Characterizing Surgical Provider Use of Telemedicine: Barriers and Facilitators to Utilization

Introduction: The use of telemedicine in surgical care quickly increased due to the COVID-19 pandemic. However, uptake among surgical specialties has not been consistent. We aimed to characterize surgical provider perceptions of barriers and facilitators to telemedicine use. Method(s): Surgeons and nurses within the gastrointestinal surgery division at a high-volume, tertiary care academic center were contacted for participation in this study. Individual semi-structured interviews explored barriers and facilitators to telemedicine use. Qualitative analysis was conducted by multiple coders using NVivo12 software. Result(s): Six surgeons and three nurses participated in this study. Among the 9 participants, 44% identified as female and 33% were over age 50. Three themes were identified as facilitators to provider utilization of telemedicine: increased accessibility for rural patients due to decreased travel time and cost, enhanced provider productivity from reduced transition time between visits, and the ability of video telemedicine to facilitate non-verbal communication and visual examination. Three themes were identified as barriers to provider utilization of telemedicine: unreliable broadband connection, negative impacts on workflow due to scheduling challenges and insufficient IT support, and the inability to conduct a physical exam and immediately manage certain complications. Conclusion(s): As telemedicine becomes highly integrated into routine care, best practice guidelines to surgeon-patient telemedicine encounters should be established. This will improve virtual communication and consistency across providers, as well as provider satisfaction with telemedicine. Future interventions should address concerns with workflow logistics and technical support by developing comprehensive training and troubleshooting strategies for healthcare providers.

Copper Deficiency Mimicking Myelodysplastic Syndrome: Zinc Supplementation in the Setting of COVID-19

While copper deficiency is rare, it can have serious consequences, including pancytopenia and neuropathy. This treatable micronutrient deficiency can present very similarly to myelodysplastic syndrome (MDS), a group of myeloid neoplasms which can carry devastating prognoses. Copper deficiency is an essential differential diagnosis in suspected MDS, as it can present with similar laboratory findings, bone marrow biopsy, and clinical picture. While copper deficiency has multiple potential causes, it typically occurs in patients with a predisposing gastrointestinal pathology. One possible cause of copper deficiency is zinc overload. Interestingly, zinc over-supplementation has been prevalent during the COVID-19 pandemic, as some believe that zinc can help prevent COVID-19 infection. Multiple case reports have illustrated the similarities between copper deficiency and MDS. They have also highlighted zinc over-supplementation as a potential cause. The following case report is unique in that our patient lacked gastrointestinal pathology. He still presented with the clinical and laboratory findings of MDS in the setting of copper deficiency. These include anemia, leukopenia, fatigue, and neuropathy. Further, this deficiency was caused by zinc over-supplementation in efforts to prevent COVID-19. The deficiency and the accompanying symptoms were treated with copper supplementation and cessation of zinc intake.

Are long waiting lists for bariatric surgery detrimental to patients? A single-centre experience

Background: We aimed to evaluate the impact of surgical delays due to the COVID-19 pandemic on a cohort of bariatric surgery waiting list patients at a single high-volume, accredited bariatric centre in Canada. Methods: We identified all patients on the waiting list who had consented to a primary bariatric operation before June 2021. A review of medical records and a structured telephone interview with each patient was conducted. Changes in weight, body mass index (BMI) and use of antiobesity medications were analyzed. Questions regarding patient experience on the waiting list were also analyzed. Results: Of 123 patients identified on the bariatric surgery waiting list, 97 (78.9%) participated in the survey and were enrolled in this study. Most patients were female (74.2%), with a mean age of 45.2 ± 10.6 years. The length of time on the waiting list was 8-33 months (mean 13.3 ± 4.8 months). The proportion of patients on antiobesity medications increased from 59.8% to 72.2%, although this was not statistically significant (p > 0.05). There was a small but statistically significant decrease in weight (140.0 ± 35.6 kg v. 135.5 ± 35.5 kg,p < 0.0001) and BMI (49.3 ± 9.9 kg/m2 v. 47.7 ± 10.2 kg/m2, p < 0.0001). However, there was no significant change in weight and BMI in the subgroup of patients who were not on antiobesity medications. In terms of patient experience, 39.2% of patients felt that they were negatively impacted by the length of time on the waiting list, and 16.5% were willing to travel out of province for their bariatric surgery. Conclusion: Patients on the bariatric surgery waiting list remained weight stable despite delays secondary to the COVID-19 pandemic. However, extended waiting times for bariatric surgery have had a negative impact on patient satisfaction.

