Civil society engagement in food systems governance in Canada: experiences, gaps, and possibilities

Civil society organizations (CSOs) commonly experience food systems governance as imposed by governments from the top down and as unduly influenced by a small group of private sector actors that hold disproportionate power. This uneven influence significantly impacts the activities and relationships that determine the nature and orientation of food systems. In contrast, some CSOs have sought to establish participatory governance structures that are more democratic, accessible, collaborative, and rooted in social and environmental justice. Our research seeks to better understand the experiences of CSOs across the food systems governance landscape and critically analyze the successes, challenges, and future opportunities for establishing collaborative governance processes with the goal of building healthier, sustainable, and more equitable food systems. This paper presents findings from a survey of CSOs in Canada to identify who is involved in this work, key policy priorities, and opportunities and limitations experienced. Following the survey, we conducted interviews with a broad cross-section of CSO representatives to deepen our understanding of experiences engaging with food systems governance. Our findings suggest that what food systems governance is, how it is experienced, and what more participatory structures might look like are part of an emergent and contested debate. We argue for increased scholarly attention to the ways that proponents of place-based initiatives engage in participatory approaches to food systems governance, examining both current and future possibilities. We conclude by identifying five key gaps in food systems governance that require additional focus and study: (1) Describing the myriad meanings of participatory food systems governance;(2) Learning from food movement histories;(3) Deepening meaningful Indigenous-settler relationships;(4) Addressing food systems labor issues;and (5) Considering participatory food systems governance in the context of COVID-19.

TEAM TEACHING THROUGH THE VOICES OF TEACHERS AND STUDENTS IN ELT PROGRAMS BEFORE, DURING COVID-19, AND BEYOND

This chapter explores the impact of team teaching in a Bachelor of Arts in English Language Teaching (ELT) and Master of Arts in Applied Linguistics in English Language Teaching (ELT) at a Mexican public university during the beginnings of COVID-19 in 2020. For several years, team teaching has been a practice which has been used across educational levels for different purposes and, more specifically, it has become an essential component of curricula in higher education for great student achievement. Using qualitative research, we examined the perspectives of teacher educators who delivered classes using a team-teaching model before and during COVID-19, as well as the students who experienced these classes. The data from these two groups were gathered using digital questionnaires. The results present the pros and cons of team teaching from the perspectives of both teacher educators and students, as well as the challenges of team teaching. Based on our findings, advice is offered for teacher educators, teachers, administrators, program coordinators, and course designers regarding what can be helpful in teacher preparation. © 2023 Taylor and Francis.

Smart textiles for personal protection equipment (PPE)

Before Covid-19 and up to January 2020, the majority of facemasks, in addition to most other PPE items such as surgical gowns, medical scrubs, caps shoe covers, and disposable bedding were treated as commodity textiles and made in Asia, and most of them in China. All of them are single-use products based on synthetic fibres derived from petrochemicals, primarily polypropylene. This resulted in a 15,000-ton mountain of waste being created every 24h - most of which at present has to be incinerated. This does not even start to touch the huge amount of consumer facemasks which are now suddenly required, having been made compulsory for many activities and situations in many countries. This is the issue which now needs to be addressed at the fibre and fabric level - as well as with new end-of-life solutions - for items of PPE to become truly smart products. © 2023 Elsevier Ltd. All rights reserved.

The force of nature: The semiotic foregrounding of nature in post-lockdown tourist place branding in rural Alsace

In one way or another, tourism often sits at the heart of place branding. Transformations of tourism induced by the ongoing Covid-19 pandemic have led to shifts in tourist demand and target markets, thus provoking changes in tourist place branding. In this article, I explore these changes from a sociolinguistic point of view by examining the ways in which a rural tourist destination in Alsace (France) mobilises language and discourse to adapt its tourist place branding strategy in response to rising demand for nature tourism. First, using data gathered during ethnographic fieldwork undertaken following the easing of lockdown restrictions, I show how ‘nature' is positioned as a central trope in defining the essential characteristics of the destination, its population, and the activities that can be undertaken there. Second, I look at how this positioning contributes to the elaboration of a coherent destination brand whilst also shaping tourist experiences and thus tourist, geographical, and spatial imaginaries. Finally, I explore the dynamics of commodification that underpin this foregrounding of nature in the (re)framing of people and place. © 2023, EQUINOX PUBLISHING.

