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We report key learning from the public health management of the first two confirmed cases of COVID-19 identified in the UK. The first case imported, and the second associated with probable person-to-person transmission within the UK. Contact tracing was complex and fast-moving. Potential exposures for both cases were reviewed, and 52 contacts were identified. No further confirmed COVID-19 cases have been linked epidemiologically to these two cases. As steps are made to enhance contact tracing across the UK, the lessons learned from earlier contact tracing during the country's containment phase are particularly important and timely.
Introduction: Cannabinoid Hyperemesis Syndrome (CHS) in pediatric patients is poorly characterized. Literature is scarce, making identification and treatment challenging. This study's objective was to describe demographics and visit data of pediatric patients presenting to the emergency department (ED) with suspected CHS, in order to improve understanding of the disorder. Methods: A retrospective chart review was conducted of pediatric patients (12-17 years) with suspected CHS presenting to one of two tertiary-care EDs; one pediatric and one pediatric/adult (combined annual pediatric census 40,550) between April 2014-March 2019. Charts were selected based on discharge diagnosis of abdominal pain or nausea/vomiting with positive cannabis urine screen, or discharge diagnosis of cannabis use, using ICD-10 codes. Patients with confirmed or likely diagnosis of CHS were identified and data including demographics, clinical history, and ED investigations/treatments were recorded by a trained research assistant. Results: 242 patients met criteria for review. 39 were identified as having a confirmed or likely diagnosis of CHS (mean age 16.2, SD 0.85 years with 64% female). 87% were triaged as either CTAS-2 or CTAS-3. 80% of patients had cannabis use frequency/duration documented. Of these, 89% reported at least daily use, the mean consumption was 1.30g/day (SD 1.13g/day), and all reported ≥6 months of heavy use. 69% of patients had at least one psychiatric comorbidity. When presenting to the ED, all had vomiting, 81% had nausea, 81% had abdominal pain, and 30% reported weight loss. Investigations done included venous blood gas (30%), pregnancy test in females (84%), liver enzymes (57%), pelvic or abdominal ultrasound (19%), abdominal X-ray (19%), and CT head (5%). 89% of patients received treatment in the ED with 81% receiving anti-emetics, 68% receiving intravenous (IV) fluids, and 22% receiving analgesics. Normal saline was the most used IV fluid (80%) and ondansetron was the most used anti-emetic (90%). Cannabis was suspected to account for symptoms in 74%, with 31% of these given the formal diagnosis of CHS. 62% of patients had another visit to the ED within 30 days (prior to or post sentinel visit), 59% of these for similar symptoms. Conclusion: This study of pediatric CHS reveals unique findings including a preponderance of female patients, a majority that consume cannabis daily, and weight loss reported in nearly one third. Many received extensive workups and most had multiple clustered visits to the ED.
Fish-oil supplements are marketed as enhancing intelligence and cognitive performance. However, empirical data concerning the utility of these products in healthy term infants are mixed, particularly with respect to lasting effects into childhood. We evaluated whether fish-oil supplementation during infancy leads to better neurocognitive/behavioural development at 6 years. We conducted a double-blind randomised controlled trial of supplementation with n-3 long-chain PUFA in 420 healthy term infants. Infants received either fish oil (containing at least 250 mg DHA and at least 60 mg EPA) or placebo (olive oil) daily from birth to 6 months of age. Neurodevelopmental follow-up was conducted at a mean age of 6 years (sd 7 months), whereby 335 children were assessed for language, executive functioning, global intelligence quotient and behaviour. No significant differences were observed between the groups for the main neurocognitive outcomes. However in parent-report questionnaire, fish-oil supplementation was associated with negative externalising (P = 0·035, d = 0·24) and oppositional/defiant behaviour (P = 0·006, d = 0·31), particularly in boys (P = 0·01, d = 0·45; P = 0·004, d = 0·40). Our results provide evidence that fish-oil supplementation to predominantly breast-fed infants confers no significant cognitive or behavioural benefit to children at 6 years.
Before October 2012 there was no service level agreement for psychiatry cover in Whiston Hospital, an acute trust in the UK. The Crisis team would visit on goodwill to assess patients. This changed when a Liaison Psychiatry (LP) service was commissioned to provide 24 hour cover, Monday to Sunday for the Emergency Department (ED) for adults.
To quantify waiting times to be assessed by psychiatry, comparing the new LP Service (intervention group) to its predecessor (control). The null hypothesis being that the waiting time for the control and intervention group are the same.
The authors prospectively collected data on all referrals received by the LP service in the first three months of operation n=305 and retrospectively collected data on a random sample of 50 patients referred from ED in the same months 2011 (control).
