An evaluation of telephone versus videoconference consults for pre-treatment medication history taking by cancer pharmacists.

INTRODUCTION: The primary aim was to compare the successful completion rates of pre-treatment medication history consults conducted by pharmacists with patients either via an unscheduled telephone consult (current standard care) or a scheduled videoconference consult model. Secondary aims were to examine pharmacist perceptions of the telephone and videoconference consults and explore patient (+/- support person) perceptions of videoconference consults. METHOD: Completion data were collected and compared for the two modalities. In addition, pharmacists commented on any positive/negative factors impacting all consults. For the final 35 participants completing a videoconference consult, patients, support people, and pharmacists involved, completed a survey exploring perceptions and satisfaction. RESULTS: A significantly higher completion rate (p < 0.0001) was found for the videoconferencing model, with 94% (76 of 81) completed successfully compared to 72% (76 of 105) of the unscheduled telephone consults. Pharmacists reported multiple factors impacting the success of the telephone consults including scheduling issues and patient factors. Survey responses revealed that 100% of patients/support people and 82% of pharmacists reported satisfaction with videoconference consults. Surveyed participants noted some technical issues, however, the 'ability to show/view medication containers and/or labels' and 'convenience of scheduled time' were benefits of the videoconference model. DISCUSSION: Results indicate that pre-treatment medication history consults should be offered via videoconference to maximise success.

Online medical history taking course: Opportunities and limitations in comparison to traditional bedside teaching.

Objective: Obtaining a systematic medical history (MH) from a patient is a core competency in medical education and plays a vital role in the diagnosis of diseases. At the Faculty of Medicine at LMU Munich, students have their first course in MH taking during their second year. Due to the COVID-19 pandemic, the traditional bedside MH taking course had to be transformed into an online course (OC). Our objectives were to implement an online MH taking course, to evaluate its feasibility and to compare the evaluation results to a historic cohort that had undertaken the traditional bedside teaching course (BTC). Methods: 874 second-year students participated in the OC (BTC=827). After teaching the theoretical background via asynchronous online lectures, students participated in a practical exercise with fellow students using the video communication platform Zoom where they were able to practice taking a MH on the basis of fictitious, text-based patient cases. Students were then asked to evaluate the course through a standardized online survey with 31 questions on teaching quality and self-perceived learning success, which had also been used in previous years. The survey results were compared to the results of the historic cohort using the Mann-Whitney U test. Results: A total of n=162 students (18.5%) evaluated the OC. In the historic cohort, n=252 (30.5%) completed the survey. 85.3% of the OC respondents thought that the atmosphere during the practical exercise was productive and 83.0% greatly appreciated the flexibility in terms of time management. Moreover, they appreciated the online resources as well as having the opportunity to undertake a MH taking course during the COVID-19 pandemic. 27.7% of the respondents thought that traditional BTCs should be supplemented through more online activities in the future. With respect to the ability of independently taking a MH upon completion of the course, the OC was rated significantly lower relative to the BTC (mean OC=2.4, SD=±1.1 vs. mean BTC=1.9, SD=±1.1 (1=strongly agree; 5=strongly disagree); p<0.0001). Conclusion: OCs are a feasible format and seem to convey the theory and practical implementation in a peer-exercise format of MH taking to medical students. The theoretical background can be acquired with great flexibility. Nevertheless, the students' self-appraisal suggested that the traditional teaching format was more effective at teaching MH taking skills. Thus, we propose a blended learning concept, combining elements of both formats. In this context, we suggest prospective, randomized trials to evaluate blended learning approaches.

Remote medico-legal assessment by telephone during COVID-19: Monitoring safety and quality when documenting evidence of torture for UK asylum applicants.

