Virtual-Reality Simulation Can Teach VATS Lobectomy to Lobectomy-Naive Trainees Within 4 Weeks: A Cross-Over Study

Objective: The aim of the cross-over study was to evaluate skill acquisition in lobectomy-naive surgical trainees completing a 4-week program to learn VATS lobectomy on a virtual reality surgical simulator (LapSim). Method(s): Lobectomynaive surgical trainees (year 1 and 2 postgraduation) were enrolled during the COVID pandemic from March to June 2021 for a 4-week course on basic VATS skills and right upper lobectomy. They were divided into 2 groups. Both groups completed an initial assessment, Group 1 completed the course first, then both groups completed a second assessment. Then Group 2 completed the course, and both groups completed a final assessment. Skill acquisition was assessed using instrument movement, procedure time, and blood loss for both the trained operation and an untrained operation (left lower lobectomy). Result(s): 16 trainees were enrolled, 10 completed the training program. There was no difference in baseline assessment. After Group 1 completed the training, they outperformed Group 2 in all metrics but this did not reach statistical significance. After training Group 2 at week 8, there was no longer difference in performance from Group 1. After completing the training program, the entire cohort showed a significant improvement in basic VATS tasks as well as lobectomies. There was statistically significant improvement in both right upper lobectomy instrument movement (P=0.002) and time (P=0.009) and left lower lobectomy time (P=0.047). Conclusion(s): This study showed that VATS simulation training on LapSim allowed junior trainees to learn advanced VATS resection during a pandemic and within 4 weeks. The acquired skills is transferrable to untrained operations. (Table Presented).

Early Clinical Experience Module: Single Medical School Experience during the Pandemic

The Early Clinical Experience (ECE) module is a module that was introduced to expose preclinical medical students to the clinical skills required for their clinical practice. COVID-19 has forced traditional face-to-face teaching into online mode. In Universiti Putra Malaysia (UPM), the teaching underwent several improvisations to cope with the online mode but still within the framework of four basic components of clinical skills namely history taking, physical examination, basic procedural skills, and communication skills. The advantages and limitations of the usage of online lectures and demonstrations, video recordings, Google Classroom (GC) platform, and written feedback were discussed. In conclusion, the online mode of ECE delivery has its advantages and limitations, and educators need to address these concerns to ensure the future success of the module. © 2022 UPM Press. All rights reserved.

Omicron breakthrough disease activity in the Swiss multiple sclerosis cohort study

Introduction: In patients with Multiple Sclerosis (pwMS), specific disease modifying treatments (DMTs) may compromise immune response following SARS-CoV-2 vaccination. Limited information is available, whether levels of anti-SARS-CoV-2 antibodies are linked to the risk of breakthrough infections in pwMS. Objective(s): To determine the rate of Omicron breakthrough infection and severity of COVID-19 in a cohort of MS patients treated with different DMTs and to estimate the impact of SARSCoV- 2-specific antibody level on breakthrough infection risk. Method(s): This study is nested within the Swiss MS Cohort, a nationwide multicenter study that has recruited 1585 pwMS. Patients who received two doses of SARS-CoV-2 vaccines before Omicron became the dominant variant in Switzerland on Dec-15, 2021 and had a follow-up thereafter were included. Data on SARS-CoV-2 infections, severity of COVID-19 according to the WHO scale and SARS-CoV-2 vaccines were collected by questionnaires. Anti-SARS-CoV-2-S antibody levels were measured after the second vaccine dose. Incidence of infections grouped by antibody level after second vaccination was visualized using Kaplan-Meier curves. Cox regression models were used to estimate the impact of antibody levels on the hazard of breakthrough infection during follow-up. Result(s): 242 pwMS (median age 49y [39,58], 162 (67%) female, 36 (15%) with progressive disease, median EDSS 2.5 [1.5,4.0]) were included. 22 (9%) had SARS-CoV-2 infection and 137 (57%) at least one additional vaccine dose prior to Omicron start. Since then, 57 breakthrough infections were reported. Severity of breakthrough disease on WHO scale ranged from 1-10: 7 were asymptomatic, 46 were symptomatic as outpatients, 3 were hospitalized and 1 died. Patients with antibody levels >150U/ml (n = 95, 39%) after second vaccination had a 64% reduced risk for Omicron breakthrough-infection compared to patients with antibody levels <0.7U/ml (n = 81, 33%) (HR 0.36, 95%CI=0.18- 0.71, p<0.01). This effect was maintained after adjustment for DMT at vaccination and time since second vaccination Conclusion(s): Humoral immune response after second SARSCoV- 2 vaccination is associated with Omicron breakthrough infection rate, a finding contrasting general populations, where antibody levels seem to have little impact on protecting from Omicron infection. Most breakthrough infections in our cohort were mild. Analyses on the effect of booster vaccinations on serology and infection rates will follow.