The median time from referral to the time of psychiatric assessment in the control group was 162.5 minutes [IQR 130–330], the mean time was 246.16 [95% CI 180 to 312]. The median time from referral to the time of psychiatric assessment following the introduction of the LP service was 30 minutes [IQR 15-90], the mean time was 79.63 [95% CI 65 to 93]. When the two samples were compared using an independent t test they were significantly different p<0.002.
The new LP service has decreased the median wait for a psychiatry assessment by 132 minutes. The team currently seeS 82% of referrals within 60 minutes. This improves patient safety and encourages appropriate and timely discharge.
Online self-reported 24-h dietary recall systems promise increased feasibility of dietary assessment. Comparison against interviewer-led recalls established their convergent validity; however, reliability and criterion-validity information is lacking. The validity of energy intakes (EI) reported using Intake24, an online 24-h recall system, was assessed against concurrent measurement of total energy expenditure (TEE) using doubly labelled water in ninety-eight UK adults (40–65 years). Accuracy and precision of EI were assessed using correlation and Bland–Altman analysis. Test–retest reliability of energy and nutrient intakes was assessed using data from three further UK studies where participants (11–88 years) completed Intake24 at least four times; reliability was assessed using intra-class correlations (ICC). Compared with TEE, participants under-reported EI by 25 % (95 % limits of agreement −73 % to +68 %) in the first recall, 22 % (−61 % to +41 %) for average of first two, and 25 % (−60 % to +28 %) for first three recalls. Correlations between EI and TEE were 0·31 (first), 0·47 (first two) and 0·39 (first three recalls), respectively. ICC for a single recall was 0·35 for EI and ranged from 0·31 for Fe to 0·43 for non-milk extrinsic sugars (NMES). Considering pairs of recalls (first two v. third and fourth recalls), ICC was 0·52 for EI and ranged from 0·37 for fat to 0·63 for NMES. EI reported with Intake24 was moderately correlated with objectively measured TEE and underestimated on average to the same extent as seen with interviewer-led 24-h recalls and estimated weight food diaries. Online 24-h recall systems may offer low-cost, low-burden alternatives for collecting dietary information.
A total of 592 people reported gastrointestinal illness following attendance at Street Spice, a food festival held in Newcastle-upon-Tyne, North East England in February/March 2013. Epidemiological, microbiological and environmental investigations were undertaken to identify the source and prevent further cases. Several epidemiological analyses were conducted; a cohort study; a follow-up survey of cases and capture re-capture to estimate the true burden of cases. Indistinguishable isolates of Salmonella Agona phage type 40 were identified in cases and on fresh curry leaves used in one of the accompaniments served at the event. Molecular testing indicated entero-aggregative Escherichia coli and Shigella also contributed to the burden of illness. Analytical studies found strong associations between illness and eating food from a particular stall and with food items including coconut chutney which contained fresh curry leaves. Further investigation of the food supply chain and food preparation techniques identified a lack of clear instruction on the use of fresh uncooked curry leaves in finished dishes and uncertainty about their status as a ready-to-eat product. We describe the investigation of one of the largest outbreaks of food poisoning in England, involving several gastrointestinal pathogens including a strain of Salmonella Agona not previously seen in the UK.
UK guidelines recommend routine HIV testing in high prevalence emergency departments (ED) and targeted testing for HBV and HCV. The ‘Going Viral’ campaign implemented opt-out blood-borne virus (BBV) testing in adults in a high prevalence ED, to assess seroprevalence, uptake, linkage to care (LTC) rates and staff time taken to achieve LTC. Diagnosis status (new/known/unknown), current engagement in care, and severity of disease was established. LTC was defined as patient informed plus ⩾1 clinic visit. A total of 6211/24 981 ED attendees were tested (uptake 25%); 257 (4.1%) were BBV positive (15 co-infected), 84 (33%) required LTC. 100/147 (68%) HCV positives were viraemic; 44 (30%) required LTC (13 new, 16 disengaged). 26/54 (48%) HBV required LTC (seven new, 11 disengaged). 16/71 (23%) HIV required LTC (10 new, five disengaged). 26/84 (31%) patients requiring LTC had advanced disease (CD4 <350, APRI (AST-to-Platelet Ratio Index) >1, Fibroscan F3/F4 or liver cancer), including five with AIDS-defining conditions and three hepatocellular carcinomas. There were five BBV-related deaths. BBV prevalence was high (4.1%); most were HCV (2.4%). HIV patients were more successfully and quickly LTC than HBV or HCV patients. ED testing was valuable as one-third of those requiring LTC (new, disengaged or unknown status patients) had advanced disease.
