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In this manuscript, we discuss the implementation and deployment of mobile integrated health/community paramedicine (MIH/CP) testing sites to provide screening, testing and community outreach during the first months of the coronavirus 2019 (COVID-19) pandemic in the metropolitan region of Charlotte, North Carolina, USA. This program addresses the need for an agile testing strategy during the current pandemic. We disclose the number of patients evaluated as “persons under investigation” (PUI) and the proportion with positive severe acute respiratory syndrome coronavirus 2 (SARS CoV-2) results from these sites. We describe how the programs were applied to patient care and include considerations on how additional staffing, scalability, and flexibility of these services may be applied to future patient and healthcare crises.
This is a descriptive report of the implementation of MIH/CP test sites in our healthcare system’s early response to the COVID-19 pandemic in March 2020. Retrospective data on the number of patients and their associated demographics are reported here as raw data. No statistical analysis was performed.
Between March 15, 2020 and April 15, 2020, our six MIH/CP test sites evaluated 4342 patients. Of these, 401 patients (9.2%) had test results positive, 62.8% of whom were women. The estimated duration of each patient under investigation encounter was 3 to 5 minutes. The paramedics were able to perform a brief history, specific physical examination, and screening for signs of hypoxemic respiratory failure. There were no cases of accidental exposure or failure of PPE for the MIH/CP paramedics.
In our healthcare system, we pivoted the traditional MIH/CP model to rapidly initiate remote drive-through testing for COVID-19 in pre-screened individuals. This model allowed us to test patients with suspected COVID-19 patients away from traditional healthcare sites and mitigate exposure to healthcare workers and other patients.
The Rapid ASKAP Continuum Survey (RACS) is the first large-area survey to be conducted with the full 36-antenna Australian Square Kilometre Array Pathfinder (ASKAP) telescope. RACS will provide a shallow model of the ASKAP sky that will aid the calibration of future deep ASKAP surveys. RACS will cover the whole sky visible from the ASKAP site in Western Australia and will cover the full ASKAP band of 700–1800 MHz. The RACS images are generally deeper than the existing NRAO VLA Sky Survey and Sydney University Molonglo Sky Survey radio surveys and have better spatial resolution. All RACS survey products will be public, including radio images (with
15 arcsec resolution) and catalogues of about three million source components with spectral index and polarisation information. In this paper, we present a description of the RACS survey and the first data release of 903 images covering the sky south of declination
made over a 288-MHz band centred at 887.5 MHz.
There is a high rate of psychiatric comorbidity in patients with epilepsy. However, the impact of surgical treatment of refractory epilepsy on psychopathology remains under investigation. We aimed to examine the impact of epilepsy surgery on psychopathology and quality of life at 1-year post-surgery in a population of patients with epilepsy refractory to medication.
This study initially assessed 48 patients with refractory epilepsy using the Structured Clinical Interview for DSM-IV Axis I Disorders (SCID-I), the Hospital Anxiety and Depression Scale (HADS) and the Quality of Life in Epilepsy Inventory 89 (QOLIE-89) on admission to an Epilepsy Monitoring Unit (EMU) as part of their pre-surgical assessment. These patients were again assessed using the SCID-I, QOLIE-89 and HADS at 1-year follow-up post-surgery.
There was a significant reduction in psychopathology, particularly psychosis, following surgery at 1-year follow-up (p < 0.021). There were no new cases of de novo psychosis and surgery was also associated with a significant improvement in the quality of life scores (p < 0.001).
This study demonstrates the impact of epilepsy surgery on psychopathology and quality of life in a patient population with refractory surgery. The presence of a psychiatric illness should not be a barrier to access surgical treatment.
Many youth with tics experience distress about having tics and how others may perceive them. Such symptoms are often more impairing and distressing than are the tics and negatively impact self-concept, functioning, and quality of life. Although treatments exist that target the frequency and severity of tics, no intervention has been developed that helps youth with tics cope with their condition and limit associated functional impairment and distress. Given this, we developed a cognitive-behaviorally oriented psychotherapy protocol that promotes adaptive coping and resiliency among youth with tics in addressing varied issues commonly experienced by this population. This poster reports data from the Phase I component of this study.
Phase I concentrated on developing the treatment protocol through expert opinion coupled with focus groups with parents and children with a tic disorder. Based on this, we developed a preliminary manual and piloted it in 6 youth with tics who met relevant inclusion/exclusion criteria. Phase II involves a preliminary test of the protocol in that focuses primarily on feasibility issues. All subjects participated in assessments (Screening, Baseline, Post-treatment) conducted by a blinded independent evaluator.
