Experiences with Flipped Classroom Methodology in US High School Chemistry Courses: Lessons Learned from Action Research Projects

Especially since the Covid-19 pandemic when teachers might have found or created videos for students to watch, flipped classroom methodology has interested many secondary-level chemistry teachers. However, as the secondary coauthor teachers here found, most of the research on the effectiveness of flipped classroom methodology has been performed at the collegiate level. To help fill this gap, six high school teachers from different schools present their research and experience with flipped classroom methodologies in their classes. Taken as a collective, their research, aligning with previous research, suggests that there likely will not be gains on exam scores or course grades for high school students when a classroom is "flipped”, but there are other positive reasons that flipped classroom methodology might be a useful tool in the secondary-level chemistry classroom. © 2023 American Chemical Society and Division of Chemical Education, Inc.

Experiences with Flipped Classroom Methodology in US High School Chemistry Courses: Lessons Learned from Action Research Projects

Especially since the Covid-19 pandemic when teachers might have found or created videos for students to watch, flipped classroom methodology has interested many secondary-level chemistry teachers. However, as the secondary coauthor teachers here found, most of the research on the effectiveness of flipped classroom methodology has been performed at the collegiate level. To help fill this gap, six high school teachers from different schools present their research and experience with flipped classroom methodologies in their classes. Taken as a collective, their research, aligning with previous research, suggests that there likely will not be gains on exam scores or course grades for high school students when a classroom is "flipped", but there are other positive reasons that flipped classroom methodology might be a useful tool in the secondary-level chemistry classroom.

Development and Evaluation of a Textanalytics Algorithm for Automated Application of the Bsr Covid-19 Shielding Criteria in Rheumatology Patients

Background/Aims In April 2020 the British Society for Rheumatology (BSR) issued a risk stratification guide to identify patients at the highest risk of COVID-19 requiring shielding. This guidance was based on patients' age, comorbidities, and immunosuppressive therapies - including biologics that are not captured in primary care records. This meant rheumatologists needed to manually review outpatient letters to score patients' risk. The process required considerable clinician time, with shielding decisions not always transparently communicated. Our aim was to develop an automated shielding algorithm by text-mining outpatient letter diagnoses and medications, reducing the need for future manual review. Methods Rheumatology outpatient letters from Salford Royal Hospital, a large UK tertiary hospital, were retrieved between 2013-2020. The two most recent letters for each patient were extracted, created before 01.04.2020 when BSR guidance was published. Free-text diagnoses were processed using Intelligent Medical Objects software1 (Concept Tagger), which utilised interface terminology for each condition mapped to a SNOMED-CT code. We developed the Medication Concept Recognition tool (MedCore Named Entity Recognition) to retrieve medications type, dose, duration and status (active/past) at the time of the letter. The medication status was established based on the heading where they appeared (e.g. past medications, current medications), but incorporated additional information such as medication stop dates. The age, diagnosis and medication variables were then combined to output the BSR shielding score. The algorithm's performance was calculated using clinical review as the gold standard. Results To allow for the comparison with manual decisions, we focused on all 895 patients who were reviewed clinically. 64 patients (7.1%) had not consented for their data to be used for research as part of the national opt-out scheme. After removing duplicates, 803 patients were used to run the algorithm. 11,558 free-text diagnoses were extracted and mapped to SNOMED CT, with 15,003 free-text medications (that included past, present and any planned treatment). The automated shielding algorithm demonstrated a sensitivity of 80.3% (95% CI: 74.7, 85.2%) and specificity of 92.2% (95% CI: 89.7, 94.2%). Positive likelihood ratio was 10.3 (95% CI: 7.7, 13.7), negative likelihood ratio was 0.21 (95% CI: 0.16, 0.28), F1 score was 0.81. False positive rate was 7.9%, whilst false negative rate was 19.7%. Further evaluation of false positives/negatives revealed clinician interpretation of BSR guidance and misclassification of medications status were important contributing factors. Conclusion An automated algorithm for risk stratification has several advantages including reducing clinician time for manual review to allow more time for direct care, improving efficiency and transparently communicating decisions based on individual risk. With further development, it has the potential to be adapted for future public health initiatives that requires prompt automated review of hospital outpatient letters.

