Diagnostic Concordance of Telemedicine as Compared With Face-to-Face Care in Primary Health Care Clinics in Rural India: Randomized Crossover Trial.

BACKGROUND: With the COVID-19 pandemic, there was an increase and scaling up of provider-to-provider telemedicine programs that connect frontline health providers such as nurses and community health workers at primary care clinics with remote doctors at tertiary facilities to facilitate consultations for rural patients. Considering this new trend of increasing use of telemedicine, this study was conducted to generate evidence for patients, health providers, and policymakers to compare if provider-to-provider telemedicine-based care is equivalent to in-person care and is safe and acceptable in terms of diagnostic and treatment standards. OBJECTIVE: This study aims to compare the diagnosis and treatment decisions from teleconsultations to those of in-person care in teleclinics in rural Gujarat. METHODS: We conducted a diagnostic concordance study using a randomized crossover study design with 104 patients at 10 telemedicine primary care clinics. Patients reporting to 10 telemedicine primary care clinics were randomly assigned to first receive an in-person doctor consultation (59/104, 56.7%) or to first receive a health worker-assisted telemedicine consultation (45/104, 43.3%). The 2 groups were then switched, with the first group undergoing a telemedicine consultation following the in-person consultation and the second group receiving an in-person consultation after the teleconsultation. The in-person doctor and remote doctor were blinded to the diagnosis and management plan of the other. The diagnosis and treatment plan of in-person doctors was considered the gold standard. RESULTS: We enrolled 104 patients reporting a range of primary health care issues into the study. We observed 74% (77/104) diagnostic concordance and 79.8% (83/104) concordance in the treatment plan between the in-person and remote doctors. No significant association was found between the diagnostic and treatment concordance and the order of the consultation (P=.65 and P=.81, respectively), the frontline health worker-doctor pair (both P=.93), the gender of the patient (both P>.99), or the mode of teleconsultation (synchronous vs asynchronous; P=.32 and P=.29, respectively), as evaluated using Fisher exact tests. A significant association was seen between the diagnostic and treatment concordance and the type of case (P=.004 and P=.03, respectively). The highest diagnostic concordance was seen in the management of hypertension (20/21, 95% concordance; Cohen kappa=0.93) and diabetes (14/15, 93% concordance; Cohen kappa=0.89). The lowest values were seen in cardiology (1/3, 33%) and patients presenting with nonspecific symptoms (3/10, 30%). The use of a digital assistant to facilitate the consultation resulted in increased adherence to evidence-based care protocols. CONCLUSIONS: The findings reflect that telemedicine can be a safe and acceptable alternative mode of care especially in remote rural settings when in-person care is not accessible. Telemedicine has advantages. for the potential gains for improved health care-seeking behavior for patients, reduced costs for the patient, and improved health system efficiency by reducing overcrowding at tertiary health facilities.

Gracin's Syndrome, a Rare Clinical Challenge in the Setting of Invasive Mucormycosis: A Systematic Review.

Garcin's Syndrome is a rare pathology involving multiple cranial nerves in the setting of invasive mucormycosis, usually in immunocompromised patients. Owing to its extremely high mortality rate, clinician should have a high suspicion for diagnosis. This article presents a rare case of Rhino-Orbito-Cerebral Mucormycosis with Garcin's syndrome in a 33-years old male along with a discussion of previously reported cases. The case is discussed in light of scant contemporary literature on the cited subject. A thorough search using the keywords Garcin's Syndrome, Invasive Mucormycosis, Rhino-orbital, Rhino-cerebral mucormycosis, was conducted on Pubmed/MEDLINE, Google scholar, LILACS, medRxiv and Google. A total of six reported cases found in international literature published between 2000 and 2020 were reviewed and analyzed. Garcin's Syndrome is associated with a high mortality rate. In our review, of the total seven patients, only three survived, bringing the collective mortality to 42.85%. Patients had multiple cranial nerve involvement leading to long term sequelae. Our case showed the unique finding of VIII nerve involvement. Early intervention helped in patient survival and better functional outcome. This literature review highlights the distinct clinical nature of the presentation of disease and the importance of prompt diagnosis and early management in the reversal of complications in an otherwise potentially fatal disease.