Hotspot and progress of minimally invasive gastrointestinal surgery.

The unprecedented year 2020 has passed. Under the shadow of the COVID-19 epidemic, the global political, social and economic patterns have changed dramatically. Due to the rapid control of epidemic spread in China, medical system soon returned to normal. Minimally invasive gastrointestinal surgery represented by laparoscopy has completely returned to normal level. In view of prevention and control of the epidemic, international communication and transportation have been greatly affected. Many academic conferences have been cancelled or changed to be held online. The epidemic has greatly accelerated the popularization of online transmission of minimally invasive surgery. However, there are some differentiation and differences in disease spectrum, surgical technology, minimally invasive technology, surgical equipment and instruments at home and abroad. In view of this special situation in 2020, this paper reviews and prospects the new hot spots and new developments of minimally invasive gastrointestinal surgery in terms of surgical technology platform, surgical technology and concept.Copyright © 2021 Chinese Medical Association

Hotspot and progress of minimally invasive gastrointestinal surgery.

The unprecedented year 2020 has passed. Under the shadow of the COVID-19 epidemic, the global political, social and economic patterns have changed dramatically. Due to the rapid control of epidemic spread in China, medical system soon returned to normal. Minimally invasive gastrointestinal surgery represented by laparoscopy has completely returned to normal level. In view of prevention and control of the epidemic, international communication and transportation have been greatly affected. Many academic conferences have been cancelled or changed to be held online. The epidemic has greatly accelerated the popularization of online transmission of minimally invasive surgery. However, there are some differentiation and differences in disease spectrum, surgical technology, minimally invasive technology, surgical equipment and instruments at home and abroad. In view of this special situation in 2020, this paper reviews and prospects the new hot spots and new developments of minimally invasive gastrointestinal surgery in terms of surgical technology platform, surgical technology and concept.Copyright © 2021 Chinese Medical Association

Impact of the COVID-19 pandemic on bariatric surgery in North America: a retrospective analysis of 834 647 patients

Background: COVID-19 has transformed surgical care, yet little is known regarding implications for bariatric surgery. We sought to characterize the impact of COVID-19 on bariatric surgery delivery and outcomes. Methods: The Metabolic and Bariatric Accreditation and Quality Improvement Program (MBSAQIP) collects data from 885 centres in North America. The MBSAQIP database was evaluated with 2 cohorts described: the COVID-19 and the pre-COVID-19, receiving surgery in 2020 and 2015-2019, respectively. Yearly operative trends were characterized, and bivariate analysis compared demographics and postoperative outcomes. Multivariable modelling evaluated 3-day readmission, reintervention, reoperation, and factors associated with undergoing Roux-en-Y gastric bypass (RYGB). Results: We evaluated 834 647 patients, with 155 830 undergoing bariatric surgery during the 2020 pandemic year. A 12.1% reduction in total cases (177 208 in 2019 v. 155 830 in 2020, p < 0.001) and 13.8% reduction in cases per centre occurred (204.2 cases/centre in 2019 v. 176.1 cases/centre in 2020, p < 0.001). Patients receiving bariatric surgery during the pandemic were younger and had fewer comorbidities. Use of sleeve gastrectomy increased (74.5% v. 72.5%, p < 0.001), and surgery during COVID-19 was associated with reduced RYGB procedural selection (odds ratio 0.83, 95% confidence interval 0.82-0.84, p < 0.001). Length of stay decreased significantly (1.4 ± 1.4 d v. 1.6 ± 1.4 d, p < 0.001), yet postoperative outcomes were similar. After adjusting for comorbidities, patients during COVID-19 had decreased 30-day odds of readmission and reintervention, with a small increased odds of reoperation. Conclusion: The COVID-19 pandemic dramatically changed the landscape of bariatric surgery delivery. Further studies evaluating the long-term effects of these changes are warranted.

