Supplement Gone Wrong: Drug-Induced Liver Injury Caused by Artemisinin

Introduction: Drug-induced liver injury (DILI) is defined as hepatic dysfunction caused by prescription medications, supplements, or xenobiotics after alternative causes have been excluded. As one of the leading causes of acute liver failure, DILI should be considered when patients present with hepatic dysfunction. We present a case of symptomatic DILI secondary to artemisinin use. Case Description/Methods: A 78-year-old Chinese man with no medical history presented to the hepatology clinic with 10 weeks of jaundice, weakness, and pruritis. He started taking Artemisinin/ Bioperine 12 weeks ago to prevent COVID-19 but stopped 3 weeks ago. He denied abdominal pain, a family history of liver disease, substance/alcohol use, and taking other concomitant drugs. Physical examination revealed scleral icterus and no other signs of chronic liver disease. Laboratory studies showed total bilirubin 11 mg/dL, alkaline phosphatase 293 U/L, aspartate transaminase 170 U/L, and alanine transaminase 196 U/L with negative workup for hepatitis A, B, and C. CT abdomen and MRCP were unremarkable for liver or biliary pathology. Further serological workup was negative and follow-up labs revealed normalization of liver enzymes and bilirubin. Given the patient's improvement, liver biopsy was not pursued. The patient was instructed to avoid supplements unless prescribed by a physician. Discussion(s): DILI is a global issue with an estimated annual incidence rate of 13.9 to 24.0 per 100,000 persons. Diagnosing DILI is important as it can cause acute liver injury and liver failure in certain cases. Since COVID-19 emerged, supplement use has increased given claims of boosting the immune system. Artemisinin is an herb used in traditional Chinese medicine with antimalarial activity investigated to be a possible COVID-19 treatment, but no current evidence exists to support it being effective against COVID-193. Our patient's supplement also contained Bioperine, a black pepper extract, which is likely benign. Contrarily, artemisinin is a well-described cause of idiosyncratic acute liver injury and hepatotoxicity, causing self-limited mild to moderate transaminitis but also severe cases requiring emergent livertransplantation. Our patient's unrevealing workup, his spontaneous improvement correlating with supplement discontinuation, and RUCAM score of 7 led to high suspicion of DILI secondary to artemisinin. Providers should always ask patients about supplement use and consider DILI when patients present with liver injury. (Table Presented).

Nutritional changes during the COVID-19 pandemic: a rapid scoping review on the impact of psychological factors.

COVID-19 and the resulting measures to curb the spread of the virus have significantly changed our lives, including our nutritional choices. In this rapid scoping review an overview is provided of what psychological factors may be associated with peoples' eating behaviour during COVID-19 restrictions. Relevant literature was identified using PubMed, PsycInfo, CINAHL and MEDLINE databases from 2019 onwards. For included studies, information on study characteristics, eating behaviours, and psychological factors were extracted. 118 articles were included, representing 30 countries. Findings indicated that most people consumed more and unhealthy food in times of COVID-19 restrictions, while some consumed less but often for the wrong reasons. Several psychological factors, related to (1) affective reactions, (2) anxiety, fear and worriers, (3) stress and (4) subjective and mental wellbeing were found to be associated with this increase in food consumption. These outcomes may help to be better inform future interventions, and with that, to be better prepared in case of future lockdown scenarios.

An Interactive Live and Online Cooking Program for Children in Vulnerable Families-An Exploratory Study.

The COVID-19 pandemic has highlighted the importance of technology for communication and social interactions. Especially for children in low-income families-a vulnerable population suffering from health and digital disparities-the situation worsened during the pandemic. Earlier studies in times of COVID-19 suggested that the children in Korea who usually do homework and dine at community childcare centers (CCCCs, free after-school care places) need to learn more about how to eat healthily and how to interact with others using digital technology. Therefore, to reduce these children's health and digital inequalities, an interactive live and online cooking program was developed and provided to 313 children and 95 staff members at the 29 CCCCs located in the southern provinces in South Korea. The aim of the current study was to explore the experiences of children and staff with the program. After surveying their experiences, a high degree of satisfaction was found (children: 3.60 ± 0.10; staff: 3.63 ± 0.08 points out of 4.00). Aspects that needed improvement in the program were related to (in)experience in online technology, the frequency and timing of the cooking classes, and the communication between the centers and (online) chefs. In addition, in a word cloud analysis, terms such as 'fun', 'delicious', and 'want' were highlighted for children, and terms such as 'participating' and 'preparation' dominantly appeared for the staff. In the analysis of negative experiences, terms related to environmental factors such as 'sound', 'hear', and 'voice' were highlighted. This novel but preliminary approach for children from low-income families, by integrating cooking with digital technology, indicates that with enough digital support, the CCCCs are a promising platform to promote healthy eating and digital literacy. Optimizing and disseminating these strategies during this pandemic period, and future pandemics, could be beneficial to keep children in their communities healthy, and ultimately reduce socioeconomic health disparities.

