A Case Report Of The Effects Of Chemotherapy On Post-heart-transplant Gene Expression Profiling

Introduction: Malignancies are a major complication of heart transplant (HT). Noninvasive surveillance after HT using gene expression (GEP) profiling and donor derived cell free DNA (dd-cfDNA) are noninferior to biopsy and are widely utilized. The interpretation of % dd-cfDNA, is not well understood in malignancies with a conceptual increase in the recipient fraction. The effect of chemotherapy on GEP in the setting of post-HT surveillance has not been described to the best of our knowledge. Hypothesis: Induction of chemotherapy will cause global transcriptional reduction in GEP. Method(s): GEP was performed with AlloMap (AM, CareDx), which evaluates expression levels of 11 mononuclear cell genes, involved in lymphocyte activation, T-cell priming, cell migration, hematopoietic proliferation, steroid sensitivity, and platelet activation. Scores range from 0-40, higher scores have a stronger correlation with rejection. At our center a total of 995 draws were analyzed from 2019-2022. In parallel dd-cfDNA, which informs about graft injury was analyzed using AlloSure (AS, CareDx). Case Events: A 71-year-old male HT recipient for nonischemic cardiomyopathy and no rejection history was diagnosed with metastatic gastric adenocarcinoma at 16 months post-HT. Following diagnosis, mycophenolic acid was stopped, prednisone 5 mg was started, and tacrolimus trough goal was gradually lowered to 4-6 given infectious complications. Palliative chemotherapy with folinic acid, fluorouracil (5-FU), oxaliplatin (FOLFOX) was initiated at 18 months post-HT with planned dose reduction of oxaliplatin and holding of 5-FU bolus to reduce risk of myelosuppression given comorbidities. Oxaliplatin was stopped at 18 months post HT. Due to COVID he last received 5-FU at 33 months post-HT. Graft function remained stable and DSA negative. At 36 months post-HT, he developed a bowel obstruction without surgical options for interventions and expired shortly thereafter. Result(s): With initiation of prednisone and following chemotherapy there was a drastic decrease in AM scores (Fig. A). Steroid therapy led to an 18% decline in AM scores, the greatest decrease occurred with chemotherapy, with 67% decline from the mean when compared to all center patients (Fig B). Dd-cfDNA levels remained stable during the course aside from one early elevation. Conclusion(s): To the best of our knowledge this is the first published case on the effect of chemotherapy on GEP profiling in the setting of post-HT surveillance. This case advises caution when interpreting GEP in the setting of chemotherapy showing great reduction in GEP scores. While dd-cfDNA levels remained relatively stable after malignancy diagnosis and treatment initiation further studies will need to inform on the use of both GEP and dd-cfDNA in these patients.Copyright © 2022

Organisational perspectives on Public Health delivery in Ireland: Lessons learned from COVID-19 : Michelle Norris

Background The COVID-19 pandemic has placed healthcare systems worldwide under unprecedented pressure, with the Irish Public Health system no different. To strengthen delivery of Essential Public Health Functions (EPHFs) and increase future pandemic preparedness, Public Health leaders are now focused on identifying learnings from the pandemic. Within Ireland, given their experience, organisations situated within the Public Health system may be in a unique position to provide valuable information around the delivery of EPHFs, both prior to and in light of the COVID-19 pandemic, and how this can be improved in the future. Methods An online survey was distributed by the Department of Health, from 2 March 2022 to 25 March 2022, amongst organisations situated within the Public Health domain in Ireland. The survey consisted of six open-ended questions around the delivery of EPHFs prior to and in light of the pandemic, success stories that could provide scalable solutions to EPHF delivery and current health system barriers, key areas in the public health system that require strengthening, and barriers to achieving these actions. Thematic analysis to identify key themes was conducted on survey responses. Results Twenty-eight organisational responses were received. Themes around the workforce were apparent throughout, with staff training, staff diversity and staff morale, identified as areas for strengthening EPHF delivery. Themes around ICT, data collection and research were frequently identified with a lack of adequate ICT identified as a key lesson from the pandemic, while the Public Health ICT strategy was identified as key to strengthening future EPHF delivery. Conclusions In general, themes around the workforce;leadership, management and governance and ICT, data collection and research were reoccurring across organisational responses and therefore may be key areas for consideration when strengthening delivery of the EPHFs in Ireland. Speakers/Panelist Louise Hendricks Department of Health, Ireland Sohel Saikat WHO, Geneva, Switzerland

Non-traditional Delivery of Hands-on Manufacturing Courses

Due to recent COVID-19 social distancing policies and procedures, there was no way to offer hands-on courses in an on-site format for many education institutions. The solution employed by many educators was to find new ways to implement web-based delivery tools and technologies in order to maintain course learning outcomes and help students successfully grasp course content. In this review paper, a number of innovative practices is highlighted used to deliver course content in several ways. Overall, the paper reports a number of available delivery mechanisms that could be implemented for several manufacturing courses and programs. © American Society for Engineering Education, 2022.

