COVID-19 in Seattle-Early lessons learned.

The coronavirus disease 2019 (COVID-19) pandemic has rapidly evolved and now dominates the attention and full efforts of the emergency medicine community, both domestic and abroad. Seattle is the site of the initial diagnosed COVID-19 cases and fatalities in the United States. We provide an overview of the system-level response of 6 Seattle emergency departments and the Washington state chapter of the American College of Emergency Physicians (ACEP) to the COVID-19 pandemic. Local efforts involved the spectrum of emergency response including on- and off-site triage strategies, an approach to personal protective equipment, testing and reporting protocols, early treatments, communication strategies, the impact on front-line providers, and ongoing work.

Setting up the Largest Mass Vaccination Center in Europe: The One-Physician One-Nurse Protocol.

To manage mass vaccination without impacting medical resources dedicated to care, we proposed a new model of Mass Vaccination Centers (MVC) functioning with minimum attending staffing requirements. The MVC was under the supervision of one medical coordinator, one nurse coordinator, and one operational coordinator. Students provided much of the other clinical support. Healthcare students were involved in medical and pharmaceutical tasks, while non-health students performed administrative and logistical tasks. We conducted a descriptive cross-sectional study to describe data concerning the vaccinated population within the MVC and the number and type of vaccines used. A patient satisfaction questionnaire was collected to determine patient perception of the vaccination experience. From 28 March to 20 October 2021, 501,714 vaccines were administered at the MVC. A mean rate of 2951 ± 1804 doses were injected per day with a staff of 180 ± 95 persons working every day. At peak, 10,095 injections were given in one day. The average time spent in the MVC was 43.2 ± 15 min (time measured between entry and exit of the structure). The average time to be vaccinated was 26 ± 13 min. In total, 4712 patients (1%) responded to the satisfaction survey. The overall satisfaction with the organization of the vaccination was 10 (9-10) out of 10. By using one attending physician and one nurse to supervise a staff of trained students, the MVC of Toulouse optimized staffing to be among the most efficient vaccination centers in Europe.

The development of new remote technologies in disaster medicine education: A scoping review.

Background: Remote teaching and online learning have significantly changed the responsiveness and accessibility after the COVID-19 pandemic. Disaster medicine (DM) has recently gained prominence as a critical issue due to the high frequency of worldwide disasters, especially in 2021. The new artificial intelligence (AI)-enhanced technologies and concepts have recently progressed in DM education. Objectives: The aim of this article is to familiarize the reader with the remote technologies that have been developed and used in DM education over the past 20 years. Literature scoping reviews: Mobile edge computing (MEC), unmanned aerial vehicles (UAVs)/drones, deep learning (DL), and visual reality stimulation, e.g., head-mounted display (HMD), are selected as promising and inspiring designs in DM education. Methods: We performed a comprehensive review of the literature on the remote technologies applied in DM pedagogy for medical, nursing, and social work, as well as other health discipline students, e.g., paramedics. Databases including PubMed (MEDLINE), ISI Web of Science (WOS), EBSCO (EBSCO Essentials), Embase (EMB), and Scopus were used. The sourced results were recorded in a Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) flowchart and followed in accordance with the PRISMA extension Scoping Review checklist. We included peer-reviewed articles, Epubs (electronic publications such as databases), and proceedings written in English. VOSviewer for related keywords extracted from review articles presented as a tabular summary to demonstrate their occurrence and connections among these DM education articles from 2000 to 2022. Results: A total of 1,080 research articles on remote technologies in DM were initially reviewed. After exclusion, 64 articles were included in our review. Emergency remote teaching/learning education, remote learning, online learning/teaching, and blended learning are the most frequently used keywords. As new remote technologies used in emergencies become more advanced, DM pedagogy is facing more complex problems. Discussions: Artificial intelligence-enhanced remote technologies promote learning incentives for medical undergraduate students or graduate professionals, but the efficacy of learning quality remains uncertain. More blended AI-modulating pedagogies in DM education could be increasingly important in the future. More sophisticated evaluation and assessment are needed to implement carefully considered designs for effective DM education.

