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Shortages of personal protective equipment during the COVID-19 pandemic has led to the extended use or re-use of single-use respirators and surgical masks by frontline healthcare workers. The evidence base underpinning such practices warrants examination.
To synthesise current guidance and systematic review evidence on extended use, re-use, or reprocessing of single-use surgical masks or filtering facepiece respirators.
World Health Organization, European Centre for Disease Prevention and Control, the US Centers for Disease Control and Prevention, and Public Health England websites to identify guidance. Medline, Pubmed, Epistemonikos, Cochrane Database and preprint servers for systematic reviews.
Two reviewers conducted screening and data extraction. Quality of included systematic reviews was appraised using AMSTAR-2. Findings were narratively synthesised.
Six guidance documents were identified. Levels of detail and consistency across documents varied. Four high-quality systematic reviews were included: three focused on reprocessing (decontamination) of N95 respirators, one on reprocessing of surgical masks. Vaporised hydrogen peroxide and ultraviolet germicidal irradiation were highlighted as the most promising reprocessing methods, but evidence on the relative efficacy and safety of different methods was limited. We found no well-established methods for reprocessing respirators at scale.
There is limited evidence on the impact of extended use and re-use of surgical masks and respirators and gaps and inconsistencies exist in current guidance. Where extended use or re-use is being practiced, healthcare organisations should ensure that policies and systems are in place to ensure these practices are carried out safely and in line with available guidance.
Many studies demonstrate that marriage protects against risky alcohol use and moderates genetic influences on alcohol outcomes; however, previous work has not considered these effects from a developmental perspective or in high-risk individuals. These represent important gaps, as it cannot be assumed that marriage has uniform effects across development or in high-risk samples. We took a longitudinal developmental approach to examine whether marital status was associated with heavy episodic drinking (HED), and whether marital status moderated polygenic influences on HED. Our sample included 937 individuals (53.25% female) from the Collaborative Study on the Genetics of Alcoholism who reported their HED and marital status biennially between the ages of 21 and 25. Polygenic risk scores (PRS) were derived from a genome-wide association study of alcohol consumption. Marital status was not associated with HED; however, we observed pathogenic gene-by-environment effects that changed across young adulthood. Among those who married young (age 21), individuals with higher PRS reported more HED; however, these effects decayed over time. The same pattern was found in supplementary analyses using parental history of alcohol use disorder as the index of genetic liability. Our findings indicate that early marriage may exacerbate risk for those with higher polygenic load.
While China's Constitution says everyone is treated equally before the law, employment discrimination continues to exist. This paper breaks new ground by analysing a quantitative survey of more than 10,000 lesbian, gay, bisexual, transgender and intersex (LGBTI) people, the largest dataset of its kind to date in China. Only 5.1 per cent of respondents were completely open about their gender and sexuality at work. More than one-fifth reported experiencing negative treatment in the workplace. Transgender and intersex people reported higher rates of negative treatment, as did respondents with lower educational levels and lower incomes and those residing in towns. Employer policies against discrimination were rare, but when in place, they were significantly associated with less negative treatment. These findings highlight an almost completely neglected segment of the workforce and document discriminatory experiences that could be addressed by changes in discrimination law and by employer policies and practices related to diversity and inclusion.
Even before starting your evening shift you know it's going to be busy. Ambulances are lined up in front of the hospital, and the charge nurse already seems stressed out. The senior Emergency Medicine (EM) resident is standing in the physician office, ready to start her shift as well. You have worked with her a few times during this rotation. She is competent, you trust in her management plans for all her individual patients. Together you both review the patient tracker: a variety of patient presentations ready to be seen, plus an additional 20 patients in the waiting room. Negotiating the learning objective for the shift, the resident indicates that she would like to work on more efficiently managing patient flow and the administration of the emergency department (ED). But…isn't that a skill you just learn from experience? You wonder what evidence-informed strategies might exist for training her for this next step.
