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Introduction: Virtual classroom training (VCT) is a novel educational method that permits accessible, distanced interactive expert instruction. We aimed to evaluate the efficacy of VCT in comparison to face-to-face training (FFT) and non-interactive computer-based learning (CBL) for basic surgical skills training. Method: 72 participants recruited from five London medical schools underwent stratified block randomisation into three equal intervention groups based on subjective and objective suturing experience. VCT was delivered via the BARCO weConnect platform and FFT was provided by expert instructors. Optimal student-to-teacher ratio was used, 12:1 for VCT and 4:1 for FFT. The assessed task was interrupted suturing with hand-tied knots. The primary outcome was post-intervention Objective Structured Assessment of Technical Skills (OSATS) score, adjudicated by two blinded experts and adjusted for baseline proficiency. Results: VCT was non-inferior to FFT (adjusted difference 0.44, 95% CI: -0.54 to 1.75, delta 0.675), VCT was superior to CBL (adjusted difference 1.69, 95% CI 0.41 to 2.96) and FFT was superior to CBL (adjusted difference 1.25, 95% CI 0.20 to 2.29). FFT alone was associated with student travel expenses (mean £4.88, SD 3.70). Instructor hours used per student for VCT and FFT were 0.25 and 0.75, respectively. Conclusions: VCT has a similar educational benefit to FFT and is a suitable modality of high-quality surgical skills education. VCT provides greater accessibility and resource efficiency compared to FFT. VCT satisfies the requirement for social distancing during the COVID-19 pandemic and is better than non-interactive CBL. VCT has the potential to improve global availability and accessibility of surgical skills training.
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STATEMENT OF PROBLEM/QUESTION: Societal and cultural barriers that prevent ethnic minorities from achieving health equity include lack of access and misinformation. COVID-19 vaccine hesitancy among ethnic minorities has limited vaccination rates thus hindering the establishment of herd immunity. Vaccination rates in college students aged 18-24 in New York state (NYS) is high (80%). However, in minority populations, college students are much less likely to be vaccinated with rates of 15% in African Americans (AA) and 21% in Latinx individuals. Access to health care also limits young minority populations from sexual health screenings, contributing to a significantly higher rate of sexually transmitted infections (STI) and HIV infection. One in five people in the United States (US) have a STI, and almost half of new STIs occur in teens aged 15-24, with a disproportionately high percentage occurring in AA. Sexual health education and screenings should therefore be focused on this at risk population. Health inequity is often grounded by multiple historical and personal factors, but access to medical professionals is an important element for intervention. DESCRIPTION OF PROGRAM/INTERVENTION: The Ally Care Center at Westchester Medical Center partnered with a local college in New Rochelle, New York to provide a multi-pronged community event. On July 22, 2021 we conducted a virtual session to address questions for the college community. We subsequently brought our multidisciplinary team of medical providers, case managers and psychologists to the college on five occasions to provide COVID-19 vaccinations and sexual health screenings. MEASURES OF SUCCESS: Vaccination rates and STI screening rates FINDINGS TO DATE: Over a total of five visits, 109 members of a predominantly minority college population received the first dose of the COVID vaccine and 98 received the second dose indicating an 89.9% rate of full vaccination. This is about 10% higher compared to NYS COVID vaccination rates in the age group 18-24 years which is 80.9% as of November 2021. Vaccination rates with atleast one dose in minority group adults older than 15 years of age are 15% for AA, 14.6% for Asians, and 21% for Latinx. Fourteen students opted for sexual health screenings, of whom two were found to be positive for chlamydia and treated. KEY LESSONS FOR DISSEMINATION: Health disparities may in part be driven by medical misinformation and lack of access to healthcare providers. Community level outreach events can ensure that routine preventative health strategies are made available to minority populations. These can be most effective when tackling multiple health care needs. These events also provide an opportunity to address misniformation and cultivate trust in medical professionals.
