Medical intensivist directed VV ECMO cannulation for the facilitation of tracheostomy in a patient with severe tracheal stenosis: A case report

Objectives: We present a case report of medical intensivist driven ECMO program using ECMO as a pre-procedural tool to maintain oxygenation in a patient with critical tracheal stenosis during tracheostomy placement. Method(s): VV ECMO is primarily used to support patients when mechanical ventilation is unable to provide adequate gas exchange. Alternatively, it has been used pre-procedurally when intubation is required in anticipation of a difficult airway. Described here is the first intensivist preformed awake VV ECMO cannulation to facilitate tracheostomy in a patient with severe tracheal stenosis. Result(s): The patient is a 41-year-old female with the relevant background of COVID19 pneumonia status post tracheostomy and subsequently decannulated after prolonged intubation and ICU stay. As a result, the patient developed symptomatic tracheal stenosis and presented two years after her ICU stay for scheduled bronchoscopy and balloon dilation. However, the patient developed worsening stridor and shortness of breath requiring heliox and BPAP. After multidisciplinary discussion between the critical care team ENT teams, the decision was made to cannulate for VV ECMO as a pre-procedural maneuver to allow for oxygenation during open tracheostomy in the OR. Dexmedetomidine and local anesthesia were used for the procedure with the patient sitting at 30 degrees on non-invasive ventilation and heliox. The patient was cannulated with a 21F right internal jugular return cannula and 25F right common femoral drainage cannula by medical intensivists in the intensive care unit using ultrasound guidance. The patient went for operative tracheostomy the next day and was subsequently decannulated from ECMO the following day without complication. She was discharged home on trach collar. Conclusion(s): Intensivist performed ECMO cannulation has been shown to be safe and effective. We anticipate the indications and use will continue to expand. This case is an example that intensivist driven preprocedural ECMO is a viable extension of that practice.

Post Covid-19 Syndrome in Patients with Autoimmune Rheumatic Diseases: Results from the Covid-19 Vaccination in Autoimmune Diseases (Covad) Study

Background/Aims Post COVID-19 syndrome (PCS) is an emerging cause of morbidity and poor quality of life in COVID-19 survivors. We aimed to assess the prevalence, risk factors, outcomes, and association with disease flares of PCS in patients with autoimmune rheumatic diseases (AIRDs) and non-rheumatic autoimmune diseases (nrAIDs), both vulnerable groups understudied in the current literature using data from the 2nd COVID-19 Vaccination in Autoimmune Diseases (COVAD) global multicentre patient self-reported e-survey. Methods The survey was circulated from February to July 2022 by the international COVAD Study Group (157 collaborators from 106 countries), and demographics, comorbidities, AIRD/nrAID status, COVID-19 history, vaccination details, and PROMIS physical and mental function were recorded. PCS was defined as symptom resolution time >90 days following acute COVID-19. Predictors of PCS were analysed using regression models for the different groups. Results 7666 total respondents completed the survey. Of these, 2650 respondents with complete responses had positive COVID-19 infection, and 1677 (45.0% AIRDs, 12.5% nrAIDs, 42.5% HCs) completed the survey >90 days post acute COVID-19. Of these, 136 (8.1%) had PCS. Prevalence of PCS was higher in AIRDs (10.8%) than healthy controls HCs (5.3%) (OR: 2.1;95%CI: 1.4-3.1, p=0.002). Across the entire cohort, a higher risk of PCS was seen in women (OR: 2.9;95%CI: 1.1-7.7, p=0.037), patients with long duration of AIRDs/ nrAIDs (OR 1.01;95%CI: 1.0-1.02, p=0.016), those with comorbidities (OR: 2.8;95%CI: 1.4-5.7, p=0.005), and patients requiring oxygen supplementation for severe acute COVID-19 (OR: 3.8;95%CI: 1.1- 13.6, p=0.039). Among patients with AIRDs, comorbidities (OR 2.0;95%CI: 1.08-3.6, p=0.026), and advanced treatment (OR: 1.9;95%CI: 1.08-3.3, p=0.024), or intensive care (OR: 3.8;95%CI: 1.01-14.4, p=0.047) for severe COVID-19 were risk factors for PCS. Notably, patients who developed PCS had poorer PROMIS global physical [15 (12-17) vs 12 (9-15)] and mental health [14 (11-16) vs 11 (8-14)] scores than those without PCS. Conclusion Individuals with AIRDs have a greater risk of PCS than HCs. Associated comorbid conditions, and advanced treatment or intensive care unit admission for severe COVID-19 confer a higher risk of PCS. It is imperative to identify risk factors for PCS for immediate multidisciplinary management in anticipation of poor physical and mental health.

