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Despite the global expansion of electronic medical record (EMR) systems and their increased integration with artificial intelligence (AI), their utilization in disaster settings remains limited, and few studies have evaluated their implementation. We aimed to evaluate Fast Electronic Medical Record (fEMR), a novel, mobile EMR designed for resource-limited settings, based on user feedback.
Methods
We examined usage data through October 2022 to categorize the nature of its use for disaster response and determine the number of patients served. We conducted interviews with stakeholders and gathered input from clinicians who had experience using fEMR.
Results
Over eight years, fEMR was employed 60 times in 11 countries across four continents by 14 organizations (universities, non-profits, and disaster response teams). This involved 37,500+ patient encounters in diverse settings including migrant camps at the US-Mexico and Poland-Ukraine borders, mobile health clinics in Kenya and Guatemala, and post-earthquake relief in Haiti. User feedback highlighted adaptability, but suggested hardware and workflow improvements.
Conclusion
EMR systems have the potential to enhance healthcare delivery in humanitarian responses, offer valuable data for planning and preparedness, and support measurement of effectiveness. As a simple, versatile EMR system, fEMR has been deployed to numerous disaster response and low-income settings.
Double hydroxide solids precipitated homogeneously from three laboratory-synthesized aqueous solutions that simulated mildly contaminated surface or groundwater. Over a limited pH range, precipitates formed rapidly from dissolved ions, and more slowly by incorporating ions dissolving from other solids, including highly soluble aluminous solids. The precipitates were characterized by size and shape via transmission electron microscopy (TEM), by composition via inductively coupled plasma-mass spectrometry (ICP-MS) of mother solutions and analytical electron microscopy (AEM) of precipitates, and by structure via powder X-ray diffraction (XRD), TEM, and extended X-ray absorption fine structure (EXAFS) spectroscopy. They were identified as nanocrystalline cobalt hydrotalcite (CoHT) of the form [Co(II)1-xAl(III)x(OH)2]x+(An−x/n)·mH2O, with x = 0.17–0.25, A = CO32−, NO3−, or H3SiO4−n = anion charge and m undetermined. Complete solid solution may exist at the macroscopic level for the range of stoichiometrics reported, but clustering of Co atoms within hydroxide layers indicates a degree of immiscibility at the molecular scale. Composition evolved toward the Co-rich endmember with time for at least one precipitate. The small layer charge in the x = 0.17 precipitate caused anionic interlayers to be incomplete, producing interstratification of hydrotalcite and brucite-like layers. Solubility products estimated from solution measurements for the observed final CoHT stoichiometries suggest that CoHT is less soluble than the inactive forms of Co(OH)2 and CoCO3 near neutral pH. Low solubility and rapid formation suggest that CoHT solids may be important sinks for Co in contact with near neutral pH waters. Because hydrotalcite can incorporate a range of transition metals, precipitation of hydrotalcite may be similarly effective for removing other trace metals from natural waters.
