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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.
Regular breakfast skipping is related to unhealthy dietary behaviours, such as consuming an overall poorer quality diet and lower rates of physical activity, both of which are linked to a higher BMI. Adolescent breakfast skippers struggle with mental focus, sleep issues and lower grades. Solutions that can be implemented to overcome breakfast skipping are needed.
A systematic literature review was undertaken to identify programmes that aimed to increase breakfast eating. Following the PRISMA framework, studies were sourced to examine details of behaviour change, evidence of theory use and other important programme learnings and outcomes.
Breakfast consumption empirical studies published from 2000 onwards.
Nineteen empirical studies that aimed to improve breakfast eating behaviour.
Out of the nineteen studies examined, ten studies reported an increase in breakfast consumption frequency for the entire study group or subgroups. Seven studies found no change, one was inconclusive and one observed a decrease in breakfast frequency. Positive changes to the dietary quality of breakfast were observed in five of the studies that did not observe increased frequency of breakfast consumption. Only six studies reported using theory in the intervention.
This evidence review points needed to extend theory application to establish a reliable evidence base that can be followed by practitioners seeking to increase breakfast eating rates in their target population.
Fibromyalgia is a chronic condition characterised by widespread musculoskeletal pain. Although accumulating evidence suggests that exposure to stressful events increases the risk for this complex disorder, this is the first meta-analysis to compare the impact of a full range of lifetime stressors (e.g. physical trauma through to emotional neglect) on adult fibromyalgia.
This review was performed in accordance with PRISMA guidelines. Random-effects models examined associations between different stressor exposures and fibromyalgia status with meta-regression investigating the effects of publication year and study quality on effect sizes.
Nineteen studies were included in the meta-analysis. Significant associations with fibromyalgia status were observed for all six exposure types examined: odds ratios (OR) were highest for physical abuse (OR 3.23, 95% confidence interval 1.99–5.23) and total abuse (3.06, 1.71–5.46); intermediate for sexual abuse (2.65, 1.85–3.79) and smaller for medical trauma (1.80, 1.19–2.71), other lifetime stressors (1.70, 1.31–2.20), and emotional abuse (1.52, 1.27–1.81). Results were not significantly changed when childhood, as opposed to adult, exposures were used in studies that reported both. Meta-regression analyses demonstrated no effect of publication year or study quality on effect sizes.
This study confirmed a significant association between stressor exposure and adult fibromyalgia with the strongest associations observed for physical abuse. Limitations related to current available literature were identified; we provide several suggestions for how these can be addressed in future studies. Stressors are likely to be one of many risk factors for fibromyalgia which we argue is best approached from a biopsychosocial perspective.
To determine whether electronically available comorbidities and laboratory values on admission are risk factors for hospital-onset Clostridioides difficile infection (HO-CDI) across multiple institutions and whether they could be used to improve risk adjustment.
All patients at least 18 years of age admitted to 3 hospitals in Maryland between January 1, 2016, and January 1, 2018.
Comorbid conditions were assigned using the Elixhauser comorbidity index. Multivariable log-binomial regression was conducted for each hospital using significant covariates (P < .10) in a bivariate analysis. Standardized infection ratios (SIRs) were computed using current Centers for Disease Control and Prevention (CDC) risk adjustment methodology and with the addition of Elixhauser score and individual comorbidities.
At hospital 1, 314 of 48,057 patient admissions (0.65%) had a HO-CDI; 41 of 8,791 patient admissions (0.47%) at community hospital 2 had a HO-CDI; and 75 of 29,211 patient admissions (0.26%) at community hospital 3 had a HO-CDI. In multivariable regression, Elixhauser score was a significant risk factor for HO-CDI at all hospitals when controlling for age, antibiotic use, and antacid use. Abnormal leukocyte level at hospital admission was a significant risk factor at hospital 1 and hospital 2. When Elixhauser score was included in the risk adjustment model, it was statistically significant (P < .01). Compared with the current CDC SIR methodology, the SIR of hospital 1 decreased by 2%, whereas the SIRs of hospitals 2 and 3 increased by 2% and 6%, respectively, but the rankings did not change.
Electronically available patient comorbidities are important risk factors for HO-CDI and may improve risk-adjustment methodology.