MONITORING OF PATIENTS IN SEVERE CONDITION IN LEVEL 1 AND LEVEL 2 MEDICAL TREATMENT ORGANIZATIONS – A TOOL FOR ORGANIZING MEDICAL CARE FOR PATIENTS AND VICTIMS IN EMERGENCY SITUATIONS

The objective of the study was to analyze the effectiveness of the "Monitoring" program for patients with new coronavirus infection and to evaluate its preparedness to work in emergency situations, as well as to substantiate the effectiveness of the program as a monitoring tool for patient care management in level 1 and level 2 medical treatment organizations when there is a shortage of intensive care beds at level 3 medical institutions. Materials and research methods. Materials of the research: normative legal documents regulating the order of application of telemedicine technologies in Russia and Kuzbass, including in the field of the Disaster Medicine Service, scientific publications, personal work experience in the organization of remote consultations. The research was based on the data on the provision of consultative medical care to the patients with the diagnoses "new coron-avirus infection” and "community-acquired pneumonia”, who were hospitalized in the intensive care departments of level 1 and level 2 medical treatment organisations. Research results and their analysis. The retrospective analysis of the calls to the monitoring center from the patients in severe condi-tion, being treated in level 1 and level 2 medical treatment organizations for the diagnoses of new coronavirus infection and pneu-monia, who needed monitoring by the specialists of the consulting center (mainly by intensive care specialists), was performed. Inclusion criteria in the study: adult patients with new coronavirus infection and pneumonia;receipt of call to the monitoring center during the study period – 01.11.2020-31.01.2022;availability of patient counseling using "Monitoring" program. Conclusion was made, that the system, linking major hospitals with local hospitals, which have the maximum load in periods of peak morbidity, through conducting emergency and urgent telemedicine consultations was created in Kuzbass. The analysis of the obtained data testifies to the effective work of the monitoring center for severe patients as a type of telemedicine tool when working in high alert mode. © Burnasyan FMBC FMBA.

KEY RESULTS OF ACTIVITIES OF THE FEDERAL CENTER FOR DISASTER MEDICINE OF THE FEDERAL STATE INSTITUTION "NATIONAL MEDICAL AND SURGICAL CENTER NAMED AFTER N.I. PIROGOV” AND OF THE DISASTER MEDICINE SERVICE OF THE MINISTRY OF HEALTH OF RUSSIA IN 2021

The preparedness of the Russian health care to react to emergency situations, issues of organization and provision of medical care and medical evacuation in emergencies are inextricably linked to the activities of the Disaster Medicine Service of the Russian Ministry of Health, the main component of the All-Russian Disaster Medicine Service. Since March 1, 2021 day-to-day administration of the All-Russian Disaster Medicine Service and of the Disaster Medicine Service of the Russian Ministry of Health is performed by the Federal Center for Disaster Medicine of National Medical and Surgical Center named after N.I. Pirogov. The aim of the study is to define the priorities for the year 2022 for the Federal Disaster Medicine Center, for Disaster Medicine Service of the Russian Ministry of Health and for the All-Russian Disaster Medicine Service as well as for the whole system of population medical support in emergencies. The priorities will be defined based on the analysis of the 2021 year activities for the Federal Center for Disaster Medicine, for territorial centers of disaster medicine, for regional centers of emergency and disaster medicine and for regional centers of disaster and emergency medicine. Materials and research methods. Regulatory and methodological documents governing the organization and functioning of the All-Russian Disaster Medicine Service and of the Disaster Medicine Service of the Ministry of Health of Russia, documents setting the procedure for medical care and medical evacuation of victims in emergencies;reports of territorial centers of disaster medicine, of regional centers of emergency and disaster medicine and of regional centers of disaster and of federal disaster medicine centres on the medical and sanitary emergency response activities in 2021 as well as other documents;scientific papers and publications on current issues of medical care in emergencies, on development of the Disaster Medicine Service information environment and on digitalization of healthcare. Research methods: analytical statistical, method of direct observation, logical and informational modeling. Research results and their analysis. The main results of activities of Federal Disaster Medicine Center and of Disaster Medicine Service of the Russian Ministry of Health in 2021 were considered, including information interaction with the operational services in conference mode, monitoring of the medical and sanitary situation, emergency data, measures to combat the COVID-19 pandemic, etc. The structure of Disaster Medicine Service at the regional level was analyzed. The main directions of Federal Disaster Medicine Center and Disaster Medicine Service of the Russian Ministry of Health activities for 2022 are presented. © Burnasyan FMBC FMBA.

