Sexual Health Implications Associated with Psychotropic Medication Usage in Adolescents during the Covid-19 Pandemic: Analysis of a Federated Research Network

INTRODUCTION AND OBJECTIVE: Psychotropic medications have a significant impact on sexual health. Long-term usage is strongly associated with dyspareunia, decreased libido, hypogonadism and erectile dysfunction. We hypothesized that the prescription rates for psychotropic medications increased in adolescent patients during the COVID-19 pandemic because of the unprecedented stress levels on youth in isolation. Therefore, we evaluated the prescription rates of psychotropic medications as well as concurrent use of PDE5i in adolescent patients during the COVID-19 pandemic compared to the pre-pandemic era. METHOD(S): We utilized data generated from TriNetX Research Network to conduct a retrospective matched cohort study. Adolescent patients aged 10-19 presenting for outpatient evaluation were placed into two cohorts: 1) outpatient evaluation before and 2) during the COVID-19 pandemic. Patients with prior psychiatric diagnoses and those with prior use of psychotropic medications were excluded. The outcomes of interest were new prescriptions within 90 days of outpatient evaluation. Propensity score matching was performed using logistic regression to build cohorts of equal size. RESULT(S): A total of 1,612,283 adolescents pre-COVID-19 and 1,008,161 adolescents presenting during the COVID-19 pandemic for outpatient evaluations were identified. After propensity matching, a total of 1,005,408 adolescents were included in each cohort each withan average age of 14.7 +/- 2.84 and 52% female and 48% male. Prescribing of antipsychotics and benzodiazepines were more frequent during the pandemic for adolescents (RR: 1.58, 95% CI 1.01-2.2). However, they were less likely to receive antidepressants (Risk Ratio (RR): 0.6, 95% Confidence Interval (CI) 0.57-0.63), anxiolytics (RR: 0.78, 95% CI 0.75-0.81), stimulants (RR: 0.26, 95% CI 0.25-0.27), as well as mood stabilizers (RR: 0.44, 95% CI 0.39-0.49). Erectile dysfunction requiring oral PDE5i in this cohort was more frequent during the pandemic for adolescents (RR: 1.53, 95% CI 1.05-2.01). CONCLUSION(S): The rates of antipsychotic and benzodiazepine prescriptions increased during the COVID-19 global pandemic compared to preceding years. This coincided with a statistically significant increase in the prescription of PDE5i for erectile dysfunction. Adolescents may face an increased risk of sexual dysfunction as both their illness and the medications they are prescribed both have a positive association with sexual dysfunction. Clinicians must be cognizant of the fact that adolescents may face an increased risk of medication related sexual dysfunction.

SARS-CoV-2 SEROPREVALENCE AMONG UGANDAN BLOOD DONORS: 2019-2022

Background: COVID-19 in Africa was less severe with fewer reported cases, hospitalizations and deaths compared to other continents. However, the lack of adequate surveillance systems in Africa makes estimating the burden of infection challenging. Serosurveillance can aid in determining the frequency of infection within this population. This study is aimed to estimate SARS-CoV-2 seroprevalence, describe the SARS-CoV-2 antibody (Ab) levels, and examine associations of seroreactivity among Ugandan blood donors. Method(s): Samples were obtained from the Mirasol Evaluation of Reduction in Infections Trial (MERIT), a randomized, double blind, controlled clinical trial evaluating transfusion transmitted infections. MERIT blood donor samples (n=3,517) were collected from Kampala, Uganda between October 2019 to April 2022. Additional blood donor samples (n=1,876) were collected from around the country between November-December 2021. Samples were tested for Ab to SARS-CoV-2 nucleocapsid (N) and spike (S) using an electrochemiluminescence immunoassay assay (Meso Scale Diagnostics, Gaithersburg, MD) per manufacturer's protocol. Samples seroreactive to both N and S Ab were considered Ab positive to SARS-CoV-2. Seroprevalence among MERIT donors were estimated within each quarter. Factors associated with seroreactivity from November-December 2021 were assessed by chi-square test. Result(s): SARS-CoV-2 seroprevalence increased from < 2.0% in October 2019- June 2020 to 82.5% in January-April 2022. Three distinct peaks in seroreactivity were seen in October-November 2020, July-August 2021, and January-April 2022 (see Figure). Among seroreactive donors, median N Ab levels increased 9-fold and median S Ab 19-fold over the study period. In November-December 2021, SARS-CoV-2 seroprevalence was higher among donors from Kampala (58.8%) compared to more rural regions of Hoima (47.7%), Jinja (47.9%), and Masaka (54.4%;p=0.007);S seroprevalence was lower among HIV+ donors (58.8% vs. 84.9%;p=0.009). Conclusion(s): Blood donors in Uganda showed high prevalence of Ab to SARSCoV- 2 by March of 2022, indicating that the infection levels were similar to many other regions of the globe. Higher seroprevalence was observed in the capital compared to more rural areas in Uganda. Further, increasingly high antibody levels among seropositive donors may indicate repeat infections. The lower COVID-19 morbidity and mortality was not due to a lack of exposure of the virus, but other factors yet to be determined.