Congenital heart disease (CHD) is the most common birth defect for infants born in the United States, with approximately 36,000 affected infants born annually. While mortality rates for children with CHD have significantly declined, there is a growing population of individuals with CHD living into adulthood prompting the need to optimise long-term development and quality of life. For infants with CHD, pre- and post-surgery, there is an increased risk of developmental challenges and feeding difficulties. Feeding challenges carry profound implications for the quality of life for individuals with CHD and their families as they impact short- and long-term neurodevelopment related to growth and nutrition, sensory regulation, and social-emotional bonding with parents and other caregivers. Oral feeding challenges in children with CHD are often the result of medical complications, delayed transition to oral feeding, reduced stamina, oral feeding refusal, developmental delay, and consequences of the overwhelming intensive care unit (ICU) environment. This article aims to characterise the disruptions in feeding development for infants with CHD and describe neurodevelopmental factors that may contribute to short- and long-term oral feeding difficulties.
Far from their image as a boring technical tool of the financial world, indexes are becoming a critical lever for investors to raise market-wide standards and to catalyse sustainable corporate business models. Investors can choose from a wide spectrum of benchmarks to suit their precise needs. The rise of benchmarks and passive investments, then ‘smart beta’ and now the emergence of ‘smart sustainability’ has been a global phenomenon, and the stage is now set for their powerful application in active ownership strategies.
Primates are one of the most threatened groups of mammals. Understanding their patterns of population occurrence and abundance, especially in response to threats, is critical for informing conservation action. The crested black macaque Macaca nigra is the only Critically Endangered species of Sulawesi's seven endemic macaques. Little is known about its distribution or its response to deforestation and hunting. We conducted a camera-trap survey across the entire species range using an occupancy-based analytical approach to (1) establish the first range-wide baseline of occurrence, (2) investigate how environmental and anthropogenic factors influence occurrence, (3) identify priority conservation subpopulations, and (4) test the efficacy of the sampling and analytical protocol for temporal monitoring of M. nigra using occupancy as the state variable. From 9,753 camera-trap days, M. nigra was detected on 473 days at 77 of the 111 camera locations. Species occupancy was 0.66 and highest inside protected areas and closed canopy forest. We identified eight distinct subpopulations, based on distribution and forest fragment size. To inform future monitoring, we used a power analysis to determine if our effort would allow us to detect inter-annual occupancy declines of 10%, and found that 90 camera locations surveyed for 3 months (8,100 camera days) across three consecutive seasons is the effort required to detect such change with 80% certainty. Our study underscores the importance of well-managed protected areas and intact forests for the long-term survival of the crested black macaque, and tests the effectiveness of camera traps to monitor primates at the landscape scale.
The Common Metrics Initiative aims to develop and field metrics to improve research processes within the national Clinical and Translational Science Award (CTSA) Consortium. A Median Accrual Ratio (MAR) common metric was developed to assess the results of efforts to increase subject accrual into a set of clinical trials within the expected time period. A pilot test of the MAR was undertaken at Tufts Clinical and Translational Science Institute (CTSI) with eight CTSA Consortium hubs. Post-pilot interviews were conducted with 9 CTSA Principal Investigators (PIs) and 23 pilot team members. Over three-quarters (78%) of respondents reported that the MAR could be useful for performance improvement, but also described limitations or concerns. The most commonly cited barrier to MAR use for performance improvement was difficulty in interpreting the single value that is produced. Most respondents were interested in using the MAR to assess recruitment at an individual trial level. Majority of respondents (63%) had mixed opinions about aggregating metric results across the CTSA Consortium for comparison or benchmarking. Collecting data about additional contextual factors, and comparing accrual between subgroups, were cited as potentially helping address concerns about aggregation. Significant challenges remain in ensuring that the MAR can be sufficiently useful for collaborative process improvement. We offer recommendations to potentially improve metric usefulness.
