In-person Exam Research Articles

Evaluating the Diagnostic Inter-rater Reliability Between Virtual and In-person Sick-call Examinations at a Military Dental Treatment Facility.

Teledentistry, also known as "virtual" dental examinations, is an innovative approach to increasing access to care. The objective of this study was to evaluate the diagnostic inter-rater reliability between virtual and in-person examinations for patients seeking emergency dental care (sick call) at a military dental treatment facility. One hundred subjects received both virtual and in-person examinations on the same day, in random order. The virtual examiner and subject were stationed in separate rooms and used only a laptop equipped with a camera, microphone, and speaker to complete the virtual exam. In contrast, the in-person examiner had access to all standard care modalities in a dental treatment room. After the first encounter, the subject proceeded to the corresponding virtual or in-person exam, and both examiners determined a diagnosis. Inter-rater agreement was determined between the two encounters for both diagnosis specialty category and diagnostic code using the Kappa coefficient. The results of the inter-rater analyses showed a Kappa score of 0.644 for the diagnosis specialty category (P < .001) and a Kappa score of 0.714 for diagnostic codes (P < .001). Both analyses indicated "substantial" agreement. We conclude that teledentistry can be an effective tool for determining a diagnosis and improving access to care for dental emergencies at military dental treatment facilities.

Comprehensive Primary Eye Care: A Comparison Between an In-Person Eye Exam and a Tele-Eye Care Exam.

Proper access to primary eye care is essential in addressing vision impairment, and tele-eye care examinations are a promising solution that could facilitate this access in many rural or remote areas. Even though remote eye exams are becoming increasingly frequent, comprehensive tele-eye care exams are still limited by the lack of published data. The aim of this study is to compare a comprehensive tele-eye care exam with a gold standard in-person primary eye care exam with an emphasis on refractive measurements, ocular health assessment, confidence level of the eye care providers and patient satisfaction. Sixty-six participants underwent two comprehensive eye exams performed by two eye care providers. One was a gold standard in-person exam, while the other was a remote exam performed by an eye care provider through videoconference. An overall patient satisfaction survey and a questionnaire for visual comfort with a trial frame from each modality were completed and the eye care providers scored their confidence level for each test. Exam results and diagnoses were compared between both modalities. Tele-refraction has a good to excellent agreement with in-person subjective refraction in terms of sphero-cylindrical power and best corrected visual acuity. There was no statistically significant difference for visual comfort between both modalities. The agreement between in-person and remote exams for ocular health assessment ranged from fair to almost perfect, but there was a low prevalence of ocular pathologies within the study sample. The confidence level of the eye care providers and patient satisfaction were statistically higher in-person. Tele-eye care appears to be statistically and clinically non-inferior to in-person eye exams, especially for refraction, but the low prevalence of ocular pathologies somewhat limits the comparison of its efficacy for ocular health assessment. More studies on comprehensive tele-eye care exams are needed.

Abstract 15375: Status of Cardiovascular Health and Early Carotid Artery Changes in Contemporary Young Adults From Disadvantaged Social Backgrounds: The Future of Families and Child Wellbeing Study (FFCWS)

Background: Effects of childhood social determinants of health (SDOH) on young adult cardiovascular health (CVH) are postulated, but few studies have measured both SDOH from birth and CVH status in young adulthood. Methods: In 1998-2000, FFCWS enrolled 4898 mother-baby dyads at delivery in 20 US cities, oversampling mothers who were unmarried, including a disproportionate number of minority and low-income families. In 2021-23, offspring were invited to an in-person exam for CVH measurement and carotid artery ultrasound. Individual CVH metrics (except sleep) and overall Life’s Essential 8 (LE8) scores (range, 0-100; higher = better CVH), as well as carotid intima-media thickness (IMT), were compared between self-identified sex and race/ethnicity groups. LE8 scores were also compared with a representative sample of US young adults aged 19-25 years from NHANES. Results: Among 1211 offspring participants (ppts), mean age was 22y, 55% were female, 50.8% Black, 25.1% Hispanic, 20.5% White, and 3.6% Other; characteristics at birth and through childhood were similar between FFCWS ppts who were/were not examined. Diet, physical activity, nicotine exposure, and BMI scores were unfavorable in FFCWS ppts (Table). Overall LE8 scores did not differ significantly by sex, and ranged from 64.6 in Black ppts to 74.8 in ppts from Other racial/ethnic groups. LE8 scores did not differ between Black and Hispanic ppts, but both groups had significantly lower scores than ppts from White and Other groups (all P≤0.01). After adjustment for age, sex, and LE8 score, Black ppts had significantly greater mean-maximum and mean-mean carotid IMT. Mean LE8 scores were lower among FFCWS ppts compared with young adults from the same racial/ethnic groups in NHANES. Conclusions: In this novel cohort of young adults largely from disadvantaged social backgrounds, overall CVH status was sub-optimal, and ppts who identified as Black had the lowest CVH and highest carotid IMT measures, even at this young age.