Only Phase I data will be presented as Phase II is ongoing. Descriptive statistics related to improvement rates; tic severity; child self-esteem and self-efficacy; and child internalizing symptoms will be reported. Qualitative data from the focus groups will also be presented regarding domains of impairment for youth with tics.
This treatment shows early promise of helping youth with tics cope with their condition.
Animal experimental studies suggest that 5-HT4 receptor activation holds promise as a novel target for the treatment of depression and cognitive impairment. 5-HT4 receptors are post-synaptic receptors that are located in striatal and limbic areas known to be involved in cognition and mood. Consistent with this, 5-HT4 receptor agonists produce rapid antidepressant effects in a number of animal models of depression, and pro-cognitive effects in tasks of learning and memory. These effects are accompanied by molecular changes, such as the increased expression of neuroplasticity-related proteins that are typical of clinically useful antidepressant drugs. Intriguingly, these antidepressant-like effects have a fast onset of their action, raising the possibility that 5-HT4 receptor agonists may be a particularly useful augmentation strategy in the early stages of SSRI treatment. Until recently, the translation of these effects to humans has been challenging. Here, we review the evidence from animal studies that the 5-HT4 receptor is a promising target for the treatment of depression and cognitive disorders, and outline a potential pathway for the efficient and cost-effective translation of these effects into humans and, ultimately, to the clinic.
Accurate methods for determining the duration of HIV infection at the individual level are valuable in many settings, including many critical research studies and in clinical practice (especially for acute infection). Since first published in 2003, the ‘Fiebig staging system’ has been used as the primary way of classifying early HIV infection into five sequential stages based on HIV test result patterns in newly diagnosed individuals. However, Fiebig stages can only be assigned to individuals who produce both a negative and a positive test result on the same day, on specific pairs of tests of varying ‘sensitivity’. Further, in the past 16 years HIV-testing technology has evolved substantially, and three of the five key assays used to define Fiebig stages are no longer widely used. To address these limitations, we developed an improved and more general framework for estimating the duration of HIV infection by interpreting any combination of diagnostic test results, whether obtained on single or multiple days, into an estimated date of detectable infection, or EDDI. A key advantage of the EDDI method over Fiebig staging is that it allows for the generation of a point estimate, as well as an associated credibility interval for the date of first detectable infection, for any person who has at least one positive and one negative HIV test of any kind. The tests do not have to be run on the same day; they do not have to be run during the acute phase of infection and the method does not rely on any special pairing of tests to define ‘stages’ of infection. The size of the interval surrounding the EDDI (and therefore the precision of the estimate itself) depends largely on the length of time between negative and positive tests. The EDDI approach is also flexible, seamlessly incorporating any assay for which there is a reasonable diagnostic delay estimate. An open-source, free online tool includes a user-updatable curated database of published diagnostic delays. HIV diagnostics have evolved tremendously since that original publication more than 15 years ago, and it is time to similarly evolve the methods used to estimate timing of infection. The EDDI method is a flexible and rigorous way to estimate the timing of HIV infection in a continuously evolving diagnostic landscape.
Research has shown that religious affiliation has a protective effect against deliberate self-harm. This is particularly pronounced in periods of increased religious significance, such as periods of worship, celebration, and fasting. However, no data exist as to whether this effect is present during the Christian period of Lent. Our hypothesis was that Lent would lead to decreased presentations of self-harm emergency department (ED) in a predominantly Catholic area of Ireland.
Following ethical approval, we retrospectively analysed data on presentations to the ED of University Hospital Limerick during the period of Lent and the 40 days immediately preceding it. Frequency data were compared using Pearson’s chi-squared tests in SPSS.
There was no significant difference in the overall number of people presenting to the ED with self-harm during Lent compared to the 40 days preceding it (χ2 = 0.75, df = 1, p > 0.05), and there was no difference in methods of self-harm used. However, there was a significant increase in attendances with self-harm during Lent in the over 50’s age group (χ2 = 7.76, df = 1, p = 0.005).
Based on our study, Lent is not a protective factor for deliberate self-harm and was associated with increased presentations in the over 50’s age group. Further large-scale studies are warranted to investigate this finding as it has implications for prevention and management of deliberate self-harm.