Telementoring for endoscopic submucosal dissection in vivo training.

The provision of endoscopic training was significantly disrupted during the coronavirus disease (COVID-19) pandemic. It is difficult to provide training on endoscopic submucosal dissection (ESD) due to the complexity of the procedure and the shortage of local trainers. We have designed and conducted a simulation training course with telementoring, incorporating the concept of rapid cycle deliberate practice (RCDP). After a short tutorial on basic setup and maneuvering, the participants undergo 2 h of training on a live anesthetized pig to acquire the necessary skills for ESD. Two overseas experts were involved virtually in real time as telementors. A video camera was set up at each station, and both external and endoscopic views were transmitted live between the animal laboratory and telementors via the Zoom application. The overseas experts actively engaged in the simulation by giving live feedback and instructions to participants using visual aids supported by the meeting application. The training model utilized the concept of RCDP, where repeated immediate feedback and discussion would be carried out to enhance the efficiency of learning. Eighteen trainees were invited to participate in the course, six of them instructed by overseas telementors. Four ESD procedures were performed by participants under telementoring and achieved 100% en bloc resection without perforation. The times required for each ESD were similar with telementoring than that of on-site mentors. The establishment of telementoring has enabled knowledge and skill transfer of complex endoscopic procedures of ESD. With the limitations of international travel, this could be an alternative model allowing remote training, particularly when local experts are not readily available.

Cirugía bariátrica y metabólica en la crisis COVID-19: estrategias frente a dos pandemias

Tras su aparición en Wuhan a finales de 2019, la pandemia del SARS-CoV-2 ha traído graves consecuencias a nivel mundial, estando España entre los países más afectados. La crisis sanitaria implicó la cancelación de cirugías por patología maligna y benigna, entre estas la cirugía bariátrica y metabólica. Los pacientes con obesidad mórbida, además de verse afectados por el retraso de las intervenciones, son considerados pacientes con riesgo elevado de presentar COVID-19 grave. Es por esto por lo que una vez alcanzada la mejoría de la situación epidemiológica en los diferentes centros y se disponga de los recursos necesarios, debería reiniciarse de forma progresiva esta actividad quirúrgica. Nuestro objetivo es revisar la literatura publicada referente a las principales recomendaciones perioperatorias para realizar cirugía bariátrica y metabólica de forma segura durante la pandemia por COVID-19.Alternate : Since its first appearance in Wuhan at the end of 2019, the SARS-CoV-2 pandemic has brought serious repercussions worldwide, Spain being among the most affected countries. This health crisis resulted in the cancellation of surgeries pertaining to both malignant and benign pathologies, including bariatric and metabolic surgery. Patients with morbid obesity, besides their delay in surgical interventions, are at high risk of contracting severe COVID-19. For this reason, once the epidemiological situation has improved in our hospitals and the necessary resources become again available, this surgical activity should be progressively restarted. The goal of this paper is to review the published literature regarding the main perioperative recommendations concerning safe bariatric and metabolic surgery during the COVID-19 pandemic.

Time to endoscopic vacuum therapy-lessons learned after > 150 robotic-assisted minimally invasive esophagectomies (RAMIE) at a German high-volume center.

