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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 Lifetech Multifunctional occluder is a versatile device with an improved delivery and flexibility that reduces the risk of atrioventricular block. This is a retrospective, descriptive, pilot study done in 25 patients who underwent transcatheter closure of ventricular septal defect using Lifetech Multifunctional occluder from February 2017 to January 2018.
The average age was 9.32 ± 7.20 years, with a range from 1 to 32 years. Procedural success was 100% with no case needing a change of device size. Closure rate on follow up was at 42% (10/24), 52% (12/23), and 81% (17/21) at 1 day, 1 month, and 6 months, respectively. At 6-month follow up, pre-procedure tricuspid regurgitation disappeared by 38%. However, the incidence of new onset tricuspid regurgitation to trace was 16% (2) and mild 8% (1). Pre-procedure mild aortic regurgitation remained the same status throughout the 6-month follow up. Closure of the defect did not improve or worsen the aortic regurgitation. Post-transcatheter closure of ventricular septal defect with mild infundibular hypertrophy, the 1-year-old patient had resolution of the infundibular hypertrophy after 6 months but our 9-year-old patient had persistence of the mild infundibular hypertrophy even after 6 months. One patient (4%) developed transient widened QRS complexes post-transcatheter closure that resolved after 1 month. In total, 92% of the patients had no periprocedural complications. While one patient each had an inadvertent urinary bladder puncture and device embolisation.
Our retrospective review of the procedural and short-term outcomes of transcatheter closure of ventricular septal defect sizes 2–10 mm, using the Lifetech Multifunctional occluder, appears to be safe and effective. However, long-term follow up is warranted.
To elucidate mechanisms across family function, home environment and eating behaviours within sociocultural context among Hispanic youth.
Two models tested via path analysis (youth fruit and vegetable (FV) consumption; empty energy consumption) using data from the Study of Latino Youth (2011–2013).
Chicago, IL; Miami, FL; Bronx, NY; San Diego, CA.
Youth (8–16-year-olds), n 1466.
Youth ate 2·4 servings of FV per d and received 27 % of total energy from empty energies. Perceiving higher acculturative stress was indirectly associated with lower FV consumption via a pathway of low family function and family support for FV (β = −0·013, P < 0·001) and via lower family closeness and family support (β = −0·004, P = 0·004). Being >12-year-olds was indirectly associated with lower FV consumption via lower family closeness and family support (β = −0·006, P < 0·001). Household food security was indirectly associated with greater FV consumption via family closeness and family support (β = 0·005, P = 0·003). In contrast, perceiving higher acculturative stress was indirectly associated with higher empty energy consumption (via family closeness and family support: β = 0·003, P = 0·028 and via low family function and low family support: β = 0·008, P = 0·05). Being older was associated with higher consumption of empty energies via family closeness (related to family support: β = 0·04, P = 0·016; parenting strategies for eating: β = 0·002, P = 0·049).
Findings suggest pathways of influence across demographic and sociocultural context, family dynamics and home environment. The directionality of these associations needs confirmation using longitudinal data.
Leg weakness (LW) issues are a great concern for pig breeding industry. And it also has a serious impact on animal welfare. To dissect the genetic architecture of limb-and-hoof firmness in commercial pigs, a genome-wide association study was conducted on bone mineral density (BMD) in three sow populations, including Duroc, Landrace and Yorkshire. The BMD data were obtained by ultrasound technology from 812 pigs (including Duroc 115, Landrace 243 and Yorkshire 454). In addition, all pigs were genotyped using genome-by-sequencing and a total of 224 162 single-nucleotide polymorphisms (SNPs) were obtained. After quality control, 218 141 SNPs were used for subsequent genome-wide association analysis. Nine significant associations were identified on chromosomes 3, 5, 6, 7, 9, 10, 12 and 18 that passed Bonferroni correction threshold of 0.05/(total SNP numbers). The most significant locus that associated with BMD (P value = 1.92e−14) was detected at approximately 41.7 Mb on SSC6 (SSC stands for Sus scrofa chromosome). CUL7, PTK7, SRF, VEGFA, RHEB, PRKAR1A and TPO that are located near the lead SNP of significant loci were highlighted as functionally plausible candidate genes for sow limb-and-hoof firmness. Moreover, we also applied a new method to measure the BMD data of pigs by ultrasound technology. The results provide an insight into the genetic architecture of LW and can also help to improve animal welfare in pigs.
