Conducting educational escape rooms during a global pandemic

PurposeEscape room-based learning is a new educational game-based learning trend which embeds student learning within an exciting escape room scenario. Ordinarily these educational escape rooms are in a table-top format which involves learners decoding clues together around a table. In the age of a global pandemic [coronavirus disease 2019 (COVID-19)] with stringent social distancing and lock-downs, this normal game modality was not possible and so an alternate online approach was required. Thus, this paper aims to study escape room activities during global pandemics.Design/methodology/approachIn this paper, the authors outline how these escape room activities have been taken online, in an synchronous virtual environment and evaluate the student perception of these escape rooms, in contrast to previous cohorts of students who completed escape rooms together in person.FindingsThe authors' results indicate that although students enjoy the escape room game-based learning environment, the remote nature of the activity means the students take longer to solve the puzzles. The students are also more likely to struggle in the activity and find them less engaging than the in-person escape room challenges.Originality/valueAlthough educational escape rooms have been devised for a variety of subjects and can be run through several different modalities (table-top, full rooms and online), this study compares different modalities (online vs table-top) for identical puzzles taken over different cohorts of students.

COVID-19 infection and maternal morbidity in critical care units in Scotland: a national cohort study.

BACKGROUND: Previous research has shown that, in comparison with non-pregnant women of reproductive age, pregnant women with COVID-19 are more likely to be admitted to critical care, receive invasive ventilation, and die. At present there are limited data in relation to outcomes and healthcare utilisation following hospital discharge of pregnant and recently pregnant women admitted to critical care. METHODS: A national cohort study of pregnant and recently pregnant women who were admitted to critical care in Scotland with confirmed or suspected COVID-19. We examined hospital outcomes as well as hospital re-admission rates. RESULTS: Between March 2020 and March 2022, 75 pregnant or recently pregnant women with laboratory-confirmed COVID-19 were admitted to 24 Intensive Care Units across Scotland. Almost two thirds (n=49, 65%) were from the most deprived socio-economic areas. Complete 90-day acute hospital re-admission data were available for 74 (99%) patients. Nine (12%) women required an emergency non-obstetric hospital re-admission within 90 days. Less than 5% of the cohort had received any form of vaccination. CONCLUSIONS: This national cohort study has demonstrated that pregnant or recently pregnant women admitted to critical care with COVID-19 were more likely to reside in areas of socio-economic deprivation, and fewer than 5% of the cohort had received any form of vaccination. More targeted public health campaigning across the socio-economic gradient is urgently required.

Outcomes of Covid-19 Patients Who Underwent Tracheostomies

INTRODUCTION: Tracheostomy is the most frequent surgical procedure performed in critically ill patients, mostly in patients requiring prolonged mechanical ventilation. We aimed to describe the outcomes associated with tracheostomies in critically ill COVID-19 patients admitted to our ICU. METHOD(S): We studied a cohort of adult patients admitted with the diagnosis of COVID-19 to a mixed ICU between 03/2020 and 06/2021. We collected patients' demographics, severity of illness, ICU resource utilization, and outcomes. Descriptive statistics were reported. RESULT(S): A total of 275 patients with confirmed COVID-19 were admitted to our ICU during the study period. Among them, 26 patients (9.45%) underwent tracheostomy. There were 10 females (38.4%) with an average age of 60 years (range 53-67). Median body mass index was 31 (range 26-41). Patients identified themselves as African American (39%), Caucasian (27%), and the remaining as other or declined to answer. Median Sequential Organ Failure Assessment (SOFA) score on admission was 10 (range 8-12) and max SOFA score was 13 (range 11-17). Mean mechanical ventilation-days was 19 days (range 12-23). Median ICU length of stay (LOS) was 41 days (range 31-48) and hospital LOS was 46 days (range 32-60). The ICU and hospital mortality rates were 23% and 27% respectively. There were no procedural causes of death. CONCLUSION(S): Although the mortality of the patients that underwent tracheostomies was relatively high, these patients were less than 3% of the total cohort of COVID-19 patients admitted to the ICU and had lower mortality than expected adjusted for their severity of illness based on the SOFA score.

