Sleep Promotion in a Busy Inner City High Dependency Unit

Introduction: Critical care patients commonly have disrupted sleep patterns, with reduction of REM sleep, duration of sleep, increased fragmentation and loss of circadian rhythm.1 Causes include the patients' pathophysiology, medications administered and the busy critical care environment. Data collection showed that our patients were sleeping, on average, for a single block of sleep of 3.5 hours. Delirium rates and its known deleterious effects are highly associated with poor sleep, as well as an impairment of psychomotor performance and neurocognitive dysfunction. Sleep deprivation in the healthy population impairs lymphocyte action, cytokine production and pro-inflammatory balance, as well as a reduction in respiratory function and prolongation of respiratory support.2 Objectives: To firstly measure the sleep quality and explore the reasons behind poor sleep from the patients themselves and to gauge the MDT knowledge and interest in sleep, as a fundamental component of patient management. Then using the results we aimed to improve the duration and quality of the patients sleep on high dependency unit. Method(s): The Adapted Richard Campbell Sleep Questionnaire was given to all patients in the HDU over a 4 week period. Results were analysed, then stored for post intervention comparison. The duration of sleep was documented for all patients and a staff questionnaire was done to assess knowledge and concern of staff. Interventions included a staff sleep awareness week with education and prompts attached to the charting tables promoting sleep. Face masks and ear plugs were freely available to be distributed at the evening ward round. The critical care pharmacist identified medications that could alter the patients ability to achieve REM sleep - e.g. evening administered PPIs, and melatonin was commenced early when sleep was troublesome. Estates fixed soft close doors and soft closed bins supplied for clinical areas. After interventions, there was a further 4 week study period where the above factors were repeated. The need for natural light was highlighted and thus this was optimized in the ward environment and those physiologically able were offered trips outdoors to facilitate normal day night wake cycle. With the COVID pandemic ongoing we also endeavored to limit movement overnight of venerable patients. Result(s): The original data collection was of 45 patients with multiple data points, and the second of 27 patients with multiple data points. Results from the Adapted Richard Campbell Sleep Questionnaire were compared using a one tailed students t test. There were significant increases in the subjective quality of sleep (p=0.046) and quantity of sleep (p=0.00018). Reasons given as to improvement of sleep were reduction in discomfort from monitoring and the bed (p=0.026), reduced ambient light (p=0.031) and reduced impact from the presence of other patients (p=0.002). Conclusion(s): There was marked improvement in the awareness of the importance of sleep within the critical care team after education promoting a change in attitude and culture towards sleep. We are planning a second iteration targeting sedation, noise from monitors and staff and overnight interventions. Although this has been done with level 2 patients, extension to level 3 areas would be beneficial.

Comparison of Knowledge and Practices among University Students of Allied Health Sciences and Engineering Departments in University of Lahore, Pakistan about Corona Virus Disease

Background: Corona Viruses is a group of viruses that cause diseases in both humans and mammals and are known to cause chronic respiratory diseases. The viruses among them include SARS, MERS and COVID-19. The most recent pandemic was a result of COVID-19. Older people and those with underlying medical problems are more likely to develop serious illness. Objective(s): To compare the knowledge and practices of Allied Health and Engineering students of the University of Lahore about Corona Virus Disease. Methodology: A cross-sectional questionnaire based survey was conducted on 326 students studying in Allied health Sciences and Engineering departments of UOL. The data was compiled in SPSS, version 24 for analysis. Result(s): The students of Allied Health Sciences had a better understanding and were more aware of COVID-19, its percussions and the methods to prevent its spread than of the Engineering Students. More than half of the Engineering students have found to have less understanding about the causative agent of the COVID-19 and similar trend was found in other categories. Health sciences students showed higher tendency towards hands hygiene practices than engineering students. Practical implication: Lessons learned from different outbreaks of infectious diseases suggested that knowledge and practices towards infectious diseases are associated with level of panic emotion among the population, which can further complicate attempts to prevent the spread of the disease. To facilitate outbreak management of COVID-19 in Lahore, Pakistan, there is an urgent need to understand the public's awareness of COVID-19. Keeping these considerations in mind this research was kicked-off to gauge the knowledge and practices of these medical and engineering students about Corona virus disease. Conclusion(s): The study shows that educational background plays a vital role in disease control and it will help in successful uptake of control interventions for prevention of COVID-19.Copyright © 2023 Lahore Medical And Dental College. All rights reserved.

Radiologic and Endoscopic Treatment for a Disconnected Pancreatic Duct Syndrome Associated to Percutaneous Pancreatic Fistula: Achieving the "Internalization of the Fistula"

