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The COVID-19 pandemic has disrupted lives and livelihoods, and people already experiencing mental ill health may have been especially vulnerable.
Quantify mental health inequalities in disruptions to healthcare, economic activity and housing.
We examined data from 59 482 participants in 12 UK longitudinal studies with data collected before and during the COVID-19 pandemic. Within each study, we estimated the association between psychological distress assessed pre-pandemic and disruptions since the start of the pandemic to healthcare (medication access, procedures or appointments), economic activity (employment, income or working hours) and housing (change of address or household composition). Estimates were pooled across studies.
Across the analysed data-sets, 28% to 77% of participants experienced at least one disruption, with 2.3–33.2% experiencing disruptions in two or more domains. We found 1 s.d. higher pre-pandemic psychological distress was associated with (a) increased odds of any healthcare disruptions (odds ratio (OR) 1.30, 95% CI 1.20–1.40), with fully adjusted odds ratios ranging from 1.24 (95% CI 1.09–1.41) for disruption to procedures to 1.33 (95% CI 1.20–1.49) for disruptions to prescriptions or medication access; (b) loss of employment (odds ratio 1.13, 95% CI 1.06–1.21) and income (OR 1.12, 95% CI 1.06 –1.19), and reductions in working hours/furlough (odds ratio 1.05, 95% CI 1.00–1.09) and (c) increased likelihood of experiencing a disruption in at least two domains (OR 1.25, 95% CI 1.18–1.32) or in one domain (OR 1.11, 95% CI 1.07–1.16), relative to no disruption. There were no associations with housing disruptions (OR 1.00, 95% CI 0.97–1.03).
People experiencing psychological distress pre-pandemic were more likely to experience healthcare and economic disruptions, and clusters of disruptions across multiple domains during the pandemic. Failing to address these disruptions risks further widening mental health inequalities.
To compare patients treated for incomplete Kawasaki disease whose practitioners followed versus did not follow American Heart Association criteria and to evaluate the association of cardiology consultation with adherence to these guidelines.
Single centre retrospective cohort study of patients <18 years old who received ≥1 dose of intravenous immunoglobulin for Kawasaki disease between 01/2006 and 01/2018. We collected demographics, clinical and laboratory data, coronary artery abnormalities, and cardiology consultation status. Patients treated for incomplete Kawasaki disease were divided into two groups based on adherence versus nonadherence to American Heart Association guidelines and compared by Wilcoxon rank sum test and chi-squared or Fisher’s exact test.
Of the 357 patients treated for Kawasaki disease, 109 (31%) were classified as incomplete Kawasaki disease. The American Heart Association algorithm for identifying patients with incomplete Kawasaki disease was followed in 81/109 (74%). Coronary artery abnormalities were present in 46/109 (42%) of the patients who were treated for incomplete Kawasaki disease. Cardiology consultation was more frequent in those fulfilling American Heart Association criteria for the diagnosis of incomplete Kawasaki disease versus those who did not fulfill criteria (76% versus 48%, p = 0.005).
Over 25% of patients treated for incomplete Kawasaki disease did not meet American Heart Association guidelines. Guidelines were more frequently followed when the paediatric cardiology team was consulted. Consulting physicians with experience and expertise in the evaluation and management of incomplete KD should be strongly considered in the care of these patients.
Studying phenotypic and genetic characteristics of age at onset (AAO) and polarity at onset (PAO) in bipolar disorder can provide new insights into disease pathology and facilitate the development of screening tools.
To examine the genetic architecture of AAO and PAO and their association with bipolar disorder disease characteristics.
Genome-wide association studies (GWASs) and polygenic score (PGS) analyses of AAO (n = 12 977) and PAO (n = 6773) were conducted in patients with bipolar disorder from 34 cohorts and a replication sample (n = 2237). The association of onset with disease characteristics was investigated in two of these cohorts.
Earlier AAO was associated with a higher probability of psychotic symptoms, suicidality, lower educational attainment, not living together and fewer episodes. Depressive onset correlated with suicidality and manic onset correlated with delusions and manic episodes. Systematic differences in AAO between cohorts and continents of origin were observed. This was also reflected in single-nucleotide variant-based heritability estimates, with higher heritabilities for stricter onset definitions. Increased PGS for autism spectrum disorder (β = −0.34 years, s.e. = 0.08), major depression (β = −0.34 years, s.e. = 0.08), schizophrenia (β = −0.39 years, s.e. = 0.08), and educational attainment (β = −0.31 years, s.e. = 0.08) were associated with an earlier AAO. The AAO GWAS identified one significant locus, but this finding did not replicate. Neither GWAS nor PGS analyses yielded significant associations with PAO.
