Article Review: Psychosocial Treatment of Schizophrenia

Canadian Treatment Guidelines for psychosocial treatments of schizophrenia were recently updated.  Each of the following treatments were supported by at least one randomized control study, though many were supported by metanalyses of randomized controlled studies.  The authors emphasize that psychosocial treatment should be provided in tandem with medical treatment.

 

  1. Family Interventions. The way family members respond to or interact with the patient can have a significant effect on clinical outcomes including reducing likelihood of hospitalization and reduction of symptoms.  Family intervention should be offered to all families once a diagnosis has been made.  This family intervention should include at least 10 sessions over the course of 3 months and topics that cover:
    1. Communication skills
    2. Problem solving
    3. Psychoeducation

 

  • Work opportunities. It is important to offer supported employment opportunities, volunteer or prevocational/educational opportunities to individuals with schizophrenia if possible.

 

  • CBT for psychosis. This treatment has been found to reduce anxiety and depressive symptoms in individuals with schizophrenia, a minimum dose of 16 sessions is recommended. Sessions should focus on raising awareness of the relationship between their thoughts, feelings, behaviors, and symptoms. In addition, therapists should encourage individuals to evaluate how their perceptions, beliefs, and thought processes that contribute to symptoms; and they should promote helpful ways of coping with symptoms and reducing stress.

 

Other treatments, including life skills, social skills and patient psychoeducation about schizophrenia don’t have sufficient empirical evidence to be recommended at this time, but they are currently being offered to many patients, and they may be beneficial. There is new interest in incorporating mindfulness and acceptance and commitment therapy into treatments for individuals with schizophrenia as well, but again, research on these interventions is limited.

 

 

References
Norman, R., Lecomte, T., Addington, D., & Anderson, E. (2017). Canadian treatment guidelines on psychosocial treatment of schizophrenia in adults. The Canadian Journal of Psychiatry62(9), 617-623.

 

Maria Stacy, MA
WKPIC Doctoral Intern

 

 

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Friday Factoids: Transgender Patient Care on an Inpatient Psychiatric Unit

Special considerations may be needed for transgender patients who are admitted to a psychiatric unit, to better assist with their care. These considerations should begin prior to the patient’s arrival. It is recommended that patients share a room with others of the same affirmed gender, and if that is not possible, a private room should be assigned. Many institutions room transgender patients with patients of the same assigned (by society to the individual at birth), but not affirmed (to which the individual has transitioned or is in the process of transitioning), gender. When this happens, it can feel invalidating, traumatizing, and discriminatory to the patient, as well as confusing to the roommate.

 

Staff should be aware of the patient’s desired name and pronouns, particularly when these do not align with the patient’s medical record. It is also important to note that withholding an outpatient hormone regimen can acutely worsen dysphoria for patients. If possible, affirming devices, such as chest binders or breast prostheses should be permitted, unless they pose a significant safety concern.

 

During the intake interview, it is crucial to have a basic understanding of the patient’s gender journey. Questions about their relationships and response to their identify in their social environment can assess for risk and protective factors. When a patient volunteers information, clarifying questions about their medical transition process should be asked. It is important to frame such questions in a manner which will enable the patient to understand the rationale of the question. It is important to remember that it is never appropriate to ask patients directly about their genitals. It is also important to phrase questions in a manner that does not assume the patient desires further medical intervention. Some individuals undergo social transitioning, while others undergo medical transitioning. Missed issues can be identified at the end of the interview by asking patients whether there is anything that can be done to make their stay on the unit more comfortable.

 

Throughout the patient’s hospitalization, it is important to follow up on how the patient’s gender identity has been affirmed on the unit. Finally, it is important to consider the patient’s psychiatric course prior to hormone therapy and whether something else might be driving the psychiatric presentation before concluding that the hormones are responsible for the decompensation.

 

References
Saw, C. (2017). Transgender patient care on the inpatient psychiatric unit. American Journal of Psychiatry Residents’ Journal.

 

James Bender, MA
WKPIC Doctoral Intern

 

 

 

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Friday Factoids: Migraines and Epilepsy Olfactory Hallucinations

Olfactory hallucinations are said to be one of the less common forms of hallucinations associated with psychotic disorders. However, olfactory hallucinations are said to occur with several other neurological disorders, most commonly temporal lobe epilepsy in which the aura before the epileptic seizure sometimes includes an olfactory hallucination lasting up to 24 hours.