OBJECTIVE OF THE STUDY: In esophageal surgery, anastomotic leak (AL) remains one of the most severe and critical adverse events after oncological esophagectomy. Endoscopic vacuum therapy (EVT) can be used to treat AL; however, in the current literature, treatment outcomes and reports on how to use this novel technique are scarce. The aim of this study was to evaluate the outcomes of patients with an AL after IL RAMIE and to determine whether using EVT as an treatment option is safe and feasible. MATERIAL AND METHODS: This study includes all patients who developed an Esophagectomy Complications Consensus Group (ECCG) type II AL after IL RAMIE at our center between April 2017 and December 2021. The analysis focuses on time to EVT, duration of EVT, and follow up treatments for these patients. RESULTS: A total of 157 patients underwent an IL RAMIE at our hospital. 21 patients of these (13.4%) developed an ECCG type II AL. One patient died of unrelated Covid-19 pneumonia and was excluded from the study cohort. The mean duration of EVT was 12 days (range 4-28 days), with a mean of two sponge changes (range 0-5 changes). AL was diagnosed at a mean of 8 days post-surgery (range 2-16 days). Closure of the AL with EVT was successful in 15 out of 20 patients (75%). Placement of a SEMS (Self-expandlable metallic stent) after EVT was performed in four patients due to persisting AL. Overall success rate of anastomotic sealing independently of the treatment modality was achieved in 19 out of 20 Patients (95%). No severe EVT-related adverse events occurred. CONCLUSION: This study shows that EVT can be a safe and effective endoscopic treatment option for ECCG type II AL.

Surgical Training during the Covid-19 Pandemic at a Designated "Cold" Site: Are We Meeting the Challenge?

Aim: There has been a marked reduction in surgical operative training opportunities during the COVID-19 pandemic. This may be improved by the establishment of "cold" sites for NHS elective surgery. We investigated the training opportunities at a newly designated elective surgery cold site in the West Midlands, UK. Method(s): An observational retrospective study was undertaken to include all gastrointestinal and urological elective surgery at a single "cold" site during the first peak of the pandemic. Patient demographics, details of surgery, and data relating to surgical training such as primary surgeon and portfolio index procedure were collected. Factors affecting the likelihood of trainees being the primary surgeon were analysed using logistic regression models. Result(s): There were 880 patients, with a median age of 62 (IQR 48-74). 658 (74.8%) procedures were defined as "index procedures" for ST4 level (409/509 (80.4%) for Urology;155/235 (66%) for Colorectal;and 94/136 (69.1%) for Upper GI). Only 253/880 (28.8%) procedures were performed by a trainee as the primary surgeon (201/509 (39.4%) for Urology;21/235 (8.9%) for Colorectal;and 31/136 (22.8%) for Upper GI). The likelihood of a trainee being the primary surgeon was reduced for major surgery (P < 0.001) and for gastrointestinal surgery when compared to urology (P < 0.001). Conclusion(s): Surgical training was facilitated at an elective surgery "cold" site during the COVID-19 pandemic, but at lower levels than anticipated. Type of surgery influenced trainee participation. Surgical training should be incorporated into "cold" site elective surgical services if trainees are to be prepared for the future.

An Innovative Curriculum Increases Internal Medicine Residents' Obesity-Care Self-Efficacy

Background: Residency offers opportunities to address obesity-care knowledge gaps, but few curricula exist. We aimed to develop and rigorously test an obesity medicine curriculum for internal medicine (IM) residents. Methods: We conducted a prospective study comparing IM residents' obesity-care self-efficacy between a residency program receiving the curriculum (n=20) and a control program (n=19). From Feb-April 2020, we delivered a curriculum that combined online modules with live case-based discussions on guidelineconcordant obesity care (lifestyle, medications, surgery);enhanced with tools for documentation and patient communication. We determined residents' change in counseling self-efficacy on nutrition, behavior change, anti-obesity medications (AOM), and bariatric surgery on 4-point Likert scales at baseline and 5 months. We also assessed change in self-reported clinical practice habits. We used t-tests to compare mean change in outcomes both within and between groups. Results: Overall, 64% of residents were women and evenly distributed across post-graduate years. Curriculum residents had statistically significant within-group increases in all self-efficacy domains (nutrition 0.8;behavior 1.2;AOM 1.2;surgery 0.9 (p<0.01)) and statistically significant within-group increases in three practice habits (behavior 0.8, AOM 0.8, surgery 0.6 (p<0.02)). Relative to controls, curriculum residents had statistically significant improvements in all self-efficacy domains (between-group differences: nutrition 0.6 (p=0.02);behavior 0.8 (p<0.01);AOM 0.7 (p=0.03);surgery 0.5 (p=0.03)). We found no between-group differences in practice habits. Conclusions: A curriculum increased residents' obesity-care selfefficacy and produced improvements beyond those achieved with usual IM training. While curriculum residents reported increases in practice habits, the between-group changes were not statistically significant - possibly related to COVID19 disruptions. Future studies should determine effect on clinical practice.

