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This SHEA white paper identifies knowledge gaps and challenges in healthcare epidemiology research related to COVID-19 with a focus on core principles of healthcare epidemiology. These gaps, revealed during the worst phases of the COVID-19 pandemic, are described in 10 sections: epidemiology, outbreak investigation, surveillance, isolation precaution practices, personal protective equipment (PPE), environmental contamination and disinfection, drug and supply shortages, antimicrobial stewardship, healthcare personnel (HCP) occupational safety, and return to work policies. Each section highlights three critical healthcare epidemiology research questions with detailed description provided in supplemental materials. This research agenda calls for translational studies from laboratory-based basic science research to well-designed, large-scale studies and health outcomes research. Research gaps and challenges related to nursing homes and social disparities are included. Collaborations across various disciplines, expertise and across diverse geographic locations will be critical.
The apocalyptic and postapocalyptic are staples of young adult fiction. While sometimes conflated with the dystopian genre, young adult postapocalyptic fiction (YAPA) is neither simply dystopian nor a watered-down version of adult postapocalyptic fiction. Young adult postapocalyptic fiction provides a stage on which young protagonists question the meaning and purpose of community and develop innovative responses to issues of identity and agency under challenging conditions (whether those come from zombies, pandemic disease, nuclear war, environmental degradation, etc.). YAPA novels include some classic postapocalyptic accounts of survival after nuclear war, as in Robert O’Brien’s Z for Zachariah (1974) and the more recent popular series starting with Suzanne Collins’s The Hunger Games (2008) and including James Dashner’s Maze Runner (2009), Scott Westerfeld’s Uglies (2005), and Veronica Roth’s Divergent (2011). These novels are to be contrasted with other YAPA novels, such as Paolo Bacigalupi’s Ship Breaker or Octavia Butler’s Parable series. In each of those novels, the fact of living after a devastating event (or series of events) is not simply the setting of the novel but also a feature of the reader’s experience with the novel.
In a survey of hospitals and of patients with Clostridioides difficile infection (CDI), we found that most facilities had educational materials or protocols for education of CDI patients. However, approximately half of CDI patients did not recall receiving education during their admission, and knowledge deficits regarding CDI prevention were common.
Resolving the detailed hydrodynamics of a slender body immersed in highly viscous Newtonian fluid has been the subject of extensive research, applicable to a broad range of biological and physical scenarios. In this work, we expand upon classical theories developed over the past fifty years, deriving an algebraically accurate slender-body theory that may be applied to a wide variety of body shapes, ranging from biologically inspired tapering flagella to highly oscillatory body geometries with only weak constraints, most significantly requiring that cross-sections be circular. Inspired by well known analytic results for the flow around a prolate ellipsoid, we pose an ansatz for the velocity field in terms of a regular integral of regularised Stokes-flow singularities with prescribed, spatially varying regularisation parameters. A detailed asymptotic analysis is presented, seeking a uniformly valid expansion of the ansatz integral, accurate at leading algebraic order in the geometry aspect ratio, to enforce no-slip boundary conditions and thus analytically justify the slender-body theory developed in this framework. The regularisation within the ansatz additionally affords significant computational simplicity for the subsequent slender-body theory, with no specialised quadrature or numerical techniques required to evaluate the regular integral. Furthermore, in the special case of slender bodies with a straight centreline in uniform flow, we derive a slender-body theory that is particularly straightforward via use of the analytic solution for a prolate ellipsoid. We evidence the validity of our simple theory with explicit numerical examples for a wide variety of slender bodies, and highlight a potential robustness of our methodology beyond its rigorously justified scope.
Bipolar disorder (BPD) and alcoholism are strongly comorbid and both have significant genetic influences but no consistent genetic vulnerability has been found. We aimed to find bipolar-alcoholism vulnerability genes.
A genome-wide association study (GWAS) of 510 patients with bipolar disorder (BPD), of whom 143 met Research Diagnostic Criteria (RDC) alcoholism diagnoses, and 506 ancestrally matched supernormal controls. We genotyped 372K genetic markers on an Affymetrix 500K-array. Chi-square analysis of allelic association using PLINK, and permutation testing for gene-wise association of genes previously associated with alcoholism-related phenotypes using COMBASSOC, were performed.