Abstract 17880: The Association of Social Determinants of Health at Birth With Cardiovascular Health in Young Adulthood: The Future of Families and Child Wellbeing Study

Background: Social determinants of health (SDoH) are known to influence an individual’s risk for CVD. Childhood is a vulnerable period during which the influences of SDoH may have a stronger impact on future health outcomes. Little is known about early life SDoH and associations with cardiovascular health (CVH) in early adulthood. Methods: In 1998-2000, the Future of Families and Child Wellbeing Study (FFCWS) enrolled 4898 mother-baby dyads from large cities across the US. Births to unmarried mothers were oversampled. When the offspring were 22 yrs, they completed an in-person exam for CVH metrics. SDoH at birth included maternal and paternal education, mother living in a public housing project, having income within the past year from public assistance/welfare/food stamps. Life’s Essential 8 (LE8) Score (without sleep) was assessed at age 22. Linear regression models examined the association of individual SDoH measures with LE8 score adjusting for age, gender and race/ethnicity. Results: This study included 1211 participants, mean age 22 yrs (55% female; 51% Black, 25% Hispanic, 20% White, 4% Other). Adverse SDoH were common with 10% living in a public housing project at birth and 36.7% of mothers having received public assistance within the past year. Adjusted CVH scores were 3.0 (95% CI 1.2-4.8) pts lower for individuals whose mother reported having received public assistance in the past year. Compared to mothers with a college or graduate degree, those with less than high school, high school, and some college had 8.0 (5.0-10.9), 7.1 (4.2-10.0) and 3.2 (0.3-6.1) lower scores CVH scores. Findings were similar for paternal education. No significant associations were observed with living in a public housing project. Conclusion: SDoH at the time of birth have long lasting influence on the CVH of offspring. Interventions to promote CVH within children and families experiencing adverse SDoH are critical to promote health equity and break the inter-generational cycle of CVD.

Abstract 15400: Association of Cardiovascular Health With Early Carotid Artery Changes in Young Adults From Disadvantaged Social Backgrounds: The Future of Families and Child Wellbeing Study (FFCWS)

Introduction: Associations of cardiovascular health (CVH), as measured by the AHA’s Life’s Essential 8 (LE8) score, with early markers of arterial injury have not been described in young adults. Methods: The FFCWS enrolled 4898 mother-baby dyads at delivery in 20 US cities in 1998-2000, oversampling mothers who were unmarried, including a disproportionate number of minority and low-income families. In 2021-23, offspring were invited to attend an in-person exam to measure CVH and perform carotid artery ultrasound. Individual CVH metric and overall LE8 scores (except sleep) were calculated for each participant (ppt). Carotid imaging was performed by 2 trained sonographers and images were analyzed by a core lab. We examined cross-sectional associations of LE8 scores with measures of carotid intima-media thickness (IMT), gray scale (a measure of early arterial injury), and distensibility, using linear regression. Results: Among 1211 offspring ppts, mean age was 22y, &gt;50% self-identified as female, and &gt;75% as Black or Hispanic. Black and Hispanic ppts had lower, and ppts from Other racial/ethnic groups had higher, overall LE8 scores compared with White ppts (all P≤0.01; Table 1A). In unadjusted analyses, Black ppts had thicker carotid IMT and lower Young’s elastic modulus measures. Prevalence of diagnostic plaque was low. In analyses adjusted for age, sex, and race/ethnicity (Table 1B), LE8 scores were significantly associated with lower carotid IMT, higher gray scale median, and lower Young’s elastic modulus. For example, for each 10 point higher (better) LE8 score, mean-maximal carotid IMT was lower by 0.008 mm. Conclusions: Among young adults largely from disadvantaged social backgrounds, the LE8 score was associated with early measures of carotid arterial injury. LE8 may be an important surrogate measure for monitoring long-term CVH and may help identify young adults with emerging subclinical disease and higher long-term cardiovascular risk.