White Paper: Open Digital Health - accelerating transparent and scalable health promotion and treatment.

In this White Paper, we outline recommendations from the perspective of health psychology and behavioural science, addressing three research gaps: (1) What methods in the health psychology research toolkit can be best used for developing and evaluating digital health tools? (2) What are the most feasible strategies to reuse digital health tools across populations and settings? (3) What are the main advantages and challenges of sharing (openly publishing) data, code, intervention content and design features of digital health tools? We provide actionable suggestions for researchers joining the continuously growing Open Digital Health movement, poised to revolutionise health psychology research and practice in the coming years. This White Paper is positioned in the current context of the COVID-19 pandemic, exploring how digital health tools have rapidly gained popularity in 2020-2022, when world-wide health promotion and treatment efforts rapidly shifted from face-to-face to remote delivery. This statement is written by the Directors of the not-for-profit Open Digital Health initiative (n = 6), Experts attending the European Health Psychology Society Synergy Expert Meeting (n = 17), and the initiative consultant, following a two-day meeting (19-20th August 2021).

DESIGNING A COST-EFFECTIVE, PATIENT-FACING DIGITAL STETHOSCOPE FOR TELEMEDICAL CARDIAC AUSCULTATION

Introduction: The COVID-19 pandemic catalyzed growth of virtual medicine, challenging providers to adapt their standard protocols for telehealth. During this time, cardiologists were unable to gather numerical/graphical heart data to guide therapy. Many examination technologies exist in-person to obtain this data, but they are not engineered for patient use during virtual visits. Objective: The team sought to develop an inexpensive diagnostic point-of-care device designed to work with telehealth applications and provide patients with the ability to transmit data on cardiovascular function to physicians in real time. Methods: The AusculBand used clinician and patient input for final design format. The AusculBand is shaped like a wristband and encapsulates a custom bell, microphone, and novel circuitry to facilitate self-auscultation for live transmission to a virtual physician. Frequency response testing was designed to verify the AusculBand’s captured cardiac sound frequency range. A comparative study was designed to test audio quality against and the Eko Duo’s, a leading competitor. Repeated cardiac auscultation signals at different points and background noise using both devices were obtained to quantify signal-to-noise ratio (SNR) on one user. Results: During frequency response analysis, the AusculBand captured frequencies up to 1997Hz in response to a signal that swept through a range of 0-3kHz. These results were within 0.2% of the 2kHz upper-limit of the cardiac range. SNR testing showed 27.29dB for the AusculBand and 24.02dB for the Eko Duo. The AusculBand is nearly twice as loud as the Eko Duo, and maintains a projected price of $80 (Eko Duo $320). Conclusions: The AusculBand is an inexpensive, patient-oriented digital stethoscope that beats industry standards in SNR and is compatible with existing telehealth platforms. Future modifications will add a single-lead ECG to promote the device as an all-in-one telemedicine tool for virtual cardiac analysis. [Formula presented] [Formula presented]

Do social and environmental factors affect level of stress during COVID-19 among nursing students? Results from single center cross-sectional study in Malaysia

Introduction: Stress in nursing students has been documented in many studies and this will lead to various health problems. However, there is scanty research assessing the level of stress among nursing students during Covid-19 in Malaysia. Hence, this study aimed to assess the level of stress and its association with social and environmental factors amongst nursing students in Universiti Malaysia Sabah, Malaysia. Methods: A cross-sectional study was conducted by random sampling among nursing students in Universiti Malaysia Sabah between March and May 2021. The primary outcome was stress symptoms, derived from the validated Perceived Stress Scale-10 (PSS) questionnaire. Socio-demographic, social, and environmental factors were also assessed. T-test was used to assess the associations between level of stress and social and environmental factors. Results: A total of 115 responses were received with the mean (SD) age of the students being 20.5 (1.3) years old. Of all the students, 84.9% were female, 54.6% received financial support from National Higher Education Fund Corporation and 46.2% were in nursing Year 2 followed by the nursing year 1 (28.6%) and nursing year 3 (25.2%). The students in this study reported a higher level of stress. The students who reported most or all the time being trapped in a hostel (p<0.01), challenges of online classes (p=0.03), and catching up with class projects (p=0.03) had a higher level of stress compared to those who reported none or little or some of the factors. Conclusion: This study showed that social and environmental factors may play a role in determining the stress level among nursing students. Hence, authorities should foster supporting strategies to lower student stress and tackles the unwanted consequences. © 2022, Sanglah General Hospital. All rights reserved.