Background and aim: A 40-year-old male was referred to our institute for the management of a percutaneous pancreatic fistula after acute pancreatitis due to SARS-COV2 infection. He developed a peripancreatic collection(PPC) which was percutaneously drained due to infection. After the resolution of PPC, a percutaneous leakage of the main pancreatic duct (MPD) was observed, so he underwent Endoscopic Retrograde ColangioPancreatography(ERCP) with biliary plus pancreatic sphincterotomy and placement of both pancreatic and biliary stent without resolution of the leak. Material(s) and Method(s): Then he was referred to our institution, where initial management included ERCP with placement of two trans-papillary pancreatic stents and the removal of percutaneous catheter, but the fistula kept to drain. Result(s): A multidisciplinary-board decided to perform a rendezvous with interventional radiology to facilitate an endoscopic ultrasound(EUS) trans-gastric drainage of the pancreatic area draining in the percutaneous fistula. Conclusion(s): The procedure included an initial ERCP with replacement of the two pancreatic stents while the radiologist places percutaneously a guidewire through the fistula to the pancreatic point of leakage into MPD. After that, EUS identified the point in which the percutaneous guidewire was getting into the MPD and a trans-gastric EUS-guided insertion of a guidewire achieved the MPD through a 19-Gauge needle. The latter guidewire crossed the percutaneous fistula and came out. At that point, a dilation up to 10 mm was performed to create a trans-gastric pancreatic fistula. The next step was to insert percutaneously a double pigtail(10 Fr) releasing the distal side into the stomach and the proximal side into the main pancreatic duct in order to stabilize the neo-fistula. Another trans-gastric plastic stent was endoscopically placed through the pancreato-gastric neo-fistula. At the end, injection of contrast dye through the percutaneous fistula showed a complete drainage into stomach. In conclusion, the procedure achieved the complete exclusion and resolution of the pancreatic-cutaneous fistula.Copyright © 2023. Editrice Gastroenterologica Italiana S.r.l.

Effect of COVID-19 on Working Women's Physical and Mental Health: A Descriptive Study of Pre and Post Pandemic Era

Background and Aim: In 2019, the World Health Organization (WHO) recognized the coronavirus outbreak as a pandemic and a public health emergency of global significance. Recent studies have revealed that these restrictions and women's anxiety of the virus itself may have had an adverse effect on their mental health. Children and family members are spending more time at home;thus, society needs to be conscious of how this is affecting working women's emotional and physical health especially in the absence of any assisting maid. Thus, the purpose of this study was to evaluate how the COVID-19 pandemic lockdown affected working women's physical and mental health. Material(s) and Method(s): To examine the effects of COVID-19 on the physical and emotional health of working women, a cross-sectional survey was conducted. Data is collected using an online survey platform. To investigate the impact of lockdown on the women's mental and physical health, a semi-structured questionnaire comprising a number of open-and closed-ended questions was prepared. Additionally, any mental health disorders and emotional difficulties that developed during lockdown or became worse were enlisted. Another goal was to gauge how much family members understood and were sympathetic to the physical and mental strain the working women were under. Result(s): The study involved 200 women from different states of India. The hours spent in the kitchen and other associated activities increased from 1.5 hours to 5.5 hours when the time between before and during the lockdown was compared. The amount of time spent engaging in physical activity, such as yoga and morning and evening walks, significantly decreased during the lockdown are coming to normal after the lockdown. 68 per cent of those surveyed said that women's behaviour had changed. About 58 per cent of the women suffered physical changes such fatigue, headaches, lower back discomfort, and other issues with women's weight gain. Conclusion(s): Additional research is required to better understand the long-term effects of the COVID-19 pandemic on women's mental health, particularly in regard to the identification of additional variables that may be connected to the pandemic's potentially multiplicative effects on women.Copyright © 2023, Institute of Medico-legal Publication. All rights reserved.

Patient satisfaction and patient costs associated with telephone clinic appointments in Inflammatory Bowel Disease (IBD) following the pandemic

Background: Prior to the COVID-19 pandemic, conventional management of outpatient care in IBD predominantly revolved around face-to-face clinic appointments. In the changing landscape of care provision during the pandemic, appointments were conducted almost exclusively through telephone consultation. An electronic questionnaire was developed to assess patient satisfaction and patient costs. Method(s): A pilot was carried out with 15 patients to identify any technical issues with e-mail delivery of the questionnaire and gauge face validity of the questionnaire content. 1400 patients registered with the TrueColours-IBD remote digital monitoring system were sent the questionnaire link via e-mail in May 2021. No demographic data were collected by design, in order to avoid the perception of bias and ensure freedom of expression through anonymity. Result(s): 506 responses were received including 21 duplicates which were excluded, totalling 485 valid responses. 408/485 patients reported having a telephone appointment with the IBD service since March 2020, 484/485 reported having had a face-to-face appointment in the past. 348/408 (86%) were either 'very satisfied' or 'somewhat satisfied' with their most recent telephone consultation, while 22 (6%) were either 'very dissatisfied' or 'somewhat dissatisfied'. 247/408 (61%) were also either 'very satisfied' or 'somewhat satisfied' with the ease of accessing further care if required, compared to 33/408 (8%) who were either 'very dissatisfied' or 'somewhat dissatisfied'. Given the choice, 195/408 (48%) patients preferred to receive a telephone appointment in the future;147/408 (36%) would opt for face-to-face and 66/408 (16%) stated no preference, all with the option of changing that choice if needed. Telephone appointments were associated with a mean total patient time off-work or leisure of 23 minutes (S.D. 51, n=408) compared to 190 minutes (S.D. 96, n=484) for face-to-face appointments. The average cost of time off work or leisure associated with telephone appointments was 5.55 (S.D. = 15.74, n=408), compared to 43.42 (S.D. = 31.27, n=484) for face-to-face appointments (Table 1). Costs of transport add further to face-to-face appointment costs. Greater proportions of patients had a companion for their face-to-face appointment and required childcare compared to telephone consultations (Table 2), which again increases the difference in costs. Conclusion(s): Almost half of surveyed patients stated a preference for telephone appointments, although a third still preferred traditional follow-up. An evolution of care pathways is supported by patient preference and the statistically significant time and cost savings to patients receiving telephone appointments. (Figure Presented).