Unproctored online exams provide meaningful assessment of student learning

In the United States, the onset of COVID-19 triggered a nationwide lockdown, which forced many universities to move their primary assessments from invigilated in-person exams to unproctored online exams. This abrupt change occurred midway through the Spring 2020 semester, providing an unprecedented opportunity to investigate whether online exams can provide meaningful assessments of learning relative to in-person exams on a per-student basis. Here, we present data from nearly 2,000 students across 18 courses at a large Midwestern University. Using a meta-analytic approach in which we treated each course as a separate study, we showed that online exams produced scores that highly resembled those from in-person exams at an individual level despite the online exams being unproctored-as demonstrated by a robust correlation between online and in-person exam scores. Moreover, our data showed that cheating was either not widespread or ineffective at boosting scores, and the strong assessment value of online exams was observed regardless of the type of questions asked on the exam, the course level, academic discipline, or class size. We conclude that online exams, even when unproctored, are a viable assessment tool.

Utilization and safety of telemedicine for pediatric lower urinary tract symptoms before and during the COVID-19 pandemic.

Telemedicine for pediatric lower urinary tract symptoms (pLUTS) is a relatively new mode of delivering bladder health education with scant evidence supporting current practice. We aim to examine the safety of pLUTS-related telemedicine visits surrounding the COVID-19 pandemic. We conducted a retrospective cohort study of new pLUTS referral diagnoses to our institution's pediatric urology clinics. Demographics, wait times, and referral diagnoses were captured and compared before and after March 2020 using χ2 /Fisher exact tests and t-tests. A retrospective chart review was performed for an initial telemedicine visit followed by an in-person visit to identify missed radiology, lab, or physical exam findings. Six hundred twelve patients were included from September 2018 to August 2021. Most were 5-10 years old (62.3%), female (56.2%), English speaking (86.5%), White (39.4%), and had private insurance (67.2%). Wait times were shorter for telemedicine versus in-person visits (t190 = -3.56, p < .001). After March 2020, patients with a urinary tract infection (UTI) and females utilized in-person visits more often (p < .001). After chart review (11 patients, mean = 10.4 years), 9 (81.8%) had comorbid conditions and/or family history of lower urinary tract symptoms. None had missed clinical findings that changed management. pLUTS care can be delivered via telemedicine without a significant change in patient volume and population, though additional investigations will clarify the needs of patients with specific referral diagnoses and comorbid conditions. The in-person exam can be omitted safely with proper clinical history taking, supporting future virtual programs that address delays in care within local communities.

Telehealth Providers: Begin Planning Now for End of COVID-19 PHE

Telehealth Providers: Begin Planning Now for End of COVID-19 PHE

Implementation of a Pediatric Telemedicine and Medication Delivery Service in a Resource-limited Setting: A Pilot Study for Clinical Safety and Feasibility

Determine the clinical safety and feasibility of implementing a telemedicine and medication delivery service (TMDS) to address gaps in nighttime access to health care for children in low-resource settings. We implemented a TMDS called 'MotoMeds' in Haiti as a prospective cohort study. A parent/guardian of a sick child ≤ 10years contacted the call center (6 PM-5 AM). A nurse provider used decision support tools to triage cases (mild, moderate, or severe). Severe cases were referred to emergency care. For nonsevere cases, providers gathered clinical findings to generate an assessment and plan. For cases within the delivery zone, a provider and driver were dispatched and the provider performed a paired in-person exam as a reference standard for the virtual call center exam. Families received a follow-up call at 10days. Data were analyzed for clinical safety and feasibility. A total of 391 cases were enrolled from September 9, 2019, to January 19, 2021. Most cases were nonsevere (92%; 361); household visits were completed for 89% (347) of these cases. Among the 30 severe cases, 67% (20) sought referred care. Among all cases, respiratory problems were the most common complaint (63%; 246). At 10 days, 95% (329) of parents reported their child had "improved" or "recovered". Overall, 99% (344) rated the TMDS as "good" or "great". The median phone consultation time was 20minutes, time to household arrival was 73minutes, and total case time was 114minutes. The TMDS was a feasible health care delivery model. Although many cases were likely self-limiting, the TMDS was associated with high rates of reported improvement in clinical status at 10days. clinicaltrials.gov: NCT03943654.