INTRODUCTION: Due to the COVID-19 pandemic, Freedom from Torture developed remote telephone assessments to provide interim medico-legal reports, ensuring people could obtain medical evidence to support their asylum claim. METHOD: To audit this new way of working, feedback was collected from the doctors, interpreters, individuals being assessed, and senior medical and legal staff who reviewed the reports. This paper presents findings from the first 20 assessments. RESULTS: Individuals assessed reported that the doctor developed good rapport, but in 35% of assessments reported that there were some experiences they felt unable to disclose. In 70% of assessments, doctors felt that rapport was not as good compared to face-to-face. In the majority of assessments, doctors were unable to gain a full account of the torture or its impact. They reported feeling cautious about pressing for more information on the telephone, mindful of individuals' vulnerability and the difficulty of providing support remotely. Nevertheless, in 85% of assessments doctors felt able to assess the consistency of the account of torture with the psychological findings, in accordance with the Istanbul Protocol (United Nations, 2004). Factors that hindered the assessment included the inability to observe body language, the person's ill health, and confidentiality concerns. CONCLUSION: This research indicates that psychological medico-legal reports can safely be produced by telephone assessment, but are more likely to be incomplete in terms of both full disclosure of torture experiences and psychological assessment. The limitations underline the need for a follow-up face-to-face assessment to expand the psychological assessment as well as undertake a physical assessment.

Genetic and Epigenetic Factors of Takotsubo Syndrome: A Systematic Review.

Takotsubo syndrome (TTS), recognized as stress's cardiomyopathy, or as left ventricular apical balloon syndrome in recent years, is a rare pathology, described for the first time by Japanese researchers in 1990. TTS is characterized by an interindividual heterogeneity in onset and progression, and by strong predominance in postmenopausal women. The clear causes of these TTS features are uncertain, given the limited understanding of this intriguing syndrome until now. However, the increasing frequency of TTS cases in recent years, and particularly correlated to the SARS-CoV-2 pandemic, leads us to the imperative necessity both of a complete knowledge of TTS pathophysiology for identifying biomarkers facilitating its management, and of targets for specific and effective treatments. The suspect of a genetic basis in TTS pathogenesis has been evidenced. Accordingly, familial forms of TTS have been described. However, a systematic and comprehensive characterization of the genetic or epigenetic factors significantly associated with TTS is lacking. Thus, we here conducted a systematic review of the literature before June 2021, to contribute to the identification of potential genetic and epigenetic factors associated with TTS. Interesting data were evidenced, but few in number and with diverse limitations. Consequently, we concluded that further work is needed to address the gaps discussed, and clear evidence may arrive by using multi-omics investigations.

Virtual epilepsy clinics - A Canadian Comprehensive Epilepsy Center experience pre-COVID and during the COVID-19 pandemic period.

OBJECTIVE: The objective of this study is to assess the role of prior experience with virtual care (through e-visits) in maintaining continuity in ambulatory epilepsy care during an unprecedented pandemic situation, comparing in person versus e-visit clinic uptake. METHODS: This is an observational study on virtual epilepsy care (through e-visits) over two years, during a pre-COVID period (14 months) continuing into the COVID-19 pandemic period (10 months). For a small initial section of patients seen during the study period a physician survey and a patient satisfaction survey were completed (n = 53). Outcomes of eVisits were analyzed using descriptive statistics. RESULTS: Median numbers of epilepsy clinic visits conducted during the COVID-19 period (27.5 new and 113 follow up) remained similar to the median uptake during the pre-COVID period (28 new and 116 follow up). Prior experience with e-visits for epilepsy yielded smooth transition into the pandemic period, with several other advantages. The majority of eVisits were successful despite technical difficulties and major components of history and management were still easily implemented. Results from patient surveys supported that a significant amount of time and money were saved, which was in keeping with our health-economic analysis. CONCLUSION: Our study is one of the first few reports of fully integrated virtual care in a comprehensive epilepsy clinic starting much before start of the COVID-19 pandemic. The results of our study support the feasibility of using virtual care to deliver specialized outpatient care in a comprehensive epilepsy center.

Current and Past Infections of HBV Do Not Increase Mortality in Patients With COVID-19.