AAO and PAO are associated with indicators of bipolar disorder severity. Individuals with an earlier onset show an increased polygenic liability for a broad spectrum of psychiatric traits. Systematic differences in AAO across cohorts, continents and phenotype definitions introduce significant heterogeneity, affecting analyses.
To describe the epidemiology of Acinetobacter baumannnii (AB) pneumonia at our center, including the antibiotic exposure patterns of individual AB pneumonia cases and to investigate whether hospital-wide antibiotic consumption trends were associated with trends in AB pneumonia incidence.
Single-center retrospective study with case-control and ecological components.
US private tertiary-care hospital.
Participants and methods:
All hospitalized patients with AB infection from 2008 to 2019 were identified through laboratory records; for those with AB pneumonia, medical records were queried for detailed characteristics and antibiotic exposures in the 30 days preceding pneumonia diagnosis. Hospital-wide antibiotic consumption data from 2015 through 2019 were obtained through pharmacy records.
Incidence of both pneumonia and nonrespiratory AB infections decreased from 2008 to 2019. Among the 175 patients with AB pneumonia, the most frequent antibiotic exposure was vancomycin (101 patients). During the 2015–2019 period when hospital-wide antibiotic consumption data were available, carbapenem consumption increased, and trends negatively correlated with those of AB pneumonia (r = −0.48; P = .031) and AB infection at any site (r = −0.63; P = .003). Conversely, the decline in AB infection at any site correlated positively with concurrent declines in vancomycin (r = 0.55; P = .012) and quinolone consumption (r = 0.51; P = .022).
We observed decreasing incidence of AB infection despite concurrently increasing carbapenem consumption, possibly associated with declining vancomycin and quinolone consumption. Future research should evaluate a potential role for glycopeptide and quinolone exposure in the pathogenesis of AB infection.
New Zealand has a strategy of eliminating SARS-CoV-2 that has resulted in a low incidence of reported coronavirus-19 disease (COVID-19). The aim of this study was to describe the spread of SARS-CoV-2 in New Zealand via a nationwide serosurvey of blood donors. Samples (n = 9806) were collected over a month-long period (3 December 2020–6 January 2021) from donors aged 16–88 years. The sample population was geographically spread, covering 16 of 20 district health board regions. A series of Spike-based immunoassays were utilised, and the serological testing algorithm was optimised for specificity given New Zealand is a low prevalence setting. Eighteen samples were seropositive for SARS-CoV-2 antibodies, six of which were retrospectively matched to previously confirmed COVID-19 cases. A further four were from donors that travelled to settings with a high risk of SARS-CoV-2 exposure, suggesting likely infection outside New Zealand. The remaining eight seropositive samples were from seven different district health regions for a true seroprevalence estimate, adjusted for test sensitivity and specificity, of 0.103% (95% confidence interval, 0.09–0.12%). The very low seroprevalence is consistent with limited undetected community transmission and provides robust, serological evidence to support New Zealand's successful elimination strategy for COVID-19.
Group Name: VHA Center for Antimicrobial Stewardship and Prevention of Antimicrobial Resistance (CASPAR) Background: Antimicrobial stewardship programs (ASPs) are advised to measure antimicrobial consumption as a metric for audit and feedback. However, most ASPs lack the tools necessary for appropriate risk adjustment and standardized data collection, which are critical for peer-program benchmarking. We created a system that automatically extracts antimicrobial use data and patient-level factors for risk-adjustment and a dashboard to present risk-adjusted benchmarking metrics for ASP within the Veterans’ Health Administration (VHA). Methods: We built a system to extract patient-level data for antimicrobial use, procedures, demographics, and comorbidities for acute inpatient and long-term care units at all VHA hospitals utilizing the VHA’s Corporate Data Warehouse (CDW). We built baseline negative binomial regression models to perform risk-adjustments based on patient- and unit-level factors using records dated between October 2016 and September 2018. These models were then leveraged both retrospectively and prospectively to calculate observed-to-expected ratios of antimicrobial use for each hospital and for specific units within each hospital. Data transformation and applications of risk-adjustment models were automatically performed within the CDW database server, followed by monthly scheduled data transfer from the CDW to the Microsoft Power BI server for interactive data visualization. Frontline antimicrobial stewards at 10 VHA hospitals participated in the project as pilot users. Results: Separate baseline risk-adjustment models to predict days of therapy (DOT) for all antibacterial agents were created for acute-care and long-term care units based on 15,941,972 patient days and 3,011,788 DOT between October 2016 and September 2018 at 134 VHA hospitals. Risk adjustment models include month, unit types (eg, intensive care unit [ICU] vs non-ICU for acute care), specialty, age, gender, comorbidities (50 and 30 factors for acute care and long-term care, respectively), and preceding procedures (45 and 24 procedures for acute care and long-term care, respectively). We created additional models for each antimicrobial category based on National Healthcare Safety Network definitions. For each hospital, risk-adjusted benchmarking metrics and a monthly ranking within the VHA system were visualized and presented to end users through the dashboard (an example screenshot in Figure 1). Conclusions: Developing an automated surveillance system for antimicrobial consumption and risk-adjustment benchmarking using an electronic medical record data warehouse is feasible and can potentially provide valuable tools for ASPs, especially at hospitals with no or limited local informatics expertise. Future efforts will evaluate the effectiveness of dashboards in these settings.
