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Parents of seriously ill children worry about their vulnerable child contracting COVID-19, whether their child's palliative care providers will be able to continue to provide the same quality of care to their child, and who can be with the child to provide comfort. For providers, shifts in healthcare provision, communication formats, and support offerings for families facing distress or loss during the pandemic may promote providers’ moral distress. This study aimed to define the ways that the COVID-19 pandemic has impacted end-of-life care and approach to bereavement care in pediatric palliative care (PPC).
The Palliative Assessment of Needed DEvelopments and Modifications In the Era of Coronavirus (PANDEMIC) survey was developed to learn about the PPC experience during COVID-19 in the United States. The survey was posted with permission on seven nationally focused Listservs.
A total of 207 PPC team members from 80 cities within 39 states and the District of Columbia participated. In the majority of hospitals, admitted pediatric patients were only allowed one parent as a visitor with the exception of both parents or nuclear family at end of life. Creative alternatives to grief support and traditional funeral services were described. The high incidence of respondents’ depicted moral distress was often focused on an inability to provide a desired level of care due to existing rules and policies and bearing witness to patient and family suffering enhanced by the pandemic.
Significance of results
The COVID-19 pandemic has had a profound impact on the provision of end-of-life care and bereavement for children, family caregivers, and PPC providers. Our results identify tangible limitations of restricted personal contact and the pain of watching families stumble through a stunted grieving process. It is imperative that we find solutions for future global challenges and to foster solidarity in PPC.
The collapse of a granular column in a liquid is investigated using numerical simulations. From previous experimental studies, it has been established that the dynamics of the collapse is mostly influenced by the Stokes number $St$, comparing grain inertia and viscous fluid dissipation, and the initial volume fraction of the granular column $\phi _i$. However, the full characterization of the collapse in the $(St,\phi _i)$ plane is still missing, restricting its modelling as a physical process for geophysical applications. Only numerical tools can allow the variation over the parameter space $(St,\phi _i)$ that is hardly reachable in experiments as well as a full description of the granular phase that plays a major role in dense granular flows. For this purpose, a dedicated numerical model is used including a discrete element method to resolve the granular phase. The specific objectives of the paper are then twofold: (i) the characterization of the dynamics of the collapse and its final deposit with respect to $(St,\phi _i)$ to complement available experimental data, and (ii) the description of the granular rheology according to these two dimensionless numbers including dilatancy effects. A simple predictive model stems from the obtained results, allowing one to explain the evolution of the final deposit with $(St,\phi _i)$.
The coronavirus disease 2019 pandemic resulted in the cessation of elective surgery. The continued provision of complex head and neck cancer surgery was extremely variable, with some UK centres not performing any cancer surgery. During the pandemic, Guy's and St Thomas’ NHS Foundation Trust received high numbers of coronavirus disease 2019 admissions. This paper presents our experience of elective complex major head and neck cancer surgery throughout the pandemic.
A head and neck cancer surgery hub was set up that provided a co-ordinated managed care pathway for cancer patients during the pandemic; the Guy's Cancer Centre provided a separate, self-enclosed coronavirus-free environment within the hospital campus.
Sixty-nine head and neck cancer patients were operated on in two months, and 13 patients had a microvascular free tissue transfer. Nosocomial infection with coronavirus disease 2019 was detected in two cases (3 per cent), neither required critical care unit admission. Both patients made a complete recovery and were discharged home. There were no deaths.
Performing major head and neck surgery, including free flap surgery, is possible during the pandemic; however, significant changes to conventional practice are required to achieve desirable patient outcomes.
The introduction of treatment and systematic vaccination has significantly reduced diphtheria mortality; however, toxigenic strains continue to circulate worldwide. The emergence of an indigenous diphtheria case with fatal outcome in Greece, after 30 years, raised challenges for laboratory confirmation, clinical and public health management. Toxigenic Corynebacterium diphtheriae was isolated from an incompletely vaccinated 8-year-old boy with underlying conditions. The child passed away due to respiratory distress syndrome, before the administration of diphtheria antitoxin (DAT). All close contacts in family, school and hospital settings were investigated. Pharyngeal swabs were obtained to determine asymptomatic carriage. Chemoprophylaxis was given for 7 days to all close contacts and a booster dose to those incompletely vaccinated. Testing revealed a classmate, belonging to a subpopulation group (Roma), and incompletely vaccinated, as an asymptomatic carrier with an indistinguishable toxigenic strain (same novel multilocus sequence type, designated ST698). This case highlights the role of asymptomatic carriage, as the entry of toxigenic strains into susceptible populations can put individuals and their environment at risk. Maintenance of high-level epidemiological and microbiological surveillance, implementation of systematic vaccination in children and adults with primary and booster doses, availability of a DAT stockpile, and allowing timely administration are the cornerstone to prevent similar incidents in the future.