 

While more rare, olfactory hallucinations also occur with headache disorders at times but are less commonly recognized and studied. This makes it essential to rule out serious medical causes of olfactory hallucinations before resorting to a schizophrenia spectrum disorder diagnosis.

 

Monica Babaian, MA
WKPIC Doctoral Intern

 

 

 

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Friday Factoid: Paradigm Shift

(Director’s Note:  Occasionally, interns are willing to share personal experiences that may advance scientific understanding, appreciation of humanity and diversity, and/or the effects of world events on individual emotions and behavior. I am always grateful for these opportunities.)

 

On September 27th of 2020 the paradigm shift began, not only for me, but for most Armenians alike. We had always known that our motherland is not the wealthiest or the most advanced, but rather impoverished and has been for hundreds of years. Since then, there has been a shift in the way that I perceive the world as well as a shift in how I see my purpose as an Armenian-American.

 

On September 27th, the region that natives call Artsakh, otherwise known as Nagorno-Kharabagh, was attacked by Azerbaijani forces and has continuously been destroyed since. Nagorno-Karabakh is home to 95% ethnic Armenians who have been inhabiting those lands since before Christ. The land was however gifted to Azerbaijan by Joseph Stalin while it was under Soviet rule. However, the people of the area have opted to become an independent republic for the last century. In 1915, a genocide took place in which 1.5 million Armenians were slaughtered, displaced, and forced into slavery. The women were raped or killed and the female children who were spared their lives most often ended up as child brides, forced to rid themselves of their Armenian-ness to be granted the opportunity to live. The greater portion of ethnic lands were ripped from Armenia and over half the population was murdered. Historically, most of Azerbaijan and Turkey were once Armenian territory too—making it quite ironic how Azerbaijan aims to “liberate” the areas that are occupied by Armenians.

 

For someone who doesn’t know about my ethnicity or culture, they may not understand why I chose to write about this rather than a once-in-a-lifetime pandemic we are living through. As Armenians, we have always carried the weight of intergenerational trauma. We have always carried the weight of belonging to a group of people who have long been victims of genocide and oppression even before 1915. We grew up on the stories that our grandparents told us and every year on April 24th we attended a march for justice in Los Angeles, in which we protested for recognition of the Armenian Genocide. An act that was promised by many US presidents for decades.

 

For those who don’t know the significance and the impact of the Armenian Genocide, I’d like to share this quote by a man named Adolf Hitler: “Who, after all, speaks today of the annihilation of the Armenians?” He was quoted saying this before he set action and began what is now known as the Holocaust. While we grew up on those stories, we always believed that they were just stories. They were historical and held much truth, but they were a thing of the past never to be repeated because times had changed and we had grown as human beings. Or so we thought…

 

On September 27th, the region of Artsakh came under attack. Since then thousands of young Armenians aged 18 to 21 have died. While we’ve been pleading for help and recognition in America, we have not yet had that happen. We have been protesting across the world. We have been spreading awareness over social media and all else. The genocide did one good thing in that it created a hell of a diaspora.

 

However, the political ties and economic ambitions of the United States as well as our strongest ally, Russia, won’t allow for the rightful members of NATO or the MINSK group to step in. Not after Azerbaijan broke a ceasefire on four separate occasions this year, not after Turkey sent ISIS jihadists to fight some twisted holy war, not after they dropped a missile on Armenian land, not after bombing civilian establishments like hospitals and churches no where near the front lines, not after the Azeri soldier posted videos of beheading and skinning Armenian soldiers, not after the illegal cluster bombs were used, not after the fighter jets, drones, or white phosphor attacks, not after the torturing of prisoners of war, not after the refusal to return prisoners of war… The list goes on and on. While an agreement has now been signed and over half of the ethnic land has been surrendered by Armenia, many of the attacks continue. Over 150,000 people were forced out of the only homes they have known. To date, many Armenian mothers and fathers are searching for dead bodies and praying that it is their child, for it is better to be dead than to be alive and in the hands of the oppressor.