COVID-19: A Comprehensive Analysis of the Pandemic's Effect on an Emergency Department.

OBJECTIVE: Coronavirus disease 2019 (COVID-19, caused by severe acute respiratory syndrome coronavirus 2 [SARS-CoV-2]) is a historic pandemic severely impacting health care. This study examines its early effect on a busy academic emergency department. METHODS: A retrospective analysis of patients from an academic tertiary care Level I trauma, cardiac and stroke center's emergency department seeing an average of 54,000 adults and 21,000 pediatric patients per year. Total visits, reasons for patient visits, demographics, disposition, and length of stay were analyzed from January through July 2020 and compared with the same time period in the previous 2 y. RESULTS: From March through July 2020 there were statistically significant decreases in the total number of patient visits (-47%) especially among pediatric (-73%) and elderly (-43%) patients and those with cardiovascular (-39%), neurological (-63%) complaints, headaches (-60%), back pain (-64%), abdominal pain (-51%), and minor trauma (-71%). There was, however, a significant increase in pulmonary complaints (+54%), as well as admissions (+32%), and length of stay (+40%). CONCLUSIONS: There was a significant drop in overall patients and select groups early in the pandemic, while admissions and emergency department length of stay both increased. This has implications for future pandemic planning.

Drawing Parallels Among Past Public Health Crises and COVID-19.

In the early stages of the coronavirus disease 2019 (COVID-19) pandemic, there were shortages of personal protective equipment (PPE) and health-care personnel across severely affected regions. Along with a lack of testing, these shortages delayed surveillance, and possible containment of the virus. The pandemic also took unprecedented tolls on the mental health of many health-care workers who treated and witnessed the deaths of critically ill patients. To address these effects and prepare for a potential second wave, a literature review was performed on the response of health-care systems during the influenza pandemics of 1918, 1957, 2009, and the epidemics of Ebola, severe acute respiratory syndrome (SARS), and Middle East respiratory syndrome (MERS). We can use lessons identified to develop a competent and effective response to the current and future pandemics. The public must continue to engage in proper health mitigation strategies, including use of face coverings, physical distancing, and hand washing. The impact the pandemic has had on the mental health of frontline health-care workers cannot be disregarded as it is essential in ensuring effective patient care and mitigating psychological comorbidities. The lessons identified from past public health crises can help contain and limit morbidity and mortality with the ongoing COVID-19 pandemic.

Disaster Training Following COVID-19 for Pediatric Medical Residents: Demand and Format.

OBJECTIVES: Assess the knowledge, confidence, and attitudes of residents toward disaster medicine education in the coronavirus disease 2019 (COVID-19) era. METHODS: Survey distributed to pediatric residents at a tertiary care center, assessing confidence in disaster medicine knowledge and skills, and preferred educational methods. Based on residents' responses, virtual and in-person educational session implemented with a postsurvey to analyze effectiveness of education. RESULTS: Distributed to 120 residents with a 51.6% response rate. Almost half (46.8%) of residents had less than 1 h of disaster training, with only 9.7% having experience with a prior disaster event. However, most residents were motivated to increase their knowledge of disaster medicine due to COVID-19 and other recent disasters, with 96.8% interested in this education as a curriculum standard. Simulation and peer learning were the most preferred method of teaching. Subsequent virtual and in-person educational session demonstrated improvement in confidence scores. However, 66.7% of the virtual subset conveyed they would have preferred in-person learning. CONCLUSIONS: COVID-19 has highlighted to trainees that disasters can affect all specialties, and pediatric residents are enthusiastic to close the educational gap of disaster medicine. However, residents stressed that, although virtual education can provide a foundation, in-person simulation is preferred for effective training.

