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To describe the pattern of transmission of SARS-CoV-2 during 2 nosocomial outbreaks of COVID-19 with regard to the possibility of airborne transmission.
Contact investigations with active case finding were used to assess the pattern of spread from 2 COVID-19 index patients.
A community hospital and university medical center in the United States, in February and March, 2020, early in the COVID-19 pandemic.
Two index patients and 421 exposed health care workers.
Exposed staff were identified by analyzing the EMR and conducting active case finding in combination with structured interviews. Staff were tested for COVID-19 by obtaining oropharyngeal/nasopharyngeal specimens, with RT-PCR testing to detect SARS-CoV-2.
Two separate index patients were admitted in February and March 2020, without initial suspicion for COVID-19 and without contact or droplet precautions in place; both patients underwent several aerosol generating procedures in this context. A total of 421 health care workers were exposed in total, and the results of the case contact investigations identified 8 secondary infections in health care workers. In all 8 cases, the staff had close contact with the index patients without sufficient personal protective equipment. Importantly, despite multiple aerosol generating procedures, there was no evidence of airborne transmission.
These observations suggest that, at least in a healthcare setting, a majority of SARS-CoV-2 transmission is likely to take place during close contact with infected patients through respiratory droplets, rather than by long-distance airborne transmission.
The coronavirus disease 2019 pandemic requires urgent modification to existing head and neck cancer diagnosis and management practices. A protocol was established that utilises risk stratification, early investigation prior to clinical review and a reduction in aerosol generating procedures to lessen the risk of coronavirus disease 2019 spread.
Two-week wait referrals were stratified into low, intermediate and high risk. Low risk patients were referred back to primary care with advice; intermediate and high risk patients underwent investigation. Clinical encounters and aerosol generating procedures were minimised. A combined diagnostic and therapeutic surgical approach was undertaken where possible.
Forty-one patients were used to assess feasibility. Thirty-one per cent were low risk, 35 per cent were intermediate and 33 per cent were high risk. Thirty-three per cent were discharged with no imaging.
Implementing this protocol reduces the future burden on tertiary services, by empowering primary care physicians to re-refer low risk patients. The protocol is applicable across the UK and avoids diagnostic delay.
Introduction: Providing comfort care support at home without transport to hospital has not traditionally been part of paramedic practice. The innovative Paramedics Providing Palliative Care at Home Program includes a new clinical practice guideline, medications, a database to share goals of care, and palliative care training. This study aimed to determine essential elements for scale and spread of this model of care through the application of an implementation science model, the Consolidated Framework for Implementation Research (CFIR). Methods: Deliberative dialogue sessions were held with paramedic, palliative care, primary care, and administrative experts in a province that had the Program (Nova Scotia, March 2018) and one that had not (British Columbia, July 2018). Sessions were audio recorded and transcribed. The CFIR was used as the foundation for a framework analysis, which was conducted by four team members independently. Themes were derived by consensus with the broader research team. Results: Inter-sectoral communication between paramedics and other health care providers was key, and challenging due to privacy concerns. Relationships with health care providers are critical to promoting the new model of care to patients, managing expectations, and providing follow up/ongoing care. Training was an essential characteristic of the intervention that can be adapted to suit local needs, although cost is a factor. There were challenges due to the culture and implementation climate as a shift in the mindset of paramedics away from traditional roles is required to implement the model. Paramedic champions can play an important role in shifting the mindset of paramedics towards a new way of practice Conclusion: The CFIR construct of cosmopolitanism, emphasizing the importance of breaking down silos and engaging diverse stakeholders, emerged as one of the most important. This will be helpful for successful scale and spread of the program.
It has been suggested that mECT reduce relapse rates in chronic/recurrent depression. We aimed to study its efficacy in this group.
A retrospective analysis of 19 patients who received mECT following a successful course of acute ECT. We compared admission rates and bed occupancy during the mECT period with periods of 2-4 years before and after mECT. Information was gathered from case-notes and hospital records. This group was then compared with a similarly matched group, who received a successful index aECT followed by other non-ECT maintenance therapies to compare for secular trends.
19 patients - average age 70.6 (44-88) received mECT (ave. 37 (12-89) applications, mean interval-2.5 weeks). Admission rate fell from 1.02 admission/year to 0.316 (p < 0.001) and acute in-patient stay from 15.24 weeks/year pre-mECT to 7.05 during mECT, p = 0.055 . This was maintained once mECT was stopped. This compared well with comparison group who went on to receive other mentainance therapy (for the same period to control for secular changes), where both admission rates and bed occupancy went up. The change in duration of hospital stay between the two groups were statistically very significant (p<0.001) in favour of the mECT group.
