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The current COVID-19 climate has caused an unforeseen supply shortage of iodinated contrast media (ICM) worldwide, disrupting global distribution.1 In addition, the scarcity has resulted in a ripple effect in healthcare facilities such as radiology departments where ICM is required to perform contrast-enhanced examinations. ICM plays a significant part in contrast-enhanced CT, angiography and fluoroscopic procedures within the radiology department, holding a primary role in the differentiation and diagnosis of pathologies which range from pulmonary emboli to tumours.1 Its use extends beyond radiology, where ICM is heavily relied on in cardiology, urology and gastrointestinal studies, further highlighting the heavy dependence on the critical agent.2 With the global increase in the number of CT examinations requested, where approximately 60% of studies require ICM, optimal usage of ICM must be considered to meet heightened demand.3 The shortage has represented an opportunity for imaging providers to re-examine current imaging protocols and identify whether non-contrast imaging, alternative contrast agents and other imaging modalities could be viable options moving forward.1,2 Additionally, current literature has discussed volume-reduction strategies and dual-energy use in newer-generation CT scanners to conserve ICM.1,4 This review will explore currently proposed solutions that can be implemented in the radiology department to maximise ICM supply with minimal impact on patient care.
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The antibiotic amoxicillin is usually recommended as a first-line treatment for many common infections affecting children. Repeated lockdowns related to the coronavirus disease 2019 pandemic have contributed to supply difficulties for many drugs, including antibiotics. However, the risks associated with amoxicillin supply shortages appear not to have been sufficiently assessed, and the crisis we are facing today is serious and particularly dangerous for children's health. Without rigorous measures to prevent shortages related to drug production and distribution, populations could face a post-antibiotic era in which common infections and minor injuries can result in serious life-threatening situations. The availability of medicines declared by WHO as essential should be guaranteed not only in production but also in fair distribution. And this principle must be ensured by national and international regulatory agencies.Copyright © 2023 Medico e Bambino. All rights reserved.
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Introduction: Enteral feeding is a physiologic process of providing adequate nutrition and has been shown to improve both mortality and quality of life in patients with inadequate oral intake. Improved critical care medicine and recent wave of Coronavirus Disease 2019 (COVID-19) has left us with a large proportion of patients needing alternative enteral nutrition. Although rare, intussusception is an important differential for patients presenting with acute abdominal pain post makeshift percutaneous endoscopic gastrostomy (PEG) tube placement. Case Description/Methods: A 58-year-old male was admitted to the hospital for coffee ground emesis over three days accompanied with epigastric pain. He had right sided hemiparesis secondary to cerebrovascular accident with PEG tube for enteral nutrition. Examination was significant for epigastric tenderness with normal bowel sounds. PEG tube aspiration revealed bile-tinged fluid. Significant labs included white blood cell count of 11,600 /mm3, hemoglobin 10.2 g/dL, and lactic acid of 2.3 mmol/L. A computerized tomography of the abdomen with IV contrast showed a small segment duodeno-duodenal intussusception at the horizontal segment around the distal end of the tube was noted (Figure A). An urgent esophagogastroduodenoscopy (EGD) revealed a Foley catheter acting as a makeshift PEG tube extending across the pylorus into the duodenum. The distal tip of the Foley catheter was visualized with an inflated balloon seen in the third portion of the duodenum (Figure B) The inflated catheter balloon acted as a lead point causing intussusception in a ball-valve effect. The balloon was deflated, and the catheter was replaced (Figure C) with a 20 Fr PEG tube. Discussion(s): Gastric outlet obstruction is an uncommon complication reported in few cases caused by migration of the gastrostomy tube. Rarely this migrating gastrostomy tube can invaginate the duodenum or the jejunum causing intussusception. Only handful of cases have been reported in the literature. Patients usually present with epigastric pain, vomiting or rarely hematemesis. CT scan of the abdomen is the investigation of choice. Amidst the pandemic and supply shortage, Foley catheters have been deemed as a viable alternative to gastrostomy tubes and are being used more often. It is important to recognize this rare complication and use of balloon catheter should raise further suspicion. Timely endoscopic intervention can help avoid bowel necrosis and surgical intervention.