Feasibility and preliminary efficacy of structured programming and a parent intervention to mitigate accelerated summer BMI gain: a pilot study.

BACKGROUND: This study assessed the initial feasibility and preliminary efficacy of providing children a free summer day camp and a parent intervention to improve self-regulation and mitigate accelerated summer BMI gain. METHODS: This pilot 2x2 factorial randomized control trial used a mixed-methods design to evaluate providing children a free summer day camp (SCV), a parent intervention (PI), and the combination of these two strategies (SCV+PI) to mitigate accelerated summer body mass index (BMI) gain. Progression criteria for feasibility and efficacy were assessed to determine if a full-scale trial was warranted. Feasibility criteria included recruitment capability (≥80 participants recruited) retention (≥70% participants retained), compliance (≥80% of participants attending the summer program with children attending ≥60% of program days, and ≥80% of participants completing goal setting calls with ≥60% of weeks syncing their child's Fitbit), and treatment fidelity (≥80% of summer program days delivered for ≥9 h/day, and ≥80% of participant texts delivered). Efficacy criteria were assessed via achieving a clinically meaningful impact on zBMI (i.e., ≥0.15). Changes in BMI were estimated using intent-to-treat and post hoc dose-response analyses via multilevel mixed-effects regressions. RESULTS: For recruitment, capability and retention progression criteria were met with a total of 89 families participating and 24 participants randomized to the PI group, 21 randomized to the SCV group, 23 randomized to the SCV+PI group, and 21 randomized to the control. However, fidelity and compliance progression criteria were not achieved due to COVID-19 and lack of transportation. Progression criteria for efficacy was also not achieved as intent-to-treat analyses did not show changes in BMI gain that were clinically meaningful. Post hoc dose-response analyses showed that for each day (0 to 29) of summer programming children attended they gained -0.009 (95CI= -0.018, -0.001) less in BMI z score. CONCLUSIONS: Engagement in both the SCV and PI was not ideal due to COVID-19 and lack of transportation. Providing children with structured summer programming to mitigate accelerated summer BMI gain may be an effective strategy. However, because feasibility and efficacy progression criteria were not met, a larger trial is not warranted until further pilot work is completed to ensure children attend the programming. TRIAL REGISTRATION: The trial reported herein was prospectively registered at ClinicalTrials.gov. Trial #: NCT04608188.