BACKGROUND AND AIMS: We compared risk of acute liver injury and mortality in patients with COVID-19 and current, past, and no HBV infection. APPROACH AND RESULTS: This was a territory-wide retrospective cohort study in Hong Kong. Patients with COVID-19 between January 23, 2020, and January 1, 2021, were identified. Patients with hepatitis C or no HBsAg results were excluded. The primary outcome was mortality. Acute liver injury was defined as alanine aminotransferase or aspartate aminotransferase ≥2 × upper limit of normal (ULN; i.e., 80 U/L), with total bilirubin ≥2 × ULN (i.e., 2.2 mg/dL) and/or international normalized ratio ≥1.7. Of 5,639 patients included, 353 (6.3%) and 359 (6.4%) had current and past HBV infection, respectively. Compared to patients without known HBV exposure, current HBV-infected patients were older and more likely to have cirrhosis. Past HBV-infected patients were the oldest, and more had diabetes and cardiovascular disease. At a median follow-up of 14 (9-20) days, 138 (2.4%) patients died; acute liver injury occurred in 58 (1.2%), 8 (2.3%), and 11 (3.1%) patients with no, current, and past HBV infection, respectively. Acute liver injury (adjusted HR [aHR], 2.45; 95% CI, 1.52-3.96; P < 0.001), but not current (aHR, 1.29; 95% CI, 0.61-2.70; P = 0.507) or past (aHR, 0.90; 95% CI, 0.56-1.46; P = 0.681) HBV infection, was associated with mortality. Use of corticosteroid, antifungal, ribavirin, or lopinavir-ritonavir (adjusted OR [aOR], 2.55-5.63), but not current (aOR, 1.93; 95% CI, 0.88-4.24; P = 0.102) or past (aOR, 1.25; 95% CI, 0.62-2.55; P = 0.533) HBV infection, was associated with acute liver injury. CONCLUSION: Current or past HBV infections were not associated with more liver injury and mortality in COVID-19.

Web-based, rapid and contactless management of ambulatory patients for SARS-CoV-2-testing.

BACKGROUND: During the SARS-CoV-2 pandemic a mass casualty incident of ambulatory patients occurred at the COVID-19 rapid response infrastructure (CRRI) facility at the University Hospital of Cologne (UHC). We report the development of a patient-centred mobile-device solution to support efficient management of the facility, triage of patients and rapid delivery of test results. METHODS: The UHC-Corona Web Tool (CWT) was developed as a web-based software useable on each patient's smartphone. It provides, among others, a self-reported medical history including type and duration of symptoms and potential risk contacts and links all retrieved information to the digital patient chart via a QR code. It provides scheduling of outpatient appointments and automated transmission of SARS-CoV-2 test results. RESULTS: The UHC-CWT was launched on 9 April 2020. It was used by 28,652 patients until 31 August 2020. Of those, 15,245 (53,2%) consulted the CRRI, representing 43,1% of all CRRI patients during the observed period. There were 8304 (29,0%) specifications concerning travel history and 17,145 (59,8%) indications of ≥1 symptom of SARS-CoV-2 infection. The most frequently indicated symptoms were sore throat (60,0%), headache (50,7%), common cold (45,1%) and cough (42,6%) while 11,057 (40,2%) patients did not report any symptoms. After implementation of the UHC-CWT, the amount of patient contacts per physician rose from 38 to 98,7 per day. The personnel for communication of test results were reduced from four on seven days to one on five days. CONCLUSION: The UHC-CWT is an effective digital solution for management of large numbers of outpatients for SARS-CoV-2 testing.

2021 Spanish Society of Hypertension position statement about telemedicine.

The pandemic caused by coronavirus SARS-CoV-2 (COVID-19) has forced, in many cases, to replace face-to-face consultation with the telematic consultation, in order to reduce the risk of contagion associated with the presence of patients in health centres. This change may represent an opportunity for a different and more effective communication between professionals and patients, allowing better accessibility to medical care and more systematic and comprehensive approach to patients with hypertension and cardiovascular risk. However, organisational tools are needed to facilitate communication between patients and professionals, specifically with the exchange of clinical data by remote monitoring of variables associated with hypertension and cardiovascular risk (blood pressure, weight, height, blood tests…), and allow monitoring of adherence to treatments, lifestyles and risk factors. It would be desirable for this to be carried out by multidisciplinary teams, both from primary care, hospital and community pharmacy, with an adequate coordination of care. This document of the Spanish Society of Hypertension (SEH-LELHA) tries to give the keys to improve the quality of care of telematic consultations of patients with hypertension and cardiovascular risk, provide basic criteria of telematic or face to face attention and systematise their content. Likewise, the follow-up criteria are proposed by the different professionals.