While involving patients in health technology assessment (HTA) has become increasingly common and important around the world, little is known about the optimal methods of evaluating patients’ involvement (PI) in HTA. This scoping review was undertaken to provide an overview of currently available methods for the evaluation of PI, specifically the impact of PI on HTA recommendations.
A literature search was conducted using nine databases as well as a grey literature search of the websites of 26 organizations related to the conduct, practice or research of HTA to identify articles, reports and abstracts related to the evaluation of PI impact in HTA.
We identified 1,248 unique citations, six of which met our eligibility criteria. These six records (five articles, and one report) were all published after 2012. Four assessed the impact of patient experience submissions on final HTA recommendations; one evaluated the impact of direct involvement on HTA committees, and one assessed impact of multiple forms of involvement. Methods of evaluation included quantitative analyses of reimbursement decisions, qualitative interviews with those directly involved in an assessment, surveys of patient groups and committee members, and the review of HTA reports.
Quantitative evaluation of PI based on associations with funding decisions may not be feasible or fully capture the relevant impact of PI in the assessment of health technologies. Rather, a combination of both qualitative and quantitative strategies may allow for the most comprehensive assessment of the impact of PI on HTA recommendations when possible.
Introduction: The oral case presentation is recognized as a core educational and patient care activity but has not been well studied in the emergency setting. The objectives of this study are: 1) to develop a competency-based assessment tool to formally evaluate the emergency medicine oral case presentation (EM-OCP) competency of medical students and ‘transition to discipline’ residents, and 2) to develop, implement and evaluate a curriculum to enhance oral case presentation (OCP) communication skills in the emergency medicine (EM) setting. Methods: Using data from a literature review, a Canadian Association of Emergency Physicians national survey, and local focus groups, the authors designed an OCP framework, blended learning curriculum, and EM-OCP assessment tool. Ninety-six clerkship students were randomly assigned to receive either the control, the standard clerkship curriculum, or intervention, the blended learning curriculum. At the beginning of their emergency medicine rotation, learners completed a pre-test using a standardized patient (SP) case to assess their baseline OCP skills. The intervention group then completed the EM-OCP curriculum. All students completed post-tests with a different SP at the end of the six-week EM rotation. Audio-recordings of pre and post-tests were evaluated using the assessment tool by two blinded evaluators. Results: Using the Kruskal-Wallis test, all students demonstrated improvement in EM-OCP skills between their pre-test and post-test, however, those who received the blended learning curriculum showed significantly greater improvement in synthesis of information (p = 0.044), management (p = 0.006) and overall entrustment decision score (p = 0.000). Conclusion: Implementation of a novel EM-OCP curriculum resulted in more effective communication and higher entrustment scores. This curriculum could improve OCP performance not only in emergency medicine settings but also across specialties where medical students and residents must manage critical patients.
Introduction: There are few large-scale studies assessing the true risk of epinephrine use during anaphylaxis in adults. We aimed to assess the demographics, clinical characteristics, and secondary effects of epinephrine treatment and to determine factors associated with major and minor secondary effects associated with epinephrine use among adults with anaphylaxis. Methods: From May 2012 to February 2018, adults presenting to the Hôpital du Sacré-Coeur de Montréal (HSCM) emergency department (ED) with anaphylaxis were recruited prospectively as part of the Cross-Canada Anaphylaxis Registry (C-CARE). Missed cases were identified through a previously validated algorithm. Data were collected on demographics, clinical characteristics, and management of anaphylaxis using a structured chart review. Multivariate logistic regression models were compared to estimate factors associated with side effects of epinephrine administration. Results: Over a 6-year period, 402 adult patients