IS REMOTE LEARNING AS EFFECTIVE AS IN-PERSON LEARNING FOR CONTOURING EDUCATION? A COMPARISON OF FACETO-FACE VERSUS ONLINE DELIVERY OF THE ANATOMY AND RADIOLOGY CONTOURING BOOTCAMP

Purpose: The Anatomy and Radiology Contouring (ARC) Bootcamp was a three-day in-person intervention providing integrated radiology, anatomy, and contouring education for radiation oncology (RO) residents and medical physicists. The course consisted of didactic radiology and contouring lectures, small group anatomy sessions using cadaveric prosections, and realtime contouring using commercial software. Acknowledging the importance of increasing access to the Bootcamp, we launched an online version of the ARC Bootcamp in November 2019. We evaluated the online (ONL) course's impact on participants' knowledge acquisition, contouring skills, and self-confidence by comparing it to the face-to-face (F2F) course. Materials and Methods: The F2F Bootcamp was adapted into an ONL version using the Teachable platform (teachable.com). The ONL course was structured in a linear progression of locked modules to offer similar content to the F2F comparator. Participants from the 2019 F2F and the 2019-2020 ONL Bootcamp provided consent for the study and completed pre-and post-intervention evaluations, which assessed anatomy/radiology knowledge, contouring skills, anatomy/radiology knowledge and contouring self-confidence, and course satisfaction. Results: Fifty-seven (F2F: n=30;ONL: n=27) participants completed both evaluations. The ONL course had a substantially wider geographic participation, with participants from 19 countries (versus four countries in the F2F course) completing the preevaluation. F2F had primarily RO resident participation (80%) compared to ONL (41%). In the ONL course, most were from a different field (52%), including medical physics residents or medical students. Compared to baseline self-assessments, both cohorts demonstrated similar self-confidence improvements with their anatomy/radiology knowledge, contouring skills, and in interpreting radiology p<0.001). In the anatomy/radiology knowledge testing, the ONL group showed improvement (mean improvement ± SD: 4.6 ± 6.3 on a 40-point scale;p<0.001) but the F2F group did not (1.6 ± 5.6;p=0.159). The F2F group demonstrated improvement with the contouring assessment (mean ± SD: 0.10 ± 0.17 on a 1-point Dice scale;p=0.004), whereas only a trend was found for the ONL group (0.07 ± 0.16;p=0.076). Both cohorts perceived the course as a positive learning experience (F2F: 4.8 ± 0.4 on a 5-point scale;ONL: 4.5 ± 0.6) and stated it will improve their professional practice (F2F: 4.6 ± 0.5 on a 5-point scale;ONL: 4.2 ± 0.8). Both groups would recommend the course to others (F2F: 4.8 ± 0.4 on a 5-point scale;ONL: 4.4 ± 0.6). Conclusions: The ONL ARC Bootcamp achieved similar results as the F2F version, with improved self-confidence, knowledge scores, and high satisfaction levels among participants. The ONL course is more accessible to diverse geographic regions and disciplines, allows for ongoing education during the COVID-19 pandemic, and can be used as a framework to develop other online educational interventions in radiation oncology.

