Optimal approaches and criteria to treat-and-extend regimen implementation for Neovascular age-related macular degeneration: experts consensus in Taiwan

The management of neovascular age-related macular degeneration (nAMD) has taken a major stride forward with the advent of anti-VEGF agents. The treat-and-extend (T&E) approach is a refined management strategy, tailoring to the individual patient’s disease course and treatment outcome. To provide guidance to implementing anti-VEGF T&E regimens for nAMD in resource-limited health care systems, an advisory board was held to discuss and generate expert consensus, based on local and international guidelines, current evidence, as well as local experience and reimbursement policies. In the experts’ opinion, treatment of nAMD should aim to maximize and maintain visual acuity benefits while minimizing treatment burden. Based on current evidence, treatment could be initiated with 3 consecutive monthly injections. After the initial period, treatment interval may be extended by 2 or 4 weeks each time for the qualified patients (i.e. no BCVA loss ≥5 ETDRS letters and dry retina), and a maximum interval of 16 weeks is permitted. For patients meeting the shortening criteria (i.e. any increased fluid with BCVA loss ≥5 ETDRS letters, or presence of new macular hemorrhage or new neovascularization), the treatment interval should be reduced by 2 or 4 weeks each time, with a minimal interval of 4 weeks. Discontinuation of anti-VEGF may be considered for those who have received 2–3 consecutive injections spaced 16 weeks apart and present with stable disease. For these individuals, regular monitoring (e.g. 3–4 months) is recommended and monthly injections should be reinstated upon signs of disease recurrence.

How did general practices organize care during the COVID-19 pandemic: the protocol of the cross-sectional PRICOV-19 study in 38 countries

Background General practitioners (GPs) play a crucial role in the fight against the COVID-19 pandemic as the first point of contact for possibly infected patients and are responsible for short and long-term follow-up care of the majority of COVID-19 patients. Nonetheless, they experience many barriers to fulfilling this role. The PRICOV-19 study investigates how GP practices in 38 countries are organized during the COVID-19 pandemic to guarantee safe, effective, patient-centered, and equitable care. Also, the shift in roles and tasks and the wellbeing of staff members is researched. Finally, PRICOV-19 aims to study the association with practice- and health care system characteristics. It is expected that both characteristics of the GP practice and health care system features are associated with how GP practices can cope with these challenges. This paper describes the protocol of the study. Methods Using a cross-sectional design, data are collected through an online questionnaire sent to GP practices in 37 European countries and Israel. The questionnaire is developed in multiple phases, including a pilot study in Belgium. The final version includes 53 items divided into six sections: patient flow (including appointments, triage, and management for routine care); infection prevention; information processing; communication; collaboration and self-care; and practice and participant characteristics. In the countries where data collection is already finished, between 13 and 636 GP practices per country participated in the study. Questionnaire data are linked with OECD and HSMR data regarding national policy responses to the pandemic and analyzed using multilevel models considering the system- and practice-level. Discussion To the best of our knowledge, the PRICOV-19 study is the largest and most comprehensive study that examines how GP practices function during the COVID-19 pandemic. Its results can significantly contribute to better preparedness of primary health care systems across Europe for future major outbreaks of infectious diseases.

Rural Otolaryngology Care Disparities: A Scoping Review

Objective To broadly synthesize the literature regarding rural health disparities in otolaryngology, categorize findings, and identify research gaps to stimulate future work. Study Design Scoping review. Data Sources A comprehensive literature search was performed in the following databases: PubMed/MEDLINE, Scopus, Cochrane Central Register of Controlled Trials, Google Scholar, and CINAHL. Review Methods The methods were developed in concordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews checklist. Peer-reviewed, English-language, US-based studies examining a rural disparity in otolaryngology-related disease incidence, prevalence, diagnosis, treatment, or outcome were included. Descriptive studies, commentaries, reviews, and letters to the editor were excluded. Studies published prior to 1980 were excluded. Results The literature search resulted in 1536 unique abstracts and yielded 79 studies that met final criteria for inclusion. Seventy-five percent were published after 2010. The distribution of literature was as follows: otology (34.2%), head and neck cancer (20.3%), endocrine surgery (13.9%), rhinology and allergy (8.9%), trauma (5.1%), laryngology (3.8%), other pediatrics (2.5%), and adult sleep (1.3%). Studies on otolaryngology health care systems also accounted for 10.1%. The most common topics studied were practice patterns (41%) and epidemiology (27%), while the Southeast (47%) was the most common US region represented, and database study (42%) was the most common study design. Conclusion Overall, there was low-quality evidence with large gaps in the literature in all subspecialties, most notably facial plastic surgery, laryngology, adult sleep, and pediatrics. Importantly, there were few studies on intervention and zero studies on resident exposure to rural populations, which will be critical to making rural otolaryngology care more equitable in the future.

