Programming courses Teaching methods Before, During, and After COVID-19 Pandemic

During the pandemic of COVID-19 educational institutions have adopted the online teaching and learning mechanisms. This has led to some challenges in teaching programming courses as those considered to be one of the most difficult disciplines. In this research paper, the online teaching methods in addition to the online assessments' methods are discussed and reviewed. A survey for students and instructors is carried out to study the effectiveness of these teaching and assessments methods, and whether students and instructors would like to continue using them after COVID. The survey included students and faculty members from Ahlia University in the Kingdom of Bahrain and University of Business and Technology in the Kingdom of Saudi Arabia. Results are then analyzed and discussed. © 2023 IEEE.

Multi-Level Governance and Emergency Management: Building a Priority Assessment Matrix in the Pandemic Outbreak

The execution of effective responses during a large-scale emergency requires gathering appropriate information and implementing priority assessment processes. In particular, the design of comprehensive and multi-dimensional evaluation methods is crucial, especially in countries characterized by the presence of multiple levels of authority and regional governance. In this article, we illustrate the development of a structured method that was used to support emergency decisions during the COVID-19 emergency in Brazil. We applied a design science roadmap in order to produce an artifact development process, based on extensive expert involvement and multiple sources, to identify the core requirements and information needs at healthcare management and governance levels. This study provides an assessment matrix and measurement scale based on twenty indicators and five key criteria (i.e., gravity, urgency, trend, amplitude, and impact). The study provides an evidence-based method for assessing the emergency status of, and defining recommendations for, operators and policymakers. This method can be adopted for other emergency management scenarios and contexts in order to support the analysis and implementation of responses;this has a specific relevance for multi-level governance contexts. © 2023 by the authors.

Development of Reference Process Model and Reference Architecture for Pharmaceutical Cold Chain

Although the competence level in pharmaceutical cold chain logistics is adequate in the current healthcare sector, the future will be more unpredictable, disruptive, and chaotic than the world of today because of rapid technological changes, as well as social disruption. This work introduces and evaluates a new cold chain structure based on the enhanced reference process model (RPM) and reference architecture (RA) for the pharmaceutical cold chain competence design. The modified Delphi technique is used to design a systematic decision context to evaluate the improved RPM and RA and produce a competence design by obtaining agreement from a panel of experts. Ten experts in cold chain logistics took part in the modified Delphi assessment process to describe the model and architecture for an evaluation lead. They defined it as the assessment associated with the professional related to cold chain accreditation. Ten participants from six countries were asked questions regarding their expertise, abilities, and opinions in the first round, and their comments were collected. In the second and third rounds, comments and consensus were collected, which were set at 80% for RPM and RA. This work proposes an innovative scheme for developing occupational standards based on the RPM and RA, as opposed to the traditional method of employing functional analysis to establish occupational standards. This work can be further expanded to develop professional competencies in the pharmaceutical cold chain. © 2023 by the authors.

Herb-induced Liver Injury-A Guide to Approach. Lessons from the Tinospora cordifolia (Giloy) Case Series Story.

Background: Tinospora cordifolia (TC) is being increasingly consumed in India for its health and suggested immune-enhancing benefits in preventing and countering COVID-19. We previously published our experience of hepatotoxicity with self-medication of TC in six individuals. Since herb-induced liver injury (HILI) has been described with Tinospora crispa (TCR) consumption, it was contested that our patients may have mistakenly self-medicated with TCR which is similar in appearance to TC. Methods: We collected the four plant samples and two commercial preparations that were consumed by our patients for further analysis. The six samples underwent high performance thin layer chromatography phytochemical analysis and DNA barcoding studies for the confirmation of the genus and species. The four plant part samples which included stems and leaves were also analysed by a botanist for the characteristic morphological and microscopic features. Results: Based on morphological, microscopic, phytochemical and DNA studies, the four plant part samples were identified as TC. The two commercial preparations could not be analysed on phytochemical analysis or DNA barcoding studies due to other ingredients that most likely interfered with the analysis. The herb consumed by our study subjects was confirmed to be Tinospora cordifolia. Conclusion: We have highlighted the key morphological and phytochemical differences between these two species. We propose an algorithmic approach to accurately identify the implicated herb in cases of HILI. Future studies on causality need to focus on the serological/histopathological identification of active herb/metabolites in human tissues.