The global coronavirus disease 2019 (COVID-19) pandemic has necessitated rapid alterations to diagnostic pathways for head and neck cancer patients that aim to reduce risk to patients (exposure to the hospital environment) and staff (aerosol-generating procedures). Transoral fine needle aspiration cytology offers a low-risk means of rapidly diagnosing patients with oral cavity or oropharyngeal lesions. The technique was utilised in selected patients at our institution during the pandemic. The outcomes are considered in this study.
Diagnostic outcomes were retrospectively evaluated for a series of patients undergoing transoral fine needle aspiration cytology of oral cavity and oropharyngeal lesions during the COVID-19 pandemic.
Five patients underwent transoral fine needle aspiration cytology, yielding lesional material in 100 per cent, with cell blocks providing additional information. In one case, excision biopsy of a lymphoproliferative lesion was required for final diagnosis.
Transoral fine needle aspiration cytology can provide rapid diagnosis in patients with oral cavity and oropharyngeal lesions. Whilst limitations exist (including tolerability and lesion location), the technique offers significant advantages pertinent to the COVID-19 era, and could be employed in the future to obviate diagnostic surgery in selected patients.
To model the potential impact and equity impact of fortifying rice on nutritional adequacy of different subpopulations in Nepal.
Using 24-h dietary recall data and a household consumption survey, we estimated: rice intakes; probability of adequacy (PA) of eight micronutrients commonly fortified in rice (vitamin A, niacin (B3), pyridoxine (B6), cobalamin (B12), thiamin (B1), folate (B9), Fe and Zn) plus riboflavin (B2), vitamin C and Ca and mean probability of adequacy (MPA) of these micronutrients. We modelled: no fortification; fortification of purchased rice, averaged across all households and in rice-buying households only. We compared adequacy increases between population subgroups.
(i) Dhanusha and Mahottari districts of Nepal (24-h recall) and (ii) all agro-ecological zones of Nepal (consumption data).
(i) Pregnant women (n 128), mothers-in-law and male household heads; (ii) households (n 4360).
Unfortified diets were especially inadequate in vitamins B12, A, B9, Zn and Fe. Fortification of purchased rice in rice-purchasing households increased PA > 0·9 for thiamin, niacin, B6, folate and Zn, but B12 and Fe remained inadequate even after fortification (PA range 0·3–0·9). Pregnant women’s increases exceeded men’s for thiamin, niacin, B6, folate and MPA; men had larger gains in vitamin A, B12 and Zn. Adequacy improved more in the hills (coefficient 0·08 (95 % CI 0·05, 0·10)) and mountains (coefficient 0·07 (95 % CI 0·01, 0·14)) but less in rural areas (coefficient −0·05 (95 % CI −0·09, −0·01)).
Consumption of purchased fortified rice improves adequacy and gender equity of nutrient intake, especially in non-rice-growing areas.
We report two cases of respiratory toxigenic Corynebacterium diphtheriae infection in fully vaccinated UK born adults following travel to Tunisia in October 2019. Both patients were successfully treated with antibiotics and neither received diphtheria antitoxin. Contact tracing was performed following a risk assessment but no additional cases were identified. This report highlights the importance of maintaining a high index of suspicion for re-emerging infections in patients with a history of travel to high-risk areas outside Europe.
Unprecedented climate change, pollutants and habitat alterations are causing abiotic stress across all plants and animals. Global increases in temperature, as well as decreases in pH in the ocean, have already caused microbiome dysbiosis in a range of species, and previously commensal microbes have turned pathogenic in response to extreme environmental conditions. This will have far-reaching consequences for host survival and associated ecosystem functions. However, host microbiomes may actually be the key to buffering these unprecedented environmental changes. The host microbiome contains massive genetic potential, and their vast numbers, high turnover, wide metabolic scope and short generation times may afford opportunities for faster acclimatisation and adaptation. Examples of this already exist, although responses are likely to be highly context-dependent. It is becoming increasingly clear that preservation of the microbiome is likely to be the key to maintaining healthy ecosystems in an uncertain future. However, there are still large knowledge gaps in almost every area, which need to be urgently addressed so we can apply conservation efforts in a judicious manner.
A classic example of microbiome function is its role in nutrient assimilation in both plants and animals, but other less obvious roles are becoming more apparent, particularly in terms of driving infectious and non-infectious disease outcomes and influencing host behaviour. However, numerous biotic and abiotic factors influence the composition of these communities, and host microbiomes can be susceptible to environmental change. How microbial communities will be altered by, and mitigate, the rapid environmental change we can expect in the next few decades remain to be seen. That said, given the enormous range of functional diversity conferred by microbes, there is currently something of a revolution in microbial bioengineering and biotechnology in order to address real-world problems including human and wildlife disease and crop and biofuel production. All of these concepts are explored in further detail throughout the book.