A Systematic Review of Physical Examination Components Adapted for Telemedicine.

Introduction: The COVID-19 pandemic ushered in a rapid, transformative adoption of telemedicine to maintain patient access to care. As clinicians made the shift from in-person to virtual practice, they faced a paucity of established and reliable clinical examination standards for virtual care settings. In this systematic review, we summarize the accuracy and reliability of virtual assessments compared with traditional in-person examination tools. Methods: We searched PubMed, Embase, Web of Science, and CINAHL from inception through September 2019 and included additional studies from handsearching of reference lists. We included studies that compared synchronous video (except allowing for audio-only modality for cardiopulmonary exams) with in-person clinical assessments of patients in various settings. We excluded behavioral health and dermatological assessments. Two investigators abstracted data using a predefined protocol. Results: A total of 64 studies were included and categorized into 5 clinical domains: neurological (N = 41), HEENT (head, eyes, ears, nose, and throat; N = 5), cardiopulmonary (N = 5), musculoskeletal (N = 8), and assessment of critically ill patients (N = 5). The cognitive assessment within the neurological exam was by far the most studied (N = 19) with the Mini-Mental Status Exam found to be highly reliable in multiple settings. Most studies showed relatively good reliability of the virtual assessment, although sample sizes were often small (<50 participants). Conclusions: Overall, virtual assessments performed similarly to in-person exam components for diagnostic accuracy but had a wide range of interrater reliability. The high heterogeneity in population, setting, and outcomes reported across studies render it difficult to draw broad conclusions on the most effective exam components to adopt into clinical practice. Further work is needed to identify virtual exam components that improve diagnostic accuracy.

Poster 129: Reliability and Accuracy of Telemedicine-Based Shoulder Examinations

Objectives:Telemedicine has become a critical component in the evaluation and management of patients with shoulder pathology. However, the reliability and accuracy of findings on a virtual physical exam relative to in-person evaluation is unclear. The purpose of this study is to determine the reliability and accuracy of a recorded telemedicine physical exam for diagnosis of shoulder pathology compared to the traditional in-person physical exam performed in an outpatient shoulder clinic.Methods:This study is a randomized controlled trial. New patients presenting with unilateral shoulder pain to a singlesurgeon shoulder clinic were recruited between July and November 2020. In a single visit, patients were evaluated with standardized in-person and telemedicine physical exams, and the order was randomized. The telemedicine exam was recorded and consisted of a pre-recorded video guide displaying self-directed shoulder exam maneuvers that patients performed under remote coaching by an independent observer. The in-person physical exam was performed by the treating physician and results were used as the gold standard. The telemedicine videos were evaluated by two independent observers for inter-observer reliability. The treating physician subsequently evaluated the telemedicine videos after a minimum 2-month washout period for intra-observer reliability. Inter- and intra-observer reliability analyses were conducted using the Kuder-Richardson 20 (KR-20) formula.Results:Thirty-two patients (17 male, 15 female; average age 50.2 ±16.2 years) were enrolled and included in the analysis. Overall KR-20 reliability across all 40 physical exam maneuvers was 0.391±0.332 (76.4% ± 15.4% agreement) between the in-person and telemedicine exams. Maneuvers conducted via telemedicine that examined range of motion (ROM) limitations had the highest degree of reliability, sensitivity, specificity, and likelihood of also producing a positive finding on the in-person exam (0.700±0.114, 66.5%, 81.0%, and 6.06, respectively). Exam maneuvers conducted via telemedicine that relied on identifying apprehension associated with glenohumeral instability were found to have the lowest reliability, sensitivity, and likelihood of producing a positive finding on the in-person exam (0.176±0.440, 23.5% and 0.518, respectively). All included patients were satisfied with their telemedicine experience.Conclusions:Overall reliability of telemedicine physical examination maneuvers was poor. ROM limitations identified on the telemedicine exams were found to be the most reliable and accurate, while techniques used to evaluate instability were found to be the least reliable and accurate. While the telemedicine exam can be reliable as a screening tool in certain pathologic conditions, providers should use the in-person exam and imaging results to confirm any suspected diagnoses.Table 1:Categories of examination techniques assessed.Table 2:Summary of sensitivity, specificity, and reliability results.Table 4:Simmiary of patient satisfaction survey results.