Background: In patients with acute hip fracture, a fascia iliaca compartment block (FICB) has been shown to provide effective non-opioid analgesia, reduce the incidence of pneumonia, and potentially decrease the rate of delirium . However, this procedure was infrequently used in the St. Michael's Hospital (SMH) emergency department (ED). Aim Statement: Our aim was to increase the proportion of patients with hip fracture receiving FICB in the ED to 50% in six months. Measures & Design: We completed two Plan-Do-Study-Act (PDSA) cycles, measuring rates of FICB before and after each cycle. The first was a departmental rounds presentation with information about the process and benefits of FICB, addressing barriers identified by surveying the group. The second cycle included a bundle of interventions comprising of an “instruction card” with the steps required to do the procedure, access to a video tutorial, and a list of experienced physicians willing to help less experienced providers perform FICB. Evaluation/Results: In the three months prior to the project, the rate of FICB in the ED was 12.5% (3/24). For the three months after the first PDSA cycle, the rate increased to 22.2% (8/36). Then, the second cycle was performed. In the following two months the rate further increased to 36.8% (7/19). Discussion/Impact: Despite the clear increase in FICB rate, these changes were not statistically significant (p = 0.063). Our methodology was shown to be safe and effective, and our model can be applied to other ED groups looking to increase their rates of FICB.
Background: Increasing Emergency Department (ED) stretcher occupancy with admitted patients at our tertiary care hospital has contributed to long Physician Initial Assessment (PIA) times. As of Oct 2019, median PIA was 2.3 hours and 90th percentile PIA was 5.3 hours, with a consequent 71/74 PIA ranking compared to all Ontario EDs. Ambulatory zone (AZ) models are more commonly used in community EDs compared to tertiary level EDs. An interdisciplinary team trialled an AZ model for five days in our ED to improve PIA times. Aim Statement: We sought to decrease the median PIA for patients in our ED during the AZ trial period as compared to days with similar occupancy and volume. Measures & Design: The AZ was reserved for patients who could walk from a chair to stretcher. In this zone, ED rooms with stretchers were for patient assessment only; when waiting for results or receiving treatment, patients were moved into chairs. We removed nursing assignment ratios to increase patient flow. Our outcome measure was the median PIA for all patients in our ED. Our balancing measure was the 90th percentile PIA, which could increase if we negatively impacted patients who require stretchers. The median and 90th percentile PIA during the AZ trial were compared to similar occupancy and volume days without the AZ. Additional measures included ED Length of Stay (LOS) for non-admitted patients, and patients who leave without being seen (LWBS). Clinicians and patients provided qualitative feedback through surveys. Evaluation/Results: The median PIA during the AZ trial was 1.5 hours, compared to 2.1 hours during control days. Our balancing measure, the 90th percentile PIA was 3.7 hours, compared to 5.0 during control days. A run chart revealed both median and 90th percentile PIA during the trial were at their lowest points over the past 18 months. The number of LWBS patients decreased during the trial; EDLOS did not change. The majority of patients, nurses, and physicians felt the trial could be implemented permanently. Discussion/Impact: Although our highly specialized tertiary care hospital faces unique challenges and high occupancy pressures, a community-hospital style AZ model was successful in improving PIA. Shorter PIA times can improve other quality metrics, such as timeliness of analgesia and antibiotics. We are working to optimize the model based on feedback before we cycle another trial. Our findings suggest that other tertiary care EDs should consider similar AZ models.
Introduction: Emergency Department (ED) crowding is an international health system issue that is worsening. Further, ED crowding and “hallway medicine” has been identified as one of the most significant healthcare challenges currently facing Canadians. One contributor is preventable transfers from long-term care facilities (LTCFs) to Emergency Departments (EDs). In Canada, there were 63,752 LTCF patient transfers to the ED in 2014, with 24% (15,202) of them due to potentially preventable conditions. Each preventable transfer exposes patients to transport and hospital-related complications, and costs the healthcare system thousands of dollars. There have been many proposed and studied interventions aimed at alleviating the issue, but few attempts to assess and evaluate different interventions across institutions in a systematic manner. Methods: A scoping review of the literature using three electronic databases was conducted. A scoping review methodology was used due to the range of interventions and the heterogeneity in study design and outcome. Inclusion criteria included: studies on interventions designed to reduce transfers from LTCFs, studies that reported key outcomes such as number of ED transfers, and studies with a control or comparison group. Articles were screened by two independent reviewers (Cohen's k = 0.68), and study quality was assessed using the National Heart, Lung, Blood Institute quality assessment tools. Results: Findings were organized into five intervention types (telemedicine, outreach teams, interdisciplinary teams, integrated approaches, and other), and both a tabular and narrative synthesis was completed. Eleven studies had a good quality assessment rating, 13 studies had a fair rating, and two studies had a poor rating. Twenty out of the 26 studies reported statistically significant reductions in ED transfer rate, ranging from 10-70%. Interdisciplinary healthcare teams staffed within LTCFs were the most effective interventions. Conclusion: There are several promising interventions that have successfully reduced the number of preventable transfers from LTCFs to EDs, in a variety of health system settings. Further analysis of the relative resource requirements of each intervention, and practices that can enable successful implementation are needed to inform healthcare policy and administrative decision making. Widespread implementation of these interventions has the potential to considerably reduce ED crowding.
