An Adapted Hybrid Model for Hands-On Practice on Disaster and Military Medicine Education in Undergraduate Medical Students During the COVID-19 Pandemic

Background The coronavirus disease 2019 (COVID-19) pandemic has resulted in substantial impacts on all aspects of medical education. Modern health systems must prepare for a wide variety of catastrophic scenarios, including emerging infectious disease outbreaks and human and natural disasters. During the COVID-19 pandemic, while the use of traditional teaching methods has decreased, the use of online-based teaching methods has increased. COVID-19 itself and the accompanying infection control measures have restricted full-scale practice. Therefore, we developed an adapted hybrid model that retained adequate hands-on practice and educational equality, and we applied it with a group of undergraduate medical students participating in a mandatory disaster education course in a military medical school. Methods The course covered the acquisition of skills used in emergency and trauma scenarios through designated interdisciplinary modules on disaster responses. Several asynchronous and synchronous online webinars were used in this one-credit mandatory disaster and military medicine education course. To allow opportunities for hands-on practice and ensure education equality, the students were divided into 15 groups, with 12 students in each group. The hands-on practice exercises were also recorded and disseminated to the students in the designated area for online learning. Results A total of 164 3rd-year medical students participated in this mandatory disaster and military medicine course during the COVID-19 pandemic. The satisfaction survey response rate was 96.5%. The students were satisfied with the whole curriculum (3.8/5). Most of the free-text comments regarding the course represented a high level of appreciation. The students felt more confident in the knowledge and skills they gained in hands-on exercises than they did in the knowledge and skills they gained in online exercises. The students showed significant improvements in knowledge after the course. Conclusions We demonstrated that this adapted hybrid arrangement provided an enhanced learning experience, but we also found that medical students were more confident in their knowledge and skills when they had real hands-on practice.

Effect of High-Flow Nasal Therapy on Patient-Centred Outcomes in Patients at High Risk of Postoperative Pulmonary Complications After Cardiac Surgery: A Statistical Analysis Plan for NOTACS, a Multicentre Adaptive Randomised Controlled Trial. (preprint)

Background: The NOTACS trial will assess the efficacy, safety and cost-effectiveness of high-flow nasal therapy (HFNT) compared to standard oxygen therapy (SOT) on the outcomes of patients after cardiac surgery. Methods: / Design NOTACS is an adaptive, international, multicentre, parallel group, randomised controlled trial, with a pre-planned interim sample size re-estimation (SSR). A minimum of 850 patients will be randomised 1:1 to receive either HFNT or SOT. The primary outcome is days alive and at home in the first 90 days after the planned surgery (DAH90), with a number of secondary analyses and cost-effectiveness analyses also planned. The interim SSR will take place after a minimum of 300 patients have been followed up for 90 days and will allow for the sample size to increase up to a maximum of 1152 patients. Discussion: This manuscript outlines the key features of the NOTACS statistical analysis plan, and was submitted to the journal before the interim analysis in order to preserve scientific integrity under an adaptive design framework. The NOTACS SAP closely follows published guidelines for the content of SAPs in clinical trials. Trial registration: ISRCTN14092678 (13 th May 2020, https://www.isrctn.com/ISRCTN14092678)

The Difference in Learning Activities of Postgraduate Students of Different Qualification Types Under the COVID-19 Pandemic: A Multi-Group Latent Class Analysis.