Empowering Patients Through Virtual Care Delivery: Qualitative Study With Micropractice Clinic Patients and Health Care Providers.

BackgroundPrior to the wider adoption of digital health technologies during the COVID-19 pandemic, applications of virtual care were largely limited to specialist visits and remote care using telehealth (phone or video) applications. Data sharing approaches using tethered patient portals were mostly built around hospitals and larger care systems. These portals offer opportunities for improved communication, but despite a belief that care has improved, they have so far shown few outcome improvements beyond medication adherence. Less is known about use of virtual care and related tools in the outpatient context and particularly in rural community contexts.ObjectiveThis study aims to reflect on the opportunities and barriers for sustainable virtual care through an example of a digitally enabled rural micropractice, which has provided 10%-15% virtual care since 2016 and 70% virtual care since March 2020.MethodsThree focus groups, 1 with providers (physician and medical office manager) and 2 with a total of 8 patients from a rural micropractice in British Columbia, were conducted in November 2020 and December 2020. Virtual care delivery was explored through the topics of communication approach, mixing virtual and in-person care, the practice team’s journey in developing these approaches, and provider and patient satisfaction with the care model. Interviews were transcribed, checked for accuracy against recordings, and thematically analyzed.ResultsBoth patients and providers reported ease of communication and high satisfaction. Either could initiate communication, and patients found the ability to share health information asynchronously through the portal allowed time to reflect and prepare their thoughts. Patients were highly engaged and reported feeling empowered and true partners in their health care, although they noted limited care coordination with specialists. The mix of virtual and in-person visits was highly regarded by patients and providers, and patients reported feeling safe and cared for 24/7, although both expressed concern about work spilling into the provider’s home life. The physician worried about missed diagnoses with virtual care. With respect to establishing the micropractice, solutions took about 5 years to optimize, with providers noting a learning curve requiring technical support for both themselves and their patients and a willingness to respond to patient feedback to identify the best solutions. Despite a mature virtual practice, patients reported deferred care due to COVID-19.ConclusionsThe micropractice’s hybrid care model encouraged patients to be true partners in their care and resulted in high patient engagement and satisfaction; yet, success may rely on the patient population being willing to engage and being comfortable with technology. Barriers lie in gaps in care coordination and provider fear that signs or symptoms more evident with an in-person exam could be missed. Even in this setting, deferral of care in light of COVID-19 was present, and opportunities to address care gaps should be sought.

Digital Storytelling Review in a Pharmacy Self-Care Course.

Digital storytelling is a type of active learning that allows instructors to simulate real-life situations through a series of connected videos. While this technique has been used in other healthcare education disciplines, its use in pharmacy has not been well documented. A digital storytelling model was incorporated in a required self-care pharmacy course to assess if the technique was helpful to improve the knowledge, confidence, and satisfaction of students. Due to a shift in online learning, the self-care course offered a remote exam review session containing a digital storytelling model, and this approach was compared to an in-person exam review that followed a lecture-based model held earlier in the course. Pre- and post-knowledge assessments were given to determine the impact of the digital storytelling review. There were 50 students involved in both sessions and there was a 70% response rate in the digital storytelling group and a 90% response rate in the lecture-based group. Students’ knowledge numerically improved, but not to a statistically significant level for most questions. Nonetheless, students reported more confidence (p < 0.05) in their ability to pass the upcoming exam following the digital storytelling review. Thematic analysis revealed that the digital storytelling session was engaging and interactive, though time-management and breakout rooms could be further optimized. Based on these results, exam review in a required self-care pharmacy course using a digital storytelling format may be a suitable method for students to apply course content and may particularly be of utility in online or hybrid courses.

