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In a single-center review of antibiotic prescribing in COVID-19 patients, 10% of patients received antimicrobials, and inpatients encounters had the highest rate and spectrum of prescribing. Prescribing rate, spectrum, and duration appeared to increase with disease severity in inpatients. Antimicrobial prescribing in patients managed in ambulatory encounters was less common.
To inform the efficient allocation of testing resources, we evaluated the characteristics of those tested for COVID-19 to determine predictors of a positive test. Recent travel and exposure to a confirmed case were both highly predictive of positive testing. Symptom-based screening strategies alone may be inadequate to control the ongoing pandemic.
Introduction: Epidemiologic and modeling studies suggest that between 45 and 70% of individuals with chronic hepatitis C virus (HCV) infection in Canada remain undiagnosed. The Canadian Association for the Study of the Liver (CASL) recommends one-time screening of baby boomers (1945-1975). Screening programs in the US have shown a very high prevalence of previously undiagnosed HCV among patients seen in the emergency department (ED). We sought to assess the feasibility of implementing a targeted birth-cohort HCV screening program in a Canadian ED setting. Methods: Patients born from 1945 to 1975 presenting to the ED of a downtown Toronto hospital were offered HCV testing. Patients with life-threatening conditions, unable to provide verbal consent in English or intoxication were excluded. Blood samples were collected by finger prick on Dried Blood Spot (DBS) collection cards and tested for anti-HCV antibody with reflex to HCV RNA. Patients with positive HCV RNA were referred to a liver specialist. Results: During a 27-month period (July 2017 - Sept 2019), 8363 patients in the birth cohort presented to the ED during daytime hours. 80% (6714) met eligibility criteria, and 48.4% (3247) were offered testing. Screening was performed by non-medical staff (mean 8/day, median spots on DBS 4). 345 (10.6%) had been previously tested, and 639 (19.7%) declined. 2136 (65.8%) patients underwent testing: median age 58.4 years (40-82), 1117 male (52.3%). Of these, 45 patients (2.1%; 95% CI 1.5%-2.7%) were anti-HCV positive: 32 (76.2%) were HCV RNA positive, 10 (23.8%) negative and 3 not done due to inadequate DBS sample. 26 patients (81.3%) were linked to care and 3 (9.4%) lost to follow-up. HCV prevalence in the ED was significantly higher than the general Canadian population (2.1% vs 0.7%; p < 0.0001) but much lower than reported rates in American EDs (2.1% vs 10.3%; p < 0.0001). Conclusion: Acceptance of HCV screening in the ED birth cohort was high and easily performed using DBS to ensure the majority of positive samples were tested for HCV RNA. Challenges included implementation that limited number of people tested, and linkage to care for HCV positive patients. HCV prevalence among this ED birth cohort was higher than the general population but lower than seen in the ED in the US. This may in part be due to exclusion of individuals with more severe medical issues, refusal by higher risk subgroups, or population and healthcare system differences between countries.
The aim of the FP7-European funded project TRIMAGE is to create a trimodal, cost-effective imaging tool consisting of PET/MR/EEG to enable effective early diagnosis of schizophrenia.
In the scope of this project we are interested in the multimodal assessment of response inhibition. The loudness dependence of auditory evoked potential (LDAEP) is a suitable biomarker of inhibitory action in signal processing. Variations in response inhibition can have great impact on different aspects of life. Individuals with reduced capability of inhibitory control have a tendency to impulsive behavior. Studies showed that they have stronger LDAEP values. Patients with schizophrenia may exhibit alterations in the responsiveness to sensory stimuli. Thus, a reduced LDAEP was found in these patients. However, these deviances differed in clinical features of the disorder. Therefore, we would like to further elucidate the relationship between multimodal neuroimaging methods and dimensions of symptoms, observable behavior, personality traits and general psychopathological dysfunction.