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Introduction: The Covid-19 pandemic in the UK led to much un-certainty about the delivery of cancer services. A shift from established therapy (and its timing) in patients with Muscle invasive Bladder Cancer (MIBC) has potential deleterious consequences. To understand outcomes, we formed a collaborative to measure overall and diseasefree survival at 3-years in patients with non-metastatic MIBC (Figure 1) treated during the UK's first wave of Covid-19. Secondary aims included comparison between treatment modalities and pre-Covid controls. Patients and Methods: The collaborative included clinicians from 13 major centres, representing 3 UK nations. A prospective clinical audit, endorsed by the National Cancer Research Institute, was started to collect comprehensive data. MIBC patients discussed at the multidisciplinary meeting (MDM) between 1/3/2020-30/06/2020 were included. Results: At submission, data were available from 12 centres for 299 patients. The mean age was 69.3 years (27- 90), and there were 72 female and 227 male patients. Mean Charlson Co-morbidity Index was 5 (1-12). Preliminary analysis of available data indicate the following: MDM recommendations for (at least) 1 in 4 patients were deemed as being modified from standard practice. Twenty six patients received neoadjuvant chemotherapy. In total (from available data), 99 received radical radiotherapy and 146 underwent radical cystectomy (65 and 74 specified as open and robotic assisted, respectively). Preliminary analysis suggests that 1 in 3 patients had died within 1 year. Conclusions: Preliminary Results indicate that recommendations for MIBC patients were significantly altered consequent to the pandemic and mortality was high. Analyses towards endpoints are awaited.
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Introduction: High costs and inaccessibility are significant barriers to face-to-face basic surgical skills (BSS) training. Virtual classrooms enable the combination of computer-based learning with interactive expert instruction. They may optimise resources and increase accessibility, facilitating larger-scale training with a similar educational benefit. We aim to evaluate the efficacy of virtual BSS classroom training compared to both non-interactive video and face-to-face teaching. Method: 72 medical students will be randomly assigned to three equal intervention groups based on year group and surgical skill confidence. Interventions will be implemented following an instructional video. Group A will practice independently, Group B will receive face-to-face training, and Group C will attend a virtual classroom. Participants will be recorded placing three interrupted sutures with hand tied knots preand post-intervention, and Objective Structured Assessment of Technical Skills (OSATS) will be blind marked by two experts. Change in confidence, time to completion and a granular performance score will also be measured. Each intervention's feasibility and accessibility will be assessed. Results: Data collection will be completed in January 2021. Significant improvement in OSATS within groups will be indicative of intervention quality. Difference in improvement between groups will determine the relative performance of the interventions. Conclusions: To our knowledge, this will be the largest randomised control trial investigating virtual BSS classroom training. It will serve as a comprehensive appraisal of the virtual classroom's suitability as an alternative to face-to-face training. The findings will assist the development and implementation of further resource-efficient training programs during the COVID-19 pandemic and in the future.
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The spread of COVID-19 has been among the most devastating events affecting the health and well-being of humans worldwide since World War II. A key scientific goal concerning COVID-19 is to develop mathematical models that help us to understand and predict its spreading behavior, as well as to provide guidelines on what can be done to limit its spread. In this paper, we discuss how our recent work on a multiple-strain spreading model with mutations can help address some key questions concerning the spread of COVID-19. We highlight the recent reports on a mutation of SARS-CoV-2 that is thought to be more transmissible than the original strain and discuss the importance of incorporating mutation and evolutionary adaptations (together with the network structure) in epidemic models. We also demonstrate how the multiplestrain transmission model can be used to assess the effectiveness of mask-wearing in limiting the spread of COVID19. Finally, we present simulation results to demonstrate our ideas and the utility of the multiple-strain model in the context of COVID-19.
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Introduction: High costs and inaccessibility are significant barriers to face-to-face basic surgical skills (BSS) training. Virtual classrooms enable the combination of computer-based learning with interactive expert instruction and feedback. They may optimise resources and increase accessibility, facilitating larger-scale training whilst producing a similar educational benefit. We aim to evaluate the efficacy of virtual BSS classroom training compared to both non-interactive video and face-to-face teaching. Method: 72 medical students will be randomly assigned to three equal intervention groups based on year group and surgical skill confidence. Interventions will be implemented following an instructional video. Group A will practice independently, Group B will receive face-to-face training, and Group C will receive virtual classroom training. The assessed task will be to place three interrupted sutures with hand tied knots. Pre-and post-intervention Objective Structured Assessment of Technical Skills (OSATS) will be blind marked by two experts. Change in confidence, time to completion and a granular performance score will be measured. Feasibility and accessibility will also be assessed. Results: Significant improvement in OSATS within groups will be indicative of intervention quality. Difference in improvement between groups will determine relative performance. Conclusion: To our knowledge, this will be the largest randomised control trial investigating virtual BSS classroom training. It will serve as a comprehensive appraisal of the suitability of virtual BSS classroom training as an alternative to face-to-face training. The findings will assist the development and implementation of further resource-efficient virtual BSS training programs during the COVID-19 pandemic and in the future.