The findings suggest that mECT may have a role in reducing the rate and duration of hospital stay of patients with major depressive disorder. The main weaknesses are the small sample size. This may translate in to socio-economic benefits both for the patients and the health services.
This study examined the effectiveness of a formal postdoctoral education program designed to teach skills in clinical and translational science, using scholar publication rates as a measure of research productivity.
Participants included 70 clinical fellows who were admitted to a master’s or certificate training program in clinical and translational science from 1999 to 2015 and 70 matched control peers. The primary outcomes were the number of publications 5 years post-fellowship matriculation and time to publishing 15 peer-reviewed manuscripts post-matriculation.
Clinical and translational science program graduates published significantly more peer-reviewed manuscripts at 5 years post-matriculation (median 8 vs 5, p=0.041) and had a faster time to publication of 15 peer-reviewed manuscripts (matched hazard ratio = 2.91, p=0.002). Additionally, program graduates’ publications yielded a significantly higher average H-index (11 vs. 7, p=0.013).
These findings support the effectiveness of formal training programs in clinical and translational science by increasing academic productivity.
We describe the investigation of two temporally coincident illness clusters involving salmonella and Staphylococcus aureus in two states. Cases were defined as gastrointestinal illness following two meal events. Investigators interviewed ill persons. Stool, food and environmental samples underwent pathogen testing. Alabama: Eighty cases were identified. Median time from meal to illness was 5·8 h. Salmonella Heidelberg was identified from 27 of 28 stool specimens tested, and coagulase-positive S. aureus was isolated from three of 16 ill persons. Environmental investigation indicated that food handling deficiencies occurred. Colorado: Seven cases were identified. Median time from meal to illness was 4·5 h. Five persons were hospitalised, four of whom were admitted to the intensive care unit. Salmonella Heidelberg was identified in six of seven stool specimens and coagulase-positive S. aureus in three of six tested. No single food item was implicated in either outbreak. These two outbreaks were linked to infection with Salmonella Heidelberg, but additional factors, such as dual aetiology that included S. aureus or the dose of salmonella ingested may have contributed to the short incubation periods and high illness severity. The outbreaks underscore the importance of measures to prevent foodborne illness through appropriate washing, handling, preparation and storage of food.
Immunoglobulin A (IgA) is a predominant immunoglobulin present in human breast milk and is known to play an important role in infant gut immunity maturation. Breast milk composition varies between populations, but the environmental and maternal factors responsible for these variations are still unclear. We examined the relationship between different exposures and levels of IgA in colostrum. The objective of this study was to examine whether exposures analysed influence levels of IgA in colostrum. The present study used 294 colostrum samples from the MecMilk International cohort, collected from women residing in London, Moscow and Verona. Samples were analysed in automated Abbott Architect Analyser. We found an inverse correlation between time postpartum and colostrum total IgA level (r=−0.49, P<0.001). Adjusting for maternal parity, smoking, fresh fruit and fish consumption and allergen sensitization, multiple regression model showed that IgA levels were influenced by colostrum collection time (P<0.0001) and country of collection (P<0.01). Mode of delivery influence did not appear to be significant in univariate comparisons, once adjusted for the above maternal characteristics it showed a significant influence on total IgA (P=0.01). We conclude that the concentration of IgA in colostrum drops rapidly after birth and future studies should always consider this factor in analysis. IgA concentration varied significantly between countries, with the highest level detected in Moscow and lowest in Verona. Mode of delivery effect should be confirmed on larger cohorts. Further work is needed to determine ways to correct for IgA decline over time in colostrum, and to find the cause of variations in IgA levels between the countries.
Offenders with an intellectual disability pose a major challenge to Intellectual Disability Service providers in the Republic of Ireland. This is especially so as no national Forensic Intellectual Disability Service currently exists.
The Forensic Intellectual Disability Working Group of the Irish College of Psychiatrists was established in order to take steps to address this issue by establishing the level of need for a Forensic Intellectual Disability Service in Ireland and developing a college position paper.
No previous study has been carried out to measure offending behaviour amongst persons with an intellectual disability attending mental health services in Ireland.
A postal survey was undertaken targeting the lead clinicians of all Intellectual Disability Psychiatry, General Adult Psychiatry and Forensic Psychiatry Services in the Republic of Ireland. This survey requested anonymous data regarding service users with an intellectual disability and offending behaviour in this population.
Data relating to 431 service users was returned. Those reported to engage in offending behaviour were predominantly young males. Assault was the most common offence type. A significant number of serious offences such as unlawful killing, sexual assault and arson were reported.