No marker met genomewide significance. Gene-wise analyses of markers clustering near genes already implicated in alcoholism, but which were not associated in non-alcoholic BPD, were: Cadherin-11 (CDH11, p = 6 × 10-4), Exportin 7 (XPO7), neuromedin-U receptor 2 (NMUR2), collagen type XI-alpha 2 (COL11A2) and Semaphorin-5A (SEMA5A).
These genes replicated prior genetic reports implicating “connectivity” (adhesion, migration and neuronal signalling) genes in addictions and comorbid BPD. Connectivity genes regulate neuronal connections during development and play roles in later neuroadaptive and mnemonic processes. These processes may influence addiction vulnerability, as seen clinically in denial, cognitive impairment, and repetitive substance misuse and relapse behaviour. We propose that we have identified genes i) increasing susceptibility to alcoholism that could be unmasked or released by the presence of bipolar affective disorder; ii) and genes increasing susceptibility to affective disorder that also predispose to secondary alcoholism. We were limited by small sample size. Larger future studies are needed.
We recently demonstrated that weight gain could be prevented in young people experiencing a first-episode of psychosis commencing treatment with antipsychotics. A 12-week, intensive lifestyle and life skills intervention – the Keeping the Body in Mind program, – was delivered by dedicated nursing, dietetic and exercise physiology clinicians, for new referrals with < one month of antipsychotic exposure. (Curtis et al., Early intervention in psychiatry, in press). At the conclusion of the intervention the 16 young people participating in the program experienced a mean weight gain of 1.8 kilograms, and a mean increase in waist circumference of 0.1 centimeters. The participants were followed up for two years after initial referral.
During the two-year follow-up, participants had continuing access to an in house gym and weekly cooking groups, but without the same intensity of follow-up. Two year follow-up data were obtained from 11 participants form the original cohort.
Mean weight gain at two-year follow-up was 0.90 (SD 8.7) kilograms, and this difference was not statistically significant [t (10) = 0.3, NS]. Waist circumference decreased by 0.7 (SD 7.7) centimeters, which was not t statistically significant [t (10) = 0.3, NS]. Nine of the participants (82%) did not experience clinically significant weight gain two years after initiation of antipsychotic medication.
This two-year follow-up data demonstrated that it is feasible to prevent weight gain in youth with first-episode psychosis over the first two years of treatment.
Disclosure of interest
The authors have not supplied their declaration of competing interest.
Nutrition interventions are critical for weight management and cardiometabolic risk reduction in people experiencing severe mental illness (SMI). As mental health teams evolve to incorporate nutrition interventions, evidence needs to guide clinical practice.
A systematic review and meta-analysis was performed to assess whether nutrition interventions improve:
– anthropometric and biochemical measures,
– nutritional intake of people experiencing SMI.
To evaluate the effectiveness of a dietician-led nutrition intervention, as part of a broader lifestyle intervention, in the early stages of antipsychotic prescription.
An electronic database search was conducted to identify all trials with nutritional components. Included trials were pooled for meta-analysis. Meta-regression analyses were run on potential anthropometric moderators. Weekly individualised dietetic consultations plus group cooking classes were then offered to clients attending a Community Early Psychosis Programme, who had recently commenced antipsychotics for a 12-week period.
From pooled trials, nutrition interventions resulted in significant weight loss (19 studies, g = –0.39, P < 0.001), reduced BMI (17 studies, g = –0.40, P < 0.001), decreased waist circumference (10 studies, g = –0.27, P < 0.001) and lower blood glucose levels (5 studies, g = –0.37, P = 0.02). Dietician-led interventions (g = –0.90) and trials focussing on preventing weight gain (g = –0.61) were the most effective. The 12-week nutrition intervention resulted in a 47% reduction in discretionary (junk) food intake (P < 0.001) and reductions in daily energy (–24%, P < 0.001) and sodium intakes (–26%, P < 0.001), while improving diet quality (P < 0.05).
Evidence supports the inclusion of nutrition interventions as part of standard care for preventing weight gain and metabolic deterioration among people with SMI.
Disclosure of interest
The authors have not supplied their declaration of competing interest.
In this paper, we examine some of the physics behind Vertical Take-Off and Landing (VTOL) flying machines, and some of the emerging technologies that are driving the recent upsurge of new VTOL projects. The paper attempts to put these into context by examining some of the projects that have been publicised over the past couple of years, particularly those that transition from hovering into wing-borne flight. Although much progress has been made, there still needs to be significant breakthroughs in technologies, particularly battery technology, before the dream of fast, quiet and environmentally friendly inter-city VTOL aircraft can be realised.