Human induced pluripotent stem cell-derived alveolar type 2 cells mature at air-liquid interface and respond to airborne stimuli

Human alveolar type II cells (AT2s) are progenitors of the alveolar epithelium and are among the pulmonary cells that are directly exposed to inhaled stimuli. Primary human AT2s can be cultured in three-dimensional alveolospheres, but are difficult to culture in the physiologically relevant air-liquid interface (ALI) format. Human induced pluripotent stem cells (iPSCs) can be directed to differentiate to iPSC-derived AT2s (iAT2s) in alveolospheres, where they transcriptomically resemble fetal lung. Here we report the successful adaptation of iAT2s to ALI culture, which promotes their maturation and permits exposure to inhaled stimuli. We transcriptomically profile iAT2s cultured at ALI and find that they mature as they downregulate cell cycle-associated transcripts. We then evaluate the extent of iAT2 maturation at ALI within the developmental context by comparison to primary AT2s. We find that iAT2s at ALI are more similar to primary AT2s than iAT2s cultured as spheres, and that differences are driven by primary AT2s' response to immune stimuli. We then test the capacity of iAT2s to respond to immune stimuli by infecting with SARSCoV-2. We find that iAT2s mount an epithelial-intrinsic interferon and inflammatory response to SARS-CoV-2 infection, and can serve as a platform for testing antiviral therapeutics. Finally, we demonstrate that iAT2s at ALI respond to cigarette smoke and electronic cigarette vapor, enabling the direct comparison of these common inhaled stimuli. Overall, we describe a novel disease modeling platform that will enable exploration of gene-environment interactions unique to inhaled exposures of the alveolar epithelium.

Modernizing Pressure Injury Risk Assessment in the ICU in the COVID Era: Ensemble Super-Learning and Explainable AI

Objectives: Hospital-acquired pressure injuries (HAPrI) are areas of injury to the skin and/or underlying tissues. Risk stratification is essential for guiding prevention in the ICU, but current risk assessment tools require labor-intensive input. This motivates a tactical, parsimonious, and automatic risk profiling algorithm, that can be based on readily available clinical measures (e.g., COVID status, race, Medicare/Medicaid status). Additionally, International Pressure Injury Prevention guidelines call for the development of machine learning-based risk assessment algorithms that are clinician-interpretable and context-informed. Method(s): Adult patients admitted to one of two ICUs between April 2020, and April 2021 were eligible for inclusion. Discrete and ensemble super-learning models, adjusting for class imbalance, were created from a rich library of candidate base learners. For explainability, SHAP (SHapley Additive exPlanations) global and local values were derived to help explain variable average marginal contributions (across all permutations) to the model. An iteration of clinical expert review was performed with the SHAP values, and simulations of patient profiles and results were used to reformat and re-weight predictor variables. All analysis was run in open Python (version 3.7), and code/results will be made available via a GitHub page. Result(s): The final sample consisted of 1,911 patients (removing 9 with missing pressure injury status). Hospital-acquired pressure injuries (defined as stage 2, or worse) occurred in 18.5% of the sample (n=354). We achieved the best overall performance on the testing data with a stacked ensemble using three base models: random forest (rf), gradient boosted machine (gbm), and neural network (NN) (Performance on 20% holdout: Accuracy: 81%;AUC: 0.77;AUCPR: 0.53). Conclusion(s): Prediction engineering should be done in collaboration with clinical experts to optimize tactical implementation to both optimize performance, with minimal interruption to workflow. XAI enhanced adoption of the experts' advice based on the selected model features. Copyright © 2022