Proteome and phosphoproteome analyses of SARS-CoV-2-infected humanized K18-ACE2 mice reveal hyperactive phenotype of circulating platelets

Background: Platelets are effectors of hemostasis and play a major role in coordinating immune and inflammatory activities. Suitable animal models are needed to study COVID-19-associated coagulopathy and platelet effector functions in COVID-19, which are currently poorly understood. Aim(s): We aimed to characterize alterations of platelets isolated from K18-hACE2 transgenic mice infected with SARS-CoV-2. Method(s): Heterozygous K18-hACE2 (human ACE2) and C57BL/6J mice were used to study SARS-CoV-2 infectivity. Lung infection, infiltration, and platelet aggregation were characterized with histology and immunohistochemistry. Platelet response to SARS-CoV-2 infection was quantified by mass spectrometry analysis of proteomics and phosphoproteomics. Western blotting, ELISA, and multiplex plasma profiling were performed to validate the proteomics and phosphoproteomics data. Result(s): SARS-CoV-2 inoculated (10E6PFU, i.n.) K18-hACE2 mice started to lose weight at 4 days post-infection (dpi) and showed 90% lethality at 7-dpi in association with viral neuroinvasion. Histopathologic findings of infected K18-hACE2 mice included progressive lymphohistiocytic interstitial pneumonia with absence of diffuse alveolar damage. Lungs of infected K18-hACE2 mice (2-/ 4-dpi) showed mild increase in CD61+ aggregates compared to sham mice, but no overt tissue thrombosis. Gene ontology and pathway analyses of platelet proteomics and phosphoproteomics revealed that SARS-CoV-2 infection significantly upregulates the complement-coagulation cascades (F2/12/13, Tfpi, C1ra, Cd55, C4bp) and platelet activation-adhesion-degranulation proteins (Vwf, Itgb3/5, Selp, Pecam1) and chemokine (Pf4, Cxcl5/12) signaling at 2-dpi. However, interferon (Ddx58, Trim25, Mapk3) signaling was dominant at 4-dpi. Activation of proteomics and phosphoproteomics protein markers were highly correlated with platelet activation and interferon signaling at 2-/ 4-dpi, respectively. Plasma chemokine (e.g., Ccl8 and Pf4) and cytokines (e.g., IL6) were significantly elevated at 2-/ 4-dpi. SARS-CoV-2 spike protein was abundant at 2-/ 4-dpi in the lungs but not in platelets and kidneys, which correlated with no infectious virus in the serum. Conclusion(s): Platelet re-programming towards activation-degranulation-aggregation is likely attributable to a pneumonia-induced elevated circulatory factors (e.g., cytokines)-driven response rather than direct platelet infection.

