Physicians' satisfaction with the use of teleconsultation in France

Background: Physicians are showing a growing interest in teleconsultation, particularly since the onset of the coronavirus disease 2019 (COVID-19) pandemic. Surveying physicians' satisfaction with telehealth helps identify areas of strength and weaknesses that need improvement to support the promotion of telemedicine in the future. This study aimed to evaluate physician satisfaction rates and perspectives on teleconsultation. Methods: A 20-item online survey on teleconsultation use, including benefits, disadvantages, and suggested optimal modalities, was distributed and collected anonymously among physicians working at a university hospital. Results: Out of 145 physicians who responded, 73.8% were satisfied with teleconsultation, and 79.3% considered that this service will persist in the future. The main disadvantages raised by the physicians were the use of the telephone for remote consultation, the risk of dehumanization of the doctor-patient relationship, and the belief of a greater risk of medical errors than in a face-to-face setting. Of the doctors who responded to our survey, 54% said that the time needed for a teleconsultation should be similar to that of a face-to-face consultation, i.e., 15 to 20 minutes. Conclusions: Most physicians were satisfied with teleconsultation. However, improvements in digital tools such as usability and efficiency are necessary for teleconsultation development in the future. Alongside these technological imperatives, the fear of an increase in medical errors and dehumanization of the doctor-patient relationship are issues that must be closely considered to promote telemedicine in medical practice. © 2023 Journal of Hospital Management and Health Policy.

Mental health during the COVID-19 pandemic: Stress and strain profiles in the German population.

Clinical observations indicate that people frequently display stress-related behavior during the COVID-19 pandemic. Although numerous studies have been published concerning pandemic-related psychological distress, systematic data on the interrelationships between stress sensitivity, personality, and behavioral characteristics of people are still lacking. In the present cross-sectional online survey study, we applied a German version of the COVID Stress Scales (CSS) and standard psychological questionnaires to systematically identify the complex interplay between stress sensitivity, gender, and personality in the modulation of quality of life and mental health in the German population (N = 1774; age ≥ 16 years). A CSS-based cluster analysis revealed two clusters characterized by higher and lower stress levels. Study participants in each cluster differed significantly with respect to neuroticism, extraversion, agreeableness, quality of life, depression, and anxiety. Females were significantly overrepresented in the higher stress cluster, while there was an overrepresentation of males in the lower stress cluster. Neuroticism was identified as a risk factor and extraversion as a protective factor for enhanced pandemic-related stress responses. For the first time our data show a taxonomy of factors, which modulate pandemic-related stress sensitivity and warrant consideration as key indicators of quality of life and psychological distress during the COVID-19 pandemic. We suggest that our data may advise governmental regulation of pandemic-related public health measures, to optimize quality of life and psychological health in different groups of the population.

A Bilateral Diaphragmatic Paralysis Post-COVID-19 Infection: A Case Report and a Review of the Literature.

The diaphragm is the essential respiratory muscle, and damage can significantly impede a human's capacity for blood oxygenation. During inspiration, the diaphragm domes permit the pleural cavity to expand. Whenever this process is disrupted, it results in decreased thoracic expansion and, as a result, hypoventilation. The phrenic nerve innervates the diaphragmatic muscle via the cervical nerve roots C3, C4, and C5. Diaphragmatic paralysis is a multifactorial consequence caused by trauma, neurogenic diseases, infections, inflammatory responses, and chest operative surgery, with the last being the most prevalent causative factor. Here, we are describing the case of a 52-year-old male patient who has had ongoing dyspnea for months after contracting COVID-19 in December 2021, despite the remission of his previous COVID-19 pneumonia in 2020. An X-ray of the chest revealed no diaphragm elevation, whereas electromyography verified diaphragm impairment. On the conservative treatment plan, he reported persistent dyspnea following a period of pulmonary rehabilitation. To a lesser extent, it is advised to wait at least one year to see if there is any reinnervation, which could benefit his lung capacity. COVID-19 has been linked to many systematic diseases. As a result, COVID-19 will not be restricted to its inflammatory effect on the lungs. In other words, it is a multi-organ systematic syndrome. One of these effects is diaphragm paralysis, which should be considered a post-COVID-19 disease. However, there is a need for more literature to support physicians as guidelines for neurological conditions related to COVID-19 infection.