To understand increasing rates of hepatitis C virus (HCV) infection in Tennessee, we conducted testing, risk factor analysis and a nested case–control study among persons who use drugs. During June–October 2016, HCV testing with risk factor assessment was conducted in sexually transmitted disease clinics, family planning clinics and an addiction treatment facility in eastern Tennessee; data were analysed by using multivariable logistic regression. A nested case–control study was conducted to assess drug-using risks and behaviours among persons who reported intranasal or injection drug use (IDU). Of 4753 persons tested, 397 (8.4%) were HCV-antibody positive. HCV infection was significantly associated with a history of both intranasal and IDU (adjusted odds ratio (aOR) 35.4, 95% confidence interval (CI) 24.1–51.9), IDU alone (aOR 52.7, CI 25.3–109.9), intranasal drug use alone (aOR 2.6, CI 1.8–3.9) and incarceration (aOR 2.7, CI 2.0–3.8). By 4 October 2016, 574 persons with a reported history of drug use; 63 (11%) were interviewed further. Of 31 persons who used both intranasal and injection drugs, 26 (84%) reported previous intranasal drug use, occurring 1–18 years (median 5.5 years) before their first IDU. Our findings provide evidence that reported IDU, intranasal drug use and incarceration are independent indicators of risk for past or present HCV infection in the study population.
We have developed high affinity Molecularly Imprinted Polymers (MIPs) for neurotransmitters such as dopamine, noradrenaline and caffeine. These polymer particles are mixed within the bulk of screen-printed ink allowing masss-producible bulk modified MIP Screen-Printed Electrodes (MIP-SPEs) to be realised. We have explored different SPE supporting surfaces, such as polyester, tracing paper and household-printing paper. The performance of those MIP-SPEs is studied using the Heat-Transfer Method (HTM), a patented thermal method. With the combination of screen-printing techniques and thermal detection, it is possible to develop a portable sensor platform that is capable of low-cost and straightforward detection of biomolecules on-site. In the future, this unique sensor architecture holds great promise for the use in biomedical devices.
Here, we present initial results from the ALFABURST radio transient survey, which is currently running in a commensal mode with the ALFA receiver at the Arecibo telescope. We observed for a total of 1400 hours and have detected single pulses from known pulsars but did not detect any FRBs. The non-detection of FRBs is consistent with the current FRB sky rates.
We performed a spatial-temporal analysis to assess household risk factors for Ebola virus disease (Ebola) in a remote, severely-affected village. We defined a household as a family's shared living space and a case-household as a household with at least one resident who became a suspect, probable, or confirmed Ebola case from 1 August 2014 to 10 October 2014. We used Geographic Information System (GIS) software to calculate inter-household distances, performed space-time cluster analyses, and developed Generalized Estimating Equations (GEE). Village X consisted of 64 households; 42% of households became case-households over the observation period. Two significant space-time clusters occurred among households in the village; temporal effects outweighed spatial effects. GEE demonstrated that the odds of becoming a case-household increased by 4·0% for each additional person per household (P < 0·02) and 2·6% per day (P < 0·07). An increasing number of persons per household, and to a lesser extent, the passage of time after onset of the outbreak were risk factors for household Ebola acquisition, emphasizing the importance of prompt public health interventions that prioritize the most populated households. Using GIS with GEE can reveal complex spatial-temporal risk factors, which can inform prioritization of response activities in future outbreaks.
The number of South American camelids (SACs) in England and Wales is increasing and with this comes a risk of new and emerging infections. Although classified as livestock, these animals are also treated as pets and may be in regular contact with humans. This paper reviews zoonotic diseases that have been identified in SACs in England and Wales, and which pose a potential risk to human health. We also highlight the importance of surveillance continuing to capture information on infections in SACs for the protection of both public and animal health.
To assess an alternative to bed rest and surgery for suspected perilymphatic fistulas using intratympanic blood injections.
A review was conducted of patients’ history, physical and audiometric data, before and after treatment by intratympanic blood injections performed from 2009 to 2015.
Twelve ears were identified, with trauma associated with air travel, water sports or nose blowing. Ten of these cases had hearing loss, six had vestibular symptoms. Four cases had audiological and vestibular symptoms, two had vestibular symptoms only, and six had audiological symptoms only. Time-to-treat varied from 1 day to 30 days. Magnetic resonance imaging scans were obtained for five cases. Ten cases received steroids. Six out of seven cases showed improvement of hearing loss. Five cases showed positive fistula test results, four with documented resolution. Seven cases had full resolution of all symptoms, four had near-full resolution and one had no improvement.
Intratympanic blood injections offer an effective alternative to conservative or surgical therapy. Advantages include sooner time-to-treat, lower financial costs and decreased psychosocial burdens. It allows a more flexible and liberal use of a potential definite treatment for perilymphatic fistula.
