Creating a smart classroom on intensive care using assisted reality technology

Introduction: Medical students receive relatively little exposure to intensive care medicine throughout their undergraduate training in comparison to other specialties. The COVID-19 pandemic further hindered students' exposure with entrance to intensive care units (ICU) limited to conserve personal protective equipment (PPE) and reduce the risk of virus spread. To address this problem, this study explored the use of assisted reality technology to create a smart classroom whereby medical students can experience intensive care medicine with the COVID-19 risks mitigated. There is existing literature describing the use of live streaming ward rounds using wearable technology to teach medical students, however, we believe this is the first time assisted reality technology has been harnessed to develop a teaching curriculum on intensive care.1 Objectives: This study aimed to assess the feasibility of using a wearable headset with assisted reality technology to live stream intensive care teaching to remotely based medical students. Method(s): Three intensive care teaching sessions were live streamed to three groups of medical students using the AMA XpertEye wearable glasses. The teaching session focused on the intensive care bed space and equipment as well as the assessment of a critically unwell intensive care patient. Two educators were required to facilitate the optimum learning environment. One educator wore the assisted reality technology glasses on the ICU whilst the other educator remained with the students to facilitate group discussion. The educators had the means to communicate via inbuilt technology on the glasses. Feedback from students was collected using the evaluation of technology-enhanced learning materials (ETELM).2 Results: The response rate for the ETELM survey was 100%. Students strongly agreed that the session was well organised, relevant and that the navigation of technology-based components was logical and efficient. 'There was a strong instructor presence and personal touch to the session' returned the strongest positive response. 'This session will change my practice' received the most varied response from students, potentially due to their stage in undergraduate training and distance from actual clinical practice. Students strongly disagreed that their learning was affected by technology issues. Educators reported problems with securing a patient appropriate to be involved alongside the busy clinical demands of the ICU. Facilitation by trained educators was crucial to ensure the teaching sessions were high quality. Conclusion(s): The use of smart classrooms on intensive care using assisted reality technology was very well received by medical students and educators. The main limitations included the necessity to balance the delivery of teaching alongside the clinical demands of the unit, however this is arguably the case with most forms of clinical teaching. There is the potential to continue using smart classrooms in the post-pandemic period, as they provide an open and safe platform for students to explore intensive care medicine and to ask questions that they may feel less able to raise in the busy clinical environment.

Trends in Medicare funded respiratory function testing in Australian laboratories

Introduction/Aim: Our study aimed to quantitate trends in Medicare funded respiratory function testing (RFT) in Australian laboratories over recent years, including assessing the impact of Medicare item number changes and the COVID-19 pandemic. Method(s): We interrogated the online Medicare database from July 1994 through to July 2022. All laboratory-based Medicare items related to RFTs were included, both before and after Medicare item changes that occurred in late 2018. Result(s): There was a steady increase in RFTs from ~25,000 tests in 1994 to ~114,000 prior to Medicare changes in 2018, corresponding to per-capita increase from ~140 to 450/100,000 Medicare registrants. A 16% dip in testing post 2018 Medicare item changes was followed by a small increase, then a sharp 46% decrease in testing during the early stages of the COVID-19 pandemic in 2020. Testing levels increased sharply towards the end of 2020 but have not consistently recovered to levels seen prior to COVID-19. The most recent quarter analysed represents 372 tests / 100,000 Medicare registrants. Conclusion(s): Australian Medicare funded laboratory RFTs increased steadily for 24 years before a small decline in 2018, related to Medicare item number changes, and a sharp decline in 2020 due to COVID-19. There has been a recovery since then, however numbers are more variable since the sharp COVID-19 decline.