Human-Centered Design in Response to a Pandemic: A Health System and Innovation Center Collaboration

Purpose of Study In the spring of 2020, the coronavirus pandemic brought new challenges to healthcare systems as the rising demand for protective equipment led to product and resource inequalities around the globe. The inability to safeguard workers led to increased infection rates and deaths of healthcare professionals worldwide. The purpose of this study is to evaluate the response of an in-house innovation committee to meet the unforeseen needs faced by healthcare systems during an acute medical crisis. Methods Used Housed directly within the University of Utah's health system (U Health), The Center for Medical Innovation (CMI) teamed up with the hospital's administration, BME, COVID task force, and occupational health to create an innovative think-tank to tackle the challenges brought in by the coronavirus pandemic, with the purpose of stratifying clinical needs based upon acuity, frequency, and urgency. While prioritizing equipment needs, CMI used human-centered design to analyze common industry practices, engineer comparable solutions from commercially available materials, test reimagined products against known gold-standards, and create open-source assembly guides that allowed others facing similar shortages to do the same. Summary of Results The close-working relationship between CMI and U Health allowed for the rapid identification, innovation, and engineering of products that met the needs of healthcare workers during the months following the COVID pandemic. Many of these were directly adopted in clinical settings, including aerosol containment tents, powered air-purifying respirators, and self-testing stations. Additionally, CMI identified and engineered 20 additional readily producible, rapid-response products in anticipation of future needs, such as a bubble CPAP, containment boxes, and re-usable PPE. From these, dozens of open source, 'Improvised Personal Protective Equipment' manuals were shared with global partners to address the inequality of medical equipment in lowresource settings. Conclusions The rapid development of easily-producible, lowcost solutions for acute clinical needs-especially those faced by the equipment shortages seen during a pandemic-is improved via the partnership between health systems and a center for medical innovation.

Effect of COVID-19 Pandemic on the Diagnosis of Breast Lesions Compared with Breast Lesions in the Previous Five Years

Background: Covid-19 pandemic caused havoc in both people, the health care system and more so in patients with malignancies. Breast malignancies being one of the most common and relatively curable malignancies got hit a lot due to the impact of the Covid-19 pandemic. The multistep impact of pandemic delayed the diagnosis as also the treatment of this multidisciplinary approach disease. Objective(s): To determine the effect of the Covid-19 pandemic on the diagnosis of breast lesions. Method(s): This is a descriptive type of histopathological study in which we have collected and studied the data of Breast lesions over the Five years (Jan 2015-Dec 2019) and compared it with the data of Breast lesions in the Covid-19 year (the year 2020). Result(s): The number of cases of breast specimens received for histopathology per year declined from an average of 224/year to 124/year in the Covid-19 year of 2020. Conclusion(s): The decrease in the number of cases alludes to the downfall in the number of patients coming for diagnosis and in turn getting treatment. This study also highlights the importance of anticipation of various cases which will cluster shortly.

Singing for people with advance chronic respiratory diseases: Qualitative meta-synthesis

Introduction/Aim: Although there remains insufficient evidence regarding singing programs as effective strategies for achieving clinically significant health outcomes, this non-pharmacological intervention appears to be subjectively low-risk and well-tolerated by people with advanced chronic respiratory diseases (CRD). Method(s): A meta-synthesis was undertaken to examine the current qualitative evidence regarding the experiences of singing for lung health programs in adults with advanced CRD and their careers. Electronic databases (Medline, CINAHL, PsycINFO, and EMBASE) were searched for qualitative studies published in English. Qualitative data was extracted and analysed, which generated descriptive and analytical themes. Result(s): Themes identified from seven included studies consisted of anticipation and reluctance to participate;physical and psychological benefits;new sense of purpose and enjoyment;social connection and achievement;and broad views regarding program structure and content. The themes were categorised into three time points to explore participants' perspectives before, during and after engaging in the singing program. Over time participants transitioned from anxiety to mastery of their chronic condition as the singing program progressed. Participants, however, raised concerns regarding several singing technicalities, the lack of ongoing support after the singing programs' conclusion and the social impacts of transitioning the sessions online during the COVID-19 pandemic. Conclusion(s): The increasing body of qualitative literature suggests that participants enjoyed the singing program and derived psychological, social and health benefits, not necessarily captured in quantitative studies. Future work should explore participants' experiences through qualitative, longitudinal methods to gain further insight into the acceptability and feasibility of singing programs and inform broader implementation of the intervention.

A Matter of Time: Anticipation Work and Digital Temporalities in Refugee Humanitarian Assistance in Turkey

Scholarly work interrogating time and temporality in CSCW predominantly focuses on the temporal coordination of work in high-resource settings and is usually based in Global North. This paper aims to complicate and complement this scholarship by investigating the temporal entanglements of digital humanitarian work with refugees and asylum seekers in Turkey during COVID-19. We interviewed 22 humanitarian workers to understand their experiences and concerns as well as strategies they employed to support refugees and immigrants at a distance. The data reveal the complex temporal, informational, and infrastructural dimensions of technologically-mediated refugee support work, challenging the trope of "pivot to remote work", as popular in western countries. Our findings contribute to the CSCW research on the theory of anticipation work and its relationship with the concept of collaborative rhythms to explicate the relational and situated aspects of the temporal experiences of humanitarian workers in low-resource settings. © 2023 ACM.

