has been universal and swift in its spread. As orthopaedic surgeons, for the most of us this timeframe has reduced our activity to emergency and trauma cases only, with virtual outpatient clinics and no elective surgeries. With some of the common deformity problems including clubfoot etc, which comprises a large number of children in the developing world, the management has been deferred, without any regional and national guidelines being framed. Updated guidelines relating to the management of clubfoot patients, in which parents can safely consult with the orthopaedic surgeon and physical rehabilitation specialists will allow them to cope with this unprecedented situation. We revisit the current scenario and the possible management protocol in the context of COVID-19 pandemic. © 2022 The Author(s).

Empirical Framework for Automatic Detection of Neural and Human Authored Fake News

The evolution of digitization and technology has increased the amount of data shared online, inevitably leading to the spread of false information. The issue has skyrocketed as COVID-19 spread across the globe and carried with it a sea-full of fake news. Recent technological advances, such as automatic text generators, have exacerbated the problem by interpolating synthetic text into the fake news. Current fake news detection approaches do not take into account the validity of synthetic news (machine-generated news), thus classifying all machine-generated material as fake. In this paper, the first-ever synthetic news classification model using CT-BERT is implemented, and a framework is proposed that not only distinguishes between human-authored and machine-generated text, but also considers the veracity of text to detect fake news. Moreover, a novel COVID-19 based synthetically generated dataset has been introduced by fusing synthetic text generated by GPT-2 and Grover model. Further, whether the GPT-2 and Grover models are vulnerable to adversarial attacks or not has been investigated. An accuracy of 98.2% and 92.4% respectively in the fake news classification of human-authored and machine-generated text have been achieved. © 2022 IEEE.

Detecting COVID-19 Opacity in X-ray Images Using YOLO and RetinaNet Ensemble

Coronavirus disease(COVID-19) is caused by SARS-COV-2 virus and has been declared as a pandemic. After almost two years of this pandemic, over five million people have lost their lives worldwide due to complications like pneumonia and acute respiratory distress syndrome. Many countries have already witnessed the second wave of pandemic and a huge loss of lives. One way to curb the disease spread is by timely and accurate diagnosis. X-rays and CT-scans can help a radiologist to detect the disease, but detecting COVID-19 on chest radiographs can become challenging as it has similarities with other bacterial and viral pneumonias. Hence, there is a need to develop an algorithm for accurate and fast detection of COVID-19 in a patient. This work showcases the use of object detection deep learning models-You Only Look Once (YOLO) and RetinaNet for accurate localization of regions associated with COVID-19. Proposed method using ensemble of both the models achieves a mean average precision (mAP) score of 0.552, offering an improvement over their individual predictions. © 2022 IEEE.

Safety and feasibility of an ed-to-outpatient pathway for transient ischemic attack or non-disabling stroke

Introduction: The evaluation and risk stratification of patients with TIA/non-disabling ischemic stroke (TIA/NDS) arriving to the Emergency Department (ED) incurs high-cost imaging and increases ED length of stay (EDLOS). We evaluated the safety and feasibility of an ED-toOutpatient Pathway for TIA/NDS. Methods: In April 2020, we developed a risk stratification algorithm for TIA/NDS in the ED using features of the clincal presentation, limited blood tests, telemetry, and head-neck CT/CTA. Patients deemed low risk based on a 'safety checklist' were discharged with plans for expedited outpatient testing as warranted (e.g., brain MRI, echocardiogram) followed by rapid outpatient follow-up. To assess safety/feasibility of this pathway, we analyzed data of the first 101 patients prospectively enrolled through October 2020. Results: Mean age 68 years (range, 33-99);53% men;median NIHSS score 0 (range 0-3). Symptom duration was classified as <10 min (24%), 10-59 min (23%), >60 min (49%), unclear (4%). Deficits included isolated weakness (16%), isolated aphasia (15%), amaurosis fugax (6%), numbness/combined deficits/other (63%). Median ABCD2 score 3 (range 1-7). Outpatient follow-up included stroke clinic (82%), primary care (4%), not required or patient declined (6%), other hospital (1%);7% were lost to follow-up;43% had follow-up within 7 days. Imaging performed in the ED included CT/CTA only (39%), MRI/MRA only (27%), both (33%), or no imaging (1%). EDLOS was significantly less for patients when CT/CTA only was performed, as per pathway (12.8 versus 16.8 hours, p<0.05). The safety checklist was followed in 69% of patients. When the checklist was used properly, there were 0 recurrent strokes or TIAs within 90-days (versus 2 when not used correctly, p<0.05). Return rates to the ED were 8% with use of checklist and 6% without use (p=0.76). Conclusion: Our TIA/NDS pathway, implemented shortly after the outbreak of Covid-19 in the USA, significantly decreased EDLOS, and still allowed for TIA/NDS patients to be safely discharged from the ED. Acceptable risk stratification and safety is suggested by the low rates of recurrent events when the pathway was followed properly. More education is needed to ensure consistent and proper use of the pathway.

