Evaluation of Early Warning Scores on In-Hospital Mortality in COVID-19 Patients: A Tertiary Hospital Study from Taiwan.

Coronavirus disease 2019 (COVID-19) remains a global pandemic. Early warning scores (EWS) are used to identify potential clinical deterioration, and this study evaluated the ability of the Rapid Emergency Medicine score (REMS), National Early Warning Score (NEWS), and Modified EWS (MEWS) to predict in-hospital mortality in COVID-19 patients. This study retrospectively analyzed data from COVID-19 patients who presented to the emergency department and were hospitalized between 1 May and 31 July 2021. The area under curve (AUC) was calculated to compare predictive performance of the three EWS. Data from 306 COVID-19 patients (61 ± 15 years, 53% male) were included for analysis. REMS had the highest AUC for in-hospital mortality (AUC: 0.773, 95% CI: 0.69-0.85), followed by NEWS (AUC: 0.730, 95% CI: 0.64-0.82) and MEWS (AUC: 0.695, 95% CI: 0.60-0.79). The optimal cut-off value for REMS was 6.5 (sensitivity: 71.4%; specificity: 76.3%), with positive and negative predictive values of 27.9% and 95.4%, respectively. Computing REMS for COVID-19 patients who present to the emergency department can help identify those at risk of in-hospital mortality and facilitate early intervention, which can lead to better patient outcomes.

AR-sculptures: Issues of Technological Creation, Their Artistic Significance and Uniqueness

The threat of the Covid-19 epidemic quickly influenced the development of remote working tools using modern IT technologies. This has led to the emergence of a significant number of cultural practices for remote (virtual) use. Among them are experimental attempts to create volumetric virtual models that could be considered sculptures. At the same time, these developments have served the emergence of cul- turological problems: solving questions of uniqueness, artistic significance of works of this kind. In this regard, this article provides the results of a scientific study of the specifics of creating virtual sculptures, authorship issues and artistic significance of virtual content, identified as a result of an examination of the authoring develop- ments of the AR-application "REMS, " as well as works presented at the exhibition "More than a sculpture. " In the example of the author's development of content for AR (augmented reality) installations, it turns out that virtual content can significant- ly change the content and ideological significance of art work. The artistic compo- nent of these objects determines their designation as art works, objects of fine art. In this way, the uniqueness and artistic significance of virtual sculptures as three-di- mensional graphic objects created using augmented reality technology is confirmed.

Pain Management and Opioid Therapy: Persistent Knowledge Gaps Among Primary Care Providers.

INTRODUCTION: Given the opioid epidemic in the US, it is vital that clinicians who prescribe opioids for pain management to do so in an evidence-based manner, eg considering all pharmacologic and non-pharmacologic options, assessing risk of opioid use disorder prior to initiating opioids. Continuing education regarding the evidence-based prescribing of opioids is now required for US healthcare providers who prescribe opioids. A "blueprint" of the content to be included in continuing education programs was developed by the US Food and Drug Administration and updated in 2018. METHODS: To understand the baseline knowledge and confidence of healthcare professionals in prescribing opioids for pain management, we posed 27 unique knowledge-based questions and 1 confidence question to clinician participants before or during 2 continuing educational programs that were based respectively on the 2016 and 2018 FDA Risk Evaluation and Mitigation Strategy (REMS) educational blueprints for pain management. RESULTS: Overall, 5571 clinicians completed these programs, including 1925 physicians (1516 [79%] identifying as primary care), 1181 physician assistants, 737 advanced practice nurses, 719 nurses, and 479 pharmacists. Responses to pretest questions in both programs indicated profound and persistent gaps in knowledge, particularly in definitions and mechanisms of pain, general principles of pharmacologic analgesic therapy, and specific aspects of opioid analgesic therapy and addiction. Participants in both programs also expressed limited confidence in their abilities to incorporate patient engagement techniques into pain management or develop a treatment plan for a patient with chronic pain. DISCUSSION: These data support an ongoing need for comprehensive clinician-based education as outlined in the FDA REMS educational blueprint, especially given recent data of escalating overdose deaths during the COVID-19 pandemic.