A sample of 20 healthy controls and 20 patients with manifest schizophrenia will be examined with the LDAEP paradigm in a trimodal approach with customary imaging tools. PET measurements with the radiotracer [11C]-flumazenil will be used to assess the binding potentials of GABA-A receptors. MRS will provide data about GABA concentrations. Simultaneously recorded EEG-fMRI data will permit new insight in the relationship between LDAEP and impulsivity.
The project will use alternative approaches to psychiatric classification. Response inhibition in sensory processing will be investigated from different angles (biochemical, neurophysiological, and neuroanatomical) and combined with psychological characteristic values.
Disclosure of interest
The authors have not supplied their declaration of competing interest.
The 10-item Autism-Spectrum Quotient (AQ10) is a self-report questionnaire used in clinical and research settings as a diagnostic screening tool for autism in adults. The AQ10 is also increasingly being used to quantify trait autism along a unitary dimension and correlated against performance on other psychological/medical tasks. However, its psychometric properties have yet to be examined when used in this way. By analysing AQ10 data from a large non-clinical sample of adults (n = 6,595), we found that the AQ10 does not have a unifactorial factor structure, and instead appears to have several factors. The AQ10 also had poor internal reliability. Taken together, whilst the AQ10 has important clinical utility in screening for diagnosable autism, it may not be a psychometrically robust measure when administered in non-clinical samples from the general population. Therefore, we caution against its use as a measure of trait autism in future research.
Insurance industry practitioners have deep knowledge of their industry, but there is a lack of a simple-to-understand, practical blueprint on applying distributed ledger technology solutions, including blockchain. This paper provides a practical guide for actuaries, risk professionals, insurance companies and their Boards on blockchain, including an education piece to provide an understanding of the technology. Examples of real-world applications and use cases in insurance are provided to illustrate the capability of the technology. The current risks and challenges in adopting the technology are also considered. Finally, a checklist of issues to consider in adopting a blockchain solution for insurance business problems is provided.
Associations between childhood abuse and various psychotic illnesses in adulthood are commonly reported. We aim to examine associations between several reported childhood adverse events (sexual abuse, physical abuse, emotional abuse, neglect and interpersonal loss) among adults with diagnosed psychotic disorders and clinical and psychosocial outcomes.
Within a large epidemiological study, the 2010 Australian National Survey of Psychosis (Survey of High Impact Psychosis, SHIP), we used logistic regression to model childhood adverse events (any and specific types) on 18 clinical and psychosocial outcomes.
Eighty percent of SHIP participants (1466/1825) reported experiencing adverse events in childhood (sexual abuse, other types of abuse and interpersonal loss). Participants reporting any form of childhood adversity had higher odds for 12/18 outcomes we examined. Significant associations were observed with all psychosocial outcomes (social dysfunction, victimisation, offending and homelessness within the previous 12 months, and definite psychosocial stressor within 12 months of illness onset), with the strongest association for homelessness (odds ratio (OR) = 2.82). Common across all adverse event types was an association with lifetime depression, anxiety and a definite psychosocial stressor within 12 months of illness onset. When adverse event types were non-hierarchically coded, sexual abuse was associated with 11/18 outcomes, other types of abuse 13/18 and, interpersonal loss occurring in the absence of other forms of abuse was associated with fewer of the clinical and psychosocial outcomes, 4/18. When adverse events types were coded hierarchically (to isolate the effect of interpersonal loss in the absence of abuse), interpersonal loss was associated with lower odds of self-reproach (OR = 0.70), negative syndrome (OR = 0.75) and victimisation (OR = 0.82).
Adverse childhood experiences among people with psychosis are common, as are subsequent psychosocial stressors. Mental health professionals should routinely enquire about all types of adversities in this group and provide effective service responses. Childhood abuse, including sexual abuse, may contribute to subsequent adversity, poor psychosocial functioning and complex needs among people with psychosis. Longitudinal research to better understand these relationships is needed, as are studies which evaluate the effectiveness of preventative interventions in high-risk groups.
To examine factors that influence decision-making, preferences, and plans related to advance care planning (ACP) and end-of-life care among persons with dementia and their caregivers, and examine how these may differ by race.