Bimekizumab safety in patients with moderate-to-severe plaque psoriasis: Analysis of pooled data from up to three years of treatment in Phase 2 and 3 clinical trials

Background: Bimekizumab (BKZ) is a monoclonal IgG1 antibody used in the treatment of psoriasis which selectively inhibits interleukin (IL)-17F in addition to IL-17A.1,2 Data pooled over two years have indicated that BKZ is generally well-tolerated.3 We report three-year BKZ pooled safety data in patients with moderate-to-severe plaque psoriasis. Method(s): Safety data were evaluated for all patients who received one or more dose BKZ in four Phase 3 trials (BE SURE [NCT03412747], BE VIVID [NCT03370133], BE READY [NCT03410992], and their ongoing open-label extension BE BRIGHT open-label extension [NCT03598790;data cut-off : 10/23/2021]) and four Phase 2 trials (BE ABLE 1 [NCT02905006], BE ABLE 2 [NCT03010527], PS0016 [NCT03025542], PS0018 [NCT03230292]). Safety data were evaluated separately for patients receiving BKZ dosed 320mg every four weeks (Q4W) or every eight weeks (Q8W). Exposureadjusted incidence rates (EAIRs) for treatmentemergent adverse events (TEAEs) are the incidence of new cases per 100 patient-years (PY). Result(s): Total BKZ exposure was 4,245.3 PY (N=1,789) across Phase 2/3 trials, and 3,876.4 PY (N=1,495) in Phase 3 trials. TEAEs occurred at a rate of 186.1 across Phase 2/3 trials, serious TEAEs at 5.6, and TEAEs leading to discontinuation at 3.5. Eighteen deaths occurred (0.4/100 PY), all unrelated to study treatment except one (relationship unknown). TEAEs occurred less frequently in Q8W- than Q4W-treated patients in Phase 3 trials. Consistent with previous reports, most common TEAEs (EAIR) in Phase 2/3 trials were nasopharyngitis (15.3), oral candidiasis (10.2), and upper respiratory tract infection (7.1).3 EAIR of serious infections was 1.2. Most frequently reported were serious coronavirus infections (0.2). There were no cases of active tuberculosis. EAIR of oral candidiasis was 10.2, decreased vs two-year data (12.6),3 and was less common with BKZ Q8W vs Q4W. The vast majority of oral candidiasis events were mild or moderate (99.4%);none were serious. EAIRs of hepatic events (4.0) and elevated liver enzymes (3.4) were decreased vs. two-year data (4.3 and 3.6, respectively).3 EAIRs for inflammatory bowel disease (0.1), adjudicated major adverse cardiac events (0.6), and adjudicated suicidal ideation and behavior (0.1) were low. EAIRs for other safety topics of interest were also low and were similar to or lower than two-year EAIRs.3 Conclusion(s): BKZ was well-tolerated over three years. No safety signals were identified;EAIRs of TEAEs did not increase compared with data from two years.3.

HostSeq: a Canadian whole genome sequencing and clinical data resource.

HostSeq was launched in April 2020 as a national initiative to integrate whole genome sequencing data from 10,000 Canadians infected with SARS-CoV-2 with clinical information related to their disease experience. The mandate of HostSeq is to support the Canadian and international research communities in their efforts to understand the risk factors for disease and associated health outcomes and support the development of interventions such as vaccines and therapeutics. HostSeq is a collaboration among 13 independent epidemiological studies of SARS-CoV-2 across five provinces in Canada. Aggregated data collected by HostSeq are made available to the public through two data portals: a phenotype portal showing summaries of major variables and their distributions, and a variant search portal enabling queries in a genomic region. Individual-level data is available to the global research community for health research through a Data Access Agreement and Data Access Compliance Office approval. Here we provide an overview of the collective project design along with summary level information for HostSeq. We highlight several statistical considerations for researchers using the HostSeq platform regarding data aggregation, sampling mechanism, covariate adjustment, and X chromosome analysis. In addition to serving as a rich data source, the diversity of study designs, sample sizes, and research objectives among the participating studies provides unique opportunities for the research community.