Introduction: There are two types of master's qualifications in China. One is the academic qualification that pays more attention to academic research, aiming to cultivate research-oriented talents; while the other is the application-oriented qualification that focuses more on practical ability, aiming to cultivate applied-oriented talents. The purpose of this study is to explore the impact of the COVID-19 on the learning activities of postgraduate students, as well as the differences in the extent to which the learning activities of postgraduate students of different qualification types are affected and their mental health status. Methods: A self-constructed scale for the pandemic's impact on master's students, the self-rating anxiety scale and the self-rating depression scale were applied in the study. The single- and multi-group latent class analyses were used to investigate the impact of the pandemic on postgraduate students of different qualification types. Results: A total of 2818 responses were collected. The single-group latent class analysis identified four classes. The multi-group latent class analysis showed that no absolute homogeneity existed between different groups. In general, the number of academic master's students affected was greater than application-oriented master's students. Application-oriented master's students were more affected by course activities, while academic master's students were more affected by academic and social activities. Results show that individuals more affected had higher levels of anxiety and depression. Compared to course activities, impacts on social activities were more likely to cause anxiety and depression. Discussion: Universities can provide a more flexible way of assistance to different qualification types of postgraduate students. Furthermore, social activities play an important role in the mental health of postgraduate students. Therefore, under the background of normalization of pandemic prevention and control, schools should pay more attention to students' interpersonal communication activities to help relieve students' anxiety, depression, and other negative emotions.

Bayesian data assimilation for estimating instantaneous reproduction numbers during epidemics: Applications to COVID-19.

Estimating the changes of epidemiological parameters, such as instantaneous reproduction number, Rt, is important for understanding the transmission dynamics of infectious diseases. Current estimates of time-varying epidemiological parameters often face problems such as lagging observations, averaging inference, and improper quantification of uncertainties. To address these problems, we propose a Bayesian data assimilation framework for time-varying parameter estimation. Specifically, this framework is applied to estimate the instantaneous reproduction number Rt during emerging epidemics, resulting in the state-of-the-art 'DARt' system. With DARt, time misalignment caused by lagging observations is tackled by incorporating observation delays into the joint inference of infections and Rt; the drawback of averaging is overcome by instantaneously updating upon new observations and developing a model selection mechanism that captures abrupt changes; the uncertainty is quantified and reduced by employing Bayesian smoothing. We validate the performance of DARt and demonstrate its power in describing the transmission dynamics of COVID-19. The proposed approach provides a promising solution for making accurate and timely estimation for transmission dynamics based on reported data.

Impact of Academic Support on Anxiety and Depression of Chinese Graduate Students During the COVID-19 Pandemic: Mediating Role of Academic Performance

Introduction The COVID-19 pandemic broke out and has spread globally since 2019. It became a public health concern. This pandemic has brought tremendous changes in students’ lives and modes of learning. Graduate students are likely to be more affected as they are a part of a special training program. According to the main-effect model, social support has a positive effect on mental health. The pandemic has exerted a negative impact on the social support of individuals, and as a result, the behavior of a person is more likely to be at risk and has resulted in psychological crisis in people/individuals. Methods A sample of 3137 graduate students responded to the instrument developed to assess the impact of the pandemic on the academic activities and performance, Self-rating Anxiety Scale and Self-rating Depression Scale. Results The results showed that: 1) the pandemic impacted the academic support and performance of graduate students in varying degrees, 21% of graduate students experienced anxiety, and 33.9% of graduate students experienced depressive symptoms in varying degrees;2) academic support variables (ie, academic exchange with mentors and peers) and academic performance variables (ie, data collection and thesis writing) were significantly associated with anxiety and depressive symptoms;3) the model fitted the data well (RMSEA = 0.029;SRMR = 0.014;TLI = 0.99;CFI = 0.996). The direct effects of academic support on anxiety and depressive symptoms were significant. The impact on academic performance played a mediating role between the impact on academic support, anxiety, and depressive symptoms. Discussion Academic support significantly affected academic performance, which in turn affected anxiety and depressive symptoms. So, it implies that, due to the pandemic, the academic support for graduate students had decreased, resulting in deterioration in academic performance, causing anxiety and depressive symptoms.

How Course Support and Academic Support Impact on Chinese Graduate Students during the COVID-19: The Multiple Mediating Roles of Thesis Writing and Anxiety.