 

While we have been protesting endlessly, raising donations spreading awareness, and doing all that we can do, it seems to never be enough. The paradigm shift happened when I realized that the world will never be as kind as I want it to be. The paradigm shift began when I recognized that it was only Armenians who were protesting for Armenians. It was when I realized that my Instagram posts and followers suddenly declined when the content became about asking people to spread awareness about what’s going on. It occurred when my follower count declined after I spread new about our ethnic brothers and sisters dying on the front lines. The paradigm shift took place very slowly and all at once.

 

I always had hopes and expectations that despite how badly the world had turned its backs on us 100 years ago, that it would be different would it to ever occur again. Regardless of those expectations however, I had never expected that it would happen again to begin with. There was this realization at some point that the intergenerational trauma will continue to continue for our people. The cycle just won’t end. As the first Christian people in existence, there is a great threat to their very being when landlocked primarily by Muslim countries who have set out to wipe them out completely. The paradigm shift occurred because I fear that if my generation lives through this, it is likely that my children’s generation will experience it too.

 

While there is a great sense of distain in my voice right now geared towards the world in and of itself, there was a personal shift within me as well, aside from the overwhelming sense of guilt for anything and everything. For every meal that I eat, every article of clothing that I purchase, every time I lay my head on my pillow, every morning that I get to say hello to my brother, the same brother who told me that he wanted to voluntarily enlist. While I forbid him from doing so, I asked myself why is it fair for me not to lose my brother when mothers and sisters in Armenia are losing their fathers, brothers, sons, and husbands?

 

When war crimes are being committed against our people and civilian cities are being attacked, there is an overwhelming sense of guilt each time that I smile. And I can’t quite shake the feeling and the thoughts in my head that ask, “How could we have been so oblivious to not have assumed that this would happen again?” or “How could we as Armenians have lived in the diaspora all these years and not have thought that we should be giving back more to our country all along and not just now during a time of crisis?” For it’s that same oblivious thought processes that have contributed to so many dying. To illustrate what I mean my this, our military is completely incapable of defending themselves. There was no money to fund a war, house the people who lost their homes, or feed the soldiers for days on end. While our boys go to battle with outdated firearms from the 80’s, we are being attacked by missiles and drones. We are defenseless and we are helpless just as we were 100 years ago.

 

While I hope this shift in my perception of the world is not a permanent one, I fear that I have forever stopped looking at the world through rose-colored glasses and I’ve started to see darkness in everything. This occurrence has taught me more about power and privilege than any intercultural or human diversity class could ever teach me. There has been a shift in how I see my privilege and that of others. There’s been a shift because I now recognize that it is a privilege to sleep through the night without fear of dying. Last week, after a scary storm hit Los Angeles, my 6-year-old nephew woke up in the middle of the night. He was crying and pleading that he does not want to die, he is too young to die. Little did he know it was a storm. He thought the Armenians were under attack in America now too. And for those of us in America, it is a privilege to not know and to not need to know what that feels like. It is a privilege to know about what is going on in Armenia and Nigeria and Ethiopia and Congo and Namibia and all the other places that are suffering right now. It is a privilege to not wake up worried and it is a privilege to not go to bed terrified.

 

Theoretically we have all known learned about oppression, marginalization, separation, the effects of war and trauma, and so on. As individuals in this field, we have been forced a to look at our own privileges and our own biases and understand deep personal issues. And while it had always made sense, it had never quite made sense the way that it does now. On September 27th, a paradigm shift occurred where all of the Armenians of the diaspora suddenly woke up to a nightmare and have not yet fallen asleep. On September 27th, something changed in our hearts and minds, and I’m certain it’ll be a long time until we can really breathe again or trust that the world won’t break our hearts 10 ways to Sunday.

 

Monica Babaian, MA
WKPIC Doctoral Intern

 

 

 

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Article Review: Missed opportunities: Childhood Learning Disabilities as Early Indicators of Risk Among Homeless Adults With Mental Illness

Many studies have shown that childhood learning disabilities have adverse effects in both childhood as well as in long term adulthood. A 2012 study by Patterson and colleagues further studied the topic and compiled interesting findings relating to homelessness, mental illness, service utilization and substance use disorders. The purpose of this study was to assess the question of, “Can outcomes such as homelessness be prevented?”