No pelvic exam, no problem: patient satisfaction following the integration of comprehensive urogynecology telemedicine.

Introduction and hypothesisThe COVID-19 pandemic revolutionized the practice of medicine, requiring rapid adoption of telemedicine. However, patient satisfaction has not been well characterized for telemedicine visits for a broad range of urogynecologic conditions.MethodsWe performed a cross-sectional survey study following a retrospective review of all urogynecologic telemedicine visits from March 1, 2020, to March 31, 2021, at a tertiary care center. The survey queried patient satisfaction using the Likert scale. Descriptive statistics and Fisher’s exact analyses were performed.ResultsThere were 256 telemedicine visits at our institution during the study period, and 88 patients (34% unadjusted response rate) completed the survey. The average age of study participants was 55 (SD 17; 24, 84) years old. The majority of patients were white (69%), lived within the five boroughs of NYC (81%), and had higher levels of education (72% with a bachelor’s or professional degree). Most visits were for urinary complaints (68%), with those patients reporting greater fulfillment of urogynecologic needs compared to patients presenting with pelvic complaints (p = 0.02). There were no significant differences in satisfaction among other demographics (p > 0.05). Altogether, high satisfaction rates were noted for scheduling (99%), technology (90%), provider interaction (96%), fulfillment of personal needs (91%), and overall satisfaction (94%).ConclusionsWe demonstrate high patient satisfaction for telemedicine visits in a tertiary urogynecology clinic for a variety of indications, with greater fulfillment of urogynecologic needs observed for those visits which may not necessitate an in-person exam (e.g., urinary complaint).

Prevalence of Somatosensory Tinnitus in Veterans With Tinnitus.

The primary objective was to estimate the prevalence of somatosensory tinnitus (ST) among Veterans with tinnitus. Three hundred four Veterans with tinnitus were phone screened for ST by performing and reporting on a series of head/neck/jaw maneuvers. A random sample of 12 individuals who screened positive and five who screened negative attended an in-person visit to confirm the presence/absence of ST. Of the 304 Veterans, 12 could not complete the screening maneuvers, 205 screened positive, and 87 screened negative. A Bayesian estimator that combines phone screening and in-person exam results establishes the prevalence of ST among Veterans with tinnitus at 56% with a 90% Bayesian confidence interval of 45% to 65%. At least half of Veterans with tinnitus have ST, suggesting that a sizable at-need population exists. Treatment addressing the biomechanical component has the potential to improve tinnitus symptoms.

Inflated scores on the online exams during the COVID-19 pandemic school lockdown

Due to the COVID-19 pandemic, colleges and universities in the US had to provide students with online-only instruction and assessment in the middle of the Spring 2020 semester. Since this was neither adequately planned nor thoroughly prepared due to little time, its effects on student academic performance are unknown. This study tested a hypothesis that students’ test scores were significantly higher on online exams during the COVID-19 school lockdown than those of the in-person exams before the lockdown. We compared the scores of the same students between one in-person exam and two online exams in a fundamental engineering class in the Spring 2020 semester. We further compared the scores between the students who took three in-person exams in the 2019 semesters and those in the Spring 2020 semester. The same instructor taught the class in both cases, and all exams had similar difficulties. We found that students achieved significantly inflated test scores when taking online exams, with the increase being in the range of 20% to 50%. Therefore, we have proven the hypothesis. Score inflation also depended on the level of prevention of student collaboration on online exams, with a loosely-controlled online exam’s scores increasing by 50% compared to exams with strict measures to prevent cheating. In comparison, students showed a similar performance at three in- person exams in the 2019 semesters, with differences ranging 6% to 8%. The current study could help show how the COVID-19 pandemic influences long-term academic performance of institutions, instructors, and more importantly, students.

T ransitioning a L arge Biology Class from a n i n Person t o a n Online Exam During the COVID 19 Pandemic

As occurred in many Universities worldwide, the response to the COVID-19 pandemic required us, professors at Western University (London, Canada), to quickly convert a first-year biology course with over 1200 enrolled students from an in-classroom format to an on-line format. This transition included the course exams. While the first multiple-choice exam in February 2020 was in-person and proctored, we changed the second multiple-choice exam in March 2020 so that it was completed by students online at home without a proctor. We had concerns about this online conversion, including whether the grades would represent student understanding of the course material when access to peers and other resources during the exam was not monitored. In this report we show student scores on the online exam were highly correlated with their prior in-person exam. A similar correlation was observed with prior first-year students who took similar exams in February and March 2019 which were both in-person and proctored. These results provide some reassurance that it is possible to rapidly transition the delivery of an exam from an in-person format to an online format without compromising the exam process.