Real-world impact of utilization management to prevent off-label use of ivermectin for COVID-19

BACKGROUND: Ivermectin gained significant traction in public discourse in 2021, based on its perceived potential to treat or prevent COVID-19. As a Google search term, "ivermectin" reached peak popularity between August 29, 2021 to September 4, 2021. Additionally, research presented at AMCP Annual 2022 identified increased utilization in 2021 of off-label ivermectin use for treatment and prevention of COVID-19. Considering its popularity and the fact that ivermectin was never FDA-approved or authorized for emergency use for prevention or treatment of COVID-19, RealRx analyzed utilization trends in August 2021. OBJECTIVE(S): To evaluate the impact of utilization management (UM) in preventing off-label ivermectin 3 mg tablet use for COVID-19. Secondary objective was to estimate pharmacy cost avoided per 100,000 lives. METHOD(S): This descriptive study compared paid and rejected pharmacy administrative claims data for ivermectin 3 mg tablets from the multi-state health plan's membership between Periods 1 (May 1, 2020 to September 15, 2021) and 2 (September 16, 2021 to April 30, 2022). The two periods were split by the employment of optimized UM (ie, Quantity Limit, Max Days' Supply, and Max Fill Limit) on ivermectin 3 mg tablets in mid-September 2021. Data within the periods were stratified by month. Costs were estimated based on the published WAC of $4.14 per tablet, and the final cost endpoint was normalized to per 100,000 lives. RESULT(S): Paid claims of ivermectin 3 mg tablets peaked in the week of August 8, 2021 to August 14, 2021. Rejected claims increased appreciably after UM was optimized in mid-September 2021, with the peak in rejected claims occurring in the week of September 19, 2021 to September 25, 2021. A total of 239 members received a paid claim for ivermectin 3 mg tablets in Period 1 vs 56 members in Period 2. A total of 48 members received more than 1 paid claim of ivermectin 3 mg tablets in Period 1 vs only one member in Period 2. An estimated $11,616 per 100,000 lives was saved in Period 2 through implementation of UM. CONCLUSION(S): This study provides real-world data on how utilization of ivermectin 3 mg tablets increased around the same time its popularity as a search term increased. Optimization of UM showed its effectiveness in preventing claims for off-label use for COVID-19 through a dramatically increased number of rejected claims and reduced monthly paid claims to baseline levels before ivermectin entered common public discourse. Overall, this study demonstrates that UM continues to be an effective tool for PBMs and health plans to counteract inappropriate trends in off-label use of medications.

Cross-sectional study for COVID-19-related mortality predictors in a Brazilian state-wide landscape: the role of demographic factors, symptoms and comorbidities.