An Entrustable Professional Activity Addressing Racism and Pediatric Health Inequities

Racism and discrimination are the root of many pediatric health inequities and are well described in the literature. Despite the pervasiveness of pediatric health inequities, we have failed to adequately educate and prepare general pediatricians and pediatric subspecialists to address them. Deficiencies within education across the entire continuum and in our health care systems as a whole contribute to health inequities in unacceptable ways. To address these deficiencies, the field of pediatrics, along with other specialties, has been on a journey toward a more competency-based approach to education and assessment, and the framework created for the future is built on entrustable professional activities (EPAs). Competency-based medical education is one approach to addressing the deficiencies within graduate medical education and across the continuum by allowing educators to focus on the desired equitable patient outcomes and then develop an approach to teaching and assessing the tasks, knowledge, skills, and attitudes needed to achieve the goal of optimal, equitable patient care. To that end, we describe the development and content of a revised EPA entitled: Use of Population Health Strategies and Quality Improvement Methods to Promote Health and Address Racism, Discrimination, and Other Contributors to Inequities Among Pediatric Populations. We also highlight the ways in which this EPA can be used to inform curricula, assessments, professional development, organizational systems, and culture change.

Enabling Research and Clinical Use of Patient-Generated Health Data (the mindLAMP Platform): Digital Phenotyping Study

Background There is a growing need for the integration of patient-generated health data (PGHD) into research and clinical care to enable personalized, preventive, and interactive care, but technical and organizational challenges, such as the lack of standards and easy-to-use tools, preclude the effective use of PGHD generated from consumer devices, such as smartphones and wearables. Objective This study outlines how we used mobile apps and semantic web standards such as HTTP 2.0, Representational State Transfer, JSON (JavaScript Object Notation), JSON Schema, Transport Layer Security (version 1.3), Advanced Encryption Standard-256, OpenAPI, HTML5, and Vega, in conjunction with patient and provider feedback to completely update a previous version of mindLAMP. Methods The Learn, Assess, Manage, and Prevent (LAMP) platform addresses the abovementioned challenges in enhancing clinical insight by supporting research, data analysis, and implementation efforts around PGHD as an open-source solution with freely accessible and shared code. Results With a simplified programming interface and novel data representation that captures additional metadata, the LAMP platform enables interoperability with existing Fast Healthcare Interoperability Resources–based health care systems as well as consumer wearables and services such as Apple HealthKit and Google Fit. The companion Cortex data analysis and machine learning toolkit offer robust support for artificial intelligence, behavioral feature extraction, interactive visualizations, and high-performance data processing through parallelization and vectorization techniques. Conclusions The LAMP platform incorporates feedback from patients and clinicians alongside a standards-based approach to address these needs and functions across a wide range of use cases through its customizable and flexible components. These range from simple survey-based research to international consortiums capturing multimodal data to simple delivery of mindfulness exercises through personalized, just-in-time adaptive interventions.

Patients with Advanced Cancer during the COVID‐19 Pandemic in Ukraine

COVID‐19 has overwhelmed the capacity of health care systems, limiting access to supportive and palliative care for patients with advanced cancer. Telemedicine has emerged as a tool to provide care continuity to patients while limiting the risk of contagion. However, implementing telemedicine in resource‐limited settings is challenging. We report the results of a multidisciplinary patient‐navigator‐led telemedicine supportive care program in Dnipro City. One‐hundred sixty‐five telemedicine interventions were provided to 77 patients (median age 67, 47% female). A quarter of the patients had less than or equal to elementary school education, and 18% lived in a rural area. The most common interventions were psychological care (30%), pain and symptom control (27%), and nutritional counseling (10%). Half of the interventions were provided by video conferencing. The most common patient‐reported barrier was limited experience using communication technology. Our results demonstrate the feasibility of providing supportive and palliative care interventions using telemedicine in resource‐limited settings.