X-ray absorption spectroscopy (XAS) was used to determine the local molecular environment of Co(II) surface complexes sorbed on three different kaolinites at ambient temperature and pressure in contact with an aqueous solution. Interatomic distances and types and numbers of backscattering atoms have been derived from analysis of the extended X-ray absorption fine structure (EXAFS). These data show that, at the lowest amounts of Co uptake on kaolinite (0.20–0.32 µmol m−2), Co is surrounded by ≈6 O atoms at 2.04–2.08 Å and a small number or Al or Si atoms (N = 0.6–1.5) at two distinct distances, 2.67–2.72 Å and 3.38–3.43 Å. These results indicate that Co bonds to the kaolinite surface as octahedrally coordinated, bidentate inner-sphere mononuclear complexes at low surface coverages, confirming indirect evidence from solution studies that a fraction of sorbed Co forms strongly bound complexes on kaolinite. In addition to inner-sphere complexes identified by EXAFS spectroscopy, solution studies provide evidence for the presence of weakly bound, outer-sphere Co complexes that cannot be detected directly by EXAFS. One orientation for inner-sphere complexes indicated by XAS is bidentate bonding of Co to oxygen atoms at two Al-O-Si edge sites or an Al-O-Si and Al-OH (inner hydroxyl) edge site, i.e., corner-sharing between Co octahedra and Al and Si polyhedra. At slightly higher surface sorption densities (0.51–0.57/ µmol m−2), the presence of a small number of second-neighbor Co atoms (average NCo < 1) at 3.10–3.13 Å indicates the formation of oxy- or hydroxy-bridged, multinuclear surface complexes in addition to mononuclear complexes. At these surface coverages, Co-Co and Co-Al/Si distances derived from EXAFS are consistent with edge-sharing between Co and Al octahedra on either edges or (001) faces of the aluminol sheet in kaolinite. Multinuclear complexes form on kaolinite at low surface sorption densities equivalent to <5% coverage by a monolayer of oxygen-ligated Co octahedra over the N2-BET surface area. These spectroscopic results have several implications for macroscopic modeling of metal ion uptake on kaolinite: 1) Primary binding sites on the kaolinite surface at low uptake are edge, non-bridging Al-OH inner hydroxyl sites and edge Al-O-Si bridging oxygen sites, not Si-OH sites typically assumed in sorption models; 2) specific adsorption of Co is via bidentate, inner-sphere complexation; and 3) at slightly higher uptake but still a small fraction of monolayer coverage, formation of Co multinuclear complexes, primarily edge-sharing with Al-OH octahedra, begins to dominate sorption.
To identify urinary catheter (UC)–associated urinary tract infection (CAUTI) incidence and risk factors.
Design:
A prospective cohort study.
Setting:
The study was conducted across 623 ICUs of 224 hospitals in 114 cities in 37 African, Asian, Eastern European, Latin American, and Middle Eastern countries.
Participants:
The study included 169,036 patients, hospitalized for 1,166,593 patient days.
Methods:
Data collection took place from January 1, 2014, to February 12, 2022. We identified CAUTI rates per 1,000 UC days and UC device utilization (DU) ratios stratified by country, by ICU type, by facility ownership type, by World Bank country classification by income level, and by UC type. To estimate CAUTI risk factors, we analyzed 11 variables using multiple logistic regression.
Results:
Participant patients acquired 2,010 CAUTIs. The pooled CAUTI rate was 2.83 per 1,000 UC days. The highest CAUTI rate was associated with the use of suprapubic catheters (3.93 CAUTIs per 1,000 UC days); with patients hospitalized in Eastern Europe (14.03) and in Asia (6.28); with patients hospitalized in trauma (7.97), neurologic (6.28), and neurosurgical ICUs (4.95); with patients hospitalized in lower–middle-income countries (3.05); and with patients in public hospitals (5.89).
The following variables were independently associated with CAUTI: Age (adjusted odds ratio [aOR], 1.01; P < .0001), female sex (aOR, 1.39; P < .0001), length of stay (LOS) before CAUTI-acquisition (aOR, 1.05; P < .0001), UC DU ratio (aOR, 1.09; P < .0001), public facilities (aOR, 2.24; P < .0001), and neurologic ICUs (aOR, 11.49; P < .0001).
Conclusions:
CAUTI rates are higher in patients with suprapubic catheters, in middle-income countries, in public hospitals, in trauma and neurologic ICUs, and in Eastern European and Asian facilities.
Based on findings regarding risk factors for CAUTI, focus on reducing LOS and UC utilization is warranted, as well as implementing evidence-based CAUTI-prevention recommendations.
Although the individual has been the focus of most research into judgment and decision-making (JDM), important decisions in the real world are often made collectively rather than individually, a tendency that has increased in recent times with the opportunities for easy information exchange through the Internet. From this perspective, JDM research that factors in this social context has increased generalizability and mundane realism relative to that which ignores it. We delineate a problem-space for research within which we locate protocols that are used to study or support collective JDM, identify a common research question posed by all of these protocols—‘What are the factors leading to opinion change for the better (‘virtuous opinion change’) in individual JDM agents?’—and propose a modeling approach and research paradigm using structured groups (i.e., groups with some constraints on their interaction), for answering this question. This paradigm, based on that used in studies of judge-adviser systems, avoids the need for real interacting groups and their attendant logistical problems, lack of power, and poor experimental control. We report an experiment using our paradigm on the effects of group size and opinion diversity on judgmental forecasting performance to illustrate our approach. The study found a U-shaped effect of group size on the probability of opinion change, but no effect on the amount of virtuous opinion change. Implications of our approach for development of more externally valid empirical studies and theories of JDM, and for the design of structured-group techniques to support collective JDM, are discussed.