Leading for High Reliability During the COVID-19 Pandemic: A Pilot Quality Improvement Initiative to Identify Challenges Faced and Lessons Learned: JCOM

Objective: The COVID-19 pandemic posed unprecedented leadership challenges to health care organizations worldwide, especially those on the journey to high reliability. The objective of this pilot quality improvement initiative was to describe the experiences of medical center leaders continuing along the journey to high reliability during the pandemic. Methods: A convenience sample of Veterans Health Administration medical center directors at facilities that had initiated the journey to high reliability prior to or during the COVID-19 pandemic were asked to complete a confidential survey to explore the challenges experienced and lessons learned. Results: Of the 35 potential participants, 15 completed the confidential web-based survey. Five major themes emerged from participants' responses: (1) managing competing priorities, (2) staying committed, (3) adapting and overcoming, (4) prioritizing competing demands, and (5) maintaining momentum. Conclusion: This pilot quality improvement initiative provides some insight into the challenges experienced and lessons learned during the COVID-19 pandemic to help inform health care leaders' responses during crises they may encounter along the journey to becoming a high reliability organization.

Hospital-Initiated Extended-Release Injectable Buprenorphine Using a Novel Reallocation Initiative From an Outpatient Addiction Medicine Clinic.

OBJECTIVES: Novel strategies for initiation and continuation of buprenorphine are critical, especially during a pandemic when traditional opioid use disorder treatment pathways may be disrupted. We describe an innovative outpatient to inpatient reallocation initiative for extended-release buprenorphine (XR-BUP) designed to repurpose an expensive medication for use in hospitalized patients facing treatment barriers upon discharge and pilot the feasibility of XR-BUP use in the inpatient setting. METHODS: We collaborated with our institution's inpatient pharmacy and a New Jersey Medicaid managed care organization to create an alternate pathway to make XR-BUP available to hospitalized patients insured by the same payor. In this process, XR-BUP doses were deidentified and transferred to the inpatient controlled substance inventory for administration to hospitalized patients at no charge by our Addiction Medicine Consult Service after a period of sublingual buprenorphine stabilization. Our reallocation pathway bypassed several existing XR-BUP regulatory barriers to allow for inpatient administration. RESULTS: To date, we have transferred approximately 85 XR-BUP 300 mg doses to the inpatient controlled substance inventory. This equates to a cost savings of nearly $145,000. CONCLUSIONS: Reallocation of XR-BUP from an outpatient to inpatient setting increased postdischarge buprenorphine treatment access while also reducing health care costs by repurposing an expensive medication that would otherwise go to waste. Use of reallocated XR-BUP in the inpatient setting may pave the way for addition of XR-BUP to the hospital's formulary to minimize treatment gaps after discharge.

Evaluation of Cerebrovascular Reactivity and Vessel Wall Imaging in Patients With Prior COVID-19: A Prospective Case-Control MRI Study.