Ethical duties in preparing for possible disasters

The experience of the COVID-19 pandemic and the horizon of expectations in relation to climate change reminds us that it is a collective responsibility to anticipate to the best of our ability and knowledge the risks of foreseeable disasters and their potential impacts on vulnerable communities. The article will examine the meaning and status of moral duties regarding disaster preparedness by adopting a disaster ethics approach which draws on the interrelationship of bioethics with public health ethics and looks at the full cycle of disaster management and the corresponding cycle of protection of victims and professionals. After discussing some normative controversies accompanying well-known classifications of disasters and characterizing the ethical turn to preparedness in disaster management, it will be argued that preparedness duties include obligations relating to planning, anticipation, and prevention of disasters and that they are derivative and positive duties involving a series of prospective, shared and institutionally mediated responsibilities.

Behavior and anticipation of the covid-19 crisis

The fact that the Covid-19 epidemic is still ongoing - and evolving in different ways in many different countries - means that there is still very little scientific synthesis work based on sufficient hindsight and objectivity that could be used to judge the behaviors that would have been necessary for curative anticipation of the Covid-19 crisis, i.e. anticipation that could permanently deal with Covid-19. The health, societal, economic and geopolitical implications of these crisis situations, which are already considerable today, may become even more significant in the near future. Communication to the public is increasingly becoming a major societal issue, as is the fight against fake news. When the time comes, it will also be appropriate to question the semantics used to describe the Covid-19 epidemic. An emerging topic is variants . This is a perfectly normal evolution of a mostly global virus, but new questions, behaviors and radical decisions emerge. © ISTE Ltd 2022.

Accommodating ''History Effects'' in Long Duration, Multisite Clinical Trials to Ensure Relevant and Compelling Evidence

Over the course of a clinical trial, changes in the practice environment have the potential to reduce internal and external validity and impact change in patient outcomes. Such ''history effects''1 can take the form of changes in standard of care, clinical guidelines and recommendations, new drug/device availability in the marketplace, testing and screening procedures, and, as recently experienced, a global pandemic. Clinical trials conducted over many years are particularly susceptible to history effects. Such effects can impact foundational ability to continue a trial, including clinician equipoise and ability to implement trial interventions, necessitating awareness and action planning. For example, Curtis et al.2 acknowledged challenges with clinical guideline history effects and issued recommendations for addressing them such as consideration of participant wellbeing, stakeholder engagement, safety monitoring, review of guideline and policy changes, and development of rules for protocol changes. This session will explore how four multisite clinical trials conducted with VA Cooperative Studies Program sponsorship and coordination have weathered history effects during prolonged periods of enrollment. Topics to be covered include the implementation of pragmatic designs, monitoring of clinical guidelines, assessing control group treatment conditions, modifying protocols, adjusting quality assurance procedures, refining recruitment pathways, and training site investigators. The speakers, Study Chairs, will describe best practices and provide recommendations for navigating history effects in prolonged multisite clinical trials that can ensure outcomes remain relevant and compelling to inform public health at trial commencement. The CSP 2008/PTXRx study is a pragmatic, randomized, double-blind, placebo-controlled, multicenter clinical trial of Veteran patients with diabetic kidney disease (DKD) examining whether pentoxifylline (PTX), when added to usual care, can delay time to end-stage renal disease or death. Enrollment for the study began in 2019, and it is anticipated that 9 years of follow-up will be required to observe the required number of primary events. Given the long duration of the study, changes in clinical guidelines were anticipated and have occurred, including the approval of new DKD therapies and introduction of a new formula for estimated glomerular filtration rate (eGFR) calculation. In anticipation of these changes, the study design allows for whatever standard of care is extant at any time during the course of the study. PTXR's pragmatic trial design and protocol leverage the VA's research infrastructure and remote platforms allowing the study to be responsive to external changes and to safely continue during a global pandemic. The CSP 596/OPTION study is a randomized, double- blind, multicenter trial of Veteran patients with a first or second recurrent Clostridium difficile infection (CDI) comparing (1) fidaxomicin and (2) vancomycin, followed by a taper and pulse to (3) a standard vancomycin regimen. Since enrollment began in 2016, significant changes in CDI epidemiology and clinical management have impacted the study. The COVID-19 pandemic also resulted in an administrative hold on all trial activity followed by staggered reopening of sites due to variable COVID-19 activity and clinical priorities. Many clinical laboratories switched to algorithms that included free toxin assays in addition to polymerase chain reaction (PCR) tests out of concern for overdiagnosis based on PCR testing alone, reducing the number of potentially enrollable cases. There has been increased empirical vancomycin treatment for recurrent CDI without confirmation by stool testing, a requirement for enrollment, and a recruitment strategy for identifying potential cases. Finally, conflicting clinical guidelines for recurrent CDI has created potential equipoise when considering enrollment. Ongoing educational efforts have been made to clarify the protocol and emphasize the validity of the research question as well as protoco changes to allow safe enrollment and follow-up of participants in the face of the ongoing COVID-19 pandemic. The CSP 2005/VALOR is a phase III randomized, open label, multicenter clinical trial of Veteran patients with operable stage I non-small cell lung cancer that compares stereotactic radiotherapy and anatomic pulmonary resection with a primary outcome measure of overall survival. The study was activated in 2017 and recruitment to the trial has been affected by ongoing changes in public and clinician perceptions about stereotactic radiotherapy and surgery that have interfered with equipoise and willingness of participants to enroll. The study team perpetually addresses this challenge through group conversations with local site investigators, study coordinators, and other research personnel to preserve group equipoise across the study. Since the study's activation, new safety information about stereotactic radiotherapy has emerged necessitating protocol modifications while aiming to preserve internal and external validity. The includes modifying standard operating procedures for the study's centralized quality assurance program that has had to adapt its process to remain contemporary. STARPORT, funded by VA CSRD with CSP collaboration, is a randomized, open label, multicenter clinical trial of Veteran patients with oligorecurrent prostate cancer comparing the effects of standard systemic therapy (SST) alone or with PET-directed local therapy using surgery or radiation. Although enrollment was initiated in 2021, changes are already evident in clinical practice guidelines regarding the use of imaging in workup in this patient population. Shortly before the start of accrual, 18F-DCFPyL PSMA PET/CT received FDA-approval. Consequently, it is being rapidly adopted at the STARPORT VA medical centers and the use of conventional imaging using CT or bone scan prior to PET/CT imaging-part of the original eligibility criteria-quickly is falling out of favor. Furthermore, shortly after the start of enrollment, NCCN guidelines adopted the stance that conventional imaging was no longer required in the setting of PSMA PET/CT imaging, solidifying the transition away from conventional imaging. Thus, the protocol is being amended to remove the requirement for conventional imaging as part of workup for oligorecurrence. In addition, to be generalizable, the study is designed to integrate future PSMA radiotracers that are incorporated into practice as well as changes in SST regimens over the time of the study.