The protected Tel-Dor coastal embayment in the eastern Mediterranean preserves an unusually complete stratigraphic record that reveals human–environmental interactions throughout the Holocene. Interpretation of new seismic profiles collected from shallow marine geophysical transects across the bay show five seismic units were correlated with stratigraphy and age dates obtained from coastal and shallow-marine sediment cores. This stratigraphic framework permits a detailed reconstruction of the coastal system over the last ca. 77 ka as well as an assessment of environmental factors that influenced some dimensions of past coastal societies. The base of the boreholes records lowstand aeolian deposits overlain by wetland sediments that were subsequently flooded by the mid-Holocene transgression. The earliest human settlements are submerged Pottery Neolithic (8.25–7 ka) structures and tools, found immediately above the wetland deposits landward of a submerged aeolianite ridge at the mouth of the bay. The wetland deposits and Pottery Neolithic settlement remains are buried by coastal sand that records a middle Holocene sea-level rise ca. 7.6–6.5 ka. Stratigraphic and geographic relationships suggest that these coastal communities were displaced by sea-level transgression. These findings demonstrate how robust integration of different data sets can be used to reconstruct the geomorphic evolution of coastal settings as well as provide an important addition to the nature of human–landscape interaction and cultural development.
To determine the utility of the Sofia SARS rapid antigen fluorescent immunoassay (FIA) to guide hospital-bed placement of patients being admitted through the emergency department (ED).
Cross-sectional analysis of a clinical quality improvement study.
This study was conducted in 2 community hospitals in Maryland from September 21, 2020, to December 3, 2020. In total, 2,887 patients simultaneously received the Sofia SARS rapid antigen FIA and SARS-CoV-2 RT-PCR assays on admission through the ED.
Rapid antigen results and symptom assessment guided initial patient placement while confirmatory RT-PCR was pending. The sensitivity, specificity, positive predictive values, and negative predictive values of the rapid antigen assay were calculated relative to RT-PCR, overall and separately for symptomatic and asymptomatic patients. Assay sensitivity was compared to RT-PCR cycle threshold (Ct) values. Assay turnaround times were compared. Clinical characteristics of RT-PCR–positive patients and potential exposures from false-negative antigen assays were evaluated.
For all patients, overall agreement was 97.9%; sensitivity was 76.6% (95% confidence interval [CI], 71%–82%), and specificity was 99.7% (95% CI, 99%–100%). We detected no differences in performance between asymptomatic and symptomatic individuals. As RT-PCR Ct increased, the sensitivity of the antigen assay decreased. The mean turnaround time for the antigen assay was 1.2 hours (95% CI, 1.0–1.3) and for RT-PCR it was 20.1 hours (95% CI, 18.9–40.3) (P < .001). No transmission from antigen-negative/RT-PCR–positive patients was identified.
Although not a replacement for RT-PCR for detection of all SARS-CoV-2 infections, the Sofia SARS antigen FIA has clinical utility for potential initial timely patient placement.
In March 2020 SPFT was preparing for the first wave of the COVID-19 pandemic. Senior medical leadership supported the rapid development and delivery of SBE workshop for assessment and management of physically unwell patients in a psychiatric setting in the context of COVID-19. The training was delivered to 102 psychiatrists across 10 sessions over 4 weeks.
A learning review was completed to identify lessons learned from the delivery of this SBE workshop.
The intervention was reviewed using open-space feedback from attendees, interviews with facilitators and medical leadership, and SWOT (Strengths, Weaknesses, Opportunities, Threats) analysis.
Overall, the simulation project met its pre-determined objectives of increasing confidence and competence in the medical workforce in the context of COVID-19 and physical health. Development and delivery of the workshop was rapid, with request to delivery taking 4 days.