 

Data was compiled by sampling 497 adult participants who were categorized as homeless and had a persisting current mental disorder in British Columbia. Of these participants, 133 identified themselves as having had a learning disability in childhood. Over 40% of participants were said to not have finished high school or being in special classes during their schooling. They found that learning disorders were predictive of poorer health outcomes, where “mood and anxiety disorders, suicidal ideation, early and severe substance use and physical health problems” were seen more readily in this population. These factors often lead to not only severe psychopathology, but also social exclusion.

 

Other interesting findings suggested that 66% of participants reported having had a serious head injury at some point in their lives. This may also indicate a need to better identify traumatic brain injury as a component of lowered cognitive functioning, which may in and of itself function as a factor related to homelessness. This study also noted that daily drug use, as compared to occasional recreational use, was a more significant predictor of a longer duration of homelessness and more severe or intense mental health symptoms.

 

The conclusion of this study was largely in regard to how structural barriers can be overcome so that children who are considered high-risk can be provided early interventions as a preventative measure. Those who came from poorer neighborhoods, had behavioral or emotional difficulties, learning problems, a history of abuse or neglect, and early use of substances were found to be the most at-risk. Further, the study placed importance on current difficulties for homeless individuals and highlighted that addressing their current learning disabilities could also mitigate difficulties

 

References
Patterson MLMoniruzzaman AFrankish CJ, et al
Missed opportunities: childhood learning disabilities as early indicators of risk among homeless adults with mental illness in Vancouver, British Columbia

 

 

Monica Babaian, MA
WKPIC Doctoral Intern

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Article Review: Clinician Behaviors in Telehealth Care

Literature on telehealth services is continuing to grow, especially in the area concerning interpersonal behaviors during telehealth sessions. Henry et al. (2017) conducted a systematic literature review to identify interpersonal health care provider behaviors and qualities related to provider-patient interaction during a telehealth session. They searched for articles which included keywords: communication, telehealth, education, and health care delivery. Of the 5,261 unique article abstracts they identified, 45 were used in their review. Among the 45 articles used, six themes were identified: pre-interactional, verbal communication, nonverbal communication, relational, environmental, and educational (Henry et al., 2017).

 

Pre-Interactional
The Pre-interactional theme included a variety of different characteristics including beliefs, attitudes, confidence, and cultural competence that precede a positive approach toward working with patients through telehealth (Henry et al., 2017). The data suggested a relationship between clinician belief that telehealth services benefitted patients and the ease with which the clinician adapted to a role in telehealth. The stronger the belief that telehealth services can benefit the patient, the more likely it is that they will have an easier time adapting to the new role. Creativity, open-mindedness, adaptability, and flexibility were also correlated with acceptance of telehealth (Henry et al., 2017).
Henry et al. (2017) also discuss how clinicians can work towards making connections with people in distant locations. An increase in cultural awareness prior to interaction was identified as a need. This includes the importance of cultural context of the patient’s locality, community resources local to the patient, language differences, and dietary differences (Henry et al., 2017).

 

Verbal Communication
Three general areas of verbal communication were discussed including: types of discourse, importance of verbal skills, and the need for clear communication (Henry et al., 2017). Findings regarding verbal communication varied across studies. Some characterized telehealth visits as less patient-centered, more verbally dominated by clinicians, and patients more frequently requested information be repeated. Patients would comment that they noticed less small talk and socialization during telehealth visits and a shorter average visit time compared to face-to-face visits. However, other studies reported greater self-disclosure and more small talk by clinicians using telehealth. Telephone conversations were found to have more patient utterances, more open-ended questions, friendly jokes, and indications of listening. Overall, it is thought that more training and practice could help develop skills specific for telephone communication (Henry et al., 2017).

 

Nonverbal Communication
Examples of nonverbal communication examined included eye contact, body positioning, movement, facial gestures, voice quality, and vocal tone (Henry et al., 2017). The importance of equipment quality and placement was noted to support a ‘telepresence’ which includes non-verbal interpersonal skills. It was discussed that providers feel less control over the non-verbal aspects of telehealth sessions, and it was recommended that clinicians exaggerate motions such as nods and other actions during sessions. In general, it is recommended that clinicians develop a video presence that includes staying visually attentive, exaggerating facial expressions at times, and ensuring the patient has a clear view of the clinician’s face and body language (Henry et al., 2017).