Feasibility of Implementing Thoracic Radiation Therapy for COVID-19 Pneumonia

Purpose/Objective(s)The value of low dose whole thoracic radiation therapy (LD-WTRT) for SARS-CoV-2 (COVID-19) pneumonia is unknown. Should ongoing clinical trials demonstrate LD-WTRT proves effective for COVID-19 pneumonia recovery, widespread rapid implementation will be helpful globally. Our aim was to outline a pragmatic process that could be implemented successfully in a community hospital.Materials/MethodsTo identify appropriate patients admitted to the hospital with COVID-19 pneumonia, we worked with Nursing Informatics to screen all currently admitted COVID+ patients requiring oxygen supplementation. For patients meeting criteria of the PreVent protocol per chart review, radiation oncologists contacted the hospitalist physician for telehealth consultation with the patient to discuss single dose LD-WTRT. After a patient had confirmed interest in treatment, at time of physical exam, we obtained consent and digitally transferred the signed consent form via secure text to avoid contaminated forms. Chest radiographs were used to estimate AP/PA field size and separation at the carina; diagnostic chest CT data was imported into the treatment planning system for field size and MU calculation before patient arrival, without using the department's CT simulator. Inpatient Nursing transported patients for treatment after clinic hours on a route pre-approved by Infection Control. The treating radiation oncologist and one ‘hot’ radiation therapist assisted with patient set-up supine or prone on the linear accelerator couch. After decontamination, the physician and a ‘cold’ therapist confirmed field size and MU calculations to prepare for treatment delivery. Nursing monitored patient O2 saturation and stayed gowned with the ‘hot’ therapist. After patient departure, Radiation Oncology contacted Facilities for decontamination of the vault before treating cancer patients the following day.ResultsFor the first treated patient, telehealth consultation lasted 40 minutes. In-person exam, evaluation and consent took 60 minutes, of which 30 were for the protocol-required consent form. With the diagnostic CT scan, field design and MU calculations took 20 minutes. Patient arrival to departure took 40 minutes. Once the patient was positioned on the couch, localization, MU confirmation and entry and treatment delivery took 16 minutes.ConclusionWe have developed a process to efficiently provide LD-WTRT for patients with COVID pneumonia that minimizes staff exposure, departmental equipment, and room contamination. Should clinical trials indicate that LD-WTRT helps treat COVID pneumonia patients, this process can work in most hospital-based radiation oncology departments to provide LD-WTRT efficiently and safely. Staff and cancer patient vaccination will further lower the risks of implementing LD-WTRT but is not necessary with careful planning and consultation with infection control.

Surgical Planning Via Telehealth Consultation Is Effective for Patients Undergoing Minimally Invasive Gynecologic Surgery