13 geographically dispersed Alzheimer’s Disease Centers across the United States.
431 racially diverse caregivers of persons with dementia.
Survey on “Care Planning for Individuals with Dementia.”
The respondents were knowledgeable about dementia and hospice care, indicated the person with dementia would want comfort care at the end stage of illness, and reported high levels of both legal ACP (e.g., living will; 87%) and informal ACP discussions (79%) for the person with dementia. However, notable racial differences were present. Relative to white persons with dementia, African American persons with dementia were reported to have a lower preference for comfort care (81% vs. 58%) and lower rates of completion of legal ACP (89% vs. 73%). Racial differences in ACP and care preferences were also reflected in geographic differences. Additionally, African American study partners had a lower level of knowledge about dementia and reported a greater influence of religious/spiritual beliefs on the desired types of medical treatments. Notably, all respondents indicated that more information about the stages of dementia and end-of-life health care options would be helpful.
Educational programs may be useful in reducing racial differences in attitudes towards ACP. These programs could focus on the clinical course of dementia and issues related to end-of-life care, including the importance of ACP.
Recognising the significant extent of poor-quality care and human rights issues in mental health, the World Health Organization launched the QualityRights initiative in 2013 as a practical tool for implementing human rights standards including the United Nations Convention on Rights of Persons with Disabilities (CRPD) at the ground level.
To describe the first large-scale implementation and evaluation of QualityRights as a scalable human rights-based approach in public mental health services in Gujarat, India.
This is a pragmatic trial involving implementation of QualityRights at six public mental health services chosen by the Government of Gujarat. For comparison, we identified three other public mental health services in Gujarat that did not receive the QualityRights intervention.
Over a 12-month period, the quality of services provided by those services receiving the QualityRights intervention improved significantly. Staff in these services showed substantially improved attitudes towards service users (effect sizes 0.50–0.17), and service users reported feeling significantly more empowered (effect size 0.07) and satisfied with the services offered (effect size 0.09). Caregivers at the intervention services also reported a moderately reduced burden of care (effect size 0.15).
To date, some countries are hesitant to reforming mental health services in line with the CRPD, which is partially attributable to a lack of knowledge and understanding about how this can be achieved. This evaluation shows that QualityRights can be effectively implemented even in resource-constrained settings and has a significant impact on the quality of mental health services.
To study the clinical outcomes of a posterior nasoseptal flap used in the endonasal reconstruction of anterior skull base defects.
The early harvested flap was used to reconstruct anterior skull base defects in patients with high-flow on-table cerebrospinal fluid leak. Post-operatively, the patients were analysed for cerebrospinal fluid leak and bleeding.
Of the 100 patients, 87 had macro defects while 13 had micro defects. Non-secretary lesions were present in 60 patients, while secretary lesions were present in 40 patients. Cerebrospinal fluid leak was present in all the patients undergoing surgery, and the majority of them had a lumbar drain fitted. Post-operatively, two patients experienced bleeding and only two patients had a cerebrospinal fluid leak.
The use of a posterior nasoseptal flap for reconstruction of the anterior skull base amongst patients with a high-flow intra-operative cerebrospinal fluid leak can help prevent post-operative cerebrospinal fluid leak. Its applicability to wide patient profiles, with respect to age, size of defect and diagnosis, make it a versatile choice for reconstruction after endonasal anterior skull base surgical procedures.
