The LiberAction Project: Implementation of a Pediatric Liberation Bundle to Screen Delirium, Reduce Benzodiazepine Sedation, and Provide Early Mobilization in a Human Resource-Limited Pediatric Intensive Care Unit

Background: Delirium, bed immobilization, and heavy sedation are among the major contributors of pediatric post-intensive care syndrome. Recently, the Society of Critical Care Medicine has proposed the implementation of daily interventions to minimize the incidence of these morbidities and optimize children functional outcomes and quality of life. Unfortunately, these interventions require important clinical and economical efforts which prevent their use in many pediatric intensive care units (PICU).Aim: First, to evaluate the feasibility and safety of a PICU bundle implementation prioritizing delirium screening and treatment, early mobilization (<72 h from PICU admission) and benzodiazepine-limited sedation in a human resource-limited PICU. Second, to evaluate the incidence of delirium and describe the early mobilization practices and sedative drugs used during the pre- and post-implementation periods. Third, to describe the barriers and adverse events encountered during early mobilization.Methods: This observational study was structured in a pre- (15th November 2019–30th June 2020) and post-implementation period (1st July 2020–31st December 2020). All patients admitted in PICU for more than 72 h during the pre and post-implementation period were included in the study. Patients were excluded if early mobilization was contraindicated. During the pre-implementation period, a rehabilitation program including delirium screening and treatment, early mobilization and benzodiazepine-sparing sedation guidelines was developed and all PICU staff trained. During the post-implementation period, delirium screening with the Connell Assessment of Pediatric Delirium scale was implemented at bedside. Early mobilization was performed using a structured tiered protocol and a new sedation protocol, limiting the use of benzodiazepine, was adopted.Results: Two hundred and twenty-five children were enrolled in the study, 137 in the pre-implementation period and 88 in the post-implementation period. Adherence to delirium screening, benzodiazepine-limited sedation and early mobilization was 90.9, 81.1, and 70.4%, respectively. Incidence of delirium was 23% in the post-implementation period. The median cumulative dose of benzodiazepines corrected for the total number of sedation days (mg/kg/sedation days) was significantly lower in the post-implementation period compared with the pre-implementation period: [0.83 (IQR: 0.53–1.31) vs. 0.74 (IQR: 0.55–1.16), p = 0.0001]. The median cumulative doses of fentanyl, remifentanil, and morphine corrected for the total number of sedation days were lower in the post-implementation period, but these differences were not significant. The median number of mobilizations per patient and the duration of each mobilization significantly increased in the post-implementation period [3.00 (IQR: 2.0–4.0) vs. 7.00 (IQR: 3.0–12.0); p = 0.004 and 4 min (IQR: 3.50–4.50) vs. 5.50 min (IQR: 5.25–6.5); p < 0.0001, respectively]. Barriers to early mobilization were: disease severity and bed rest orders (55%), lack of physicians' order (20%), lack of human resources (20%), and lack of adequate devices for patient mobilization (5%). No adverse events related to early mobilization were reported in both periods. Duration of mechanical ventilation and PICU length of stay was significantly lower in the post-implementation period as well as the occurrence of iatrogenic withdrawal syndrome.Conclusion: This study showed that the implementation of a PICU liberation bundle prioritizing delirium screening and treatment, benzodiazepine-limited sedation and early mobilization was feasible and safe even in a human resource-limited PICU. Further pediatric studies are needed to evaluate the clinical impact of delirium, benzodiazepine-limited sedation and early mobilization protocols on patients' long-term functional outcomes and on hospital finances.