Highlights of the drug-induced liver injury literature for 2021.

INTRODUCTION: In 2021, over 3,000 articles on Drug-Induced Liver Injury (DILI) were published, nearly doubling the annual number compared to 2011. This review selected DILI articles from 2021 we felt held the greatest interest and clinical relevance. AREAS COVERED: A literature search was conducted using PubMed between 1 March 2021 and 28 February 2022. 86 articles were included. This review discusses new and established cases of hepatotoxins, including new FDA approvals and COVID-19 therapeutics. Developments in biomarkers and causality assessment methods are discussed. Updates from registries are also explored. EXPERT OPINION: DILI diagnosis and prognostication remain challenging. Roussel Uclaf Causality Assessment Method (RUCAM) is the best option for determining causality and has been increasingly accepted by clinicians. Revised Electronic Causality Assessment Method (RECAM) may be more user-friendly and accurate but requires further validation. Quantitative systems pharmacology methods, such as DILIsym, are increasingly used to predict hepatotoxicity. Oncotherapeutic agents represent many newly approved and described causes of DILI. Such hepatotoxicity is deemed acceptable relative to the benefit these drugs offer. Drugs developed for non-life-threatening disorders may not show a favorable benefit-to-risk ratio and will be more difficult to approve. As the COVID-19 landscape evolves, its effect on DILI deserves further investigation.

Microplastics in the Ecosystem: An Overview on Detection, Removal, Toxicity Assessment, and Control Release

In recent decades, the accumulation and fragmentation of plastics on the surface of the planet have caused several long-term climatic and health risks. Plastic materials, specifically microplastics (MPs;sizes < 5 mm), have gained significant interest in the global scientific fraternity due to their bioaccumulation, non-biodegradability, and ecotoxicological effects on living organisms. This study explains how microplastics are generated, transported, and disposed of in the environment based on their sources and physicochemical properties. Additionally, the study also examines the impact of COVID-19 on global plastic waste production. The physical and chemical techniques such as SEM-EDX, PLM, FTIR, Raman, TG-DSC, and GC-MS that are employed for the quantification and identification of MPs are discussed. This paper provides insight into conventional and advanced methods applied for microplastic removal from aquatic systems. The finding of this review helps to gain a deeper understanding of research on the toxicity of microplastics on humans, aquatic organisms, and soil ecosystems. Further, the efforts and measures that have been enforced globally to combat MP waste have been highlighted and need to be explored to reduce its potential risk in the future. © 2022 by the authors.

Assessing the Future City Post COVID-19: Linking the SDGs, Health, Resilience, and Psychological Impact

This paper explores how the COVID-19 pandemic has affected progress toward urban sustainability. A methodological framework was developed as an integrated-assessment tool for future cities, triangulating indicators that are relevant to cities. The development of this framework was based on understanding the dimensions of sustainable cities and factors related to the urgent crises, and the related lifestyle and psychological factors. The study focuses on the SDGs and health and resilience requirements and links them with the behavioral changes resulting from the COVID-19 pandemic. This paper builds on the advantages of various methodological frameworks by integrating their respective approaches, to offer a more comprehensive solution. A series of measures and actions (scenarios) related to sustainable cities and pandemics are discussed. This approach involves developing relevant indicators by fitting the urban health and resilience goals to the social, economic, and environmental goals of sustainable cities, as well as considering the factors affecting people's perception of cities during and after the pandemic. The paper provides insights into how future cities could be planned, designed, and governed to reduce the impact of health crises and to enable the assessment of cities in relation to the chosen dimensions (health, resilience, sustainability, human). © 2023 by the authors.

Icu-Acquired Delirium in Covid Year of 2021 and Its Outcomes: A Retrospective Study