Assessment of a Risk-Based Approach for Triaging Mammography Examinations During Periods of Reduced Capacity.

Importance: Breast cancer screening, surveillance, and diagnostic imaging services were profoundly limited during the initial phase of the coronavirus disease 2019 (COVID-19) pandemic. Objective: To develop a risk-based strategy for triaging mammograms during periods of decreased capacity. Design, Setting, and Participants: This population-based cohort study used data collected prospectively from mammography examinations performed in 2014 to 2019 at 92 radiology facilities in the Breast Cancer Surveillance Consortium. Participants included individuals undergoing mammography. Data were analyzed from August 10 to November 3, 2020. Exposures: Clinical indication for screening, breast symptoms, personal history of breast cancer, age, time since last mammogram/screening interval, family history of breast cancer, breast density, and history of high-risk breast lesion. Main Outcomes and Measures: Combinations of clinical indication, clinical history, and breast cancer risk factors that subdivided mammograms into risk groups according to their cancer detection rate were identified using classification and regression trees. Results: The cohort included 898 415 individuals contributing 1 878 924 mammograms (mean [SD] age at mammogram, 58.6 [11.2] years) interpreted by 448 radiologists, with 1 722 820 mammograms in individuals without a personal history of breast cancer and 156 104 mammograms in individuals with a history of breast cancer. Most individuals were aged 50 to 69 years at imaging (1 113 174 mammograms [59.2%]), and 204 305 (11.2%) were Black, 206 087 (11.3%) were Asian or Pacific Islander, 126 677 (7.0%) were Hispanic or Latina, and 40 021 (2.2%) were another race/ethnicity or mixed race/ethnicity. Cancer detection rates varied widely based on clinical indication, breast symptoms, personal history of breast cancer, and age. The 12% of mammograms with very high (89.6 [95% CI, 82.3-97.5] to 122.3 [95% CI, 108.1-138.0] cancers detected per 1000 mammograms) or high (36.1 [95% CI, 33.1-39.3] to 47.5 [95% CI, 42.4-53.3] cancers detected per 1000 mammograms) cancer detection rates accounted for 55% of all detected cancers and included mammograms to evaluate an abnormal mammogram or breast lump in individuals of all ages regardless of breast cancer history, to evaluate breast symptoms other than lump in individuals with a breast cancer history or without a history but aged 60 years or older, and for short-interval follow-up in individuals aged 60 years or older without a breast cancer history. The 44.2% of mammograms with very low cancer detection rates accounted for 13.1% of detected cancers and included annual screening mammograms in individuals aged 50 to 69 years (3.8 [95% CI, 3.5-4.1] cancers detected per 1000 mammograms) and all screening mammograms in individuals younger than 50 years regardless of screening interval (2.8 [95% CI, 2.6-3.1] cancers detected per 1000 mammograms). Conclusions and Relevance: In this population-based cohort study, clinical indication and individual risk factors were associated with cancer detection and may be useful for prioritizing mammography in times and settings of decreased capacity.

Clinical Pathway for Early Diagnosis of COVID-19: Updates from Experience to Evidence-Based Practice.

The COVID-19 pandemic is a significant global event in the history of infectious diseases. The SARS-CoV-2 appears to have originated from bats but is now easily transmissible among humans, primarily through droplet or direct contact. Clinical features of COVID-19 include high fever, cough, and fatigue which may progress to ARDS. Respiratory failure can occur rapidly after this. The primary laboratory findings include lymphopenia and eosinopenia. Elevated D-dimer, procalcitonin, and CRP levels may correlate with disease severity. Imaging findings include ground-glass opacities and patchy consolidation on CT scan. Mortality is higher in patients with hypertension, cardiac disease, diabetes mellitus, cancer, and COPD. Elderly patients are more susceptible to severe disease and death, while children seem to have lower rates of infection and lower mortality. Diagnostic criteria and the identification of persons under investigation have evolved as more data has emerged. However, the approach to diagnosis is still very variable from region to region, country to country, and even among different hospitals in the same city. The importance of a clinical pathway to implement the most effective and relevant diagnostic strategy is of critical importance to establish the control of this virus that is responsible for more and more deaths each day.