presented to the ED at HSCM with anaphylaxis. The median age was 38 years (Interquartile Range [IQR]: 27, 52) and 40.4% were males. The main trigger for anaphylaxis was food (53.0%). A total of 286 patients (71.1%) received epinephrine treatment, of which 23.9% were treated in the pre-hospital setting, 47.0% received treatment in the ED, and 5.0% received epinephrine in both settings. Among patients treated with epinephrine, major secondary effects were rare (1.4% of patients), including new changes to electrocardiogram, arrhythmia, and neurological symptoms. Minor secondary effects due to epinephrine were reported in 50.0% of patients, mainly inappropriate sinus tachycardia (defined as a rate over 100 beats/minute in 30.1%). Major cardiovascular secondary effects were associated with regular use of beta-blockers (aOR 1.10 [95%CI, 1.02, 1.18]), regular use of ACE-inhibitors (aOR 1.16 [95%CI, 1.07, 1.27]), and receiving more than two doses of epinephrine (aOR 1.09 [95%CI, 1.00, 1.18]). The model was adjusted for age, history of ischemic heart disease, trigger of anaphylaxis, presence of asthma, sex, and reaction severity. Inappropriate sinus tachycardia was more likely in females (aOR 1.18 [95%CI, 1.04, 1.33]) and palpitations, tremors, and psychomotor agitation were more likely in females (aOR 1.09 [95%CI, 1.00, 1.19]) and among those receiving more than two doses of epinephrine (aOR 1.49 [95%CI, 1.14, 1.96]). The models were adjusted for age, regular use of medications, history of ischemic heart disease, triggers of anaphylaxis, presence of asthma, reaction severity, and IV administration of epinephrine. Conclusion: The low rate of occurrence of major secondary effects of epinephrine in the treatment of anaphylaxis in our study demonstrates the overall safety of epinephrine use.
Introduction: Time-to-treatment plays a pivotal role in survival from sudden cardiac arrest (SCA). Every minute delay in defibrillation results in a 7-10% reduction in survival. This is particularly problematic in rural and remote regions, where bystander and EMS response is often prolonged and automated external defibrillators (AED) are often not available. Our objective was to examine the feasibility of a novel AED drone delivery method for rural and remote SCA. A secondary objective was to compare times between AED drone delivery and ambulance response to various mock SCA resuscitations. Methods: We conducted 6 simulations in two different rural communities in southern Ontario. During phase 1 (4 simulations) a “mock” call was placed to 911 and a single AED drone and an ambulance were simultaneously dispatched from the same location to a pre-determined destination. Once on scene, trained first responders retrieved the AED from the drone and initiated resuscitative efforts on a manikin. The second phase (2 scenarios) were done in a similar manner save for the drone being dispatched from a regionally optimized location for drone response. Results: Phase 1: The distance from dispatch location to scene varied from 6.6 km to 8.8 km. Mean (SD) response time from 911 call to scene arrival was 11.2 (+/- 1.0) minutes for EMS compared to 8.1 (+/- 0.1) for AED drone delivery. In all four simulations, the AED drone arrived before EMS, ranging from 2.1 to 4.4 minutes faster. The mean time for trained responders to retrieve the AED and apply it to the manikin was 35 (+/- 5) sec. No difficulties were encountered in drone activation by dispatch, drone lift off, landing or removal of the AED from the drone by responders. Phase 2: The ambulance response distance was 20km compared to 9km for the drone. Drones were faster to arrival at the scene by 7 minutes and 8 minutes with AED application 6 and 7 minutes prior to ambulance respectively. Conclusion: This implementation study suggests AED drone delivery is feasible with improvements in response time during a simulated SCA scenario. These results suggest the potential for AED drone delivery to decrease time to first defibrillation in rural and remote communities. Further research is required to determine the appropriate distance for drone delivery of an AED in an integrated EMS system as well as optimal strategies to simplify bystander application of a drone delivered AED.
The risk factors of criminal behavior in patients with schizophrenia are not well explored. This study is to explore the risk factors for criminal behavior in patients with schizophrenia in rural China.
We used data from a 14-year prospective follow-up study (1994-2008) of criminal behavior among a cohort (n=510) of patients with schizophrenia in Xinjin County, Chengdu, China.