Camouflage in the Streets: Emergency Powers, the Military, and the Philippines’ COVID-19 Pandemic Response

With emergency powers, President Rodrigo Duterte mobilized and deployed military and police to enforce lockdown measures in Metro Manila and Cebu City. For several months in 2020, the deployed forces ran quarantine control points in borders and city wards, and enforced curfew and liquor bans. This article examines how said deployment affected civilian control by the President and local civil-military dynamics. The heightened visibility of uniformed personnel in these urban spaces, and subsequent arrests and detention of quarantine violators came under heavy criticism. Against the backdrop of ex-military dominated national Inter Agency Task Force for Infectious Diseases (IATF), the militarized lockdown failed to stem the virus’ spread and expanded the military’s reach into civilian domain. Its involvement in law enforcement operations alongside the police poses dangers to local civil-military balance and to democracy. President Duterte’s reliance on the state’s coercive apparatus to carry out the pandemic response enabled him to assert control over local governments and to repress dissent. © Koninklijke Brill NV, Leiden, 2022.

The unemployed with jobs and without jobs *

Potential workers are classified as unemployed if they seek work but are not working. The unemployed population contains two groups -those with jobs and those without jobs. Those with jobs are on furlough or temporary layoff. This group expanded tremendously in April 2020, at the trough of the pandemic recession. They wait out periods of non-work with the understanding that their jobs still exist and that they will be recalled. We show that the resulting temporary-layoff unemployment mostly dissipated by the end of 2020. Potential workers without jobs constitute what we call jobless unemployment. Shocks that elevate jobless unemployment have much more persistent effects. Historical major adverse shocks, such as the financial crisis in 2008, created mostly jobless unemployment and consequently caused extended periods of elevated unemployment. Jobless unemployment reached its pandemic peak in November 2020, at 4.9%, modest by historical standards, and has declined at a faster-than-historical pace since.

Efficacy and Safety of a Delayed Graft Function Protocol in Kidney Transplant Recipients

Purpose: To evaluate the efficacy and safety of a protocol increasing the net state of immunosuppression for adult kidney transplant recipients (KTR) with delayed graft function (DGF). Method(s): Single-center retrospective cohort of adult KTR with DGF transplanted from January 2017 to March 2021. Pre- vs post-DGF protocol implementation outcomes were evaluated. Protocol included cumulative 6 mg/kg rabbit antithymocyte globulin (rATG) induction, non-weight-based mycophenolate mofetil dosing (1000 mg bid), and higher goal tacrolimus trough (9-12 ng/mL). Pre-protocol patients received cumulative 4.5 mg/kg rATG. Efficacy outcomes were biopsy proven acute rejection (BPAR) and graft loss at 6 months. Safety outcomes were incidence of cytopenia, infection, and all-cause readmission at 6 months. Result(s): Eighty-nine DGF patients met inclusion criteria. Baseline characteristics were similar between groups, with median age (57+/-19) years and majority Hispanic (42.7%) males (61.8%) with a negative crossmatch (100%). Most post-protocol patients received 6 mg/kg cumulative rATG induction (71.4%) and mycophenolate mofetil 1,000 mg bid (80.3%) with therapeutic tacrolimus troughs by discharge (64.3%). Significantly less BPAR was observed post-protocol (7/56, 12.5% vs 10/33, 30.3%;p = 0.04). Of those with BPAR, significantly less post-protocol patients experienced T-cell mediated rejection (TCMR) than pre-protocol (2/7, 28.6% vs 9/10, 90.0%;p = 0.03). However, antibody-mediated (4/7, 57.1% vs 1/10, 10%) and mixed (1/7, 14.3% vs 0%) rejection were more frequent post-protocol (p = 0.10 and 0.41, respectively). Graft loss was similar post- vs pre-protocol (5/56, 8.9% vs 0;p = 0.16). All post-protocol graft losses were due to death (4 from COVID-19 and 1 unknown). Safety outcomes were similar between groups (Table 1). Conclusion(s): An increased net state of immunosuppression in DGF KTR significantly lowered the 6-month incidence of BPAR without significantly affecting safety. TCMR incidence was significantly decreased, but displaced by antibody-mediated and mixed rejection, implying need to conduct further prospective studies of larger sample sizes. Given majority of graft losses were due to COVID-19 pneumonia, studies are needed to evaluate the risk of COVID-19 infections in DGF KTR, especially with the availability of vaccines. (Table Presented).