The Impact of Financial Incentives on Attendance and Motivation for Bariatric Support Groups

Background: Attending bariatric support groups is associated with higher weight loss post-bariatric surgery;however, attendance can be low due to several important barriers (e.g., time, motivation, distance). Incentivizing participation in desired behaviors is one strategy that has been used widely in many areas (e.g., health behaviors, work performance) but has not been used specifically to increase attendance to bariatric support groups. Methods: A single-center, prospective, pilot study was performed from January 1, 2020 - March 1, 2020 (timeline shortened drastically due to COVID-19 pandemic). Participants who were > 1-year postoperative were eligible to receive a monetary incentive ($20 per support group meeting) for attending bariatric surgery support groups. They also were asked to complete the Treatment Self-Regulation Questionnaire (TSRQ) to assess motivation at each support group they attended. Results: Attendance pre-incentive (2019) to post-incentive (2020) increased significantly (RR = 9.1, 95% CI: 4.8-19.2, p < .0001). Results from the TSRQ at baseline suggested higher intrinsic motivation (m = 4.75, sd = 1.09) than extrinsic motivation (m= 1.55, sd = 0.91), and there was no change in motivation level over time (p's > .05). Conclusions: This pilot study suggests the potential benefit of providing incentives to increase attendance to bariatric surgery support groups. It also suggests that motivation for many people participating in this study was intrinsic despite the provision of an extrinsic reward for attendance. Future research over a longer period may clarify what level and type of incentives provide the most benefit and how this impacts motivation over time.

Efficacy of Online-Based Intervention for Anxiety during COVID-19: A Systematic Review and Meta-Analysis of Randomized Controlled Trials

COVID-19 has caused widespread psychological suffering. Anxiety is one of the several psychological disorders that are escalating globally, yet social distance constraints restrict in-person mental health therapy. Anxiety and other psychological disorders whose treatments are limited due to social distancing continue to grow, so there is an increasing need to use mental healthcare that can be offered remotely, especially in the pandemic era. This study aimed to conduct a systematic review and meta-analysis of the efficacy of online-based interventions for anxiety during COVID-19. This study followed the Preferred Reporting Item for Systematic Review and Meta-analysis (PRISMA). We collected data from three databases, namely PubMed, CINAHL, and Oxford Library Press, published in 2020–2022. Additionally, we collected data using the snowball technique. This meta-analysis analyzed the pooled mean difference (MD) and its p-value using random-effects models. Critical appraisal and risk of bias were assessed using Cochrane Risk of Bias (Rob) 2. We retrieved 34 RCTs for systematic review and 14 RCTs for meta-analysis, yielding 9159 participants for general anxiety disorder (GAD-7) measurement and 1303 participants for depression anxiety stress scale (DASS-21) measurement. This study shows that online-based interventions significantly reduce GAD-7 score (a pooled MD of 1.30;95% CI: 2.83–4.65;p = 0.00001) and insignificantly reduce DASS-21 (0.05;95% CI: −2.63–2.72;p = 0.97) according to pre- and post-test in intervention group. Additionally, there is a significant difference between the intervention and control groups, where the intervention group performed statistically progressively better than the controls (−7.26;95% CI: −11.58–−2.95;p = 0.001) (−2.08;95% CI: −6.71–2.55;p = 0.001). Online-based interventions have proved effective for reducing general anxiety during the COVID-19 pandemic. Consequently, this meta-analysis can be adapted as a model for mental health services in the new normal.