When Hurricane Harvey landed along the Texas coast on August 25, 2017, it caused massive flooding and damage and displaced tens of thousands of residents of Harris County, Texas. Between August 29 and September 23, Harris County, along with community partners, operated a megashelter at NRG Center, which housed 3365 residents at its peak. Harris County Public Health conducted comprehensive public health surveillance and response at NRG, which comprised disease identification through daily medical record reviews, nightly “cot-to-cot” resident health surveys, and epidemiological consultations; messaging and communications; and implementation of control measures including stringent isolation and hygiene practices, vaccinations, and treatment. Despite the lengthy operation at the densely populated shelter, an early seasonal influenza A (H3) outbreak of 20 cases was quickly identified and confined. Influenza outbreaks in large evacuation shelters after a disaster pose a significant threat to populations already experiencing severe stressors. A holistic surveillance and response model, which consists of coordinated partnerships with onsite agencies, in-time epidemiological consultations, predesigned survey tools, trained staff, enhanced isolation and hygiene practices, and sufficient vaccines, is essential for effective disease identification and control. The lessons learned and successes achieved from this outbreak may serve for future disaster response settings. (Disaster Med Public Health Preparedness. 2019;13:97-101)
In June 2012, the Botswana Ministry of Health and Wellness (MOHW; Gaborone, Botswana) initiated a national Emergency Medical Services (EMS) system in response to significant morbidity and mortality associated with prehospital emergencies. The MOHW requested external expertise to train its developing workforce. Simulation-based training was planned to equip these health care providers with clinical knowledge, procedural skills, and communication techniques.
The objective of this study was to assess the educational needs of the pioneer Botswana MOHW EMS providers based on retrospective EMS logbook review and EMS provider feedback to guide development of a novel educational curriculum.
Data were abstracted from a representative sample of the Gaborone, Botswana MOHW EMS response log from 2013-2014 and were quantified into the five most common call types for both adults and children. Informal focus groups with health professionals and EMS staff, as well as surveys, were used to rank common response call types and self-perceived educational needs.
Based on 1,506 calls, the most common adult response calls were for obstetric emergencies, altered mental status, gastrointestinal/abdominal pain, trauma, gynecological emergencies, and cardiovascular and respiratory distress-related emergencies. The most common pediatric response calls were for respiratory distress, gastrointestinal complaints/dehydration, trauma and musculoskeletal injuries, newborn delivery, seizures, and toxic ingestion/exposure. The EMS providers identified these same chief complaints as priorities for training using the qualitative approach. A locally relevant, simulation-based curriculum for the Botswana MOHW EMS system was developed and implemented based on these data.
: Trauma, respiratory distress, gastrointestinal complaints, and puerperal/perinatal emergencies were common conditions for all age groups. Other age-specific conditions were also identified as educational needs based on epidemiologic data and provider feedback. This needs assessment may be useful when designing locally relevant EMS curricula in other low-income and middle-income countries.GlombNW, KosokoAA, DoughtyCB, RusMC, ShahMI, CoxM, GalapiC, ParkesPS, KumarS, LabaB.Needs Assessment for Simulation Training for Prehospital Providers in Botswana. Prehosp Disaster Med. 2018;33(6):621–626.
We reviewed all patients who were supported with extracorporeal membrane oxygenation and/or ventricular assist device at our institution in order to describe diagnostic characteristics and assess mortality.
A retrospective cohort study was performed including all patients supported with extracorporeal membrane oxygenation and/or ventricular assist device from our first case (8 October, 1998) through 25 July, 2016. The primary outcome of interest was mortality, which was modelled by the Kaplan–Meier method.
A total of 223 patients underwent 241 extracorporeal membrane oxygenation runs. Median support time was 4.0 days, ranging from 0.04 to 55.8 days, with a mean of 6.4±7.0 days. Mean (±SD) age at initiation was 727.4 days (±146.9 days). Indications for extracorporeal membrane oxygenation were stratified by primary indication: cardiac extracorporeal membrane oxygenation (n=175; 72.6%) or respiratory extracorporeal membrane oxygenation (n=66; 27.4%). The most frequent diagnosis for cardiac extracorporeal membrane oxygenation patients was hypoplastic left heart syndrome or hypoplastic left heart syndrome-related malformation (n=55 patients with HLHS who underwent 64 extracorporeal membrane oxygenation runs). For respiratory extracorporeal membrane oxygenation, the most frequent diagnosis was congenital diaphragmatic hernia (n=22). A total of 24 patients underwent 26 ventricular assist device runs. Median support time was 7 days, ranging from 0 to 75 days, with a mean of 15.3±18.8 days. Mean age at initiation of ventricular assist device was 2530.8±660.2 days (6.93±1.81 years). Cardiomyopathy/myocarditis was the most frequent indication for ventricular assist device placement (n=14; 53.8%). Survival to discharge was 42.2% for extracorporeal membrane oxygenation patients and 54.2% for ventricular assist device patients. Kaplan–Meier 1-year survival was as follows: all patients, 41.0%; extracorporeal membrane oxygenation patients, 41.0%; and ventricular assist device patients, 43.2%. Kaplan–Meier 5-year survival was as follows: all patients, 39.7%; extracorporeal membrane oxygenation patients, 39.7%; and ventricular assist device patients, 43.2%.
