Identification and estimation of mediational effects of longitudinal modified treatment policies (preprint)

We demonstrate a comprehensive semiparametric approach to causal mediation analysis, addressing the complexities inherent in settings with longitudinal and continuous treatments, confounders, and mediators. Our methodology utilizes a nonparametric structural equation model and a cross-fitted sequential regression technique based on doubly robust pseudo-outcomes, yielding an efficient, asymptotically normal estimator without relying on restrictive parametric modeling assumptions. We are motivated by a recent scientific controversy regarding the effects of invasive mechanical ventilation (IMV) on the survival of COVID-19 patients, considering acute kidney injury (AKI) as a mediating factor. We highlight the possibility of "inconsistent mediation," in which the direct and indirect effects of the exposure operate in opposite directions. We discuss the significance of mediation analysis for scientific understanding and its potential utility in treatment decisions.

The pandemic, COVID-19 disease and perinatal health (preprint)

Adverse effects of COVID-19 on perinatal health have been documented, however there is a lack of research that separates individual disease from other changing risks during the pandemic period. We linked California statewide birth and hospital discharge data for 2019-2020, and compared health indicators among 3 groups of pregnancies: [a] 2020 delivery with COVID-19, [b] 2020 delivery with no documented COVID-19, and [c] 2019 pre-pandemic delivery. We aimed to quantify the links between COVID-19 and perinatal health, separating individual COVID-19 disease (a vs b) from the pandemic period (b vs c). We examined the following health indicators: preterm birth, hypertensive disorders of pregnancy, gestational diabetes mellitus and severe maternal morbidity. We applied model based standardization to estimate "average effect of treatment on the treated" risk differences (RD), and adjusted for individual and community-level confounders. Among pregnancies in 2020, those with COVID-19 disease had higher burdens of preterm birth (RD[95% confidence interval (CI)]=2.8%[2.1,3.5]), hypertension (RD[95% CI]=3.3%[2.4,4.1]), and severe maternal morbidity (RD[95% CI]=2.3%[1.9,2.7]) compared with pregnancies without COVID-19 (a vs b) adjusted for confounders. Pregnancies in 2020 without COVID-19 had a lower burden of preterm birth (RD[95% CI]=-0.4%[-0.6,-0.3]), particularly spontaneous preterm, and a higher burden of hypertension (RD[95% CI]=1.0%[0.9,1.2]) and diabetes RD[95%CI]=0.9%[0.8,1.1] compared with pregnancies in 2019 (b vs c) adjusted for confounders. Protective associations of the pandemic period for spontaneous preterm birth may be explained by socioenvironmental and behavioral modifications, while increased maternal conditions may be due to stress and other behavioral changes. To our knowledge, our study is the first to distinguish between individual COVID-19 disease and the pandemic period in connection with perinatal outcomes.

Time-Varying and Quantile-Based Relationship among Geopolitical Risks, Oil, and Gold Prices

This paper probes the relationship between geopolitical risks (GPR), WTI oil, and gold prices utilizing the time-varying causality and quantile regression approaches. The sample period spans from January 1986 to January 2022, comprising 433 monthly observations and representing the longest common period of data availability. The results show that there is no causality between the pairs of GPR–WTI, and GPR–gold prices for the full sample period, while the causality between gold and WTI is unidirectional, running from gold to WTI. Using the rolling causality test, however, the findings show that the dynamic causal relations strengthen over time. The Granger causality from the gold prices to GPR and WTI is stronger than the other way around, suggesting that the gold market dominates the other two variables in terms of strength of the lead-lag structure of causality. Besides, the findings reveal the strongest causation effects between GPR and WTI spot prices. Before 2009, the causal relationship between WTI and GPR is mostly unidirectional while also a bidirectional linkage emerges, coinciding with the crisis periods including the Dot-Com and 2007 US Subprime crises. During the causal periods, these variables respond negatively to changes in others. For the COVID19 period, the direction of causality considerably changes in favor of WTI for the GPR–WTI pair whereas it is unchanged for the WTI–gold pair. The results indicate that WTI has positive and negative predictive powers for GPR and gold while it receives negative and positive causation effects from GPR and gold during the pandemic, respectively. The results, in overall, may offer important insights for investors and regulatory authorities in building portfolio and risk management strategies as well as pricing and trading activities and constructing monetary policies over various market conditions. Copyright © 2022 Erkan Kara, Remzi Gökb. Published by Vilnius University Press.