Because of the impact of the COVID-19 pandemic, the learning style of graduate students has changed considerably, making them more susceptible to psychological problems. This study aimed to explore the mediating roles of thesis writing and anxiety between course support (including course-arrangement, course-assessment, and course-learning), academic support (including academic exchange with colleges, tutors and schoolmates) and depression. There were 3137 graduate students investigated by self-developed Graduate Students' Academic Affected Questionnaire, Self-Rating Anxiety Scale and Self-Rating Depression Scale. The results showed that (1) 82% of graduate students reported their course support, academic support and thesis writing were affected to varying degrees; (2) course support and academic support correlated with thesis writing, anxiety and depression (p < 0.001); (3) the mediation model fitted well, the mediating effect of anxiety between academic support and depression was significant (ß = 0.086, SE = 0.02, p < 0.001), the serial multiple mediating effects of thesis writing and anxiety between academic support and depression were significant (ß = 0.02, SE = 0.008, p = 0.013) and the serial multiple mediating effects of thesis writing and anxiety between course support and depression were also found to be significant (ß = 0.014, SE = 0.006, p = 0.014).

Comparison of epidemiological and clinical characteristics of COVID-19 patients with and without Wuhan exposure / 浙江省有无武汉暴露史新型冠状肺炎患者的流行 病学和临床特征的比较研究

Background: A novel coronavirus called severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), first identified in Wuhan, China, has been rapidly spreading around the world. This study investigates the epidemiological and clinical characteristics of coronavirus disease 2019 (COVID-19) patients in Zhejiang Province who did or did not have a history of Wuhan exposure. Methods: We collected data from medical records of confirmed COVID-19 patients in Zhejiang Province from Jan. 17 to Feb. 7, 2020 and analyzed epidemiological, clinical, and treatment data of those with and without recorded recent exposure in Wuhan. Results: Patients in the control group were older than those in the exposure group ((48.19±16.13) years vs. (43.47±13.12) years, P<0.001), and more were over 65 years old (15.95% control vs. 5.60% exposure, P<0.001). The rate of clustered onset was also significantly higher in the control group than in the exposure group (31.39% vs. 18.66%, P<0.001). The symptom of a sore throat in patients in the exposure group was significantly higher than that in the control group (17.30% vs. 10.89%, P=0.01); however, headache in the exposure group was significantly lower than that in the control group (6.87% vs. 12.15%, P=0.015). More patients in the exposure group had a significantly lower level of lactate dehydrogenase (LDH) and aspartate aminotransferase (AST) than those in the control group. There was no significant difference in any degree of COVID-19 including mild, severe, and critical between the two groups. Conclusions: From the perspective of epidemiological and clinical characteristics, there was no significant difference between COVID-19 patients with and without Wuhan exposure history.

Revealing the Transmission Dynamics of COVID-19: A Bayesian Framework for Rt Estimation (preprint)

In epidemiological modelling, the instantaneous reproduction number, Rt, is important to understand the transmission dynamics of infectious diseases. Current Rt estimates often suffer from problems such as lagging, averaging and uncertainties demoting the usefulness of Rt. To address these problems, we propose a new method in the framework of sequential Bayesian inference where a Data Assimilation approach is taken for Rt estimation, resulting in the state-of-the-art ‘DARt’ system for Rt estimation. With DARt, the problem of time misalignment caused by lagging observations is tackled by incorporating observation delays into the joint inference of infections and Rt; the drawback of averaging is improved by instantaneous updating upon new observations and a model selection mechanism capturing abrupt changes caused by interventions; the uncertainty is quantified and reduced by employing Bayesian smoothing. We validate the performance of DARt through simulations and demonstrate its power in revealing the transmission dynamics of COVID-19.

Bayesian data assimilation for estimating epidemic evolution: a COVID-19 study (preprint)

The evolution of epidemiological parameters, such as instantaneous reproduction number Rt, is important for understanding the transmission dynamics of infectious diseases. Current estimates of time-varying epidemiological parameters often face problems such as lagging observations, averaging inference, and improper quantification of uncertainties. To address these problems, we propose a Bayesian data assimilation framework for time-varying parameter estimation. Specifically, this framework is applied to Rt estimation, resulting in the state-of-the-art DARt system. With DARt, time misalignment caused by lagging observations is tackled by incorporating observation delays into the joint inference of infections and Rt; the drawback of averaging is overcome by instantaneously updating upon new observations and developing a model selection mechanism that captures abrupt changes; the uncertainty is quantified and reduced by employing Bayesian smoothing. We validate the performance of DARt and demonstrate its power in revealing the transmission dynamics of COVID-19. The proposed approach provides a promising solution for accurate and timely estimating transmission dynamics from reported data.