We investigate the phased evolution and variation of the South Asian monsoon and resulting weathering intensity and physical erosion in the Himalaya–Karakoram Mountains since late Pliocene time (c. 3.4 Ma) using a comprehensive approach. Neodymium and strontium isotopic compositions and single-grain zircon U–Pb age spectra reveal the sources of the deposits in the east Arabian Sea, and show a combination of sources from the Himalaya and the Karakoram–Kohistan–Ladakh Mountains, with sediments from the Indian Peninsula such as the Deccan Traps or Craton. We interpret shifts in the sediment sources to have been forced by sea-level changes that correlate with South Asian monsoon rainfall variation since late Pliocene time. We collected 908 samples from the International Ocean Discovery Program Hole U1456A, which was drilled in the east Arabian Sea. Time series of hematite content and grain size of the sediments were examined downcore. We found South Asian monsoon precipitation and weathering intensity experienced three phases from late Pliocene time. Lower monsoon precipitation, with a lower variability and strong weathering intensity, occurred during 3.4–2.4 Ma; an increased and more variable South Asian monsoon rainfall, along with strengthened but fluctuating weathering intensity, occurred at 1.8–1.1 Ma; and a reduced rainfall with lower South Asian monsoon precipitation variability and moderate weathering intensity marked the period 1.1–0.1 Ma. Maximum entropy spectral analysis and wavelet transform show that there were orbital-dominated cycles of periods c. 100 and c. 41 ka in these proxy-based time series. We propose that the monsoon, sea level, global temperature and insolation together forced the weathering and erosion in SW Asia.
Little is known about medication adherence among Asians and Asian Americans in psychiatric treatment.
We conducted a systematic review of studies of Asian American and Asian patients with depression or schizophrenia to understand adherence rates and tools used to measure adherence.
A key word search of PubMED and PsycINFO, restricted to journal articles available in English or Chinese and published between 1960 and March 2010 was performed. Reference lists of studies meeting inclusion criteria were manually reviewed and content experts were consulted. Two investigators independently reviewed all identified publications for inclusion using predetermined criteria and a pilot tested data-abstraction form.
Of the 1520 journal articles retrieved, 10 met criteria for inclusion. Adherence rates among patients with schizophrenia ranged from 5–71%; adherence rates among patients with depression ranged from 16–67%. Adherence rates varied among Asian sub-populations: Chinese patients’ rates ranged from 6–56%; Taiwanese patients’ rate was 46–61%; Asian American patients’ rate was 16%; Japanese patients’ rate was 56–71%; and Singaporean patients’ rate was 4.3%. Adherence was measured by: self-report; blood levels; refill rates; chart review; or physician/nurse or family caregiver report.
Medication adherence rates varied across clinical populations and country of origin. Nearly all of the rates are lower than many clinicians would consider acceptable. A critical step to research on improving adherence will involve reaching consensus on how to measure rates.
We describe an ultra-wide-bandwidth, low-frequency receiver recently installed on the Parkes radio telescope. The receiver system provides continuous frequency coverage from 704 to 4032 MHz. For much of the band (
), the system temperature is approximately 22 K and the receiver system remains in a linear regime even in the presence of strong mobile phone transmissions. We discuss the scientific and technical aspects of the new receiver, including its astronomical objectives, as well as the feed, receiver, digitiser, and signal processor design. We describe the pipeline routines that form the archive-ready data products and how those data files can be accessed from the archives. The system performance is quantified, including the system noise and linearity, beam shape, antenna efficiency, polarisation calibration, and timing stability.