BIODIVERSITY, WHAT KIND OF RESEARCH TO FORSEE RISKS?

Biodiversity combines species, their genetic variability, their ecosystems and all the relationships between them. Endosymbiosis is one of the more important, the probable way between prokaryotes and eukaryotes. Evolution of life relies on combining previous elements into new ones. The discovery of microbiome changes the way microorganisms are considered within the whole biodiversity and for their links with sanitary challenges. Cooperation seems as important as competition. Is it then pertinent to see the development of genomics as the only possibility to discover new viruses in reservoir species before they start new pandemics and to prevent them? Is it the good way to ask the question of new sanitary risks emergence? What about considering the ecology of epidemiological cycles? Or working breeding practices with more connection to local biodiversity? How human sciences could be taken into account? A few examples will illustrate some of these points. © 2022 Academie Veterinaire de France. All rights reserved.

BIODIVERSITY, WHAT KIND OF RESEARCH TO FORSEE RISKS?

Biodiversity combines species, their genetic variability, their ecosystems and all the relationships between them. Endosymbiosis is one of the more important, the probable way between prokaryotes and eukaryotes. Evolution of life relies on combining previous elements into new ones. The discovery of microbiome changes the way microorganisms are considered within the whole biodiversity and for their links with sanitary challenges. Cooperation seems as important as competition. Is it then pertinent to see the development of genomics as the only possibility to discover new viruses in reservoir species before they start new pandemics and to prevent them? Is it the good way to ask the question of new sanitary risks emergence? What about considering the ecology of epidemiological cycles? Or working breeding practices with more connection to local biodiversity? How human sciences could be taken into account? A few examples will illustrate some of these points. Copyright © 2022 Academie Veterinaire de France. All rights reserved.

Antibody-negative silent thyroiditis after vaccination with SARS-CoV-2 mRNA-vaccine: a novel entitity (not) to be confused