Patient with Myxedema Coma and Subsequent Iatrogenic Thyrotoxicosis - Role of COVID-19 Pandemic

Introduction: Myxedema coma is a rare presentation of severe hypothyroidism. The low incidence of this life-threatening disease may be attributed to easy availability of TSH testing and thyroid hormone replacement therapy. Well documented cases of thyroiditis and thyrotoxicosis due to SARS-CoV-2 are now available in medical literature. Additionally, COVID-19 pandemic has also caused higher rates of non-compliance with medications and appointments. This has resulted in higher rates of exacerbations of most chronic illnesses, including thyroid diseases. We present a case of myxedema coma and subsequent iatrogenic hyperthyroidism during the COVID-19 pandemic. Clinical Case: 57-year-old male with paroxysmal atrial fibrillation, CHF, CKD stage IV, type 2 diabetes mellitus, hypertension, and post ablative hypothyroidism was found unresponsive at home. Initial vitals were temperature 95.1F, HR 52 beats per minute, RR 14 breaths per min, BP 90/62 mmHg, and glucose 68 mg/dL. There was no evidence of goiter, and he had generalized edema. Initial labs showed hyponatremia, elevated CPK, TSH 111uIU/mL (0.27-4.2 uIU/mL) and free T4 was <0.1 ng/dL (0.93-1.7 ng/dL). He was intubated, needed vasopressor support, and was treated with empiric antibiotics. He was diagnosed with myxedema coma which was treated with 200 mcg IV levothyroxine, and stress dose hydrocortisone. He was extubated on day 4 of hospital admission after which oral levothyroxine 275 mcg daily was initiated, and steroids were tapered off. Patient's pharmacy confirmed that Levothyroxine was not last filled more than eight months ago. Patient was hospitalized 3 weeks later for pneumonia and Levothyroxine dose was further increased to 300 mcg due to persistently elevated TSH levels. Three months later, patient was admitted for Atrial fibrillation in rapid ventricular response with difficult to control tachycardia. His TSH was 0.01 uIU/mL and thyroxine of 1.93 ng/dL despite not taking any medication for 2 weeks. He admitted to not following up with endocrinologist due to the surge in COVID-19 cases. Dose of levothyroxine was decreased to weight-based dose of 225 mcg, and patient discharged with instructions to repeat labs in 6 weeks and follow up with a clinical provider. Conclusion: This case highlights the consequences of under and over replacement of thyroid hormone. Viral illnesses including SARS-CoV-2 can precipitate myxedema coma in patients with severe hypothyroidism. A high index of suspicion is needed to treat this disease in a timely manner. Providers must make allowances for the limitations in our system to function in a pandemic. Prescribing extra medication refills and offering virtual medicine appointments may help lower hospitalizations. Also, understanding the effect of non-thyroidal illness on thyroid function tests and knowing that TSH takes six weeks to normalize after starting/ adjusting thyroid hormone dose will avoid premature adjustment in hormone doses.Presentation: Saturday, June 11, 2022 1:00 p.m. - 3:00 p.m.

Splanchnic Nerve Block as a Bridge Therapy in Painful Chronic Pancreatitis During COVID 19 Pandemic: A Case Report

Agonizing and debilitating pain is what most patients with chronic pancreatitis endure. Chronic pain often leads to depression and poor quality of life. Surgical decompression can result in permanent pain relief by reducing intraductal hypertension. Elective surgical procedures had to be postponed during the Covid-19 pandemic as the resources, including oxygen supplies, workforce, and ventilators, were dedicated to the service of Covid-19 patients. We present a case of 20 year-old-male suffering from severe abdominal pain due to chronic pancreatitis refractory to analgesic medications. Given the refractory pain and inability to proceed with surgery due to the pandemic, we subjected him to undergo splanchnic nerve block (SNB) with local anesthetic and steroid. SNB provided adequate analgesia and enabled the patient to tide over the crisis. To our knowledge, no case has been reported using a combination of local anesthetic and steroid in SNB for a patient with chronic pancreatitis.