A Study To Assess The Quality Of Life Among Elderly In Relation To Covid-19 Pandemic In Selected Area Of Sonipat, Haryana State

The first case of the corona virus illness (COVID-19) was discovered in Wuhan, China, in December 2019, and India discovered its first case on January 30, 2020. As it expanded slowly over the world, several nations began to experience its effects. Because of its severity, the World Health Organization declared it a new pandemic on March 11, 2020. Although while all age groups were affected by Covid-19, some were shown to be particularly susceptible in terms of morbidity and death. Immune system deterioration is a common side effect of aging. Thus it only seems sense that older people are more impacted by COVID-19. According to the CDC (Centre for Disease Control), 8 out of every 10 fatalities in the US are caused by those 65 years of age or older. These results made it very evident that older people are sufficiently concerned about Covid-19 infection. Coupled with the limits imposed by the government as a result of the epidemic, several health concerns among the elderly population also surfaced. Physical health suffered from restricted access to medical services already in place, while elderly people's mentality suffered from the frightening environment brought on by the epidemic. Older people's social lives were also negatively impacted by lockup or Covid-19 restrictions. So, there is a strong assumption by researcher that the quality of life of elderly need to be assessed in present pandemic situation. Methodology: In this current study researcher adopted a quantitative approach with descriptive research design to investigate the research problem. The elderly was identified as a population whereas the elderlies of selected areas of Sonipat, Haryana identified as samples. Based on power analysis method researcher identified the sample size as 500 elderlies, which were recruited based on eligibility criteria of sample identification. RThe non-probability convenient sampling strategy was chosen by the researcher to assemble the study's sample. For the purpose of gathering pertinent information from study participants, research instruments were devised. These tools were divided into two categories: socio-demographic factors, which collected baseline data on participants;and quality of life assessment measures, which were used to gauge research participants' quality of life. These tools were developed and verified by specialists, and a pilot study was used to evaluate their viability and dependability. Elderly people were given these instruments, and comprehensive data were gathered. The collected data were tabulated and analysed in SPSS version-23. Result(s): findings in regard to quality of life among elderly in relation to covid-19 have mentioned. It reflected that majority of elderlies 79.4% (397) were scored at poor level of quality of life whereas remaining 20.6% (103) found at average level of quality of life. The mean and standard deviation of quality of life among elderlies during Covid-19 was 89.45+/-19.74. In Section-IV the significant association in between quality of life among elderly with selected demographic variables were stated and it revealed that gender (4.266), education (10.483), family monthly income (8.662), working status of elderlies (4.065), and suffering with other disease (8.924) were significantly associated at 0.05 level of significance. Based on analysed data the research hypothesis H1 were accepted by investigator. Conclusion(s): Based on findings of the study, researcher concluded that majority of elderlies are facing poor level of quality of life in relation with Covid-19 pandemic and none of study participant found with good level of quality of life, which shows that current pandemic deeply influenced the life of elder population. Thus, the researcher advises that a process intervention be implemented to improve the aged population's quality of life during this difficult period of the Covid-19 epidemic.Copyright © 2022 Wolters Kluwer Medknow Publications. All rights reserved.

Exploring Inequities in Adolescent Sexual and Reproductive Health and Rights During the COVID-19 Pandemic: A Youth-Led Study in Ontario, Canada

Background: COVID-19 posed a significant threat to adolescents' sexual and reproductive health and rights (ASRHR), with disproportionate impacts on disadvantaged groups. However, existing research has not centered adolescents' experiences or expertise. Youth-led participatory action research (YPAR) is a collaborative approach to research that recognizes young people as experts to generate knowledge, empower youth, and catalyze action to improve their health. The objective of this study was to support three teams of youth researchers in developing and implementing their own research projects examining the impact of COVID-19 on an ASRHR issue of their choosing, using YPAR methodology. Method(s): Purposive sampling was used to recruit four teams of female-identified youth researchers (ages 16-19 years) in three high-priority regions of Ontario, Canada. Interested youth were interviewed to gauge motivation, relevant intersectional experiences, interest in collaborating, and sense of service to their communities. Selected youth completed a five-day virtual training covering critical thinking, ASRHR, qualitative/quantitative data collection and analysis, research ethics, and project logistics. Each youth team was paired with two adult research mentors and engaged in a four step YPAR process depicted in Figure 1. Youth researchers received compensation for their work and were included as study collaborators. This study was approved by IRB. Result(s): Team 1 identified barriers to having SRH needs met during COVID-19 for assigned females 13-21 yrs old in London, Ontario, using survey methodology. They found that among 58 assigned-female youth, 50% reported difficulties accessing sexual health-related treatment during COVID-19. Team 2 sought to understand how the intersectional identities of youth in Hamilton and Niagara Falls regions influenced experiences of sex education, using in-depth interviews. Key themes were the need to recognize diversity, that the relevance of sex ed changes as adolescence progresses, and that sex ed should focus on positive sexuality. Team 3 identified factors that influenced access to SRH products for teens in Northern Ontario using a survey of 114 adolescents. They found 32% of respondents experienced barriers to buying sexual health products locally, including stigma, cost, distance, disability, and 2SLGBTQIA+ identity. See https://www.shareproject.ca Conclusion(s): This study amplified youth voices through a social justice-framed approach to examining ASRHR during the COVID-19 pandemic. Centering the perspectives, values and experiences of youth introduced the potential to positively impact the youth researchers themselves, while yielding results that were relevant, meaningful, adolescent-responsive and culturally-informed. Supporting Figures or Tables https://www.abstractscorecard.com/uploads/Tasks/upload/19245/RGXGDRUQ-1380706-1-ANY.docxCopyright © 2023