Mental health of patients with psoriasis during the COVID-19 pandemic: a cross-sectional study in a tertiary setting

Patients with psoriasis are at increased risk of depression. Furthermore, psoriasis is linked to social isolation, stress-related disorders and suicidality. The COVID-19 pandemic and social distancing represent potential stressors for patients, which may disproportionately affect the wellbeing of this vulnerable population. Our aim was to investigate whether the pandemic increased the affective burden of patients with psoriasis. We surveyed 194 patients with dermatologist-confirmed psoriasis attending our tertiary service. Ninety-three patients had completed questionnaires [Hospital Anxiety and Depression Scale (HADS);Quick Inventory of Depressive Symptomatology Self- Report (QIDS-SR);Sheehan Suicidality Tracking Scale;Dermatology Life Quality Index (DLQI)] before March 2020 in a pre-existing study. From May to October 2020, we recruited a different patient sample (n = 101) who completed the same questionnaires. We analysed separately data from 22 patients, who completed the survey both before and during the pandemic. Cases of depression and anxiety were defined as having a HADS subscale score of >= 8. Analysis was performed in R. Ninety-three patients completed the survey before the pandemic [49 5% female;mean (SD) age 42 (18) years] and 101 during the pandemic [38% female;mean (SD) age 52 (16) years;74% shielding]. Patient proportions across treatment groups did not differ before vs. during the pandemic (73 1% vs. 78 2% on biologics;P = 0 8). Depression, anxiety and suicidality were highly prevalent at both timepoints. However, there were no significant differences in depression [31% vs. 40%;adjusted odds ratio (aOR) 1 2, 95% confidence interval (CI) 0 6-2 5], anxiety (39% vs. 47 5%;aOR 1 7, 95% CI 0 8-3 5) or suicidal ideation prevalence (13% vs. 20%;aOR 2 19, 95% CI 0 8-5 9] before vs during the pandemic. During the pandemic, depression was not associated with living alone (P = 0 45) or shielding (P = 0 13). In the paired analysis, depression scores did not differ during compared with before the pandemic (QIDS-SR 9 4 x 5 8 vs. 8 8 x 6 1;P = 0 56). DLQI changes did not correlate with changes in QIDS-SR (r = 0 08, P = 0 7). At follow-up, three patients (14%) reported 12-month passive suicidal ideation;no patient reported 12- month active suicidality. Depression and the prevalence of anxiety are high in patients with psoriasis. Suicidal ideation rates appear to be higher than the rates in the general population during the COVID-19 pandemic. However, we did not observe a significant increase in the psychological burden or shielding of our patients during the pandemic compared with previous levels. Our findings are consistent with recent research on psoriasis-related quality of life during the COVID- 19 pandemic and may reflect population-specific resilience mechanisms. They also highlight the importance of continued monitoring of psychiatric comorbidity in this population, independently of acute stressors. Future research should address the long-term pandemic impact on patients.

Gastrointestinal Symptoms in Covid-19 Patients

Aim: Gastrointestinal (GI) symptoms have been reported with coronavirus disease (COVID-19), but our understanding of their clinical significance is limited and this can be a safety concern for surgeons as patients might present with GI symptoms only. Method(s): A prospectively maintained database of emergency patients was reviewed between 20/03/2020 and 20/04/2020 (Cohort A) and 05/01/2021-26/ 01/2021. (Cohort B) All of them had a positive Polymerase Chain Reaction (PCR) COVID-19 test. We evaluated the prevalence of GI symptoms and their association with the severity of COVID-19 and looked at the prevalence of symptoms in different ethnicities. Chi-squared test in R software environment was used to analyse the data. Result(s): Cohort A consisted of 189 patients (100 male) 14 had nausea, 18 vomiting, 39 diarrhoea and 9 abdominal pain. 17 had ITU admissions and 68 died. Cohort B consisted of 348 patients (185 male) 50 had nausea, 46 vomiting, diarrhoea 84 and 23 had abdominal pain. 30 had ITU admissions and 75 died. In this cohort the COVID-19 Alpha Variant was making up nearly 100% of cases. Nausea was more common in Cohort B 50/348 (P = 0.01641) There was no difference in vomiting (18/189 Cohort A P = 0.198898), diarrhoea (39/189 Cohort A, P = 0.3385) and abdominal pain (9/189 Cohort A P = 0.379). There was no difference in GI symptoms for the severe and non-severe cases in Cohort A (P = 0.150813) but they were more prevalent in the non-severe group of Cohort B (P = 0.008). There was no diifference between ethnic groups in terms of GI symptoms (Cohort A 35 Black patients,17 Asian, 102 White and 35 Other Ethnicities, Cohort B 40 Black, 33 Asian, 174 White and 101 Other Ethnicities). Conclusion(s): Acute GI symptoms associated with COVID-19 are highly prevalent and were seen more often in non-severe cases of Cohort B. The SARS-CoV- 2 Alpha Variant was endemic in our region and the UK vaccination programme was being rolled out at the time of our study. More research is required to establish the significance of these factors.