OBJECTIVE: The Brazilian state of Paraná has suffered from COVID-19 effects, understanding predictors of increased mortality in health system interventions prevent hospitalisation of patients. We selected the best models to evaluate the association of death with demographic characteristics, symptoms and comorbidities based on three levels of clinical severity for COVID-19: non-hospitalised, hospitalised non-ICU ward and ICU ward. DESIGN: Cross-sectional survey using binomial mixed models. SETTING: COVID-19-positive cases diagnosed by reverse transcription-PCR of municipalities located in Paraná State. PATIENTS: Cases of anonymous datasets of electronic medical records from 1 April 2020 to 31 December 2020. PRIMARY AND SECONDARY OUTCOME MEASURES: The best prediction factors were chosen based on criteria after a stepwise analysis using multicollinearity measure, lower Akaike information criterion and goodness-of-fit χ2 tests from univariate to multivariate contexts. RESULTS: Male sex was associated with increased mortality among non-hospitalised patients (OR 1.76, 95% CI 1.47 to 2.11) and non-ICU patients (OR 1.22, 95% CI 1.05 to 1.43) for symptoms and for comorbidities (OR 1.89, 95% CI 1.59 to 2.25, and OR 1.30, 95% CI 1.11 to 1.52, respectively). Higher mortality occurred in patients older than 35 years in non-hospitalised (for symptoms: OR 4.05, 95% CI 1.55 to 10.54; and for comorbidities: OR 3.00, 95% CI 1.24 to 7.27) and in hospitalised over 40 years (for symptoms: OR 2.72, 95% CI 1.08 to 6.87; and for comorbidities: OR 2.66, 95% CI 1.22 to 5.79). Dyspnoea was associated with increased mortality in non-hospitalised (OR 4.14, 95% CI 3.45 to 4.96), non-ICU (OR 2.41, 95% CI 2.04 to 2.84) and ICU (OR 1.38, 95% CI 1.10 to 1.72) patients. Neurological disorders (OR 2.16, 95% CI 1.35 to 3.46), neoplastic (OR 3.22, 95% CI 1.75 to 5.93) and kidney diseases (OR 2.13, 95% CI 1.36 to 3.35) showed the majority of increased mortality for ICU as well in the three levels of severity jointly with heart disease, diabetes and CPOD. CONCLUSIONS: These findings highlight the importance of the predictor's assessment for the implementation of public healthcare policy in response to the COVID-19 pandemic, mainly to understand how non-pharmaceutical measures could mitigate the virus impact over the population.

Patient reported experiences (PREM): Cancer care pathway in the Stockholm-Gotland region

Background: Patient satisfaction is a goal that is part of the Swedish initiative for cancer care pathway (CCP). A questionnaire has been developed specifically to request patients‘ experiences (PREM) of care and an overall goal is that the patient perspective has a clear influence in the follow-up and evaluation of CCP. The purpose of this project is to describe patient reported experiences from CCP in the Stockholm-Gotland Region, during the period 2017 to q1 2021. It includes patients’ experiences from CCP, comparisons between groups and whether it differs before and during the COVID-19 pandemic. Methods: An invitation letter to complete a validated PREM questionnaire consisting of 34 questions, is sent to patients 8-10 weeks after CCP has ended. The main questions consist of seven dimensions and own comments can be shared. Results: A total of 14,141 persons responded to the questionnaire with an average response rate of 57%. Representativeness is good for patients where the investigation led to a cancer diagnosis, among the elderly and among patients who have undergone care processes for breast cancer, colon and rectal cancer, prostate cancer, bladder cancer or skin melanoma. Most of the patients are satisfied with CCP regarding overall impression, respect & treatment, continuation & coordination, information & knowledge, and availability. However, areas that can be improved are emotional support as well as participation & involvement. Where the investigation did not lead to a cancer diagnosis and during the COVID-19 pandemic has affected the relative’s situation negatively, both in terms of relatives' opportunity to participate in care and the relative's opportunity to get in touch with health care regarding their own issues or need of support. Conclusions: Most of the patients are satisfied with CCP. Areas that might be improved are emotional support as well as participation & involvement. The COVID-19 pandemic has affected the relatives' situation negatively. Legal entity responsible for the study: Region Stockholm-Gotland. Funding: Has not received any funding. Disclosure: All authors have declared no conflicts of interest.

Use of inhaled nitric oxide in ICU - When is a therapy trial enough?