Using Natural Language Processing to Facilitate Student Feedback Analysis

This research paper compares the results of a novel computer-assisted approach for analyzing a large volume of open-ended responses with those of a more traditional open coding approach. The work is motivated by the observation that in engineering education ecosystems, community members produce text through myriad activities both inside and outside of the classroom in teaching and research settings. In many of these cases, there is an abundance of text available to educators and researchers that could provide insight into various phenomena of interest within the system - student conceptual understanding, student experiences outside the classroom, how instructors can improve their teaching, or even shifts in collective conversations. Unfortunately, while these bodies of text have the potential to provide novel insights to educators and researchers, traditional analysis techniques do not scale well. For example, analyzing larger amounts of text can take one grader or researcher significantly more time than grading a small set of text responses. A larger body of text also creates more challenges for intrarater reliability. Likewise, expanding the size of the grading or research team can create interrater reliability challenges and the possibility of bias. To address this opportunity, we have created a natural language processing system that augments human analysis so as to facilitate and enhance the work of one person (or team). Specifically, we take minimally pre-processed text, embed them using a pre-trained transformer (a specific kind of neural network architecture trained to encode inputs and decode outputs), and perform a sequence of dimension reduction techniques capped with a final clustering step. Such a system can help reduce the amount of time needed to analyze the text by effectively running a first pass on the text to group similar responses together. The human user can utilize these groupings to perform further analysis to fine tune and identify meanings in ways that only a human could. The system also can help improve consistency by analyzing across the entire collection of texts simultaneously and grouping similar items together. This is in contrast with a single person or a team that would have to work in series, analyzing responses sequentially and thereby creating the potential for inconsistencies across time. In this paper we describe the system's architecture and data processing steps. We demonstrate the utility of this approach by applying the method on three questions from an end-of-semester feedback survey in a large, required introductory engineering course. The survey questions were part of a general feedback survey and asked students about their experiences in the transition to online learning subsequent to the SARS-CoV-2 outbreak.. Our results suggest that the pre-analysis text clustering can improve speed and accuracy of coding when compared with unassisted human coding-the system augments what we have traditionally done in coding, grading, or making sense of large quantities of textual data. As natural language processing techniques continue to develop, the engineering education research community should continue to explore potential applications to improve understanding and sensemaking from large volumes of underutilized text data from both within and outside of classroom settings. © American Society for Engineering Education, 2021

Myocarditis after COVID-19 vaccination

As of 6/2021, over 165 million Americans have received at least one dose of the COVID-19 vaccine. Two of the major COVID-19 vaccines administered in the United States utilize mRNA technology. With the novel vaccine being administered to millions, rarer adverse effects are more likely to be identified. The following case highlights a young male patient with myocarditis in the days after mRNA COVID-19 vaccination. Case presentation: Patient is a 31-year-old male with no past medical history who presented with burning chest pain for two days after receiving his second [MN1] mRNA COVID-19 vaccine. The pain was associated with orthopnea and paroxysmal nocturnal dyspnea. Initial EKG showed no acute ischemic changes. [MN2] Blood work revealed elevated troponin of 1.7 and negative CRP and ESR. [MN3] Transthoracic echocardiogram revealed an ejection fraction of 55% with no wall motion abnormalities. The following day patient had CMR that showed an area of myocardial hyper-enhancement in the apical anterior segment suggesting the diagnosis of myocarditis. Patient was discharged with Metoprolol and was instructed to refrain from strenuous exercise. Patient was seen outpatient, and endorses to still experience intermittent burning substernal chest pain. Discussion: In the past few months, myocarditis and myopericarditis have been increasingly reported in CDC and case series following mRNA vaccination. A case review in Pediatrics outlines seven cases in healthy 14- to 19-year-olds who developed symptoms within four days of receiving their second dose. A large Israeli study reported 275 cases of myocarditis over the span of five months. These cases seem to be mild in character and tend to resolve within a week of onset. The connection between the mRNA vaccines and these cases has yet to be confirmed and remains under investigation by the CDC. We present this case in support of the growing literature, as recognition of the relationship between myocarditis and mRNA COVID-19 vaccines will allow these patients presenting with chest pain to receive higher value care while hopefully sparing them from receiving unnecessary invasive cardiac procedures.

Is Remote Learning as Effective as In-Person Learning for Contouring Education? A Comparison of Face-to-Face vs. Online Delivery of the Anatomy and Radiology Contouring Bootcamp