Parental Burnout Across the Globe during the COVID-19 Pandemic

The COVID-19 pandemic has affected all societies worldwide. The heightened levels of stress that accompanied the crisis were also expected to affect parenting in many families. Since it is known that high levels of stress in the parenting domain can lead to a condition that has severe consequences for health and well-being, we examined whether the prevalence of parental burnout in 26 countries (9,923 parents;75% mothers;mean age 40) increased during COVID-19 compared to few years before the pandemic. In most (but not all) countries, analyses showed a significant increase in the prevalence of parental burnout during the pandemic. The results further revealed that next to governmental measures (e.g., number of days locked down, homeschooling) and factors at the individual and family level (e.g., gender, number of children), parents in less (vs. more) indulgent countries suffered more from parental burnout. The findings suggest that stricter norms regarding their parenting roles and duties in general and during the pandemic in particular might have increased their levels of parental burnout. © 2022 Hogrefe Publishing.

Urological imaging trends in Australia and the impact of COVID-19: A ten-year analysis of national data

Introduction & Objectives: During the COVID-19 pandemic there has been a drastic shift in access and utilisation of healthcare resources globally. There has been widespread implementation of social distancing policies, isolation to homes and reduced non-essential activities within communities. These public health measures coupled with reductions in non-urgent elective surgeries and a transition to telehealth may have affected presentations of common urological conditions. We hypothesised there may be an impact on the number of common urological imaging studies carried out over this time frame. We have retrospectively analysed the number of CT KUB, US renal tract and mpMRI prostate studies done during the first three months of the COVID-19 outbreak in Australia and compared them to the previous decade. Methods: Australian Medicare Benefit Schedule item statistics reports for US renal tract and CT KUB usage were generated for the months of March, April and May from the Department of Health and Human Services website from 2010 to 2020. Data for 2019 and 2020 was examined for mpMRI prostate. Data was then analysed using GraphPad Prism 8 (La Jolla, CA, USA), one-way ANOVA with Fisher's-LSD post hoc test utilised and statistical significance set at p-value <0.05. Results: From 2010 through to 2019 there was a year-on-year increase in the number of CT KUB and US Renal tract studies performed across Australia. An average increase of 6.0% (±3.6%) for CT KUB and 5.2% (±3.3%) for US Renal tract. A statistically significant decrease was seen in the corresponding months of 2020 of 10.4% and 20.9%, respectively. There was no significant reduction in the number of mpMRI prostate studies performed from March to May 2020. Conclusion: There was a statistically significant decline in the number of some common urological imaging studies across the first 3 months of the COVID-19 pandemic in Australia. We may well see an associated trend of reduced referrals or potentially a spike in delayed diagnoses during and after COVID-19 crisis due to reduced presentations and investigations throughout lockdown periods. Reassuringly, we have not seen a decline in the number of mpMRI prostate studies undertaken during this same time frame.

Building back better after COVID-19: why South Africa needs an equitable food system for small-scale farmers and fishers, street traders and consumers - and how to build it

This policy brief reports headline findings from research investigating the impacts of Covid-19 regulations and mitigation measures on actors in South Africa's food system. The research focuses on fresh produce in Gauteng and KwaZulu-Natal and fish in the Western Cape. The researchers conducted 211 in-depth interviews, facilitated the production of 24 food diaries and visited 16 primary field sites.