Introduction: Inhaled nitric oxide (iNO) can be utilized as a rescue treatment option in refractory hypoxaemia and in the potential reversal of pulmonary vascular resistance by pulmonary vasodilation.1 Its use remains controversial due to limited evidence regarding efficacy and potential side effects.2 Furthermore, it requires additional equipment and consumables and its infrequent use means staff may be relatively unfamiliar with the treatment. Objectives: Investigate use of iNO within our adult critical care unit in order to identify potential quality improvements that could be made to the delivery of this therapy. Clarify the proportion of patients who demonstrated a favourable PaO2/FiO2 (PF) response to iNO. Methods: We conducted a single-centre retrospective analysis of consecutive patients treated with iNO on the General & Cardiac Intensive Care Unit at Manchester Royal Infirmary between 01/01/2018 and 25/06/2021. Data was extracted from electronic patient records on patient characteristics, indication for iNO, starting dose, ventilatory characteristics, change in PF ratio and ICU outcome. Results were recorded at iNO initiation, 2, 6, 12 and 24 hours. A responder was defined by improvement in the PF ratio of ≥20% at any point up to 6 hours after initiation. Results: 37 patients were identified, mean age 51 years (SD 14). 84% were male and 16% were female. 27 patients (73%) had a diagnosis of COVID-19 pneumonitis (Figure 1). Primary indication for iNO was acute respiratory failure (ARF) in32 (86%) and right ventricular failure in 5 (14%)patients. Prior to iNO, patients had been in ICU for 11 days (SD 11) and had received invasive mechanical ventilation for 163 hours (SD 188). PF ratios at initiation were 12.8kPa (SD 5.0), in keeping with severe ARDS and 13 (39%) were already proned at initiation. Median troponin result prior to therapy was 21[IQR 14-81]. 12 patients (32%) had ECHO evidence of raised pulmonary artery pressures. A starting dose of 20ppm iNO was observed for each patient. By 6 hours, 14/37 patients (37%) were classified as positive responders. There was a significant increase in PF ratios at 6 hours compared to baseline in responders (15.9kPa vs 12.0kPa, p=0.04) but no significant difference at any other time point. There was no difference in the duration of therapy in responders vs non responders (76 vs 85 hours, p=0.72). Conclusion: iNO therapy may offer short-term improvement in oxygenation in <40% of patients at 6 hours. Duration of therapy was similar regardless of response. This may suggest reluctance to discontinue therapy once started possibly through fear of precipitating deterioration, belief that iNO has halted decline or reluctance to recognize futility when there are few other therapeutic options. iNO is typically commenced when patients have already been invasively ventilated for several days. It is unknown whether earlier initiation would affect response. Use of iNO has increased markedly since the start of the COVID-19 pandemic which should prompt units to evaluate their own practice with this therapy.

CHARACTERISTICS AND OUTCOMES OF PATIENTS WITH ACUTE MYELOID LEUKAEMIA TREATED WITH VENETOCLAX COMBINATION THERAPY: REAL-WORLD EXPERIENCE IN BOTH FRONTLINE AND RELAPSED/REFRACTORY SETTINGS