There were 489 patients (95.9%) who were followed up from 1994 to 2008. The rate of criminal behavior was 13.5% among these patients with schizophrenia during the follow-up period. Compared with female subjects (6 cases, 20.0%), male patients had significantly higher rate of violent criminal behavior (e.g., arson, sexual assault, physical assault, and murder) (24 cases, 80.0%) (p< 0.001). Bivariate analyses showed that the risk of criminal behavior was significantly associated with being unmarried, of younger age, previous violent behavior, homelessness, lower family economic status, no family caregivers, and higher scores on measures (PANSS) of positive, negative, and total symptoms of illness. In multiple logistic regression analyses being unmarried and previous violent behavior were identified as independent predictors of increased criminal behavior in persons with schizophrenia.
The risk factors for criminal behavior among patients with schizophrenia should be understood within a particular social context. Criminal behavior may be predicted by specific characteristics of patients with schizophrenia in rural community. The findings of risk factors for criminal behavior should be considered in planning community mental health care and interventions for high-risk patients and their families.
Currently there is no consensus regarding how long anti-psychotics medication should be continued following a first/single psychotic episode. Clinically patients often request discontinuation after a period of remission. This is one of the first double-blind randomized-controlled studies designed to address the issue.
Patients with DSM-IV schizophrenia and related psychoses (excluding substance induced psychosis) who remitted well following a first/single-episode, and had remained well on maintenance medication for one year, were randomized to receive either maintenance therapy with quetiapine (400 mg/day), or placebo for 12 months. Relapse was defined by the presence of (i) an increase in at least one of the following PANSS psychotic symptom items to a threshold score (delusion, hallucinatory behaviour, conceptual disorganization, unusual thought content, suspiciousness); (ii) CGI Severity of Illness 3 or above; and (iii) CGI Improvement 5 or above.
178 patients were randomized. 144 patients completed the study (80.9%). The relapse rate was 33.7% (30/89) for the maintenance group and 66.3% (59/89) for the placebo group (log-rank test, chi-square=13.328, p<0.001). Relapse was not related to age or gender. Other significant predictors of relapse include medication status, pre-morbid schizotypal traits, verbal memory and soft neurological signs.
There is a substantial risk of relapse if medication is discontinued in remitted first-episode psychosis patients following one year of maintenance therapy. On the contrary 33.7% of patients discontinued medication and remained well.
Medication discontinuation in remitted single episode patients after a period of maintenance therapy is a major clinical decision and thus the identification of risk factors controlling for medication status is important.
Following a first/single episode with DSM-IV schizophrenia and related psychoses, remitted patients who had remained well on maintenance medication for at least one year were randomized to receive either maintenance therapy (with quetiapine 400 mg/day), or placebo for 12 months.
178 patients were randomized. Relapse rates were 33.7% (30/89) in maintenance group and 66.3% (59/89) in placebo group. Potential predictors were initially identified in univariate Cox regression models (p<0.1) and were subsequently entered into a multivariate Cox regression model for measuring the relapse risk. Significant predictors included patients on placebo (hazard ratio, 0.41; CI, 0.25 – 0.68; p=0.001); having more pre-morbid schizotypal traits (hazard ratio, 2.32; CI, 1.33 – 4.04; p=0.003); scoring lower in the logical memory test (hazard ratio, 0.94; CI, 0.9 – 0.99; p=0.028); and having more soft neurological signs (disinhibition) (hazard ratio, 1.33; CI, 1.02 – 1.74; p=0.039).
Relapse predictors may help to inform clinical decisions about discontinuation of maintenance therapy specifically for patients with a first/single episode psychosis following at least one year of maintenance therapy.
We are grateful to Dr TJ Yao at the Clinical Trials Center, University of Hong Kong, for statistical advice. The study was supported by investigator initiated trial award from AstraZeneca and the Research Grants Council Hong Kong (Project number: 765505).