INTRODUCTION: ICU-acquired delirium results in increased LOS, duration of mechanical ventilation, and mortality. Patients with COVID are at increased risk. Current literature suggests that delirium without coma occurs in at least about 30 % of COVID patients admitted to ICU. In our ICU we use an EPIC EMR-based daily ICU checklist with ABCDEF bundle during our rounds and utilized virtual ICU during the daytime in addition to the nights with peak surges. With our study, we wanted to evaluate the incidence of Delirium during our COVID year of 2021 and its relation to Mortality rate and ICU Length of stay (LOS). METHOD(S): A retrospective evaluation of patients admitted to Houston Methodist Baytown ICU from January to December 2021. Patients with covid positive were included. Data were obtained from the EPIC and ICU dashboard. Compliance with the ABCDEF ICU checklist was reviewed by auditing 20 patient charts per month. Delirium screening compliance was evaluated on AM and PM shifts for all ICU patients. Hospital ICU acquired delirium % was defined as all patients discharged from the ICU unit in that month that didn't have a positive CAM-ICU in the first 48 hrs. and then had a positive CAM-ICU after 48 hrs. in the ICU. ICU Mortality rate is defined as the percentage of patients with ICU stays who expired during ICU stay. Descriptive statistics and linear regression were used to compare and correlate. RESULT(S): In 2021, we had 377 ICU patients with COVID positive, an Average CMI of 4.986, and a LOS index of 1.24. Compliance with the daily ABCDEF ICU Checklist was 98%. Compliance to am screening was 89.41% vs. pm screening 90.56%. Mean Incidence of ICU acquired Delirium in COVID patients was only 7.14 % (2.77- 15.22) with peaks occurring during COVID surges. Linear regression analysis predicted a strong direct relationship between Delirium % and ICU Mortality rate (P< 0.05), and ICU Length of Stay(P< 0.05). CONCLUSION(S): Our data from 2021 shows Delirium % that is significantly less than the incidence. The lower % might have been from continuing to adhere to the ABCDEF bundle, utilization of the ICU checklist, and effective use of virtual ICU. Hospital ICU acquired delirium % correlated with ICU mortality and ICU length of stay. Hence, it is important to continue to focus on ways to decrease ICU delirium.

The Eyecontrol-Med Device in Ventilated Icu Patients: A Study of Communication and Delirium

INTRODUCTION: Communication with ventilated patients in the Intensive care unit (ICU) is challenging. This may lead to anxiety and frustration, potentially contributing to the development of delirium. Various technologies, such as eye-tracking devices, have been employed to facilitate communication with varying grades of success. The EyeControl-Med device is a novel technology that delivers audio content and allows patients to interact by eye movements and could potentially allow for better communication in this setting. METHOD(S): A single-arm pilot study of patients in a mixed ICU. Patients underwent at least 3 sessions with the EyeControl-Med device administered by a speech-language pathologist. Communication and consciousness were assessed using the Lowenstein communication scale (LCS) and delirium was assessed by a computerized version of the CAM-ICU during the first and last device usage sessions. RESULT(S): 15 patients were included, 40% of whom were diagnosed with COVID-19. All patients completed three to seven usage sessions. The mean LCS score improved by 19.3 points (p < 0.0001), with each of its five components showing significant improvements as well. The mean number of errors on the CAM-ICU tool decreased from 6.5 to 2.5 (p=0.0006), indicating lower rates of delirium. No adverse effects were observed. CONCLUSION(S): The EyeControl-Med device may help enhance communication and re-orientation in this patient population while reducing the helplessness and anxiety associated with lack of communication. It may reduce the manifestations and duration of delirium in ventilated critically ill patients. Controlled studies are required to establish this effect.

Dissemination and Implementation of Age-Friendly Care and Geriatric Emergency Department Accreditation at Veterans Affairs Hospitals