Background: Venetoclax (Ven) in combination with hypomethylating agents, such as azacitidine (Aza) and low dose cytarabine (LDAC) has been shown to be effective therapy in acute myeloid leukaemia (AML) and has become standard of care for newly-diagnosed patients unfit for intensive chemotherapy (DiNardo et al., 2020;Wei et al., 2019;Pollyea et al., 2020). Efficacy has also been shown in the relapsed/refractory (R/R) setting in more limited data sets (Báez-Gutiérrez et al., 2021;Pollyea et al., 2020, Stahl et al., 2020;DiNardo et al., 2019). Ven combination therapy has become widely used in newly-diagnosed patients in the UK since its approval during the COVID-19 pandemic as an alternative to intensive chemotherapy and subsequently for patients unfit for intensive therapy. Aims: We describe the characteristics and outcomes of patients with AML or high risk myelodysplastic syndrome (HRMDS) receiving Ven combinations in frontline and R/R settings to provide real-world insight into their use in UK clinical practice. Methods: A retrospective analysis was performed of all patients with AML or HR-MDS who received Ven combination therapy at University College London Hospital between April 2020 and September 2021. Patient demographics, treatment history and bone marrow results were obtained from electronic health care and laboratory records. Disease stratification and response assessments were made as per European LeukemiaNet (ELN) criteria (Döhner et al., 2017). Results: At the time of analysis, 95 patients received Ven combinations (61 as frontline treatment and 34 for R/R AML), with a median follow up of 14 months. The majority of patients in both groups had adverse risk ELN classification (70.5% of frontline patients, 64.7% of R/R) and received Ven-Aza (100% frontline and 91.1% R/R) (Table 1). The median ages were 72 and 59 years respectively. The incidence of composite CR/CRi was 70.5% in the frontline setting, with median duration of response (DoR) of 8.3 months and overall survival (OS) of 7.1 months. In R/R AML, the CR/CRi rate was 64.7%, median DoR 10.5 months and median OS 9.8 months. Four out of the 43 patients who achieved CR/CRi (9.3%) following frontline treatment and 9 of the 22 R/R (40.9%) patients proceeded to allogeneic stem cell transplant (alloSCT) post induction. The median survival for all patients who underwent alloSCT is not reached in this analysis. The highest CR/CRi rates were observed in intermediate risk patients (90.9% in frontline treatment, 71.4% in R/R), with lower rates in both favourable (80% and 66.7%) and adverse risk patients (65.1% and 59.1% respectively). The presence of NPM1 and IDH1/2 mutations were associated with high CR/CRi rates in both the frontline (85.7% and 84.6% respectively) and R/R groups (100% and 81.8%), with below average response rates seen in TP53 mutated AML (62% in frontline, 40% in R/R). Notable responses were seen in patients with RUNX1 mutations in both settings (77.8% frontline, 66.6% R/R). Summary/Conclusion: Our data describes real world effectiveness for venetoclax combinations as both frontline and salvage therapy in UK clinical practice, similar to that seen in clinical trials. This further contributes to our understanding of these therapies, in particular their use as a viable treatment option in R/R patients and as a bridge to alloSCT, and highlights the importance of further characterisation of genetic predictors of response to inform treatment decisions in real-world practice.

PIVOTING IN A PANDEMIC: THE IMPACT OF COVID-19 ON THE PROVISION OF CARE FOR PATIENTS WITH INFLAMMATORY BOWEL DISEASE: A PRELIMINARY ANALYSIS

Background: The severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) outbreak, also known as COVID-19, was declared a worldwide pandemic in March of 2020. Since the onset of the pandemic, the focus of many healthcare systems has shifted toward limiting non-essential visits to hospitals in order to prioritize and allocate resources toward treating those affected by COVID-19, and preventing further exposures. While the effect of COVID-19 has been felt amongst many patient populations, those with inflammatory bowel disease (IBD) have been particularly impacted through delayed appointments and endoscopy, which is critical in disease monitoring. Aims: We aimed to determine how changes to the provision of IBD care due to the COVID-19 pandemic have affected IBD patients. Methods: A retrospective cohort study was conducted using administrative data comparing IBD patients admitted to the gastroenterology ward from March 17 to August 31 2019, with IBD patients admitted from March 17 to August 31 2020 at a tertiary care centre in London, Ontario. Patients were reviewed to assess differences in care utilization and IBD-related outcomes such as hospitalization, surgery and length of stay and in-patient drug therapy. Results: A total of 538 patients (259 in 2019 cohort and 279 in 2020 cohort) were reviewed with 48 and 60 IBD patients meeting the inclusion criteria for 2019 and 2020 respectively. Patient demographics were similar between 2019 and 2020 cohort for age, sex, rurality, disease type, and biologic exposure. A greater proportion of patients were admitted with IBD flares in 2020 (86.7% vs 75%, p=0.03). Furthermore, the 2020 cohort also had a 45% increase in in-patient surgical consultations (p=0.07), a 50% increase in in-patient IBD-related surgeries (p=0.39), a 69% increase in inpatient Remicade prescription (p=0.13) and a 70% increase in infectious complications at presentation to hospital (p=0.21). A shorter median length of stay was reported for patients in the 2020 cohort (4 days IQR 3.95 vs 5.85 IQR 4.65, p=0.09). Conclusions: Preliminary data suggest that during the COVID-19 pandemic, we have seen more deleterious outcomes in our IBD patients such as increased flares necessitating hospital admission. There was also a non-significant trend toward increased infectious complications as well as in-patient surgeries and need for inpatient Remicade. Though these results cannot be fully interpreted due to the need for further sampling, they suggest that IBD patients may be at-risk for poor outcomes in the current climate of medical care. Completion of this study will help define the full impact of care shifts related to reducing the spread of the novel coronavirus on IBD patients and highlight areas of care that need careful assessment and consideration to protect IBD patient health.