The absence of clinical information in the aftermath of disasters in resource-constrained environments costs lives. fEMR– fast Electronic Medical Records–is a medical records system designed for mobile clinics and has proven useful in post-disaster settings. While the original version of the system was developed for areas without access to the Internet, a new version of this system was developed in 2019 to accommodate regions with connectivity.
Method:
We reviewed the design, implementation, and usage of fEMR from June 2014 to October 2022. We used logged data of the number of users, patient encounters, and the circumstances of each deployment. We compared usage between the original fEMR system and fEMR-on-chain.
Results:
The original fEMR system was created in an iterative process by students in Computer Science classes at three different American universities. The system creates a closed intranet signal to which clinicians connect their own device to access the software. The hardware is transported to the medical team in a carry-on suitcase prior to deployment. All data are stored on a laptop that acts as a server. The online version, fEMR On-Chain, was developed under a grant, but is sustained in development through academic partnerships. Both versions are designed so that the provider can complete an encounter with as few clicks as possible and with as little input as necessary to identify patients.The original fEMR system has been deployed to mobile clinics worldwide since 2014. The system has about 14,181 patients and 16,021 clinical encounters from 12 different countries. fEMR On-Chain has been deployed to refugee and migrant settings since 2019, containing about 18,000 patients and 22,000 encounters in two different countries.
Conclusion:
Successive versions of the fEMR system have been used in a variety of conditions and settings, with usage accelerating since 2019 in refugee and migrant health centers.
COVID-19 impacts population health equity. While mRNA vaccines protect against serious illness and death, little New Zealand (NZ) data exist about the impact of Omicron – and the effectiveness of vaccination – on different population groups. We aim to examine the impact of Omicron on Māori, Pacific, and Other ethnicities and how this interacts with age and vaccination status in the Te Manawa Taki Midland region of NZ. Daily COVID-19 infection and hospitalisation rates (1 February 2022 to 29 June 2022) were calculated for Māori, Pacific, and Other ethnicities for six age bands. A multivariate logistic regression model quantified the effects of ethnicity, age, and vaccination on hospitalisation rates. Per-capita Omicron cases were highest and occurred earliest among Pacific (9 per 1,000) and Māori (5 per 1,000) people and were highest among 12–24-year-olds (7 per 1,000). Hospitalisation was significantly more likely for Māori people (odds ratio (OR) = 2.03), Pacific people (OR = 1.75), over 75-year-olds (OR = 39.22), and unvaccinated people (OR = 4.64). Length of hospitalisation is strongly related to age. COVID-19 vaccination reduces hospitalisations for older individuals and Māori and Pacific populations. Omicron inequitably impacted Māori and Pacific people through higher per-capita infection and hospitalisation rates. Older people are more likely to be hospitalised and for longer.
Microscopic examination of blood smears remains the gold standard for laboratory inspection and diagnosis of malaria. Smear inspection is, however, time-consuming and dependent on trained microscopists with results varying in accuracy. We sought to develop an automated image analysis method to improve accuracy and standardization of smear inspection that retains capacity for expert confirmation and image archiving. Here, we present a machine learning method that achieves red blood cell (RBC) detection, differentiation between infected/uninfected cells, and parasite life stage categorization from unprocessed, heterogeneous smear images. Based on a pretrained Faster Region-Based Convolutional Neural Networks (R-CNN) model for RBC detection, our model performs accurately, with an average precision of 0.99 at an intersection-over-union threshold of 0.5. Application of a residual neural network-50 model to infected cells also performs accurately, with an area under the receiver operating characteristic curve of 0.98. Finally, combining our method with a regression model successfully recapitulates intraerythrocytic developmental cycle with accurate lifecycle stage categorization. Combined with a mobile-friendly web-based interface, called PlasmoCount, our method permits rapid navigation through and review of results for quality assurance. By standardizing assessment of Giemsa smears, our method markedly improves inspection reproducibility and presents a realistic route to both routine lab and future field-based automated malaria diagnosis.