Federal, state, and institutional barriers to the expansion of medication and telemedicine abortion services in Ohio, Kentucky, and West Virginia during the COVID-19 pandemic.

OBJECTIVES: We aimed to characterize the combined impact of federal, state, and institutional policies on barriers to expanding medication and telemedicine abortion care delivery during the COVID-19 pandemic in the abortion-restrictive states of Ohio, Kentucky, and West Virginia. STUDY DESIGN: We analyzed 4 state policies, 2 COVID-related state executive orders, and clinic-level survey data on medication abortion provision from fourteen abortion facilities in Ohio, Kentucky, and West Virginia from December 2019 to December 2020. We calculated the percent of medication abortions provided at these facilities during the study period by state, to assess changes in medication abortion use during the pandemic. RESULTS: We ascertained that COVID-19-executive orders in Ohio and West Virginia that limited procedural abortion in Spring 2020 coincided with an increase in the overall number and proportion of medication abortions in this region, peaking at 1613 medication abortions (70%) in April 2020. Ohio and West Virginia, which had executive orders limiting procedural abortion, saw relatively greater increases in April compared to Kentucky. Despite temporary lifting of the mifepristone REMS, prepandemic regulations banning telemedicine abortion in Kentucky and West Virginia and requiring in-person clinic visits for medication abortion distribution in Ohio limited clinics' ability to adapt to offer medication abortion by mail. CONCLUSIONS: Our findings illustrate how restrictive medication and telemedicine abortion policies in Ohio, Kentucky, and West Virginia created additional obstacles for patients seeking medication abortion during the pandemic. Permanently lifting federal regulations on in-clinic distribution of mifepristone would only advantage abortion seekers in states without restrictive telehealth and medication abortion policies. State policies that limit access to comprehensive abortion services should be central in larger efforts toward dismantling barriers that impinge upon reproductive autonomy. IMPLICATION STATEMENT: We find that abolishing the REMS on mifepristone would not be enough to expand access to patients in abortion-restrictive states with telemedicine and medication abortion laws. While the REMS is a barrier, it represents one of several hindrances to the expansion of telemedicine abortion distribution across the United States.

Abortion exceptionalism and the mifepristone REMS.

Since its initial approval, mifepristone has been regulated with a strictness out of proportion to its risks. This paper explores how the regulation of mifepristone, specifically the Risk Evaluation and Mitigation Strategies (REMS) requirements, are a manifestation of abortion exceptionalism-the phenomenon of abortion being treated differently under the law than other comparable health care. The weight of medical and public health evidence demonstrates that mifepristone is extremely safe and the REMS are unnecessary. In fact, the mifepristone REMS is neither justified by the absolute risk of the medication itself, nor comprehensible as a logical response to the risks actually posed by mifepristone. Nevertheless, the REMS remain in place. From July 2020 through January 2021, enforcement of the REMS elements requiring in-person distribution of mifepristone were enjoined by court order due the COVID-19 pandemic. In other words, COVID-19 created a context so exceptional as to temporarily outweigh abortion exceptionalism. However, the reprieve did not last-in January 2021, the Supreme Court ruled to dissolve the injunction, allowing FDA to resume enforcement of the in-person requirements. In response, advocates called on the incoming Biden administration to direct FDA to suspend enforcement once more. This regulatory whiplash is itself further evidence that the REMS flow from political, rather than scientific, concerns. Abortion exceptionalism is apparent in the specific requirements of the REMS, and it is also apparent in the precarity of the regulatory scheme itself.

The future of abortion is now: Mifepristone by mail and in-clinic abortion access in the United States.