Microbes provide a diverse source of functional traits that can be used to address a whole range of human and environmental problems, from agriculture and farming, to human and wildlife health, and energy production and climate change mitigation. Although microbes and their derivatives have been used for decades in some contexts, recent advances in sequencing and other technologies have allowed us to identify and understand novel sources and applications. Here, we review a range of different types of microbial biotechnology, including probiotics or microbial inputs, prebiotics, enzybiotics, microbiome transplants, antimicrobial peptides and secondary metabolites, across a range of contexts including human health, agriculture, biofuel production and wildlife disease, among others. We discuss the advances made in these fields, along with the complexities and problems associated with success. We also comment on ethical issues surrounding the use of microbial biotechnology and areas of policy and risk assessment that will need to develop to promote safe implementation.
It may be that this chapter will appear to make too much of the word ‘things’. After all, in common usage ‘things’ and ‘objects’ are more or less synonymous, and with that understanding the chapter might as well have been called ‘The Power of Objects in Lyrical Ballads’. What follows is written in the belief not only that there is a distinction between things and objects but that Wordsworth attends carefully to the distinction, and that it is helpful to think of Lyrical Ballads as an exploration, at certain moments, of the imagination’s way of seeing objects primordially – of seeing them, that is, as things. Much of the time, to be sure, things and objects are as interchangeable in Wordsworth’s vocabulary as they are for most of us. But sometimes there is a difference, an important difference that helps to explain the frequent vagueness of his language in his more ecstatic moments (in contrast, for example, with the precise niceties of Coleridge even in such moments), a vagueness disagreeable to his detractors, yet perhaps the very quality his admirers relish most when they find him most affecting. There will be no need here to pause over his vagueness, let alone subject it to stylistic analysis; rather, it will be taken for granted as his way of expressing the power of things, all things in their unity, including the senses in which humans too are things.
Rapid growth of Palmer amaranth (Amaranthus palmeri S. Watson) poses a challenge for timely management of this weed. Dose–response studies were conducted in 2017 and 2018 under field and greenhouse conditions near Garden City and Manhattan, KS, respectively, to evaluate the efficacy of dicamba to control ≤10-, 15-cm, and 30-cm-tall A. palmeri, which mimics three herbicide application timings: on-time application (Day 0) and 1- (Day 1) and 4-d (Day 4) delays. Visual injury rating and reduction in shoot biomass (% of nontreated), and mortality were assessed at 4 wk after treatment using a three- and four-parameter log-logistic model in R. Increasing dicamba doses increased A. palmeri control regardless of plant height in both the field and greenhouse studies. The results suggest that delaying application 1 (15 cm) and 4 d (30 cm) resulted in 2- and 27-fold increases in the effective dose of dicamba on A. palmeri, respectively, under field conditions. However, in the greenhouse, for the same level of A. palmeri control, more than 1- and 2-fold increases in dicamba dose, respectively, were required. Similarly, the effective dose of dicamba required for 50% reduction in A. palmeri shoot biomass (GR50) increased more than 4- and 8-fold or more than 1- and 2-fold when dicamba application was delayed by 1 (15 cm) and 4 d (30 cm), in the field or in the greenhouse, respectively. To understand the basis of increased efficacy of dicamba in controlling early growth stages of A. palmeri, dicamba absorption and translocation studies were conducted. Results indicate a significant reduction in dicamba absorption (7%) and translocation (15%) with increase in A. palmeri height. Therefore, increased absorption and translocation of dicamba results in increased efficacy in improving A. palmeri control at early growth stages.
This research was carried out to quantify the effects of a range of variables on milk fat globule (MFG) size for a herd of Holstein-Friesian cows managed through an automatic milking system with year-round calving. We hypothesised that the overall variation in average MFG size observed between individual animals of the same herd cannot sufficiently be explained by the magnitude of the effects of variables that could be manipulated on-farm. Hence, we aimed to conduct an extensive analysis of possible determinants of MFG size, including physiological characteristics (parity, days in milk, days pregnant, weight, age, rumination minutes, somatic cell count) and milk production traits (number of milkings, milk yield, fat yield, protein and fat content, fat-protein ratio) on the individual animal level; and environmental conditions (diet, weather, season) for the whole herd. Our results show that when analysed in isolation, many of the studied variables have a detectable effect on MFG size. However, analysis of their additive effects identified days in milk, parity and milk yield as the most important variables. In accordance with our hypothesis, the estimated effects of these variables, calculated using a multiple variable linear mixed model, do not sufficiently explain the overall variation between cows, ranging from 2.70 to 5.69 µm in average MFG size. We further show that environmental variables, such as sampling day (across seasons) or the proportion of pasture and silage in the diet, have limited effects on MFG size and that physiological differences outweigh the effects of milk production traits and environmental conditions. This presents further evidence that the selection of individual animals is more important than the adjustment of on-farm variables to control MFG size.