The number of people over the age of 65 attending Emergency Departments (ED) in the United Kingdom (UK) is increasing. Those who attend with a mental health related problem may be referred to liaison psychiatry for assessment. Improving responsiveness and integration of liaison psychiatry in general hospital settings is a national priority. To do this psychiatry teams must be adequately resourced and organised. However, it is unknown how trends in the number of referrals of older people to liaison psychiatry teams by EDs are changing, making this difficult.
Method
We performed a national multi-centre retrospective service evaluation, analysing existing psychiatry referral data from EDs of people over 65. Sites were selected from a convenience sample of older peoples liaison psychiatry departments. Departments from all regions of the UK were invited to participate via the RCPsych liaison and older peoples faculty email distribution lists. From departments who returned data, we combined the date and described trends in the number and rate of referrals over a 7 year period.
Result
Referral data from up to 28 EDs across England and Scotland over a 7 year period were analysed (n = 18828 referrals). There is a general trend towards increasing numbers of older people referred to liaison psychiatry year on year. Rates rose year on year from 1.4 referrals per 1000 ED attenders (>65 years) in 2011 to 4.5 in 2019 . There is inter and intra site variability in referral numbers per 1000 ED attendances between different departments, ranging from 0.1 - 24.3.
Conclusion
To plan an effective healthcare system we need to understand the population it serves, and have appropriate structures and processes within it. The overarching message of this study is clear; older peoples mental health emergencies presenting in ED are common and appear to be increasingly so. Without appropriate investment either in EDs or community mental health services, this is unlikely to improve.
The data also suggest very variable inter-departmental referral rates. It is not possible to establish why rates from one department to another are so different, or whether outcomes for the population they serve are better or worse. The data does however highlight the importance of asking further questions about why the departments are different, and what impact that has on the patients they serve.
For the last two decades, high-dimensional data and methods have proliferated throughout the literature. Yet, the classical technique of linear regression has not lost its usefulness in applications. In fact, many high-dimensional estimation techniques can be seen as variable selection that leads to a smaller set of variables (a “submodel”) where classical linear regression applies. We analyze linear regression estimators resulting from model selection by proving estimation error and linear representation bounds uniformly over sets of submodels. Based on deterministic inequalities, our results provide “good” rates when applied to both independent and dependent data. These results are useful in meaningfully interpreting the linear regression estimator obtained after exploring and reducing the variables and also in justifying post-model-selection inference. All results are derived under no model assumptions and are nonasymptotic in nature.
Intrauterine preeclampsia exposure affects the lifelong cardiometabolic health of the child. Our study aimed to compare the growth (from birth to 6 months) of infants exposed to either a normotensive pregnancy or preeclampsia and explore the influence of being born small for gestational age (SGA). Participants were children of women participating in the Post-partum, Physiology, Psychology and Paediatric follow-up cohort study. Birth and 6-month weight and length z-scores were calculated for term and preterm (<37 weeks) babies, and change in weight z-score, rapid weight gain (≥0.67 increase in weight z-score) and conditional weight gain z-score were calculated. Compared with normotensive exposed infants (n = 298), preeclampsia exposed infants (n = 84) were more likely to be born SGA (7% versus 23%; P < 0.001), but weight gain from birth to 6 months, by any measure, did not differ between groups. Infants born SGA, irrespective of pregnancy exposure, were more likely to have rapid weight gain and had greater increases in weight z-score compared with those not born SGA. Preeclampsia exposed infants born SGA may benefit from interventions designed to prevent future cardiometabolic disease.
With no approved treatments for COVID-19 initially available, the Food and Drug Administration utilized multiple preapproval pathways to provide access to investigational agents and/or medical devices: Expanded Access, Emergency Use Authorizations, and Clinical Trials. Regulatory units within an Academic Medical Center (AMC), including those part of the Clinical and Translational Science Award (CTSA) consortium, have provided support for clinicians in navigating these options prior to the pandemic. As such, they were positioned to be a resource for accessing therapies during the COVID-19 public health emergency.