Automatic Hand Sanitizer and Body Temperature Measurement System with Low Liquid Hand Sanitizer Condition Notification

Coronavirus disease (Covid-19) still exists, but the implementation of health protocols, namely maintaining distance, wearing masks, and washing hands (3M) is not optimal and has received more attention lately. Previous studies applied the IoT concepts to hand sanitizer systems and automatic body temperature measurements. However, this research has not been optimal for system integration in solving problems. Existing research only focuses on temperature sensor readings which can be monitored in real-time by installing third-party applications first. Therefore, we make an automatic hand sanitizer and body temperature measurement system equipped with low liquid hand sanitizer condition notification by implementing modifications using PHP MySQL website and notification feature via Twilio bot integrated with WhatsApp. The feature is based on previous research proposals. Based on the test results, the performance of the system prototype is considered good. The system prototype can produce an average of 1.1 mL as the recommended average hand sanitizer in one use of less than 1.74 mL. Then the system prototype has a hand sanitizer fluid accuracy of 90.4% and an accuracy of MLX90614 temperature sensor of 99.9%. © 2022 IEEE.

Education Ambassadors Program of the International Society of Nephrology in Africa Onsite Vs Hybrid: 7 Years of Experience

Introduction: The Education Ambassadors program was established in 2008 by the International Society of Nephrology (ISN). To push new projects, skills, or services, community-based research, or screening programs, the Renal centers throughout the world can submit an application to the Educational Ambassadors (EA) Program to receive professional assistance and hands-on training. ISN ambassadors provide guidance on clinical cases and studies pertaining to peritoneal dialysis, transplantation, nephrology, interventional nephrology, and hemodialysis for up to four weeks in an effort to enhance patient care, professional confidence, and the quality of life for all involved, including nurses and technicians. Here, we provide our ISN Educational Ambassadors program experience over the last seven years in the Africa region, focusing on the educational outcomes of onsite versus hybrid approaches. Method(s): In Africa, many locations in Egypt and Sudan hosted an annual ISN Education Ambassadors program. (1) Wadmadani in Sudan, (2) Mineyat Elnasr in Egypt, Port said, Atmedah, Belkas, Talkha, and Dikirnis. The COVID-19 pandemic's emergence caused ISN education to transition from an onsite to a hybrid style. In terms of attendance and surveys to gauge knowledge retention (% of questions with the correct answers/number of questions) following the training, onsite and hybrid education were compared. Result(s): First: In Egypt: Mineyat Elnasr, Instructors [Doctors n=30, Nurses n=3], Attendance [Nephrologist n=11, Nurses n=19], Evaluation [70%]), Port said, Instructors [Doctors n=9, Nurses n=2], Attendance [Nephrologist n=24 (Males 43.5%, Females 56.5%), Nurses n=25], Evaluation [63.05%]), Atmedah, Instructors [Doctors n=12, Nurses n=2], Attendance [Nephrologist n=20 (males 78.8%, females 22.2%), Nurses n=27], Evaluation [77.8% ]), Belkas, Instructors [Doctors n=14, Nurses n=3], Attendance [Nephrologist n=12 (males 62.5%, females 37.5%), Nurses n=54], Evaluation [62.5%]), Talkha, Instructors [Doctors n=15, Nurses n=2], Attendance [Nephrologist n=32 (males 42.5%, females 57.5%), Nurses n=82], Evaluation [75%]), Dikirnis, Instructors [Doctors n=33], Attendance [Nephrologist n=104 (males 31.8%, females 68.2%, Nurses n=51, medical students n=3], Evaluation [Pre-course 70.1%, post course 92.4%]). Second: In Sudan, Wadmadani (Instructors [Doctors n=10, Nurses n=2], Attendance [Nephrologist n=70, Nurses n=57], Evaluation [70%]). Onsite education acquisition (68.3+7%) versus hybrid education acquisition (83.7+12%) (p=0.001). Conclusion(s): By imparting nephrology information to trainees at their place of employment, the ISN Education Ambassadors program aims to expand knowledge and nephrology service in rural areas. While Hybrid training does not take the place of hands-on training, it helps enhance skill development and has the added advantage of bringing in experts from around the world to share their knowledge. No conflict of interestCopyright © 2023