AN IMPROVED DATA DRIVEN DYNAMIC SIRD MODEL FOR PREDICTIVE MONITORING OF COVID-19

COVID-19 pandemic spreaded across the world in early 2020. It forced many countries to impose lockdown to prevent surge in the number of infected cases. There has been a huge impact on social and economic activities worldwide. In this work, we carry out the functional modeling of COVID-19 infection trends using two models: the Gaussian mixture model (GMM) and the composite logistic growth model (CLGM). Unlike the traditional SIRD models that use numerical data fitting, we utilize the best data-fitted curves employing GMM and/or CLGM to construct the Susceptible-Infected-Recovered-Dead (SIRD) pandemic model. Further, we derive the explicit expressions of time-varying parameters of the SIRD model unlike most works that consider static parameters without any closed form solution. The proposed parameterized dynamic SIRD model is generically applicable to any pandemic, can capture the day-to-day dynamics of the pandemic and can assist the governing bodies in devising efficient action plans to deal with the prevailing pandemic.

A multicentric observational study of imaging findings in COVID-19-related rhino-orbito-cerebral mucormycosis: a new Pandora’s box

Background: There is a sudden rise of fungal infection with corona virus disease. This is attributed to the immunomodulation by the disease and the drugs used, diabetes mellitus, steroid use, oxygen inhalation using dirty water, use of zinc and iron supplements, etc. Early diagnosis and prompt medical and surgical intervention is the mainstay of treatment. This can greatly reduce the high morbidity and mortality associated with this disease. The objective of the study is to describe the imaging findings of acute invasive rhino-orbito-cerebral mucormycosis (ROCM) in 25 patients with severe acute respiratory syndrome corona virus 2, from three different centers with proven mucormycosis. Special emphasis is placed on the signal enhancement patterns of sinonasal mucosa, the earliest and most common findings. Statistical analysis was performed using descriptive statistics. Results: Computed tomography (CT) and magnetic resonance imaging (MRI) of 25 patients showed most commonly involved sinuses as maxillary and ethmoid sinuses (19, 76%) together. Sino-nasal mucosal thickening was the most common finding (24, 96%). Periantral infiltration (18, 72%) preceded before orbital (15, 60%), cerebral (5, 20%) and vascular (2, 8%) complications, with grossly intact bones. Sinus wall erosions were seen in only 2 patients (8%). Palatal (22%) and maxillary alveolar arch erosion (39%) were frequent findings. CT showed minimally enhancing hypodense soft tissue thickening as the predominant finding in involved areas, while MRI showed T1 and T2 iso- to hypointense mucosal thickening (62%) and intense (43%) and no (33%) contrast enhancement as the main finding. Conclusions: Contrast enhanced MRI is better at demonstrating early mucosal abnormalities, turbinate necrosis, non-enhancing devitalized tissues, orbital apex involvement and intra-cerebral extension. Imaging findings of inflammatory tissue infiltration adjacent to the paranasal sinuses in premaxillary, retroantral fat, facial muscles, pterygopalatine fossa, temporal, infratemporal fossa and extraconal orbital fat along with typical patterns of sinonasal mucosal enhancement should raise the suspicion of acute invasive fungal etiology given the short duration of history and immunocompromised status. High incidence of periantral and orbital extension of the disease is suggestive of acute invasive form of fungal infection. Also the rapidly progressive inflammatory changes without much bone involvement should suggest the suspicion of ROCM. Bony, cerebral and vascular involvements are relatively late complications.