Study Objectives: In 2018, the US Department of Veterans Affairs (VA) Offices of Emergency Medicine and Geriatrics & Extended Care partnered to improve acute, unscheduled care for older Veterans. The goals of the partnership were to create a VA core team to promote best geriatric emergency care practices via standardization, education, and Geriatric Emergency Department (ED) Accreditation (GEDA) through the American College of Emergency Physicians. The objective of this will be to describe the current progress of GED implementation and dissemination at the VA. Study Design / Methods: This is a descriptive summary of Veterans seen in VA EDs from January 2018 - March 2022 with data from the VA Corporate Data Warehouse. We collected GED implementation data by extracting rates of screening for documented geriatric assessments, health care utilization patterns, and demographic data from ED visits. We compared EDs with and without GED implementation (non-GED versus Level 3 to 1 (L1 = highest GEDA implementation)) based on date of accreditation [RLCD1] application submission or approval. Standardized GED assessments in the electronic health record did not begin until 2019[RLCD2], although some sites collected local data on GED programming in 2018. Results / Findings: During this implementation phase, 1.07 million unique Veterans 65+ years in age made 4.08 million VA ED visits. Over 40% of these visits were made atoccurred in a VA ED seeking or receiving GEDA. Forty percent of VA EDs (44/111) began GED initiatives and applied for or received GED accreditation (4 as Level 1, 7 as Level 2, and 33 as Level 3);28 (25%[MCM((3] [RLCD4] ) of VA ED are now GED accredited. The nationally standardized GED assessments include the Identification of Seniors At Risk (ISAR), Delirium Triage Screen (DTS), Brief Confusion Assessment Method, Mini-Cognitive assessment, a falls risk screen, Activities of Daily Living, and Caregiver Burden screen. The most heavily adopted screens completed in GEDs were the ISAR and DTS. ISAR screening documentation continuously increased, especially at Level 1 GEDs, (from 0% in 2018 to 57.5% of Veterans screened in 2022). The DTS screening documentation also increased at Level 1 GEDs (from 0% in 2018 and 2019 to 23.7% in 2022). There were no differences by admission rates when comparing Level 1 GEDs versus non-GEDs (27.9% vs. 27.3%;p=0.18). GEDs, however, had lower ED revisit rates at 24 hours (1.5% vs. 2.1%), 72 hours (4.0% vs. 5.3%), 30 days (23.3% vs. 25.1%), and 90 days (33.8% vs. 36.3%) compared to non-GEDs (all p<0.01) [RLCD5]. Conclusion(s): The VA is the country's largest integrated health care system implementing and disseminating geriatric emergency care. Adoption of geriatric-focused screenings has steadily increased over time as more facilities pursue GEDA. With 40% of its EDs seeking GED accreditation, and 25% sites achieving this (during the COVID pandemic), the VA approach to implementation and spread of geriatric emergency care can be a model for other health care systems. No, authors do not have interests to disclose Copyright © 2022

Quetiapine once daily versus twice daily for treatment of icu delirium

Introduction: Although guidelines recommend twice daily (BID) dosing of quetiapine for treatment of intensive care unit (ICU) delirium in most patients, once daily dosing at bedtime (HS) is commonly prescribed to reduce daytime somnolence. No studies have evaluated differences in outcomes. Research Question or Hypothesis: To determine if BID dosing of quetiapine reduces duration of delirium versus HS dosing for treatment of ICU delirium. Study Design: Retrospective analysis of ICU patients treated with BID versus HS dosing of quetiapine for ICU delirium. Method(s): Electronic health records were analyzed between January 1, 2017 and December 31, 2021 for patients prescribed quetiapine for ICU delirium. Patients were excluded for alcohol withdrawal, history of psychiatric conditions, receipt of <24 hours of therapy, alternative dosing variations, and death or transfer from the ICU <24 hours after beginning quetiapine. The primary outcome was recovery of delirium per Confusion Assessment Method (CAM-ICU) evaluated with Mann- Whitney U. Secondary outcomes included lengths of stay, mechanical ventilation duration, in-hospital death, and QTc prolongation. Unpaired t-test, chi-square with yates' correction, and Fisher's exact test were performed as appropriate using Graph-Pad Prism. Result(s): Baseline characteristics differed for sex in BID (38.9% female, n=23) versus HS (61.1% female, n=18) dosing and admission diagnosis (38.9% vs 17.4% COVID-19, respectively). No differences in time to delirium recovery [3 days (interquartile range [IQR], 2-5) vs 2.5 days (IQR, 1-5;p=0.6651)], ICU length of stay [16.9 days (standard deviation [SD], 9) versus 18.5 days (SD=13);p=0.6651)], duration of mechanical ventilation [9.6 (SD=8) vs 13.9 days (SD=12);p=0.2587)], or in-hospital death (60.9% vs 50%;p=0.7047) existed in the BID versus HS dosing group, respectively. Incidence of QTc prolongation was also similar between groups. Conclusion(s): Twice daily versus bedtime dosing of quetiapine did not significantly alter outcomes. These findings suggest similar efficacy without increased adverse events.