Shocks to the System: COVID-19's Perceived Interference With the Academic Performance and Plans of University Undergraduates

The COVID-19 pandemic disrupted and reshaped undergraduate students' social, learning, and workplace environments. Using an ecological systems framework, we draw on survey data from a sequential, mixed-methods study of undergraduate students at an urban, Minority-Serving Institution (n = 1,272) to examine the association between health, economic, and other pandemic-related shocks and students' academic perceptions. First, we conducted exploratory factor analyses on two groups of measures: "basic need concerns” and "interference with academic performance and plans.” Second, we connected student perceptions of the pandemic's interference with their academic performance and plans to ecological changes using regression analysis. Our model found a significant amount of the variance (12.6%) could be attributed to economic and health-related shocks and academic disruptions, including changes to caretaker responsibilities. However, students' perceptions of how well they were doing with online learning accounted for most of the modeled variance. Implications for undergraduate student retention are discussed.

Introducing longitudinal modified treatment policies: a unified framework for studying complex exposures (preprint)

This tutorial discusses a recently developed methodology for causal inference based on longitudinal modified treatment policies (LMTPs). LMTPs generalize many commonly used parameters for causal inference including average treatment effects, and facilitate the mathematical formalization, identification, and estimation of many novel parameters. LMTPs apply to a wide variety of exposures, including binary, multivariate, and continuous, as well as interventions that result in violations of the positivity assumption. LMTPs can accommodate time-varying treatments and confounders, competing risks, loss-to-follow-up, as well as survival, binary, or continuous outcomes. This tutorial aims to illustrate several practical uses of the LMTP framework, including describing different estimation strategies and their corresponding advantages and disadvantages. We provide numerous examples of types of research questions which can be answered within the proposed framework. We go into more depth with one of these examples -- specifically, estimating the effect of delaying intubation on critically ill COVID-19 patients' mortality. We demonstrate the use of the open source R package lmtp to estimate the effects, and we provide code on https://github.com/kathoffman/lmtp-tutorial.

The Effects of COVID-19 on the Balance System

The new coronavirus disease-2019 is clearly showing its effect in our country and around the world. Dizziness or balance disorder is defined as a clinical manifestation of COVID-19 as of 2020. Balance disorders should not be underestimated as they have been shown to be a notable clinical finding in coronavirus disea se-2019patients. Coronavirus disease-2019post-treatment and balance disorders should be thoroughly investigated. Non-specific symptoms, especially vestibular disorders, can be easily overlooked during evaluation. Therefore, this is a situation that requires attention in the clinic. The purpose of this review is to examine the studies in the literature on how the vestibular system is affected in people who are infected by coronavirus disease-2019. © 2022 AVES. All Rights Reserved.

Approaches of the Physicians on COVID-19 Vaccination: An Online Survey from Turkiye

Introduction: Coronavirus disease 2019 (COVID-19) is caused by a newly discovered coronavirus, SARS-CoV-2. The Turkish govern-ment has planned to procure COVID-19 vaccine through multiple agencies and companies in order to vaccinate at least 75% of the population. Physicians' beliefs and attitudes to COVID-19 vaccines are important for the immunization rate of the public. This study aimed to evaluate the vaccination approaches of the Turkish physicians against COVID-19.Materials and Methods: This study was conducted as an online survey between 15.01.2021-12.02.2021, among mainly infectious disease and internal medicine physicians in Turkiye. The survey included questions on the demographics of physicians and their approaches toward vaccination against COVID-19.Results: Among the 486 participants, 34.6% were internal medicine physicians and 17.5% were infectious diseases physicians. Total acceptance rate of the COVID-19 vaccine among physicians was 89.9%. Physicians who stated having sufficient information about COVID-19 vaccines had a higher rate of COVID-19 vaccine recommendation to their patients compared to those who stated not having sufficient information (95.8% vs 86.7%, p= 0.011). Physicians with concerns about adverse effects or efficacy of the COVID-19 vaccine had a lower rate of COVID-19 vaccine recommendation to their patients/relatives/friends (p< 0.001). Female and younger physicians were more concerned about the adverse effects of the COVID-19 vaccine (p< 0.05). Recommendation of COVID-19 vaccine was higher among physicians with confidence in having sufficient information and without concern about efficacy of the vaccine. Conclusion: Since physicians have an important role in providing information and reducing COVID-19 vaccine hesitancy among the community, improvement in the knowledge and concerns of physicians should be considered.