ALL-RUSSIAN CENTER FOR DISASTER MEDICINE "ZASHCHITA" OF FEDERAL MEDICAL AND BIOPHYSICAL CENTER NAMED AFTER A.I. BURNAZYAN OF THE FEDERAL MEDICAL AND BIOLOGICAL AGENCY OF THE RUSSIAN FEDERATION: RESULTS OF WORK IN 2021 AND OBJECTIVES FOR 2022

The need to protect the population of the territories and personnel of the facilities serviced by the Federal Medical and Biological Agency in emergency situations by medical treatment organizations and mobile medical formations sets them an important task — to provide timely emergency and urgent medical care to victims in an emergency in accordance with modern principles of medical evacuation routing. The aim of the study is to analyze and to evaluate the main results of the activities of the All-Russian Center for Disaster Medicine "Zaschita" as a part of Federal Medical and Biophysical Center named after A.I. Burnazyan of the Federal Medical and Biological Agency of the Russian Federation, to develop proposals and to define objectives for further development and improvement of the system to organize medical care and medical evacuation in emergencies at facilities and territories served by FMBA of Russia. Materials and research methods. Materials: regulatory, legal and methodological documents governing the procedure for provid-ing medical aid to the victims of emergencies;reports of the structural units of the All-Russian Center for Disaster Medicine "Zaschita", including special exercises held in 2021;scientific papers on topical issues of medical support to the population in emergencies. Research methods: analytical, statistical, method of direct observation. Results of the study and their analysis. The results of the first year of operation of the the All-Russian Center for Disaster Medicine "Zaschita" as a part of Federal Medical and Biophysical Center named after A.I. Burnazyan of the Federal Medical and Biological Agency of the Russian Federation in 2021 are presented. The following results are considered and analyzed: special trainings of the Field Multidisciplinary Hospital and Consolidated medical detachment;work on medical support of mass events — "Tavrida" Forum of Young Culture and Arts Workers and "Silk Road" international rally. The work of the laboratory of scientific and methodical problems of medical support in emergency situations established in the All-Russian Center for Disaster Medicine "Zaschita" within the past year was characterized. Decrease of the Center of sanitary avia-tion and ambulance services abroad activities due to borders closing, caused by COVID-19 pandemic, is highlighted. The activities of the All-Russian Center for Disaster Medicine "Zaschita" in the field of civil defense in the interests of FMBA of Russia, are listed. The main tasks for the All-Russian Center for Disaster Medicine "Zaschita" for 2022 are formulated. © Burnasyan FMBC FMBA.

Age, gender, and setting's effect on community pharmacists' stress and confidence in the COVID-19 pandemic.

Background: Reports of increased stress among healthcare workers were commonplace during the early days of the COVID-19 pandemic, but little is known about community pharmacists' experiences. Objective: To characterize community pharmacists' stress and confidence during the early COVID-19 pandemic and identify associated factors. Methods: Pharmacists who worked in a brick-and-mortar community pharmacy (e.g., big-box, chain, independent, or grocery pharmacies) located in Connecticut and had regular face-to-face interaction with the public were surveyed. Survey items were selected from the Perceived Stress Scale-10 (PSS-10) and adapted from the Emergency Risk-Communication (ERC) framework. Data were analyzed using chi-square and ANOVA. Results: Survey results suggested pharmacists experienced moderate levels of stress, as negative responses to PSS-10 items ranged between 6.4% to 43.3%, respectively. Overall, pharmacists had high rates of confidence in their ability to manage the pandemic, agreeing or strongly agreeing that they could manage their own mental health (73.1%), and communicate the risks of the pandemic (72.0%). However, 28.0% reported that they had avoided talking about the pandemic because it made them feel "stressed, or nervous." Women and those working in chain community pharmacies tended to report significantly higher rates of stress to several items in the PSS-10 compared to men and pharmacists working in non-chain settings. Women and chain community pharmacists were also significantly more likely to report overall that they had avoided talking about public health risks because it made them feel anxious, stressed, or depressed (29.4% men vs. 34.5% women χ2 (4) > 22.6, p < 0.01). However, confidence to communicate critical risk messages neither differed between men and women (77.6% men vs. 68.8% women χ2 (4) > 8.3, p = 0.08), nor between chain and non-chain community pharmacists (71.0% chain vs. 73.7% non-chain χ2 (4) > 8.9, p = 0.32). Conclusion: Being female, younger age, and employed at a chain pharmacy were associated with higher rates of stress and lower self-confidence among community pharmacists during the COVID-19 pandemic.

Spatial Scattering Radiation to the Radiological Technologist during Medical Mobile Radiography.