Purpose/Objective(s): The Anatomy and Radiology Contouring (ARC) Bootcamp was a three-day in-person course providing integrated radiology, anatomy, and contouring education for radiation oncology (RO) residents and medical physicists. The course consisted of didactic radiology and contouring lectures, small group anatomy sessions using cadaveric prosections, and real-time contouring using commercial software. Acknowledging the importance of increasing access to the Bootcamp, we launched an online (ONL) version of the ARC Bootcamp in November 2019. We evaluated the ONL course's impact on participants' knowledge acquisition, contouring skills, and self-confidence by comparing it to the face-to-face (F2F) course. Materials/Methods: The F2F Bootcamp was adapted into an ONL version using the Teachable platform (teachable.com). The ONL course was structured in a linear progression of locked modules to offer similar content to the F2F comparator. Participants from the 2019 F2F and the 2019–2020 ONL Bootcamp provided consent for the study and completed pre-and post-intervention evaluations, which assessed anatomy/radiology knowledge, contouring skills, anatomy/radiology knowledge and contouring self-confidence, and course satisfaction. Results: Fifty-seven (F2F: n = 30;ONL: n = 27) participants completed both evaluations. The ONL course had a substantially wider geographic participation, with participants from 19 countries (vs. 4 countries in the F2F course) completing the pre-evaluation. F2F had primarily RO resident participation (80%) compared to ONL (41%). In the ONL course, most were from a different field (52%), including medical physics residents or medical students. Compared to baseline self-assessments, both cohorts demonstrated similar self-confidence improvements with their anatomy knowledge, contouring skills, and in interpreting radiology images (all P < 0.001). In the anatomy/radiology knowledge testing, the ONL group showed improvement (mean improvement ± SD: 4.6 ± 6.3 on a 40-point scale;P < 0.001) but the F2F group did not (1.6 ± 5.6;P = 0.159). The F2F group demonstrated improvement with the contouring assessment (mean ± SD: 0.10 ± 0.17 on a 1-point Dice scale;P = 0.004), whereas only a trend was found for the ONL group (0.07 ± 0.16;P = 0.076). Both cohorts perceived the course as a positive learning experience (F2F: 4.8 ± 0.4 on a 5-point scale;ONL: 4.5 ± 0.6) and stated it will improve their professional practice (F2F: 4.6 ± 0.5 on a 5-point scale;ONL: 4.2 ± 0.8). Both groups would recommend the course to others (F2F: 4.8 ± 0.4 on a 5-point scale;ONL: 4.4 ± 0.6). Conclusion: The ONL ARC Bootcamp achieved similar results as the F2F version, with improved self-confidence, knowledge scores, and high satisfaction levels among participants. The ONL course is more accessible to diverse geographic regions and disciplines, allows for ongoing education during the COVID-19 pandemic, and can be used as a framework to develop other online educational interventions in radiation oncology.

Utility of testing for respiratory viral co-infections with sars-cov-2 at time of initial diagnosis

INTRODUCTION: Over 4.8 million cases of COVID-19 have been diagnosed in the United States as of 8/2/2020, with >50,000 new cases diagnosed per day since 6/24/2020. The question arises at the point of care of whether to test patients initially diagnosed with SARS-CoV-2 for a secondary respiratory co-infection. The CDC has endorsed testing for respiratory pathogens other than SARS-CoV-2 to date. However, there is little evidence to support, or recommend against, additional respiratory pathogen testing. METHODS: The following is a retrospective cohort study of all adult patients with nasal swabs positive for SARSCoV- 2 by PCR from 3/16/2020 to 4/20/2020 at a 500- bed community teaching hospital in Northern New Jersey. Decisions regarding test selection for secondary respiratory pathogens were performed by emergency department providers per individual clinical judgement. Both a 12- 25 target respiratory PCR panel and 3-target PCR were available at our institution. Being unable to measure direct costs, 2020 Medicare clinical laboratory fee schedules were used to estimate cost. Approval to perform this study (IRB #1597737, decision 4/29/2020) was obtained through the Atlantic Health System Institutional Review Board. RESULTS: 1,676 adult patients without a prior SARSCoV- 2 diagnosis were identified as having the virus at time of emergency department presentation. 572 patients were tested with a 12-25 target respiratory PCR while 195 patients were tested with a 3-target viral PCR. Seven 12-25 target PCRs were positive for a co-infection (1 Influenza B, 1 Human Metapneumovirus, 2 Rhinovirus/enterovirus, 3 non-COVID coronaviruses) while all 3-target PCRs were negative. Positive viral testing changed management in one case (patient who tested positive for Influenza B received oseltamivir). CONCLUSIONS: Data supports emerging literature showing respiratory viral co-infection during the initial outbreak was rare. Testing at our hospital cost an estimated $326,425.45 but had minimal impact on patient care. As most respiratory viral co-infections are unlikely to change management in patients with SARS-CoV-2 infection, minimizing use of high-target respiratory viral PCRs will free up laboratories to perform more targeted viral testing and allow better resource allocation during our current pandemic.