Assessment of the impact of an integrated interprofessional working group to promote the ICU Liberation initiatives -Our story two years on

Introduction: Pain, agitation, delirium, weakness, and sleep deprivation are well recognized symptoms during an ICU stay.1 In 2019, our institution set up an ICU Liberation Working Group (ILWG)2, aiming to reduce the harmful effects of these symptoms. This interprofessional working group encompassed medical, pharmacy, nursing and allied health members and utilised a multifocal approach. Objectives: To review the impact of various initiatives implemented on the outcomes of the ABCDEF (A2F) bundle in the last two years. Methods: These initiatives are based on each aspect of the A2F bundle. As shown in Table 1, the interventions were each targeted to one aspect of the A2F bundle and were grouped under four themes of teaching, operational interventions, informatics, and guidelines/policies. These interventions were audited regularly, with the results displayed on awareness boards, aiming to encourage staff engagement. An ICU Liberation week was also held to improve awareness and compliance with the A2F bundle. Results: Audit cycles were performed in April 2019, December 2019, and November 2020, assessing data representing each arm of the A2F bundle. Two-thirds of the audit standards showed a significant improvement after initial interventions were employed. The third cycle showed improvement has been maintained in half of the standards. Unfortunately, adherence did reduce in several fields. The greatest improvement was seen in sedation target documentation. A further cycle in January 2021 assessed the impact of COVID-19 on A2F application, showing a reduction across most audit criteria. There were, however, improvements in family updates and early mobilisation. Conclusion: The ongoing work of an interprofessional ILWG has shown a cohesive approach application of the A2F bundle, which has resulted in improved harm prevention and management. The impact of COVID-19 has been shown to have reduced our ability to provide improvements in A2F application. Ongoing interventions are a bespoke sleep tool and more detailed CAM-ICU assessment, designed to elucidate the underlying causes of sleep disruption and delirium. A focused quality improvement project has started, where specific interventions are to be trialed on one ICU before expectant deployment throughout other ICUs. Data will continue to be collected and presented to further assess the most effective methodology for application of the A2F bundle.

Incidence, Risk Factor and Outcome of Delirium in Intensive Care Unit (COVID vs Non-COVID ICU): An Observational Study

Aim and background: Delirium is the disturbance of consciousness characterised by acute onset, rapid fluctuations in mental status, and impaired cognitive functioning. The patient's ability to receive, process, store, and recall information is impaired in delirium. Objective: To study the incidence of delirium in patients in COVID and non-COVID ICU. To also study various risk factors associated with delirium. Materials and methods: After ethical committee approval and written informed consent, this study was carried out over a period of 1 year (August 2020 to July 2021). Each patient meeting the inclusion criteria was evaluated on the RAAS score within 24 hours of admission, then screened for delirium according to CAM-ICU worksheet every 6th hourly after admission in MICU. 50 patients were studied each in COVID and non-COVID ICU. Patients found to have delirium after the first assessment were classified as new cases. Various risk factors were evaluated prospectively. Results: Incidence of delirium in non-COVID ICU was 29%, while in COVID ICU was 37%. Delirium is present in a patient who has risk factors including smoking, higher severity of illness, oversedation, and mechanical ventilation. Antipsychotics can be used for patients who develop delirium. Conclusion: Delirium is a preventable issue in ICU patients that can be managed by preventing the risk factors that will decrease overall length of stay in ICU.

The Political Response to the COVID-19 Crisis in Italy: A First Assessment for the National Food System

The objective of this paper is to explore the policies that have been implemented and planned in relation to the impacts that the COVID-19 health crisis has had on the Italian food system. This is an evaluation exercise useful to understand what the directions imprinted on the food system will be in relation to some frameworks of particular importance at the international level, such as the 2030 Agenda, the Farm to Fork Strategy, the Biodiversity Strategy, the UN Food Summit, and the agroecological perspective. The article is divided into multiple sections. In paragraph 1.1 and 1.2, the shocks generated by COVID-19 in the global context and in the Italian national context are examined. In both, attention is drawn to changes in GDP, employment, poverty, and the food system. In paragraph 3, the methodological approach, based on the DPSIR model, is explained, as well as the materials used for the drafting of the work. In paragraph 4, all of the components (Driving Forces, Pressures, States, Impacts) of the DPSIR model are analyzed. In paragraph 5, attention is focused on all policy responses implemented during COVID-19, both on the Italian and European side. In paragraph 6, a detailed analysis of the Italian responses is made in order to fully understand the degree of influence on the Italian economy and food system. The analysis carried out, therefore, highlights the socioeconomic threats faced by the Italian government and the main measures adopted to counter them. Through a critical analysis of policies, it was possible to identify their criticalities and propose possible integrations, starting from the concept of “syndemia”. This concept was introduced in the 1990s by Merril Singer, and in this paper, it plays an important role because it takes into account the negative effects of the pandemic at the economic, health, and social levels and the importance of the sustainability of the food chain. © 2022 by the authors. Licensee MDPI, Basel, Switzerland.