A summary of the key lessons include:
An existing simulation faculty within the trust was essential, allowing for rapid identification of key stakeholders and those able to deliver the project.
A “direct-line” relationship to senior leadership enabled the project to be dynamic and responsive to changing demands as COVID-19 guidelines and objectives evolved.
Redeploying higher trainees with SBE experience to develop the project as a focussed team allowed for rapid delivery which was resource-effective.
The workforce found reassurance from understanding what was not expected of them, as much as what was. For example, making clear that Arterial Blood Gases would not be introduced to the psychiatric setting.
There is an ongoing learning need for physical health training through SBE in non-covid scenarios.
SBE can be an effective intervention for a range of medical grades and covering a large geographical area.
There are opportunities for developing multi-disciplinary training on physical health in psychiatry.
We have outlined some of the key learning outcomes from a successfully implemented SBE project during the first COVID-19 wave in spring 2020. The project has cemented the role of the relatively new simulation faculty within the trust and highlighted the effectiveness of close collaboration between leadership and a small, dedicated group of facilitators. The project has continued to be used for training new staff members and the resources have been widely shared, used by other NHS trusts and also internationally.
At the start of the COVID-19 pandemic there was significant uncertainty for the NHS and it's workforce. Within psychiatry, there was an expectation that junior doctors would be redeployed, with senior psychiatrists stepping down to cover physical health and on-call duties.
Senior leadership in mental health trusts were also preparing for COVID-19 outbreaks on psychiatric wards and were developing strategies for managing a novel illness with a poorly understood clinical course. Many psychiatrist expressed anxieties around their competency in assessing and managing acutely physically unwell patients in a mental health setting.
This project aimed to improve confidence of psychiatrists in core physical health competencies through devising and delivering an evolving SBE package.
Sussex Partnership Foundation Trust redeployed two higher trainees from their simulation faculty to work full time on developing a SBE package. This was requested by senior leadership to deliver training about assessing and managing physically unwell patients in the context of COVID-19. This training was devised as a 90 minute didactic lecture following by 90 minutes of SBE.
This was delivered at 6 sites through 10 opt-in sessions available to all doctors in the trust over 4 weeks. Pre and post-course questionnaires were given to all participants to measure the effect.
102 medical staff attended the SBE workshops. Feedback was completed by 93 (91%) doctors prior to the course and 97 (95%) post. Before the workshop, 33% did not feel they had a structured approach for assessing an acutely unwell patient, which reduced to 0% after completing the course.
On a 5-point Likert scale, confidence in managing COVID-19 symptoms increased from 2.54/5 to 4.07/5 overall with 89% of doctors feeling “confident” or “very confident”. There were similar increases in confidence in managing critically unwell patients (2.7/5 pre; 3.95/5 post) and in identifying alternative causes for acutely unwell patients (2.63/5 pre; 4.02/5 post).
This project demonstrates that SBE is an effective way to rapidly develop effective interventions for the medical workforce, increasing confidence in the face of significant uncertainty and reducing anxiety within the system to meet the learning needs identified by medical leadership.
As part of this project Sussex Partnership Medical Education freely shared the workshop materials, which were later adopted and used by psychiatry departments internationally.
The aim of this medical education case report was to outline the development and outcomes of a reverse-mentorship project that enabled cross-generational collaborative learning. The project took the shape of a philosophy of psychiatry journal club facilitated by a psychiatry core trainee in west London, UK.
Reverse-mentorship reverses traditional roles of mentor and mentee. It is an increasingly fashionable concept in medical education. The junior mentors the senior clinician. The implicit learning outcomes include provision of a two-way learning process, development of mentoring skills for the more junior clinician and collaboration that builds social capital within the workplace. Reverse-mentorship is effective when the junior mentor is recognised for their expertise in a particular area. In this instance, the junior mentor has a special interest in the philosophy of psychiatry.
Junior mentor and senior mentees formed a monthly journal club. The club tracked arguments from anti- and biological psychiatry on the meaning of mental illness. The debate offered insight into a semantic analysis of mental illness and a deeper conceptual understanding of medicine. The learning material derived from the core concepts of philosophy and mental health (Fulford et al.). The role of the mentor was to facilitate group discussion around arguments from relevant papers. A survey, adapted from a recent reverse-mentorship review article, measured the quality of educational experience for mentor and mentees.