Dicamba-resistant (DR) kochia is an increasing concern for growers in the US Great Plains, including Kansas. Greenhouse and field experiments (Garden City and Tribune, KS, in the 2014 to 2015 growing season) were conducted to characterize the dicamba resistance levels in two recently evolved DR kochia accessions collected from fallow fields (wheat–sorghum–fallow rotation) near Hays, KS, and to determine the effectiveness of various PRE herbicide tank mixtures applied in fall or spring prior to the fallow year. Dicamba dose–response studies indicated that the KS-110 and KS-113 accessions had 5- to 8-fold resistance to dicamba, respectively, relative to a dicamba-susceptible (DS) accession. In separate field studies, atrazine-based PRE herbicide tank mixtures, dicamba + pendimethalin + sulfentrazone, and metribuzin + sulfentrazone when applied in the spring had excellent kochia control (85% to 95%) for 3 to 4 mo at the Garden City and Tribune sites. In contrast, kochia control with those PRE herbicide tank mixtures when applied in the fall did not exceed 79% at the later evaluation dates. In conclusion, the tested kochia accessions from western Kansas had evolved moderate to high levels of resistance to dicamba. Growers should utilize these effective PRE herbicide tank mixtures (multiple sites of action) in early spring to manage kochia seed bank during the summer fallow phase of this 3-yr crop rotation (wheat–corn/sorghum–fallow) in the Central Great Plains.
Current methods of control recruitment for case-control studies can be slow (a particular issue for outbreak investigations), resource-intensive and subject to a range of biases. Commercial market panels are a potential source of rapidly recruited controls. Our study evaluated food exposure data from these panel controls, compared with an established reference dataset. Market panel data were collected from two companies using retrospective internet-based surveys; these were compared with reference data from the National Diet and Nutrition Survey (NDNS). We used logistic regression to calculate adjusted odds ratios to compare exposure to each of the 71 food items between the market panel and NDNS participants. We compared 2103 panel controls with 2696 reference participants. Adjusted for socio-demographic factors, exposure to 90% of foods was statistically different between both panels and the reference data. However, these differences were likely to be of limited practical importance for 89% of Panel A foods and 79% of Panel B foods. Market panel food exposures were comparable with reference data for common food exposures but more likely to be different for uncommon exposures. This approach should be considered for outbreak investigation, in conjunction with other considerations such as population at risk, timeliness of response and study resources.
To test the hypothesis that long-term care facility (LTCF) residents with Clostridium difficile infection (CDI) or asymptomatic carriage of toxigenic strains are an important source of transmission in the LTCF and in the hospital during acute-care admissions.
A 6-month cohort study with identification of transmission events was conducted based on tracking of patient movement combined with restriction endonuclease analysis (REA) and whole-genome sequencing (WGS).
Veterans Affairs hospital and affiliated LTCF.
The study included 29 LTCF residents identified as asymptomatic carriers of toxigenic C. difficile based on every other week perirectal screening and 37 healthcare facility-associated CDI cases (ie, diagnosis >3 days after admission or within 4 weeks of discharge to the community), including 26 hospital-associated and 11 LTCF-associated cases.
Of the 37 CDI cases, 7 (18·9%) were linked to LTCF residents with LTCF-associated CDI or asymptomatic carriage, including 3 of 26 hospital-associated CDI cases (11·5%) and 4 of 11 LTCF-associated cases (36·4%). Of the 7 transmissions linked to LTCF residents, 5 (71·4%) were linked to asymptomatic carriers versus 2 (28·6%) to CDI cases, and all involved transmission of epidemic BI/NAP1/027 strains. No incident hospital-associated CDI cases were linked to other hospital-associated CDI cases.
Our findings suggest that LTCF residents with asymptomatic carriage of C. difficile or CDI contribute to transmission both in the LTCF and in the affiliated hospital during acute-care admissions. Greater emphasis on infection control measures and antimicrobial stewardship in LTCFs is needed, and these efforts should focus on LTCF residents during hospital admissions.
To what extent is there spatial and temporal patterning in the spread of our genus around the planet, and what environmental and behavioural factors specify this patterning? The prevailing model of Pleistocene dispersals of Homo holds that this process was essentially terrestrial, with oceans and seas inhibiting and directing the movement of hominins out of Africa (e.g. Mellars 2006; Dennell & Petraglia 2012; Gamble 2013), although some scholars propose short-range maritime hops at both the Strait of Gibraltar and Bab-el-Mandeb (Lambeck et al.2011; Rolland 2013). The relatively recent discovery of stone tools with apparently Lower and Middle Palaeolithic characteristics on islands in the eastern Mediterranean and in Island Southeast Asia (ISEA) has, however, been used by some scholars to challenge this terrestrial model.