Lessons post-lockdown: science and engineering education switching to online learning

For universities, COVID-19 made traditional means of providing quality teaching and learning impossible. Nevertheless, students required delivery and assessment to progress or graduate on time. Subjects in Science and Engineering with practical components presented a particular challenge, and this paper assesses institutional means and the perspectives of both instructors and students to determine best practice in this context. By triangulating institutional data (from pre- and post-pandemic policy and module delivery data) with staff and student surveys, followed up by semi-structured interviews, this paper examines both macro and micro perspectives and highlights successful and less-than-successful strategies for skill-based subjects. Somewhat surprisingly, our data indicates higher initial satisfaction among students than teachers. Further, we provide institutional and individual suggestions to implement successful online teaching and learning under different delivery scenarios (e.g., simulation vs. actualisation, or the employment of virtual and augmented reality systems) while mitigating potential negative impacts on the experience. Copyright © 2022 Inderscience Enterprises Ltd.

In the Middle of Hope and Crisis What Union Budget 2022-23 Offers for Education?

The fund allocations of the Union Budget 2022-23 to education are analysed in the context of the devastating impact of the COVID-19 pandemic on the education sector and the implementation of the National Education Policy, 2020. © 2022 Economic and Political Weekly. All rights reserved.

Just-in-Time, but Still Planned: Lessons Learned From Speeding up the Development and Implementation of an Intervention to Promote COVID-19 Vaccination in University Students.

The process of developing a behavior change intervention can cover a long time period. However, in times of need, this development process has to be more efficient and without losing the scientific rigor. In this article, we describe the just-in-time, planned development of an online intervention in the field of higher education, promoting COVID-19 vaccination among university students, just before they were eligible for being vaccinated. We demonstrate how intervention development can happen fast but with sufficient empirical and theoretical support. In the developmental process, Intervention Mapping (IM) helped with decision-making in every step. We learned that the whole process is primarily depending on the trust of those in charge in the quality of the program developers. Moreover, it is about applying theory, not about theory-testing. As there was no COVID-19-related evidence available, evidence from related fields helped as did theoretical knowledge about change processes, next to having easy access to the target population and important stakeholders for informed qualitative and quantitative research. This project was executed under unavoidable time pressure. IM helped us with systematically developing an intervention, just-in-time to positively affect vaccine acceptance among university students.

Facilitating Informed Decision Making: Determinants of University Students' COVID-19 Vaccine Uptake.

BACKGROUND: Although several COVID-19 vaccines are available, the current challenge is achieving high vaccine uptake. We aimed to explore university students' intention to get vaccinated and select the most relevant determinants/beliefs to facilitate informed decision making around COVID-19 vaccine uptake. METHODS: A cross-sectional online survey with students (N = 434) from Maastricht University was conducted in March 2021. The most relevant determinants/beliefs of students' COVID-19 vaccine intention (i.e., determinants linked to vaccination intention, and with enough potential for change) were visualized using CIBER plots. RESULTS: Students' intention to get the COVID-19 vaccine was high (80%). Concerns about safety and side effects of the vaccine and trust in government, quality control, and the pharmaceutical industry were identified as the most relevant determinants of vaccine intention. Other determinants were risk perception, attitude, perceived norm, and self-efficacy beliefs. CONCLUSION: Our study identified several determinants of COVID-19 vaccine intention (e.g., safety, trust, risk perception, etc.) and helped to select the most relevant determinants/beliefs to target in an intervention to maximize COVID-19 vaccination uptake. Concerns and trust related to the COVID-19 vaccine are the most important targets for future interventions. Other determinants that were already positive (i.e., risk perception, attitudes, perceived norms, and self-efficacy) could be further confirmed.

A Safe Return to Campus in Times of COVID-19: A Survey Study among University Personnel to Inform Decision Makers.