This article presents the results of a program of radiocarbon dating and Bayesian modeling from the precontact Yup'ik site of Nunalleq (GDN-248) in subarctic southwestern Alaska. Nunalleq is deeply stratified, presenting a robust relative chronological framework of well-defined individual house floors abundant in ecofacts suitable for radiocarbon dating. Capitalizing on this potential, we present the results of one of the first applications of Bayesian statistical modeling of radiocarbon data from an archaeological site in the North American Arctic. Using these methods, we demonstrate that it is possible to generate robust, high-resolution chronological models from Arctic archaeology. Radiocarbon dates, procured prior to the program of dating and modeling presented here, suggested an approximately three-century duration of occupation at the site. The results of Bayesian modeling nuance this interpretation. While it is possible that there may have been activity for almost three centuries (beginning in the late fourteenth century), occupation of the dwelling complex, which dominates the site, was more likely to have endured for no more than a century. The results presented here suggest that the occupation of Nunalleq likely encompassed three generations beginning cal AD 1570–1630 before being curtailed by conflict around cal AD 1645–1675.
Introduction: Skin and soft tissue infections (SSTIs) are a common reason for presentation to an emergency department (ED). Although many patients with mild SSTI are managed with oral antibiotics, those with mild-moderate infections are often treated with parenteral antibiotics, managed in EDs as outpatients using once daily intravenous cefazolin combined with oral probenecid. The purpose of our study was to determine if cephalexin 500 mg orally four times daily was non-inferior to cefazolin 2 g intravenously daily plus probenecid 1 g orally daily in the management of uncomplicated mild-moderate SSTIs patients presenting to the ED.. Methods: This was a prospective, multi-center, double dummy-blind, randomized controlled non-inferiority trial conducted at two tertiary care teaching hospitals in Canada. Patients were enrolled if they presented to the ED with an uncomplicated SSTI, in a 1:1 fashion to oral cephalexin or intravenous cefazolin plus oral probenecid for up to 7 days. The primary outcome was failure of therapy at 72 hours. Clinical cure at 7 days, intravenous to oral step-down, admission to hospital and adverse events were also evaluated. Results: 206 patients were randomized with 104 patients in the cephalexin group and 102 in the cefazolin and probenecid group. The proportion of patients failing therapy at 72 hours was similar between the treatment groups (4.2% and 6.1%, risk difference 1.9%, 95% CI (-3.3% to 7.1%), p-value for non-inferiority=0.001). Clinical cure at seven days was not significantly different (100% and 97.7%, risk difference -2.3%, 95% CI (-4.9% to 0.3%), p-value for non-inferiority=0.008). Conclusion: Cephalexin at appropriate doses appears to be a safe and effective alternative to outpatient parenteral cefazolin and probenecid in the treatment of uncomplicated mild to moderate SSTIs who present to the ED.
To explore the factors affecting intra-household food allocation practices to inform the development of interventions to prevent low birth weight in rural plains of Nepal.
Qualitative methodology using purposive sampling to explore the barriers and facilitating factors to improved maternal nutrition.
Rural Dhanusha District, Nepal.
We purposively sampled twenty-five young daughters-in-law from marginalised groups living in extended families and conducted semi-structured interviews with them. We also conducted one focus group discussion with men and one with female community health volunteers who were mothers-in-law.
Gender and age hierarchies were important in household decision making. The mother-in-law was responsible for ensuring that a meal was provided to productive household members. The youngest daughter-in-law usually cooked last and ate less than other family members, and showed respect for other family members by cooking only when permitted and deferring to others’ choice of food. There were limited opportunities for these women to snack between main meals. Daughters-in-law’ movement outside the household was restricted and therefore family members perceived that their nutritional need was less. Poverty affected food choice and families considered cost before nutritional value.
It is important to work with the whole household, particularly mothers-in-law, to improve maternal nutrition. We present five barriers to behaviour change: poverty; lack of knowledge about cheap nutritional food, the value of snacking, and cheap nutritional food that does not require cooking; sharing food; lack of self-confidence; and deference to household guardians. We discuss how we have targeted our interventions to develop knowledge, discuss strategies to overcome barriers, engage mothers-in-law, and build the confidence and social support networks of pregnant women.