We have detected 27 new supernova remnants (SNRs) using a new data release of the GLEAM survey from the Murchison Widefield Array telescope, including the lowest surface brightness SNR ever detected, G 0.1 – 9.7. Our method uses spectral fitting to the radio continuum to derive spectral indices for 26/27 candidates, and our low-frequency observations probe a steeper spectrum population than previously discovered. None of the candidates have coincident WISE mid-IR emission, further showing that the emission is non-thermal. Using pulsar associations we derive physical properties for six candidate SNRs, finding G 0.1 – 9.7 may be younger than 10 kyr. Sixty per cent of the candidates subtend areas larger than 0.2 deg2 on the sky, compared to < 25% of previously detected SNRs. We also make the first detection of two SNRs in the Galactic longitude range 220°–240°.
This work makes available a further
of the GaLactic and Extragalactic All-sky Murchison Widefield Array (GLEAM) survey, covering half of the accessible galactic plane, across 20 frequency bands sampling 72–231 MHz, with resolution
. Unlike previous GLEAM data releases, we used multi-scale CLEAN to better deconvolve large-scale galactic structure. For the galactic longitude ranges
$345^\circ < l < 67^\circ$
$180^\circ < l < 240^\circ$
, we provide a compact source catalogue of 22 037 components selected from a 60-MHz bandwidth image centred at 200 MHz, with RMS noise
and position accuracy better than 2 arcsec. The catalogue has a completeness of 50% at
, and a reliability of 99.86%. It covers galactic latitudes
towards the galactic centre and
for other regions, and is available from Vizier; images covering
for all longitudes are made available on the GLEAM Virtual Observatory (VO).server and SkyView.
We examined the latest data release from the GaLactic and Extragalactic All-sky Murchison Widefield Array (GLEAM) survey covering 345° < l < 60° and 180° < l < 240°, using these data and that of the Widefield Infrared Survey Explorer to follow up proposed candidate Supernova Remnant (SNR) from other sources. Of the 101 candidates proposed in the region, we are able to definitively confirm ten as SNRs, tentatively confirm two as SNRs, and reclassify five as H ii regions. A further two are detectable in our images but difficult to classify; the remaining 82 are undetectable in these data. We also investigated the 18 unclassified Multi-Array Galactic Plane Imaging Survey (MAGPIS) candidate SNRs, newly confirming three as SNRs, reclassifying two as H ii regions, and exploring the unusual spectra and morphology of two others.
Introduction: Telephone Triage Services (TTS) manage phone calls from the public regarding general medical problems and provide telephone advice. This telephone based care can overlap with care provided by Poison Centres. Our objective was to examine the impact of a provincial 811 TTS on the IWK Regional Poison Centre (RPC). Methods: This is a retrospective descriptive study using interrupted time series methodology. We compared monthly IWK RPC call volume in the pre-811 era (January 2007-July 2009) and the post-811 era (September 2009-December 2017). We summarized the characteristics of callers who accessed the IWK RPC in terms of client age, sex, intentionality, time of day, call disposition and outcome. Caller characteristics were compared between the pre- and post-811 eras using chi-square test for categorical variables. We used segmented regression analysis to evaluate changes in slope of call volume in the pre- and post 811 eras. The Durbin-Watson statistic was performed to test for serial correlation and the Dickey-Fuller test to investigate seasonality. Results: The dataset included 82683 calls to the IWK RPC – 27028 pre-811 and 55655 post-811. Overall, 55% of calls were for female clients and the largest age group was children aged 0-5 years (37%). Most calls originated from home (47%), followed by a health care facility (23%). Most calls were managed at home (65%). Less than 3% of calls resulted in major effect or death. The Durbin Watson statistic was not statistically significant (p = 0.94). The Dickey-Fuller test indicated series stationarity (p = 0.001). There was no statistically significant change in call volume to the IWK RPC due to the introduction of 811 (p = 0.39). There was no significant variation by time of day, day of week or month, with most calls occurring in the evening. There were significantly more calls regarding intentional ingestions in the post-811 era (23% vs. 19% pre-811, p < .001). Outcomes in the pre and post 811 eras were as follows: minor/no effect/non-toxic/minimal 80% vs. 78%; moderate 7% vs. 10%; and, major/death 1.7% vs. 2.0%. Conclusion: The introduction of a TTS did not change call volumes at our RPC. The increase in the percentage of calls about intentional ingestions may reflect an increase in call acuity as the 811-TTS likely manages calls about minor/non-toxic ingestions without consulting with the RPC. Our future research will examine the nature of poison related calls to the 811-TTS.