The COVID-19 pandemic disrupted health care delivery in all aspects of medicine, including abortion care. For 6 months, the mifepristone Risk Evaluation and Mitigation Strategy (REMS) was temporarily blocked, allowing for the remote provision of medication abortion. Remote medication abortion may become a dominant model of care in the future, either through the formal health system or through self-sourced, self-managed abortion. Clinics already face pressure from falling abortion rates and excessive regulation and with a transition to remote abortion, may not be able to sustain services. Although remote medication abortion improves access for many, those who need or want in-clinic care such as people later in pregnancy, people for whom abortion at home is not safe or feasible, or people who are not eligible for medication abortion, will need comprehensive support to access safe and appropriate care. To understand how we may adapt to remote abortion without leaving people behind, we can look outside of the U.S. to become familiar with emerging and alternative models of abortion care.

Adoption of no-test and telehealth medication abortion care among independent abortion providers in response to COVID-19.

OBJECTIVE: Access to abortion care in the United States (US) is restricted by numerous logistical and financial barriers, which have been further intensified by the COVID-19 pandemic. We sought to understand the ways in which COVID-19 prompted changes in clinical practices in abortion care among independent abortion clinics. STUDY DESIGN: We surveyed independent US abortion clinics and documented changes in practice regarding the provision of abortion since March 1, 2020. RESULTS: Among about 153 independent clinics invited, 100 clinics contributed relevant data and were included in the analytic sample. A total of 87% reported changes in protocols in response to the COVID-19 pandemic. Reported changes included moving to telehealth (phone or video) for follow-up (71%), starting or increasing telehealth for patient consultations and screening (41%), reducing Rh testing (43%) and other tests (42%), and omitting the preabortion ultrasound (15%). A total of 20% reported allowing quick pickup of medication abortion pills, and 4% began mailing medications directly to patients after a telehealth consultation. Clinical practice changes were reported throughout all regions of the US, but facilities in the Northeast (73%) were more likely to report starting or increasing telehealth than facilities in the South (23%, p < .001). CONCLUSION: The COVID-19 pandemic accelerated use of telehealth among independent abortion clinics, but many clinics, particularly those in the South, have been unable to make these changes. Other practices such as reducing preabortion ultrasounds were less common in all regions despite clinical guidelines and evidence supporting such changes in practice and positive benefits for public health and patient-centered care. IMPLICATIONS: The COVID-19 pandemic has created a window of opportunity to remove barriers to abortion, including expanding telehealth and reducing preabortion tests. Clinics can strive for a culture shift towards simplifying the provision of medication abortion and routinely avoiding preabortion tests and in-person visits. Such changes in practice could have positive benefits for public health and patient-centered care.

Predicting intensive care unit admission and death for COVID-19 patients in the emergency department using early warning scores.

AIMS: To identify the most accurate early warning score (EWS) for predicting an adverse outcome in COVID-19 patients admitted to the emergency department (ED). METHODS: In adult consecutive patients admitted (March 1-April 15, 2020) to the ED of a major referral centre for COVID-19, we retrospectively calculated NEWS, NEWS2, NEWS-C, MEWS, qSOFA, and REMS from physiological variables measured on arrival. Sensitivity, specificity, positive (PPV) and negative predictive value (NPV), and the area under the receiver operating characteristic (AUROC) curve of each EWS for predicting admission to the intensive care unit (ICU) and death at 48 h and 7 days were calculated. RESULTS: We included 334 patients (119 [35.6%] females, median age 66 [54-78] years). At 7 days, the rates of ICU admission and death were 56/334 (17%) and 26/334 (7.8%), respectively. NEWS was the most accurate predictor of ICU admission within 7 days (AUROC 0.783 [95% CI, 0.735-0.826]; sensitivity 71.4 [57.8-82.7]%; NPV 93.1 [89.8-95.3]%), while REMS was the most accurate predictor of death within 7 days (AUROC 0.823 [0.778-0.863]; sensitivity 96.1 [80.4-99.9]%; NPV 99.4[96.2-99.9]%). Similar results were observed for ICU admission and death at 48 h. NEWS and REMS were as accurate as the triage system used in our ED. MEWS and qSOFA had the lowest overall accuracy for both outcomes. CONCLUSION: In our single-centre cohort of COVID-19 patients, NEWS and REMS measured on ED arrival were the most sensitive predictors of 7-day ICU admission or death. EWS could be useful to identify patients with low risk of clinical deterioration.