Overall, mentees (senior clinicians) agreed that the mentor (junior clinician) displayed attributes and behaviours for effective mentoring across most domains, including enthusiasm, effective communication, respect for mentee expertise and active listening to the needs of the mentee. The mentor was particularly impressed with the mentees’ openness to learn new concepts and respect shown. General reflections on the experience of reverse-mentorship were positive overall. A thematic review highlighted particular aspects, including: a good way to learn a new skill and great opportunity to develop professional skills of mentoring.
The importance of mentoring in medical education is well established. Reverse-mentorship is a new concept that looks to harness the unique qualities of millennials, including their aptitudes for empowerment, innovation and collaboration. This medical education case report shows that an enthusiastic junior clinician can successfully pilot an educational-mentoring scheme aimed at senior clinicians. To make more explicit the intuitive benefits of reverse-mentorship, longitudinal reviews are needed. However, this case report contributes important insights into this burgeoning field of medical education.
Ethnohistoric accounts indicate that the people of Australia's Channel Country engaged in activities rarely recorded elsewhere on the continent, including food storage, aquaculture and possible cultivation, yet there has been little archaeological fieldwork to verify these accounts. Here, the authors report on a collaborative research project initiated by the Mithaka people addressing this lack of archaeological investigation. The results show that Mithaka Country has a substantial and diverse archaeological record, including numerous large stone quarries, multiple ritual structures and substantial dwellings. Our archaeological research revealed unknown aspects, such as the scale of Mithaka quarrying, which could stimulate re-evaluation of Aboriginal socio-economic systems in parts of ancient Australia.
In 2020 a group of U.S. healthcare leaders formed the National Organization to Prevent Hospital-Acquired Pneumonia (NOHAP) to issue a call to action to address non–ventilator-associated hospital-acquired pneumonia (NVHAP). NVHAP is one of the most common and morbid healthcare-associated infections, but it is not tracked, reported, or actively prevented by most hospitals. This national call to action includes (1) launching a national healthcare conversation about NVHAP prevention; (2) adding NVHAP prevention measures to education for patients, healthcare professionals, and students; (3) challenging healthcare systems and insurers to implement and support NVHAP prevention; and (4) encouraging researchers to develop new strategies for NVHAP surveillance and prevention. The purpose of this document is to outline research needs to support the NVHAP call to action. Primary needs include the development of better models to estimate the economic cost of NVHAP, to elucidate the pathophysiology of NVHAP and identify the most promising pathways for prevention, to develop objective and efficient surveillance methods to track NVHAP, to rigorously test the impact of prevention strategies proposed to prevent NVHAP, and to identify the policy levers that will best engage hospitals in NVHAP surveillance and prevention. A joint task force developed this document including stakeholders from the Veterans’ Health Administration (VHA), the U.S. Centers for Disease Control and Prevention (CDC), The Joint Commission, the American Dental Association, the Patient Safety Movement Foundation, Oral Health Nursing Education and Practice (OHNEP), Teaching Oral-Systemic Health (TOSH), industry partners and academia.
The objectives were to examine clinical characteristics, length of recovery, and the prevalence of delayed physician-documented recovery, compare clinical outcomes among those with sport-related concussion (SRC) and non-sport-related concussion (nSRC), and identify risk factors for delayed recovery.
Included patients (8–18 years) were assessed ≤14 days post-injury at a multidisciplinary concussion program and diagnosed with an acute SRC or nSRC. Physician-documented clinical recovery was defined as returning to pre-injury symptom status, attending full-time school without symptoms, completing Return-to-Sport strategy as needed, and normal physical examination. Delayed physician-documented recovery was defined as >28 days post-injury.
Four hundred and fifteen patients were included (77.8% SRC). There was no difference in loss of consciousness (SRC: 9.9% vs nSRC: 13.0%, p = 0.39) or post-traumatic amnesia (SRC: 24.1% vs SRC: 31.5%, p = 0.15) at the time of injury or any differences in median Post-Concussion Symptom Scale scores (SRC: 20 vs nSRC: 23, p = 0.15) at initial assessment. Among those with complete clinical follow-up, the median physician-documented clinical recovery was 20 days (SRC: 19 vs nSRC: 23; p = 0.37). There was no difference in the proportion of patients who developed delayed physician-documented recovery (SRC: 27.7% vs nSRC: 36.1%; p = 0.19). Higher initial symptom score increased the risk of delayed physician-documented recovery (IRR: 1.39; 95% CI: 1.29, 1.49). Greater material deprivation and social deprivation were associated with an increased risk of delayed physician-documented recovery.
Most pediatric concussion patients who undergo early medical assessment and complete follow-up appear to make a complete clinical recovery within 4 weeks, regardless of mechanism.