Continuous Artificial Intelligence Video Monitoring of ICU Patient Activity for Detecting Sedation, Delirium and Agitation

Introduction: Activity monitoring is important in the ICU where delirium, sedation, and critical illness are associated with both inactivity and agitation. Staff monitoring of motion and sleep is intermittent and resource intense. Wearable actigraphic devices are poorly tolerated and limited to limb motion. Here we demonstrate continuous AI video monitoring in the ICU to provide alwayson, unobtrusive patient activity monitoring. Methods: We conducted a pilot study of AI video monitoring in the Duke University Hospital Medical Intensive Care Unit. Video carts continuously recorded data on encrypted hard drives. Second-by-second AI analysis generated binary motion “counts” that were summed to generate our patient motion metric: counts per minute (CPM). Scene intelligence from AI object and people detectors provided room environment information. These data streams along with de-identified (blurred) video data were used to generate prototype graphical and visual summaries of patient activity patterns and the hospital room environment. Results: We enrolled 22 patients and collected 2155 hours (116 days) of video. Representative time-series data streams are shown in the Figure (top left). These data were acquired from a 76-year-old with liver failure and an escalating nasal cannula oxygen requirement who was endotracheally intubated on the subsequent day. Note 1) the declining patient activity as the patient deteriorates and 2) the significant bedside activity (high acuity) throughout the day. We developed a prototype “overnight report” that summarizes patient activity and room environment. The Figure (bottom left) shows the overnight report for a 54-year-old post-COVID-19 patient admitted to the MICU for respiratory failure with hypoactive delirium that resolved per CAM-ICU on day 5 of data collection. Notably, our report demonstrates significant overnight movement, possibly consistent with a mixed or hyperactive delirium. To visually summarize patient motion, we generated activity “heat maps” over 10-minute intervals. As a control, we showed that the intubated and sedated liver failure patient generated a still heat map (Figure upper right). Further, we visualized daytime hypoactivity/sleep in the delirious post-COVID patient (Figure lower right), suggesting disrupted circadian rhythm, giving additional context to the negative CAM assessment. Conclusions: We demonstrated the feasibility of AI to monitor patient activity in a quaternary-care MICU. Our method has advantages compared to wearable actigraphic methods for monitoring patient activity, including being unobtrusive and being able to visualize and summarize wholebody motion. The data presented here suggest that such monitoring may be able to provide clinically actionable insights in delirium care and sedation weaning.

The Effect of Sedation with Inhaled Anesthetics on Cognitive and Psychiatric Outcomes in Critically Ill Adults: A Systematic Review

Rationale: The COVID-19 pandemic has renewed interest in the use of inhaled anesthetics for sedation of ventilated critically ill patients. Compared to intravenous sedatives, inhaled anesthetics reduce lung inflammation, time to extubation, and ICU length of stay. However, their impact on cognitive and psychiatric outcomes is less clear. In this systematic review we summarize the impact of inhaled sedatives on cognitive and psychiatric outcomes in ventilated critically ill patients. Methods: We searched MEDLINE, EMBASE, and PsychINFO for studies from 1970 - 2021 that assessed cognitive and psychiatric outcomes in critically ill adult patients sedated with inhaled anesthetics. We included case series, observational, cohort, and randomized controlled trials. Outcome(s) of interest included cognition, anxiety, depression, hallucinations, psychomotor recovery, and PTSD, as well as instruments for assessing these outcomes. Results: We identified a total of twelve studies that examined at least one of our outcomes of interest (16 total outcomes). Four studies were in post cardiac arrest survivors, three in post-operative (non-cardiac) patients, two in post-operative cardiac patients, and three more in mixed medical-surgical patients. Seven studies reported incidence of delirium, two assessed neurologic recovery post cardiac-arrest, and two examined ICU memories. One study reported on each of anxiety, depression, hallucinations, PTSD, psychomotor recovery, and long-term cognitive dysfunction more than 3 months following ICU discharge. Of the seven studies reporting on delirium, only one reported an increase in delirium for those sedated with intravenous sedation compared to volatile. The remaining studies did not report any difference in delirium incidence between modes of sedation. Similarly, no difference between sedation methods were observed for neurologic recovery following cardiac arrest, anxiety, depression, hallucinations, PTSD, psychomotor recovery, or long-term cognitive dysfunction. The most commonly used tool used was the CAM-ICU tool (delirium outcome;3 studies). Five studies used subjective chart review to assess their outcome of interest, or did not report their method of assessment. Conclusions: Few studies examined cognitive and psychiatric outcomes in critically ill adults sedated with volatile anesthetics. As volatile anesthetics offer a promising alternative mode of sedation in the ICU, future studies should incorporate assessment of these important patientcentered outcomes using validated objective tools during and following hospital stay.

