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Objectives: The COVID-19 pandemic disrupted many facets of healthcare including patients delaying medical care for potentially life-threatening conditions. This study sought to compare specific key outcomes related to ischemic stroke that occurred before and during the COVID-19 pandemic. We assessed mortality rates, morbidity rates, and the administration of thrombolytics in patients with ischemic stroke admitted to emergency departments (ED) in the Stroke Belt, a region of the United States with historically worse stroke outcomes. Method(s): Cerner Real-World Data was used to identify patients residing in the Stroke Belt (Southeastern United States) who were admitted to the ED with ICD-10 codes indicating acute ischemic stroke. We determined in-hospital and 30-day mortality rates, morbidity rates (physical disability tracked 1-year post-ischemic stroke), and administration of thrombolytics for acute ischemic stroke patients before the COVID-19 pandemic (March 2019-February 2020) and during the pandemic (March 2020-February 2021). Result(s): In the defined period prior to COVID-19, 2,338 patients presented to the ED with ischemic strokes (49.5% male;mean age 64.8, SD:15.23;69.6% white). During COVID-19, 2,052 ischemic stroke patients presented to the ED (50.9% male;mean age 65.8, SD:15.04;71.5% white). Our analyses show a significant decrease in thrombolytic administration during the pandemic compared to before the pandemic (12.2% and 14.5%, respectively;p<0.05). There was no significant difference in rates of in-hospital mortality, 30-day mortality, or morbidity following ischemic strokes. Conclusion(s): The findings of our study suggest a reduction in ischemic stroke related ED encounters during the COVID-19 period, but no differences were observed in mortality and morbidity rates in ischemic stroke compared to before the pandemic. Future studies are required to determine if these trends were true in other regions of the United States, as well as to investigate other potential covariates linked to outcomes before and during the COVID-19 pandemic.Copyright © 2023
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75% of the world's poor reside in rural areas where the local economy is tied to agriculture. We interpret new panel data on COVID-19 from Nepal and Bangladesh in relation to agricultural seasonality. Conditions in April–June 2020 were comparable to a typical lean season even though the pandemic arrived at harvest time. Income losses stem from both depressed local employment as well as lower migration and remittances. We also document indirect adverse health impacts on nutrition and mental health. Findings are specific to the nature of economic activity at harvest, and effective pandemic policy must evolve with the agricultural season. © 2023 Agricultural & Applied Economics Association.
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Background: Most patients are diagnosed with cystic fibrosis (CF) based on newborn screening (NBS). The goal of CF NBS is to achieve early CF diagnosis to start medical and psychosocial therapies before the onset of clinical symptoms to improve disease outcomes. Thus, infants require diagnostic testing before 4 weeks of age. With the onset of the COVID-19 pandemic and shut-down of nonurgent medical services from March to May 2020, many health care systems transitioned from traditional, inperson clinical visits to a telemedicine platform. We outline our institutional review board-exempt, quality-improvement efforts to transition to a CF NBS clinic that occurs primarily via telemedicine at our CFFaccredited pediatric center in Delaware. Method(s): The medical records of infants with inconclusive CF NBS referred to our clinic were reviewed from May 2020 to December 2021 once telemedicine visits were offered. Demographic information including date of birth, age completing NBS, age at referral for diagnostic sweat chloride testing (ST), number of family contacts to schedule ST, age at successful ST completion, and format for subsequent discussion of results via telemedicine or alternate mode plus date was reviewed. Charts of infants referred from Delaware and surrounding states were also reviewed to assess ST success rates and need for additional testing, genetic counseling consultation, or in-person CF clinic visits. Result(s): One hundred eighty-seven infants (68 between May 2020 and December 2020, 119 in 2021) were referred. Average age at completion of CF NBS was 1.4 days (range 1-8 days) in 2020 and 1.78 days (range 1-14 days) in 2021. Average age at referral for diagnostic testing was 10.7 days (range 1-78 days) in 2020 and 10.3 days (range 0-150 days) in 2021 in Delaware. Forty-eight of 52 (92%) Delaware families were contacted to schedule diagnostic testing before 21 days of age in 2020 and 88 of 94 (94%) in 2021. The CF NBS clinic made an average of 1 contact (range 1-5) with each family to schedule testing and appointments in 2020 and 2 (range 1- 10) in 2021. The overall ST success rate from May 2020 to December 2021 was 87% (n = 189/217 ST completed). Diagnostic test results were relayed via telemedicine to 92 patients, telephone to 61 patients, in person to 21 patients, by primary care provider to five patients, and not specified in eight patients. Genetic counseling was completed for nine families based on CF NBS results. Over the period, four infantswere diagnosed with CF-all had in-person clinic visits on average at age 11 days (range 9 to 21 days). A diagnosis of CF transmembrane conductance regulator-related metabolic syndrome (CRMS)was noted in three infants who had in-person visits at an average age of 20 days (range 16-21 days);two required rescheduling from telemedicine to in-person assessment within 24 to 72 hours of initial time based on intermediate ST results. Conclusion(s): Telemedicine visits offer an alternate way to communicate diagnostic ST results to families of infants with inconclusive CF NBS. Infants identified with CF and CRMS were scheduled for a traditional clinic visit or required rapid follow-up scheduling for an in-person evaluation. A need for better communication between CF NBS clinic staff and families to schedule and complete testing was noted. Future directions include assessing optimal ways to contact families and reminders for ST and clinical appointments Copyright © 2022, European Cystic Fibrosis Society. All rights reserved