Post-Traumatic Stress in Children and Adolescents during the COVID-19 Pandemic: A Meta-Analysis and Intervention Approaches to Ensure Mental Health and Well-Being

Background: Since the World Health Organization (WHO) declared the COVID-19 pandemic in March 2020, many measures have been taken to prevent the spread of the virus. Consequently, many minors have been confined to their homes and have had to subsequently adapt to countless protocol changes. These factors appear to have contributed to post-traumatic stress disorder (PTSD) in many children. Materials and Methods: The authors searched Medline through PubMed and other databases for studies published from 1 December 2019 to 31 December 2021 on the prevalence of PTSD in schoolchildren. The authors used a random-effects model to calculate the pooled prevalence of PTSD. Results: A total of six studies were included in this review. Our results show a pooled prevalence of PTSD of 14% in children and adolescents. Subgroup analyses identify a significantly higher prevalence of PTSD for studies conducted in China and a higher prevalence in boys. The prevalence of PTSD appeared independent of child age or the methodological rigor of the study. Conclusions: Our results suggest that a large number of children may be suffering from PTSD (post-traumatic stress disorder). Public health measures are thus needed to improve children's mental health during and after the pandemic, so that the suffering is mitigated to prevent long-lasting effects.

High Structure Renewable Assignments: A Design Study

We seek to guide design, development, and adoption of Renewable Assignments by testing ways learners can contribute to Open Educational Resources (OER). We design, test, and iterate four assignment structures to this end. Testing was completed in an upper-division undergraduate endocrinology course, taught emergency remote due to COVID-19. Using mixed methods: surveys, focus groups, and iterations, we assessed assignment structures and created design guidance for renewable assignments and open pedagogy. We find that in a remote course, these assignments were effective in advancing learning goals. Both students and teachers favored their inclusion in the course. Analysis revealed six design principles to maximize effectiveness of renewable assignments and courses. and empowering teachers and learners to contribute to open knowledge. These principles also provide insight to praxis related to theories of open pedagogy, scaffolding, peer interaction, and active learning.

Caring for the caregiver during COVID-19 suspended visitation

During the 4th surge of COVID-19, August to November 2021, visitation was suspended in a hospital system in North Georgia. The Compassionate Connections Call Center (CCCC) was created to alleviate staff stress and to manage calls and communication. The goal of the initiative was to reduce interruptions to patient care caused by the increased number of calls to the clinical units by patients, families, loved ones and personal caregivers. The CCCC managed all incoming calls and communicated with the patient’s primary nurse through a coordinated process which limited interruptions. By caring for the caregiver, the aim was to improve the workplace experience of the nurses. Ninety-seven volunteers from over 13 departments across the organization worked in the CCCC and managed 3200 calls. With an average call time of roughly three minutes, the center freed up approximately 160 hours daily for nurses who might otherwise have paused patient care to answer calls. In addition, a family liaison role was created to proactively provide updates to families. This team of forty-six Registered Nurses worked a total of 2925 hours proactively updating families and facilitating virtual visits. © The Author(s), 2022.

VALIDATION OF THE DIAGNOSTIC ACCURACY OF THE EPIC SEPSIS PREDICTION MODEL FOR DETECTION OF SEPSIS IN HOSPITALIZED PATIENTS