Despite overwhelming evidence demonstrating a persisting gap in life expectancy between those with psychotic illness and the general population, there has been no widespread implementation of interventions to improve the physical wellbeing of people with psychotic illness. This article explores opportunities to ‘Bridge the Gap’ in life expectancy. We describe an Australian evidence-based intervention that has substantially improved the physical health of young people recently commenced on antipsychotic medication. Further epidemiological research, accompanied by cultural change within mental health services, is an essential precursor to the implementation of effective and sustainable lifestyle interventions. There are other relatively neglected areas of physical wellbeing for people with psychotic illness, such as screening and diagnosis of malignancies, which need more research and clinical attention. While there has been progress with intervention development and evaluation, translation of evidence-based short-term intervention studies into feasible and sustainable system-wide changes within routine mental health service settings remains a challenge. Developing an implementation framework to support such change is an urgent priority so as to bridge the persisting premature mortality in people living with psychotic illness.
Placebo responses raise significant challenges for the design of clinical trials. We report changes in agitation outcomes in the placebo arm of a recent trial of citalopram for agitation in Alzheimer's disease (CitAD).
In the CitAD study, all participants and caregivers received a psychosocial intervention and 92 were assigned to placebo for nine weeks. Outcomes included Neurobehavioral Rating Scale agitation subscale (NBRS-A), modified AD Cooperative Study-Clinical Global Impression of Change (CGIC), Cohen-Mansfield Agitation Inventory (CMAI), the Neuropsychiatric Inventory (NPI) Agitation/Aggression domain (NPI A/A) and Total (NPI-Total) and ADLs. Continuous outcomes were analyzed with mixed-effects modeling and dichotomous outcomes with logistic regression.
Agitation outcomes improved over nine weeks: NBRS-A mean (SD) decreased from 7.8 (3.0) at baseline to 5.4 (3.2), CMAI from 28.7 (6.7) to 26.7 (7.4), NPI A/A from 8.0 (2.4) to 4.9 (3.8), and NPI-Total from 37.3 (17.7) to 28.4 (22.1). The proportion of CGI-C agitation responders ranged from 21 to 29% and was significantly different from zero. MMSE improved from 14.4 (6.9) to 15.7 (7.2) and ADLs similarly improved. Most of the improvement was observed by three weeks and was sustained through nine weeks. The major predictor of improvement in each agitation measure was a higher baseline score in that measure.
We observed significant placebo response which may be due to regression to the mean, response to a psychosocial intervention, natural course of symptoms, or nonspecific benefits of participation in a trial.
Marcus Aurelius (AD 121–180) was the renowned emperor of Imperial Rome from AD 161 until his death. However, his civic virtues and military victories will scarcely be mentioned in this chapter since Marcus Aurelius’ place in psychology comes from his only book, now known as the Meditations. The perspective on psychology described in the Meditations has long been influential in Western civilization and appears to be having a major resurgence at the beginning of the twenty-first century. The essence of Marcus Aurelius’ Stoic perspective on psychology is that if people adopt a few basic principles of living, they will have everything they need for coping with life’s travails with serenity, virtue, and a degree of happiness.
Much as Plato inspired philosophical movements in the ancient world called “Platonism” and later “Neoplatonism,” Marcus Aurelius became a leading figure in a philosophical movement called “Stoicism,” which had had a centuries-long history prior to his lifetime. By his time, the goals of “late Stoicism” had been narrowed down to a philosophy of life that laid out the rules for virtue and happiness (Hays’ Introduction in Aurelius, circa AD 170/2003, pp. xx–xxxv). Two other late Stoic writers still celebrated today are Seneca (circa AD 64/1969) and Epictetus (see Seddon, 2005). With the aid of Marcus Aurelius’ powerful and moving writing, late Stoicism was much more than just an academic philosophy; it became the philosophy of some of Rome’s great leaders, including some of its emperors. Late Stoicism:
… became the true religion of the educated classes [in Rome]. It furnished the principles of virtue, coloured the noblest literature of the time, and guided all the developments of moral enthusiasm.