Evaluation of the frequency and intensity of COVID-19 in patients with ankylosing spondylitis under anti-TNF therapy

BACKGROUND: This study aimed to investigate pregnancy frequency and evaluate the factors affecting live births in hemodialysis (HD) patients. METHODS: Female HD patients whose pregnancy was retrospectively reported between January 1, 2014, and December 31, 2019. The duration of HD, primary disease, and the information on whether the pregnancy resulted in abortion, stillbirth, or live birth, whether the HD duration was prolonged after diagnosing the pregnancy and whether it accompanied preeclampsia were recorded. RESULTS: In this study, we reached 9038 HD female patients' data in the study. A total of 235 pregnancies were detected in 145 patients. The mean age was 35.42 (35 ± 7.4) years. The mean age at first gestation was 30.8 ± 6.5 years. The average birth week was 32 (28 -36) weeks. A total of 53.8% (no = 78) of the patients had live birth, 51.7% (no = 70) had at least one abortion in the first 20 weeks, and 13.1% (no = 19) had at least one stillbirth after 20 weeks. The rate of patients' increased numbers of dialysis sessions during pregnancy was 71.7%. The abortion rate was 22.4% in those with increased HD sessions, whereas 79.3% in those not increased HD sessions (p < 0.001). Live birth frequency was 67.2% in the increased HD sessions group and 3.4% in those who did not differ in HD sessions (p < 0.001). DISCUSSION: For the first time, we reported pregnancy outcomes in HD female patients, covering all regions of Turkey. It has been observed that;increasing the number of HD sessions in dialysis patients will decrease fetal and maternal complications and increase live birth rates.

Performance Comparison of Oral, Laryngeal and Thoracic Sounds in the Detection of COVID-19 by Employing Machine Learning Techniques

COVID-19 can directly or indirectly cause lung involvements by crossing the upper airways. It is essential to quickly detect the lung involvement condition and to follow up and treat these patients by early hospitalization. In recent COVID-19 diagnosis procedure, PCR testing is applied to the samples taken from the patients and a quarantine period is applied to the patient until the test results are received. As a complement to PCR tests and for faster diagnosis, thin-section lung computed tomography (CT) imaging is used in COVID-19 patients. In this study, it is aimed to develop a method that is as reliable as CT, and compared to CT, less risky, more accessible, and less costly for the diagnosis of COVID-19 disease. For this purpose, first speech and cough sounds from the oral, laryngeal and thoracic regions of COVID-19 patients and healthy individuals were obtained with the multi-channel voice recording system we proposed, the obtained data were processed with machine learning methods and their accuracies in COVID-19 diagnosis were presented comparatively. In our study, the best results were obtained with the features extracted from the cough sounds taken from the oral region. © 2022 IEEE.

THE LONGITUDINAL EVOLUTION OF COVID-19 OUTCOMES AMONG HEMODIALYSIS PATIENTS: A NATIONWIDE MULTICENTRE CONTROLLED STUDY

BACKGROUND AND AIMS: Haemodialysis (HD) patients are at increased risk for adverse short-term consequences of COVID-19. In this study, we investigated the characteristics of chronic HD patients in the post-COVID-19 period and compared them with the control group. METHOD: We conducted a national multicentre observational study involving adult chronic HD patients recovering from COVID-19. The control HD group was selected from patients with similar characteristics who did not have COVID-19 in the same center. SARS-CoV-2 RT-PCR negative patients and patients in the active period of COVID-19 were not included. RESULTS: A total of 1223 patients (635 COVID-19 groups, 588 control groups) were included in the study from the data collected from 47 centres between 21 April 2021 and 11 June 2021. The patients' baseline demographics, comorbidities, medications, HD characteristics and basic laboratory tests were quite similar between the groups (Table 1). 28th-day mortality and between 28th day and 90th day mortality were higher in the COVID-19 group than in the control group [19 (3.0%) patients and 0 (0%) patients;15 (2.4%) patients and 4 (0.7%) patients, respectively]. Presence of respiratory symptoms, rehospitalization, need for home oxygen therapy, lower respiratory tract infection and A-V fistula thrombosis were significantly higher in the COVID-19 group in the first 28 days of illness and between 28 and 90 days. Mortality was significantly associated with preexisting COVID-19, age, current smoking, use of tunneled HD catheter, persistence of respiratory symptoms, rehospitalization, need for home oxygen support, presence of lower respiratory tract infection within 28 days and persistence of respiratory symptoms. CONCLUSION: In the post-COVID-19 period, mortality, rehospitalization, respiratory problems and vascular access problems are higher in maintenance HD patients who have had COVID-19 compared to control HD patients. (Table Presented).