Thrombocytopenia: Evaluation and Management

Thrombocytopenia is a platelet count of less than 150 × 103 per μL and can occur from decreased platelet production, increased destruction, splenic sequestration, or dilution or clumping. Patients with a platelet count greater than 50 × 103 per μL are generally asymptomatic. Patients with platelet counts between 20 and 50 × 103 per μL may have mild skin manifestations such as petechiae, purpura, or ecchymosis. Patients with platelet counts of less than 10 × 103 per μL have a high risk of serious bleeding. Although thrombocytopenia is classically associated with bleeding, there are conditions in which bleeding and thrombosis can occur, such as antiphospholipid syndrome, heparin-induced thrombocytopenia, and thrombotic microangiopathies. Patients with isolated thrombocytopenia in the absence of systemic illness most likely have immune thrombocytopenia or drug-induced thrombocytopenia. In stable patients being evaluated as outpatients, the first step is to exclude pseudothrombocytopenia by collecting blood in a tube containing heparin or sodium citrate and repeating the platelet count. If thrombocytopenia is confirmed, the next step is to distinguish acute from chronic thrombocytopenia by obtaining or reviewing previous platelet counts. Patients with acute thrombocytopenia may require hospitalization. Common causes that require emergency hospitalization are heparin-induced thrombocytopenia, thrombotic microangiopathies, and the hemolysis, elevated liver enzymes, and low platelet count (HELLP) syndrome. Common nonemergency causes of thrombocytopenia include drug-induced thrombocytopenia, immune thrombocytopenia, and hepatic disease. Transfusion of platelets is recommended when patients have active hemorrhage or when platelet counts are less than 10 × 103 per μL, in addition to treatment (when possible) of underlying causative conditions. It is important to ensure adequate platelet counts to decrease bleeding risk before invasive procedures;this may also require a platelet transfusion. Patients with platelet counts of less than 50 × 103 per μL should adhere to activity restrictions to avoid trauma-associated bleeding. (Am Fam Physician. 2022;106(3):288–298. Copyright © 2022 American Academy of Family Physicians.)

Myeloid Sarcoma Mimicking Dental Abscess in a Patient with Chronic Myeloid Leukemia: Diagnostic and Therapeutic Dilemma

Chronic myeloid leukemia (CML) is a hematologic malignancy that has significant improvement in its prognosis after the introduction of tyrosine kinase inhibitors. Transformation to accelerated phase or blast phase can happen. Myeloid sarcoma or chloroma is an uncommon extramedullary disease. It is very unusual for patients with CML to develop myeloid sarcoma. We report a young man with CML in the chronic phase who developed myeloid sarcoma. There were many difficulties in the diagnosis of myeloid sarcoma due to the simulation of other more common conditions like infections and other malignancies. In addition, there are treatment challenges because of lack of standardized treatment. The case shed light on this rare complication, the challenging diagnosis, and its implication in patients with CML.

Estimating the impact of weight management treatments on childhood obesity in England