Experience of Covid 19 Vaccination in Children with Bleeding Disorders

Introduction: There are no contraindications to COVID-19 vaccination for people with inherited bleeding disorders. The COVID vaccine trials demonstrating efficacy have only been performed using an intramuscular (IM) route of administration. Subcutaneous administration, which is an option for other types of vaccines for people in people with bleeding disorders (1) is not recommended. There is little data on the safety of intramuscular (IM) injections in children with bleeding disorders (2) Expert consensus guidelines from theWFH and other major medical & patient organisations advised to use the smallest gauge needle available, apply pressure to the site for at least 10 min. Children with severe or moderate haemophilia should receive prophylactic replacement therapy prior to IM vaccination if available. For those on Emicizumab tranexamic acid to be considered. For children with VWD, depending onVWFactivity levels therapies such asDDAVP or tranexamic acid can be considered in consultation with the clinicians. Haemostatic support for patients with rare bleeding disorders should depend on the severity of the disorder and be decided in consultation with their treatment centre. Method(s): The haemostatic advice given at Birmingham Children's Hospital (BCH), was in line with these published guidelines. We designed a short retrospective survey and asked parents to complete the survey after their child received COVID-19 vaccination in order to assess if patients were experiencing bleeding complications. The survey link (survey monkey) was distributed via text to patients registered at our haemophilia centre. The survey was registered and approved as an audit at BCH. Result(s): We received 24 responses. 50% had received 2 vaccinations. 23/24 (95.8%) reported no bleeding complications. Although the uptake of the survey was poor, no child attended the haemophilia unit or the emergency department for management of any post-vaccination bleeding problem. Discussion/Conclusion: We conclude that COVID-19 IM vaccination can be safely administered in children with bleeding disorders, following guidelines. (Figure Presented) .

Milrinone-induced platelet inhibition in patients supported on veno-aterial extracorporal membrane oxygenation: a case series

Case Report: Purpose: Milrinone is an inodilator that is used in the treatment of cardiogenic dysfunction and shock. It causes increased cardiac output by stimulating myocardial contractility, enhancing cardiac relaxation, and reducing afterload via phosphodiesterase III inhibition, preventing cyclic adenosine monophosphate (cAMP) degradation. Increased cAMP concentrations are known to inhibit platelet aggregation. Veno-arterial-extracorporeal membrane oxygenation (VA-ECMO) is an extracorporeal treatment option for inotrope-refractory cardiogenic shock and is often used in conjunction with inodilators. Often, patients supported on ECMO require systemic anticoagulation to prevent clotting complications. Therefore, thromboelastography (TEG) with platelet mapping is used to help gauge a patient's clotting status and gives clinicians information about the degree of platelet inhibition present. We present the case of two patients, both supported on VA-ECMO, who developed platelet inhibition with clinically significant bleeding while on milrinone, requiring the cessation of the milrinone infusion. Cases: First, we present an adult female in her fourth decade of life who required VA-ECMO for Covid-19 ARDS and cardiogenic shock. TEG platelet mapping was obtained for clinically significant bleeding from her trachea and gastrointestinal tract. Ten days after starting milrinone, adenosine-5'-diphosphate (ADP) inhibition was elevated at 67.4% and arachidonic acid (AA) inhibition normal at 1.8%. Twenty days after starting milrinone, ADP inhibition was 93.3% and AA inhibition was 76.4%. Milrinone discontinued and repeat TEG platelet mapping (10 days after discontinuation) showed ADP inhibition of 76.8% and AA inhibition of 0%. Her lowest ADP inhibition was 41.9%, approximately 1 month after milrinone discontinuation. Milrinone again attempted and ADP inhibition was 87.9% and AA inhibition 89.2% within 24 hours of initiation. No data available for platelet inhibition prior to starting milrinone. Next, we present a 9 year old female with acute myeloid leukemia who required VA-ECMO for septic shock. Initial TEG platelet mapping, obtained 2 days after milrinone initiation, showed ADP inhibition of 43.6% and AA inhibition of 98.7%. Two days after discontinuation of milrinone, her ADP inhibition was 19.6% but AA inhibition remained elevated at 91.9%. However, after 4 days off milrinone, her ADP inhibition was normal at 15.5% and AA inhibition mildly elevated at 33.6%. No data available for platelet inhibition prior to starting milrinone. Conclusion(s): Milrinone is a known platelet inhibitor due to increased intracellular cAMP concentrations. For patients on ECMO and milrinone, care should be given to the degree of platelet inhibition and potential risk of clinically significant bleeding. Further studies are needed to further investigate the correlation between milrinone, platelet inhibition, and clinically significant bleeding in ECMO patients. Copyright © 2023 Southern Society for Clinical Investigation.