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Introduction: Bartter's syndrome (BS) is a rare genetic tubulopathy affecting the loop of Henle leading to salt wasting. Acquired BS is very rare and is associated with underlying medical conditions or certain drugs. We report a unique case of idiopathic BSlike phenotype that was diagnosed in the setting of COVID infection. Case Description: 71-year-old man with coronary artery disease, hypertension and diabetes presented after a mechanical fall. On admission, he was found to be hypotensive to 107/88 mmHg. Physical exam was within normal limits. Initial blood work was significant for Potassium 2.6 mEq/L, Bicarbonate 34 mEq/L, Calcium 8.0 mg/dL and Magnesium 1.7 mg/dL. Patient also tested positive for COVID-19. Upon further questioning, patient reported a remote history of hypokalemia but never needed any oral supplementation. He denied diuretic use or surreptitious vomiting. Hypokalemia work up revealed increased urinary potassium of 85.4 mEq/L, Renin 15.72 ng/mL/hour and Aldosterone 8 ng/dL. Patient was then started on aggressive intravenous and oral potassium repletion. He continued to require multiple doses of intravenous potassium to maintain potassium levels of 3 mEq/L. He was subsequently started on Eplerenone on Day 3 of admission with excellent response. He remained otherwise asymptomatic from COVID and as his infection improved, hypokalemia stabilized and he was ultimately discharged with a Potassium level of 3.6 mEq/L. Discussion: The primary defect in BS is in sodium chloride reabsorption in the medullary thick ascending limb of the loop of Henle resulting in hypokalemia, metabolic alkalosis and secondary hyperaldosteronism. Rare cases of acquired BS are reported in association with tuberculosis, sarcoidosis, sjogrens, and certain drugs. All of these were ruled out in our patient and hence a diagnosis of idiopathic BS like phenotype was made. In our patient, we attribute the BS like phenotype to underlying COVID infection. As his infection improved, his hypokalemia also resolved. Hyperkalemia is a more common finding in COVID infection. However, in our patient, hypokalemia secondary to BS like phenotype was a unique presentation which was challenging to treat. In the absence of usual causes of acquired BS, unexplained hypokalemia in a patient with COVID infection should prompt suspicion for BS-like phenotype. Early and aggressive correction of electrolyte abnormalities is crucial.
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Background: AKI has historically plagued those with ARDS and during the pandemic especially so with large resultant mortality rates. During the past year those centers so equipped offered ECMO to treat severe COVID pneumonia. We compared the non COVID ARDS requiring ECMO with patients with COVID pneumonia requiring ECMO. The aim of the study was to understand the difference in the renal outcomes and its effects of mortality and thereby help in prognostication. Methods: This is a single center retrospective study where patients with COVID pneumonia needing ECMO in between March 2020 to April 2021 were compared with non COVID ARDS patients needing ECMO between April 2013 to April 2021. The 2 groups were compared and risk ratio calculated for the incidence of AKI, the need for Renal replacement therapy (RRT) and the mortality associated with it. Results: After excluding the patients who did not meet the criteria, 26 COVID patients treated with ECMO were compared with 22 patients with non COVID ARDS treated with ECMO. The median age of COVID group was higher (48 years vs 36 years) and the median number of days needing ECMO for the COVID group was higher (13 days vs 31 days). Incidence of AKI and the AKI needing RRT were similar in the 2 groups. The overall mortality in patients with COVID pneumonia was higher. Patients with COVID who developed AKI had 1.32 times the risk of mortality, which increased to 1.62 when RRT was needed. Conclusions: This is a first study comparing the renal outcomes of COVID ARDS requiring ECMO and non COVID ARDS requiring ECMO. Even though the median age and the median number of the days on ECMO were higher for the COVID group, surprisingly the incidence of AKI and those needing RRT were similar. But there was a significantly higher mortality when patients on ECMO developed AKI and even higher for those on RRT. This could be attributed to the cytokine storm seen with causing a multiorgan dysfunction which can manifest in the form of AKI. Presence of AKI needs to be identified early and can be used for the prognostication in COVID pneumonia.