Mobile radiography allows for the diagnostic imaging of patients who cannot move to the X-ray examination room. Therefore, mobile X-ray equipment is useful for patients who have difficulty with movement. However, staff are exposed to scattered radiation from the patient, and they can receive potentially harmful radiation doses during radiography. We estimated occupational exposure during mobile radiography using phantom measurements. Scattered radiation distribution during mobile radiography was investigated using a radiation survey meter. The efficacy of radiation-reducing methods for mobile radiography was also evaluated. The dose decreased as the distance from the X-ray center increased. When the distance was more than 150 cm, the dose decreased to less than 1 µSv. It is extremely important for radiological technologists (RTs) to maintain a sufficient distance from the patient to reduce radiation exposure. The spatial dose at eye-lens height increases when the bed height is high, and when the RT is short in stature and abdominal imaging is performed. Maintaining sufficient distance from the patient is also particularly effective in limiting radiation exposure of the eye lens. Our results suggest that the doses of radiation received by staff during mobile radiography are not significant when appropriate radiation protection is used. To reduce exposure, it is important to maintain a sufficient distance from the patient. Therefore, RTs should bear this is mind during mobile radiography.

Relationship between intensive care surge capacity and hospital factors: an extensive experience.

As a prolonged surge scenario, the COVID-19 pandemic has offered an unparalleled opportunity to improve hospital surge capacity (SC) understanding and the ability to manage it. In this study, the authors report the experience of a large hospital network and evaluate potential relationships between Intensive Care Units SC (ICU-SC) and some hospital-related variables: bed occupancy, emergency department admissions, ward admission from ED, and elective surgery procedures. Pearson's partial correlation coefficient (r) has been used to define the relationship between SC and the daily values of the above variables, collected through a dedicated digital platform that also ensured a regular quality check of the data. The observation has concerned several levels of analysis, namely two different types of SC calculation (SC base-SCb and SC actual-SCa), hospital category level and multi-hospital level, and two consecutive pandemic waves. Among the 16 hospitals observed, the correlation was shown to be moderate-positive with non-ICU bed occupancy (r/ = 0.62, r/ = 0.54), strong/moderate with ICU bed occupancy (r/ = 0.72, r/ = 0.54), and moderate with ward admissions from ED (r/ = 0.50, r/ = 0.51) On the contrary, the correlation proved to be moderate-negative with ED admissions (r/ = - 0.69, r/ = - 0.62) and low with the number of elective surgery procedures (r/ = - 0.10, r/ = - 0.16). This study identified a positive correlation between SC and three variables monitored: ICU bed occupancy, non-ICU bed occupancy, and ward admissions from ED. On the contrary, the correlation was negative for ED admission and the number of elective surgery procedures. The results have been confirmed across all levels of analysis adopted.

Clinical support during covid-19: An opportunity for service and learning? A cross-sectional survey of UK medical students.

PURPOSE: Medical students providing support to clinical teams during Covid-19 may have been an opportunity for service and learning. We aimed to understand why the reported educational impact has been mixed to inform future placements. METHODS: We conducted a cross-sectional survey of medical students at UK medical schools during the first Covid-19 'lockdown' period in the UK (March-July 2020). Analysis was informed by the conceptual framework of service and learning. RESULTS: 1245 medical students from 37 UK medical schools responded. 57% of respondents provided clinical support across a variety of roles and reported benefits including increased preparedness for foundation year one compared to those who did not (p < 0.0001). However, not every individual's experience was equal. For some, roles complemented the curriculum and provided opportunities for clinical skill development, reflection, and meaningful contribution to the health service. For others, the relevance of their role to their education was limited; these roles typically focused on service provision, with few opportunities to develop. CONCLUSION: The conceptual framework of service and learning can help explain why student experiences have been heterogeneous. We highlight how this conceptual framework can be used to inform clinical placements in the future, in particular the risks, benefits, and structures.[Box: see text].

[Pandemic relief volunteers-increasing resilience for disasters]. / Pandemienotfallhelfer ­ gestärkte Resilienz für den Katastrophenfall.

BACKGROUND: The corona pandemic demands new solutions from our health care system in order to expand treatment capacities in a resilient manner within a short period of time. The last stage of expansion is disaster protection, the resilience of which can also be improved by volunteers. However, these spontaneous volunteers require training in order to be integrated into the disaster relief structures. METHODS: In a step-by-step process, an ad hoc expert panel developed a curriculum for pandemic relief volunteer (PRV) training. RESULTS: The goal of PRV is to assist fully trained responders during transport and care in a makeshift hospital. The curriculum for training as a PRV comprises 16 instructional units of 45 min each on the topics of deployment, self-protection, protection of others, and direct patient care. The focus is on practical skills for which the participants can take responsibility for execution. CONCLUSION: The concept of the PRV is the first structured training and integration of spontaneous responders in German civil protection. It is not a substitute for fully trained full-time and voluntary staff, but can provide useful support.