BACKGROUND. SARS-CoV-2 infection is associated with acute stroke, possibly caused by viral tropism to the vascular endothelium. Whether cerebrovascular endothelial dysfunction and inflammation persist after acute infection is poorly understood. OBJECTIVE. The purposes of this study were to assess the association between prior SARS-CoV-2 infection and cerebrovascular reactivity (CVR) and vessel-wall imaging (VWI) abnormalities and to explore the association between CVR impairment and post-COVID neurologic conditions. METHODS. This prospective study included 15 participants with prior SARS-CoV-2 infection (11 women, four men; mean age, 43 years; mean time since infection, 238 days; three with prior critical illness, 12 with prior mild illness; seven with post-COVID neurologic conditions) and 10 control participants who had never had SARS-CoV-2 infection (two women, two men; mean age, 44 years) from July 1, 2021, to February 9, 2022. Participants underwent research MRI that included arterial spin labeling perfusion imaging with acetazolamide stimulus to measure cerebral blood flow (CBF) and calculate CVR. Examinations also included VWI, performed with a contrast-enhanced black-blood 3D T1-weighted sequence. An age- and sex-adjusted linear model was used to assess associations between CVR and prior infection. A t test was used to assess associations between CVR and post-COVID neurologic conditions in participants with previous infection. A difference of proportions test was used to assess associations between VWI abnormalities and infection status. RESULTS. Mean whole-cortex CBF after acetazolamide administration was greater in participants without previous infection than in participants with previous infection (73.8 ± 13.2 vs 60.5 ± 15.8 mL/100 gm/min; p = .04). Whole-brain CVR was lower in participants with previous infection than those without previous infection (difference, -8.9 mL/100 g/min; p < .001); significantly lower CVR was also observed in participants with previous infection after exclusion of those with prior critical illness. Among participants with previous infection, CVR was lower in those with than those without post-COVID neurologic conditions, although this difference was not significant (16.9 vs 21.0 mL/100 g/min; p = .22). Six of 15 (40%) participants with previous infection versus 1 of 10 (10%) participants without previous infection had at least one VWI abnormality (p = .18). All VWI abnormalities were consistent with atherosclerosis. CONCLUSION. SARS-CoV-2 infection is associated with chronic impairment of CVR. The mechanism is unknown from this study. CLINICAL IMPACT. Future studies are needed to determine the clinical implications of SARS-CoV-2-associated CVR impairment.

Interactive Videos: Student Perceptions before and after the Great Pivot

The purpose of this study was to survey undergraduate students of a management statistics course about their perceptions on the usefulness of a series of instructional videos with embedded quiz questions created by their instructor to provide students with knowledge of Excel functions needed to understand the course materials and complete course work. Due to COVID-19, the intended study was split between academic years and three different course types (in-person pre-COVID-19, fully-online post-COVID-19, in-person post-COVID-19, all taught by the same instructor, were surveyed resulting in a study that compared three different course types rather than a simple replication study. The results of the survey showed that there were significant positive changes to perceptions of video quizzing usefulness for students as they progressed through the in-person pre-COVID-19 course, but not significant differences for students who progressed through the two other course. In comparing the courses with each other, the only area in which all three had significant differences to each other was in students feeling the video quizzes enabled them to skip synchronous sessions. This was the only area in which the pre-COVID-19 course had any significant differences from the two post-COVID-19 courses, but the two post-COVID-19 courses were found to be significantly different from each other on almost every item with the fully-online students rating all items higher than the in-person students did. The researchers of this study felt that these results pointed to two major areas for future study, one being on how class modality post-COVID-19 impacts student perceptions of online tools and the other being related to the value and replicability of the in-person experience among those who were forced into remote learning during the pandemic.

Cisatracurium in Coronavirus Disease 2019 and Moderate-to-Severe Acute Respiratory Distress Syndrome