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Masks are used as part of a comprehensive strategy of measures to limit transmission and save lives during the COVID-19 pandemic. Research about the impact of mask-wearing in the COVID-19 pandemic has raised formidable interest across multiple disciplines. In this paper, we investigate the impact of mask-wearing in spreading processes over complex networks. This is done by studying a heterogeneous bond percolation process over a multi-type network model, where nodes can be one of two types (mask-wearing, and not-mask-wearing). We provide analytical results that accurately predict the expected epidemic size and probability of emergence as functions of the characteristics of the spreading process (e.g., transmission probabilities, inward and outward efficiency of the masks, etc.), the proportion of mask-wearers in the population, and the structure of the underlying contact network. In addition to the theoretical analysis, we also conduct extensive simulations on random networks. We also comment on the analogy between the mask-model studied here and the multiple-strain viral spreading model with mutations studied recently by Eletreby et al.
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TOPIC: Chest Infections TYPE: Original Investigations PURPOSE: Severe acute respiratory syndrome coronavirus (SARS-COV-2) infection continues to spread at exponential rates globally with more than 145 million confirmed cases worldwide and over 3 million deaths. SARS-COV-2 presents with different clinical manifestations ranging from asymptomatic to severe infection, requiring various levels of O2 support, facing high rates of mortality. Systemic inflammatory response to the viral infection contributes to a variety of clinical manifestations and to the degree of severity of illness. Limited evidence exists on potential biomarkers to quantify severity and outcomes of SARS-COV-2 infection. Our objective is to see if Advanced lung cancer inflammation index (ALI) calculated at the time of admission to the hospital can be used as a prognostic marker for oxygen requirements and adverse clinical outcomes. METHODS: We conducted a retrospective chart review of all patients ages 18 and above admitted to Memorial Hermann Hospitals between March 1, 2020 to June 30, 2020 who tested positive for SARS-COV-2 by RT-PCR. The ALI was calculated using patients Body mass index (BMI), serum albumin and neutrophil/lymphocyte ratio (NLR) from the admission labs using the formula ALI= BMI (kg/m2) × albumin (g/dL)/NLR. Patient related information was obtained by reviewing medical records after obtaining Institutional review board approval. RESULTS: A total of 700 patients were identified out of which 417 patients had complete medical records for analysis. Patients were stratified into group A (high inflammation (ALI < 18) n = 205) and group B (low inflammation (ALI ≥ 18) n = 218). 67% of the patients were aged 45 or older. 52.5% of the patients had a BMI < 30. 22.3% of patients in group A, 22.3% and 16.7% patients in group B, 16.7% were of white race. ALI < 18 was associated with higher oxygen requirements (73% vs 52%, p ≥ 0.0001), higher mechanical ventilation requirements (16.59% vs 9.91%, p = 0.04) and higher mortality rates (14.15% vs 7.08%, p = 0.02). In multi-variate analysis, ALI < 18 was significantly associated with oxygen requirements, (OR 2.62 (1.64 - 4.17), p ≤ 0.0001). CONCLUSIONS: In patients diagnosed with SARS-CoV-2 infection, an ALI < 18, representing high systemic inflammation, calculated at the time of admission is associated with significantly increased oxygen requirements, severe disease and mortality. CLINICAL IMPLICATIONS: Advanced lung cancer inflammation index can be easily calculated from basic clinical parameters available in most clinical settings. It can be used as a tool in early identification of patients who are likely to have more severe respiratory disease and poorer outcomes in patients with SARS-COV-2 infections. Early use of steroids can be considered in this population of patients with an ALI <18. DISCLOSURES: No relevant relationships by Shailesh Advani, source=Web Response No relevant relationships by Syed Jafri, source=Web Response No relevant relationships by Pushan Jani, source=Web Response No relevant relationships by Arthi Sridhar, source=Web Response No relevant relationships by Wei Yang, source=Web Response