Halfway through 2021 in the midst of a public health crisis, a new academic year was fast approaching. Dutch universities were preparing to reopen their campuses to students and personnel in a safe manner. As the vaccination uptake was increasing and societies were slowly reopening, inviting students and personnel to campus became the next step to "the new normal". To absorb this change seamlessly, it was considered important to investigate personnel's beliefs about returning to campus and their perceptions of a safe working environment. An online survey was conducted among personnel (N = 1965) of Maastricht University, the Netherlands. University personnel's beliefs about a safe return to campus were assessed. The data were collected between 11 June and 28 June 2021. This study showed that, while most personnel (94.7%) were already vaccinated or willing to do so, not all personnel did feel safe to return to campus in September 2021. Over half of the respondents (58%) thought that the university is a safe place to return to work when the new academic year starts. However, the remainder of personnel felt unsafe or were uncertain for various reasons such as meeting in large groups or becoming infected. Moreover, when returning to campus, employees stated that they would require some time to reacclimate to their former work culture. The group who felt relatively more unsafe indicated that returning in September was too risky and that they worried about being infected. They wanted the safety guidelines to still be in force. On the other hand, the "safe" group stated safely returning to be "certainly possible" and trusted that others would still stick to the prevention guidelines. The findings led to practical recommendations for the University Board as they were preparing for organizing research and teaching for the upcoming academic year in the context of the COVID-19 pandemic. A brief intervention was developed: a webinar in which the data were linked to the board's plans for safe returning. This study demonstrates that university boards may use research among personnel to develop adequate measures promoting safety and feelings of safety among personnel in similar future situations.

Vasopressor use and 60-day outcomes among covid-19 patients in the intensive care unit

Introduction: Vasopressor use has been associated with higher mortality rates in patients with COVID-19, the association between the maximum number of concurrent vasopressors with mortality has not yet been studied. Methods: A retrospective cohort study was conducted on patients admitted with COVID-19 to the intensive care unit (ICU) at Rush University System for Health in Illinois between March and October 2020. Multivariable logistic regression, adjusted for age, BMI, history of CAD and diabetes, was used to determine if an increasing number of vasopressors is associated with higher 60-day mortality. Results: A total of 637 patients met the inclusion criteria. Composite 60-day mortality was 28.6%. Of the 637 patients who met inclusion criteria, 338 (53.1%) required the support of at least one vasopressor. When compared to patients with no vasopressor requirement, those who required 1 (adjusted OR [aOR] 3.27, p<0.01), 2 (aOR 4.71, p<0.01), 3 (aOR 26.2, p<0.01), and 4 or 5 (aOR 106.38, p<0.01) vasopressor(s) were at increased risk of 60-day mortality (Figure 1). Additionally, the incidence of mechanical ventilation, venous thromboembolism, ventricular arrhythmia, and new renal replacement therapy increased with additional vasopressor requirement (p < 0.001 for each outcome;Table 1). There was no statistical difference in the incidence of MACE between the groups (p = 0.139). Conclusion: In this cohort, each additional vasopressor added was associated with escalating 60-day mortality. Identifying these high-risk patients can help determine prognostic outcomes and guide decision-making.

In-hospital predictors of 60-day readmission in COVID-19 patients

Introduction: Preventing hospital readmissions can improve a patient's quality of life and decrease healthcare costs. While prior work has focused on pre-existing comorbidities to predict COVID-19 readmissions, the prognostic role of in-hospital data and complications has been less studied. Methods: Data was collected on adult patients diagnosed with COVID-19 and admitted to a multicenter hospital system in Illinois between March and November 2020. Our cohort consisted of COVID-19 hospitalization survivors excluding those discharged to hospice care. Major adverse events (MAEs) were defined as venous thromboembolism (VTE), myocardial injury (troponin greater than upper limit of normal), stroke, new requirement for renal replacement therapy (RRT), life-threatening arrhythmia, or acute heart failure exacerbation. The primary outcome was readmission within 60 days of initial hospitalization. Results: From the 1406 survivors of the index hospitalization, 223 (15.9%) patients were readmitted within 60 days. Those readmitted were older and more likely to have underlying comorbidities including atrial fibrillation, coronary artery disease, and hypertension (Table 1). Length of stay between the readmission and non-readmission groups was trending towards statistical significance (10.52 days vs 8.95 days, p=0.053). Those with one or more MAE during their index hospitalization, when adjusted for age and body mass index, were at an increased risk of readmission (adjusted odds ratio [aOR] 1.90, p<0.01). Readmitted patients were more likely to have VTE during their index hospitalization than those not readmitted (7.2% vs 3.7%, p<0.05). The incidence of new RRT (4.9% vs 2.5%, p=0.083) and myocardial injury (3.6% vs 1.5%, p=0.067) between the groups was also trending towards statistical significance (Table 1). No statistical difference was present between the other individual MAEs;however, this is limited by small sample sizes of certain MAEs. Of the 322 patients with echocardiography during the index admission, 82 (25.5%) were readmitted. In this cohort, left ventricular ejection fraction (LVEF) that was reduced (LVEF <50%) or hyperdynamic (LVEF >65%) was not a statistically significant predictor of readmission (Figure 1). Lastly, discharge disposition was predictive of readmission as those being sent to acute rehab (OR 2.04, p<0.01), long-term acute care (OR 2.58, p<0.01), or skilled nursing facility (OR 2.67, p<0.001) were at higher risk compared to those who were discharged to home (Figure 1). Conclusion: In this cohort, the occurrence of any MAE during index COVID-19 hospitalization, particularly VTE, RRT, and myocardial injury, can be used to predict 60-day readmission. Furthermore, discharge disposition, but not LVEF, demonstrated prognostic value in our cohort. Identifying high risk patients prior to discharge helps health care providers focus resources on patients most likely to be readmitted.