Introduction: Cardioactive steroid poisoning occurs worldwide with the use of pharmaceutical digoxin and botanical cardiac glycosides. The wholesale price of the antidote, digoxin immune fab, has increased over 300% from 2010 to 2015. Our objective was to identify gaps in the existing literature with respect to the use of digoxin immune fab in cardioactive steroid toxicity in acute care settings. Methods: We used scoping study methodology, as described by Arksey and O'Malley, to assess the range and scope of empiric research and will report: 1) sources of cardioactive steroid toxicity in acute settings; 2) doses of digoxin immune fab used in treatment; and, 3) intervention outcomes of acute cardioactive steroid toxicity following the administration of digoxin immune fab as first or second-line therapy. We collaborated with a library scientist to devise search strategies for PubMed, CINAHL, EMBASE, CENTRAL and Toxnet. We sought unpublished literature through the Canadian Electronic Library, Proquest, and Scopus and searched reference lists of included studies. We hand searched relevant conference proceedings and applicable guidelines. Two reviewers independently reviewed titles and abstracts using predetermined criteria. Using a structured data abstraction form, two reviewers independently extracted data. All discrepancies were resolved through consensus. Results: Our search strategy yielded 3458 results. After screening titles and abstracts 384 underwent full text screening. We included 147 studies and are currently extracting data from 12 French studies and 135 English studies. To date we have extracted data from 90 case reports and case series. Conclusion: Given concerns over rising costs, our findings will shed light on the extent of the evidence for use of digoxin immune fab in acute care settings.
To evaluate the impact of a hard stop in the electronic health record (EHR) on inappropriate gastrointestinal pathogen panel testing (GIPP).
We used a quasi-experimental study to evaluate testing before and after the implementation of an EHR alert to stop inappropriate GIPP ordering.
Midwest academic medical center.
Hospitalized patients with diarrhea for which GIPP testing was ordered, between January 2016 through March 2017 (period 1) and April 2017 through June 2018 (period 2).
A hard stop in the EHR prevented clinicians from ordering a GIPP more than once per admission or in patients hospitalized for >72 hours.
During period 1, 1,587 GIPP tests were ordered over 212,212 patient days, at a rate of 7.48 per 1,000 patient days. In period 2, 1,165 GIPP tests were ordered over 222,343 patient days, at a rate of 5.24 per 1,000 patient days. The Poisson model estimated a 30% reduction in total GIPP ordering rates between the 2 periods (relative risk, 0.70; 95% confidence interval [CI], 0.63–0.78; P < .001). The rate of inappropriate tests ordered decreased from 21.5% to 4.9% between the 2 periods (P < .001). The total savings calculated factoring only GIPP orders that triggered the hard stop was ∼$67,000, with potential savings of $168,000 when factoring silent best-practice alert data.
A simple hard stop alert in the EHR resulted in significant reduction of inappropriate GIPP testing, which was associated with significant cost savings. Clinicians can practice diagnostic stewardship by avoiding ordering this test more than once per admission or in patients hospitalized >72 hours.
The use of targets with surface structures for laser-driven particle acceleration has potential to significantly boost the particle and radiation energies because of enhanced laser absorption. We investigate, via experiment and particle-in-cell simulations, the impact of micron-scale surface-structured targets on the spectrum of electrons and protons accelerated by a picosecond laser pulse at relativistic intensity. Our results show that, compared with flat-surfaced targets, structures on this scale give rise to a significant enhancement in particle and radiation emission over a wide range of laser–target interaction parameters. This is due to the longer plasma scale length when using micro-structures on the target front surface. We do not observe an increase in the proton cutoff energy with our microstructured targets, and this is due to the large volume of the relief.
To examine the impact of multiple psychiatric disorders over the lifetime on risk of mortality in the general population.
Data came from a random community-based sample of 1397 adults in Atlantic Canada, recruited in 1992. Major depression, dysthymia, panic disorder, generalised anxiety disorder and alcohol use disorders were assessed using the Diagnostic Interview Schedule (DIS). Vital status of participants through 2011 was determined using probabilistic linkages to the Canadian Mortality Database. Cox proportional hazard models with age at study entry as the time scale were used to investigate the relationship between DIS diagnoses and mortality, adjusted for participant education, smoking and obesity at baseline.
Results suggested that mood and anxiety disorders rarely presented in isolation – the majority of participants experienced multiple psychiatric disorders over the lifetime. Elevated risk of death was found among men with both major depression and dysthymia (HR 2.56; 95% CI 1.12–5.89), depression and alcohol use disorders (HR 2.45; 95% CI 1.18–5.10) and among men and women who experienced both panic disorder and alcohol use disorders (HR 3.80; 95% CI 1.19–12.16).