Aim/Introduction: Since the start of the SARS-CoV-2 pandemic in Germany 03/2020 we monitored our patient collective for Covid-19 related changes in thyroid function. Aside from the overt Covidthyroiditis we noticed a new form of silent antibody-negative thyroiditis after mRNA-vaccination which due to its unexpected occurrence can be mistaken for other thyroid disorders. Material(s) and Method(s): We searched our local database for patients with new diagnosis or suspicion of thyroiditis from 03/2020 to 04/2022. Excluding (prepandemic) specific forms of thyroiditis (Graves, deQuervain, etc.), 18 patients remained for analysis. Median followup was 6 months [min 0, max 12]. Result(s): 12 asymptomatic patients presented one month [0,3] after vaccination with a mRNA vaccine, 6 symptomatic patients 6 months [4,8] after infection with SARS-CoV-2. All patients presented with features of thyroiditis once we had a better understanding of disease progression, no specific antibodies were present except in patients with preexisting autoimmune thyroiditis (4/18). In one patient FNAC was performed showing lymphocytic infiltrates resembling Hashimoto's. Using our two earliest patients (one female 75y, one male 78y) with unexpected low uptake after mRNA-vaccination despite established history of disseminated thyroid autonomy as prototypes we could follow the typical progression of thyroiditis with low, increased and normalization of uptake with typical changes of thyroid hormones and sonography over the course of 12 and 10 months respectively. The male patient was planed for radio-iodine therapy for disseminated autonomy (TcU 3.2%), was vaccinated with an mRNA vaccine before pre-therapy I131-uptake three weeks later which was unexpectedly low (3.7%) making therapy doses unreasonably high. In the female patient low uptake was at first thought to be due to iodine contamination (TcU 0,19%) which was ruled out and on follow-up 4 weeks later had an TcU of 16.4% with hyper-perfusion of the thyroid. Even though both patients required carbimazole before vaccination they haven't for the entire time since vaccination and were euthyroid for approximately one year currently returning to their original latent hyperthyroid state. Conclusion(s): With the anticipation of an antibody-negative silent thyroiditis after mRNAvaccination for SARS-CoV-2 we were able to correctly predict and confirm low thyroid uptake or incorrect diagnosis in 3/5 patients planned for radio-iodine therapy approximately one month after mRNA-vaccination (one graves disease, one suspected disseminated thyroiditis and one unifocal thyroid autonomy) preventing therapy failure, in 2 patients with unifocal autonomic nodules no lowered uptake after vaccination was seen and radio-iodine therapy was performed as planned.

Patients Attitude Towards Orthodontics Treatment Post Covid

With COVID-19 declared as a worldwide pandemic, a nationwide lockdown was implemented overnight in India on March 24, 2020. With no prior warning or anticipation, patient appointments were temporarily ceased as institutions and clinics were indefinitely closed. Thus, with no prior warning or anticipation, orthodontic appointments were temporarily ceased. In the field of orthodontics, treatment is generally not considered an emergency. However, what is not understood is the importance of regular check-ups or monthly appointments, as well as the impact of restrictions put on patients concerning visiting their orthodontists in times of need. Understanding whether patients realize the importance of regular follow-ups, feel the need for orthodontic treatment to be regarded as emergencies, or assess the reasons for fear or inconveniences in the minds of patients undergoing orthodontic treatment in a time where they are entirely restricted to the confines of their homes are grey areas that are left unexplored. A set of 12 questions was formulated and distributed among the study. The participants were asked to fill the questionnaire. The survey was conducted in an online forum. A total of 100 validated entries were collected. Data was entered into Microsoft Excel and analyzed in SPSS V20. Associations between categorical variables were determined using Chi-square. P<0.05 was considered statistically significant.85% of the population are aware of orthodontic treatment, 93% of the population responded that they are concerned about their facial appearance. 84% of the population believes orthodontic treatment is must. 76% of the population responded that orthodontic treatment affects their hygiene system. 63% of the population felt safe to visit dental clinics post COVID, 52% of the population are not aware of permanent teeth extraction during orthodontic treatment. Orthodontic treatment is required mainly in smile correction or any other dental problems like elimination of malocclusion, trauma, periodontitis. Hence awareness on orthodontic treatment post COVID was improved. Copyright © 2022 Wolters Kluwer Medknow Publications. All rights reserved.

Successful Collaboration of a Hospital Based Blood Center and Blood Bank during the Pandemic and Blood Shortage

Introduction/Objective: At the beginning of the SARSCo- V2 pandemic, many hospitals implemented mitigating strategies to preserve their blood supply in anticipation of a blood shortage. Our health system, Inova (IHS), which includes 5 hospitals supported by our hospital based blood services, was no different. During the pandemic we experienced a decline in donations and available blood products. In anticipation of this shortage, our institution mobilized the Patient Blood Management (PBM) initiative. A multidisciplinary review of transfusion criteria was performed across the system. This included enforcing single unit red blood cell (RBC) transfusions, partial RBC exchanges for sickle-cell disease, and reduction in plasma replacement volume during plasma exchanges for patients with thrombotic thrombocytopenic purpura (TTP). By implementing these strategies, patient outcomes were not impacted despite the constraints to our blood supply. Methods/Case Report: IHS Executive leaders were identified to participate along with key stakeholders in the PBM committee meetings to ensure proper blood utilization for our patients. Clinical guidelines were updated within the physician order sets. Data was compiled with a focus on hemoglobin metrics along with the percentage of single unit transfusions. Collaborating with IHS Apheresis Services and our providers, we developed a strategy to reduce the number of blood products transfused. Results (if a Case Study enter NA): Although there was decline in donor blood collections during the pandemic due to significant concerns of SARS-CO-V2 exposure, the implementation of Patient Blood Management strategies at our institution proved to be beneficial for product management and resource allocation. Although there was a decline in the number of donations (6.5%) we were able to transfuse more patients. Conclusion(s): The SARS-Co-V2 pandemic significantly reduced the blood inventory nationwide. By implementing a robust Patient Blood Management program, we were able to successfully utilize our blood inventory while maintaining transfusion practices that aligned with standards of care. The collaborative efforts between our hospital based blood center and the blood bank led to the optimal use of a reduced blood supply during the pandemic. Incorporating Patient Blood Management principles and safe implementation of novel treatment plans for certain apheresis patient population during the pandemic enabled our system to have more available blood products and care for more patients with improved patient outcomes.