There is an urgent need for the development of a Forensic Intellectual Disability Service in the Republic of Ireland. The current efforts of the National Forensic Mental Health Service to establish such a service by the creation of a post of Consultant Forensic Psychiatrist (special interest in intellectual disability) are to be welcomed.
Grass silage is typically fed to dairy cows in temperate regions. However, in vivo information on methane (CH4) emission from grass silage of varying quality is limited. We evaluated the effect of two rates of nitrogen (N) fertilisation of grassland (low fertilisation (LF), 65 kg of N/ha; and high fertilisation (HF), 150 kg of N/ha) and of three stages of maturity of grass at cutting: early maturity (EM; 28 days of regrowth), mid maturity (MM; 41 days of regrowth) and late maturity (LM; 62 days of regrowth) on CH4 production by lactating dairy cows. In a randomised block design, 54 lactating Holstein–Friesian dairy cows (168±11 days in milk; mean±standard error of mean) received grass silage (mainly ryegrass) and compound feed at 80 : 20 on dry matter basis. Cows were adapted to the diet for 12 days and CH4 production was measured in climate respiration chambers for 5 days. Dry matter intake (DMI; 14.9±0.56 kg/day) decreased with increasing N fertilisation and grass maturity. Production of fat- and protein-corrected milk (FPCM; 24.0±1.57 kg/day) decreased with advancing grass maturity but was not affected by N fertilisation. Apparent total-tract feed digestibility decreased with advancing grass maturity but was unaffected by N fertilisation except for an increase and decrease in N and fat digestibility with increasing N fertilisation, respectively. Total CH4 production per cow (347±13.6 g/day) decreased with increasing N fertilisation by 4% and grass maturity by 6%. The smaller CH4 production with advancing grass maturity was offset by a smaller FPCM and lower feed digestibility. As a result, with advancing grass maturity CH4 emission intensity increased per units of FPCM (15.0±1.00 g CH4/kg) by 31% and digestible organic matter intake (33.1±0.78 g CH4/kg) by 15%. In addition, emission intensity increased per units of DMI (23.5±0.43 g CH4/kg) by 7% and gross energy intake (7.0±0.14% CH4) by 9%, implying an increased loss of dietary energy with advancing grass maturity. Rate of N fertilisation had no effect on CH4 emissions per units of FPCM, DMI and gross energy intake. These results suggest that despite a lower absolute daily CH4 production with a higher N fertilisation rate, CH4 emission intensity remains unchanged. A significant reduction of CH4 emission intensity can be achieved by feeding dairy cows silage of grass harvested at an earlier stage of maturity.
In nature, biomolecules guide the formation of hierarchically-ordered, lightweight, inorganic-organic composites such as corals, shells, teeth and bones. M13 bacteriophage has been used to mimic bio-inspired material development due to its rigid, nanoscale rod-like morphology. Liquid-crystalline monolayers of genetically engineered phage have been used to template crystallization of thin layers of inorganic and metallic materials. We have created thin films composed of engineered M13 phage capable of binding inorganic components. We employed both a dip-cast and a drop-cast film fabrication method on both smooth and rough gold, silica and glass casting surfaces to create thin films and 3D structures of various degrees of hierarchical order. We have found the engineered M13 phage and the inorganic mineral significantly affected both film morphology and the mechanical properties of the film. Similarly, film fabrication parameters such as solution chemistry, temperature, and pulling speed affected film properties. Using a calcium phosphate biomineralized 4E phage, film thickness increased linearly with the number of layers/dips in the phage solution. The stiffness of these composites (Young's modulus) were >80 GPa for mineralized, multilayer films. These materials are an order of magnitude stiffer than the biological equivalent collagen. Stiffness, however, does not appear to increase in a multilayer film beyond a saturation point. Ultimately, we have developed a platform for phage-based bio-composites for developing high performance materials.
Satellite altimetric time series allow high-precision monitoring of ice-sheet mass balance. Understanding elevation changes in these regions is important because outlet glaciers along ice-sheet margins are critical in controlling flow of inland ice. Here we discuss a new airborne altimetry dataset collected as part of the ICECAP (International Collaborative Exploration of the Cryosphere by Airborne Profiling) project over East Antarctica. Using the ALAMO (Airborne Laser Altimeter with Mapping Optics) system of a scanning photon-counting lidar combined with a laser altimeter, we extend the 2003–09 surface elevation record of NASA’s ICESat satellite, by determining cross-track slope and thus independently correcting for ICESat’s cross-track pointing errors. In areas of high slope, cross-track errors result in measured elevation change that combines surface slope and the actual Δz/Δt signal. Slope corrections are particularly important in coastal ice streams, which often exhibit both rapidly changing elevations and high surface slopes. As a test case (assuming that surface slopes do not change significantly) we observe a lack of ice dynamic change at Cook Ice Shelf, while significant thinning occurred at Totten and Denman Glaciers during 2003–09.