Construct validity for the self-reported competency and sub-construct associated characteristics of Romanian physicians in autism spectrum disorder

Background Lack of physicians’ knowledge regarding mental health, including Autism Spectrum Disorder (ASD) could have adverse effects on affected individuals’ health and quality of life. The purpose of this study was to provide construct validity for a modified questionnaire in order to determine the self-reported competency for underlying sub-constructs in ASD, make inferences on perceived competence in ASD based on a sample of Romanian physicians, and identify physicians’ characteristics associated with these sub-domains of competency. Methods For this survey, we modified a questionnaire that was used in Pakistan and Turkey, and administered it to a sample of 383 practicing physicians in Romania to assess their perceived competency regarding ASD. Exploratory factor analysis on 12 knowledge questions revealed five sub-domains: stigma, potential causes, children’s behavior, misconceptions, and educational needs associated with ASD knowledge. Using General Linear Models, we determined physicians’ characteristics that predict the total competency score and various competency sub-scores. Results Seventy-five percent of the responding physicians were female and 30% had over 30 years practicing medicine. The majority (73–94%) of physicians have correctly responded to some basic questions regarding knowledge about ASD. We also found that younger physicians were more knowledgeable about potential causes of ASD than older physicians (Adjusted Mean Score (AMS): 2.90 vs. 2.18, P < 0.01), while older physicians knew more about the behavior of children with ASD (AMS: 0.64 vs. 0.37, P = 0.02). We found a significant interaction (P < 0.01) between television as source of ASD knowledge and city where the clinic is located in relation to knowledge of the physicians regarding stigma related to ASD. However, the total score was not associated with the variables associated with sub-domains. Conclusion Using factor analysis, we demonstrated construct validity of five sub-domains related to Romanian physicians’ knowledge about ASD that include stigma, potential causes, behavior in ASD children, special education needs, and misconceptions related to ASD. The lack of significant association of the knowledge of physicians on ASD neither with the Psychiatry nor the Pediatric ward rotations at medical school may support the need for improving the curriculum on ASD in Romanian medical schools.

COVID-CGAN: Efficient Deep Learning Approach for COVID-19 Detection Based on CXR Images Using Conditional GANs

COVID-19, a novel coronavirus infectious disease, has spread around the world, resulting in a large number of deaths. Due to a lack of physicians, emergency facilities, and equipment, medical systems have been unable to treat all patients in many countries. Deep learning is a promising approach for providing solutions to COVID-19 based on patients’ medical images. As COVID-19 is a new disease, its related dataset is still being collected and published. Small COVID-19 datasets may not be sufficient to build powerful deep learning detection models. Such models are often over-fitted, and their prediction results cannot be generalized. To fill this gap, we propose a deep learning approach for accurately detecting COVID-19 cases based on chest X-ray (CXR) images. For the proposed approach, named COVID-CGAN, we first generated a larger dataset using generative adversarial networks (GANs). Specifically, a customized conditional GAN (CGAN) was designed to generate the target COVID-19 CXR images. The expanded dataset, which contains 84.8% generated images and 15.2% original images, was then used for training five deep detection models: InceptionResNetV2, Xception, SqueezeNet, VGG16, and AlexNet. The results show that the use of the synthetic CXR images, which were generated by the customized CGAN, helped all deep learning models to achieve high detection accuracies. In particular, the highest accuracy was achieved by the InceptionResNetV2 model, which was 99.72% accurate with only ten epochs. All five models achieved kappa coefficients between 0.81 and 1, which is interpreted as an almost perfect agreement between the actual labels and the detected labels. Furthermore, the experiment showed that some models were faster yet smaller compared to the others but could still achieve high accuracy. For instance, SqueezeNet, which is a small network, required only three minutes and achieved comparable accuracy to larger networks such as InceptionResNetV2, which needed about 143 min. Our proposed approach can be applied to other fields with scarce datasets.

Diagnosis of tarsal coalitions

Tarsal coalitions (TC) are congenital abnormal connections of the rearfoot bones. They occur in 1 to 13 % of all population. The article deals with the features of clinical and instrumental diagnosis of TC according to the literature. The main clinical manifestations are pain syndrome in the subtalar area, rigid flat foot; peroneal spastic flat foot is possible. Radiographic imaging of TC includes direct and indirect signs. To verify bone coalition, computed tomo-graphy is indicated, in cases of cartilaginous and fibrous — magnetic resonance imaging. Despite the long history of studying the problem, the diagnosis of TC remains a live issue today. Difficulties in diagnosing this pathology are due to the lack of physicians’ awareness of the clinical and radiographic picture of TC. Classical orthopedic exa-mination and suspicion of possible TC will allow detecting pathology in time and avoiding inappropriate treatment. The use of modern imaging techniques, such as computed tomography and magnetic resonance imaging, helps increase the accuracy of TC diagnosis.