Distinguishing Features of Mis-C to Other Paediatric Febrile Diseases in the Acute Setting

Background Multisystem inflammatory syndrome in children (MIS-C) presents with fever, shock, rash, abdominal pain and raised inflammatory markers, as well as common features of inflammatory childhood illnesses. In the acute setting, especially in countries where infectious diseases are common differential diagnoses, it is challenging to diagnose MIS-C. Therefore, data differentiating MIS-C from other inflammatory and/or febrile diseases at presentation is needed. Methods Prospective data was collected from children admitted to the Red Cross War Memorial Children's Hospital in Cape Town, South Africa from May 2020 to end November 2021 where MIS-C was part of their differential diagnoses. Clinical features on the day of admission were compared between children with confirmed MIS-C (MIS-C+) and those with alternate diagnoses (MIS-C-). Results In this time period, 60 children were MIS-C+ and 34 were MIS-C-. There was no significant difference in age (p = 0.321), sex (p = 0.525), ethnicity (p = 0.279), or in the frequency of comorbidities (p = 0.151) between the two groups. The presence of conjunctivitis (OR=8.12), rash (OR=8.67), tachycardia (OR=2.8) and oral mucositis (OR=3.75) was associated with MIS-C+ while abdominal pain and hypotension were not. MIS-C+ had statistically higher median C-reactive protein (CRP), pro-brain natriuretic protein (pro-BNP) and ferritin, and lower median lymphocyte count, platelet count and sodium levels than MISC-. Ferritin discriminated MIS-C+ well (AUC=0.86) with a 94% sensitivity and 60% specificity at a cut off of>195ng/l. Sodium had an AUC of 0.72, with a 70% sensitivity and 71% specificity at a cut off of<132.5 mmol/l. CRP did not distinguish MIS-C well (AUC=0.52) and although they had good AUC, platelet count and pro-BNP had cut off values in the normal range decreasing clinical utility. Conclusion We provide evidence for the use of accessible clinical and laboratory variables for the diagnosis of MIS-C in diverse settings. Implications These data will aid clinicians to do a rapid diagnosis (and ultimately treat earlier) of patients with MIS-C in the acute setting, especially those in under-resourced settings.

Estimation of incidence of MIS-C in Cape Town, South Africa

Background: Multisystem inflammatory syndrome is a severe manifestation of SARS-CoV-2 in children. The incidence of MIS-C after SARS-CoV-2 infection is poorly understood. There are very few cohorts describing MIS-C in Africa despite MIS-C being more common in Black children worldwide. Methods: A cohort of children with MIS-C and healthy children was recruited from May 2020 to May 2021 from the two main paediatric hospitals in Cape Town, South Africa. Clinical and demographic data were collected, and serum was tested for SARS-CoV-2 antibodies. The incidence of MIS-C was calculated using an estimation of population exposure from seroprevalence in the healthy group. Summary data, non-parametric comparisons and logistic regression analyses were performed. Results: Sixty-eight children with MIS-C were recruited with a median age of 7 years and 97 healthy children were recruited with a 30% seroprevalence. The estimated incidence of MIS-C was 22/100 000 SARS-COV-2 infections in children under 14 years old in the city at that time. Black children were over-represented in the MIS-C group (62% vs 37%, p = 0.002). The most common clinical features in MIS-C were fever (100%), tachycardia (98.5%), rash (85.3%), conjunctivitis (77.9%), abdominal pain (60.3%) and hypotension (60.3%). Median levels of haemoglobin, sodium, CRP, ferritin, cardiac (pro-BNP, trop-T) and coagulation markers (D-dimer and fibrinogen), neutrophil and white cell count were markedly deranged in MIS-C. Cardiac, pulmonary, central nervous and renal organ systems were involved in 71%, 29.4%, 27.9% and 27.9% respectively. Ninety-four point one per cent patient received intravenous immune globulin, 64.7% received methylprednisolone and 61.7% received both. ICU admission was required in 39.7% patient while 38.2% required inotropic support, 38.2% required oxygen therapy, 11.8% required invasive ventilation and 6% required peritoneal dialysis. The median hospital stay duration was 7 days with no deaths. Conclusion: The lack of reports from Southern Africa does not reflect a lack of cases of MIS-C. The clinical manifestations and outcomes of MIS-C in this region highlight the need for improved surveillance, reporting and data to inform diagnosis and treatment. Implications: To our knowledge, these are the first data on MIS-C in Africa. This shows that children in Africa are indeed presenting with MIS-C which will increase surveillance around the continent.