SARS-CoV-2 infection of K18-HACE2 transgenic mice induces an early hyperactive phenotype in circulating platelets

Background: Coronavirus disease 2019 (COVID-19) is associated with a hypercoagulable state and increased incidence of cardiovascular complications. Platelets are effectors of hemostasis and play a major role in coordinating immune and inflammatory activities. Suitable animal models are needed to study COVID-19-associated coagulopathy and platelet effector functions in COVID-19, which are currently poorly understood. Aims: We aimed to characterize alterations of platelets isolated from K18-hACE2 transgenic mice infected with SARS-CoV-2. Methods: Heterozygous K18-hACE2 (human ACE2) and C57BL/6J mice were used to study SARS-CoV-2 infectivity. Lung infection, infiltration, and platelet aggregation were characterized with histology and immunohistochemistry. Platelet response to SARS-CoV-2 infection was quantified by mass spectrometry analysis of proteome. Results: SARS-CoV-2 inoculated ( 10 6 PFU, i.n. ) K18-hACE2 mice started to lose weight at 4 days post-infection(dpi) and showed 90% lethality at 7-dpi in association with viral neuroinvasion. SARSCoV-2 RNA copies peaked at 4-dpi in K18-hACE2 mouse lungs, but not in C57BL/6J mice, confirming the need for human ACE2 receptor for viral entry. Histopathologic findings of infected K18-hACE2 mice included progressive lymphohistiocytic interstitial pneumonia with absence of diffuse alveolar damage. Lungs and kidneys of infected K18-hACE2 mice (2-/4-dpi) showed mild increase in CD61+ aggregates compared to sham mice, but no overt tissue thrombosis. Gene ontology and pathway analysis of platelet proteome revealed that SARS-CoV-2 infection significantly upregulates the complement-coagulation cascades ( F2/12/13, Tfpi, C1ra, Cd55, C4bp) and platelet activation-adhesion-degranulation proteins ( Vwf, Itgb3/5, Gp9, Selp, Pecam1 ) and chemokine ( Pf4, Cxcl5/12, Ccl8 ) signaling at 2-dpi. However, interferon ( Ddx58, Trim25, Mapk3 ) signaling was dominant at 4-dpi. Abundance of SARS-CoV-2 spike protein at 2-/4-dpi in the lungs, but not in the kidneys and platelets of K18-hACE2 mice, suggests that platelet re-programming towards activation-degranulation-aggregation is likely attributable to pneumonia-induced cytokine-driven response rather than direct platelet infection. Conclusions: Circulating platelets in SARS-CoV-2 infected K18-hACE2 mice demonstrate a specific early hyperactive phenotype consistent with procoagulant platelets.

T-cell-mediated immunity to SARS-CoV-2 defines COVID-19 risk and severity in transplanted and non-transplanted individuals and associates with myeloid-derived suppressor cells

Purpose: We assessed whether COVID-19-risk is enhanced by chronic immunosuppression, and is associated with suppressor cells. Methods: We tested 66 COVID-19 patients, including 26 with solid organ transplants at median 11 days after diagnosis, and 64 unexposed healthy subjects including 21 with transplants, who were sampled pre-pandemic. T- and B-cells, which express CD154 were measured after stimulation with peptide mixtures representing the spike protein S, its conserved C-terminal S2, and less conserved N-terminal S1 components. Monocytic myeloid-derived suppressor cells (M-MDSC) were measured in an independent cohort of 47 COVID-19 patients Results: Frequencies (%) of S-reactive T-cells (Mean±SEM 2.0±0.3 vs 3.8±0.3, p=5.6E-05) and B-cells (3.0±0.4 vs 5.1±0.4, p=0.0003) were significantly lower in COVID-19 compared with healthy subjects, but were measurable in all samples. Transplanted and non-transplanted subjects demonstrated similar within group frequencies of S-reactive T-cells (4.1±0.3 vs 3.7±0.5, p=NS in healthy and 1.5±0.4 vs 2.4±0.3, p=NS in the COVID-19 group) and other S-reactive cells. Among COVID-19 patients, intubated patients showed lower S-reactive CD8 frequencies compared with non-intubated patients. (1.4±0.5 vs 3.5±0.5, p=0.003). In logistic regression analysis using training and test sets, S-reactive CD3 and CD8 cells, age, race, and transplantation status distinguished COVID-19 from healthy subjects (test set negative and positive predictive values 75% and 85% respectively, AUC 0.9). Among 66 COVID-19 patients, S-reactive CD8 cells and age predicted respiratory failure with NPV 62%, PPV 86%, AUC 0.73. S2-reactive T-cells demonstrated similar predictive performance. S1 antigen elicited minimal cellular responses. Transplanted COVID-19 patients show lower cytomegalovirus-specific CD154+CD3 frequencies compared with non-transplanted patients (0.5±0.1 vs 1.3±0.2, p=0.006). Frequencies of CD14+CD33+CD11b+HLADR-ve M-MDSC (14.5±2.9 vs 3.3±1.5, p=0.002) were higher in 47 independent COVID-19 patients compared with 6 healthy subjects. Conclusions: Conserved SARS-CoV-2-spike antigen drives T-cell immunity to COVID-19 in unexposed transplanted and non-transplanted subjects. This immunity declines with COVID-19 infection, is accompanied by increased myeloid derived suppressor cells, and can predict infection-risk and disease severity. Transplant patients demonstrate increased COVID-19-risk and co-infection-risk.