AimsTrials demonstrate that childhood obesity treatments are effective but to varying degrees. Some treatment programmes are less effective (e.g., lifestyle programmes), while others are deemed more effective but invasive (e.g. bariatric surgery). Yet, we know relatively little about the most effective way to implement childhood obesity treatments at a population level. That is: which children would benefit most from treatment and at what age;and at which management tier (e.g., lower tiers are low cost with greater reach, but less effective, while higher tiers are high cost with low reach, but more effective). The main aim of this work was to estimate the potential impact of weight management treatments and interventions on population prevalence and inequalities in childhood obesity in England.MethodsUsing Health Survey for England data, we created a ‘digital twin’ of the English population and identified children with a range of weight status categories (e.g., obesity and extreme obesity), obesity comorbidities (e.g., physical and mental health conditions), and indicators of heightened risk of cardiovascular disease (e.g., blood pressure and cholesterol). Other risk factors for obesity were also identified using sociodemographic data (e.g., level of deprivation, ethnicity, income and region). Using NICE guidelines for treatment eligibility, we estimated the number of children who would be eligible for each management tier of treatment in England;where tier 1 represents interventions in primary care, tier 2 represents community interventions, tier 3 represents pharmaceutical interventions, and tier 4 represents surgical interventions. In Phase 1 of our analysis, in addition to a universal preventative intervention, we modelled a number of scenarios that represented each management tier of treatment with a range of effect sizes (based on the best available evidence) and for varying levels of uptake. We applied these scenarios individually and in combination, before comparing stepped and staged approaches. We presented Phase 1 of our analyses to a stakeholder group consisting of multi-disciplinary academics, practitioners and experts in childhood obesity treatment. Stakeholders were consulted on reasonable treatment effect sizes, levels of uptake and other model parameters in order that we could better inform our scenarios, and where there were gaps in the evidence base. Following this modified Delphi approach, we revised our assumptions and model parameters and are currently undertaking Phase 2 of our analyses.ResultsAnalyses from Phase 1 showed substantially higher prevalences of obesity and severe obesity, compared to other estimates across all age groups and levels of deprivation. Recent data from the National Child Measurement Programme in England suggest that these prevalences have increased following the Covid-19 pandemic. We have not reported summary findings from Phase 1 of this work here as these findings will be superseded upon completion of Phase 2.ConclusionIn this presentation, I plan to present the latest findings from Phase 2 of this work.

Meeting in the metaverse - a new paradigm for scientific mentorship

81 Figure 1A photograph of our co-author, Mr. Teddy Tai Loy Lee, a pharmacy student using a virtual reality head-mounted display during the metaverse meeting. Informed consent was provided for the publication of identifiable information[Figure omitted. See PDF] 81 Figure 2A screenshot of the virtual experience during the mentorship sessions and research meetings taken using the selfie function. All participants consented to the publication of their avatars[Figure omitted. See PDF]ConclusionThe metaverse is an effective system for facilitating and enabling interactions amongst international colleagues, breaking down barriers between colleagues from different countries and across traditional hierarchies.Conflict of InterestN/A

COVID-19 Gastrointestinal Tract Affection: An Updated Review

Although it was initially believed that the coronavirus disease 2019 (COVID-19) only attacked the respiratory system, reports over time demonstrated that this disease could attack the gastrointestinal tract (GIT) as well. The predominant presenting symptoms in patients infected with COVID-19 were gastrointestinal (GI), resulting in GI pathological changes. While clinicians' concerns are mostly related to respiratory system manifestations, GI symptoms should be monitored and managed appropriately. This review summarizes the essential information about COVID-19 GIT infection in terms of pathogenesis, major pathological changes, microbiological bases of infection, the possibility of feco-oral transmission, the severity of associated symptoms, the major radiological findings, the impact on GI surgery, the role of therapeutic agents in induction or magnification of GI symptoms, and a pitfall on the nutritional supplementation in COVID-19 patients.

Progress and early outcomes of a cardiometabolic clinic in a uk tertiary cardiology centre

128 Table 1Referral origin of patients seen 128 Table 2Patient characteristics 128 male 54 female 128 Table 3Onward referrals 128 Table 4Medications initiated, titrated, stoppedConclusionThe CMC is a novel integrative approach to optimising management of cardiometabolic risk and incorporation of evidence-based cardiometabolic medications. As risk of morbidity and mortality due non-communicable diseases intensifies in an increasingly comorbid population and in the context of a resource-strained health service, efficient care models such as the CMC are an important enterprise to address cardiometabolic risk and disease. As this clinic expands its service, it will continue to serve as example for comparable innovation in other centres.Conflict of InterestNone