Neurodiversity, Networks, and Narratives: Exploring Intimacy and Expressive Freedom in the Time of Covid‐19

The Narratives of Neurodiversity Network (NNN) is a neurodivergent academic, creative, and educator collective that came together with allies during the Covid‐19 pandemic to create a network centred around emerging narratives about neuro-diversity and exploring new ways of learning and socialising. The network focuses on exploring the roles of written, spoken, and visual narratives across cultural locations about neuro‐atypical experiences in generating improved agency and self‐advocacy for those who have been subject to pathologization through neuro‐normativity and intersecting oppression. During the last year, widening access to digital platforms has provided a space to explore these issues outside of traditional academic spaces. We run a monthly "Salon,” our mixed‐media "reading, listening, and watching” group, in an effort to find positive representation within contemporary culture. Discussions have moved beyond mimesis and into a consideration of how narrative and storyworlds can question the supposed naturalness of certain ways of being in and perceiving the world. This article interrogates the network's core principles of nonhierarchical co‐production, including the roles of creativity, community, identity, and emancipatory research which were animated by the new techno‐social context. We consider the cultural lives of neurodiversity in the West and beyond, including ethical and aesthetic dimensions. We share a faith in the power of storytelling to inform new social identities for neurodivergent people and to inform scientific understandings of atypical cognition. In exploring this, we speak through a porous first‐person plural narrator, to unsettle the idea that there is a hegemonic "we” speaking on behalf of all neurodivergent people.

PACE-A: An international phase 3 randomised controlled trial (RCT) comparing stereotactic body radiotherapy (SBRT) to surgery for localised prostate cancer (LPCa)-Primary endpoint analysis

Background: People presenting with early-stage LPCa have several treatment options. There is therapeutic equipoise with lack of randomised evidence for superiority of radiotherapy or surgery. PACE-A aimed to determine if there is improved quality of life (QoL) following SBRT compared to surgery. Method(s): PACE (NCT01584258) is a phase 3 open-label multiple-cohort RCT. In PACE-A, people with LPCa, T1-T2, Gleason<=3+4, PSA<=20ng/mL & suitable for surgery were randomised (1:1) to SBRT or surgery. SBRT dose was 36.25Gy/5 fractions in 1-2 weeks;surgery was laparoscopic or robotically assisted prostatectomy. Androgen deprivation was not permitted. Co-primary endpoints were patient reported outcomes (PROs) of Expanded Prostate Index Composite (EPIC-26) questionnaire number of absorbent pads per day & EPIC bowel subdomain score at 2 years. Target sample size was 234 participants (pts) to detect 9% difference in urinary incontinence (80% power, 5% 2-sided alpha) & 5-point difference in mean bowel subdomain score (90% power, 5% 2-sided alpha) with higher EPIC score (range 0-100) indicating better QoL. Secondary endpoints included clinician reported toxicity and additional PROs (1% significance level). Analysis is by treatment received. Result(s): From Aug 2012 to Feb 2022, 123 men from 10 UK centres were randomised. The IDMC advised stopping recruitment after a 2-year gap in during COVID. Pts had median age 66years (IQR: 61, 69), median PSA 8ng/ml (6, 11) with 52% tumours >=T2b and 79% Gleason 3+4;93% pts were of white race. 58/63 pts received SBRT as allocated (2 received surgery, 2 unknown, 1 withdrawn);48/60 received surgery as allocated (1 received SBRT, 3 received CRT, 2 unknown, 6 withdrawn). 8 laparoscopic and 42 robotic assisted operations were performed. Median follow-up is 50 months (IQR 41, 74). At 2 years, fewer SBRT pts reported use of urinary pads: 2/43 (4.5%) vs 15/32 (46.9%), p<0.001. SBRT pts had significantly worse bowel subdomain score (mean (SD) 88.4 (12.7) vs 97.3 (5.5), p<0.001). 7/45 (15.6%) SBRT and 0/31 (0%) surgery pts reported moderate/big problem with bowel symptoms (p=0.04). SBRT pts reported less EPIC sexual subdomain score (58.0 (31.9) vs 29.3 (20.5), p<0.001);there was no evidence of a difference in urinary subdomain score (85.5 (19.8) vs 80.5 (20.8), p=0.29). At 2 years, CTCAE genitourinary grade 2 or higher(G2+) toxicity was seen in 5/54 (9.3%) SBRT vs 4/42 (9.5%) surgery pts (p=0.97);there was no G2+ gastrointestinal (GI) events seen in either group. Conclusion(s): PACE-A contributes the first randomised data to the comparison of SBRT with surgery in LPCa providing PRO data relevant to informed decision making. Compared to surgery, pts receiving SBRT had better urinary continence & sexual bother score;clinician reported GI toxicity was low but SBRT pts reported more bowel bother at 2 years.