Ukraine's Agrarian Sector in the Conditions of COVID-19 Distribution and Restrictive Quarantine Measures: Methodological Principles of Empirical Evaluation

Conditioned upon the negative impact of pandemic restrictions explained by the spread of COVID-19 disease, the global economy is declining, which has led to real risks and threats to the development of the Ukrainian agricultural sector. Identifying these risks and threats, assessing the impact of the spread of the COVID-19 pandemic and the quarantine measures introduced in response to the agricultural sector is an important problem of agricultural policy that requires maximum efforts to solve it. The purpose of the article is to summarise the methodological basis for assessing the impact of restrictive quarantine measures 2020-2021 related to the spread of the COVID-19 pandemic for the agricultural sector of the Ukrainian economy, to substantiate the basis for determining criteria and indicators of impact and to carry out their empirical measurement. Analysis and synthesis, induction and deduction, analogy and comparison are used to generalise the theoretical and methodological aspects of the study. To diagnose the dynamics of economic indicators, economic and statistical methods are used in analytical studies. A number of techniques of -logical tools made it possible to formulate intermediate and final conclusions. Methodological foundations, scientific, methodological and practical approaches to assessing the impact of restrictive quarantine measures 2020-2021 related to the spread of the COVID-19 pandemic for the agricultural sector of the Ukrainian economy have been improved by substantiating the optimal research tools, identifying the most informative indicators and indicators. It is proved that from the standpoint of an integrated approach, all indicators that are a measure of the impact of the spread of COVID-19 and restrictive quarantine measures on the development of the agricultural sector should be considered in accordance with the target segments for assessing changes at the macro and micro levels. In particular: Macroeconomic trends in business efficiency;entrepreneurial activity;foreign economic activity;social and labour relations;finance and investment, state support, etc. The analysis showed that the progressive development of agriculture in Ukraine during 2020 explained by quarantine restrictions demonstrated structural, economic and financial effects (results) of a downward nature. Promising areas for further research in this direction should include the development of a set of strategic measures to minimize risks for the agricultural sector of Ukraine during and after the end of the COVID-19 pandemic. © 2022 The Author(s).

Liver Injury in COVID-19 Patients with Drugs as Causatives: A Systematic Review of 996 DILI Cases Published 2020/2021 Based on RUCAM as Causality Assessment Method.