National Benchmark Study of Employment Equity among Multiply Marginalized Persons of Color with Disabilities during the COVID-19 Pandemic: A Bootstrap Approach

BACKGROUND: Research examining state vocational rehabilitation agency (SVRA) sponsored service patterns during the COVID-19 pandemic is needed to improve employment outcomes among multiply marginalized persons of color with disabilities (i.e., African Americans, Asian Americans, Native Americans or Alaska Natives, Latinx, and Native Hawaiians/Pacific Island¬ers). Scarce attention has been paid to examining outcome inequities in the crisis. OBJECTIVE: This study applied a stratified bootstrap data expansion approach to assess the relationship between race/ethnicity, gender, level of educational attainment at closure and em¬ployment outcomes among target group members. METHODS: National fiscal year (FY) 2019 Rehabilitation Services Administration (RSA)-911 case records (N =114,229) closed between January 20, 2020 (date of first reported COVID-19 infection in the U.S.) to June 30 2020 were extracted and re-sampled across multiple trials using bootstrap procedures to increase logistic regression model accuracy. RESULTS: The findings indicated that African Americans, Asian Americans and Native Ameri¬can or Alaska Natives were statistically significantly less likely to achieve successful employment than non-Latinx Whites. Success probabilities in the COVID-19 pandemic were 'poorest'for Na¬tive American or Alaska Native VR consumers followed by African Americans, Asian Americans, Latinx, non-Latinx Whites, and then Native Hawaiians/Pacific Islanders. African Americans and Native Americans or Alaska Natives were more often closed unsuccessful because they could not be located when compared to non-Latinx Whites. CONCLUSIONS: These findings call for new targeted SVRA service initiatives. © 2022 National Rehabilitation Association. All rights reserved.

COVID-19 Health and Rehabilitation Implications among Multiply Marginalized People of Color with Disabilities: A Scoping Review

The purpose of this scoping review was to examine the literature about Coro- navirus disease 2019 (COVID-19) and health and rehabilitation implications for persons of color, including those with multiple marginalized statuses (i.e., racial/ethnic minority and disability), and map out research gaps. Several themes emerged from this review that included disproportionate burdens of infections, hospitalizations and deaths;structural racism as a driver of inequity;diminished employment opportunities, and limited data on race and disability. The findings revealed the existence of serious evidence gaps relating to multiply marginalized people of color with disabilities within the COVID-19 context. A clear need exists for more research on COVID-19 outcomes disaggregated by disability and race so that the field has a fuller understanding of the impact of the pandemic on people of color with disabilities. Additionally, minority serving institutions (e.g., HBCUs and TCUs), as experts in addressing marginalized communities' needs, should play a leadership role in equity research. © 2022 National Rehabilitation Association. All rights reserved.

Investigating the clinical characteristics of paediatric COVID-19 in Cape Town, South Africa: Initial results from the University of Cape Town (UCT), Department of Paediatrics and Child Health, COVID-19 paediatric repository

Introduction: Studies show that children account for only 1-5% of diagnosed COVID-19 cases, they have milder disease than adults and deaths are extremely rare. The complete clinical picture of pediatric COVID-19 has not yet been fully reported or defined. Additionally, the South African pediatric population has unique clinical characteristics and risk implications and needs investigating. We aimed to characterize COVID-19 in Cape Town children. Methods: The UCT COVID-19 pediatric repository is a prospective cohort recruited via convenience sampling at 3 Western Cape Hospitals. All patients ≤ 18 years who test COVID-19 positive are eligible for inclusion in the study. Results: To date 227 participants, 56%(125/227) male with median age 2 years (IQR:0-6), have been enrolled. Only 28(12%) participants were in contact with a confirmed COVID-19 positive case, 67% of these, were first degree relatives, 28% second degree relatives and 6% health care workers. Comorbidities were present in 125(56%) participants. Of 32 recorded comorbidities, congenital heart disease (CHD), found in 7% of participants, ranked third. CHD subtypes included PDA (4), Tetralogy of Fallot (3), AVSD (2), Pulmonary atresia with VSD (2), truncus arteriosus (1), Coarctation of the Aorta (1), Congenital aortic valve stenosis (1), and ASD (1). Other cardiac comorbidities were, cardiomyopathy (2), primary pulmonary hypertension (1) and rhabdomyoma (1). On presentation 173 (76%) were symptomatic. Predominant symptoms included cough 40%, history of fever 36%, documented fever 34%, difficulty breathing 28%, and nausea or vomiting 20%. On examination, 65% had abnormal heart rates, 47% abnormal respiratory rates, 35% were in respiratory distress and 24% were hypoxic. Of the 227 patients, 169(74%) were admitted to hospital and 33 (15%) were admitted to ICU. In the ICU 79% of patients required non-invasive and 24% invasive ventilation, median length of ICU admission was 3 days (IQR:2-7.5). During admission 38(17%) patients developed COVID-19 complications: secondary infection 10%, sepsis 4%, MIS-C 2%, and myocarditis or new onset heart failure 1%) and 2(0.9%) died, including one patient with AVSD, who presented with severe pulmonary hypertension and acute heart failure post cardiac surgery. Conclusion: We present the initial findings of the UCT pediatric COVID-19 registry. We anticipate that these data will help to complete the clinical picture of COVID-19 in the South African pediatric population.