Designing new materials with well-defined structures and desired functions is a challenge in materials science, especially with nanomaterials. Nature, however, solves design of these materials through a self-assembling, hierarchically ordered process. We have investigated the mechanisms by which the high- aspect ratio and unique surface chemistry of M13 bacteriophage can give rise to increasingly complex, hierarchically ordered, bundled phage structures with a wide range of material applications. A molecular dynamic simulation of the 3-D structure of a 20-nm section of wild type (WT) and mutant phage types were developed based on WT phage crystal structure and ab initio calculations. Simulations of these phage were then used to examine repulsive and attractive forces of the particles in solution. Examination of contact interactions between two WT phage indicated the phage were maximally attracted to each other in a head to tail orientation. A mutant phage (4E) with a higher negative surface charge relative to WT phage also preferentially ordered head to tail in solution. In contrast, a mutant phage (CLP8) with a net positive surface charge had minimal repulsion in a 90° orientation. Understanding the self-assembly process through molecular dynamic simulations and decomposition of fundamental forces driving inter- and intra-strand interactions has provided a qualitative assessment of mechanisms that lead to hierarchical phage bundle structures. Results from simulation agree with experimentally observed patterns from self-assembly. We anticipate using this system to further investigate development of hierarchical structures not only from biological molecules but also from synthetic materials.
An urgent neurology assessment clinic was created at our institution to improve access to prompt neurological assessment, and has been in operation for over a decade. We assessed its timeliness and impact.
The clinic database was examined retrospectively for trends in the volume and waiting time to assessments, neurologic diagnoses, and whether neurologic assessment changed patients’ diagnoses. Before and after implementation, the frequency of emergency department neurology assessments and hospital admissions for neurological investigation were compared.
In the first decade, 25145 referrals were received; 12460 patients were accepted and assessed within an average of 3.8 working days. The most common problems seen included headache and seizure (20.2% each). Overall, 44.6% of assessments resulted in a change to the referring diagnosis; this proportion varied by the type of problem seen (from 10.5% for seizures to 92.5% for psychiatric disturbances). From the pre- to post-opening periods, there were fewer emergency room neurological assessments (35.7% reduction) and fewer hospital admissions for neurological investigation (4.4/week to 2.2/week, 50% reduction).
The urgent neurology clinic model at our institution has provided excellent service, including wait times of a few days, to a catchment of over two million Canadians for over a decade; clinic assessments have affected diagnoses and patient care.
The Dome C (Concordia) station in Antarctica (75°06′S, 123°21′E, 3233 m above mean sea level) has a unique opportunity to test the quality of remote-sensing measurements and meteorological analyses because it is situated well inside the Eastern Antarctic Plateau and is less affected by local phenomena. Measurements of tropospheric temperature and water vapour (H2O) together with the integrated water vapour (IWV) performed in 2010 are statistically analysed to assess their quality and to study the yearly correlation between temperature and H2O over the entire troposphere. The statistical tools include yearly evolution, seasonally-averaged mean and bias, standard deviation and linear Pearson correlation. The datasets are made of measurements from the ground-based microwave radiometer H2O Antarctica Microwave Stratospheric and Tropospheric Radiometer (HAMSTRAD), radiosonde, in situ sensors, the space-borne infrared sensors Infrared Atmospheric Sounding Interferometer (IASI) on the MetOp-A platform and the Atmospheric InfraRed Sounder (AIRS) on the Aqua platform, and the analyses from the European Centre for Medium-Range Weather Forecast (ECMWF). Despite some obvious biases within all these datasets, our study shows that temperature and IWV are generally measured with high quality whilst H2O measurement quality is slightly worse. The AIRS and IASI measurements do not have the vertical resolution to correctly probe the lowermost troposphere, whilst HAMSTRAD loses sensitivity in the upper troposphere-lower stratosphere. Within the entire troposphere over the whole year, it is found that the time evolution of temperature and H2O is highly correlated (> 0.8). This suggests that, in addition to the variability of solar radiation producing an obvious diurnal cycle in the planetary boundary layer in summer and an obvious seasonal cycle over the year, the H2O and temperature intra-seasonal variabilities are affected by the same processes, e.g. related to the long-range transport of air masses.