SESSION TITLE: Sepsis: Beyond 30cc/kg and Antibiotics SESSION TYPE: Rapid Fire Original Inv PRESENTED ON: 10/19/2022 11:15 am - 12:15 pm PURPOSE: The Sepsis Prediction Model (SPM) is a proprietary decision support tool created by Epic Systems. The basis of the SPM is a Predicting Sepsis Score (PSS) calculated from demographic, comorbidity, vitals, labs, medication, and procedural data. We assessed the diagnostic accuracy and timeliness of the PSS for sepsis as defined by Centers for Disease Control (CDC) Adult Sepsis Event (ASE) criteria. The performance of the PSS was compared to, Systemic Inflammatory Response Syndrome (SIRS), quick Sequential Organ Failure Assessment (qSOFA), and SOFA scores. METHODS: Retrospective review of 62,460 adults admitted to 4 Wake Forest Baptist Health System hospitals from June 1, 2019 through December 31, 2020 with PSS scores calculated every 15 minutes. A sepsis event was defined as receipt of 4 or more days of antimicrobials, blood cultures collected within 48 hours of initial antimicrobial administration, and at least one organ dysfunction. This definition of sepsis was modified to also include Covid-19 infection with organ dysfunction. Time zero was defined as time of first contact for the healthcare encounter. 30-day readmissions, facility transfers, and deaths in the Emergency Department were excluded. RESULTS: The prevalence of sepsis in the sample was 4.5%. The optimal PSS threshold based on Youden’s J statistic was a score of 8 (sensitivity 0.72, specificity 0.74, Youden’s J 0.46). SIRS (sensitivity 0.90, specificity 0.42), qSOFA (sensitivity 0.64, specificity 0.69), and SOFA (sensitivity 0.89, specificity 0.43) had a Youden’s J statistic for sepsis of 0.32, 0.33, and 0.32, respectively. At a PSS score of ≥ 8, median time to score positivity among those who reached that score (28.4% of sample) was 217 minutes (IQR 74-1477 minutes). For SIRS, qSOFA and SOFA, median time to score positivity was 54 minutes (IQR 24-456), 360 minutes (IQR 53-1593) and 107 minutes (IQR 39-474), respectively. CONCLUSIONS: Discrimination of the PSS for detection of sepsis was highest at a threshold score of 8. Overall, the PSS discriminated better than SIRS, qSOFA and SOFA. Positive SIRS and SOFA scores occurred at an earlier time-point than PSS score. The time to positivity appears to limit the tool’s best expected performance to improve time to initial antimicrobial and compliance with the 3-hour sepsis bundle. CLINICAL IMPLICATIONS: Clinical application of the Epic SPM to improve adherence with sepsis treatment goals is constrained by time to positive screen as compared to other screening tools. DISCLOSURES: No relevant relationships by Alain Bertoni No relevant relationships by Kristin Lenoir No relevant relationships by Beverly Levine No relevant relationships by Morgana Mongraw-Chaffin No relevant relationships by Adam Schertz Stock Ownership Interest relationship with Johnson & Johnson Please note: years Added 04/15/2022 by Karl Thomas, value=Ownership interest stock ownership relationship with Gilead Sciences Please note: years Added 04/15/2022 by Karl Thomas, value=Ownership Stock ownership interest relationship with Bristol-Myers Squibb Please note: years Added 04/15/2022 by Karl Thomas, value=Ownership interest Stock Ownership Interest relationship with Pfizer Please note: years Added 04/15/2022 by Karl Thomas, value=Ownership interest Stock Ownership Interest relationship with Doximity Please note: 1 year Added 04/15/2022 by Karl Thomas, value=Ownership interest No relevant relationships by Brian Wells No relevant relationships by Jack White

Low Toxicity and Excellent Cosmesis with Highly Conformal Accelerated Partial Breast Irradiation Delivered Either Twice Daily or Every Other Day