Reintroduction practitioners must often make critical decisions about reintroduction protocols despite having little understanding of the reintroduction biology of the focal species. To enhance the available knowledge on the reintroduction biology of the warru, or black-footed rock-wallaby Petrogale lateralis MacDonnell Ranges race, we conducted a trial reintroduction of 16 captive individuals into a fenced predator and competitor exclosure on the An̲angu Pitjantjatjara Yankunytjatjara Lands in South Australia. We conducted seven trapping sessions and used radio-tracking and camera traps to monitor survival, reproduction and recruitment to the population over 36 months. Blood samples were collected pre-release and during two trapping sessions post-release to assess nutritional health. The survival rate of founders was 63%, with all losses occurring within 10 weeks of release. Post-release blood biochemistry indicated that surviving warru adapted to their new environment and food sources. Female warru conceived within 6 months of release; 28 births were recorded during the study period and 52% of births successfully recruited to the population. Our results suggest that captive-bred warru are capable of establishing and persisting in the absence of introduced predators. However, the high mortality rate immediately post-release, with only a modest recruitment rate, suggests that future releases into areas where predators and competitors are present should use a trial approach to determine the viability of reintroduction. We recommend that future releases of warru into unfenced areas include an intensive monitoring period in the first 3 months post-release followed by a comprehensive long-term monitoring schedule to facilitate effective adaptive management.
An anecdotal increase in C. perfringens outbreaks was observed in the North East of England during 2012–2014. We describe findings of investigations in order to further understanding of the epidemiology of these outbreaks and inform control measures. All culture-positive (>105 c.f.u./g) outbreaks reported to the North East Health Protection Team from 1 January 2012 to 31 December 2014 were included. Epidemiological (attack rate, symptom profile and positive associations with a suspected vehicle of infection), environmental (deficiencies in food preparation or hygiene practices and suspected vehicle of infection) and microbiological investigations are described. Forty-six outbreaks were included (83% reported from care homes). Enterotoxin (cpe) gene-bearer C. perfringens were detected by PCR in 20/46 (43%) and enterotoxin (by ELISA) and/or enterotoxigenic faecal/food isolates with indistinguishable molecular profiles in 12/46 (26%) outbreaks. Concerns about temperature control of foods were documented in 20/46 (43%) outbreaks. A suspected vehicle of infection was documented in 21/46 (46%) of outbreaks (meat-containing vehicle in 20/21). In 15/21 (71%) identification of the suspected vehicle was based on descriptive evidence alone, in 5/21 (24%) with supporting evidence from an epidemiological study and in 2/21 (10%) with supporting microbiological evidence. C. perfringens-associated illness is preventable and although identification of foodborne outbreaks is challenging, a risk mitigation approach should be taken, particularly in vulnerable populations such as care homes for the elderly.
To demonstrate that the elevated prevalence of migraine in patients with vertigo disorders is due to enhanced sensitivity to dizziness, which could cause migraineurs to seek more, or earlier, medical care for vertigo disorders, confounding the ability to show causation.
This case–control study investigated whether migraineurs perceive dizziness more intensely than non-migraineurs by comparing caloric responses in migraineurs, non-migraineurs and possible migraineurs. The summed caloric responses in the best responding ear were reviewed.
The migraine group had higher caloric response values, with a mean of 37.97 degrees per second, which was statistically significant when compared to the values for the possible migraine group (30.74 degrees per second (p < 0.05)) and the non-migraine group (30.70 degrees per second (p < 0.001)).
The findings suggest that migraineurs experience vestibular stimuli more intensely compared to non-migraineurs, which might explain the association of migraine with vestibular disorders in general.
Gender differences in the prevalence of alcohol use disorder (AUD) have motivated the separate study of its risk factors and consequences in men and women. However, leveraging gender as a third variable to help account for the association between risk factors and consequences for AUD could elucidate etiological mechanisms and clinical outcomes.
Using data from a large, community sample followed longitudinally from 17 to 29 years of age, we tested for gender differences in psychosocial risk factors and consequences in adolescence and adulthood after controlling for gender differences in the base rates of AUD and psychosocial factors. Psychosocial factors included alcohol use, other drug use, externalizing and internalizing symptoms, deviant peer affiliation, family adversity, academic problems, attitudes and use of substances by a romantic partner, and adult socio-economic status.
At both ages of 17 and 29 years, mean levels of psychosocial risks and consequences were higher in men and those with AUD. However, the amount of risk exposure in adolescence was more predictive of AUD in women than men. By adulthood, AUD consequences were larger in women than men and internalizing risk had a stronger relationship with AUD in women at both ages.
Despite higher mean levels of risk exposure in men overall, AUD appears to be a more severe disorder in women characterized by higher levels of adolescent risk factors and a greater magnitude of the AUD consequences among women than men. Furthermore, internalizing symptoms appear to be a gender-specific risk factor for AUD in women.