SARS-COV2 antibody phenotype and immune gene expression in MIS-C

Introduction: Multisystem Inflammatory Syndrome in Children (MIS-C) is a severe disease that affects a small proportion of children exposed to Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2). Differences in SARS-CoV-2 antibody responses and immune gene expression between SARS-CoV-2-infected children who develop MIS-C and those who do not may provide insight into the mechanism of MIS-C. Objectives: To determine the difference in SARS-CoV2 antibody responses and immune gene expression in children with MIS-C and healthy children with evidence of previous SARS-CoV2 infection. Methods: Healthy children presenting for elective surgery and those with MIS-C were recruited between 22 June 2020 and 5 November 2020 from a single paediatric hospital during the first wave of SARSCoV- 2 in the region. Clinical data, whole blood RNA and serum were collected. Titres of SARS-CoV-2 spike-specific antibody (SAb) and their capacity to perform neutralization, antibody-dependent cellular phagocytosis (ADCP) and antibody dependant cellular cytotoxicity (ADCC) were measured. Whole blood RNA gene expression was measured using multiplex Fluidigm quantitative Polymerase Chain Reaction (qPCR) with a panel of 84 immune genes. Principal component analysis was performed to assess for differences in gene expression. A linear regression model was developed with a forward stepwise model selection method to assess which genes associated with Creactive protein (CRP) in MIS-C after controlling for the neutrophil to lymphocyte ratio (NLR). Results: Twenty-three children with MIS-C and 25 healthy children were recruited. Nine healthy children had detectable SARS-CoV-2 serum antibodies (healthy exposed). No children had preceding clinical disease related to SARS-CoV-2 infection. Comparing children with MIS-C and healthy exposed children showed no difference in SAb binding responses (p=0.372) or ADCC (p=0.992). Increased neutralisation titre (p=0.084) and ADCP (p=0.086) in children with MIS-C was observed although was non-significant. Antibody function or titre did not change over time or with treatment in MIS-C. There was a clear distinction in immune gene expression between healthy children and those with MIS-C. Immune gene expression in MIS-C resolved to become indistinct from healthy children with time. Whole blood immune gene expression associated with an abundance of neutrophils in MIS-C. In a model that accounted for 66% of the variance in CRP (adjusted R2 = 0.66) the expression of IL27 accounted for 64% of the model effect (B=35;p<0.001) followed by NLR (15%, B=6.6, p=0.002) and the expression of MCP2 (11%, B=-14.59, p=0.008). Conclusion: Comparing children infected with SARS-COV-2 from the same time period and region with or without MIS-C provides unique mechanistic insight into the disease. A trend towards higher SAb titres and ADCP implies a distinct humoral immune response to SARSCOV- 2 in children with MIS-C, although further studies are required to validate this observation. The resolution of the abnormal immune gene expression in MIS-C implies a monophasic immune perturbation. The association of IL27 and MCP2 with CRP suggests that these may be important targets in future studies for possible pathogenicity and as potential biomarkers in MIS-C.