INTRODUCTION: Acute respiratory distress syndrome (ARDS) develops in approximately 33% of hospitalized coronavirus disease 19 (COVID-19) patients with 75% of COVID-19-related intensive care unit (ICU) admissions caused by an ARDS diagnosis. Currently, there is conflicting evidence regarding the mortality benefit of early neuromuscular blocking agents (NMBAs) being used in moderate-to-severe ARDS, and data is especially lacking in COVID-19-related ARDS despite increased NMBA utilization. This study aims to assess if early versus late initiation of a cisatracurium infusion in critically ill COVID-19 adults with moderate-to-severe ARDS has an effect on 28- day breathing without assistance. METHOD(S): Retrospective cohort study conducted at a multi-hospital community health system between March 2020 and November 2021. Eligible patients included adults >= 18 years, admitted to the ICU with COVID-19 infection and moderate-to-severe ARDS requiring mechanical ventilation, and received a cisatracurium infusion for at least four hours. Patients were divided into two groups: early (within 48 hours) versus late (greater than 48 hours) initiation of cisatracurium infusion from the time of mechanical ventilation. RESULT(S): A total of 118 patients were included in the final analysis. At day 28, there were no significant differences in the rate of breathing without assistance between the early and late group (15.3% and 10.2%, respectively;p = 0.407). Similarly, there were no significant differences between groups in all-cause mortality or death in the ICU at day 28. Intensive care unit length of stay was significantly shorter among the early group with a median of 10.6 days versus 15.1 days in the late group (p = 0.028). Additionally, mechanical ventilation duration was significantly shorter in the early group compared to the late group (median, 7.3 and 11.6 days, respectively;p = 0.001). Incidence of barotrauma during cisatracurium infusion did not differ between groups. CONCLUSION(S): Early initiation of a cisatracurium continuous infusion was not associated with a significant improvement in breathing without assistance at day 28 in moderate-to-severe ARDS patients with COVID-19. The utilization and timing of cisatracurium in this patient population remains uncertain.

SARS-CoV-2 spike protein variant binding affinity to an angiotensin-converting enzyme 2 fusion glycoproteins.

Severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2), the causative agent of the Coronavirus disease 2019 (Covid-19) pandemic, continues to evolve and circulate globally. Current prophylactic and therapeutic countermeasures against Covid-19 infection include vaccines, small molecule drugs, and neutralizing monoclonal antibodies. SARS-CoV-2 infection is mainly mediated by the viral spike glycoprotein binding to angiotensin converting enzyme 2 (ACE2) on host cells for viral entry. As emerging mutations in the spike protein evade efficacy of spike-targeted countermeasures, a potential strategy to counter SARS-CoV-2 infection is to competitively block the spike protein from binding to the host ACE2 using a soluble recombinant fusion protein that contains a human ACE2 and an IgG1-Fc domain (ACE2-Fc). Here, we have established Chinese Hamster Ovary (CHO) cell lines that stably express ACE2-Fc proteins in which the ACE2 domain either has or has no catalytic activity. The fusion proteins were produced and purified to partially characterize physicochemical properties and spike protein binding. Our results demonstrate the ACE2-Fc fusion proteins are heavily N-glycosylated, sensitive to thermal stress, and actively bind to five spike protein variants (parental, alpha, beta, delta, and omicron) with different affinity. Our data demonstrates a proof-of-concept production strategy for ACE2-Fc fusion glycoproteins that can bind to different spike protein variants to support the manufacture of potential alternative countermeasures for emerging SARS-CoV-2 variants.

Retrospective cohort study to assess the association between treatment with tocilizumab and mortality among mechanically ventilated patients with COVID-19.