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Background: Total parenteral nutrition (TPN) is a life-saving therapy for patients with chronic intestinal failure. TPN typically consists of macronutrients (amino acids, dextrose, and lipids) as well as micronutrients (multi-vitamins [MVI] and trace elements) to meet fluid, calorie, and micronutrient needs. With the early years of PN administration, multiple deficiencies were noted leading to guidelines regarding need for daily use of essential trace element and MVI preparation for parenteral use. Unfortunately, during the last few years we have seen multiple shortages of PN related supplies including the most recent shortage of parenteral MVI preparation. Major organizations such as ASPEN have developed recommendations regarding management of shortages, however their clinical impact has not been fully evaluated. The current study evaluated the impact of MVI shortage on change in clinical practice and the prevalence of deficiency. Method(s): A retrospective review of electronic medical records for patients who received TPN during time of shortage in IV multivitamins supply due to COVID-19 crisis between January 2021 and June 2021. In our program, the shortage affected one TPN supplier. We included patients who received their TPN from affected supplier and who were tested for micronutrients including Vitamins A, B12, C, and D in the 6 months preceding the shortage in supply (period 1) as well as during the shortage period (period 2). Period 1 was defined as from July 1, 2020, to December 31, 2020, and period 2 was defined as from January 1, 2021, to June 30, 2021. In addition to baseline clinical characteristics, we captured changes in studied micronutrients. Result(s): Current retrospective analysis of a prospectively maintained database noted 21 patients (mean age of 63.3 +/- 13.8, 62% female) were impacted by MVI shortage during study period (Table 1). Most common primary diagnosis was Crohn's disease (33.3%) followed by enterocutaneous fistula (19%), and gastrointestinal dysmotility (14.3%). In 19/21 (90%) patients, MVI was administered 3 days per week in PN. In the remaining two patients who had short bowel,MVI was continued 7 days per week. Additionally, 19/21 (90%) patients also were supplemented orally with Vitamin D (17/21), Vitamin B12 (5/21), MVI (3/21), Vitamin C (1/21). There was a decline in average Vitamin C levels between the two study periods (Table 2) with a trend towards a decline in average 25-hydroxy vitamin D levels, while mean vitamin A and B12 levels did not change significantly. There was a significant increase in Vitamin D and C deficiencies, while no increase in deficiencies in Vitamin E, A, and B12 levels was noted (Figure 1). Conclusion(s): Unfortunately, shortages of key PN related supplies have become commonplace in the last few years. The most recent shortage affected MVI supplies. Our group managed the shortage through a combination of reduction of parenteral MVI administration to 3 days per week along with additional supplementation of specific micronutrients orally. Although with this strategy, there was an increase in Vitamin D and C levels falling below reference range, no significant deficiencies were noted. (Table Presented).
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BACKGROUND: COVID-19 has highlighted already existing human resource gaps in health care systems. New Brunswick health care services are significantly weakened by a shortage of nurses and physicians, affecting regions where Official Language Minority Communities (OLMCs) reside. Since 2008, Vitalité Health Network (the "Network"), whose work language is French (with services delivered in both official languages, English and French), has provided health care to OLMCs in New Brunswick. The Network currently needs to fill hundreds of vacant physician and nurse positions. It is imperative to strengthen the network's retention strategies to ensure its viability and maintain adequate health care services for OLMCs. The study is a collaborative effort between the Network (our partner) and the research team to identify and implement organizational and structural strategies to upscale retention. OBJECTIVE: The aim of this study is to support one of New Brunswick health networks in identifying and implementing strategies to promote physician and registered nurse retention. More precisely, it wishes to make 4 important contributions to identify (and enhance our understanding of) the factors related to the retention of physicians and nurses within the Network; determine, based on the "Magnet Hospital" model and the "Making it Work" framework, on which aspects of the Network's environment (internal or external) it should focus for its retention strategy; define clear and actionable practices to help the Network replenish its strength and vitality; and improve the quality of health care services to OLMCs. METHODS: The sequential methodology combines quantitative and qualitative approaches based on a mixed methods design. For the quantitative part, data collected through the years by the Network will be used to take stock of vacant positions and examine turnover rates. These data will also help determine which areas have the most critical challenges and which ones have more successful approaches regarding retention. Recruitment will be made in those areas for the qualitative part of the study to conduct interviews and focus groups with different respondents, either currently employed or who have left it in the last 5 years. RESULTS: This study was funded in February 2022. Active enrollment and data collection started in the spring of 2022. A total of 56 semistructured interviews were conducted with physicians and nurses. As of manuscript submission, qualitative data analysis is in progress and quantitative data collection is intended to end by February 2023. Summer and fall 2023 is the anticipated period to disseminate the results. CONCLUSIONS: Applying the "Magnet Hospital" model and the "Making it Work" framework outside urban settings will offer a novel outlook to the knowledge of professional resource shortages within OLMCs. Furthermore, this study will generate recommendations that could contribute to a more robust retention plan for physicians and registered nurses. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): DERR1-10.2196/41485.