This single-institutional 18-year review documents the differential probability of survival for various sub-groups of patients who require support with extracorporeal membrane oxygenation or ventricular assist device. The indication for mechanical circulatory support, underlying diagnosis, age, and setting in which cannulation occurs may affect survival after extracorporeal membrane oxygenation and ventricular assist device. The Kaplan–Meier analyses in this study demonstrate that patients who survive to hospital discharge have an excellent chance of longer-term survival.
Ischemic stroke treatment is time-sensitive, and barriers to providing prehospital care encountered by Emergency Medical Services (EMS) providers have been under-studied.
This study described barriers to providing prehospital care, identified predictors of these barriers, and assessed the impact of these barriers on EMS on-scene time and administration of tissue plasminogen activator (tPA) in the emergency department (ED).
A retrospective cohort study was performed using the Get With The Guidelines-Stroke (GWTG-S; American Heart Association [AHA]; Dallas, Texas USA) registry at two hospitals to identify ischemic stroke patients arriving by EMS. Variables were abstracted from prehospital and hospital medical records and merged with registry data. Barriers to care were grouped into themes. Logistic regression was used to identify predictors of barriers to care, and bi-variate tests were used to assess differences in EMS on-scene time and the proportion of patients receiving tPA between patients with and without barriers.
Barriers to providing prehospital care were documented for 15.5% of patients: 29.6% related to access, 26.7% communication, 23.0% extrication and transportation, 20.0% refusal, and 14.1% assessment/management. Non-white and non-black race (OR: 3.69; 95% CI, 1.63-8.36) and living alone (OR: 1.53; 95% CI, 1.05-2.23) were associated with greater odds of barriers to providing care. The EMS on-scene time was ≥15 minutes for 70.4% of patients who had a barrier to care, compared with 49.0% of patients who did not (P<.001). There was no significant difference in the proportion of patients who were administered tPA between those with and without barriers to care (14.1% vs 19.2%; P=.159).
Barriers to providing prehospital care were documented for a sizable proportion of ischemic stroke patients, with the majority related to patient access and communication, and occurred more frequently among non-white and non-black patients and those living alone. Although EMS on-scene time was longer for patients with barriers to care, the proportion of patients receiving tPA in the ED did not differ.
LiT, CushmanJT, ShahMN, KellyAG, RichDQ, JonesCMC. Barriers to Providing Prehospital Care to Ischemic Stroke Patients: Predictors and Impact on Care. Prehosp Disaster Med.2018;33(5):501–507.
Little is known about what motivates people to enroll in research registries. The purpose of this study is to identify facilitators of registry enrollment among diverse older adults.
Participants completed an 18-item Research Interest Assessment Tool. We used logistic regression analyses to examine responses across participants and by race and gender.
Participants (N=374) were 58% black, 76% women, with a mean age of 68.2 years. All participants were motivated to maintain their memory while aging. Facilitators of registry enrolled varied by both race and gender. Notably, blacks (estimate=0.71, p<0.0001) and women (estimate=0.32, p=0.03) were more willing to enroll in the registry due to home visits compared with whites and men, respectively.
Researchers must consider participant desire for maintaining memory while aging and home visits when designing culturally tailored registries.