The Relationship Between the Presence of Severe Acute Respiratory Syndrome-Coronavirus-2 during Pregnancy and Neonatal Hearing Loss

Introduction: In this study, we investigated the maternal severe acute respiratory syndrome-coronavirus-2 (SARS-CoV-2) infection's effect on newborn hearing loss. Methods: Thirty-nine newborns whose mother's SARS-CoV-2 real time-polymerase chain reaction test was positive at the time of parturition were included in this study. Another 39 newborns who were born from healthy pregnancies were selected as the control group. Neonates with risk factors for hearing loss determined by the American Academy of Pediatrics Joint Committee on Infant Hearing 2007 and those with ear pathology were excluded. The newborn hearing screening was done with auditory brainstem response (ABR) test. Second ABR test (ABR-2) was performed on newborns who failed the 1st test (ABR-1). The third ABR test (ABR-3) was performed on newborns who failed the second ABR test (ABR-2). The screening results were analyzed statistically. Results: In the control group, a total of 6 (15.4%) newborns failed ABR-1, five newborns in one ear (3 right, 2 left), and one newborn in both ears. In the study group, a total of 14 (35.9%) newborns failed ABR-1, 11 newborns from both ears and 3 (2 right, 1 left) newborns from one ear. ABR-1 results were significantly worse in the study group's neonates (p=0.038). In addition, the rate of involvement of both ears was higher in the study group (p=0.018;p<0.05). 1 (16.7%) newborn in the control group and 2 (14.3%) newborns in the study group failed the ABR-2 in both ears. There was no statistically significant difference according to the ABR-2 test (p=0.681;p>0.05). All babies passed the ABR-3. Conclusion: There was a significant relationship between neonatal hearing loss and maternal SARS-CoV-2 infection. This hearing loss is usually bilateral and temporary.

Knowledge and attitudes of pharmacy students about COVID-19. (COVID-19 dedicated issue.)

The level of knowledge about COVID-19 varies among students in the field of healthcare. In this study, it was aimed to compare pharmacy students' level of knowledge about COVID-19 before and after an educational seminar. This study was conducted in the first wave of COVID-19 and just at the beginning of the pandemic. A seminar on COVID-19 and protection ways was presented by an infectious disease physician to the pharmacy students in a faculty of pharmacy from Ankara. Before and after the seminar, a questionnaire about COVID-19 consisting of 17 multiple-choice or open-ended questions was applied to the students. A total of 114 pharmacy students (46.5% female) attended the seminar and all of them participated in the study. The most common information resources in terms of COVID-19 that were used by the participants was internet (non-scientific resources) (n=90, 78.9%), classical media (TV, newspaper) (n=79, 69.3%) and social media (n=77, 67.5%). The rates of knowing that the coronavirus is a zoonotic virus (p < 0.001) and awareness of cough and dyspnea, which are symptoms of COVID-19, showed a statistically significant increase after the seminar (p=0.039 and p < 0.001, respectively). The students' knowledge of protection from the disease such as covering the nose and mouth with tissue paper, using eyeglasses, and wearing protective clothing was significantly improved after the seminar (p=0.043, p < 0.001, p < 0.004, respectively). Although the knowledge of pharmacy students about the new pandemic was not insufficient, it had also increased significantly after the seminar. It is thought that determining and improving their knowledge about the pandemic will contribute to pandemic management.

Impact of the Pandemic on Audiology: Practices in Tele-Audiology

Social distance, quarantine measures, and the risk of infection during the new coronavirus pandemic have limited course of diagnosis, follow-up, and rehabilitation of patients with hearing loss. Audiologists are looking for innovative ways to meet the patients’ needs and to overcome these difficulties. Tele-audiology applications, supported by new technologies, can help reduce the risk of spreading the infection and maintain social distancing by avoiding direct patient contact. This review aims to examine the opportunities offered by tele-audiology applications to overcome the clinical difficulties caused by the need for social distancing and the pandemic. © 2022 Archives of Health Science and Research. All rights reserved.