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Objective: The pandemic 2019 Coronavirus disease (COVID-19) is the greatest concern globally. Here we analyzed the epidemiological features of China, South Korea, Italy and Spain to find out the relationship of major public health events and epidemiological curves. Study design: In this study we described and analyzed the epidemiological characteristics of COVID-19 in and outside China. We used GAM to generate the epidemiological curves and simulated infection curves with reported incubation period. Result(s): The epidemiological curves derived from the GAM suggested that the infection curve can reflect the public health measurements sensitively. Under the massive actions token in China, the infection curve flattened at 23rd of January. While surprisingly, even before Wuhan lockdown and first level response of public emergency in Guangdong and Shanghai, those infection curve came to the reflection point both at 21st of January, which indicated the mask wearing by the public before 21st Jan were the key measure to cut off the transmission. In the countries outside China, infection curves also changed in response to measures, but its rate of decline was much smaller than the curve of China's. Conclusion(s): The present analysis comparing the epidemiological curves in China, South Korea, Italy and Spain supports the importance of mask wearing by the public. Analysis of the infection curve helped to clarify the impact of important public health events, evaluate the efficiencies of prevention measures, and showed wearing masks in public resulted in significantly reduced daily infected cases.Copyright © 2020 The Author(s)
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Purpose:The purpose of this study was to assess the impact of ongoing waves of the COVID-19 pandemic and resulting guidelines on the corneal donor pool with resumption of clinical operations.Methods:A retrospective analysis of donors deemed eligible for corneal transplantation at an eye bank from July 1, 2020, through December 31, 2021. Donors ineligible due to meeting Eye Bank Association of America (EBAA) COVID-19 guidelines or a positive postmortem COVID-19 testing were examined. The correlation between COVID-19 rule outs and state COVID positivity was calculated. The number of scheduled surgeries, suitable corneas, imports, and international exports was compared with a pre-COVID period. Postmortem testing was reduced for the final 5 months of the study, and numbers were compared before and after the policy change.Results:2.85% of referrals to the eye bank were ruled out because of EBAA guidelines. 3.2% of postmortem tests were positive or indeterminate resulting in an ineligible tissue donor (0.42% of referrals). Over the 18-month period, there was a 4.30% shortage of suitable corneas compared with transplantation procedures. There was a significant correlation between postmortem testing and state COVID-19 positivity (r = 0.37, P <0.01), but not with EBAA guidelines (r = 0.19, P = 0.07). When postmortem testing was reduced, significantly more corneas were exported internationally.Conclusions:Although corneal transplant procedures were back to normal levels, there was a shortage of suitable corneal tissue. The discontinuation of postmortem testing was associated with a significant increase in international exports of corneal donor tissue. © 2023 Lippincott Williams and Wilkins. All rights reserved.
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Polymerase chain reaction (PCR) invented by Kary Mullis (1983), has become the centrepiece of molecular detection of various infectious diseases including coronavirus disease 2019 (COVID-19). Many developing countries like Nepal faces various challenges and grab many future opportunities during and after establishment of molecular PCR laboratories throughout the country. This viewpoint describes the involvement of laboratory employees, development and adoption of new protocols or framework, deliberate partnership with national and international community is very efficient for the establishment of PCR laboratories. Beside this, continued alliance and nation leadership is crucial to generate a unified and sustainable PCR laboratory network in the country like Nepal. In future the established PCR laboratories can be utilized for the diagnosis of others pandemic diseases and can be used for multipurpose like in verification of infectious diseases;Oncology;Blood test;Genetic testing. Copyright © 2020, Kathmandu University. All rights reserved.