Coronavirus disease 2019 scenarios for a long-term strategy under fundamental uncertainty.

Early on, scientists have pointed out that coronavirus disease 2019 is most likely here to stay, although its course and development are uncertain. This requires a long-term strategy of living with the virus. However, the urgency of new waves of infection and the emergence of new variants have invoked an approach of acute crisis management over and over, hindering the design of a structural approach for the long term. Exploratory scenarios can provide scientific strategic guidance to policy processes to be better prepared in this situation of fundamental uncertainty. We have therefore developed five scenarios, which describe the possible long-term development of the pandemic from an epidemiological, virological, and broader societal perspective. These scenarios are based on four driving forces that are both important and uncertain: immunity, vaccination, mutations, and human behavior. The scenarios are (1) return to normal, (2) flu+, (3) external threat, (4) continuous struggle, and (5) worst case. Working with scenarios is crucial for appropriate public communication and provides guidance for anticipating the various conceivable possibilities for the further course of the pandemic.

Novel Methods for Evaluation of Herbal Plants Benefits during Covid-19: Knowledge, Attitudes and Practices Perspective

Purpose: Herbal plants have been utilized in medical services since the days of yore. Studies have been completed all around the world to confirm their viability, and a portion of the discoveries have prompted the development of plant-based Ayurveda medications. It is generally utilized for the arrangement of different Ayurveda plans for the treatment of bronchitis and flu. Herbal dynamic fixings showed calming properties and, furthermore, assumed a part in the balance of both cell and humeral resistance. The plant has hepatic injury recovery properties as well as other ailment properties. Plants recover from stress, reestablish and develop body susceptibility. For this purpose, we have illustrated the study of roof gardening plants with empirical proof and also shown the impact of plant behavior. Objective: The objective of this review is to introduce the fascinating and arising viewpoints in the field of herbal plants. An experimental review is proposed for planning the future job and spotting herbal plants in sickness anticipation and how to strengthen the immune system of the body. Approach: We have used the KAP framework and Multi Decision Criteria Concept (AHP) for empirical evaluation of the study. Tryouts: Herbal plants and roof gardening assume fundamental roles in infection anticipation and their advancement and utilization fit into all current counteraction procedures. Endeavors should be outfitted towards measures that will improve the viability, adequacy, and sane utilization of herbal plants. The current review focuses on the information on restorative applications of plants and the logical examination to confirm their therapeutic qualities, as well as the role, commitments, and usefulness of herbal plants in dealing with illnesses of general wellbeing significance.

The Superhero Scrub Project: Assembling Positive Paediatric Experiences

Aims Throughout the Covid-19 pandemic, several working practices were changed to allow for better infection control awareness and practice. St Richard's Hospital paediatric department adopted the use of medical scrubs as the standard workwear for medical staff. Children frequently find the hospital environment frightening and unfamiliar, and it is well recognised that practices that utilise play and 'fun' are effective in improving patient and parent engagement and outcomes.1 Furthermore, direct communication with the child and engagement of their interests and activities beyond their medical needs is also acknowledged as a critical element of patient centred care.2 The use of more child friendly imagery such as teddy bears or cartoons on medical clothing/devices within paediatrics is well established. The aim of this project was to trial a 'fun' but practical scrubs uniform that children and their parents would recognise and enjoy seeing, with the aim of providing a positive and less threatening experience for the child and to summarise early feedback as a proof of concept. Methods 5 sets of superhero themed scrubs were created, based on the appearances of Marvel's 'Avengers' and were worn as clinical workwear throughout the pandemic period. Verbal feedback from patients, parents and colleagues was documented and analysed for common themes. Results 'I liked Ben/Spiderman! He made me feel HAPPY!' - 8 year old female patient Feedback was positive overall. Patients generally responded positively to the superhero appearance, and frequently expressed excitement at recognising a character. However, this was sometimes short lived depending on the nature of the clinical encounter. For younger patients in particular, painful procedures remained a source of upset. Parents across the paediatric, A&E, maternity and neonatal departments frequently expressed positive sentiments about the scrubs and often made reference to their expectation that children would enjoy the appearance. No specific negative sentiment was directly fed back, however this may reflect withheld judgement and the need for a more anonymised assessment. Similar positive sentiments were fielded from medical and nursing staff across departments, though with occasional concerns expressed about the professionalism of the clothing, especially if there were a scenario of needing to break bad news. An unexpected effect was to cause amusement and anticipation of what outfit would be expected for the duty - which acted as a morale boost of sorts. Conclusion Incorporating familiar character appearances into medical workwear was well received by patients, parents and staff;and may help lessen feelings of a hospital environment seeming threatening to the child. This could benefit rapport, communication and patient outcomes. Scrub patterns are widely available and easily adaptable for different characters, though this is limited by sewing skill, cost and motivation. There are also limitations their use, particularly where the use of 'fun' imagery is emotionally incongruent. (Figure Presented).