Two landmark randomized controlled trials (RCT) of external beam accelerated partial breast irradiation (EB-APBI) using 38.5 Gy/10 fractions (F) BID demonstrated excellent cancer control outcomes in appropriately selected patients but conflicting results regarding cosmesis. A recent RCT reported high rates of acceptable cosmesis using 30 Gy/5F QOD, making the most appropriate schedule for EB-APBI unclear. We utilized the BID regimen largely until the COVID-19 pandemic with strict contouring, dosimetric, and planning guidelines for gross/clinical/planning target volumes (GTV/CTV/PTV) and organs-at-risk (OAR). We report our experience with BID and QOD EB-APBI with a hypothesis that our treatment planning approach would result in acceptable acute toxicity and cosmesis. We identified patients that received EB-APBI from 4/2017 through 12/2021. Clinical, pathologic, acute toxicity, cosmesis and dosimetric data for the lumpectomy (Lump) GTV/CTV/PTV and key OARs (ipsilateral breast [IB V50%, V80% and V100% of the Rx dose] heart (mean dose, V5% Rx dose;V3 Gy], ipsilateral lung [IL V30% Rx dose] and mean total lung dose [TLD]) were collected. Cosmesis was physician-reported using the 4-point NRG Oncology/RTOG Global Cosmetic Score (GCS): Excellent (E)/Good (G)/Fair (F)/Poor (P). We report descriptive statistics to summarize our results. 245 patients were included with median follow-up 19 months (IQR, 9-30 months): median age, 66 y (IQR, 59-71 y);51% left-sided;82% invasive;100% invasive tumors HR+/HER2-;95% of DCIS HR+;median invasive tumor size 9.5 mm (IQR, 6-13 mm) and DCIS size 8mm (IQR, 4-12 mm);96% nodal surgery in invasive disease. Fractionation was BID in 55%, QOD in 45%. 3DCRT was used in 88% with median 6 fields (IQR, 5-7) and 96% were treated prone. Median Lump PTV eval volume was 176 mL and median breast volume 1335 mL resulting in median breast V50%Rx Dose=40.3% (IQR, 34.5-45.8%) and median breast V100=15.6% (IQR, 10.2-18.6%). Lump PTV coverage was high (median V95=100%). The mean heart dose was 35 cGy (IQR, 15-59 cGy), heart V5%=1.1% (IQR, 0-8.1%), and median heart V3Gy=0% (0-0.5%). The IL V30% (median 0%, IQR 0-0.4%) and TLD (median 49 cGy, IQR 26-93.1 cGy) were also low. The majority of patient had no acute toxicity (55% grade 0 dermatitis;57% grade 0 fatigue;97% grade 0 pruritis). The rate of E/G cosmesis was 97.1% (N=238) and F/P 2.9% (N=7). In patients with at least 2 years follow-up, rates were 96% E/G (N=95) and 4% F/P (N=4). The IB V100 was marginally associated with increased odds of F/P cosmesis (OR=1.18, 95% CI 0.99-1.42, p=0.07). With multiple-field 3DCRT in the prone position, EB-APBI can be delivered with low toxicity and great cosmetic results with BID or QOD treatment. Given the low rate of F/P cosmesis, longer follow-up is needed to confirm stability of these results and to help identify optimal dose-volume parameters to minimize the rate of F/P cosmesis. [ FROM AUTHOR] Copyright of International Journal of Radiation Oncology, Biology, Physics is the property of Pergamon Press - An Imprint of Elsevier Science and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use. This may be abridged. No warranty is given about the accuracy of the copy. Users should refer to the original published version of the material for the full . (Copyright applies to all s.)

The impact of COVID-19 on the specificity of d-dimer for pulmonary embolism

Study Objective: D-dimer utility in diagnosing pulmonary embolism (PE) in the setting of COVID-19 has not been clearly established. Patients presenting with COVID-19 are screened for disease severity with d-dimer. The primary outcome of this study was to evaluate the test characteristics of d-dimer assay for the exclusion of PE in patients with COVID-19 in both the academic and community setting.

Papers Please-Predictive Factors of National and International Attitudes Toward Immunity and Vaccination Passports: Online Representative Surveys

Background: In response to the COVID-19 pandemic, countries are introducing digital passports that allow citizens to return to normal activities if they were previously infected with (immunity passport) or vaccinated against (vaccination passport) SARS-CoV-2. To be effective, policy decision-makers must know whether these passports will be widely accepted by the public and under what conditions. This study focuses attention on immunity passports, as these may prove useful in countries both with and without an existing COVID-19 vaccination program;however, our general findings also extend to vaccination passports.Objective: We aimed to assess attitudes toward the introduction of immunity passports in six countries, and determine whatMethods: We collected 13,678 participants through online representative sampling across six countries-Australia, Japan, Taiwan, Germany, Spain, and the United Kingdom-during April to May of the 2020 COVID-19 pandemic, and assessed attitudes and support for the introduction of immunity passports.Results: Immunity passport support was moderate to low, being the highest in Germany (775/1507 participants, 51.43%) and the United Kingdom (759/1484, 51.15%);followed by Taiwan (2841/5989, 47.44%), Australia (963/2086, 46.16%), and Spain (693/1491, 46.48%);and was the lowest in Japan (241/1081, 22.94%). Bayesian generalized linear mixed effects modeling was used to assess predictive factors for immunity passport support across countries. International results showed neoliberal worldviews (odds ratio [OR] 1.17, 95% CI 1.13-1.22), personal concern (OR 1.07, 95% CI 1.00-1.16), perceived virus severity (OR 1.07, 95% CI 1.01-1.14), the fairness of immunity passports (OR 2.51, 95% CI 2.36-2.66), liking immunity passports (OR 2.77, 95% CI 2.61-2.94), and a willingness to become infected to gain an immunity passport (OR 1.6, 95% CI 1.51-1.68) were all predictive 0.61, 95% CI 0.57-0.65), and risk of harm to society (OR 0.71, 95% CI 0.67-0.76) predicted a decrease in support for immunity