Neurodiversity, Networks, and Narratives: Exploring Intimacy and Expressive Freedom in the Time of Covid-19

The Narratives of Neurodiversity Network (NNN) is a neurodivergent academic, creative, and educator collective that came together with allies during the Covid-19 pandemic to create a network centred around emerging narratives about neuro-diversity and exploring new ways of learning and socialising. The network focuses on exploring the roles of written, spo-ken, and visual narratives across cultural locations about neuro-atypical experiences in generating improved agency and self-advocacy for those who have been subject to pathologization through neuro-normativity and intersecting oppression. During the last year, widening access to digital platforms has provided a space to explore these issues outside of traditional academic spaces. We run a monthly "Salon,” our mixed-media "reading, listening, and watching” group, in an effort to find positive representation within contemporary culture. Discussions have moved beyond mimesis and into a consideration of how narrative and storyworlds can question the supposed naturalness of certain ways of being in and perceiving the world. This article interrogates the network's core principles of nonhierarchical co-production, including the roles of creativ-ity, community, identity, and emancipatory research which were animated by the new techno-social context. We consider the cultural lives of neurodiversity in the West and beyond, including ethical and aesthetic dimensions. We share a faith in the power of storytelling to inform new social identities for neurodivergent people and to inform scientific understandings of atypical cognition. In exploring this, we speak through a porous first-person plural narrator, to unsettle the idea that there is a hegemonic "we” speaking on behalf of all neurodivergent people. © 2023 by the author(s);licensee Cogitatio (Lisbon, Portugal).

Extension's use of Zoom to Address a Public Health Risk Among Older Adults

Mandates that require social distancing and sheltering-in-place to stop the spread of the coronavirus have worsened an already concerning public health issue for older adults –social isolation and loneliness. Alabama Extension System at Alabama A&M University developed a program focused on helping older adults connect with family and friends. A descriptive study of 37 older adults indicated that their knowledge, ability, and comfort with implementing Zoom sessions increased significantly after completing the program. Findings show the potential use of the Zoom for Seniors program in preventing social isolation or loneliness among older adults. © This work is licensed under a Creative Commons Attribution-Noncommercial-Share Alike 4.0 License.

The impact of mindfulness training in early adolescence on affective executive control, and on later mental health during the COVID-19 pandemic: a randomised controlled trial.

BACKGROUND: Previous research suggests that mindfulness training (MT) appears effective at improving mental health in young people. MT is proposed to work through improving executive control in affectively laden contexts. However, it is unclear whether MT improves such control in young people. MT appears to mitigate mental health difficulties during periods of stress, but any mitigating effects against COVID-related difficulties remain unexamined. OBJECTIVE: To evaluate whether MT (intervention) versus psychoeducation (Psy-Ed; control), implemented in after-school classes: (1) Improves affective executive control; and/or (2) Mitigates negative mental health impacts from the COVID-19 pandemic. METHODS: A parallel randomised controlled trial (RCT) was conducted (Registration: https://osf.io/d6y9q/; Funding: Wellcome (WT104908/Z/14/Z, WT107496/Z/15/Z)). 460 students aged 11-16 years were recruited and randomised 1:1 to either MT (N=235) or Psy-Ed (N=225) and assessed preintervention and postintervention on experimental tasks and self-report inventories of affective executive control. The RCT was then extended to evaluate protective functions of MT on mental health assessed after the first UK COVID-19 lockdown. FINDINGS: Results provided no evidence that the version of MT used here improved affective executive control after training or mitigated negative consequences on mental health of the COVID-19 pandemic relative to Psy-Ed. No adverse events were reported. CONCLUSIONS: There is no evidence that MT improves affective control or downstream mental health of young people during stressful periods. CLINICAL IMPLICATIONS: We need to identify interventions that can enhance affective control and thereby young people's mental health.