A rapid review and meta-analysis of the laboratory phenotype of multisystem inflammatory syndrome in children

Introduction: Laboratory features are included in the current case definitions of the multisystem inflammatory syndrome in children (MIS-C) associated with the severe acute respiratory syndrome coronavirus-2 (SARS-CoV2). Objectives: We reviewed the clinical laboratory test values reported in MIS-C, to better characterise the laboratory phenotype. Methods: A comprehensive search of the WHO COVID-19 database was conducted from January to November 2020. The median test values reported in children 0-19 years with MIS-C, were extracted for each laboratory variable reviewed. Random effects meta-analyses were performed and the quantile estimation method used to determine estimates of the pooled median for each variable. The risk of bias was assessed using the QUADAS-2 tool. Results: Twenty-two observational studies were included in the analyses N=831 children. The overall risk of bias was considered moderate with varying heterogeneity between the studies reviewed for each variable (I2 52.4 - 96.63%). The estimated pooled median values which were abnormal included CRP 188.12 mg/L (95% CI 158.54, 217.70), ESR 60.07 mm/hr (95% CI 49.88, 70.26), ferritin (587.63 ng/ml;95% CI (476.29, 698.97), pro-BNP 6927ng/ml (95% CI 794.52, 13061.13), D-dimer 3.03 ng/L (95% CI 2.41, 3.65), absolute neutrophil count 9.61x109L (95% CI 7.72, 11.50), absolute lymphocyte count 0.92 x109/L (95% CI 0.74, 1.10), platelet count 150.82 x109/L (95% CI 135.09, 145.07), albumin 28.89g/L (95% CI 25.56, 32.22) and sodium 132.67mmol/L (95% CI 131.44, 133.89). Limitations The analyses were limited by varying reporting methods and the use of different normal reference ranges across studies. Conclusion: Markers of inflammation, coagulopathy and cardiac dysfunction, were confirmed as important features of the laboratory phenotype of MIS-C. It is necessary however, to further compare the laboratory values of MIS-C to those with COVID-19 and other hyperinflammatory syndromes in children, to develop evidence-based diagnostic criteria.

MIS-C at two tertiary hospitals in Cape Town, South Africa: clinical phenotype and distinguishing features from similar acute inflammatory conditions

Introduction: Distinguishing Multisystem Inflammatory Syndrome in Children (MIS-C) associated with Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV2) from acute, pyrexial childhood illness can be challenging. We present a case series from two tertiary centres in Cape Town, South Africa and compare the clinical phenotype of MISC with mimicking systemic inflammatory disorders. Objectives: 1. Describe the clinical characteristics of children with MIS-C in the region. 2. Compare the clinical features of children with confirmed MIS-C to those who presented during the same period with suspected MIS-C and ultimately an alternative diagnosis of inflammatory or infective conditions (inflammatory controls). Methods: Children with MIS-C admitted to the Red Cross War Memorial Children's Hospital (RXH) and Tygerberg Hospital (TBH) between 22 June 2020 and 5 March 2021 were recruited. At RXH only, children with suspected MIS-C with an ultimate alternate diagnosis (inflammatory controls) were also recruited. Clinical data were collected. Results: During the time period, 70 children had confirmed MIS-C and 27 suspected MIS-C cases had an alternate diagnosis including typhoid, tuberculosis, sepsis and appendicitis among others. Sixty five percent of children with MIS-C had no SARS-CoV2 contact but all had evidence of SARS-CoV2 exposure by antibody (90%) or Polymerase Chain Reaction (PCR) tests (14%). There was no difference in age, sex or ethnic distribution between children with MIS-C and inflammatory controls (Table 1). The most common presenting features of MIS-C were fever (100%), tachycardia (99%), rash (86%), conjunctivitis (79%), and abdominal pain (60%). Compared to inflammatory controls, the presence of tachycardia, abdominal pain and conjunctivitis resulted in 96%;93% and 91% respectively increased odds of a diagnosis of MIS-C after controlling for all other presenting features. Compared to inflammatory controls, children with MIS-C had lower platelets, sodium and albumin and higher troponin-T and pro-brain natriuretic peptide (pro-BNP) (Table 1). The median minimum ejection fraction in MIS-C was lower than inflammatory controls (52% vs 63%, p=0.048). Ninety four percent of MIS-C patients received at least one dose of intravenous immunoglobulin (IVIG), 63% required methylprednisolone and 6% received IL-6 inhibition. Children with MIS-C were more commonly admitted to ICU compared to inflammatory controls (38% vs 12.5%, p=0.013) although there was no difference in mean hospital stay which was 8.2 days in MIS-C. There was no difference in requirement for inotropes (p=0.142) or ventilation (p=0.493). No children died. Conclusion: Distinguishing MIS-C from acute infectious or inflammatory causes of childhood fever may be challenging. The presence of conjunctivitis, tachycardia or abdominal pain associates with higher odds of MIS-C in this population. Differences in widely available blood tests like sodium, albumin and platelets may be useful to differentiate MIS-C in the acute setting.