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This perspectives piece focuses on the detrimental cost of ignoring vaccines and refusing vaccination against COVID-19 in the United States. Much of the existing literature regarding the consequences of the unvaccinated emphasizes the impact to population health;however, few academic articles have explored the burden the unvaccinated pose to various sectors of society. This paper analyzes the impact that the unvaccinated have on healthcare systems, the US economy, and global health. Throughout the COVID-19 pandemic, unvaccinated populations were found to have put significant strain on healthcare systems, depleting medical resources and contributing to high rates of healthcare worker shortages. Furthermore, research suggests that between November and December 2021, over 692,000 preventable hospitalizations occurred in unvaccinated individuals, costing the US economy over $13.8 billion. Lastly, it is proposed that the strong international presence of the US, when coupled with high levels of disease transmissibility in the unvaccinated, provides a significant threat to global health. In conclusion, the unvaccinated have caused impacts far beyond that of population health;they have also posed a burden to healthcare systems, the economy, and global public health. Copyright © 2022, Yale Journal of Biology and Medicine Inc. All rights reserved.
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Introduction/Objective: Both point of care (POC) antigen-based assays and reverse transcriptase polymerase chain reaction (RT-PCR) laboratory-based assays exist for diagnosis of COVID-19. COVID-19 RT-PCR tests are the gold standard based on their higher sensitivity. However, in this era of inflation and supply chain disruptions, the use of only RT-PCR tests would be more expensive and may be vulnerable to reagent supply chain shortages. Triage of resources of both test types is important in ensuring access and equity in testing distribution as well as ensuring economical RT-PCR testing access for sicker patients. A comparison of costs was explored by contrasting a model of cost effectively reserving RT-PCR tests for those with significant disease requiring hospitalization and using POC tests for those with mild disease (defined as at most mild symptoms not requiring hospitalization) versus universal provision of RT-PCR to all. Methods/Case Report: Cost information from the regional Veteran Affairs Medical Center (VAMC), specifically for the Alinity-m (RT-PCR) and BinaxNOW (POC) by Abbott (Chicago IL), and from the community (median COVID-19 RT- PCR pricing obtained from the Peterson KFF Health System Tracker) were included. Based on this cost information, a model of 100 tested COVID-19 suspected patients was created. A percentage of mild disease not requiring hospitalization (81%) was utilized based on literature from early in the COVID-19 pandemic. Results (if a Case Study enter NA): The cost per test at VAMC factored in was $28.34 (Alinity-m) and $5 (BinaxNOW). The median community RT-PCR and POC price factored in was $148 and $25, respectively. From the model of 100 COVID-19 with a mild disease percentage of 81%, the total testing cost of including POC assays for mild cases vs. universal RT-PCR assays would be $943.46 vs. $2,834 at the VAMC and similarly $4,837 vs. $14,800 in the community for a 67% reduction in costs at both settings. Conclusion(s): A model of testing including both POC and RT-PCR testing may be economical and critically help ensure triage of resources in this era of inflation and supply chain shortages.
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Background: The Covid-19 pandemic has introduced a number of challenges in managing populations with both acute kidney failure and those dependent on chronic dialysis. Due to a shortage of outpatient dialysis supplies, on February 14, 2022, the Dpt. of Veteran's Affairs issued a memorandum to dialysis units requiring a contingency standard of care. This required a universal reduction of dialysate flow rate to 500 cc/min. Prior to this change, the standard prescription at the Lexington, KY VA unit was 750 cc/min. We evaluated the effect of this change on the adequacy of our dialysis population. Method(s): Data was collected for sp Kt/V urea and urea reduction ratio for 17 chronic hemodialysis patients for the two months prior and three months following the reduction of dialysate flow rate to 500 cc/min from the previous standard of 750 cc/min. There was no change of blood flow rate or dialysis time during this 5 month period for all the patients included. Result(s): A trend towards lower clearance values as measured by single-pool Kt/V and urea reduction ratio was noted between January and April of 2022. Table 1 shows the average spKt/V and URR for each month. The majority of patients maintained adequate spKt/V of >1.2 and urea reduction ratio of >65%. However, 4 patients (23.5% of the population) failed to reach Kt/V and URR goal in April 2022. Conclusion(s): Though this represents only 17 patients from one dialysis unit, the data suggests a significant decline in adequacy due to this reduction in dialysis flow rate to 500 cc/min. Until the current dialysis supply shortage has been addressed, adaptive measures such as utilizing higher efficiency dialyzers or increasing blood flow rates may be necessary.