Alternative approaches for clinical clerkship during the COVID-19 pandemic: online simulated clinical practice for inpatients and outpatients-A mixed method.

BACKGROUND: The COVID-19 pandemic has created a need for educational materials and methods that can replace clinical clerkships (CCs) for online simulated clinical practice (online-sCP). This study evaluates the impact of using simulated electronic health records (sEHR) for inpatients, and electronic problem-based learning (e-PBL) and online virtual medical interviews (online-VMI) for outpatients, for an online-sCP using a learning management system (LMS) and online meeting system facilitated by a supervising physician. METHODS: The sEHR was reviewed by medical students and subsequently discussed with a supervising physician using an online meeting system. In the e-PBL, medical students reviewed the simulated patients and discussed on the LMS. For the online-VMI, a faculty member acted as an outpatient and a student acted as the doctor. Small groups of students discussed the clinical reasoning process using the online meeting system. A mixed-method design was implemented. Medical students self-assessed their clinical competence before and after the online-sCP. They answered questionnaires and participated in semi-structured focus group interviews (FGIs) regarding the advantages and disadvantages of the practice. RESULTS: Forty-three students completed the online-sCP during May and June 2020. All students indicated significant improvement in all aspects of self-evaluation of clinical performance after the online-sCP. Students using sEHR reported significant improvement in writing daily medical records and medical summaries. Students using e-PBL and online-VMI reported significant improvement in medical interviews and counseling. Students also indicated CCs as more useful for learning associated with medical interviews, physical examinations, and humanistic qualities like professionalism than the online-sCP. Eight FGIs were conducted (n = 42). The advantages of online-sCP were segregated into five categories (learning environment, efficiency, accessibility, self-paced learning, and interactivity); meanwhile, the disadvantages of online-sCP were classified into seven categories (clinical practice experience, learning environment, interactivity, motivation, memory retention, accessibility, and extraneous cognitive load). CONCLUSIONS: Online-sCP with sEHR, e-PBL, and online-VMI could be useful in learning some of the clinical skills acquired through CC. These methods can be implemented with limited preparation and resources.

Authentic SP-based teaching in spite of COVID-19 - is that possible?

Objective: Medical conversation plays a central role in disease management and therapy. In teaching, standardized patients (SPs) are increasingly being used to present conversation situations with students and provide feedback afterwards. In order to maintain this teaching concept under pandemic conditions, a digital model was developed that should offer both high security and high authenticity. Methodology: A total of 176 teaching units of 45 minutes each were conducted digitally from May to August 2020. During the teaching units, medical students conducted interviews with SPs portraying various patients. The online conference software "HeiConf" was used for this purpose. During the teaching units, a total of 354 students were able to practice conversation techniques such as NURSE and SPIKES. After the teaching units, feedback was provided by students and SPs. Results: The digital lessons about medical conversation with SPs received positive feedback from SPs and students. The authenticity of the role portrayal of SPs seemed to be unaffected by the new format. Students were successful in training and observing conversation techniques. However, aspects of non-verbal communication, atmosphere and group dynamics as well as further discussions could not be carried out to the same extent as in the usual classroom teaching. Conclusion: The conversion of SP-based teaching to a digital format was successful in a short period of time and was able to prevent a cancellation of teaching units about medical conversation. Concrete conversation techniques could be tried out digitally by students. Due to the deficits of digital teaching in terms of non-verbal communication and atmosphere, a blended-learning format is planned for the future. In the first instance, concrete conversation techniques will be learned online in order to focus more on profound aspects of communication and discussions in a later physical teaching unit with SPs, thus enabling a learning experience that is as authentic as possible.