OBJECTIVES: Assess the association between tocilizumab administration and clinical outcomes among mechanically ventilated patients with COVID-19 pneumonia. DESIGN: Retrospective cohort study. SETTING: Large integrated health system with 9 million members in California, USA. PARTICIPANTS: 4185 Kaiser Permanente members hospitalised with COVID-19 pneumonia requiring invasive mechanical ventilation (IMV). INTERVENTIONS: Receipt of tocilizumab within 10 days of initiation of IMV. OUTCOME MEASURES: Using a retrospective cohort of consecutive patients hospitalised with COVID-19 pneumonia who required IMV in a large integrated health system in California, USA, we assessed the association between tocilizumab administration and 28-day mortality, time to extubation from IMV and time to hospital discharge. RESULTS: Among 4185 patients, 184 received tocilizumab and 4001 patients did not receive tocilizumab within 10 days of initiation of IMV. After inverse probability weighting, baseline characteristics were well balanced between groups. Patients treated with tocilizumab had a similar risk of death in the 28 days after intubation compared with patients not treated with tocilizumab (adjusted HR (aHR), 1.21, 95% CI 0.98 to 1.50), but did have a significantly longer time-to-extubation (aHR 0.71; 95% CI 0.57 to 0.88) and time-to-hospital-discharge (aHR 0.66; 95% CI 0.50 to 0.88). However, patients treated with tocilizumab ≤2 days after initiation of IMV had a similar risk of mortality (aHR 1.47; 95% CI 0.96 to 2.26), but significantly shorter time-to-extubation (aHR 0.37; 95% CI 0.23 to 0.58) and time-to-hospital-discharge (aHR 0.31; 95% CI CI 0.17 to 0.56) compared with patients treated with tocilizumab 3-10 days after initiation of IMV. CONCLUSIONS: Among mechanically ventilated patients with COVID-19, the risk of death in the 28-day follow-up period was similar, but time-to-extubation and time-to-hospital-discharge were longer in patients who received tocilizumab within 10 days of initiation of IMV compared with patients who did not receive tocilizumab.

An Interpretable Chest CT Deep Learning Algorithm for Quantification of COVID-19 Lung Disease and Prediction of Inpatient Morbidity and Mortality.

RATIONALE AND OBJECTIVES: The burden of coronavirus disease 2019 (COVID-19) airspace opacities is time consuming and challenging to quantify on computed tomography. The purpose of this study was to evaluate the ability of a deep convolutional neural network (dCNN) to predict inpatient outcomes associated with COVID-19 pneumonia. MATERIALS AND METHODS: A previously trained dCNN was tested on an external validation cohort of 241 patients who presented to the emergency department and received a chest computed tomography scan, 93 with COVID-19 and 168 without. Airspace opacity scoring systems were defined by the extent of airspace opacity in each lobe, totaled across the entire lungs. Expert and dCNN scores were concurrently evaluated for interobserver agreement, while both dCNN identified airspace opacity scoring and raw opacity values were used in the prediction of COVID-19 diagnosis and inpatient outcomes. RESULTS: Interobserver agreement for airspace opacity scoring was 0.892 (95% CI 0.834-0.930). Probability of each outcome behaved as a logistic function of the opacity scoring (25% intensive care unit admission at score of 13/25, 25% intubation at 17/25, and 25% mortality at 20/25). Length of hospitalization, intensive care unit stay, and intubation were associated with larger airspace opacity score (p = 0.032, 0.039, 0.036, respectively). CONCLUSION: The tested dCNN was highly predictive of inpatient outcomes, performs at a near expert level, and provides added value for clinicians in terms of prognostication and disease severity.

Case Series: Hypercalcemia From Granulomatous Silicosis Developing After COVID-19 Infection.

Hypercalcemia is one of the most commonly encountered laboratory abnormalities in clinical medicine. Various causes have been well established. However, it is likely that the novel coronavirus, severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), may be a newly found cause of this frequent finding, especially amongst those with a history of cosmetic surgery, specifically by means of silicone injection. In this case series, we describe 2 patients presenting with symptomatic hypercalcemia likely from their prior silicone injections. Interestingly, each patient only developed symptoms of hypercalcemia following infection with SARS-CoV-2.

Covid-19 à La Réunion : peut-on parler d'un « confinement des pathologies » pour les passages aux urgences et les consultations en médecine libérale en 2020 ?

Déclaration de liens d’intérêts: Les auteurs déclarent ne pas avoir de liens d’intérêts.

Post-COVID-19 Fatigue: A Case of Infectious Hypothyroidism.