Study Objective To determine if the proposed treatment plan created for new patients during telehealth consultation concurred with the treatment plan at the subsequent in-person visit. Our secondary objectives were to determine the average time of telehealth consultation and perioperative safety. Design Retrospective cohort. Setting New patient telehealth consultations during COVID pandemic. Patients or Participants Women undergoing telehealth evaluation at a minimally invasive gynecologic surgical practice, with subsequent in-person examination. Interventions N/A. Measurements and Main Results The primary outcome was concurrence of treatment plan (surgical or conservative) during the initial telehealth visit with plan made at the in-person examination. Between April and November 2020, 148 women completed new patient phone visits, and 10 completed new patient video visits. When pandemic restrictions were lifted, patients returned for in-person exam to confirm the treatment plan of surgery or conservative management. During the telehealth consultation, 138 women (87.3%) elected for surgical treatment and 111 returned for in-person follow up. 20 women (12.7%) elected for conservative treatment; four returned for in-person follow up and two changed to a surgical plan. Overall concordance between treatment plan made at initial telehealth consultation and in-person visit was 96.5% (p<0.01). Of those who elected for surgery at initial consultation and completed in-person examination, 110 had surgery (99.1% concordance.) Of those who planned conservative management at initial consultation and completed in-person examination, two proceeded with conservative management (50% concordance.) Visit duration was obtained from billing notation and was 30.4±9.7min. Ultimately, 112 women underwent surgery with few complications. There were two intraoperative complications: one EBL > 500mL and one cystotomy. Postoperatively, three women (1.9%) developed a surgical site infection, four (2.5%) were diagnosed with a urinary tract infection, and one (0.6%) returned to the OR for small bowel obstruction. Conclusion Telehealth consultations performed at a minimally invasive gynecologic surgery practice are an effective modality for safe surgical planning. To determine if the proposed treatment plan created for new patients during telehealth consultation concurred with the treatment plan at the subsequent in-person visit. Our secondary objectives were to determine the average time of telehealth consultation and perioperative safety. Retrospective cohort. New patient telehealth consultations during COVID pandemic. Women undergoing telehealth evaluation at a minimally invasive gynecologic surgical practice, with subsequent in-person examination. N/A. The primary outcome was concurrence of treatment plan (surgical or conservative) during the initial telehealth visit with plan made at the in-person examination. Between April and November 2020, 148 women completed new patient phone visits, and 10 completed new patient video visits. When pandemic restrictions were lifted, patients returned for in-person exam to confirm the treatment plan of surgery or conservative management. During the telehealth consultation, 138 women (87.3%) elected for surgical treatment and 111 returned for in-person follow up. 20 women (12.7%) elected for conservative treatment; four returned for in-person follow up and two changed to a surgical plan. Overall concordance between treatment plan made at initial telehealth consultation and in-person visit was 96.5% (p<0.01). Of those who elected for surgery at initial consultation and completed in-person examination, 110 had surgery (99.1% concordance.) Of those who planned conservative management at initial consultation and completed in-person examination, two proceeded with conservative management (50% concordance.) Visit duration was obtained from billing notation and was 30.4±9.7min. Ultimately, 112 women underwent surgery with few complications. There were two intraoperative complications: one EBL > 500mL and one cystotomy. Postoperatively, three women (1.9%) developed a surgical site infection, four (2.5%) were diagnosed with a urinary tract infection, and one (0.6%) returned to the OR for small bowel obstruction. Telehealth consultations performed at a minimally invasive gynecologic surgery practice are an effective modality for safe surgical planning.

Comparison of Online Assessment with Traditional Assessment of Ophthalmology Students: Experience from Public Sector Medical College in Pakistan

Purpose: To perform online assessment of undergraduate ophthalmology students and compare the online examination results with conventional in-person examination during COVID-19 pandemic.&#x0D; Study Design: Comparative, cross-sectional study.&#x0D; Place and Duration of Study: Department of Ophthalmology, Allama Iqbal Medical College, Lahore, Pakistan. From October 2019 to December 2020.&#x0D; Methods: We used online Google Assessment Forms to administer the online ophthalmology send-up examination to 4th-year MBBS students. The exam consisted of 50 test items with varying difficulty levels and pictures were incorporated into them. The examination results were compared with the conventional face-to-face send-up ophthalmology examination conducted a year ago, which consisted of 50 multiple-choice questions (MCQs).&#x0D; Results: There were 50 questions in the online examination with categorization into C1:C2:C3 levels of cognition. A total of 336 students submitted their responses for online assessment with a mean score of 36.28 out of 50 marks (73.0%) (Range: 7 – 45 marks). C1, C2, and C3 questions were correctly answered by 95.3%, 45.1%, and 11.0% of the students, respectively. The conventional examination was taken by 326 students and consisted of 50 MCQs with C1:C2:C3 questions. The online exam yielded more mean scores than the in-person exam (73.0% versus 56.0%, p-value: 0.001). The rate of failure with scores less than 50% marks was significantly higher in students appearing in conventional exam versus online exam (16.6% versus 1.5% respectively, p-value: 0.0412).&#x0D; Conclusion: Online assessment of undergraduate ophthalmology students is a possible alternative to the conventional examinations during this pandemic.&#x0D; Key Words: Ophthalmology, COVID-19 Pandemic. Medical education.