Failure to accrue participants into clinical trials incurs economic costs, wastes resources, jeopardizes answering research questions meaningfully, and delays translating research discoveries into improved health. This paper reports the results of a pilot test of the Median Accrual Ratio (MAR) metric developed as a part of the Common Metrics Initiative of the NIH’s National Center for Advancing Translational Science (NCATS) Clinical and Translational Science Award (CTSA) Consortium. Using the metric is intended to enhance the ability of the CTSA Consortium and its “hubs” to increase subject accrual into trials within expected timeframes. The pilot test was undertaken at Tufts Clinical and Translational Science Institute (CTSI) with eight CTSA Consortium hubs. We describe the pilot test methods, and results regarding feasibility of collecting metric data and the quality of data that was collected. Participating hubs welcomed the opportunity to assess accrual efforts, but experienced challenges in collecting accrual metric data due to insufficient infrastructure and inconsistent implementation of electronic data systems and lack of uniform data definitions. Also, the metric could not be constructed for all trial designs, particularly those using competitive enrollment strategies. We offer recommendations to address the identified challenges to facilitate progress to broad accrual metric data collection and use.
COVID-19 and its associated disease control measures have greatly altered everyday life. The burden of these challenges has fallen disproportionately on women. Drawing on qualitative inquiry in agrarian north India and Nepal, this research note analyzes how South Asian COVID-19 lockdowns have affected women's labor responsibilities in sometimes surprising ways. We find increased responsibilities for caregiving within the household, substantial stress in responding to food insecurity, and growing expectations to fulfill public roles in disease response measures. However, we also find that the return of male migrants and youth has, in some cases, reduced women's farming responsibilities and created opportunities for household togetherness at a time of great uncertainty. We conclude that more research is needed to examine the nuanced aspects of COVID-19's gendered labor impacts to create comprehensive policy responses to address the multiple and sometimes conflicting effects the lockdown has had on agrarian women's informal labor and well-being.
Dialysis patients may not have access to conventional renal replacement therapy (RRT) following disasters. We hypothesized that improvised renal replacement therapy (ImpRRT) would be comparable to continuous renal replacement therapy (CRRT) in a porcine acute kidney injury model.
Following bilateral nephrectomies and 2 hours of caudal aortic occlusion, 12 pigs were randomized to 4 hours of ImpRRT or CRRT. In the ImpRRT group, blood was circulated through a dialysis filter using a rapid infuser to collect the ultrafiltrate. Improvised replacement fluid, made with stock solutions, was infused pre-pump. In the CRRT group, commercial replacement fluid was used. During RRT, animals received isotonic crystalloids and norepinephrine.
There were no differences in serum creatinine, calcium, magnesium, or phosphorus concentrations. While there was a difference between groups in serum potassium concentration over time (P < 0.001), significance was lost in pairwise comparison at specific time points. Replacement fluids or ultrafiltrate flows did not differ between groups. There were no differences in lactate concentration, isotonic crystalloid requirement, or norepinephrine doses. No difference was found in electrolyte concentrations between the commercial and improvised replacement solutions.
The ImpRRT system achieved similar performance to CRRT and may represent a potential option for temporary RRT following disasters.
OBJECTIVES/GOALS: Traumatic interpersonal experiences are associated with higher rates of chronic pain, increased pain severity and poorer functioning. The objective of this ongoing project is to obtain prevalence rates for various forms of interpersonal trauma among individuals with chronic pain, and to explore the potential mediating effect of heightened sensory and social sensitivity on the experience of pain. METHODS/STUDY POPULATION: Patients at Michigan Medicine between the ages of 18 and 65 complete an online survey. Patients are being recruited through a tertiary-care, outpatient pain clinic, as well as through an online health research portal. We aim to recruit 700 participants; we currently have 59.6% of our goal (n = 417). Participants also have the option to be included in a registry from which we can recruit for future studies. Approximately 85% of our participants have agreed to be in the registry. RESULTS/ANTICIPATED RESULTS: Preliminary data show that, of the 263 (63.4%) participants for whom data on chronic pain is available, 167 (63.5%) report chronic or persistent pain over the previous 3 months. Of these, 54% reported some form of childhood abuse or neglect. Approximately 41% reported four or more adverse childhood experiences. Additionally, of the 122 participants (73%) who were in a current romantic relationship, 20% reported some form of physical violence victimization from their romantic partner. We anticipate that interpersonal trauma will be associated with poorer perceptions of social relationships, higher sensory sensitivity, and higher perceived stress. DISCUSSION/SIGNIFICANCE OF IMPACT: The PASE Project parent study will be used to better understand prevalence rates for various forms of interpersonal trauma in our chronic pain population. Future analyses and studies will explore alternative pathways linking interpersonal trauma to the experience of pain through sensory and social sensitivity, which will inform interventions aimed at reducing pain among patients with a history of trauma.