Physicians` awareness level assessment of the epidemiology and diagnosis features of nosocomial infection caused by Clostridium difficile in a multidisciplinary hospitals

Background. Clostridium difficile has an important place among healthcare associated infections pathogens , mainly due to the widespread and inappropriate antibiotics use. Over the past 10 years an incidence of this infection has increased in the USA and European countries. Unfortunately, Clostridium difficile infection cases in the Russian Federation are almost not register, probably due to the lack of physicians awareness and underestimation of the pathogen role in the etiology of nosocomial infections. The study purpose is to study the different specialties physicians awareness of patients` Clostridium difficile infections development in multidisciplinary hospitals. Materials and methods. A questionnaire survey of 115 physicians of two multidisciplinary hospitals in Kazan was carried out. The questionnaire included 15 questions related to etiology, transmission mechanism, risk factors, clinical presentation, diagnosis and prevention of C. difficile infection. Statistical data processing was carried out in MS Excel. Results. A low level of physicians` awareness on this issue was revealed. 92.2% of physicians did not have any Clostridium difficile infection cases in their practice. 31.3% of respondents underestimate the role of antibiotic use as the main risk factor for the development of the disease; at the same time, there are frequent cases of unreasonable prescription of antibiotics. 32.2% of the respondents are poorly informed about diagnosis methods of clostridiosis. 20% of physicians deny the role of bacteria carriers as a source of infection. 77.4% of respondents indicated the alimentary route as the main route of infection transmission. Only 38.2% of respondents noted the hospital environment objects as a possible factor in the transmission of Clostridium difficile. Conclusions. There is no alertness regarding antibiotic-associated diarrhea caused by Clostridium difficile infection among multidisciplinary hospital physicians. Insufficient knowledge of epidemiology, clinical manifestations, laboratory diagnostics of Clostridium difficile infection are factors that determine the low frequency of its detection and, accordingly, impede the implementation of required anti-epidemic measures. There is a need to include Clostridium difficile infection issues in professional development programs for medical workers. It is advisable to develop and implement Clostridium difficile infection control.

Why a Consideration of Race is Important to Medical School Admissions

The tremendous toll that COVID-19 has taken on this country’s minority population is the most recent reminder of the health disparities between people of color and people who classify themselves as white. There are many reasons for these disparities, but one that gets less attention than it deserves is the lack of physicians of color available to treat patients of color.

A New Approach for Detecting Sleep Apnea Using a Contactless Bed Sensor: Comparison Study

Background At present, there is an increased demand for accurate and personalized patient monitoring because of the various challenges facing health care systems. For instance, rising costs and lack of physicians are two serious problems affecting the patient’s care. Nonintrusive monitoring of vital signs is a potential solution to close current gaps in patient monitoring. As an example, bed-embedded ballistocardiogram (BCG) sensors can help physicians identify cardiac arrhythmia and obstructive sleep apnea (OSA) nonintrusively without interfering with the patient’s everyday activities. Detecting OSA using BCG sensors is gaining popularity among researchers because of its simple installation and accessibility, that is, their nonwearable nature. In the field of nonintrusive vital sign monitoring, a microbend fiber optic sensor (MFOS), among other sensors, has proven to be suitable. Nevertheless, few studies have examined apnea detection. Objective This study aims to assess the capabilities of an MFOS for nonintrusive vital signs and sleep apnea detection during an in-lab sleep study. Data were collected from patients with sleep apnea in the sleep laboratory at Khoo Teck Puat Hospital. Methods In total, 10 participants underwent full polysomnography (PSG), and the MFOS was placed under the patient’s mattress for BCG data collection. The apneic event detection algorithm was evaluated against the manually scored events obtained from the PSG study on a minute-by-minute basis. Furthermore, normalized mean absolute error (NMAE), normalized root mean square error (NRMSE), and mean absolute percentage error (MAPE) were employed to evaluate the sensor capabilities for vital sign detection, comprising heart rate (HR) and respiratory rate (RR). Vital signs were evaluated based on a 30-second time window, with an overlap of 15 seconds. In this study, electrocardiogram and thoracic effort signals were used as references to estimate the performance of the proposed vital sign detection algorithms. Results For the 10 patients recruited for the study, the proposed system achieved reasonable results compared with PSG for sleep apnea detection, such as an accuracy of 49.96% (SD 6.39), a sensitivity of 57.07% (SD 12.63), and a specificity of 45.26% (SD 9.51). In addition, the system achieved close results for HR and RR estimation, such as an NMAE of 5.42% (SD 0.57), an NRMSE of 6.54% (SD 0.56), and an MAPE of 5.41% (SD 0.58) for HR, whereas an NMAE of 11.42% (SD 2.62), an NRMSE of 13.85% (SD 2.78), and an MAPE of 11.60% (SD 2.84) for RR. Conclusions Overall, the recommended system produced reasonably good results for apneic event detection, considering the fact that we are using a single-channel BCG sensor. Conversely, satisfactory results were obtained for vital sign detection when compared with the PSG outcomes. These results provide preliminary support for the potential use of the MFOS for sleep apnea detection.