PESTLE+ risk analysis model to assess pandemic preparedness of digital ecosystems

COVID-19 pandemic has affected every country in many ways. Its substantial economic impacts are causing businesses to fade, pushing many nations into an economic downturn. This exposes organizations worldwide to unique risks which cannot be foreseen with conventional methods of risk analysis. This research is part of a broader action design research project conducted in collaboration with industry partner to answer an important research question: How to extend PESTLE risk analysis model to assess pandemic preparedness? In this context, the health factor is added to extend the traditional PESTLE risk analysis model. Furthermore, the interdependence between PESTLE factors has also been investigated, which has not been discussed before. The contribution of this research is the novel PESTLE+ risk analysis model that will help individuals and businesses to improve their understanding of the health crisis, such as the COVID-19, adjust accordingly and eventually endure the ongoing crisis, which is driving most businesses into liquidation.

Selection of determinants of students' adherence to COVID-19 guidelines and translation into a brief intervention.

BACKGROUND: When reopening universities in times of COVID-19, students still have to adhere to COVID-19 behavioral guidelines. We explored what behavioral determinants (and underlying beliefs) related to the adherence to guidelines are both relevant and changeable, as input for future interventions. METHODS: A cross-sectional online survey was conducted (Oct-Nov 2020), identifying behavioral determinants (and underlying beliefs) of university students' adherence to COVID-19-guidelines, including keeping 1.5 m distance, getting tested, and isolating (N = 255). RESULTS: Attitude, perceived norm, self-efficacy, and several beliefs (e.g., risk perception beliefs 'I am not afraid because I am young' [r = -0.33; p < .001]; attitudinal beliefs, e.g., 'I feel responsible for telling people to adhere to guidelines' [r = 0.37; p < .001]; self-efficacy beliefs, e.g., 'COVID-19-prevention guidelines are difficult to adhere to' [r = -0.30; p < .001]) were associated with intention to adhere to guidelines, and for those beliefs there was room for improvement, making them suitable as possible intervention targets. CONCLUSIONS: Students mostly adhere to COVID-19 guidelines, but there is room for improvement. Interventions need to enhance students' adherence behavior by targeting the most relevant determinants as identified in this study. Based on these findings, a small intervention was introduced targeting the determinants of students' adherence to guidelines.

Uncommon Presentations of COVID-19

A Novel Corona virus, SARS-CoV-2 causing COVID-19 disease has become a global public health problem with varied presentations. The common clinical presentations include pneumonia, myocarditis, gastroenteritis, delirium, though few uncommon cases also came into light showing features of spontaneous pneumothorax, pneumomediastinum, encephalopathy, stroke, psychosis, bowel ischemia, pancreatitis, thrombosis and adrenal insufficiency. These features were more often seen in critically unwell patients with high morbidity and mortality;presented either late in the disease course or early prior to even common symptoms. Our aim of the article is to summarize 'Uncommon Presentations' which might get misdiagnosed, possibly leading to further transmission or delayed diagnosis resulting in poor outcome.

The Future of Teaching Post-COVID-19: Microlearning in Product Design Education

The recent COVID-19 pandemic has placed a huge strain on higher education institutions and educators around the world, which has included the closure of campuses, removal of face-to-face instruction and a shift to remote teaching and learning. However, this situation has also created unique opportunities and conditions that can foster innovation in teaching and learning practices and content delivery. One such innovation gaining traction is Microlearning, which offers learning opportunities through small bursts of training materials that learners can comprehend in a short time, according to their preferred schedule and location. This paper explores the potential of Microlearning within design education and how it can be implemented into the Product Design & Manufacture programme at University of Nottingham Ningbo China to support teaching instruction and enhance the student learning experience post-COVID-19.