Patients with coronavirus disease 19 (COVID-19) commonly show abnormalities of liver tests (LTs) of undetermined cause. Considering drugs as tentative culprits, the current systematic review searched for published COVID-19 cases with suspected drug-induced liver injury (DILI) and established diagnosis using the diagnostic algorithm of RUCAM (Roussel Uclaf Causality Assessment Method). Data worldwide on DILI cases assessed by RUCAM in COVID-19 patients were sparse. A total of 6/200 reports with initially suspected 996 DILI cases in COVID-19 patients and using all RUCAM-based DILI cases allowed for a clear description of clinical features of RUCAM-based DILI cases among COVID-19 patients: (1) The updated RUCAM published in 2016 was equally often used as the original RUCAM of 1993, with both identifying DILI and other liver diseases as confounders; (2) RUCAM also worked well in patients treated with up to 18 drugs and provided for most DILI cases a probable or highly probable causality level for drugs; (3) DILI was preferentially caused by antiviral drugs given empirically due to their known therapeutic efficacy in other virus infections; (4) hepatocellular injury was more often reported than cholestatic or mixed injury; (5) maximum LT values were found for alanine aminotransferase (ALT) 1.541 U/L and aspartate aminotransferase (AST) 1.076 U/L; (6) the ALT/AST ratio was variable and ranged from 0.4 to 1.4; (7) the mean or median age of the COVID-19 patients with DILI ranged from 54.3 to 56 years; (8) the ratio of males to females was 1.8-3.4:1; (9) outcome was favorable for most patients, likely due to careful selection of the drugs and quick cessation of drug treatment with emerging DILI, but it was fatal in 19 patients; (10) countries reporting RUCAM-based DILI cases in COVID-19 patients included China, India, Japan, Montenegro, and Spain; (11) robust estimation of the percentage contribution of RUCAM-based DILI for the increased LTs in COVID-19 patients is outside of the current scope. In conclusion, RUCAM-based DILI with its clinical characteristics in COVID-19 patients and its classification as a confounding variable is now well defined, requiring a new correct description of COVID-19 features by removing DILI characteristics as confounders.

Iatrogenic opioid withdrawal syndrome in the intensive care unit: A case report

Purpose of Study Describe possible iatrogenic opioid withdrawal syndrome in a mechanically ventilated and sedated COVID-19 patient. Methods Used Case study Summary of Results A 41-year-old man presented with acute hypoxic respiratory failure due to COVID-19 requiring mechanical ventilation and high dose sedation with fentanyl over several days. Past medical history included type 2 diabetes, hypertension, rheumatoid arthritis on immunosuppressive medications, gout, and morbid obesity. The patient received an IV fentanyl infusion over fifteen days of approximately 50,000 mcg of fentanyl IV. The patient had frequent episodes of hypertension, delirium, and agitation while weaning from this sedation protocol. The CAM-ICU score and vital signs were used to assess for possible opioid withdrawal. Post-extubation, he received fentanyl at 10 micrograms per hour for three days to limit withdrawal symptoms. Discussion Approximately one-fourth of mechanically ventilated patients who received opioid infusions experience iatrogenic opioid withdrawal syndrome. Opioid withdrawal syndrome in an intubated and sedated patient can be challenging to identify. Classical diagnostic criteria outlined in the DSM-V include three or more of the following: dysphoric mood, nausea, vomiting, muscle aches, lacrimation, rhinorrhea, pupillary dilation, piloerection, sweating, diarrhea, yawning, fever, and insomnia. Relying on these symptoms in intubated and sedated patients with complex medical pathologies can confound the results of identifying and adequately treating Iatrogenic Opioid Withdrawal Syndrome. This case emphasizes the importance of judicious sedation in the intensive care setting and using bedside scales, such as the CAM-ICU score and autonomic changes in vital signs, to assess patients for withdrawal.

Revising College Algebra Instruction to Accept and Incorporate the Use of Smart Phone Applications

The unavoidable transition to online education due to Covid-19 pandemic has impacted instruction at all grades and in all subject areas, including college level Mathematics courses. One of the issues that has been faced is the inability to proctor exams properly. Calculators with Computer Algebra Systems and their corresponding smart phone applications can provide not only answers to most problems, but they also provide solution steps. Mathematics departments at many institutions have established policies which regulated the use of calculators and smart phones in lectures and exams. However, lack of proper proctoring in online courses makes it possible for students to pass a course, even with a decent grade, without learning the concepts. On the other hand, as the use of computers became more common, many skills previously considered as required are not required anymore, such as learning how to use logarithmic tables to evaluate logarithms. In this study, we first demonstrate the capabilities of smart phone applications and provide tips for writing procedural problems that are not easily solvable by these apps. We show examples of problems that are solvable by the apps and suggestions to revise them. Second, we discuss general suggestions on how to revise the College Algebra instruction, especially for engineering students. Our suggestions aim to fill in the gaps that could potentially be created when these apps are commonly used among students. In summary, we review and revise College Algebra instruction and assessments to accept and incorporate the use of smart phone applications. Revised topics, together with effective assessment strategies will potentially improve learning outcomes, especially when the course is taught online. Our work concentrates on revision of College Algebra topics for Engineering students, but our strategy can be applied to revise other mathematics topics for any major. © American Society for Engineering Education, 2021