Investigation on Mental Health Well-Being for Students Learning from Home Arrangements Using Clustering Technique

The excitement of travelling from hometown to a university, well dressed along with carrying notes and laptop, attending classes physically with friends has become a myth in year 2020 and perhaps until the end of the year 2021. COVID-19 has robbed the lifestyle of being a university student and transformed the learning system into online. However, from the perspective of digitalization, it’s an achievement but a sudden change has stirred many conflicts on the mental health of students in terms of accepting drastic movement taken by the university due to the COVID-19 pandemic. Academic performance of students is in limbo as they tend to avoiding registered for subjects due to lack of absorbance of changes in the mode of learning with limited facilities to support them along the way. In response, it gives monumental pressure to grasp the subjects via online where it can affect the academic performance of students. This study investigated the state of mind of students who are undergoing classes via online. As such, mental state, physical and ergonomic factors associating with academic background among students will be the focus of this study. Data had been collected from a private university in Malaysia by using online platform. We used non-parametric clustering technique K-medoids based on unsupervised approach and Davies-Bouldin Index to measure cluster quality. Though in the past a few researchers have investigated similar studies, there is no research work reported using the clustering technique to study the aforementioned factors. A total of 8 distinct clusters were obtained. The patterns in the clusters indicated that high mental stress, poor ergonomic settings, alongside high potential risk of injuries were present in students in the clusters regardless of academic background. In particular, the two groups of clusters namely C4, C5, C6, C7 and C1, C2 need immediate attention in respect of mental, health and pedagogy support. As of result, the management of university, family members and university stakeholders should play their part by providing students with psychological support, comfortable study workspace, appropriate pedagogy support. © 2021, The Author(s), under exclusive license to Springer Nature Switzerland AG.

Investigation on Ergonomic Well-Being for Academician’s Work from Home Arrangements by Using Association Rules Technique

Corona virus or most popularly known as the Covid-19 has paralyzed the people movement as well as various sectors that includes the education sector. Henceforth, it gave a breakthrough for academia to venture themselves into work from home with the aid of information technology. It is known as online teaching and learning (OTL). Frequent and continuous usage of OTL to conduct lessons for learners from home may take a toll on the health aspect of academicians. Demographic factors associating with the factors related to ergonomic settings among academicians will be the focus of this study. Data was collected from private universities in Malaysia by using online platform. Association rules technique based on unsupervised approach had been used to find interesting patterns between demographics and ergonomic settings. With association rules, finding co-occurrences of demographics factors leading to the factors of ergonomic settings is the main strength of the technique. Despite many researchers in the past has done ergonomics studies in various areas/fields, only simple and descriptive statistical techniques were used. At present, there is no research work reported using the association rules technique in the educational field in the context of ergonomics. Association rules algorithms FP-Growth and Apriori were used and the evaluation metrics used in this study were support, confidence and lift. The results from this study indicated that the academic group with demographic factors (Married, Male) particularly vulnerable to the risk of mental health while the academic group (Married, Female, Years of experience is less than 10 years) did not have adequate ergonomics facilities at home and lacked a better sense of interpretation of the information provided to them by the management in the process of executing OTL. The results could facilitate further improvements to establish good working conditions for academicians to use OTL from home. The management could undertake the necessary initiatives targeting specific academic groups to address the issues facing them. © 2021, The Author(s), under exclusive license to Springer Nature Switzerland AG.