A critical conversation about mindfulness for school leadership

The global COVID-I9 pandemic has dramatically changed the scope of teaching and leading and has had negative effects on the academic outcomes for students. As a result of stress-induced demands provoked by this pandemic, school leaders are at an increased risk for physical, emotional, and mental health challenges. Recent studies about the pandemic's psychological impact on the general population reveal increased depression and stress levels. This chapter discusses ways university educational leadership programs can integrate self-care using mindfulness practice to effectively prepare aspiring school leaders. Practical approaches and resources for university programs are provided. In addition to suggestions for practical application, this chapter also discusses recommendations for universities and school districts regarding self-care for school leaders. © 2022, IGI Global.

COVID-19 Cases Prediction Using Different LSTM Models and Comparison of Effectiveness of Different Models

Large infectivity and transmissibility of COVID-19 caused severe damage to the economy, education and health of many countries. Due to the increasing number of COVID-19 cases in the world, some predictive methods are therefore needed to forecast the number of cases of COVID-19 in the future. Long short-term memory (LSTM) predicts the correlation between confirmed cases and predicts COVID-19 spread over time. The system shall be trained using training data containing confirmed cases. Various parameters considered are the no of positive cases, the number of recovered cases and the no of deaths every day. LSTM models in different types are evaluated for the time series forecasting confirmed cases, deaths and recovery and the accuracy of the prediction is compared. Different LSTM models like bidirectional LSTM, Gated Recurrent unit, W-LSTM and simple LSTM are helps to predict the no of cases in each country. Model performance is measured using the root mean square error, mean absolute percentage error and r2-score indices. Proposed method can be used to predict other types of pandemics for improved planning. © 2022, The Author(s), under exclusive license to Springer Nature Singapore Pte Ltd.

THE IMPACT of COVID-19 on MEDICATION NON-ADHERENCE in A RHEUMATOID and PSORIATIC ARTHRITIS UK COHORT

Background: In March 2020, as part of the UK's COVID-19 prevention strategy, those identifed as 'clinically extremely vulnerable,' were advised to shield. This included a number of patients prescribed anti-rheumatic drugs, who were asked to continue their current treatment unless they developed symptoms of infection. Suboptimal treatment adherence (16.0%-81.0%) has been reported in patients with arthritic diseases, and is associated with psychological factors, including anxiety (1). Previous literature in non-UK cohorts has highlighted suboptimal adherence levels in immunosuppressed patients during the pandemic, although many were single centre studies (2,3). Objectives: The aim of this multi-centre study is to investigate the impact of the COVID-19 pandemic on adherence to anti-rheumatic medications in patients with established rheumatoid (RA) and psoriatic (PsA) arthritis in the UK who had recently commenced a biologic or targeted synthetic DMARD. Methods: Between September 2020 and May 2021, RA and PsA patients prescribed biologic or targeted synthetic anti-rheumatic drugs from two multi-centre observational studies (BRAGGSS and OUTPASS) were sent a questionnaire on medication usage, adherence, and perceptions to establish the impact of COVID-19 on these parameters. Patients were asked about compliance during the COVID-19 pandemic using a 5-point Likert scale (always, often, sometimes, rarely, and never) and the reason for non-adherence. Adherence was defned as never missing or delaying a dose, unless medically advised. Descriptive summary statistics were calculated, and logistic regression and Pearson's chi-squared tests were employed to investigate variables associated with self-reported non-adherence. Results: In total 159 questionnaires were returned (81.1% RA and 18.9% PsA). Methotrexate (53.5%) was the most frequently prescribed agent, followed by etan-ercept (25.2%), sulfasalazine (22.6%), hydroxychloroquine (21.4%) and adalimumab (19.5%). Furthermore, 68.6% of patients were prescribed ≥2 drugs. During the pandemic, 42.1% of patients reported missing or delaying a treatment dose for any reason. Adherence information was available for 97.5% of patients with 25.8% reporting non-adherence which was not medically advised. Methotrexate non-adherence was 27.1%, with similar levels reported for etanercept (20.0%), sulfasalazine (27.8%), hydroxychloroquine (35.3%) and adalimumab (29.0%). No drugs had signifcantly different adherence compared to methotrexate. Furthermore, there was no association between disease type or perception of disease control and adherence. Of non-adherent patients, 17.5% reported increased anxiety, fear, and increased risk due to the COVID-19 pandemic as an influencing factor. Meanwhile, 37.5% of non-adherent patients listed non-COVID-19 intentional reasons and 45.0% reported non-intentional reasons, with forgetting and running out of treatment listed most frequently. Conclusion: In a UK cohort self-reported non-adherence was reported in 25.8% of patients during the COVID-19 pandemic, despite medical advice, with reasons including increased anxiety due to COVID-19.