Health Care Management during a Major Planned Event in Italy.

Events involving a high number of participants should be planned and implemented with the primary objective of guaranteeing the highest possible level of safety, which is ever more essential in the recent years due to the risk of terrorism, violence, and highly transmissible pathogens like coronavirus disease 2019 (COVID-19).The aim of this study was describing health care management of the Vasco Modena Park July 1, 2017 concert by the artist Vasco Rossi that involved 220,000 participants, more than doubling the population of Modena (Italy), the city hosting the event.Data were retrospectively collected from all health care registers used during the concert. Descriptive data regarding the event were recorded, as well as the medical records generated by the advanced medical posts.For analysis, patients were divided into two groups: the LOW-Severity (admission code green) and HIGH-Severity (admission codes yellow and red). The number of patients within the inclusion period was 1,088; there were 953 green discharge codes (97.74%), 16 yellow (1.64%), and six red (0.61%). Patients who needed a second-level assessment were 5.85% (57 events). HIGH-Severity patients needed to be further evaluated in 45.45% of the cases versus 4.93% of the LOW-Severity patient group (P value <.001).The health care management proved adequate to the number of participants and the severity of patients. Descriptive data reported add the mass-gathering database useful for further events.

Nonintensivist Training to Increase the Staff Capacity of Intensive Care Units During COVID-19 Pandemic Surge in Argentina.

OBJECTIVE: The aim of this study was to report the results of a nationwide critical-care course for non-intensivists to increase staff capacity of intensive care units (ICUs) during the coronavirus disease 2019 (COVID-19) pandemic in Argentina. METHODS: Three academic organizations, with special funding from 55 private companies, developed a short virtual course comprised of Web-based videos, virtual tutorials, and a forum chat. Each state assigned scholarships to non-ICU staff from public hospitals. Students received active follow-up for the completion of the course and took a survey upon course completion. RESULTS: After 4 m, there were 10,123 students registered from 661 hospitals in 328 cities. Of these, 67.8% passed the course, 29.1% were still ongoing, and 3.1% were inactive. Most students were female (74.2%) with a median of 37 y old (IQR 31-44). The group was composed of 56.5% nurses, 36.2% physicians, and 7.4% physiotherapists, of whom 48.3% did not have any experience in critical care. Mean overall satisfaction was 4.4/5 (standard deviation, 0.9), and 90.7% considered they were able to apply the contents to their practice. CONCLUSIONS: This course was effective for rapid training of non-ICU personnel. The assignment strategy, the educational techniques, and the close follow-up led to low dropout and high success rates and satisfaction.

Willingness to Work amongst Australian Frontline Healthcare Workers during Australia's First Wave of Covid-19 Community Transmission: Results of an Online Survey.

OBJECTIVES: The majority of research investigating healthcare workers' (HCWs) willingness to work during public health emergencies, asks participants to forecast their perceptions based on hypothetical emergencies, rather than in response to the actual public health emergencies they have experienced. This research explored frontline HCWs willingness to work during Australia's first wave of the COVID-19 pandemic among frontline HCWs. METHODS: Participants (n = 580) completed an online questionnaire regarding their willingness to work during the pandemic. RESULTS: A total of 42% of participants reported being less willing to work during the pandemic compared to before. Availability of personal protective equipment (PPE), concern expressed by family members, and viral exposure were significant barriers. A third of participants disagreed that some level of occupational risk for exposure to infectious disease was acceptable while a quarter of participants had received communications from their workplace concerning obligations to work during COVID-19. CONCLUSIONS: The COVID-19 pandemic has impacted Australian frontline HCWs' willingness to work. Scarcity of PPE and exposure to the virus were the most cited reasons impacting on willingness to work. Appropriate policies and practices should be implemented and communicated efficiently to frontline HCW's. This research provides insight into the lived experiences of Australian healthcare professionals' willingness to work during a pandemic.