Methods:
A small survey and a follow-on poll of the national Investigational New Drug (IND)/Investigational Device Exemption (IDE) Workgroup were conducted in October and December 2020 to determine whether CTSA regulatory units assisted in facilitating access to COVID-19 therapies and the extent of pandemic-related challenges these units faced.
Results:
Fifteen survey and 21 poll responses were received, which provided insights into the demands placed on these regulatory support units due to the pandemic and the changes required to provide critical support during this and future crises. Key changes and lessons learned included the importance of regulatory knowledge to support the institutional response, the critical need for electronic submission capacity for Food and Drug Administration (FDA) documents, and the nimble reallocation of regulatory and legal resources to support patient access to investigational agents and/or medical devices during the pandemic.
Conclusion:
AMC- and CTSA-based regulatory units played a meaningful role in the COVID-19 pandemic but further unit modifications are needed for enabling more robust regulatory support in the future.
Bede is the inaugural volume in the Sources of Anglo-Saxon Literary Culture series, which seeks to comprehensively map British literary culture from 500 to 1100 CE. This volume presents four texts, or fascicles, dedicated to the Venerable Bede (d. 735), theologian and author of the Historia ecclesiastica gentis Anglorum. Articles provide a wealth of information on Bede through manuscript evidence, medieval library catalogs, citations, and quotations. Using discussions of source relationships, the entries weigh and consider different interpretations of Bede's works and suggest possibilities for future research. Part of an exciting new reference series, this book”and those that follow”will be indispensable to anyone interested in the history and literature of the period.
This newest volume in a long-running work of mapping the sources of Anglo-Saxon literary culture in England from 500 to 1100 CE takes up one of the most important authors of the period, the eighth-century monk-scholar known as the Venerable Bede. Bede is best known as the author of the Historia ecclesiastica gentis Anglorum, which is one of the key sources for our historical and cultural knowledge of the period; this collection covers that and more, drawing on manuscript evidence, medieval library catalogues, Anglo-Latin and Old English versions, citations, quotations, and more, putting Bede and his work in the context of his period.
The principal aim of this study was to optimize the diagnosis of canine neuroangiostrongyliasis (NA). In total, 92 cases were seen between 2010 and 2020. Dogs were aged from 7 weeks to 14 years (median 5 months), with 73/90 (81%) less than 6 months and 1.7 times as many males as females. The disease became more common over the study period. Most cases (86%) were seen between March and July. Cerebrospinal fluid (CSF) was obtained from the cisterna magna in 77 dogs, the lumbar cistern in f5, and both sites in 3. Nucleated cell counts for 84 specimens ranged from 1 to 146 150 cells μL−1 (median 4500). Percentage eosinophils varied from 0 to 98% (median 83%). When both cisternal and lumbar CSF were collected, inflammation was more severe caudally. Seventy-three CSF specimens were subjected to enzyme-linked immunosorbent assay (ELISA) testing for antibodies against A. cantonensis; 61 (84%) tested positive, titres ranging from <100 to ⩾12 800 (median 1600). Sixty-one CSF specimens were subjected to real-time quantitative polymerase chain reaction (qPCR) testing using a new protocol targeting a bioinformatically-informed repetitive genetic target; 53/61 samples (87%) tested positive, CT values ranging from 23.4 to 39.5 (median 30.0). For 57 dogs, it was possible to compare CSF ELISA serology and qPCR. ELISA and qPCR were both positive in 40 dogs, in 5 dogs the ELISA was positive while the qPCR was negative, in 9 dogs the qPCR was positive but the ELISA was negative, while in 3 dogs both the ELISA and qPCR were negative. NA is an emerging infectious disease of dogs in Sydney, Australia.