USING MACHINE LEARNING TO DEVELOP MODELS FOR THE PREDICTION OF UPPER GASTROINTESTINAL CANCERS

Introduction Machine learning methods have been used to develop predictive models in gastroenterology.1 Previously we identified features including age, history of psychological disorders and severity of dysphagia symptoms which were correlated with upper gastrointestinal (UGI) cancers.2 We sought to create a machine learning based model which could be used to predict the presence of UGI in patients referred for endoscopy. Methods Patients were recruited as part of the Saliva to Predict rIsk of disease using Transcriptomics and epigenetics (SPIT) study. Patients were recruited from 2-week wait suspected UGI pathway referrals at 20 hospitals in the United Kingdom. We enriched the cohort with additional patients admitted with confirmed oesophageal adenocarcinoma. 60% of the data was used for model generation with 10-fold cross validation, while the models were tested on the remaining 40% of the data. We used seven methods to generate our models: Linear Discriminant Analysis (lda), Classification and Regression Tree (cart), k-Nearest Neighbour (knn), Support Vector Machines (svm), Random Forest (rf), Logistic Regression (glm) and Regularised Logistic Regression (glmnet). Model performance was assessed using area under the receiver operating characteristic curve (AUC) and DeLong test was used for model comparison. Results 93 cancer and 715 non-cancer patients were included. The best three models with 18 features were glmnet, lda and glm which all achieved an AUC of greater than 0.80 (figure 1). For the testing dataset, AUC was 0.75 (95%CI: 0.67- 0.83), 0.74 (95%CI: 0.66-0.82) and 0.75 (95%CI: 0.68-0.83) (p=ns for all 3 pairwise comparisons) respectively. When applying a cost function, the three models all achieved a sensitivity of 0.973 and a specificity of 0.234 to 0.388 for the testing dataset. Conclusions Our models compare favourably with the Edinburgh Dysphagia Scale, which has a sensitivity and specificity of 0.984 and 0.093 respectively.3 Our models have the advantage of an improved specificity, which could equate to fewer endoscopies being performed for low risk patients. Given rising waiting lists as a direct result of COVID-19, our tool could be used to prioritise patients who should be investigated sooner.4 We plan next to validate our models on a validation cohort to assess its generalisability.

Running a Scientific Conference During Pandemic Times

The October 2020 Virtual Symposium by the International Atmospheric Rivers Conference What: Despite the COVID-19 pandemic, the science of atmospheric rivers was well served by the organization of a virtual symposium joined by more than 100 researchers. In addition to conveying new science, significant lessons were learned on how to run virtual events. When: 5-9 October 2020 Where: Online. [ FROM AUTHOR] Copyright of Bulletin of the American Meteorological Society is the property of American Meteorological Society 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.)