Using time-resolved laser-scanning confocal microscopy and ultrafast optical pump/THz probe spectroscopy, we measure photoluminescence (PL) and THz-conductivity in perovskite micro-crystals and films. PL quenching and lifetime variations occur from local heterogeneity. Ultrafast THz-spectra measure sharp quantum transitions from excitonic Rydberg states, providing weakly bound excitons with a binding energy of ~13.5 meV at low temperatures. Ab-initio electronic structure calculations give a direct band gap of 1.64 eV, a dielectric constant of ~18, heavy electrons, and light holes, resulting in weakly bound excitons, consistent with the binding energies from the experiment. The complementary spectroscopy and simulations reveal fundamental insights into perovskite light-matter interactions.
We consider the actions of (semi)groups on a locally compact group by automorphisms. We show the equivalence of distality and pointwise distality for the actions of a certain class of groups. We obtain a decomposition for contraction groups of an automorphism under certain conditions. We give a necessary and sufficient condition for distality of an automorphism in terms of its contraction group. We compare classes of (pointwise) distal groups and groups whose closed subgroups are unimodular. In particular, we study relations between distality, unimodularity and contraction subgroups.
Determining the most appropriate level of care for patients in the prehospital setting during medical emergencies is essential. A large body of literature suggests that, compared with Basic Life Support (BLS) care, Advanced Life Support (ALS) care is not associated with increased patient survival or decreased mortality. The purpose of this special report is to synthesize the literature to identify common study design and analytic challenges in research studies that examine the effect of ALS, compared to BLS, on patient outcomes. The challenges discussed in this report include: (1) choice of outcome measure; (2) logistic regression modeling of common outcomes; (3) baseline differences between study groups (confounding); (4) inappropriate statistical adjustment; and (5) inclusion of patients who are no longer at risk for the outcome. These challenges may affect the results of studies, and thus, conclusions of studies regarding the effect of level of prehospital care on patient outcomes should require cautious interpretation. Specific alternatives for avoiding these challenges are presented.
LiT, JonesCMC, ShahMN, CushmanJT, JuskoTA. Methodological Challenges in Studies Comparing Prehospital Advanced Life Support with Basic Life Support. Prehosp Disaster Med. 2017;32(4):444–450.
We compared the cost-effectiveness (CE) of an active case-finding (ACF) programme for household contacts of tuberculosis (TB) cases enrolled in first-line treatment to routine passive case-finding (PCF) within an established national TB programme in Peru. Decision analysis was used to model detection of TB in household contacts through: (1) self-report of symptomatic cases for evaluation (PCF), (2) a provider-initiated ACF programme, (3) addition of an Xpert MTB/RIF diagnostic test for a single sputum sample from household contacts, and (4) all strategies combined. CE was calculated as the incremental cost-effectiveness ratio (ICER) in terms of US dollars per disability-adjusted life years (DALYs) averted. Compared to PCF alone, ACF for household contacts resulted in an ICER of $2155 per DALY averted. The addition of the Xpert MTB/RIF diagnostic test resulted in an ICER of $3275 per DALY averted within a PCF programme and $3399 per DALY averted when an ACF programme was included. Provider-initiated ACF of household contacts in an urban setting of Lima, Peru can be highly cost-effective, even including costs to seek out contacts and perform an Xpert/MTB RIF test. ACF including Xpert MTB/RIF was not cost-effective if TB cases detected had high rates of default from treatment or poor outcomes.
The Learning Health System Network clinical data research network includes academic medical centers, health-care systems, public health departments, and health plans, and is designed to facilitate outcomes research, pragmatic trials, comparative effectiveness research, and evaluation of population health interventions.
The Learning Health System Network is 1 of 13 clinical data research networks assembled to create, in partnership with 20 patient-powered research networks, a National Patient-Centered Clinical Research Network.
Results and Conclusions
Herein, we describe the Learning Health System Network as an emerging resource for translational research, providing details on the governance and organizational structure of the network, the key milestones of the current funding period, and challenges and opportunities for collaborative science leveraging the network.