Redefining Coronavirus: Update on the Impacts of COVID-19 in the Rural Areas of Abia State

Public health professionals working in rural communities are aware of the health disparities which result from lack of physicians, limited services, and income during the pandemic. Also they are aware that some populations are more vulnerable than others. People in the rural areas are experiencing problems on their physical, social and economic life styles because the pandemic is exacerbating some inequities. Individuals especially women and children in the rural areas are facing barriers in accessing health care services due to lack of resources and availability of health care providers in the communities. With COVID-19, women are less likely to seek services, including sexual and reproductive health services. Such services may be postponed to limit exposure to COVID-19 infection. This is particularly disturbing because in addition to the women maintaining their own health, they are also responsible for taking care of the mental, emotional and physical health needs of their families as well as all domestic responsibilities. As such, women in rural settings face special challenges as a result of these significant roles they play. Therefore, the impacts of COVID-19 are exacerbated on women by virtue of their sex and the roles they play in the family. This is a qualitative study that reviewed the reports of the 36 health care professionals under the aegis of members of COVID-19 committee working in partnership with state government to control, prevent and cushion the effects of COVID-19 in the society. This study is therefore, a summary of the observations of the COVID-19 committee members made up of 10(27.8%) females and 26(72.2%) males. The study focused on exploring how individual lifestyles in the rural areas have been affected in the face of COVID- 19 pandemic by identifying the vulnerabilities in social, political and economic systems which can amplify the impacts of the pandemic. Findings showed that preventive measures like lockdown and social distancing rules, wearing of face mask, hand washing with soap, and environmental cleanliness were not observed. The study noted that health seeking behaviours, sexual and marital life including income, education, employment and social interactions were all negatively affected. Most hospitals were battered and health care professionals boycotted the hospitals for fear of being infected. It was found that lack of health workers in the hospitals caused a good number of individuals to engage in self-medications. Also most pregnant women delivered their babies at home and few with traditional birth attendants. Some of the women who had deliveries at home experienced complications during and after delivery. Unfortunately, the report showed that governments’ financial supports to these women and their family members were insignificant as the government was more concerned with mitigating the spread of COVID-19 than assisting women to have safe deliveries. Therefore, the vulnerable groups especially women, children, and the elderly who experienced threats to their safety and wellbeing as a result of the services that were disrupted during the pandemic, should be assisted so as not to lose their lives to preventable diseases.