FetchZo: Real-Time Mobile Application for Shopping in COVID-19 Pandemic Situation

In this paper, FetchZo real-time application is developed for the shopping purpose in COVID-19 pandemic situation. Coronavirus is a serious virus in India, which spreads via close contacts. Maintaining social distancing becomes more important to avoid coronavirus infection. Shopping for daily needs is a great issue with social distancing and have come up with FetchZo application, which will locate your nearest shop and update you with many people currently present in the shop. This sustainable application provides security with login credentials for the shopkeeper as well as the customer. The shopping list also can be updated by the shopkeeper thus providing a real-time application for this pandemic COVID 19 situation. © The Author(s), under exclusive license to Springer Nature Singapore Pte Ltd. 2021.

Screening of covid-19 suspect cases in a cargo ship: A rare field experience

Background: World Health Organization (WHO), China Country Office informed cases of pneumonia of unknown aetiology detected in Wuhan City, Hubei Province of China. On 7th January 2020, Chinese authorities identified a new strain of Coronavirus as the causative agent for the disease. By 1st April 2020, the disease since its first detection in China has spread to over 200 countries/territories leading to a total of 823626 confirmed cases and 40598 deaths. WHO declared the novel Coronavirus outbreak as a Pandemic on 11 March 2020 and named the 2019 novel Coronavirus as COVID-19. As the screening of these suspects in ships is a challenging and novel one, the present study was aimed at identifying the proper and systematic way of screening of these suspects. Screening if done systematically aids in early diagnosis of the COVID-19 suspects and if coupled with pre-arrival preparedness through e-mail follow up helps in proper planning. Proper risk communication can help in alleviating the fears of the stakeholders and public. Aims & Objectives: The primary objective of this study was to screen the COVID-19 suspect cases systematically in the vessels and the secondary objectives were to identify any gaps in the process of collection, transport and receipt of results of samples of COVID-19 Suspect cases, know the process of risk communication & to share the experience to other seaports for duplication. Materials & Methods: Screening was done for all the crew by the Investigators with proper Personal Protective Equipment (PPE) on the Bridge (Navigation Deck) of the vessel mainly for recording the temperature and eliciting other signs & symptoms of COVID-19. It was then followed by sending the samples of the two COVID-19 suspects for testing to the Government approved laboratory in a systematic way. Risk communication was also done to all the stakeholders and media in a well-coordinated manner at the earliest to update them on the facts and to prevent false communication. Results: Pre-arrival preparedness through screening of pre-arrival documents and systematic approach adopted for screening of the COVID-19 suspects led to early diagnosis of the suspects. Samples were collected as per protocol and sent for testing to the laboratory and reports of the same were obtained without any much constraints through proper liaison with Tamilnadu State Health team. Risk communication to the stakeholders and media prevented panic among the public and stakeholders. Conclusions: Pre-arrival e-mail follow-up and arrangements like coordination meeting with the stakeholders led to proper planning. Systematic screening and proper liaison with State Health team helped in the early diagnosis of the suspects. Proper and early risk communication to the stakeholders and media prevents panic, facilitates good support and prevents communication of maleficious information to the public. © 2020, Indian Association of Preventive and Social Medicine. All rights reserved.