Privacy and disability have an odd relationship. States, communities, and families, sometimes forcibly, have hidden people with disabilities from public view and engagement. In the shadow of a history of forced isolation and as a way of managing the stigma of disability, people with disabilities have, at times, rejected their public identity as disabled. While some people may explicitly deny disability identity for a host of legitimate reasons, more often, people with disabilities capable of “passing” choose to move in the world without disclosing their disability identity even when disclosure can lead to greater access to services, accommodations, or other benefits. At other times, people capable of passing who wish to disclose are discouraged and, at times, prevented from disclosing.
Variations of circadian activity profiles and sleep patterns are altered in various neurospsychiatric disorders. In this context, changes in heart rate (HR), -variability (HRV) and related parameters have been reported, too. However, data situation is presently heterogeneous and nonstandard-ized. As long-term evaluation may provide more valuable information, applicability and data us-ability of a new data acquisition system was tested in patients with major depression.
The course of a depressive episode in inpatients was assessed by standard psychometric in-struments. ECG and motor activity were recorded continuously with a new wearable sensor sys-tem (EP04106001.3) consisting of a textile with three electrodes for 1-lead ECG recordings, and an electronic module (2D-accelerometer, microcontroller, memory, rechargeable batteries, Bluetooth unit) to be attached to the waistband of standard underpants.
ECG signal quality highly depended on physical activity, but sufficient data quality was obtained during sleep. From the accelerometer signal, time in bed and movement time were identifiable. Preliminary data of patients (n=15) versus healthy controls (n=9) showed a reduction of HRV in several time domain parameters, high frequency (HF) power, and daytime activity (24h/day, mean 8 weeks).
This first pilot study demonstrates alterations of physiological parameters potentially relevant for depression, with continuous monitoring of inpatient treatment period. Facing long-term monitoring the device proved to be robust and safe and might provide a psychobiological profile of the clini-cal course of depression, useful for evaluation of disorder and therapy.
This work is part of the European research project ‘MyHeart’ (6th framework, IST 507816).
Many institutions are attempting to implement patient-reported outcome (PRO) measures. Because PROs often change clinical workflows significantly for patients and providers, implementation choices can have major impact. While various implementation guides exist, a stepwise list of decision points covering the full implementation process and drawing explicitly on a sociotechnical conceptual framework does not exist.
To facilitate real-world implementation of PROs in electronic health records (EHRs) for use in clinical practice, members of the EHR Access to Seamless Integration of Patient-Reported Outcomes Measurement Information System (PROMIS) Consortium developed structured PRO implementation planning tools. Each institution pilot tested the tools. Joint meetings led to the identification of critical sociotechnical success factors.
Three tools were developed and tested: (1) a PRO Planning Guide summarizes the empirical knowledge and guidance about PRO implementation in routine clinical care; (2) a Decision Log allows decision tracking; and (3) an Implementation Plan Template simplifies creation of a sharable implementation plan. Seven lessons learned during implementation underscore the iterative nature of planning and the importance of the clinician champion, as well as the need to understand aims, manage implementation barriers, minimize disruption, provide ample discussion time, and continuously engage key stakeholders.
Highly structured planning tools, informed by a sociotechnical perspective, enabled the construction of clear, clinic-specific plans. By developing and testing three reusable tools (freely available for immediate use), our project addressed the need for consolidated guidance and created new materials for PRO implementation planning. We identified seven important lessons that, while common to technology implementation, are especially critical in PRO implementation.