CAN YOU HEAR ME? A MEDICAL STUDENT-LED QUALITY IMPROVEMENT INITIATIVE FOR HOSPITALIZED PATIENTS WITH HEARING LOSS

In acute care settings hearing loss (HL) is associated with impaired patient-provider communication, increased length of stay, and increased mortality. COVID-19 has exacerbated this problem with the widespread use of masks and eye shields which muffle speech and prevent lip reading. Our 800-bed tertiary care medical center lacked a standardized approach to identify patients with HL and address communication barriers. Three first year medical students spearheaded the initiative as part of a health systems improvement curriculum with support from a faculty coach and a faculty researcher. From September 2020 to October 2021, the students met with stakeholders, leadership and champions and unit staff, identified the current state and completed a gap analysis through interviews, surveys, and direct observation. The pilot in May 2021 included two week-long PDSA cycles on one hospital unit to: 1) screen patients aged 65 and older using the validated 10-item HHIE-S questionnaire, 2) implement an education and awareness campaign with bedside signage, posters, and conferences and 3) provide a personal amplifier (purchased in bulk by the medical center) with verbal and written instructions. A total of 29 patients screened positive and were given personal amplifiers. Post-pilot interviews reported increased provider awareness and knowledge around best communication practices. Patients and staff reported limited amplifier use due to poor sound quality, small dials, poorly fitting ear buds and a short battery life. Based on these results the team recommended discontinuing the personal amplifiers and identifying other communication tools including higher quality personal amplifiers and speech to text applications.

Wake-Cough: cough spotting and cougher identification for personalised long-term cough monitoring

We present 'wake-cough', an application of wake-word spotting to coughs using a Resnet50 and the identification of coughers using i-vectors, for the purpose of a long-term, personalised cough monitoring system. Coughs, recorded in a quiet (73±5 dB) and noisy (34±17 dB) environment, were used to extract i-vectors, x-vectors and d-vectors, used as features to the classifiers. The system achieves 90.02% accuracy when using an MLP to discriminate between 51 coughers using 2-sec long cough segments in the noisy environment. When discriminating between 5 and 14 coughers using longer (100 sec) segments in the quiet environment, this accuracy improves to 99.78% and 98.39% respectively. Unlike speech, i-vectors outperform x-vectors and d-vectors in identifying coughers. These coughs were added as an extra class to the Google Speech Commands dataset and features were extracted by preserving the end-to-end time-domain information in a trigger phrase. The highest accuracy of 88.58% is achieved in spotting coughs among 35 other trigger phrases using a Resnet50. Thus, wake-cough represents a personalised, non-intrusive cough monitoring system, which is power-efficient as on-device wake-word detection can keep a smartphone-based monitoring device mostly dormant. This makes wake-cough extremely attractive in multi-bed ward environments to monitor patients' long-term recovery from lung ailments such as tuberculosis (TB) and COVID-19. © 2022 European Signal Processing Conference, EUSIPCO. All rights reserved.