Improving surgical teaching for junior trainees internationally in light of COVID-19

Aim: During the Covid-19 pandemic there has been a gross effect on surgical training at all grades. A cohort that has been affected but reported less frequently are medical students and foundation doctors (junior trainees), whose interest in the field and clinical skills may have been affected by reduced service provision. Method: A survey of junior trainees was conducted to analyse their perceived adequacy of surgical teaching in light of the effect of Covid-19. An online teaching course was then designed to target areas of weakness identified in the survey. The content was designed with the Imperial College London surgery curriculum and was vetted by a consultant surgeon. Results: Of the 713 people surveyed, 393 (55%) had received little or no surgical teaching and 496 (70%) respondents said they were 'not' or 'slightly' confident in managing common and emergency surgical presentations. A free text box highlighted that deteriorating patients, clinical decision-making, and initiating management were the greatest concerns. This was used to design an international online teaching course for junior trainees, that focused explicitly on clinical care. The sessions were run live on MindTheBleep via Facebook live, to answer questions in real time and examine cases with live audience participation, receiving feedback after every session. This model has reached trainees in >30 countries with >200 feedback responses and an average rating of 4.5/5. Conclusions: Junior trainees are a key cohort whose interest and education in surgery has suffered due to the pandemic. An innovative, online, clinically orientated course is assisting to re-engage trainees internationally.

Impact of the Covid-19 pandemic on the device therapy for patients with the heart failure

Introduction: Hospital admissions of patients with cardiovascular disease were markedly reduced in the UK in 2020 during the Covid-19 pandemic. In many institutions, including ours, patient care was redistributed from a specialty-based approach to a ward-based system, meaning some patients being admitted and managed under the care of non-specialist teams. Purpose: We wished to examine the impact of these changes on heart failure (HF) patients presenting during the pandemic and on appropriate delivery of complex device therapies. Methods: The study was undertaken in a large UK teaching hospital. The institution audit programme includes cardiac device therapy provision, aiming to ensure that implantable cardioverter defibrillators and cardiac resynchronisation therapy are offered to the target population in accordance with NICE guidance [Technology Appraisal 314]. In accordance with the guidance, patients admitted to hospital with serious ventricular arrhythmia, familial cardiac condition with high risk of sudden cardiac death (SCD), surgical repair of congenital heart disease (CHD) and patients with HF and LVEF<36% were identified from hospital coding. Findings during the pandemic (March to August 2020) were compared with the same period in 2019. Fisher's exact test was used to compare proportions. Results: Among non-HF patients, device therapy prescription was consistent in the two periods observed. Table 1 shows how many patients were eligible for device therapy and how many were offered it. Table 2 contains details of HF admissions, showing an 8% reduction in admissions during the pandemic. The proportion of patients eligible for device therapy did not change significantly. However, there was a significant reduction in the proportion of eligible patients who were offered device therapy (79% vs 94% p=0.03). In addition, during the pandemic there was a trend towards a greater chance of patients being considered too frail for device therapy (p=0.08). Among 12 patients overlooked for device therapy, 10 were not under the care of Cardiology. Among 31 patients considered too frail for device therapy, 26 were not under the care of Cardiology. Conclusion: During the Covid-19 pandemic, a modest reduction in HF hospital admission was observed with a marked fall in identification of patients eligible for device therapy. Possible explanations include intense pressure to discharge patients quickly, an increased perception of patient frailty during a crisis and the lack of recognition of indications for device therapy when patients are under the care of non-specialists. These findings suggest that cardiac services should actively look for HF patients who may have missed out on life-saving device therapies during the pandemic.