Physical activity in children during COVID-19 period: systematic review

The aim of this study is to evaluate the importance of physical activitiy in protecting the health of children and adolescents whose physical activity opportunities were restricted during the coronavirus disease-2019 (COVID-19) epidemic. Physical activity contributes to the physical and mental health of children and young people, especially a stronger immune system. On March 11, 2020, The World Health Organization described the COVID-19 virus outbreak as a global pandemic. Due to the restrictions made as a result of the decisions taken by many countries due to the COVID-19 virus epidemic, significant changes have occurred in the Daily lives of children, young people and families. Many countries have restricted the use of physical distance, social interactions, sports, playgrounds and parking spaces. As a result of these restrictions, the decrease in physical activity habits in children has been a cause for concern. Given the strong relationship between health status and physical activity, it appears that during the COVID-19 pandemic, children's health deteriorated further due to a sedentary lifestyle. Because an inactive lifestyle;it is directly related to obesity, weakening of the immune system and risk of chronic diseases. Parents, educators, healthcare professionals and the media have a great role to play in increasing children's physical activity levels. During this period, children should try tos tay healthy with simple exercises that combine games and fun activities while staying at home. Suggestions fort his include participating in physical activities appropriate to pandemic constraints, participating in new leisure activities, using online health and/or physical activity practices. As a result;parents and authorities have great responsibilities in creating adequate physical activity opportunities to protect the health of children and young people during the epidemic.

Measuring Physical Activity in Children With Cochlear Implants Using Self-Reported PAQ-C Before and During the COVID-19 Pandemic

Physical inactivity is common during periods of self-isolation, but for children with special needs, there are crucial benefits to be gained from maintaining moderate to vigorous physical activity throughout the COVID-19 pandemic. This study aimed to compare the physical activity levels of children with cochlear implants and their typically developed peers before and during the COVID-19 pandemic. The sample included 135 children with cochlear implants and 105 typically developed peers. We compared the daily activity levels of the two groups, measured by a 10-item questionnaire and the triangulation method. Results of this study showed that the girls were less active than the boys. Most items had adequate variance, and their means were close to the center of the range of values. The PAQ-C scores for the children with cochlear implants were distributed across a wider range than the scores for the typically developed children. Children with cochlear implants were physically active during school hours but were less active outside school, spending 3 to 6 hours per day using digital media during the COVID-19 pandemic. Children with cochlear implants need to increase their physical activity in and out of school by increasing their level of independence and their ability to adapt to social life. Giving information about physical activity opportunities to parents of children with cochlear implants is an important issue. School presents an opportunity for children to engage in regular physical activity, which is beneficial for their health status.

Sexual and reproductive health (SRH): a key issue in the emergency response to the Coronavirus disease (COVID- 19) outbreak

The novel coronavirus disease (COVID-19) outbreak was first declared in China in December 2019, and WHO declared the pandemic on 11 March 2020. A fast-rising number of confirmed cases has been observed in all continents, with Europe at the epicentre of the outbreak at this moment. Sexual and reproductive health (SRH) and rights is a significant public health issue during the epidemics. The novel coronavirus (SARS-CoV-2) is new to humans, and only limited scientific evidence is available to identify the impact of the disease COVID-19 on SRH, including clinical presentation and outcomes of the infection during pregnancy, or for persons with STI/HIV-related immunosuppression. Beyond the clinical scope of SRH, we should not neglect the impacts at the health system level and disruptions or interruptions in regular provision of SRH services, such as pre- and postnatal checks, safe abortion, contraception, HIV/AIDS and sexually transmitted infections. Furthermore, other aspects merit attention such as the potential increase of gender-based violence and domestic abuse, and effects of stigma and discrimination associated with COVID-19 and their effects on SRH clients and health care providers. Therefore, there is an urgent need for the scientific community to generate sound clinical, epidemiological, and psycho-social behavioral links between COVID-19 and SRH and rights outcomes.

Acute kidney injury in hospitalized COVID-19 patients: A multicentre study by Turkish society of nephrology