Exploring Critical Factors Influencing the Usage of Video Conferencing Apps for Virtual Learning System

The COVID-19 outbreak harmed populations, was deleterious to those of the social groups most at risk, and affected all facets of the community. Because of the widespread effects of COVID-19, schools and other educational institutions had to close. Technology, here, helped to advance education by enabling virtual connections between students and teachers through online classrooms, webinars, digital tests and other means. To promote synchronous learning sessions, video conferencing apps are used in the majority of online learning activities. Many Academicians weren't used to utilizing video conferencing apps, but they were forced to use them anyhow despite their level of preparation. In this study, the authors have tried to establish a theoretical model to determine the level of awareness among Academicians and Faculty members regarding critical factors & dimensions influencing the usage of video conferencing apps for online sessions. This study further tries to identify factors that determine the usage of video conferencing apps with UTAUT Model. The study lays the foundation for future research on examining how the use of technology plays a significant role in cognitive engagement and learning process.

Post Viral Olfactory Dysfunction After SARS-CoV-2 Infection: Anticipated Post-pandemic Clinical Challenge.

Persistent olfactory dysfunction (OD) is the second most common symptom of post coronavirus disease-19 (COVID-19) now being termed long-COVID. Its prevalence after recovery from COVID-19 is estimated to be 12% after nearly 6 months of follow-up. It thus becomes imperative for the treating clinicians to update themselves with the pathophysiology of this post COVID disability as well as the tools for diagnosis and the available treatment options. A systematic literature search was performed as per PRISMA guidelines in MEDLINE, Cochrane Library, LILACS, Google Scholar, ClinicalTrials.gov, and medRxiv databases. The keywords used were covid-19, Olfactory Disorders, Smell, Anosmia, PVOD, Post Viral Olfactory Disorders, post-covid and post haul. All articles were studied for definition, mechanism, diagnostic tests and treatment options for post COVID OD. 33 published articles and 8 ongoing trials were found relevant and included after full-text review. SARS-CoV-2 can cause conductive, neural and central OD. Olfactory evaluation can be done both subjectively (visual analogue scale) and objectively (Sniffin' sticks, Sinonasal Outcome Test, University of Pennsylvania Smell Identification Test and modified Davidson's alcohol sniff test). They can be used to detect and follow-up patients. Despite several on-going clinical trials, the most reliable and advisable treatment option available till date is olfactory training.

Assessment of Infant and Young Child Feeding (IYCF) practices in rural areas of Dehradun, Uttarakhand.

Introduction: The practice of infant and young child feeding (IYCF) is critical for a child's growth and development throughout the first two years of life. Poor feeding habits in early childhood contribute to malnutrition and child mortality in India. Aim and Objective: To assess the IYCF practices in children under the age of 2 years. Material and Methods: In rural Uttarakhand, India, a cross-sectional study was undertaken from March 2021 to May 2021. A probability proportional to size (PPS) method was used to select 400 children under the age of 2 years. The World Health Organization IYCF questionnaire, was used to collect house to house data. An appropriate statistical test was used for analysing the data. Results: According to the findings, 47.5 percent of babies under the age of six months were nursed within the first hour of delivery. About 73.9 percent of babies were exclusively breastfed. Approximately 22 percent infants were given pre-lacteal feeds and 20 percent were bottle fed. In addition to breast milk, half of babies aged 6 to 8 months had solid, semi-solid, or soft meals, however minimum acceptable diet was provided to only 33.5 percent children. Odds of male child who were bottle fed in the age group of 6-23 months were 2.02 times higher to that of female child. Also the odds of male child in the age group of 6-8 months to be introduced with solids, semi-solid, or soft food were 4.91 times higher to that of female child. Similarly, odds of male child received minimum dietary diversity (2.35), minimum meal frequency (1.82), and minimum acceptable diet (2.35) in the age group of 6-23 months were found to be higher to that of female child in the similar age group. Total of six mothers reported coronavirus disease (COVID) positive status and only two of them breastfed their babies using COVID appropriate behavior. Conclusion: Exclusive breastfeeding (EBF) has been practiced in more than two-thirds of children, but early breastfeeding is practised in less than half of children. Only one third children of more than six months of age are getting minimum acceptable diet.