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Introduction: Recruitment in intensive care has long been discussed, with the pandemic bringing this into sharp focus. Most anaesthetists in training were fully redeployed into ICU rotas or provided technical expertise. As surge rotas settle and a 'new normal' is regained, the challenge of ICU consultant recruitment needs to be addressed. Historically, ICUs have been predominantly staffed by consultants trained in both anaesthetics and intensive care medicine (ICM), but the challenges of this career path have been augmented by COVID-19. Forecasts suggest a concerning supply shortage of both anaesthetic and ICM consultants.1 The latest recruitment round for ICM has been the most competitive year for applications (ratio 2.9:1 in 2021 compared to 1.49:1 in 2020).2 However, the anaesthetic/ICM dual-training contribution to this workforce has worryingly decreased from approximately twothirds to less than a half. But what factors are causing this and has COVID-19 redeployment worsened this? Objectives: As we emerge from the second wave of the pandemic, we assessed the attitudes of anaesthetists about future careers in intensive care. Methods: We performed a brief electronic survey of 100 dual-or single-specialty anaesthetists in training from four LETBs across England who were redeployed to ICU. Results: Our survey showed that 29% had a negative experience that dissuaded them from pursuing ICM careers or, in some circumstances, relinquish their ICM training number altogether. Promisingly, 64% had a positive experience, and of these 39% reaffirmed their desire to pursue a career in ICU and 13% developed a new interest in pursuing a career in ICU since their redeployment. Positive factors included, 'teamwork', 'complexity of patients' and 'adding variety to my anaesthetic practice'. Prominent negative factors were 'additional exams', 'two separate portfolios' and 'high risk of burnout'. Respondents suggested changes to attract more anaesthetists to dual-accredit with ICM. This included the removal of hurdles such as additional exams, separate portfolios, and duplicated assessments. The additional training time was also highlighted, particularly given that trainees already contribute significantly to ICM rotas. There was a need for more flexibility in training with dual trainees wanting to undertake advanced training modules like their anaesthetic counterparts. They also reported wanting more anaesthetic sessions in their future job plans possibly reflecting the desire for varied practice as a consultant. Conclusion: Although COVID-19 has had a positive effect by increasing ICM applications, this may be at the expense of dual-trained anaesthetic/ICM trainees. FFICM should consider the factors which dissuade these applicants and its future impact on skills available in ICU. Both the RCoA and the FFICM have recently announced changes to curricula and e-portfolio which may close some of these gaps. The pandemic has grabbed the attention of a few anaesthetists and presented an opportunity to work in a team that solves difficult physiological puzzles, rapidly escalates capacity, and increasingly focuses on staff wellbeing. We should capitalise on this and hope that COVID-19 will result in the conversion of some of our anaesthetic colleagues into dual-specialty ICM consultants.