SYMPTOM STATUS AND POSTAL KIT RETURN RATES OF INDIVIDUALS ACCESSING AN ONLINE SEXUALLY TRANSMITTED INFECTION (STI) TESTING SERVICE

Background Online sexual health services (e-services) are being increasingly used for STI testing. Reduced sexual health clinic capacity due to the Covid-19 pandemic prompted our regional e-service to widen eligibility and enable individuals with mild symptoms to access our service. Prior to placing a kit order, information was shown to all symptomatic service users, advising them of the benefits of attending a sexual health clinic and/or to attend a clinic if symptoms persist/worsen. Method A retrospective analysis was performed of service users that ordered a testing kit between March 2020, and December 2021. Kit return rates were compared according to symptom status. Results Of 888,619 kit orders 163,023 (18.3%) came from symptomatic users. The most common symptom reported was vaginal discharge (41.1%), followed by dysuria/frequency (18.4%) and itching (13.8%). The kit return rate among asymptomatic service users was significantly higher (79.3%) compared to symptomatic users (74.3%) (X2 6.04. p =0.01401). The highest return rates were seen among individuals with itching (75.8%), dysuria/frequency (75.7%) and vaginal discharge (74.6%). The lowest return rate was seen by individuals with genital lumps (71.2%). Discussion Significantly fewer kits were returned by symptomatic e-service users compared to asymptomatics. It is plausible the e-service advisory information deterred some users from returning kits, encouraging them to instead test at a clinic. However, many users opted to complete testing online or perhaps did so because of difficulty accessing a sexual health clinic. Further work is needed to explore the preferred modality of testing provider and the suitability of online services for symptomatic individuals.

TRANSPLANT-ASSOCIATED THROMBOTIC MICROANGIOPATHY SUCCESSFULLY TREATED WITH RAVULIZUMAB

Background: Transplant-associated thrombotic microangiopathy (TA-TMA) is an increasingly recognized complication of hematopoietic stem cell therapy (HSCT) with incidence rates ranging from 10-35%. The predominant mechanism leading to TA-TMA is endothelial cell damage leading to complement dysregulation and microvascular hemolysis. Complement dysregulation is particularly important in the pathophysiology of TA-TMA as initial trials have shown response to complement blockade using eculizumab, a humanized monoclonal antibody targeting the terminal complement pathway. Ravulizumab is a longer acting monoclonal antibody with the same target as eculizumab that is increasingly used for treatment of atypical hemolytic uremic syndrome. Herein, we describe the case of an African American female with relapsed/refractory infantile B-cell acute lymphoblastic leukemia (B-ALL) who underwent 10/10 HLA-matched sibling donor allogeneic transplant (conditioning: busulfan/fludarabine/thiotepa;GVHD prophylaxis: tacrolimus/methotrexate) who developed TA-TMA marked by pericardial effusion, elevated LDH, proteinuria, hypertension, thrombocytopenia, anemia, and evidence of microangiopathy. Upon diagnosis, as ravulizumab was on formulary and readily available unlike eculizumab, she was treated with ravulizumab instead of eculizumab. Objectives: To describe the therapeutic response to ravulizumab in one patient diagnosed with TA-TMA. Design/Method: A retrospective chart review was performed regarding this patient's ravulizumab treatment course, and direct discussions were had with the patient's care team. Results: Ravulizumab (loading dose of 600 mg followed 2 weeks later by maintenance dosing of 600 mg every 4 weeks) was administered. Pre-treatment CH50 was >75 U/mL (range: 30-75 U/mL) with sC5b9 and C3 complement levels at the upper limit of normal at 220 ng/mL (range: ≤244 ng/mL) and 143 mg/dL (range: 72-164 mg/dL), respectively. Clinical normalization of the patient's TA-TMA was achieved two weeks after loading dose administration with normalization of LDH and blood pressure values, improved proteinuria, decreased transfusion requirements, absence of schistocytes on peripheral smear, and complete resolution of pericardial effusion. A total of 5 maintenance doses of ravulizumab were administered approximately every 4 weeks with CH50 ranging <3-33 U/mL during this time period. Five maintenance doses were administered as the optimal duration was unknown and the patient's TA-TMA treatment course was complicated by COVID-19 infection, for which there was concern could lead to TA-TMA reactivation (which did not occur). The ravulizumab was well tolerated throughout with amoxicillin used for meningococcal prophylaxis. Conclusion: While studies evaluating ravulizumab for treatment of TA-TMA are ongoing, ravulizumab successfully led to complement blockade and clinical improvement in this patient with TA-TMA.