Effective community engagement in T3–T4 research is widespread, however, similar stakeholder involvement is missing in T1–T2 research. As part of an effort to embed community stakeholders in T1–T2 research, an academic community partnered team conducted discussion groups with researchers to assess perspectives on (1) barriers/challenges to including community stakeholders in basic science, (2) skills/training required for stakeholders and researchers, and (3) potential benefits of these activities. Engaging community in basic science research was perceived as challenging but with exciting potential to incorporate “real-life” community health priorities into basic research, resulting in a new full-spectrum translational research model.
Percutaneous tunneled drainage catheter (PTDC) placement is a palliative alternative to serial paracenteses in patients with end-stage cancer and refractory ascites. The impact of PTDC on quality of life (QoL) and long-term outcomes has not been prospectively described. The objective was to evaluate changes in QoL after PTDC.
Method
Eligible adult patients with end-stage cancer undergoing PTDC placement for refractory ascites completed the European Organization for Research and Treatment of Cancer Quality of Life Questionnaire and McGill Quality of Life instruments before PTDC placement and at 2 to 7 days and 2 to 4 weeks after PTDC. Catheter function, complications, and laboratory values were assessed. Analysis of QoL data was evaluated with a stratified Wilcoxon signed-rank test.
Result
Fifty patients enrolled. Survey completion ranged from 65% to 100% (median 88%) across timepoints. All patients had a Tenckhoff catheter, with 98% technical success. Median survival after PTDC was 38 days (95% confidence interval = 32, 57 days). European Organization for Research and Treatment of Cancer scores showed improvement in global QoL (p = 0.03) at 1 week postprocedure (PP). Significant symptom improvement was reported for fatigue, nausea/vomiting, pain, dyspnea, insomnia, and appetite at 1 week PP and was sustained at 3 weeks PP for dyspnea (p < 0.01), insomnia (p < 0.01), and appetite loss (p = 0.03). McGill Quality of Life demonstrated overall QoL improvement at 1 (p = 0.03) and 3 weeks (p = 0.04) PP. Decline in sodium and albumin values pre- and post-PTDC slowed significantly (albumin slope –0.43 to –0.26, p = 0.055; sodium slope –2.50 to 1.31, p = 0.04). Creatinine values increased at an accelerated pace post-PTDC (0.040 to 0.21, p < 0.01). Thirty-eight catheter-related complications occurred in 24 of 45 patients (53%).
Significance of results
QoL and symptoms improved after PTDC placement for refractory ascites in patients with end-stage malignancy. Decline in sodium and albumin values slowed postplacement. This study supports the use of a PTDC for palliation of refractory ascites in cancer patients.
Self-harm in young people is associated with later problems in social and emotional development. However, it is unknown whether self-harm in young women continues to be a marker of vulnerability on becoming a parent. This study prospectively describes the associations between pre-conception self-harm, maternal depressive symptoms and mother–infant bonding problems.
Methods
The Victorian Intergenerational Health Cohort Study (VIHCS) is a follow-up to the Victorian Adolescent Health Cohort Study (VAHCS) in Australia. Socio-demographic and health variables were assessed at 10 time-points (waves) from ages 14 to 35, including self-reported self-harm at waves 3–9. VIHCS enrolment began in 2006 (when participants were aged 28–29 years), by contacting VAHCS women every 6 months to identify pregnancies over a 7-year period. Perinatal depressive symptoms were assessed with the Edinburgh Postnatal Depression Scale during the third trimester, and 2 and 12 months postpartum. Mother–infant bonding problems were assessed with the Postpartum Bonding Questionnaire at 2 and 12 months postpartum.
Results
Five hundred sixty-four pregnancies from 384 women were included. One in 10 women (9.7%) reported pre-conception self-harm. Women who reported self-harming in young adulthood (ages 20–29) reported higher levels of perinatal depressive symptoms and mother–infant bonding problems at all perinatal time points [perinatal depressive symptoms adjusted β = 5.40, 95% confidence interval (CI) 3.42–7.39; mother–infant bonding problems adjusted β = 7.51, 95% CI 3.09–11.92]. There was no evidence that self-harm in adolescence (ages 15–17) was associated with either perinatal outcome.
Conclusions
Self-harm during young adulthood may be an indicator of future vulnerability to perinatal mental health and mother–infant bonding problems.