BACKGROUND AND AIMS: Acute kidney injury (AKI) is common in coronavirus disease-2019 (COVID-19) and the severity of AKI is linked to adverse outcomes. In this study, we investigated the factors associated with in-hospital outcomes among hospitalized patients with COVID-19 and AKI. METHOD: In this multicenter retrospective observational study, we evaluated the characteristics and in-hospital renal and patient outcomes of 578 patients with confirmed COVID-19 and AKI. Data were collected from 34 hospitals in Turkey from March 11 to June 30, 2020. AKI definition and staging were based on the Kidney Disease Improving Global Outcomes criteria. Patients with end-stage kidney disease or with a kidney transplant were excluded. Renal outcomes were identified only in discharged patients. RESULTS: The median age of the patients was 69 years, and 60.9% were males. The most frequent comorbid conditions were hypertension (70.5%), diabetes mellitus (43.8%), and chronic kidney disease (41.5%). The proportions of AKI stages 1, 2, and 3 were 54.0%, 24.7%, and 21.3%, respectively. 291 patients (50.3%) were admitted to the intensive care unit. Renal improvement was complete in 80.7% and partial in 17% of the patients who were discharged. Renal outcomes were worse in patients with AKI stage 3 or baseline CKD. The overall in-hospital mortality in patients with AKI was 38.9%. By multivariate Cox regression analysis, age (hazard ratio [HR] [95% confidence interval (95%CI)]: 1.01 [1.0-1.03], p = 0.035], male gender (HR [95%CI]: 1.47 [1.04-2.09], p = 0.029), diabetes mellitus (HR [95%CI]: 1.51 [1.06-2.17], p = 0.022) and cerebrovascular disease (HR [95%CI]: 1.82 [1.08-3.07], p = 0.023), serum lactate dehydrogenase (greater than two-fold increase) (HR [95%CI]: 1.55 [1.05-2.30], p = 0.027) and AKI stage 2 (HR [95%CI]: 1.98 [1.25-3.14], p = 0.003) and stage 3 (HR [95%CI]: 2.25 [1.44-3.51], p = 0.0001) were independent predictors of in-hospital mortality. The in-hospital mortality rates across AKI stages by age, gender, and diabetes mellitus were shown in the Figure. CONCLUSION: Advanced-stage AKI is associated with extremely high mortality among hospitalized COVID-19 patients. Age, male gender, comorbidities, which are risk factors for mortality in patients with COVID-19 in the general population, are also related to in-hospital mortality in patients with AKI. Renal problems continue in a significant portion of the patients who were discharged.

EFFECT OF SURGICAL MASK USE ON BREATHING AIR QUALITY AND OXYGEN SATURATION: A QUASI-EXPERIMENTAL MODEL

This study aimed to investigate the effect of surgical masks (SM), which are widely used in the community in the fight against COVID-19, on breathing air quality and blood oxygen saturation among healthy people. This study included 45 healthy individuals. At rest and indoor conditions: blood oxygen concentrations and heart rates were recorded, while simultaneous oxygen (O-2), carbon monoxide (CO), sulphur dioxide (SO2), nitrogen oxides (NOx), VOC (volatile organic compounds) concentrations, and humidity and temperature were measured both in the mouth-nose area (MNA) in the indoor area before the mask was worn, and in MNA inside the mask (in-mask) after the mask was worn. The mean age of 45 healthy participants was 36.06 with a male to female ratio of 53.3% to 46.7%. When the indoor room air values in MNA without SM were compared with in-mask MNA values;in-mask O-2 saturation was observed to decrease, CO to increase in smokers, and VOC, humidity and temperature to significantly increase in all participants. SM wearing was observed not to significantly alter simultaneously measured peripheral blood O-2 saturation and resting heart rate. The (measured) effect of SM wearing on O-2 saturation and heart rate was found to be very small. Wearing a surgical mask was found not to impair blood O-2 saturation in healthy individuals at rest. Further studies can be recommended to support the results in this study.

Digital pathology in the muscle biopsy services during the COVID-19 pandemic: A large UK center experience

Introduction: In March 2020, the WHO declared the COVID-19 outbreak as a pandemic and soon after the UK governments declared "lockdown" measures. In line with the UK General Medical Council guidance to the healthcare workers, we adopted new working practices to meet the need for flexible and remote working including virtual clinical meetings. Methods and adaptations: The "fresh" muscle biopsy sample was handled with necessary precautions as per the Public Health England safe handling guidance. The whole slide digital images were acquired using an advanced digital slide scanner. The images were analyzed on a virtual microscopy platform with high resolution PC monitor. The digital pathology reporting was introduced as per the UK Royal College of Pathologists guidelines. Initial selfvalidation, comparing digital images with the respective glass slides was undertaken. To maintain the clinical standards and patient safety, whenever in doubt, we concurred with the glass slide findings. The multi-disciplinary neuromuscular team meetings and clinical discussions were held on a virtual platform by taking appropriate steps to protect patient confidentiality. Results: The digital reporting has enabled quicker turn around. The virtual meeting platform has enabled expansion of clinical audience and participation. It has facilitated better training opportunities to the junior doctors. Despite intermittent challenges such as scan failure, poor quality audio/video, the overall end-user feedback has been very positive. Conclusion: The COVID-19 has brought about several changes. We share our novel experience over the last year, which we hope will help to improve diagnosis and treatment in the neuromuscular services.