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Background Acute respiratory distress syndrome (ARDS) is a major complication in patients with severe coronavirus disease in 2019 (COVID-19). COVID-19 convalescent plasma (CCP) has been proposed as a specific therapy for patients with COVID-19. Our goal is to assess changes in oxygenation and inflammatory markers in patients after receiving CCP. Methods This is a retrospective, health system-based, a case-control study comparing hospitalized patients with COVID-19 who received CCP and were discharged (survivors) to patients who died after receiving CCP (non-survivors). We analyzed the severity of ARDS, oxygenation, and inflammatory markers of 295 patients, comparing 202 survivors to 93 non-survivors with COVID-19 who received CCP. Demographic information and laboratory data were collected on the day of the admission (initial), the day of the plasma infusion (D1), and post-infusion days 3, 7, 15, and 30 (when available). Results Survivors were younger (52.48 y versus 64.02 y;p<0.001) with no pre-existing conditions (25.2% versus 13.9%;p=0.03) compared to non-survivors. Severe ARDS (PaO2/FiO2 <100) was predictive of increased mortality after CCP in non-survivors (p<0.001). Survivors with mild (20%) or moderate (46%) ARDS on D1 had a 54% resolution of ARDS on D7 after CCP (p<0.001). After 72 hours of transfusion, supplemental oxygen requirements decreased by 63% of the survivors, compared to 33% of non-survivors (p<0.001). Inflammatory markers, including white blood cells, absolute neutrophils, platelets, C-reactive protein (CRP), lactate dehydrogenase (LDH), and creatinine, improved within three days in survivors after CCP (p<0.05). Baseline findings associated with a poor prognosis on D1 include a lower platelet count (219.02 versus 281.64, p<0.001), higher blood urea nitrogen (BUN) (35.41 versus 21.48, p<0.001), higher creatinine (2.24 versus 1.26, p<0.001), higher D-dimer (5.88 versus 2.46, p<0.001) and elevated lactate dehydrogenase (LDH) (698.3 versus 464.51, p<0.001) when comparing non-survivors to survivors, respectively. After 72 hours post-transfusion, the following changes were remarkable: normalization of creatinine with a mean of 1.07 in survivors versus 1.92 in non-survivors (p<0.001), a significant decrease in CRP improving from 129.27 to 84.25 in survivors versus 139.11 to 130.0 in non-survivors (p<0.001), and lower lactate dehydrogenase (LDH) in survivors (459.47) versus non-survivors (674.56, p<0.001). Conclusion In this retrospective, health system-based, case-control study, we found that the improvement in oxygenation, resolution of ARDS, and reduced inflammatory markers are seen in survivor patients after early COVID-19 convalescent plasma transfusion. These parameters can be used to assess response to COVID-19 convalescent plasma after 72 hours of the transfusion and could help physicians in the decision-making when administering CCP, especially if resources are scarce. [Formula presented] Disclosures: No relevant conflicts of interest to declare.
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Background Effective feedback is an important tool in medical education for the learning and growth of trainees and for faculty development. It allows learners to remain on course in reaching competence in clinical, research, and interpersonal skills, yet the impact of teaching feedback during hematology-oncology training has not been studied in depth. To tackle the lack of effective constructive feedback within our hematology oncology fellowship program, we initiated a quality improvement (QI) project to identify barriers in delivering and receiving high-quality feedback in the program and to create a curriculum aimed at teaching fellows and faculty how to engage in more effective feedback conversations. In the initial phase of the pilot study, a pre-intervention survey identified the two main barriers for effective feedback in our program as discomfort in giving feedback and lack of protected time. A virtual workshop improved quality of feedback by addressing these barriers and providing tools necessary to give and receive constructive feedback. We aimed to highlight the sustainability of these interventions. Methods Utilizing the results of the pre-intervention survey, we built three 2-hour interactive virtual workshop sessions conducted through the ASCO Quality Training Program. Skills that were emphasized and practiced included appropriate set-up, low-inference observations, dialogic feedback conversations and a structured approach to reinforcing and modifying feedback. A follow up session was conducted three months later allowing for reinforcement of the skills. Post-intervention surveys were given immediately after the initial workshop and after the follow-up session. All surveys were identical employing Likert scale and open-ended questions. Weekly email reminders for protected feedback time were also set up. This project was developed through the ASH Medical Educators Institute. Results Eleven out of 15 attendees completed each of the questionnaires. At baseline, 81.8 % of the participants reported they do not have protected time to complete evaluations. This decreased to 63.6% immediately post-intervention and to 27.3% at the three-month point. Similarly, only 65.5% of the participants reported they were comfortable giving feedback prior to the workshop, increasing to 81.8% immediately after the intervention and was sustained at 81.8% at three months. Half of the participants reported that the feedback was not actionable in the initial questionnaire, decreasing to 10% post-intervention. Majority of the participants agreed that the workshop helped address barriers for effective feedback in our program. Conclusions This study showed the sustainability of positive changes, even during the COVID-19 pandemic, for giving and receiving quality feedback implemented in our fellowship program. Its outcomes are salient given that it utilizes a simple intervention that could be expanded to other training programs as feedback is a systemic problem in medicine. It also underscores the importance of formal workshops in overcoming barriers for effective feedback. Limitations of this QI study include the small sample size and single-institutional design. Our future goals include incorporating a formal yearly curriculum assigning weekly protected time for feedback to ensure these results are sustainable and reproducible with incoming fellows. Disclosures: No relevant conflicts of interest to declare.