Understanding the Relationship Between the Emergency Department Built Environment and Physician Burnout Through High Fidelity Virtual Reality Modeling

Study Objectives: To understand how the emergency department built environment contributes to physician burnout. Methods: We conducted semi-structured interviews of attending physicians who work regularly at the study institution, an urban ED, Level 1 Trauma Center with an annual census of 85, 000 and an EM residency program. Physicians were first asked about overall burnout followed by questions relating the physical environment to burnout. Subjects participated in a virtual reality (VR) simulation of the study ED. In the VR simulation, subjects placed virtual “sticky notes” to describe elements of the environment that contributed to or relieved burnout. Physicians also completed occupant comfort surveys to measure their overall satisfaction with the built environment for three different ED spaces. The surveys contained prompts for 6 categories: acoustics, air quality, cleanliness and maintenance, lighting, layout and furnishings, temperature (photo). A modified grounded theory approach was used to analyze interview transcripts, VR collected virtual memos and surveys. Results: 19 emergency physicians were enrolled (68% male, 42% early-, 42% mid-, 16% late-career) Average Maslach Burnout Inventory scores were 2.8 for emotional exhaustion, 2.4 for depersonalization and 4.8 for personal accomplishment. Sources of overall ED burnout were most commonly attributed to to ED volume, crowding, lack of resources, lack of institutional support, provider metrics, difficult patients, medico-legal concerns, worsening job market and effects of COVID-19. For the main study question, 71 themes were coded over 6 built environment domains and 25 themes related to impact and burnout. Of the 6 environmental domains, layout, cleanliness and acoustics were more commonly associated with burnout compared to air quality, lighting and temperature. An internal waiting room was the strongest contributor to physician burnout due to the close proximity to unassigned (waiting) patients associated with interruptions, distractions and concern for provider safety which contributed to emotional exhaustion and depersonalization. Increased distance to patient rooms was connected with a sense of depersonalization. Clutter, non-useful displays, poor organization and equipment issues were frequently noted and connected to a sense of disorganization and decreased personal accomplishment. Additionally, poor visualization of patients and monitors from physician workstations contributed to decreased situational awareness, anxiety, lack of provider safety and decreased personal accomplishment. Other frequently cited components included lack of visual/acoustical privacy in hallways, patient proximity to physician workstations associated with patient discomfort, medico-legal concerns, emotional exhaustion and depersonalization. 100% of the physicians agreed or strongly agreed that the VR simulation was helpful to elicit memories and reflection about the built environment. Conclusion: The study reflects associations between the ED built environment and components of physician burnout. Interventions aimed at balancing distance to patients (unassigned and assigned), reducing clutter and disorganization, balancing the acoustical environment and improving patient comfort and privacy may improve provider wellness. [Formula presented]