Infectious disease immunotherapies - An update: Revisiting an age-old adage in times of COVID-19

This review article tries to bring together the important active and passive immunotherapeutic modalities currently under consideration for COVID-19 disease. The basis of immunotherapy is based on use of naturally occurring agents or drugs to modify the body's immune response to certain antigens, the host immune system competent to successfully target and eliminate the infectious agent, without altering the normal physiology. Pubmed was screened for studies using key words;COVID-19, Convalescent plasma therapy, Immunotherapy, Clinical trials. We identified 537 studies through database searches. After reviewing the title and abstracts, we excluded 452 studies that were not relevant, leaving 85 studies for full-text evaluation. Of these, 53 studies fulfilling predefined inclusion/exclusion criteria were finally included. This study found that the common immunotherapies which were used in COVID-19 pandemic times were plasma therapy, T-reg based therapy, tocilizumab, hydroxychloroquine, dexamethasone, and baricitinib.

What actually happens in a specialist heart failure clinic?

Introduction Provision of specialist outpatient services has struggled to keep up with the growing demands of the heart failure (HF) epidemic in the UK. The Covid-19 pandemic necessitated a dramatic change in how HF clinics are delivered, with a reduction in face-to-face contact. The need for in-person appointments remains unknown. We evaluated prepandemic face-to-face clinic appointments in detail, to see what appointments achieved, in order to plan future services. Methods We conducted a retrospective cohort study of patients who had completed 3 years of follow up (1st January 2017 to 31st December 2019) in a specialist HF clinic. Inclusion criteria were a clinician diagnosis of HF or left ventricular systolic dysfunction (from clinic letters and echocardiography), or at least moderate valvular disease with symptoms. Patient electronic health records were reviewed, and for each clinic attendance, the following were noted: •Presence of new or worsening symptoms or signs of HF, or symptoms relating to HF treatment, as assessed by the clinician• Change in cardiovascular medications•Investigations requested•Documented patient education, advice, or discussion of care plan Results 100 patients were included in the cohort. The median age was 68, and patients were predominantly male (80%) with HFrEF (78%). There was a total of 666 appointments over the 3 years of follow up. Patients had a median of 2 appointments per year (Figure 1). Figure 2 shows the frequency of investigations, symptoms and clinician actions in appointments. 21% of appointments documented new or worsening HF or treatment-related symptoms, and cardiovascular therapy was changed in 36% of appointments, ranging from 55% of nurse-led appointments to 31% where the patient saw a junior doctor. Therapy change was more common in appointments when there was a change in symptoms (53% vs 31%, p <0.001). 41% of patients had no documented worsening in HF symptoms throughout the entire 3 year follow up period. Patient education or clinical advice was documented in 32% of appointments. Follow-up duration was shorter following a change in symptoms (127 vs 163 days, p=0.03) and therapy change (128 vs 170 days, p=0.03). 45% of appointments had no documented worsening HF symptoms, change in cardiovascular therapy, specialist referral or specialist test (excluding echocardiography and phlebotomy);we consider these to be 'routine' follow-up appointments. Conclusion Most HF patients were seen in a specialist HF clinic at least 6-monthly, but worsening symptoms and therapy change at the time of consultation were uncommon. Investigations other than phlebotomy and echocardiography, which may be performed outside of specialist centres, were rarely performed. Many appointments may therefore be suitable for community services or by telemedicine, thus freeing up capacity and responsiveness of in-person specialist clinics for patients with more complex needs, worsening symptoms or new diagnoses.

Designing an educational app for patients with heart failure

Introduction Patient education and engagement is a priority for heart failure (HF) care but given low health literacy and high anxiety around diagnosis in HF, consultations and written materials may not be the optimum medium for this, particularly with the rise in remote consultations following the Covid-19 pandemic. Mobile applications (Apps) have shown early promise as patient education tools. In particular, 'Avatar'-based Apps, where a virtual, interactive 3D character serves as a teacher, have shown potential in other conditions such as ischaemic heart disease and rheumatoid arthritis. Methods A moderated, structured focus group of 8 HF patients and one patient carer was held to explore their experiences with patient education and identify areas in which HF education and knowledge of self-care was lacking. All participants shared their thoughts during moderated discussion, and recurring themes were identified. Participants then developed a 'curriculum' of topics that they considered most important in an educational App, with input from the HF team. Results Key themes that emerged from patients' prior experience of patient education included feelings of being overwhelmed and isolated during the initial diagnosis of HF, the importance of a trusted medium for accessing health information (and fear of misinformation), and 'a picture says a thousand words' - visual information was easier to absorb than text. The educational curriculum developed by participants prioritised the following areas: impact on lifestyle, medical management (including the importance of HF medicines), lifestyle changes and care planning, and self-management (including monitoring for signs of deterioration). A prototype App was developed in conjunction with Cognitant Group, using an Avatar (figure 1). The Avatar was designed to be a patient expert in HF, aged ∼65 years old. A living room setting was picked for the content for viewers to feel more relaxed. For Avatar movements to seem natural, voice and movements were recorded and synchronised using motion-capture technology. The first module entitled 'Living with heart failure' outlines of the following topics: explaining HF and the typical patient journey, the purpose of HF medications, lifestyle advice (including exercise and healthy eating, smoking and alcohol, sex and relationships), self-monitoring of HF symptoms, when to call for help and signposts to trusted HF educational resources. Acceptability of the App is currently being evaluated in the HF cohort at this specialist centre. Conclusions Avatar-based Apps may be a useful tool in patient education in HF when co-designed with patients. Further research will evaluate the acceptability of such an App to a cohort of patients in a specialist HF centre.