Automatic Tuberculosis and COVID-19 cough classification using deep learning

We present a deep learning based automatic cough classifier which can discriminate tuberculosis (TB) coughs from COVID-19 coughs and healthy coughs. Both TB and COVID-19 are respiratory diseases, contagious, have cough as a predominant symptom and claim thousands of lives each year. The cough audio recordings were collected at both indoor and outdoor settings and also uploaded using smartphones from subjects around the globe, thus containing various levels of noise. This cough data include 1.68 hours of TB coughs, 18.54 minutes of COVID-19 coughs and 1.69 hours of healthy coughs from 47 TB patients, 229 COVID-19 patients and 1498 healthy patients and were used to train and evaluate a CNN, LSTM and Resnet50. These three deep architectures were also pre-trained on 2.14 hours of sneeze, 2.91 hours of speech and 2.79 hours of noise for improved performance. The class-imbalance in our dataset was addressed by using SMOTE data balancing technique and using performance metrics such as F1-score and AUC. Our study shows that the highest F1-scores of 0.9259 and 0.8631 have been achieved from a pre-trained Resnet50 for two-class (TB vs COVID-19) and three-class (TB vs COVID-19 vs healthy) cough classification tasks, respectively. The application of deep transfer learning has improved the classifiers' performance and makes them more robust as they generalise better over the cross-validation folds. Their performances exceed the TB triage test requirements set by the world health organisation (WHO). The features producing the best performance contain higher order of MFCCs suggesting that the differences between TB and COVID-19 coughs are not perceivable by the human ear. This type of cough audio classification is non-contact, cost-effective and can easily be deployed on a smartphone, thus it can be an excellent tool for both TB and COVID-19 screening. © 2022 IEEE.

Note: Home Location Detection from Mobile Phone Data: Evidence from Togo

Algorithms for home location inference from mobile phone data are frequently used to make high-stakes policy decisions, particularly when traditional sources of location data are unreliable or out of date. This paper documents analysis we performed in support of the government of Togo during the COVID-19 pandemic, using location information from mobile phone data to direct emergency humanitarian aid to individuals in specific geographic regions. This analysis, based on mobile phone records from millions of Togolese subscribers, highlights three main results. First, we show that a simple algorithm based on call frequencies performs reasonably well in identifying home locations, and may be suitable in contexts where machine learning methods are not feasible. Second, when machine learning algorithms can be trained with reliable and representative data, we find that they generally out-perform simpler frequency-based approaches. Third, we document considerable heterogeneity in the accuracy of home location inference algorithms across population subgroups, and discuss strategies to ensure that vulnerable mobile phone subscribers are not disadvantaged by home location inference algorithms. © 2022 Owner/Author.

Characterization of a dynamic self-replicating mammalian expression vector based on the circular ssDNA genome of beak and feather disease virus.

In vivo nucleic expression technologies using DNA or mRNA offer several advantages for recombinant gene expression. Their inherent ability to generate natively expressed recombinant proteins and antigens allows these technologies to mimic foreign gene expression without infection. Furthermore, foreign nucleic acid fragments have an inherent ability to act as natural immune adjuvants and stimulate innate pathogen- and DNA damage-associated receptors that are responsible for activating pathogen-associated molecular pattern (PAMP) and DNA damage-associated molecular pattern (DAMP) signalling pathways. This makes nucleic-acid-based expression technologies attractive for a wide range of vaccine and oncolytic immunotherapeutic uses. Recently, RNA vaccines have demonstrated their efficacy in generating strong humoral and cellular immune responses for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). DNA vaccines, which are more stable and easier to manufacture, generate similar immune responses to RNA, but typically exhibit lower immunogenicity. Here we report on a novel method of constructing self-amplifying DNA expression vectors that have the potential to amplify and enhance gene/antigen expression at a cellular level by increasing per cell gene copy numbers, boost genomic adjuvating effects and mitigate through replication many of the problems faced by non-replicating vectors such as degradation, methylation and gene silencing. These vectors employ a viral origin rolling circle replication cycle in mammalian host cells that amplifies the vector and gene of interest (GOI) copy number, maintaining themselves as nuclear episomes. We show that these vectors maintain persistently elevated GOI expression levels at the cellular level and induce morphological cellular alterations synonymous with increased cellular stress.