Nicu admissions for hypoglycaemia during the COVID-19 pandemic after changes to practice in diagnosis of gestational diabetes

Background Hypoglycaemia is a leading cause of admissions to neonatal units. A major risk factor for neonatal hypoglycaemia is maternal gestational diabetes mellitus (GDM). Since 2013, diagnosis of GDM in the UK has relied upon the oral glucose tolerance test (OGTT) at 28 weeks of pregnancy. In response to the COVID-19 pandemic, however, guidance released by the Royal College of Obstetricians and Gynaecologists [RCOG] (2020) advised replacing OGTT with alternative measures such as HbA1C and random blood glucose (RBG) measurement. Objectives 1. Compare the number of neonatal admissions for hypoglycaemia to a level two unit before and during the COVID-19 pandemic. 2. Detect differences in diagnostic modalities used for gestational diabetes in mothers of newborns admitted with hypoglycaemia before and during COVID-19. 3. Compare outcomes of neonates admitted with hypoglycaemia before and during COVID-19. Methods Neonates admitted with hypoglycaemia to our unit during two time periods - April to August 2019 and April to August 2020 - were identified using an online portal and formed the two groups for auditing. Maternal and neonatal health records were then retrospectively reviewed to determine: (1) the presence of risk factors for GDM during pregnancy among mothers of neonates in both groups, and (2) the diagnostic methods for GDM performed in mothers of neonates in each group. We further collected data on selected outcomes for neonates, including length of stay, IV glucose delivery, umbilical venous cannulation (UVC) and parenteral feeding, in both groups. Results The number of neonatal admissions with hypoglycaemia to the unit doubled during the COVID-19 pandemic (group 2 [n=32] vs group 1 [n=17]). Fewer newborns admitted during COVID-19 had a mother with a diagnosis of GDM (group 2 [15.6%] vs group 1 [23.5%]) despite mothers of newborns in this group being more likely to be at risk for GDM (group 2 [69.6%] vs group 1 [64.3%]). In all, less OGTTs were performed in mothers of neonates admitted with hypoglycaemia during COVID-19 than before (group 2 [31.3%] vs group 1 [35.3%]) and HbA1C and RBG measurements were more likely to be performed (group 2 [25%] vs group 1 [0%] and group 2 [15.6%] vs group 1 [11.8%], respectively). Nevertheless, median length of admission for newborns was shorter during the COVID- 19 pandemic (group 2 [4 days;IQR 2-16] vs group 1 [7 days;IQR 3-11.5]) and the proportion receiving treatments such as intravenous glucose did not increase [53.1% vs 58.8%]). Conclusions The number of admissions to NICU of newborns with hypoglycaemia increased considerably during the COVID- 19 pandemic. This rise is likely, at least in part, to reflect missed diagnoses of GDM in pregnancy, resulting in less access to treatment for mothers and delays in identification of newborns at risk for hypoglycaemia. As there exists some overlap among our COVID-19 group as to when changes to maternal screening for GDM were introduced and when OGTT was still in use, we have extended this study and further data collection is underway which may reveal greater differences between our groups.

Heart failure admissions and device therapy provision during the COVID-19 pandemic

Introduction The 2020 Covid-19 pandemic saw a marked nationwide reduction in hospital admissions due to cardiovascular disease. In many institutions, including ours, it also saw redistribution of patient care from a specialty-based approach to a ward-based system, meaning patients being admitted and remaining under the care of non-specialist teams. We wished to examine the impact of these changes on heart failure patients presenting during the pandemic and on appropriate delivery of complex device therapies. Methods The study was undertaken in a large UK teaching hospital, where the annual audit programme includes NICE guidance (Technology Appraisal 314: Implantable Cardioverter Defibrillators and Cardiac Resynchronisation Therapy for Arrhythmias and Heart Failure). As per the NICE guideline, patients admitted to hospital were identified, using discharge codes, with: serious ventricular arrhythmia;familial cardiac condition with high risk of sudden cardiac death (SCD);surgical repair of congenital heart disease;and patients with heart failure and LVEF <36%. Findings during the pandemic (March to August 2020) were compared with non-pandemic (the same period in 2019). Fisher's exact test was used to compare proportions. Results Table 1 shows how many patients were eligible for device therapy and how many were offered it. Among nonheart failure patients, device therapy prescription was consistent in the 2 periods observed. Table 2 shows details of heart failure admissions during the study periods. Among heart failure patients, an 8% reduction in hospital admissions due to heart failure was observed during the pandemic. Among these patients, the proportion eligible for device therapy did not alter significantly. However, there was a significant reduction in the proportion of eligible patients who were offered device therapy (79% vs 94%, p=0.03). In addition, there was a trend towards a greater chance of patients being considered too frail for device therapy during the pandemic (p=0.08). Among 12 patients overlooked for device therapy, 10 were not under the care of Cardiology. Among 31 patients considered too frail for device therapy, 26 were not under the care of Cardiology. Conclusion During the Covid-19 pandemic, a modest reduction in hospital admission for heart failure was observed with a marked fall in identification of those eligible for device therapy. There are a number of possible explanations, including the lack of recognition of indications for device therapy when patients are under the care of non-specialists, an increased perception of patient frailty during a crisis and intense pressure to discharge patients quickly. These findings suggest that cardiac services should actively look for heart failure patients who may have missed out on life-saving device therapies during the pandemic.