Clinician experiences of 1 year of telemedicine heart failure clinics: The video-HF study

Background Prior to Covid-19, telemedicine clinics in heart failure (HF) were rare, but social distancing measures and increased demands on health services resulted in a shift to 'remote by default' clinic appointments in many organisations across Europe. We evaluated clinician experiences of telemedicine to determine its potential use post-Covid-19. Methods From 16th March 2020 all HF appointments at a specialist centre were telemedicine by default, with in-person appointments only in exceptional circumstances. HF clinicians were invited to participate in semi-structured interviews about their experiences of telemedicine consultations. Interviews were conducted using Microsoft Teams, recorded and transcribed verbatim. Each interview lasted approximately 30 minutes. Narrative data were explored by thematic analysis: the iterative coding and comparison of transcripts to identify themes. Analysis was performed until themes saturated. Results Between 16th March 2020 and 15th March 2021, there were 2725 HF clinic appointments, 98.9% of which were by telemedicine. 8 clinicians were interviewed: 4 HF consultants, 3 HF specialist nurses and one training-grade doctor. Four key themes emerged (figure 1): Time management - telemedicine consultations were perceived to be more efficient, owing to more focused assessments, less time between appointments and ability to multitask, but more administrative and preparation time was required. Clinicians felt less guilty keeping consultations brief, as patients had not travelled for their appointment.Information gathering - without physical examination clinicians relied more on objective data such as test results. Video was perceived as superior to telephone for assessing patients. Examination of oedema was possible by video, but more difficult and perceived to be less reliable.Rapport and relationships - telemedicine changed the patient-clinician interaction. Clinicians experienced difficulty establishing rapport with new patients by telephone;video was better than telephone, but clinicians felt that new patients were generally best assessed in-person to establish a 'connection' and relationship of trust. Choice and flexibility - clinicians expressed a fear of 'topdown' diktats on future delivery of care. This was exemplified by the quote '?the health service has got a great tradition of making up its mind as to what the patient thinks'. Clinicians felt telemedicine consultations would continue to play a major role, as they were considered more convenient for patients, but patient choice was essential. Figure 2 shows a word cloud generated from interview transcripts. Conclusions Telemedicine HF consultations were acceptable for clinicians, but changed workflows, consultation dynamics, and how clinicians developed rapport and trust. Understanding these changes is essential for future delivery of care. We will now seek to understand the views of patients and their families.

N95 respirator decontamination: a study in reusability.

The coronavirus disease 2019 (COVID-19) pandemic had caused a severe depletion of the worldwide supply of N95 respirators. The development of methods to effectively decontaminate N95 respirators while maintaining their integrity is crucial for respirator regeneration and reuse. In this study, we systematically evaluated five respirator decontamination methods using vaporized hydrogen peroxide (VHP) or ultraviolet (254 nm wavelength, UVC) radiation. Through testing the bioburden, filtration, fluid resistance, and fit (shape) of the decontaminated respirators, we found that the decontamination methods using BioQuell VHP, custom VHP container, Steris VHP, and Sterrad VHP effectively inactivated Cardiovirus (3-log10 reduction) and bacteria (6-log10 reduction) without compromising the respirator integrity after 2-15 cycles. Hope UVC system was capable of inactivating Cardiovirus (3-log10 reduction) but exhibited relatively poorer bactericidal activity. These methods are capable of decontaminating 10-1000 respirators per batch with varied decontamination times (10-200 min). Our findings show that N95 respirators treated by the previously mentioned decontamination methods are safe and effective for reuse by industry, laboratories, and hospitals.