 

Relational
Studies throughout the review reported ease with rapport-building through telephone communication as well as face-to-face appointments (Henry et al., 2017). It was discussed that conversations may be improved through a telephone and that non-verbal communication continues when listening is the focus. However, when working without visual cues there is a need to balance more detailed and close-ended questions with allowing the patient to talk. It was also found that caller satisfaction was higher when clinicians met expectations in five dimensions: caring, listening, clarity, collaborating, and competency (Henry et al., 2017)

 

Environmental
Studies highlighted the importance of the environment that the clinician is in when delivering telehealth care (Henry et al., 2017). At times, patients appreciate assurances of privacy and confidentiality that go beyond the transmission of data. It was found to be problematic when clinicians delivered telehealth services while in a shared space. It is recommended that clinicians utilize headphones to increase the privacy of conversations. A clinician should do their best to make their space look like a familiar setting, instead of an unfamiliar space such as a board room. A clinician should also do their best to keep their environment distraction free, limiting interruptions that could arise during the visit.

 

Educational
There was a lack of consensus among the studies about what learning objectives are necessary to form clinicians with excellent interpersonal skills (Henry et al., 2017).

 

Summary
These findings reinforce the need for clinicians to consider visual cues and listening style when delivering telehealth services. Understanding these issues and developing adaptive mechanisms could make telehealth more readily accepted by clinicians, even when there is not a pandemic forcing them to conduct treatment this way.

 

References
Henry, B. W., Block, D. E., Ciesla, J. R., McGowan, B. A., Vozenilek, J. A. (2017). Clinician behaviors in telehealth care delivery: a systematic review. Advances in Health Science Education, 22(1), 869-888. https://doi.org/10.1007/s10459-016-9717-2

 

James Bender, MA
WKPIC Doctoral Intern

 

 

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Friday Factoids: Treatment-Resistant Schizophrenia

While most individuals diagnosed with schizophrenia respond to the first or second anti-psychotic prescribed, up to 30% of patients diagnosed with schizophrenia fail to respond to these initial treatments. In addition, some individuals who responded to the first or second anti-psychotic eventually fail to respond to those same anti-psychotics after several years.

 

These populations are considered “treatment resistant”, and they can exhibit more severe positive and negative symptoms than others diagnosed with schizophrenia.  The reason for treatment resistance is not known, though some believe that some individuals who have taken antipsychotics for several years develop a dopamine hypersensitivity that triggers the worsening symptoms. In addition, some physicians have found that Clozapine is a helpful psychopharmacological treatment for treatment-resistant individuals, though care should be taken to monitor the side effects of this medication.

 

References
Kane, J. M., Agid, O., Baldwin, M. L., Howes, O., Lindenmayer, J. P., Marder, S., … & Correll, C. U. (2019). Clinical guidance on the identification and management of treatment-resistant schizophrenia. The Journal of Clinical Psychiatry80(2), 0-0.

 

Maria Stacy, MA
WKPIC Doctoral Intern

 

 

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Friday Factoids: Differential Diagnosis of Psychosis

A number of different medical conditions can cause psychotic symptoms in individuals.  Some, like the delirium after surgery, epilepsy and urinary tract infections, are well known, but some are less well-known. This is a more comprehensive list of medical conditions that sometimes cause psychotic symptoms.  These conditions should be ruled out prior to a diagnosis of a psychiatric disorder. Information about age, and health history should be used to determine if these conditions are a likely reason for the emergence of psychotic symptoms:

 

 

  • Hyper- or hypothyroidism
  • Cushing’s Disease (Cushing’s Syndrome) (increased release of cortisol due to a tumor)
  • Insulinoma (tumor on the pancreas)
  • Adult-onset Tay-Sachs Disease and Neimann-Pick Type C disorders (genetic conditions)
  • Lupus (auto-immune disorder)
  • Hashimoto Encephalopathy
  • Diseases uncommon in the US, but prevalent in other places may cause psychosis
    1. Cerebral malaria
    2. Toxoplasmosis
  • HIV
  • Syphilis/neurosyphilis
  • Narcolepsy (excessive daytime sleepiness)

 

Freudenreich, O. (2010). Differential diagnosis of psychotic symptoms: medical mimics. Psychiatric Times27(12), 56-61.