Abstract P188: Building A Pipeline To Address San Joaquin Health Inequity

Introduction: San Joaquin Valley (SJV) is the most underserved valley for health care with the lowest ratios of physicians for any region in California. For the last 40 years, SJV continues to face health inequity and disparities with not enough physicians to tend to the community. With a diverse community of low income and minority groups, the lack of physicians do not represent the workforce of SJV. Many of the talented youth who aspire to be physicians from SJV leave to bigger cities rather than coming back to enrich their vulnerable communities. Objectives: I created no cost pipeline medical programs (summer program, year long internships and online class) for SJV high school students to increase diversity in the medical profession, encourage underrepresented in medicine (URM) students to pursue medicine and come back to SJV to practice medicine in an effort to lower the patient provider gap. Methods: I trained and provided mentorship to medically ambitious low-income high school students in the programs to better understand SJV health inequity to instill a passion in them to come back after their medical education to practice medicine in SJV. Through the program, students learned about SJV health disparities and applied precision medicine to their own health inequity projects in SJV. Findings: -About 46% (33 of 72) of program participants were first generation -About 47% (34 of 72) of program participants identified as URM -About 65% (47 of 72) of program participants aspire to practice medicine in SJV -About 83% (60 of 72) of program participants feel that the pipeline program has helped them solidify their passion in medicine -About 100% (72 of 72) of program participants feel the program gave them guidance in health disparities, precision medicine, and applying design thinking concepts as a future leader in medicine Direct Outcomes: -Students were able to understanding community concerns beyond science and apply community activism through a precision medicine lens -Served as agents of change by directly communicating with physicians and understanding the need for more URM physicians -Students received mentorship and confidence to rise as first generation college students -Youth learned the value of service to disadvantaged communities

A New Approach for Detecting Sleep Apnea Using a Contactless Bed Sensor: Comparison Study (Preprint)

BACKGROUND At present, there is an increased demand for accurate and personalized patient monitoring because of the various challenges facing health care systems. For instance, rising costs and lack of physicians are two serious problems affecting the patient’s care. Nonintrusive monitoring of vital signs is a potential solution to close current gaps in patient monitoring. As an example, bed-embedded ballistocardiogram (BCG) sensors can help physicians identify cardiac arrhythmia and obstructive sleep apnea (OSA) nonintrusively without interfering with the patient’s everyday activities. Detecting OSA using BCG sensors is gaining popularity among researchers because of its simple installation and accessibility, that is, their nonwearable nature. In the field of nonintrusive vital sign monitoring, a microbend fiber optic sensor (MFOS), among other sensors, has proven to be suitable. Nevertheless, few studies have examined apnea detection. OBJECTIVE This study aims to assess the capabilities of an MFOS for nonintrusive vital signs and sleep apnea detection during an in-lab sleep study. Data were collected from patients with sleep apnea in the sleep laboratory at Khoo Teck Puat Hospital. METHODS In total, 10 participants underwent full polysomnography (PSG), and the MFOS was placed under the patient’s mattress for BCG data collection. The apneic event detection algorithm was evaluated against the manually scored events obtained from the PSG study on a minute-by-minute basis. Furthermore, normalized mean absolute error (NMAE), normalized root mean square error (NRMSE), and mean absolute percentage error (MAPE) were employed to evaluate the sensor capabilities for vital sign detection, comprising heart rate (HR) and respiratory rate (RR). Vital signs were evaluated based on a 30-second time window, with an overlap of 15 seconds. In this study, electrocardiogram and thoracic effort signals were used as references to estimate the performance of the proposed vital sign detection algorithms. RESULTS For the 10 patients recruited for the study, the proposed system achieved reasonable results compared with PSG for sleep apnea detection, such as an accuracy of 49.96% (SD 6.39), a sensitivity of 57.07% (SD 12.63), and a specificity of 45.26% (SD 9.51). In addition, the system achieved close results for HR and RR estimation, such as an NMAE of 5.42% (SD 0.57), an NRMSE of 6.54% (SD 0.56), and an MAPE of 5.41% (SD 0.58) for HR, whereas an NMAE of 11.42% (SD 2.62), an NRMSE of 13.85% (SD 2.78), and an MAPE of 11.60% (SD 2.84) for RR. CONCLUSIONS Overall, the recommended system produced reasonably good results for apneic event detection, considering the fact that we are using a single-channel BCG sensor. Conversely, satisfactory results were obtained for vital sign detection when compared with the PSG outcomes. These results provide preliminary support for the potential use of the MFOS for sleep apnea detection. CLINICALTRIAL