Interferon-α2b spray inhalation did not shorten virus shedding time of SARS-CoV-2 in hospitalized patients: a preliminary matched case-control study.

BACKGROUND: Currently, there are no drugs that have been proven to be effective against severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). Because of its broad antiviral activity, interferon (IFN) should be evaluated as a potential therapeutic agent for treatment of coronavirus disease 2019 (COVID-19), especially while COVID-19-specific therapies are still under development. METHODS: Confirmed COVID-19 patients hospitalized in the First Affiliated Hospital, School of Medicine, Zhejiang University in Hangzhou, China, from January 19 to February 19, 2020 were enrolled in a retrospective study. The patients were separated into an IFN group and a control group according to whether they received initial IFN-α2b inhalation treatment after admission. Propensity-score matching was used to balance the confounding factors. RESULTS: A total of 104 confirmed COVID-19 patients, 68 in the IFN group and 36 in the control group, were enrolled. Less hypertension (27.9% vs. 55.6%, P=0.006), dyspnea (8.8% vs. 25.0%, P=0.025), or diarrhea (4.4% vs. 19.4%, P=0.030) was observed in the IFN group. Lower levels of albumin and C-reactive protein and higher level of sodium were observed in the IFN group. Glucocorticoid dosage was lower in the IFN group (median, 40 vs. 80 mg/d, P=0.025). Compared to the control group, fewer patients in the IFN group were ventilated (13.2% vs. 33.3%, P=0.015) and admitted to intensive care unit (ICU) (16.2% vs. 44.4%, P=0.002). There were also fewer critical patients in the IFN group (7.4% vs. 25.0%, P=0.017) upon admission. Although complications during admission process were comparable between groups, the discharge rate (85.3% vs. 66.7%, P=0.027) was higher and the hospitalization time (16 vs. 21 d, P=0.015) was shorter in the IFN group. When other confounding factors were not considered, virus shedding time (10 vs. 13 d, P=0.014) was also shorter in the IFN group. However, when the influence of other factors was eliminated using propensity score matching, virus shedding time was not significantly shorter than that of the control group (12 vs. 15 d, P=0.206). CONCLUSIONS: IFN-α2b spray inhalation did not shorten virus shedding time of SARS-CoV-2 in hospitalized patients.

Clinical characteristics of different subtypes and risk factors for the severity of illness in patients with COVID-19 in Zhejiang, China.

BACKGROUND: The outbreak of coronavirus disease 2019 (COVID-19) is now becoming an enormous threat to public health. The clinical spectrum of COVID-19 is extensive, of which critical cases are with rapid disease progression and high mortality. The aim of our study is to summarize the characteristics of different subtypes and explore risk factors of illness severity for early identification and prompt treatment. METHODS: In this retrospective study, we collected data of patients confirmed COVID-19 in Zhejiang Province from 17 January to 12 February 2020. According to the definition of clinical classification, we divided confirmed cases into four types, and summarize epidemiological and clinical characteristics, laboratory and radiograph findings, treatments, and outcomes, respectively. Moreover, we used univariate and multivariate ordinal logistic regression models to explore risk factors for the severity of illness in patients with COVID-19. RESULTS: A total of 788 patients were enrolled in our study, of whom 52 cases (6.6%) were mild type, 658 cases (83.5%) were common type, 61 cases (7.2%) were severe type, and 17 cases (2.2%) were critical type. Multivariate ordinal logistic regression demonstrated increasing odds of the severity of illness in patients with COVID-19 associated with male (odds ratio [OR] = 1.7, 95% confidence interval [CI]: 1.2-2.6 P = 0.008), fever (OR = 3.6, 95% CI: 2.1-6.3, P <  0.001), cough (OR = 1.7, 95% CI: 1.0-2.9, P = 0.041), hemoptysis (OR = 3.4, 95% CI: 1.1-10.3, P = 0.032), gastrointestinal symptoms (OR = 1.9, 95% CI: 1.0-3.5, P = 0.047), hypertension (OR = 2.6, 95% CI: 1.2-5.6, P = 0.013). With the increase of age-grading, risk for the severity of illness was gradually higher (≤ 18 years [OR = 1.0], 19-40 years [OR = 12.7, 95% CI: 4.5-36.0, P < 0.001], 41-65 years [OR = 14.8, 95% CI: 5.2-42.1, P <  0.001], ≥ 66 years [OR = 56.5, 95% CI: 17.1-186.5, P < 0.001]). CONCLUSIONS: Clinicians should pay close attention to these features in patients with COVID-19 including older age, male, fever, cough, hemoptysis, gastrointestinal symptoms and hypertension to identify the severity of illness as early as possible.