Wall-resolved large-eddy simulations (LES) of the incompressible Navier–Stokes equations together with empirical modelling for turbulent Taylor–Couette (TC) flow are presented. LES were performed with the inner cylinder rotating at angular velocity
and the outer cylinder stationary. With
the inner and outer radii respectively, the radius ratio is
. The subgrid-scale stresses are represented using the stretched-vortex subgrid-scale model while the flow is resolved close to the wall. LES is implemented in the range
is the cylinder gap. It is shown that the LES can capture the salient features of the flow, including the quantitative behaviour of spanwise Taylor rolls, the log variation in the inner-cylinder mean-velocity profile and the angular momentum redistribution due to the presence of Taylor rolls. A simple empirical model is developed for the turbulent, TC flow for both a stationary outer cylinder and also for co-rotating cylinders. This consists of near-wall, log-like turbulent wall layers separated by an annulus of constant angular momentum. Model results include the Nusselt number
(torque required to maintain the flow) and measures of the wall-layer thickness as functions of both the Taylor number
. These are compared with results from measurement, direct numerical simulation and the LES. A model extension to rough-wall turbulent flow is described. This shows an asymptotic, fully rough-wall state where the torque is independent of
, and where
Prehospital vital signs are used to triage trauma patients to mobilize appropriate resources and personnel prior to patient arrival in the emergency department (ED). Due to inherent challenges in obtaining prehospital vital signs, concerns exist regarding their accuracy and ability to predict first ED vitals.
The objective of this study was to determine the correlation between prehospital and initial ED vitals among patients meeting criteria for highest levels of trauma team activation (TTA). The hypothesis was that in a medical system with short transport times, prehospital and first ED vital signs would correlate well.
Patients meeting criteria for highest levels of TTA at a Level I trauma center (2008-2018) were included. Those with absent or missing prehospital vital signs were excluded. Demographics, injury data, and prehospital and first ED vital signs were abstracted. Prehospital and initial ED vital signs were compared using Bland-Altman intraclass correlation coefficients (ICC) with good agreement as >0.60; fair as 0.40-0.60; and poor as <0.40).
After exclusions, 15,320 patients were included. Mean age was 39 years (range 0-105) and 11,622 patients (76%) were male. Mechanism of injury was blunt in 79% (n = 12,041) and mortality was three percent (n = 513). Mean transport time was 21 minutes (range 0-1,439). Prehospital and first ED vital signs demonstrated good agreement for Glasgow Coma Scale (GCS) score (ICC 0.79; 95% CI, 0.77-0.79); fair agreement for heart rate (HR; ICC 0.59; 95% CI, 0.56-0.61) and systolic blood pressure (SBP; ICC 0.48; 95% CI, 0.46-0.49); and poor agreement for pulse pressure (PP; ICC 0.32; 95% CI, 0.30-0.33) and respiratory rate (RR; ICC 0.13; 95% CI, 0.11-0.15).
Despite challenges in prehospital assessments, field GCS, SBP, and HR correlate well with first ED vital signs. The data show that these prehospital measurements accurately predict initial ED vitals in an urban setting with short transport times. The generalizability of these data to settings with longer transport times is unknown.
Perinatal depression threatens the health of maternal women and their offspring. Although screening programs for perinatal depression exist, non-uptake of referral to further mental health care after screening reduces the utility of these programs. Uptake rates among women with positive screening varied widely across studies and little is known about how to improve the uptake rate. This study aimed to systematically review the available evidence on uptake rates, estimate the pooled rate, identify interventions to improve uptake of referral and explore the effectiveness of those interventions.
This systematic review has been registered in PROSPERO (registration number: CRD42019138095). We searched Pubmed, Web of Science, Cochrane Library, Ovid, Embase, CNKI, Wanfang Database and VIP Databases from database inception to January 13, 2019 and scanned reference lists of relevant researches for studies published in English or Chinese. Studies providing information on uptake rate and/or effectiveness of interventions on uptake of referral were eligible for inclusion. Studies were excluded if they did not report the details of the referral process or did not provide exact uptake rate. Data provided by observational studies and quasi-experimental studies were used to estimate the pooled uptake rate through meta-analysis. We also performed meta-regression and subgroup analyses to explore the potential source of heterogeneity. To evaluate the effectiveness of interventions, we conducted descriptive analyses instead of meta-analyses since there was only one randomised controlled trial (RCT).