The Impact of COVID-19 on Neuro-Oncology Clinical Trials DuringWave 1 andWave 2 at a Frontline Detroit Healthcare System

Objective: 1. N/A 2. Background: In the wake of the Coronavirus disease outbreak (COVID-19), clinical trial operations were significantly impacted following the shutdown of elective healthcare services and, in some cases, emergency operations. When the pandemic hit Detroit, Michigan in March 2020, the Hermelin Brain Tumor Center (HBTC) at Henry Ford Health System was consumed in COVID-19 emergency care which affected patient enrollment, conduct of trial activities, therapeutic treatment, deviation from protocol requirements, and sponsor-study site contact. The first Metro-Detroit COVID-19 case was confirmed March 10th 2020. At that time there were 18 active brain tumor clinical trials (phase 1 - 3) providing anti-cancer therapies. Design/Methods: Modifications included decentralized operations to buildings with clinic and radiology access away from inpatient COVID-19 care, utilization of telemedicine for nonessential visits, shipping of investigational products to patient home, and in some cases utilization of local results in place of central histopathological confirmation. By April 2020, trials were ranked based on availability of alternate therapies and subject safety in 4 tiers that correlated with subject benefit and impact on care. Trials were given a prioritization level to commence enrollment with priority given to trials where no standard of care exists. Of the HBTC trials, one was graded Tier 1 and most were graded Tier 2. All patients already enrolled, continued study participation. As restrictions eased, trials were opened in a sequential manner. Results: N/A Conclusions: Changes that were made during the first wave of the pandemic helped to minimize its effect on clinical trial operation and enrollment during the second wave in Fall 2020. Thus, leading toward a decrease in trial deviations and increased enrollment during the 2 wave. Changes made during the first wave helped to safely continue enrollment and treatment during the second wave and will have a longstanding impact on how clinical trials are conducted in the future.

Complementary and Integrative Health in the Community: Expanding Access for Veterans Seeking Care through the Veterans Health Administration

Methods: Data were pulled from an internal administrative dashboard. Referrals include services for Veterans who live a prescribed driving distance from a VAMC, wait times over threshold, services unavailable, or for reasons of the best medical interest. Data was pulled for fiscal years 2020 through 2021 and included: chiropractic care, acupuncture, biofeedback, neuron feedback, clinical hypnosis, massage therapy, meditation (specifically MBSR), Tai Chi/qigong, and yoga. Standardized tracking of referrals began with the implementation of Standard Episodes of Care (SEOC) which define care requested and include number of visits permitted and timeframe. Results: Referrals increased for all approaches from FY20-21 shown as (FY20;FY21): chiropractic (104,197;197,357), acupuncture (59,787;100,908), massage therapy (5,021;17,646), biofeedback (31;69), neuron feedback (27;74), clinical hypnosis (10;40), MBSR (2;8), Tai Chi (2;8) and Yoga (1;2). Background: The Veterans Health Administration (VHA) Directive 1137: Provision of Complementary and Integrative Health (CIH) identifies the inclusion of evidence-based CIH approaches in the VHA's Medical Benefits Package (acupuncture, biofeedback, clinical hypnosis, guided imagery, massage therapy, meditation, Tai Chi/qigong, and yoga). The purpose of this administrative data review is to identify which approaches are being referred to Community Care from VHA medical centers (VAMC), and to identify if COVID-19 has had an impact on referrals to the community. Conclusion: CIH is expanding across the VHA and could be useful in supporting a cultural transformation that includes integrative health approaches within conventional medical systems. While all VAMCs provide some CIH in-house, a substantial amount is provided through Community Care. As the largest integrated healthcare system in the United States, this could impact growth of CIH and the need for more providers in the community. By hiring CIH professionals onstation and expanding the network to the community, VHA could be one of the largest providers and users of CIH.

Veteran Engagement in Well-being Programming in the VA Whole Health System of Care Prior to and During COVID-19 Operations

Methods: The population included Veterans enrolled in the WHS nationally. Students t-test was used to assess the difference in unique Veterans engaged in WBP the six quarters prior to COVID (pre-COV) and the six quarters during COVID response (resp-COV). The differences in delivery of virtual WBP was assessed, including: (RFLX) Intro to WH Group, (HTAC) Take Charge of My Life & Health Group, (SCHC) EVP WH, (SNVC) EVP Mindful Movement, (HTFC) WH Partner Indiv., (WCHC) WH Coaching Indiv., (WCDC) WH Coaching Group, (CGQC) Qigong, (TAIC) TAI CHI, (YOGA) YOGA, (GIMA) Guided Imagery, (RLXT) Relaxation Techniques, (MANT) Mantram Repetition, (MDTN) Meditation, (MMMT) Mindfulness (non-MBSR), (REIK) REIKI, and (TPHT) Therapeutic/ Healing Touch. Results: Pre-COV, a total of 58,165 unique Veterans were engaged in 14,163 tele-health WBP encounters, compared to 63,648 unique Veterans engaged in 334,472 tele-health WBP encounters resp-COV. A significant increase in average number of tele-health WBP encounters per quarter was observed: 2,593 (95%CI 1537, 3649) telehealth pre-COV compared to 52,548 (95%CI 34169, 70926) during resp-COV, p=0.0008. There were significant increases in the delivery of all virtual WBP offerings (all P <0.05), except for SCHC and TPHT. Background: Well-being programming (WBP) is a core part of delivery of Whole Health (WH). During the COVID response, there was a pronounced decrease in delivery of WBP care, with a shift of delivery from face-to-face to virtual. This study describes the impact of COVID on delivery of WBP within the VA WH System (WHS). Conclusion: These data suggest that the response to COVID had little impact on the number of unique Veterans engaged in WBP overall, but the number of virtual WBP encounters increased significantly, comparing the same time periods. This analysis shows that the VA COVID response to increase delivery of virtual WBP as part of the national offering of the WHS was effective.