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Using detailed microdata, we document how migration-dependent households are especially vulnerable during the COVID-19 pandemic. We create pre- and post-COVID panel datasets for three populations in Bangladesh and Nepal, leveraging experimental and observational variation in prior migration dependence. We report 25 per cent greater declines in earnings and fourfold greater prevalence of food insecurity among migrant households since March. Causes include lower migration rates, less remittance income per migrant, isolation in origin communities, and greater health risks. We compile a large set of secondary data to demonstrate the extent of vulnerability worldwide and conclude with recommendations for policy targeted at migrants.
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Background: Feedback is an integral part of the learning process, allowing learners to remain on course in reaching competence in clinical, research, and interpersonal skills. However, the impact of teaching feedback during hematologyoncology training has not been studied. We aimed to identify barriers in delivering and receiving highquality feedback in our fellowship program and to create a curriculum aimed at teaching fellows and faculty how to engage in more effective feedback conversations. Methods: This pilot study aimed at determining and addressing perceived barriers to high-quality feedback in the hematology-oncology fellowship program. A pre-intervention questionnaire, consisting of Likert scale and openended questions, was administered to identify barriers to giving feedback and to assess satisfaction with the quality of feedback received in our fellowship program. The results of the baseline questionnaire were utilized to build a virtual interactive three-session workshop provided by the ASCO Quality Training Program in which the importance of feedback and methods of providing effective feedback were taught. Topics included feedback set-up, low-inference observation, and a structured approach to reinforcing and modifying feedback. One month after the intervention the participants completed a follow up questionnaire. This project was developed through the ASH Medical Educators Institute. Results: Each questionnaire was completed by 11 participants. The two main barriers to high-quality feedback identified were the discomfort with both giving and receiving feedback, and the lack of protected time. At baseline only 54% of the participants reported they were comfortable giving feedback, increasing to 81% post- intervention. Pre-intervention, 81% of participants reported they did not have protected time for feedback, decreasing to 64% after the intervention and institution of weekly protected time for feedback. Half of the participants reported that the feedback was not actionable in the initial questionnaire, decreasing to 10% postintervention. Overall, fellows reported that their feedback was mostly focused on notes, followed by presentations and interpersonal skills. Faculty reported that most of the feedback they received was about time management and patient care. Conclusions: This pilot study helped address a major barrier to improvement and growth within our training program and confirmed that feedback skills must be taught and practiced. A 6-hour virtual workshop showed tangible results in the satisfaction with and quality of feedback given to both fellows and faculty. Our findings are salient as we completed the intervention during the COVID pandemic. Limitations of the study include its single-institutional design and sample size. A major challenge anticipated is sustainability, which will be addressed by maintaining periodic lectures and assigning protected time for feedback.
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Background: The epidemiology of psychiatric symptoms among patients with coronavirus disease 2019 is poorly characterized. Objective: This article sought to identify the prevalence of anxiety, depression, and acute stress disorder among hospitalized patients with coronavirus disease 2019. Methods: Adult patients recently admitted to nonintensive care unit medical ward settings with coronavirus disease 2019 were eligible for enrollment. Enrolled patients were screened for depression, anxiety, and delirium. Subsequently, patients were followed up by phone after 2 weeks and rescreened for depression, anxiety, and acute stress disorder symptoms. Subjects' medical records were abstracted for clinical data. Results: A total of 58 subjects were enrolled;of whom, 44 completed the study. Initially, 36% of subjects had elevated anxiety symptoms and 29% had elevated depression symptoms. At 2-week follow-up, 9% had elevated anxiety symptoms, 20% had elevated depression symptoms, and 25% had mild-to-moderate acute stress disorder symptoms. Discharge to home was not associated with improvement in psychiatric symptoms. Conclusions: A significant number of patients hospitalized with coronavirus disease 2019 experienced symptoms of depression and anxiety. While anxiety improved after index admission, depression remained fairly stable. Furthermore, a significant minority of patients experienced acute stress disorder symptoms, though these were largely mild to moderate.