Since the beginning of the coronavirus disease 2019 (COVID-19) global pandemic, an array of different clinical sequela and comorbid conditions have been discovered to be associated with COVID-19 infection. Of these sequela, subacute thyroiditis (SAT) causing hyperthyroidism has been prominent, more commonly affecting women. However, our case details a 49-year-old male patient with no history of thyroid disease showing signs and symptoms of hypothyroidism for six months after recovery from COVID-19 infection. His blood work was consistent with hypothyroidism, showing markedly elevated thyroid-stimulating hormone (TSH), suppressed T3 levels, and positive anti-thyroid peroxidase antibody titers. The patient was treated with Synthroid and showed quick clinical improvement in symptoms. This case demonstrates that COVID-19 infection can cause overt hypothyroidism in male patients, adding yet another clinical sequela of COVID-19 infection to our clinical repertoire from recently published case reports.

Hypertriglyceridemia in mechanically ventilated COVID-19 patients

INTRODUCTION: Incidence and pharmacotherapy of hypertriglyceridemia (HTG) in COVID-19 have not been well characterized. HTG could lead to added COVID-19 complications such as pancreatitis. We aimed to describe HTG in a COVID-19 cohort. METHODS: Triglyceride (TG) values for an observational cohort of consecutive mechanically ventilated patients with COVID-19 were reviewed in two cohort intensive care units between March 22 and April 15, 2020. Data was retrospectively reviewed for the first 30 days of admission on baseline demographics, concomitant lipid therapies, TG levels, treatment, and incidence of pancreatitis. RESULTS: Forty-eight patients were identified. Overall prevalence of moderate hyperTG (175-499 mg/dL) was 85%, severe hyperTG (>500 mg/dL) 35% and 10% had a TG value > 1000 mg/dL. Mean TG was 258 mg/dL, with a median maximum value of 371 mg/d and increase from baseline of 139 mg/dL. Most patients received propofol infusions (94%) for sedation over a mean of six days at a mean dose of 29 mcg/kg/min for a mean of 146 hours. The cohort received enteral nutrition (100%), tocilizumab (40%), insulin infusions (25%), statins (23%), omega-3 fatty acids (10%), fibrates (8%). All patients with TG levels >1000 utilized insulin infusions for rapid TG lowering along with at least one oral therapy. Mean hospital length of stay was 23 days. No episodes of acute pancreatitis were noted in this cohort in whom acute treatment was initiated. CONCLUSIONS: An elevated occurrence of moderate and severe HTG was seen in this COVID-19 cohort, potentially related to multiple underlying mechanisms and pharmacotherapy. Clinicians should be aware of this disease characteristic and monitor TG levels closely, with consideration to avoid lipid infusion.

Anti-inflammatory drugs and the renin-angiotensin-aldosterone system: Current knowledge and potential effects on early SARS-CoV-2 infection.

Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) is the etiologic agent of coronavirus disease 19 (COVID-19), and is genetically related to the 2003 SARS and Middle East respiratory syndrome (MERS-CoV) coronaviruses. Recent studies have reported that similar to SARS-CoV, this strain expresses a spike protein (S) with a receptor binding domain (RBD) that binds to angiotensin-converting enzyme 2 (ACE2) - an enzyme expressed mostly in the endothelium, kidneys, heart, gastrointestinal tract and lungs - to facilitate viral entry and intracellular replication. Incidentally, the renin-angiotensin-aldosterone system (RAAS) is integral to physiologic control of both ACE and ACE2 expression, and is an essential system utilized by SARS-CoV-2, albeit with varying schools of thought on how it can affect viral entry. In this paper, we will review current knowledge on the RAAS and how it can be affected by non-steroidal anti-inflammatory drugs (NSAIDs) and corticosteroid use at the organ and cellular levels. We will then discuss the relevance of these interactions on organ-specific ACE2 expression, and provide scientific insights on how this mechanism can potentially affect SARS-CoV-2 infection in the early phases of disease. From the standpoint of other known viruses, we will then aim to discuss the potential uses or restrictions of these drugs in viral infection, and provide an update on relevant studies about COVID-19.