Adherence problems are an inherent issue with any bio-psycho-social-spiritual prescription for any disease or behvaioural entity. It is all the more important in a patient with severe mental illness like Schizophrenia with limited insight. In several countries various interventions have been studied to address adherence problems in psychosis. Such as compliance therapy, family and psycho educational interventions, telephonic prompting and also legislative measures like Community Treatment Orders (CTO) have to date shown inconsistent and only modest benefits. Incentives based interventions have been tested for both preventive measures and also for adherence problems in chronic diseases. The Institute of Mental Health, Singapore has implemented a Pilot Supervision Programme (PSP) that incentivise patient engagement through quarterly vouchers as well as minimising barriers to accessing service by waiving off certain treatment fees whilst also offering them intensive intervention for one year. Our Pilot Programme, that focused on high risk patients with diagnosis of severe mental illness needing involuntary admission with history of either prolonged or repeated admissions, has begun recruiting patients since October 2012. The comparison was done between pre and post intervention phase. Total of 58 patients (95% suffering from schizophrenia or schizoaffective disorder) accepted into the treatment programme and of that nearly half of them have completed 6 months interventions. The results are promising with more than 50% improvemnt in length of stay, number of admissions and psychiatric emergency room visits, making significant impact on our high risk patients with severe mental illness.
Social anxiety disorder (SAD) is a strong risk factor for the development of depressive disorders (major depressive disorder or dysthymia).
Identification of blood-based molecular predictors of a subsequent depressive episode in SAD.
Objectives: To screen SAD patient serum for biomarkers which predict the onset of depressive disorders over a 2-year follow-up period.
Multiplexed-immunoassay data obtained from 143 SAD patients without co-morbid depressive disorders, recruited within the Netherlands Study of Depression and Anxiety (NESDA), were investigated. The serum screen included 165 mainly immunological, metabolical and hormonal analytes. Predictive performance of identified biomarkers and clinical variables (e.g. Beck Anxiety Inventory) was assessed using receiver operating characteristics curves (ROC) and represented by the area under the ROC curve (AUC). Stepwise logistic regression was used to select an optimal set of patient parameters, combining predictive serum analytes and clinical variables.
A set of four serum analytes and four associated clinical variables reached an AUC of 0.86 for the identification of SAD individuals, who developed a subsequent depressive episode. Throughout our analyses, biomarker panels yielded superior discriminative performance compared to clinical variables alone.
We report the discovery of a serum marker panel with good predictive performance to identify SAD individuals prone to develop depressive disorders in a naturalistic cohort design. Furthermore, we emphasise the importance to combine biological markers and clinical parameters for disease course predictions in psychiatry. Validated biomarkers could help to identify SAD patients at risk of a depressive episode, thus facilitating early treatment and improving clinical outcome.
The Community Treatment Order (CTO) Programme has been in place in several countries and encompasses the legislative requirement of a group of psychiatric patients to receive psychiatric treatment.
The Institute of Mental Health (IMH),Singapore has implemented a pilot supervision programme (PSP) that contains elements of the CTO programme (but without the requirement for legislative changes).
The objective of PSP is to engage patients with serious mental disorders, such as schizophrenia, delusional disorder, bipolar disorder (as per the Diagnostic and Statistical Manual of Mental Disorders IV criteria) to continue to receive treatment while living in the community, the least restrictive environment.
This paper focuses on the implementation of Phase 1 of PSP. Phase 1 which cover a period of one year focuses on ‘high-risk‘ patients who suffer from a major psychiatric disorder and had 3 and more inpatient admissions over the past 1 year. They are then divided into 3 groups (70 each):
1) Group 1: Receiving standard community mental health treatment (monthly visit) and service is chargeable.
2) Group 2: Same as Group 1 but service is pro-bono.
3) Group 3: Receiving intensive community mental health treatment (weekly visit) and service is pro-bono.
In addition, patients in Group 2 and 3 will also receive incentives such as welfare voucher.
The results of Phase 1 will provide a better understanding of the patient's motivation and/or compliance for treatment and forms the test bed for Phase 2 which will include psychiatric patients with significant Axis II diagnoses.
Studies have shown that mental health problems during pregnancy have adverse effects on fetal growth. The impact of depressive and anxiety symptoms during pregnancy on the fetus have not yet been examined in Singapore.