The patient experience of telehealth access and clinical encounters in Australian health care during COVID-19: implications for enhancing integrated care

Purpose: Telehealth consultations are likely to continue while living with COVID-19 and the risk of other pandemics. Greater understanding of patient perceptions is important in order to inform future integrated care models involving telehealth. Design/methodology/approach: An interpretative qualitative study. Fifteen, in-depth qualitative interviews were conducted with diverse range of community dwelling patients who attended outpatient clinics at The John Hunter Hospital, Newcastle. Data were analysed using an inductive thematic approach. Findings: Key themes were identified: (1) telehealth is valuable in a pandemic;(2) telehealth accessibility can be challenging;(3) there are variations in care experiences, especially when visual feedback is lacking;(4) telehealth for acute and complex care needs may lead to gaps and (5) considerations towards the future of telehealth, beyond a pandemic. Research limitations/implications: There is a shortfall in evidence of the patient experience of integrated care within a telehealth framework. The results provided practical insights into how telehealth services can play a greater role in integrated care. Practical implications: Apart from the need for affordable access to high-speed data for basic Internet access, the author posit the need for patient and clinician training towards promoting communication that is underpinned by choice, trust and shared decision-making. Originality/value: Telehealth is important towards keeping patients safe during COVID-19. Key findings extend knowledge of the practical implications need to promote integrated telehealth systems. While there is a benefit in extending telehealth to more preventative activities, there is also a need for greater service coordination and sharing of information between treating clinicians. Overall the results highlight telehealth consultations to be an effective means of treating well-known conditions and for follow-up rather than for acute conditions. © 2021, Emerald Publishing Limited.

Emergency Politics After Globalization

Exceptional times call for exceptional measures-this formula is all too familiar in the domestic setting. Governments have often played loose with their state's constitution in the name of warding off an urgent threat. But after decades of increasing interconnectedness and emerging transnational governance, today one sees new forms of emergency politics that are cross-border in range. From the European Union to the World Health Organization, from supranational institutions to state governments acting in concert, the logic of emergency is embraced in international contexts, with Covid-19 the latest occasion. This Forum offers an entry-point into this emerging phenomenon. Taking as its point of departure two recent books, it examines the origins, forms, effects and normative stakes of emergency politics beyond the state. Among the matters discussed are the concept of emergency politics, the historical context of its contemporary forms, the patterns of decision-making associated with it, the implications for the legitimacy of transnational institutions, and the constitutional and political ways in which it might be contained. Transnational emergency politics seems likely to remain a central feature of the coming years, and our aim is to further its study in international relations.

Drug Combinations as a First Line of Defense against Coronaviruses and Other Emerging Viruses

The world was unprepared for coronavirus disease 2019 (COVID-19) and remains ill-equipped for future pandemics. While unprecedented strides have been made developing vaccines and treatments for COVID-19, there remains a need for highly effective and widely available regimens for ambulatory use for novel coronaviruses and other viral pathogens. We posit that a priority is to develop pan-family drug cocktails to enhance potency, limit toxicity, and avoid drug resistance. We urge cocktail development for all viruses with pandemic potential both in the short term (<1 to 2 years) and longer term with pairs of drugs in advanced clinical testing or repurposed agents approved for other indications. While significant efforts were launched against severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), in vitro and in the clinic, many studies employed solo drugs and had disappointing results. Here, we review drug combination studies against SARS-CoV-2 and other viruses and introduce a model-driven approach to assess drug pairs with the highest likelihood of clinical efficacy. Where component agents lack sufficient potency, we advocate for synergistic combinations to achieve therapeutic levels. We also discuss issues that stymied therapeutic progress against COVID-19, including testing of agents with low likelihood of efficacy late in clinical disease and lack of focus on developing virologic surrogate endpoints. There is a need to expedite efficient clinical trials testing drug combinations that could be taken at home by recently infected individuals and exposed contacts as early as possible during the next pandemic, whether caused by a coronavirus or another viral pathogen. The approach herein represents a proactive plan for global viral pandemic preparedness.