Early Awake Proning in COVID-19 Patients to Reduce Invasive Ventilation: A Prospective Interventional Study ABS0264)

Aim: To prevent endotracheal intubations in the COVID wards with early awake proning, allowing time for lung to recover, and decrease mortality in COVID-19 patients. Objectives: 1. To assess the effect of prone positioning on the requirement for invasive mechanical ventilation. 2. To calculate PaO2/FiO2 before prone position. 3. To measure PaO2/FiO2 after prone position. 4. To assess how much increase in PaO2 during prone. 5. To assess the length of time tolerating prone positioning. Materials and methods: Inclusion criteria: (1) Age >18 years. (2) Patient with confirmed COVID with or without chest X-ray infiltrates. (3) Isolated hypoxemic respiratory failure without substantial dyspnea (the paradoxically well appearing hypoxemic patient). Requiring >2 L of O2 to maintain SpO2 >92%. A reasonable candidate might meet the following criteria: • not in multi-organ failure, • expectation that patient has a fairly reversible lung injury and may avoid intubation, • no hypercapnia or substantial dyspnea, • normal mental status, able to communicate distress, • no anticipation of difficult airway. (4) Patients who do not wish to be intubated (DNI). The main risk of awake proning is that it could cause excessive delays in intubation. In the DNI patient who is failing other modes of ventilation, there is little to be lost by trialing awake proning. Exclusion criteria: (1) Signs of respiratory fatigue (RR > 40/minute, PaCO2 > 50 mm Hg/pH< 7.30, and obvious accessory respiratory muscle use), (2) immediate need for intubation (PaO2/FiO2 < 50 mm Hg, unable to protect airway or change of mental status), (3) unstable hemodynamic status, and (4) inability to collaborate with prone position with agitation or refusal. Also, it is observed that the mean O2 requirement is slightly higher in females (Baseline-7.74 L) as compared to males (Baseline-6.06 L), however, this difference is not statistically significant when observed using an independent sample t test (t value = -1.728, df = 48, p > 0.05). The mean reduction of O2 requirement from baseline to Day 3 post proning amongst male patients is 4.53 L, while in females it is 5.16 L. There is no statistically significant mean reduction of O2 requirement in males and females which was observed using independent sample t-test (t value = -0.675, df = 47, p > 0.05). SpaO2 increase after awake proning Overall, a total of 21 patients were followed up until Day 3 post proning and an increase in SpaO2 was observed in these patients. It is seen that the Mean Baseline SpaO2 in these 21 patients was 68.43 ± 2 (14.172) and after 3 days of awake proning it increased to 77.24 + 2 (17.023). However, this difference is not statistically significant using the paired sample t-test (t value = -1.819, df = 20, p > 0.05). Conclusion: It can be concluded from the study that 3 out of 50 patients (6.0%) required NIV or intubation after giving awake proning. The SpaO2 increases after awake proning but the increase is not statistically significant. However, the O2 requirement is reduced 4 to 6 times after awake proning and this reduction is statistically very highly significant. Thus, awake proning significantly helps in the reduction of the requirement of O2.

Fine Tuning of Simple Things During Pandemic Improves Quality, Criticality, and Outcomes