 

Maria Stacy, MA
WKPIC Doctoral Intern

 

 

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Article Review: Psychosis Following TBI


Psychotic symptoms are two to three times more likely to be experienced by individuals who have had a traumatic brain injury (TBI) than in the general population, but previous studies haven’t been able to indicate how traumatic brain injuries and psychosis are related.  This condition is called Psychosis following traumatic brain injury (PFTBI). Batty et al. (2013) looked at 26 studies that explored the relationship between TBI and psychosis to help determine how traumatic brain injuries might influence the likelihood of experiencing delusions, hallucinations or disordered thoughts. The researchers found that traumatic brain injuries likely increase the chance of experiencing psychosis by the following mechanisms:

 

  • Causing stress to a person who has a genetic predisposition to schizophrenia or other psychotic disorder, and increasing the likelihood they would experience those symptoms AND/OR
  • Causing additional stress to a person who is experiencing environmental factors known to increase likelihood of psychosis ( ie. Low socio-economic status etc.) AND/OR
  • Causing structural changes to the brain that parallel the changes in the brain exhibited by people with schizophrenia or other psychotic disorder, and thereby eliciting similar symptoms

 

The researchers emphasize that more than one factor could affect each person.

 

The article also identifies trends that have been identified across all 26 articles.

  • Generally, increased severity of the brain injury, measured by the amount of cell death or length of time patient was unconscious after the injury, was related to increased risk of psychotic symptoms
  • Most researchers found that symptoms in patients experiencing psychosis after a TBI mimic the same symptoms patients with schizophrenia exhibit: positive and negative symptoms as well as cognitive impairment, so it may be difficult to distinguish these symptoms from schizophrenia.
  • People with psychosis following TBI typically experience deficits in language, vocabulary, verbal memory and verbal learning.
  • EEG scans have shown that PFTBI patients typically have functional abnormalities in their temporal lobe, which might explain why there are deficits in language and verbal memory, specifically.

The authors of this study note that there are many problems associated with PFTBI research, for example, many participants are recruited from inpatient units, which means people with mild or moderate psychotic symptoms may not be included in research.  In addition, participants with very different kinds of traumatic brain injuries are often all included in the same study, though the kind and severity of injury can have a significant influence on the severity of psychotic symptoms experienced.  Caution should be taken when interpreting the results summarized in this article.

 

 

References
Batty, R. A., Rossell, S. L., Francis, A. J., & Ponsford, J. (2013). Psychosis following traumatic brain injury. Brain Impairment14(1), 21.

 

 

Maria Stacy, MA
WKPIC Doctoral Intern

 

 

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Friday Factoids: Can AI Detect COVID Cough?

As of November of 2020, there have been more than 225,000 deaths due to COVID-19 in the United States alone. One of biggest barriers during this pandemic is the inability to test for COVID-19 at a global scale. However, this does not mean that researchers have not been working around the clock to develop a screening tool. One research team is currently developing and testing an Artificial Intelligence (AI)-powered screening solution for COVID-19 called A14COVID-19, which is deployable via a smartphone app. The app records and sends three 3-second cough sounds to an AI engine operating in the cloud and returns results within two minutes.

 

Coughing is a symptom of over thirty related medical conditions, which makes the diagnosis of COVID-19 by cough alone very challenging. However, the research team investigated the distinctness of pathomorphological alteration in the respiratory system induced by COVID-19 infection when compared to other respiratory infections. They found that their app can distinguish among COVID-19 coughs and several types of non-COVID-19 coughs.

 

The accuracy of the study was promising enough to encourage a large-scale collection of labeled cough data to examine the generalization capability of the app. While the app is not a clinical grade testing tool, it is a screening tool that can be deployed anytime, anywhere, by anyone. It can also be used to assist clinical decisions to channel clinical-testing and treatment to those who need it most.

 

References

Imran, A., Posokhova, I., Qureshi, H. N., Masood, U., Riaz, S., Ali, K., John, C., Hussain, I., & Nabeel, M. (2020). AI4COVID-19: AI enabled preliminary diagnosis for COVID-19 from cough samples via an app. Informatics in Medicine Unlocked, 20(1).

 

 

James Bender, MA
WKPIC Doctoral Intern

 

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