Tragic Triad of Tobacco Dependence, Cancer, and COVID-19 Pandemic: An Urgent Call for Attention by Health Care Systems and Professionals

Tobacco smoke is a well-known carcinogen associated with multiple malignancies. Patients with cancer, as well as survivors, who continue to smoke are at a greater risk for poor cancer treatment outcomes. With the emergence of the COVID-19 pandemic, there is increased frequency and severity of the infection in patients with cancer. Furthermore, smoking and/or vaping increases incidence or likelihood of progression of COVID-19. Cigarette smoking, cancer, and COVID-19 each impose disproportionate burden of illness and death among racial and ethnic minorities. Geographic and population-specific analyses reveal that neighborhoods with lower income and higher minority populations have more tobacco/vape shops and face increased risk associated with tobacco marketing. Referral to tobacco cessation has been reduced during the pandemic. To reduce the adverse health effects of tobacco dependence among patients with cancer during the pandemic, urgent evidence-based solutions are described for health systems and professionals to prioritize tobacco cessation for patients with cancer in the midst of the COVID-19 pandemic, on the basis of cessation implementation at City of Hope Medical Center.

The impact of the COVID-19 pandemic on non-COVID induced sepsis survival

Background The COVID-19 pandemic has taken a toll on health care systems worldwide, which has led to increased mortality of different diseases like myocardial infarction. This is most likely due to three factors. First, an increased workload per nurse ratio, a factor associated with mortality. Second, patients presenting with COVID-19-like symptoms are isolated, which also decreases survival in cases of emergency. And third, patients hesitate to see a doctor or present themselves at a hospital. To assess if this is also true for sepsis patients, we asked whether non-COVID-19 sepsis patients had an increased 30-day mortality during the COVID-19 pandemic. Methods This is a post hoc analysis of the SepsisDataNet.NRW study, a multicentric, prospective study that includes septic patients fulfilling the SEPSIS-3 criteria. Within this study, we compared the 30-day mortality and disease severity of patients recruited pre-pandemic (recruited from March 2018 until February 2020) with non-COVID-19 septic patients recruited during the pandemic (recruited from March 2020 till December 2020). Results Comparing septic patients recruited before the pandemic to those recruited during the pandemic, we found an increased raw 30-day mortality in sepsis-patients recruited during the pandemic (33% vs. 52%, p = 0.004). We also found a significant difference in the severity of disease at recruitment (SOFA score pre-pandemic: 8 (5 - 11) vs. pandemic: 10 (8 - 13); p < 0.001). When adjusted for this, the 30-day mortality rates were not significantly different between the two groups (52% vs. 52% pre-pandemic and pandemic, p = 0.798). Conclusions This led us to believe that the higher mortality of non-COVID19 sepsis patients during the pandemic might be attributed to a more severe septic disease at the time of recruitment. We note that patients may experience a delayed admission, as indicated by elevated SOFA scores. This could explain the higher mortality during the pandemic and we found no evidence for a diminished quality of care for critically ill sepsis patients in German intensive care units.

Construction of the Enterococcal Strain Expressing Immunogenic Fragment of SARS-Cov-2 Virus

Contemporary SARS-Cov-2 pandemic, besides its dramatic global influence on the human race including health care systems, economies, and political decisions, opened a window for the global experiment with human vaccination employing novel injectable vaccines providing predominantly specific IgG response with little knowledge of their impact on the mucosal immunity. However, it is widely accepted that protection against the pathogens at the gates of the infection - on mucosal surfaces—predominantly rely on an IgA response. Some genetically modified bacteria, including probiotics, represent attractive vehicles for oral or nasal mucosal delivery of therapeutic molecules. Probiotic-based vaccines for mucous membranes are easy to produce in large quantities; they have low cost, provide quite a long T-cell memory, and gut IgA response to oral vaccines is highly synchronized and strongly oligoclonal. Here we present a study demonstrating construction of the novel SARS-Cov-2 vaccine candidate employing the gene fragment of S1 SARS-Cov-2 gene. This DNA fragment was inserted in frame into major pili protein gene with d2 domain of enterococcal operon encoding for pili. The DNA sequencing proved the presence of the insert in enterococcal genome. RNA transcription, immunoprecipitation, and immune electron microscopy with human sera obtained from the SARS-Cov-2 patients demonstrated expression of SARS-Cov-2 antigens in bacteria. Taken together the data obtained allowed considering this genetically modified probiotic strain as an interesting candidate for vaccine against SARS-Cov-2.