COVID pandemic has made the health care system difficult to prepare for demanding situations. Second wave of the pandemic made many hospitals unable to handle the relentless inflow of patients whilst also running short of beds, oxygen cylinders, health care workers, and other essentials, with limited resources, we had two challenges to secure better supplies and judiciously use the resources. The aim of the study was to use judiciously the resources, fine tune the patient care, reduce the work load/burden of HCW and improve the outcomes and to see whether these fine tuning will sustain better care and improve the outcomes This observation is done at tertiary care centre. The innovation or fine-tuning were done as follows, 1. Oxygen Boy: The O2 is lifesaving in COVID-19 and its a long game. The neglect of O2 systems have been partly market failure, partly lack of knowledge and anticipation, and misuse Robust O2 systems that would support the pandemic take time to put in place, so conducting training programmes in short period for HCW regarding using or misusing O2 can be done in the relatively short times if there is good planning and management. We selected an HCW as O2 boy;his job was only checking O2 delivery and monitoring SPO2. He was given SPO2 targets to maintain. He would adjust the O2 depending on the targets, we found care was better, reduced O2 misuse, and less burden on HCW including hospital authorities. He also used to monitor continuous prone positions. 2. Foleys Catheters and Diapers: Due to the shortage of ICU/HDU beds during the peak of pandemic, moderate to severe patients were managed in wards with close monitoring. In the initial stages, we faced problems in patients on high o2 when they were mobilized to restrooms. Continuous o2 awake prone was disturbed and derecruited and had severe hypoxia with symptoms and few near codes. So we started catheterizing the patients on high o2 requirements/ elderly, and diapers used if very hypoxic. After these changes the surprises were less, compliance for care was more, and complaints from the patients were very less. 3. Family Visit: Allowing family person visit with precautions was very useful. Family visits made patients comfortable, more compliant with the care, families were happy and reduced the significant burden of HCW's and brought transparency of the care. Complaints of misusing of the drugs were less. 4. Simple Protocols: Due to scarcity of HCW and over working, we analyzed the work flow and found more time was taken for documenting and following the reports than actual patient care. So we simplified the charts with only two sheets, one for the doctor one for the staff. These simple changes made work easy and more efficient and also help in collecting data. 5. 'Drug' Boy: Drugs indenting and on-time delivery was challenging with limited staff and a high workload. We selected a person only for drug delivery and later with drugs becoming precious and anticipating problems, drug boy used to deliver in family presence. This reduced the further burden of HCW's. 6. Continuous Monitoring by a Leader: COVID is a dynamic process and requires continuous monitoring, timely interventions. Leaders have to take complete charge continuously from admission to discharge. Fragmented care by multiple people worsens the situation. 7. Support from the Other Specialities: With above mentioned fine tuning, we found rounds by any specialists doctors was comfortable, less time-consuming, and could manage many patients. This reduces the burden of intensivists and physicians. 8. Monitored Hydration: Most patients were hydrated in view of reduced appetite, druginduced, third spacing, and on NIV. This simple regime significantly reduced acute kidney injuries. 9. DVT Stockings: COVID is a prothrombotic state for the prevention of clots all moderate to severe patients were applied DVT stockings, this prevented DVT significantly. 10. Anxiolytics, Restricted Mobilization, and Spirometry: Mild anxiolytics reduce the stress, work of breathing, and good compliance to the NIV. Stric restriction in mobilizing and no spirometry in moderate to severe COVID in early stages. Conclusion: COVID pandemic is very challenging, till data no proper pharmacological treatment available. So fine tuning of the resources available will have multiple benefits and also improve outcomes. With these innovations, quality improves, cost-effective, and can easily be replicable in any centre.

A Physician-led, Qi-based Approach to Pediatric Disaster Preparedness

Purpose/Objectives: Deficiencies in day-to-day operational readiness are exacerbated during a disaster, disproportionately affecting children. Two 6-month long initiatives were piloted to recognize deficient areas of preparedness and create change strategies to address preparedness for disasters in both pediatric clinics and hospitals. We demonstrate that a physicianled, QI-based approach is an effective strategy to enhance pediatric clinics and hospitals disaster preparedness. Design/Methods: Pediatric considerations were divided into seven domains (Figure 1 and Figure 2), each domain delineated primary drivers, change strategies, and resources to minimize knowledge barriers and drive improvement. After completing initial quality improvement education, physicians scored their plan in each of the domains using a 6-point scale (max. score 42 pts.). This environmental scan intended to evaluate deficiencies in the participant's disaster plan. Physicians conducted 4 meetings over the course of 6 months to review improvement strategies. Teams repeated the environmental scan monthly, aiming to achieve at least a 2-point increase per domain or a total score of 30 by the end of the 6 months. Upon completion of the project, participants were eligible for 25 Maintenance of Certification Part 4 credits. Results: The clinic-based initiative was led from January 1 - June 30, 2020 with 11 registered physicians. The median overall preparedness score increased from 18 (IQR=11.5;n=11), to 38.5 (IQR=6;n=4) at the conclusion of the project, an overall 48.81% (42.86% to 91.67%) increase in total preparedness. The hospital-based initiative was led from June 30 - December 31, 2020 with 71 registered physicians. The median overall preparedness score increased from 14 (IQR=12.5;n=7) to 33.5 (IQR=10.25;n=12) by the conclusion of the project, an overall 46.43% (33.33% to 79.76%) increase in total preparedness. Conclusion/Discussion: The COVID-19 pandemic affected participation in the project as many participants were tasked with additional duties at their institution. Nonetheless, this model of physician-led preparedness efforts proved to be a successful strategy for improving disaster preparedness of both pediatric clinics and hospitals. Clinic-based physicians focused on vaccine storage. Some purchased generators to ensure safe vaccine storage while others worked with their local hospital pharmacy to store vaccines in the event of a disaster. Others moved their electronic medical records to cloud storage. The hospital-based physicians identified staff education and communication as the most useful domains. This was closely followed by surge planning, many of which were immediately tested by the current pandemic. Others highlighted efforts to improve patient-centered care by improving coordination with social work, administrators, and chaplains to meet patient needs. The next cohort for both the clinic-based and hospitalbased initiatives will be launched late summer or early fall 2021. In anticipation of large pediatric COVID-19 vaccination efforts, these cohorts will have a heightened focus on vaccine storage and mass pediatric vaccination strategies.