Sars-cov-2 infection and enac activity are both inhibited by nafamostat applied apically on human airway epithelial cells in air-liquid interface culture

Background: Nafamostat (NF) is a small molecule drug with activity against a range of serine proteases (SP) expressed by human airway epithelial cells (HAEC) including transmembrane protease serine 2 (TMPRSS2) and prostasin. NF is used in Asia as an i.v. anti-coagulant and has an established safety profile. NF, soluble in aqueous solutions, can be delivered by inhalation to the airways. It is currently being repurposed for treatment of both SARS-CoV-2 (CoV) infection and Cystic Fibrosis. CoV binding and entry into HAEC requires host proteases, particularly TMPRSS2, which cleaves the viral spike protein. NF is a potent inhibitor of TMPRSS2. Excessive airway epithelia sodium channel (ENaC) activity in CF causes failure to clear purulent secretions. Full ENaC activity requires an inhibitory peptide domain to be cleaved from the ENaC gamma subunit by membrane bound SP, particularly prostasin. This study reports safety of NF on HAEC, its efficacy and potency to inhibit CoV infection, and the IC50 of NF and its time course to inhibit ENaC in HAEC. Methods: HAEC cultured in 3D MucilAirTM tissue model were exposed to NF 0.002 to 20μM for up to 72h and evaluated for cytotoxicity and inflammatory effects. To study infectivity, CoV viral inoculum was added apically for 1h. Cells were exposed to NF 0.2 to 20μM for up to 72h. Apical washes taken at 48 and 72h were measured for viral RNA by qRT-PCR. ENaC activity in HAEC was measured as amiloride-dependent decrease in short-circuit current. Time course and dose dependency of NF induced decrease in ENaC activity was studied. Results: Conclusions: 1. No detrimental effects of NF up to 20 μM applied to surface of HAEC. 2. Anti-viral effects of NF on CoV infection of HAEC consistent with inhibition of TMPRSS2 and prevention of viral entry via ACE2 receptor (Yamamoto et al. Antimicrob. Agents & Chemotherapy 2016, 60 p6532). 3. NF induced inhibition of ENaC in HAEC is consistent with data in pig airways (Hall & Cole Pediatr. Pulmonol. 2017, 52S2, p239) where NF caused decreased ENaC activity and increased ciliary transport of secretions with long duration of action. 4. Inhibition of CoV infection and ENaC activity by NF occurs over a similar dose range suggesting the potential for a double benefit of NF inhalation in CoV infection;i.e. prevention of viral entry to airway epithelial cells, and increased removal of mucus and viral particles from the lung/nose by up-regulated ciliary clearance.

Food in the time of coronavirus: why we should be very, very afraid

The social legitimacy of the 'COVID-19 lockdown', government's regulations imposed to contain the spread of the virus, is most likely to run aground unless an urgent plan can be made to ensure that everyone in the country has access to sufficient food. And it's not looking good. Based on interviews, statements by various organisations and our own experience, here is our summary of the already-evident impacts of the lockdown on poor people's access to food, and on the informal food economy - from small farmers to street vendors and spaza shops - that is so important in meeting people's daily food needs.