The experience of multiple mental disorders over the lifetime is extremely common, and associated with increased risk of mortality, most notably among men. Clinicians should be aware of the importance of considering contemporaneous symptoms of multiple psychiatric conditions.
Global inequity in access to and availability of essential mental health services is well recognized. The mental health treatment gap is approximately 50% in all countries, with up to 90% of people in the lowest-income countries lacking access to required mental health services. Increased investment in global mental health (GMH) has increased innovation in mental health service delivery in LMICs. Situational analyses in areas where mental health services and systems are poorly developed and resourced are essential when planning for research and implementation, however, little guidance is available to inform methodological approaches to conducting these types of studies. This scoping review provides an analysis of methodological approaches to situational analysis in GMH, including an assessment of the extent to which situational analyses include equity in study designs. It is intended as a resource that identifies current gaps and areas for future development in GMH. Formative research, including situational analysis, is an essential first step in conducting robust implementation research, an essential area of study in GMH that will help to promote improved availability of, access to and reach of mental health services for people living with mental illness in low- and middle-income countries (LMICs). While strong leadership in this field exists, there remain significant opportunities for enhanced research representing different LMICs and regions.
Introduction: Screening for organ and tissue donation is an essential skill for emergency physicians. In 2015, 4564 individuals were on a waiting list for organ transplant and 242 died while waiting. As Canadas donation rates are less than half that of other comparable countries, it is crucial to ensure we are identifying all potential donors. Patients deceased from poisoning are a source that may not be considered for referral as often as those who die from other causes. This study aims to identify if patients dying from poisoning represent an under-referred group and determine what physician characteristics influence referral decisions. Methods: In this cross-sectional unidirectional survey study, physician members of the Canadian Association of Emergency Physicians were invited to participate. Participants were presented with 20 organ donation scenarios that included poisoned and non-poisoned deaths, as well as one ideal scenario for organ or tissue donation used for comparison. Participants were unaware of the objective to explore donation in the context of poisoning deaths. Following the organ donation scenarios, a range of follow-up questions and demographics were included to explore factors influencing the decision to refer or not refer for organ or tissue donation. Results were reported descriptively and associations between physician characteristics and decisions to refer were assessed using odds ratios and 95% confidence intervals. Results: 208/2058 (10.1%) physicians participated. 25% did not refer in scenarios involving a drug overdose (n=71). Specific poisonings commonly triggering the decision to not refer included palliative care medications (n=34, 18%), acetaminophen (n=42, 22%), chemical exposure (n=48, 27%) and organophosphates (n=87, 48%). Factors associated with an increased likelihood to refer potential donors following overdose included previous organ and tissue donation training (OR=2.6), having referred in the past (OR=4.3), available donation support (OR=3.9), greater than 10 years of service (OR=2.1), large urban center (OR=3.8), holding emergency medicine certification (OR=3.6), male gender (OR=2.2, CI), and having indicated a desire to be a donor on government identification (OR=5.8). Conclusion: Scenarios involving drug overdoses were associated with under-referral for organ and tissue donation. As poisoning is not a contraindication for referral, this represents a potential source of donors. By examining characteristics that put clinicians at risk for under-referral of organ or tissue donors, becoming aware of potential biases, improving transplant knowledge bases, and implementing support and training programs for the organ and tissue donation processes, we have the opportunity to improve these rates and reduce morbidity and mortality for Canadians requiring organ or tissue donation.
The global spread of non-tuberculous mycobacteria (NTM) may be due to HIV/AIDS and other environmental factors. The symptoms of NTM and tuberculosis (TB) disease are indistinguishable, but their treatments are different. Lack of research on the epidemiology of NTM infections has led to underestimation of its prevalence within TB endemic countries. This study was designed to determine the prevalence and clinical characteristics of pulmonary NTM in Bamako. A cross-sectional study which include 439 suspected cases of pulmonary TB. From 2006 to 2013 a total of 332 (76%) were confirmed to have sputum culture positive for mycobacteria. The prevalence of NTM infection was 9.3% of our study population and 12.3% of culture positive patients. The seroprevalence of HIV in NTM group was 17.1%. Patients who weighed <55 kg and had TB symptoms other than cough were also significantly more likely to have disease due to NTM as compared to those with TB disease who were significantly more likely to have cough and weigh more than 55 kg (OR 0.05 (CI 0.02–0.13) and OR 0.32 (CI 0.11–0.93) respectively). NTM disease burden in Bamako was substantial and diagnostic algorithms for pulmonary disease in TB endemic countries should consider the impact of NTM.