Better Care Through Hypofractionation

Aim: In the context of the COVID-19 pandemic, the radiation oncology department at our institution aimed to adapt its approach by analyzing and expanding the use of hypofractionation in order to be able to continue treating patients according to prescribed timelines, to reduce the risks of patient and staff exposure to COVID-19 and minimize the risks of service interruptions due to departmental outbreaks. Process: Site specific treatment groups were asked to review existing literature on hypofractionation. Practice guides were then developed for each tumour site and a hypofractionation policy was created. To ensure close follow-up of this policy, weekly meetings were established in each treatment group in which all cases were reviewed. The use of non-hypofractionated schedules had to be justified by the treating physician. Data were collected to analyze the impact of these measures on the service. Patients were surveyed to gauge the level of safety felt during their treatments. Benefits/Challenges: When the same number of patients treated per year is maintained, hypofractionation increases availability at treatment machines, allowing reallocation of human resources. For example, technologists could be allocated to other tasks such as quality improvement initiatives, patient education and research. Hypofractionation also reduces overall costs to cancer programs, where potential savings from the reduced costs could be reinvested in new technologies and radiotherapy equipment. Fewer fractions also increase patient comfort, reduce the number of visits and improve waiting room management. This approach also increases the capacity to prepare for the next wave of patients that is anticipated post-pandemic due to decreased access to diagnosis and care during the past two years. Impact/Outcomes: The use of hypofractionation quickly became common practice in our centre. In only a few months, the number of fractions given per new treatment start fell from 10.81 in 2019-2020 to 8.29 in 2020-2021. The sustainability of this practice change is maintained, as hypofractionation is now standard practice for most tumour sites at our institution. Satisfaction amongst patients regarding this change during the first wave of the pandemic was very high (70% very satisfied and 30% satisfied). Radiotherapy centres facing human resource shortages as well as the health care network as a whole would benefit from expanding the use of hypofractionation in their centres. Copyright © 2022

A telemedicine approach to goals of care discussions in motor neuron disease

Background: Multidisciplinary care has been shown to improve life expectancy and quality of life in patients with ALS (pALS) and is the cornerstone of pALS management. During the COVID 19 pandemic public safety precautions patients on noninvasive ventilation (NIV) and invasive ventilation were not seen in person due to hospital-wide infectious disease guidelines. Additionally, only one caregiver was permitted with each pALS during multidisciplinary clinic appointments. Objective(s): To facilitate the adoption of video-based telemedicine for discussion of goals of care in advanced ALS. Method(s): During the COVID 19 pandemic period ranging from 3/15/2020 to 5/10/2022, pALS enrolled in the VCU Health ALS clinic participated in in-person clinic visits as well as videobased telemedicine visits with the multi-disciplinary team. The pALS on NIV and invasive ventilation were seen, per VCU ALS clinic protocols, every 1-2 months by home care respiratory therapists (RT). The home care RT protocols alerted the team to a pALS vital capacity approaching 30% of normal. This triggered a goals of care discussion with the patient, family members, and caregivers. The neurologist, nurse navigator, respiratory therapist, and social worker discussed the two options for goals of care at this point in the disease process. One option involved discussion of all aspects of choosing a scheduled tracheostomy and long-term 24-hour care requirements for pALS by their caregivers. The second goals of care option presented to pALS was palliative care to manage symptoms and hospice at home. Telemedicine also enabled pALS to DocuSign Durable Do Not Resuscitate forms that were reviewed by the hospital attorney and placed in the electronic medical record. Out of the 53 patients who died during this time frame, 33 had the goals of care discussion via telemedicine. In-person discussions took place with 7 pALS. One pALS committed suicide 2 months after diagnosis and 2 pALS were lost to follow up. Ten pALS had no documented goals of care discussion prior to their death, per chart review. Two pALS, one via telemedicine and one in person, chose tracheostomy after the goals of care discussion. Conclusion(s): More patients had goals of care discussion via telemedicine (62%) than in person (13.2%) suggesting that video technology telemedicine with the multi-disciplinary team helped establish relationships with the team members and facilitated rapid access to the team for pALS. Telemedicine allowed the multi-disciplinary team to discuss at length with pALS and all their family members goals of care when pre-specified clinical end points of their disease were reached. Telemedicine was adopted by our clinic for discussion of withdrawal of invasive ventilator support on one patient who had been ventilated for several years. Further studies would be beneficial to gauge patient and caregiver satisfaction with goals of care discussion via telemedicine appointments.

A Brief Report Of The Upcoming & Present Economic Impact To Hospitality Industry In COVID19 Situations

The focal point of this investigation is the appraisal of the effect of the Covid-19 pandemic in the travel industry and accommodation area which has prompted worldwide frenzy because of the current circumstance. The extent of a task is in the direction of examine the impacts of Covid-19, current occasions, and evaluation from end to end understanding while it is fundamental to research how a business determination recuperate subsequent to Corona virus and how it tends to be supportable. The present task is to break down the upcoming through a small amount of way in addition to quick recuperation what's more, recapture of the travel industry and friendliness area in favour of the Indian financial system, and work along with industry. The examination has a few proposals of the neighbourhood effect of the episode, impacts as well as is fundamentally assessed in this survey. This is the need of great importance to set aside gauges before effort to manage the belongings. Copyright © 2022 Wolters Kluwer Medknow Publications. All rights reserved.