Full cycle audit on definitive management of biliary pancreatitis

Aim: To reaudit the practice of definitive management of gall stones pancreatitis in our trust for the period of 1st May-31st October and compare the result with previous one (1st June 2019-31st Dec 2019). Method: It was a retrospective collection of data of patients admitted to our trust with biliary pancreatitis. Electronic notes, PACS for US report, Electronic discharge summary and Operative notes analysed. Results: We identified 4 patients admitted with biliary pancreatitis during the re-audit period. US report was checked for confirmation of diagnosis of gall stones. The EDN was checked for date for Laparoscopic cholecystectomy. Unfortunately, none of them had their procedure time in 2 weeks' time of their diagnosis. The reason behind this was because of COVID-19 pandemic, we were backlogging with our elective list. All the patients eventually underwent their procedure, but not in 2 weeks' time as per the guidelines. All suitable patients had their cholecystectomy in a timely manner during first audit. None had it in timely manner during second audit. Conclusions: Early Laparoscopic cholecystectomy for simple gallstone pancreatitis prevents life threatening Pancreatitis and readmissions. The UK guidelines on management of pancreatitis issued by British society guidelines (BSG) states that all mild gall stones pancreatitis should have definitive management of lithiasis on the same admission or within 2 weeks (Recommendation B). In our practice, all our suitable patients during first audit had timely Laparoscopic cholecystectomy, however, no one had it in timely manner on the next audit for COVID-19 pandemic.

The Scleroderma Patient-centered Intervention Network Self-Management (SPIN-SELF) Program: protocol for a two-arm parallel partially nested randomized controlled feasibility trial with progression to full-scale trial.

BACKGROUND: Systemic sclerosis (scleroderma; SSc) is a rare autoimmune connective tissue disease. We completed an initial feasibility trial of an online self-administered version of the Scleroderma Patient-centered Intervention Network Self-Management (SPIN-SELF) Program using the cohort multiple randomized controlled trial (RCT) design. Due to low intervention offer uptake, we will conduct a new feasibility trial with progression to full-scale trial, using a two-arm parallel, partially nested RCT design. The SPIN-SELF Program has also been revised to include facilitator-led videoconference group sessions in addition to online material. We will test the group-based intervention delivery format, then evaluate the effect of the SPIN-SELF Program on disease management self-efficacy (primary) and patient activation, social appearance anxiety, and functional health outcomes (secondary). METHODS: This study is a feasibility trial with progression to full-scale RCT, pending meeting pre-defined criteria, of the SPIN-SELF Program. Participants will be recruited from the ongoing SPIN Cohort ( http://www.spinsclero.com/en/cohort ) and via social media and partner patient organizations. Eligible participants must have SSc and low to moderate disease management self-efficacy (Self-Efficacy for Managing Chronic Disease (SEMCD) Scale score ≤ 7.0). Participants will be randomized (1:1 allocation) to the group-based SPIN-SELF Program or usual care for 3 months. The primary outcome in the full-scale trial will be disease management self-efficacy based on SEMCD Scale scores at 3 months post-randomization. Secondary outcomes include SEMCD scores 6 months post-randomization plus patient activation, social appearance anxiety, and functional health outcomes at 3 and 6 months post-randomization. We will include 40 participants to assess feasibility. At the end of the feasibility portion, stoppage criteria will be used to determine if the trial procedures or SPIN-SELF Program need important modifications, thereby requiring a re-set for the full-scale trial. Otherwise, the full-scale RCT will proceed, and outcome data from the feasibility portion will be utilized in the full-scale trial. In the full-scale RCT, 524 participants will be recruited. DISCUSSION: The SPIN-SELF Program may improve disease management self-efficacy, patient activation, social appearance anxiety, and functional health outcomes in people with SSc. SPIN works with partner patient organizations around the world to disseminate its programs free-of-charge. TRIAL REGISTRATION: ClinicalTrials.gov NCT04246528 . Registered on 27 January 2020.

COVID-19 Presenting as Acute Icteric Hepatitis.

As the coronavirus pandemic continues to evolve, so does the understanding of different presentations of disease. In this case report, we describe a patient whose presentation of COVID-19 was with acute icteric hepatitis without respiratory symptoms. This is the first case in the literature to our knowledge to report jaundice as the initial presentation of disease and adds to just a handful of cases in the literature of acute hepatitis as the sole presentation of COVID-19. Additionally, despite severe hepatitis, the patient had a benign course of COVID-19 and did not require aggressive medical care; this strays from conventional paradigms that associate severity of COVID-19 with a degree of aminotransferase elevation. The purpose of this report is to make physicians aware of acute icteric hepatitis as a presentation of COVID-19 infection and to facilitate discussion and further research in the area of COVID-19-induced hepatitis.