Hacking Covid-19 with Technology.

The development, implementation and advancement of technology solutions aimed at combating the COVID-19 outbreak are rapidly taking shape in India. Governments, Venture Capitalists, Academic Institutions, Incubators, Start-ups, and businesses large and small are all doing their part to deploy new innovative solutions as quickly as possible. Various databases were searched to look for different advancements in technology during the current coronavirus pandemic. It is seen that on one end nonpharmacological measure (social distancing, self-isolation, clean hands, and face masks) are time-tested and low-tech ways to help mitigate the viral spread. On the other end, Science and technology sector constituting of data science, machine learning, rapid diagnostic tests, mobile-first telehealth and computational simulation systems for drug development, artificial intelligence, virtual collaboration, and data tracking are complex ways of using the technology that have strengthened our pandemic response.

Proton-Coupled Conformational Activation of SARS Coronavirus Main Proteases and Opportunity for Designing Small-Molecule Broad-Spectrum Targeted Covalent Inhibitors.

The SARS coronavirus 2 (SARS-CoV-2) main protease (Mpro) is an attractive broad-spectrum antiviral drug target. Despite the enormous progress in structure elucidation, the Mpro's structure-function relationship remains poorly understood. Recently, a peptidomimetic inhibitor has entered clinical trial; however, small-molecule orally available antiviral drugs have yet to be developed. Intrigued by a long-standing controversy regarding the existence of an inactive state, we explored the proton-coupled dynamics of the Mpros of SARS-CoV-2 and the closely related SARS-CoV using a newly developed continuous constant pH molecular dynamics (MD) method and microsecond fixed-charge all-atom MD simulations. Our data supports a general base mechanism for Mpro's proteolytic function. The simulations revealed that protonation of His172 alters a conserved interaction network that upholds the oxyanion loop, leading to a partial collapse of the conserved S1 pocket, consistent with the first and controversial crystal structure of SARS-CoV Mpro determined at pH 6. Interestingly, a natural flavonoid binds SARS-CoV-2 Mpro in the close proximity to a conserved cysteine (Cys44), which is hyper-reactive according to the CpHMD titration. This finding offers an exciting new opportunity for small-molecule targeted covalent inhibitor design. Our work represents a first step toward the mechanistic understanding of the proton-coupled structure-dynamics-function relationship of CoV Mpros; the proposed strategy of designing small-molecule covalent inhibitors may help accelerate the development of orally available broad-spectrum antiviral drugs to stop the current pandemic and prevent future outbreaks.

Assessment of proton-coupled conformational dynamics of SARS and MERS coronavirus papain-like proteases: Implication for designing broad-spectrum antiviral inhibitors.

Broad-spectrum antiviral drugs are urgently needed to stop the Coronavirus Disease 2019 pandemic and prevent future ones. The novel severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) is related to the SARS-CoV and Middle East respiratory syndrome coronavirus (MERS-CoV), which have caused the previous outbreaks. The papain-like protease (PLpro) is an attractive drug target due to its essential roles in the viral life cycle. As a cysteine protease, PLpro is rich in cysteines and histidines, and their protonation/deprotonation modulates catalysis and conformational plasticity. Here, we report the pKa calculations and assessment of the proton-coupled conformational dynamics of SARS-CoV-2 in comparison to SARS-CoV and MERS-CoV PLpros using the recently developed graphical processing unit (GPU)-accelerated implicit-solvent continuous constant pH molecular dynamics method with a new asynchronous replica-exchange scheme, which allows computation on a single GPU card. The calculated pKa's support the catalytic roles of the Cys-His-Asp triad. We also found that several residues can switch protonation states at physiological pH among which is C270/271 located on the flexible blocking loop 2 (BL2) of SARS-CoV-2/CoV PLpro. Simulations revealed that the BL2 can open and close depending on the protonation state of C271/270, consistent with the most recent crystal structure evidence. Interestingly, despite the lack of an analogous cysteine, BL2 in MERS-CoV PLpro is also very flexible, challenging a current hypothesis. These findings are supported by the all-atom fixed-charge simulations and provide a starting point for more detailed studies to assist the structure-based design of broad-spectrum inhibitors against CoV PLpros.