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Background & Aim: The SARS-CoV-2 (COVID-19) pandemic caused global challenges throughout 2020. Cell and Gene Therapy (CGT) trials were halted initially to allow healthcare workers and supply manufacturers to address the immediate and urgent needs from the pandemic. The initial decrease in cases of the alpha variant led to the re-launch of many of these trials;however, critical supplies required for manufacturing and administration of products have continued to be in short supply or available with prolonged lead times. An initial survey for CGT Critical Supply Challenges was distributed to the field in late October 2021 and open for two weeks to obtain a baseline understanding of the key challenges. This survey was distributed a second time in early 2022 to assess the changes in critical supply chain shortages over the intervening months. Here we report the cumulative results of the two surveys and describe the continued impact of the COVID-19 pandemic on the critical supply chain within the Cell and Gene Therapy field. Methods, Results & Conclusion: Methods. The survey was created using SurveyMonkey®, an online platform, and contained 10 questions aimed to understand key supply shortages in the context of product type and stage of production. The survey was disseminated through CGT society networks, Google Groups (Small Cell Therapy Lab), LinkedIn®, and personal emails. The survey was distributed initially for one week in October 2021 and data was analyzed. The survey (Figure Presented) was distributed a second time in early 2022 and results from the second survey were analyzed separately and compared to the initial results. Results. The initial survey contained 58 responses and 91% of these had experienced a critical supply shortage in the past 18 months. The most common supply category causing the largest impact was transfer supplies, including plastics, tubing, bags and vials (Fig 1). Half of the respondents experienced a backorder of over 6 months (Fig 2);however, 40% of respondents did not have to delay productions (Fig 3). Supply shortages have continued into 2022 and the second distribution of the survey is to assess any changes in types of supplies that are delayed. Conclusion. A majority of survey respondents have dealt with supply chain challenges since the onset of the COVID-19 pandemic. Shortages and long lead times continue to be present throughout early 2022;however, groups have been able to continue productions through a variety of mechanisms. (Figure Presented) (Figure Presented)
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Medical information systems (MIS) play a vital role in managing and scheduling medical resources to underpin healthcare services, which has become more critically important during major public health emergencies. During the Covid-19 pandemic, MIS is facing significant challenges to cope with the surge in demands of medical resources, resulting in more deaths and wider spreading of the disease. Our research examines how to allocate and utilize the medical resources across hospitals in a more accurate, and effective way to mitigate medical resource shortages and sustain the resource provisions. This paper mainly investigated the hospital's supply-and-demand problems for medical resources under major public health emergencies by analyzing the allocation of medical staff resources. Furthermore, a formal method based on the Colored Petri Nets (CPN) has been proposed to model and characterize the medical business process and resource scheduling tasks. The experiments demonstrate that our approach can correctly and efficiently complete the dynamical scheduling process for surging requests. © 2021 IEEE.
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Background. The COVID-19 pandemic had a considerable impact on US healthcare systems, straining hospital resources, staff, and operations. Our objective was to evaluate the impact of COVID-19 pandemic on incidence and trends of healthcare-associated infections (HAIs) in a network of hospitals. Methods. This was a retrospective review of central-line-associated bloodstream infections (CLABSIs), catheter-associated urinary tract infections (CAUTIs), C. difficile infections (CDI), and ventilator-associated events (VAE) in 51 hospitals from 2018 to 2021. Descriptive statistics were reported as mean hospital-level monthly incidence rates (IR) and compared using Poisson regression GEE models with period as the only covariate. Segmented regression (SR) analysis was performed to estimate changes in monthly IR of CAUTIs, CLABSIs and CDI in the baseline period (01/2018 - 02/2020) and the Pandemic period (03/2020 -03/2021). SR model was not appropriate for VAE based on the plot. All models were constructed using SAS v.9.4 (SAS Institute, Cary NC). Results. Compared to the baseline period, CLABSIs increased significantly by 50% from 0.6 to 0.9/ 1000 catheter days (P< 0. 001). In contrast, no significant changes were identified for CAUTI (P=0.87). Similar trends were seen in SR models for CLABSI and CAUTI (Figures 1, 2 and Table 1). While overall CDIs decreased significantly from 3.5 to 2.5/10,000 patient days in the pandemic period (P< 0.001), SR model showed increasing pandemic trend change (Figure 3). VAEs increased > 700% from 6.9 to 59.7/1000 ventilator days (P=0.15), but displayed considerable variation during the pandemic period (Figure 4). Compared to baseline period, there was a significant increase in central line days (647 vs 677, P=0.02), ventilator days (156 vs 215, P< 0.001), but no change in urinary catheter days (675 vs 686, P=0.32) during the pandemic period. Conclusion. The COVID-19 pandemic was associated with substantial increases in CLABSIs and VAEs, no change in CAUTIs, and an increasing trend in CDI incidence. These variations in trends of different HAIs are likely due, in part, to unique characteristics of the underlying infection, resource shortages, staffing concerns, increased device use, changes in testing practices, and the limitations of surveillance definitions.