The American Government and "Total War" on COVID-19

In the Economic Impact Payment letter to American citizens in Spring 2020, President Donald Trump wrote that "we wage total war on this invisible enemy." Trump likely did not intend to explicitly link this to the rich theory about "total war" in military history, but this article examines the American rhetoric surrounding the war on COVID-19 to see whether it corresponds to definitions of total war in military strategic thought. The Clausewitzian origins of the idea of "absolute war" and limited war will also be examined to ascertain their relevance as a framework for understanding the American approach to the conflict with the virus. A total war strategy would have implied either mobilizing the entire population into the health sector or imposing a total national lockdown. This article examines both the strategy outlined by Donald Trump and the reality of what was undertaken by the Federal Government. The military was involved in the war effort against the virus in the U.S., but only in a logistical and financial sense. A national lockdown was never intended due to its potential adverse effects on the economy, and in any case, the Federal Government did not have the authority to impose health policy on individual states and local authorities. The result was a variety of local responses to the crisis with little federal coordination, much like what occurred with the Influenza Epidemic of 1918-19. Despite its military and hyperbolic rhetoric, the Trump Administration did not choose a total war strategy. Instead, it decided to adopt a limited holding strategy that accepted human losses while protecting the economy and waiting for a Government-sponsored vaccine to save the day. © 2021 Societe des Anglicistes de l?Enseignement Superieur. All Rights Reserved.

The Impact of the COVID-19 Pandemic on Practice Patterns in Breast Radiation Oncology: A Case-Based Survey Study in the United States

Purpose/Objective(s): The COVID-19 pandemic posed challenges in resource allocation and breast cancer (BC) treatment decisions. Our study aims to understand changes in practice patterns of United States radiation oncologists (RO) treating BC during the COVID-19 pandemic. Materials/Methods: An IRB-approved 58-question survey with 6 clinical scenarios was distributed between July 17 and November 8, 2020 to ASTRO directory members. The cases included 1) Low-grade ductal carcinoma in situ (DCIS), 2) Low-risk BC treated with lumpectomy, 3) Low-risk BC treated with mastectomy with reconstruction 4) BC treated with neoadjuvant chemotherapy and mastectomy with reconstruction 5) BC treated with mastectomy and adjuvant chemotherapy but without reconstruction 6) Metastatic BC with enlarging breast mass. RO were surveyed about treatment recommendations if cases were seen pre-pandemic (PP) and hypothetically during the peak of pandemic (DTPP). Chi-square and McNemar-Bowker tests were used to examine the significance of changes. Results: A total of 285 respondents from 48 states completed the survey and reported treating at least one patient with BC in the past 12 months. 45% primarily practice in university affiliated hospitals and 43% in private practice. 22% reported treating ≥ 1 COVID-positive BC patients. Moderate hypofractionation (2.31 - 3 Gy per fraction) in the PMRT and immediate reconstruction setting was recommended by 0.7% PP compared to 10.5% DTPP. In the low-risk PMRT setting, recommendation of no further treatment increased from 13% PP to 20% DTPP. Further, 56% changed their DCIS recommendations if the patient was seen DTPP. For low-risk BC, whole breast RT was preferred by 83.5% PP compared to 46.7% DTPP, and 35.1% recommended delay of RT DTPP compared to 0.4% PP (P < 0.05). Increase in ultra-hypofractionation (> 5 Gy per fraction) was significant for low-risk BC after lumpectomy as 0.4% reported its use PP compared to 3.8% DTPP. In addition, utilization of brachytherapy as PBI modality decreased from 23.9% to 17% among respondents PP and DTPP respectively. The Florence fractionation schedule for PBI was recommended by 46.2% for early-stage BC and by 51.7% for DCIS DTPP compared to 20% and 34.4% PP. Finally, 68.1% reported the use of 10-25 fractions PP for the palliative scenario. However, of those who would change their recommendation (48.8%), 62.8% reported recommendation of ≤ 5 fractions DTPP. Additional subset analysis by geographic region and practice type were notable for variable changes in treatment recommendations, and will be presented. Conclusion: This large survey of Breast RO clinical decision making demonstrates significant differences in recommendations and rapid adoption of unique fractionation. While likely reflective of intent to optimize resource allocations during the pandemic, maintenance of new practice patterns remains subject to future investigation.