Liver Enzyme Elevation in Coronavirus Disease 2019: A Multicenter, Retrospective, Cross-Sectional Study.

INTRODUCTION: Elevated liver enzyme levels are observed in patients with coronavirus disease 2019 (COVID-19); however, these features have not been characterized. METHODS: Hospitalized patients with COVID-19 in Zhejiang Province, China, from January 17 to February 12, 2020, were enrolled. Liver enzyme level elevation was defined as alanine aminotransferase level >35 U/L for men and 25 U/L for women at admission. Patients with normal alanine aminotransferase levels were included in the control group. Reverse transcription polymerase chain reaction was used to confirm severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection, and patients symptomatic with SARS-CoV-2 infection were defined as patients with COVID-19. Epidemiological, demographic, clinical, laboratory, treatment, and outcome data were collected and compared. RESULTS: Of 788 patients with COVID-19, 222 (28.2%) patients had elevated liver enzyme levels (median [interquartile range {IQR}] age, 47.0 [35.0-55.0] years; 40.5% women). Being male, overweight, and smoking increased the risk of liver enzyme level elevation. The liver enzyme level elevation group had lesser pharyngalgia and more diarrhea than the control group. The median time from illness onset to admission was 3 days for liver enzyme level elevation groups (IQR, 2-6), whereas the median hospitalization time for 86 (38.7%) discharged patients was 13 days (IQR, 11-16). No differences in disease severity and clinical outcomes were noted between the groups. DISCUSSION: We found that 28.2% of patients with COVID-19 presented with elevated liver enzyme levels on admission, which could partially be related to SARS-CoV-2 infection. Male patients had a higher risk of liver enzyme level elevation. With early medical intervention, liver enzyme level elevation did not worsen the outcomes of patients with COVID-19.

Comparison of epidemiological and clinical characteristics of COVID-19 patients with and without Wuhan exposure

A novel coronavirus called severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), first identified in Wuhan, China, has been rapidly spreading around the world. This study investigates the epidemiological and clinical characteristics of coronavirus disease 2019 (COVID-19) patients in Zhejiang Province who did or did not have a history of Wuhan exposure. We collected data from medical records of confirmed COVID-19 patients in Zhejiang Province from Jan. 17 to Feb. 7, 2020 and analyzed epidemiological, clinical, and treatment data of those with and without recorded recent exposure in Wuhan. Patients in the control group were older than those in the exposure group ((48.19±16.13) years vs. (43.47±13.12) years, P<0.001), and more were over 65 years old (15.95% control vs. 5.60% exposure, P<0.001). The rate of clustered onset was also significantly higher in the control group than in the exposure group (31.39% vs. 18.66%, P<0.001). The symptom of a sore throat in patients in the exposure group was significantly higher than that in the control group (17.30% vs. 10.89%, P=0.01);however, headache in the exposure group was significantly lower than that in the control group (6.87% vs. 12.15%, P=0.015). More patients in the exposure group had a significantly lower level of lactate dehydrogenase (LDH) and aspartate aminotransferase (AST) than those in the control group. There was no significant difference in any degree of COVID-19 including mild, severe, and critical between the two groups. From the perspective of epidemiological and clinical characteristics, there was no significant difference between COVID-19 patients with and without Wuhan exposure history.