A quality control audit into the diagnostic accuracy of US guided thyroid FNA following a recent change in clinical practice

Purpose: The primary aim was to review the diagnostic accuracy of US guided thyroid FNA at a local teaching hospital following a recent change in practice. Prior to COVID-19 our experience across multiple teaching hospitals was that a pathologist attended thyroid FNA's to confirm adequacy of sample and prepare the slides. Since COVID-19 this practice has changed with reduced pathologist attendance. Secondary aims of the audit were to review potential contributory factors to diagnostic accuracy as well as review the appropriateness of referrals for thyroid FNA. Methods and Materials: This audit meets the CALHN research governance committee criteria for a quality control audit not requiring formal ethics approval. Patient's privacy was protected by de-identifying all patient information. Data was collected from the LMH RIS and PACS for diagnostic thyroid US as well as the report from the individual US guided FNA. Oacis was used to obtain the pathology reports and to follow up any subsequent surgical pathology. A review was performed of all thyroid FNA's performed in LMH radiology department from September 2020 to March 2021. Data collected included: size of nodule, TIRADs score, Bethesda score, cytology report, number of passes, needle gauge, level of experience of the performing clinician and any subsequent surgical pathology. Result(s): Overall non-diagnostic rate from 126 thyroid FNA was 42% with 53 non-diagnostic FNA's (defined as Bethesda category 1) and 73 diagnostic samples. Of the variables assessed there was no significant difference in diagnostic rate based on: appropriateness of FNA (based on TIRADS recommendations) or nodule size. There was a difference observed in level of experience with consultants having the highest diagnostic rate and RMO's having the lowest diagnostic rate. 61% of the 126 thyroid FNA's performed were indicated based on TIRADS criteria, meaning 39% were not indicated. 2 were not able to be assessed due to TIRADS not being documented on the referral or absence of available prior imaging. Conclusion(s): The non-diagnostic rate of 42% is higher than previous studies and higher than the recommended non-diagnostic rates which is reported as 2-20% (Cibas et all 2009). The only variable that we identified as contributory to the non-diagnostic rate in this study was level of experience which is expected. A previous audit performed in South Australian hospitals found a non-diagnostic rate of 13% (Goldfinch, Prowse 2018) with pathologists in attendance suggesting this may be a contributory factor to this audits higher diagnostic rate.

Case-Based Online Training for Improving Visual Inspection Capability of Employee in Electronic Manufacturing

Many different types of PCB defects can occur throughout the printed circuit board assembly process. The procedure of quality control is essential. A human inspection is important to ensure that the PCBA is delivered in excellent condition. It is critical to train QC employees to understand PCBA inspection standards to determine which PCBAs are acceptable. High rates of PCBA reject, even though the defects are acceptable to the customer, will have an impact on production costs. To improve Quality control performance, the development of decision-making skills of PCBA visual inspection employees was researched. Because to the COVID19 situation, case-based training was provided via online tools. However, in order to clear up any misunderstandings and conduct PCBA inspection tests, face-to-face discussion was still needed. In addition, the trained QC employee's performance was measured using attribute gauge repeatability and reproducibility, which indicated that the QC employee's decision-making capability had increased. When compared to appraisers before training and standard respectively, employee inspection performance was 11.94 % and 5.69 % better. © 2022 IEEE.

The Impact of the COVID-19 Pandemic on Physical Activity Levels and Access to Fitness Programs for Children with Disabilities

Background and/or Objectives: Current guidelines recommend all children, including those with disabilities, obtain 60 minutes of daily physical activity. The COVID-19 pandemic has affected children with disabilities' (CWD) access to physical activity, with studies reporting 50-70% of CWD exercising less during the pandemic than before. The aims of this study were to assess whether a cohort of CWD were getting less physical activity than recommended national guidelines, examine specific barriers, and gauge parental interest in physical activity programs for their children. Design(s): Cross-sectional survey study Setting: Multi-center outpatient study within academic freestanding hospitals Participants: 59 parents of children with chronic disabilities Interventions: N/A Main Outcome Measure(s): Likert scale for how much child is leaving home compared to pre-pandemic, how much physical activity child is getting daily, main barriers to physical activity, interest for physical activity programs. Result(s): There were n=59 parents of children with disabilities who participated in the study. Child's age had a mean of 10.1 +/- 5.6 years. Twenty of the children were female and 39 were male. Forty-six parents (78%) either agreed or strongly agreed that their child left the house less during the pandemic than before. Forty parents (68%) reported their child was getting less than 60 mins of daily physical activity. The main barrier to physical activity was "concern for COVID transmission," with 38 parents (64%) citing that as a concern. If there were structured physical activity programs available, 41 parents (70%) said they were interested in enrolling their child. Conclusion(s): The physical activity levels of children with disabilities have been impacted by the COVID-19 pandemic, which can have deleterious effects on overall mental and physical health. The main barrier to physical activity for CWD is parental concern for COVID transmission. Virtual physical activity programs tailored towards children with disabilities could be a methodology for improving physical activity engagement in these children during the pandemic.