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Introduction: High costs and inaccessibility are significant barriers to face-to-face basic surgical skills (BSS) training. Virtual classrooms enable the combination of computer-based learning with interactive expert instruction. They may optimise resources and increase accessibility, facilitating larger-scale training with a similar educational benefit. We aim to evaluate the efficacy of virtual BSS classroom training compared to both non-interactive video and face-to-face teaching Method: 72 medical students will be randomly assigned to three equal intervention groups based on surgical skills experience and confidence Interventions will be implemented following an instructional video Group A will practice independently, Group B will receive face-to-face training, and Group C will attend a virtual classroom. Participants will be recorded placing three interrupted sutures with hand tied knots preand post-intervention. Objective Structured Assessment of Technical Skills (OSATS) will be blind marked by two experts Result: Change in confidence, time to completion and a novel granular performance score will also be measured. Each intervention's feasibility and accessibility will be assessed. Significant improvement in OSATS within groups will be indicative of intervention quality Difference in improvement between groups will determine the relative performance of the interventions Conclusion: This will be the largest randomised control trial investigating virtual BSS classroom training. It will serve as a comprehensive appraisal of the suitability of virtual classrooms as an alternative to faceto- face training. The findings will assist the development and implementation of further resource-efficient training programs during the COVID-19 pandemic and beyond Take-home Message: This is the first RCT assessing virtual basic surgical skill classroom training and serves as a comprehensive appraisal of the suitability of virtual classrooms as an alternative to face-to-face training. The findings will assist the development and implementation of further resource-efficient training programs during the COVID-19 pandemic and in the future .
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Introduction: High costs and inaccessibility are significant barriers to face-to-face (F2F) basic surgical skills (BSS) training. We aim to evaluate the efficacy of virtual (VC) BSS classroom training compared to both non-interactive video and face-to-face teaching. Patients and Methods: 72 UK medical students underwent stratified block randomisation into CBL, VC and F2F arms based on previous surgical skill experience and confidence. They were assessed pre- and post-intervention using the Objective Structured Assessment of Technical Skills (OSATS) scores developed by the Royal College of Surgeons and marked by independent expert, blinded examiners. The task was to place three interrupted sutures with hand-tied knots. Results: Mean OSAT score improved significantly after VC training (8.88/16 to 14.17/16). VC (+5.29) improved significantly greater than CBL (+4.75) and similar to F2F (+5.38). VC and F2F were scored similarly in time to completion but both scored significantly better than CBL. Suturing confidence improved in all three groups. Cost per participant was significantly lower for VC (£8) than F2F (£30) and time spent travelling was also significantly lower for VC (0mins) compared to F2F (50mins). Conclusion: This is the largest randomised control trial investigating virtual BSS classroom training. VC is an effective method of delivering basic surgical skill training. VC is more effective than non-interactive CBL and just as effective as F2F teaching. VC is cheaper and more accessible than F2F. The VC is a safe and effective training method during the COVID-19 pandemic and can be used in the future to improve accessibility of surgical training.
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Objective: Delivery of a safe cystectomy service is a multidisciplinary exercise. In this article, we detail the measures implemented at our institution to deliver a cystectomy service for bladder cancer patients during coronavirus disease 2019 (COVID-19). Methods: A ‘one-stop’ enhanced recovery clinic had been established at our hospital, consisting of an anaesthetist, an exercise testing service, urinary diversion nurses, clinical nurse specialists and surgeons. During COVID-19, we modified these processes in order to continue to provide urgent cystectomy safely for bladder cancer. We collected patients’ outcomes prospectively measuring demographic characteristics, oncological and perioperative outcomes, the presence of COVID-19 symptoms and confirmed COVID-19 test results. Results: From March to May 2020, 25 patients underwent radical cystectomy for bladder cancer. Twenty-four procedures were performed with robotic assistance and one open as part of a research trial. We instituted modifications at various multidisciplinary steps, including patient selection, preoperative optimisation, enhanced recovery protocols, patient counselling and perioperative protocols. Thirty-day mortality was 0%. The 30-day rate of Clavien ⩾3 complications was 8%. Postoperatively, none of the patients developed COVID-19 based on World Health Organization criteria and testing. Conclusion: We safely delivered a complex cystectomy service during the peak of the COVID-19 pandemic without any COVID-19-related morbidity or mortality. Level of evidence: Level 2b.