The updated common rule, for human subjects research, requires that consents “begin with a ‘concise and focused’ presentation of the key information that will most likely help someone make a decision about whether to participate in a study” (Menikoff, Kaneshiro, Pritchard. The New England Journal of Medicine. 2017; 376(7): 613–615.). We utilized a community-engaged technology development approach to inform feature options within the REDCap software platform centered around collection and storage of electronic consent (eConsent) to address issues of transparency, clinical trial efficiency, and regulatory compliance for informed consent (Harris, et al. Journal of Biomedical Informatics 2009; 42(2): 377–381.). eConsent may also improve recruitment and retention in clinical research studies by addressing: (1) barriers for accessing rural populations by facilitating remote consent and (2) cultural and literacy barriers by including optional explanatory material (e.g., defining terms by hovering over them with the cursor) or the choice of displaying different videos/images based on participant’s race, ethnicity, or educational level (Phillippi, et al. Journal of Obstetric, Gynecologic, & Neonatal Nursing. 2018; 47(4): 529–534.).
We developed and pilot tested our eConsent framework to provide a personalized consent experience whereby users are guided through a consent document that utilizes avatars, contextual glossary information supplements, and videos, to facilitate communication of information.
The eConsent framework includes a portfolio of eight features, reviewed by community stakeholders, and tested at two academic medical centers.
Early adoption and utilization of this eConsent framework have demonstrated acceptability. Next steps will emphasize testing efficacy of features to improve participant engagement with the consent process.
Electroconvulsive therapy (ECT) is an effective NICE-approved treatment for severe depression, treatment-resistant mania and catatonia; the Royal College of Psychiatrists’ (RCPsych) guidelines also support its use fourth line for treatment-resistant schizophrenia.
Evaluate the use of ECT at Broadmoor High Secure psychiatric hospital, focusing on the indications for its prescription and patients’ capacity to consent.
Analyse case records of all patients who received ECT, and of all patients referred for Second Opinion Appointed Doctor (SOAD) certified ECT treatment under Section 58 of the Mental Health Act 1983 (MHA) due to incapacity, between 01.09.11 and 30.07.15.
All patients lacked capacity to consent to treatment during this time. Thirty-three referrals were made to the SOAD service for 15 patients, and of these 30 resulted in certification (T6) of which 10 were not subsequently used. Improvements in mental state and agreement to take clozapine were common reasons for T6s either not being certified or used. Urgent treatment under Section 62 of the MHA was employed 7 times for 4 patients during this period. Of the referrals to the SOAD service, 25 were for treatment-resistant schizophrenia, 5 for mania, 3 for catatonia and none for depression.
Those patients requiring ECT within this population tended to be the most unwell and all lacked the capacity to consent to it. The majority (76%) of patients receiving ECT at Broadmoor do so outside of NICE (but within RCPsych) guidelines. ECT may be an effective strategy for promoting compliance with clozapine.
Disclosure of interest
The authors have not supplied their declaration of competing interest.
Between 2001 and 2017, the Royal Botanic Garden Edinburgh conducted training and research in Belize built around an annual two-week field course, part of the Edinburgh M.Sc. programme in Biodiversity and Taxonomy of Plants, focused on tropical plant identification, botanical-collecting and tropical fieldwork skills. This long-term collaboration in one country has led to additional benefits, most notably capacity building, acquisition of new country records, completion of M.Sc. thesis projects and publication of the findings in journal articles, and continued cooperation. Detailed summaries are provided for the specimens collected by students during the field course or return visits to Belize for M.Sc. thesis projects. Additionally, 15 species not recorded in the national checklist for Belize are reported. The information in this paper highlights the benefits of collaborations between institutions and countries for periods greater than the typical funding cycles of three to five years.
Koch’s postulates originally proposed a one microorganism–one disease approach to disease; however, it is now clear that many diseases of plants and animals are associated with changes in the taxonomic composition and function of the microbiome, and that health and disease are mediated by a dynamic interplay between host factors, environmental factors, the host microbiota and pathogenic microorganisms. Commensal microbes can become pathogenic under certain conditions, and disease can arise from complex polymicrobial infections. Although causation and correlation can be difficult to untangle, it is clear that the host microbiome plays a key role in resisting colonisation by pathogens across all host taxa, from plants to animals to humans. This offers exciting possibilities for manipulating microbiomes in order to reduce pathogenic infection in a range of contexts, including agriculture, wildlife and human health, through the use of probiotics, prebiotics and microbiome transplants, among other approaches.