Epidemiology and Choice of Treatment in the Adjuvant Setting of Hormone Receptor Positive Her2 Negative (Hr+/Her2-) Breast Cancer (Bc), Evidence from Administrative Databases, with a Focus on the Sarscov2 Pandemic

Background: Real-world evidence through secondary use of data (SUD) in oncology is gaining increasing interest, to better understand cancer epidemiology and provide insights into treatment patterns in daily practice. This study evaluates incidence of HR+/HER2- early BC (eBC) and its management in clinical practice through SUD and gauge the impact of the SARS-COV2 pandemic. Method(s): This observational retrospective analysis integrates administrative databases for healthcare resources consumption (pharmaceuticals, hospitalizations, diagnostic tests and specialist visits databases) from a sample of Italian Local Health Units, based on 15 million inhabitants across Italy. Patients with >=1 hospitalization discharge diagnosis for BC, with surgical intervention and HR+ status (determined by coding for HR+ status or by presence of endocrine therapy) between 01/2010-06/2021 were included. Patients with at least one prescription of anti- HER2 monoclonal antibodies were excluded. Patients were classified by menopausal state through prescription for the gonadotropin-releasing hormone analogues (GnRHa). Incidence was calculated during all study period. Result(s): Incidence rate has a slight upwards trend, as expected, ranging from 53.9 in 2013 to 62.7 in 2019 per 100,000 health-assisted subjects. Incidence in 2020 is 49.2 per 100,000 (table 1 for quarter split). As for adjuvant therapies, 31,836 patients were included in the analysis of which 5343 (16.8%) were classified as premenopausal. Mean age was 64.5 years. Most patients (78.8%) were treated with only adjuvant endocrine therapy (ET). 16.5% of the sample received adjuvant chemotherapy (CT). CT treatment was more prescribed in premenopausal patients. CT treatment was started within 12 weeks of surgery for 3.9% of the sample. Most patients (12.7%) started it between 12 weeks and 24 weeks. Conclusion(s): SUD can provide lots of information with the right queries. The analysis confirms the slight increase in incidence observed by national registries and provides an estimate of the impact of SARS-COV2 with a 22% reduction of breast surgery in 2020. Administrative data can be used to assess clinical variables (e.g. premenopause through GnRHa prescription), and could be further explored for disease stage through axillary dissection, and recurrence through prescription of therapies used in metastatic setting.

Establishing Interest in the Development of a Novel Telehealth Curriculum for Emergency Medicine Resident Physicians

Learning Objectives: To assess EM resident enthusiasm for a telehealth curriculum and to develop a series of telehealth training modules for EM resident physicians. Introduction/Background: According to the American College of Emergency Physicians (ACEP), emergency telehealth is a core domain of emergency medicine (EM) and is inclusive of remotely providing acute medical care. In 2016, the American Medical Association Council on Medical Education released a report advocating for the implementation of formalized telehealth training into graduate medical education accreditation requirements. There was rapid growth in telehealth during the COVID-19 pandemic: An industry analysis showed overall telehealth utilization grew 38 times from February 2020 to February 2021. Despite this, training in telehealth for residents remains substandard, with experts calling for formal curricula. To our knowledge there is no standardized graduate medical education curriculum for telehealth. Objective(s): To assess EM resident enthusiasm for a telehealth curriculum and to develop a series of telehealth training modules for EM resident physicians. Curricular Design: We distributed a ten question survey to 44 EM residents to gauge their interest in pursuing telehealth education. We developed a series of 30 minute modules focused on different aspects of telehealth delivery targeted to an audience of EM residents. We created four key telehealth learning modules to train EM residents: Historical Socioeconomic Relevance, The Virtual Patient Encounter, The Telehealth Physical Exam, and Documentation Medicolegal Implications. Impact/Effectiveness: The vast majority of survey respondents feel that telehealth education is probably or definitely important, and would pursue education in telehealth. Future directions include soliciting feedback from residents who complete the curriculum and learning assessment. As telehealth continues its rapid growth beyond a protracted pandemic it is critical that we educate and equip the next generation of emergency physicians to harness the skills to provide emergency telehealth services to their patients.

Virtually Transforming healthcare at scale: Implementing improved access to stroke care across regional and rural areas

Aim: The NSW Telestroke project implemented a virtual model of care to improve access to hyperacute stroke treatment across 23 hospitals. To understand and extrapolate the success factors involved in effective project implementation and sustainability. Objective: The successful implementation of large-scale service redesigns with demonstrated improvement in patient outcomes are limited. The implementation at scale to 23 hospitals with varying local contextual features including resourcing, culture, leadership and facility set up has provided insights into the key elements of successful implementation. Undertaking a systematic approach to implementation including formulating a well-developed and attainable proposal for change in practice with clear targets, assessing the performance and mapping potential barriers indicates markers for successful implementation. Lessons learned has provided a gauge of what future endeavours should consider to inform large scale system transformation. Results: The Telestroke project has been implemented across 18 hospitals to date, with a further five sites by June 30, 2022. This is within the expected timeframe despite COVID-19 outbreaks in NSW and subsequent restrictions limiting activity at crucial time periods. Discussion: Through reflective lesson learned discussions at a program, hospital and individual level key drivers for successful implementation and sustainability of the project were highlighted. They include: 1. A clear roadmap, detailing the implementation approach with matching resources and education packages, have allowed expedited delivery of the program at a site level 2. Skilled, dedicated and consistent staffing in program implementation lead roles has enabled stability in coordination and knowledge management. This supports key learnings being adapted and utilised for future go-lives. 3. Leveraging skill mix at each site to fill knowledge/experience gaps to support and embed Telestroke. 4. A supportive executive team and clearly identified key champions in each department to drive the change forward. 5. Adapting training to suit the local environment including resources and COVID-19 restrictions was crucial during implementation.