Of 2302 records identified, 41 studies were eligible for inclusion, including 39 observational studies (n = 9337), one quasi-experimental study (n = 43) and one RCT (n = 555). All but two studies were conducted in high-income countries. The uptake rates reported by included studies varied widely and the pooled uptake rate of referral was 43% (95% confidence intervals [CI] 35–50%) by a random-effect model. Meta-regression and subgroup analyses both showed that referral to on-site assessment or treatment (60%, 95% CI 51–69%) had a significantly higher uptake rate than referral to mental health service (32%, 95% CI 23–41%) (odds ratio 1.31, 95% CI 1.13–1.52). The included RCT showed that the referral intervention significantly improved the uptake rate (p ＜ 0.01).
Almost three-fifths of women with positive screening results do not take up the referral offers after perinatal depression screening. Referral to on-site assessment and treatment may improve uptake of referral, but the quality of evidence on interventions to increase uptake was weak. More robust studies are needed, especially in low-and middle-income countries.
Maternal supraphysiological estradiol (E2) environment during pregnancy leads to adverse perinatal outcomes. However, the influence of oocyte exposure to high E2 levels on perinatal outcomes remains unknown. Thus, a retrospective cohort study was conducted to explore the effect of high E2 level induced by controlled ovarian stimulation (COH) on further outcomes after frozen embryo transfer (FET). The study included all FET cycles (n = 10,581) between 2014 and 2017. All cycles were categorized into three groups according to the E2 level on the day of the human Chorionic Gonadotropin trigger. Odds ratios (ORs) and their confidence intervals (CIs) were calculated to evaluate the association between E2 level during COH and pregnancy outcomes and subsequent neonatal outcomes. From our findings, higher E2 level was associated with lower percentage of chemical pregnancy, clinical pregnancy, ongoing pregnancy, and live birth as well as increased frequency of early miscarriage. Preterm births were more common among singletons in women with higher E2 level during COH (aOR1 = 1.93, 95% CI: 1.22–3.06; aOR2 = 2.05, 95% CI: 1.33–3.06). Incidence of small for gestational age (SGA) was more common in both singletons (aOR1 = 2.01, 95% CI: 1.30–3.11; aOR2 = 2.51, 95% CI: 1.69–3.74) and multiples (aOR1 = 1.58, 95% CI: 1.03–2.45; aOR2 = 1.99, 95% CI: 1.05–3.84) among women with relatively higher E2 level. No association was found between high E2 level during COH and the percentage of macrosomia or large for gestational age. In summary, oocyte exposure to high E2 level during COH should be brought to our attention, since the pregnancy rate decreasing and the risk of preterm birth and SGA increasing following FET.
Enteric illness outbreaks are complex events, therefore, outbreak investigators use many different hypothesis generation methods depending on the situation. This scoping review was conducted to describe methods used to generate a hypothesis during enteric illness outbreak investigations. The search included five databases and grey literature for articles published between 1 January 2000 and 2 May 2015. Relevance screening and article characterisation were conducted by two independent reviewers using pretested forms. There were 903 outbreaks that described hypothesis generation methods and 33 papers which focused on the evaluation of hypothesis generation methods. Common hypothesis generation methods described are analytic studies (64.8%), descriptive epidemiology (33.7%), food or environmental sampling (32.8%) and facility inspections (27.9%). The least common methods included the use of a single interviewer (0.4%) and investigation of outliers (0.4%). Most studies reported using two or more methods to generate hypotheses (81.2%), with 29.2% of studies reporting using four or more. The use of multiple different hypothesis generation methods both within and between outbreaks highlights the complexity of enteric illness outbreak investigations. Future research should examine the effectiveness of each method and the contexts for which each is most effective in efficiently leading to source identification.
The authors report on strong exciton–photon coupling in all-metal microcavities containing functionalized anthradithiophene (ADT) in host poly(methyl methacrylate) matrices for a wide range of ADT concentrations. Angle-resolved reflectance of polycrystalline films revealed Rabi splittings up to 340 meV. Angle-resolved photoluminescence in films with low ADT concentrations (dominated by “isolated” ADT molecules) showed Rabi splittings which scaled with the square root of oscillator strength. When “aggregated” and “isolated” ADT molecules coexisted in film, cavities preferentially coupled to “isolated” molecules due to an anisotropic distribution of aggregates. As a solution-processable high-performance organic semiconductor, ADT shows promise as an (opto)electronic polaritonic material.