To examine the association between mental health problems during the second trimester of pregnancy on the quality of the pregnancy, reflected by birth weight and birth length of the newborn.
This study aims to understand the importance of mental health during pregnancy on the development of the child in an Asian population.
Preliminary data of a prospective cohort study of pregnant women (GUSTO), were followed from pregnancy onwards. At 26 weeks of the pregnancy, the Edinburgh Postnatal Depression Scale (EPDS), the Beck Depression Inventory (BDI) and the State Trait Anxiety Inventory (STAI) were administered. Data on birth parameters were collected from medical records.
Linear regression analyses of preliminary data show negative correlations between depressive symptoms measured with EPDS (n = 1025, P = 0.54), BDI (n = 1012, P = 0.001), and anxiety symptoms measured with STAI (n = 1023, P = 0.002) and birth length (corrected for gestational age and gender). No associations were found for birth weight.
There is an association between depressive and anxiety symptoms reported at the end of the second trimester of the pregnancy and birth length, but not birth weight, of the newborn. As it is known that fetal length increases mainly in the second trimester, it suggests that stress of the mother influences the development of the fetus during this trimester.
To describe the infection control preparedness measures undertaken for coronavirus disease (COVID-19) due to SARS-CoV-2 (previously known as 2019 novel coronavirus) in the first 42 days after announcement of a cluster of pneumonia in China, on December 31, 2019 (day 1) in Hong Kong.
A bundled approach of active and enhanced laboratory surveillance, early airborne infection isolation, rapid molecular diagnostic testing, and contact tracing for healthcare workers (HCWs) with unprotected exposure in the hospitals was implemented. Epidemiological characteristics of confirmed cases, environmental samples, and air samples were collected and analyzed.
From day 1 to day 42, 42 of 1,275 patients (3.3%) fulfilling active (n = 29) and enhanced laboratory surveillance (n = 13) were confirmed to have the SARS-CoV-2 infection. The number of locally acquired case significantly increased from 1 of 13 confirmed cases (7.7%, day 22 to day 32) to 27 of 29 confirmed cases (93.1%, day 33 to day 42; P < .001). Among them, 28 patients (66.6%) came from 8 family clusters. Of 413 HCWs caring for these confirmed cases, 11 (2.7%) had unprotected exposure requiring quarantine for 14 days. None of these was infected, and nosocomial transmission of SARS-CoV-2 was not observed. Environmental surveillance was performed in the room of a patient with viral load of 3.3 × 106 copies/mL (pooled nasopharyngeal and throat swabs) and 5.9 × 106 copies/mL (saliva), respectively. SARS-CoV-2 was identified in 1 of 13 environmental samples (7.7%) but not in 8 air samples collected at a distance of 10 cm from the patient’s chin with or without wearing a surgical mask.
Appropriate hospital infection control measures was able to prevent nosocomial transmission of SARS-CoV-2.
The national implementation of competency-based medical education (CBME) has prompted an increased interest in identifying and tracking clinical and educational outcomes for emergency medicine training programs. For the 2019 Canadian Association of Emergency Physicians (CAEP) Academic Symposium, we developed recommendations for measuring outcomes in emergency medicine training in the context of CBME to assist educational leaders and systems designers in program evaluation.
We conducted a three-phase study to generate educational and clinical outcomes for emergency medicine (EM) education in Canada. First, we elicited expert and community perspectives on the best educational and clinical outcomes through a structured consultation process using a targeted online survey. We then qualitatively analyzed these responses to generate a list of suggested outcomes. Last, we presented these outcomes to a diverse assembly of educators, trainees, and clinicians at the CAEP Academic Symposium for feedback and endorsement through a voting process.
Academic Symposium attendees endorsed the measurement and linkage of CBME educational and clinical outcomes. Twenty-five outcomes (15 educational, 10 clinical) were derived from the qualitative analysis of the survey results and the most important short- and long-term outcomes (both educational and clinical) were identified. These outcomes can be used to help measure the impact of CBME on the practice of Emergency Medicine in Canada to ensure that it meets both trainee and patient needs.