Community hospitals emerge as models for disaster readiness with rapid cycle in situ simulation

INTRODUCTION: COVID-19 exposed the vulnerability of healthcare systems at all levels. Preparedness necessitated collaboration, innovation, leadership, and flexibility to implement risk-mitigating protocols. Community hospitals quickly adapted and were active front-line providers during this pandemic. Many non-tertiary centres emerged as models for disaster readiness with innovative, real-time strategies that fostered practice change. We describe how rapid cycle in-situ simulation contributed to improved safety through identification and prompt resolution of latent safety threats (LSTs). METHODS: A QI initiative involving front-line stakeholders in two large community hospitals was launched focusing on protected code blue and pre-code scenarios. In-situ simulations were adapted to multiple wards, including the emergency department, labour and delivery, general medicine, intensive care, diagnostic imaging, the operating room and post anesthetic care unit, the coronary catheterization lab, and renal dialysis. LSTs included concerns related to the protected code blue resuscitation and those unique to individual department environments. Real-time solutions were adopted and rapidly disseminated through both institutions. RESULTS: Over a three-month period (March to May, 2020), we conducted over 30 in-situ simulations. LSTs included breaches in donning and doffing, lack of clarity in roles and responsibilities, gaps in strategies to minimize aerosolization, barriers for effective team communication, and patient transfer logistics. Institution-wide policies were developed in real-time and distributed to hospital staff after each cycle to promote immediate knowledge translation. This created a collaborative, evolving protected code blue policy that improved healthcare worker confidence, readiness and safety. CONCLUSIONS: Community hospitals are ideal settings for disaster readiness as they can quickly design QI models, integrate results and modify processes in real time. Rapid cycle in-situ simulation empowered two community hospitals to expeditiously implement practice changing policies during the peak of the COVID-19 pandemic. This is a robust example of an easily adoptable community-based QI strategy that effectively fosters rapid institutional change when required to weather the storm of a natural disaster.

In situ simulations for protected code blue in the COVID-19 pandemic to detect latent safety threats

INTRODUCTION: With the emergence of Covid-19, a respiratory illness caused by the novel coronavirus SARS-Cov-2, a global pandemic has called for adjustments in hospital protocols and procedures in an effort to prevent spread of the virus, protect frontline healthcare workers, and preserve limited resources, such as personal protective equipment (PPE). One such important protocol was for protected code blue policy for hospitals dealing with cardiac arrests and potential AGMPs (aerosol generating medical procedures), deemed high risk requiring appropriate PPE and precautionary measures. We used in-situ simulation to aid in designing the new protected code blue protocol at our institution. METHODS: In our institution, a code blue policy was informed by American Heart Association and Heart and Stroke Foundation guidelines and Ontario Public Health Guidelines. It was however recognized that implementation of the protected code blue policy and judicious use of PPE would be very challenging. A quality improvement project was thus designed to utilize in situ simulations to train physicians, nurses and respiratory therapist in the different clinical units in the hospital and detect the latent safety threats that would hinder the safe implementation of the protected code blue policy. Iterative PDSA (Plan-Design- Study-Act) cycles were designed and implemented and at each stage the latent threats were identified and mitigated in the following domains- knowledge, personnel and staff, process, policy, systems issues, and medications. RESULTS: Over 80 in situ simulations were completed from March to June 2020. Latent safety threats such as effective communication, appropriate PPE use, personnel, overcrowding, intubation procedure and safety lead roles were identified and mitigated through policy changes, training and retesting. The simulations were time consuming and challenging but overall received good feedback and resulted in more compliance with the protected code blue policy. CONCLUSIONS: In-situ simulation is an effective modality in quality improvement, especially when rapid training is required and real-world threats must be identified and mitigated in a timely manner to optimize both patient and healthcare worker safety.