The effect of clinical face shields on aerosolized particle exposure

Background: Face shields protect healthcare workers (HCWs) from fluid and large droplet contamination. Their effect on smaller aerosolized particles is unknown. Materials & methods: An ultrasonic atomizer was used to simulate particle sizes equivalent to human breathing and forceful cough. Particles were measured at positions correlating to anesthetic personnel in relation to a patient inside an operating theatre environment. The effect of the application of face shields on HCW exposure was measured. Results & Conclusion: Significant reductions in particle concentrations were measured after the application of vented and enclosed face shields. Face shields appear to reduce the concentration of aerosolized particles that HCWs are exposed to, thereby potentially conferring further protection against exposure to aerosolized particles in an operating theatre environment.

Undiagnosed comorbidities among individuals hospitalised with COVID-19 in South African public hospitals.

BACKGROUND: Previous studies have reported comorbid disease, including hypertension, diabetes mellitus, chronic cardiac and renal disease, malignancy, HIV, tuberculosis (TB) and obesity, to be associated with COVID­19 mortality. National demographic surveys have reported a high proportion of undiagnosed and untreated comorbid disease in South Africa (SA). OBJECTIVES: To determine the number of individuals with previously undiagnosed HIV, TB and non-communicable diseases (NCDs) among patients hospitalised with COVID­19, and the level of medical control of these chronic diseases. METHODS: We conducted a sentinel surveillance study to collect enhanced data on HIV, TB and NCDs among individuals with COVID­19 admitted to 16 secondary-level public hospitals in six of the nine provinces of SA. Trained surveillance officers approached all patients who met the surveillance case definition for inclusion in the study, and consenting patients were enrolled. The data collection instrument included questions on past medical history to determine the self-reported presence of comorbidities. The results of clinical and laboratory testing introduced as part of routine clinical care for hospitalised COVID­19 patients were collected for the study, to objectively determine the presence of hypertension, diabetes, HIV and TB and the levels of control of diabetes and HIV. RESULTS: On self-reported history, the most prevalent comorbidities were hypertension (n=1 658; 51.5%), diabetes (n=855; 26.6%) and HIV (n=603; 18.7%). The prevalence of self-reported active TB was 3.1%, and that of previous TB 5.5%. There were 1 254 patients admitted with COVID­19 (39.0%) who met the body mass index criteria for obesity. On clinical and laboratory testing, 87 patients were newly diagnosed with HIV, 29 with TB, 215 with diabetes and 40 with hypertension during their COVID­19 admission. There were 151/521 patients living with HIV (29.0%) with a viral load >1 000 copies/mL and 309/570 (54.2%) with a CD4 count <200 cells/µL. Among 901 patients classified as having diabetes, 777 (86.2%) had a glycated haemoglobin (HbA1c) level ≥6.5%. CONCLUSION: The study revealed a high prevalence of comorbid conditions among individuals with COVID­19 admitted to public hospitals in SA. In addition, a significant number of patients had previously undiagnosed hypertension, diabetes, HIV and active TB, and many and poorly controlled chronic disease, as evidenced by high HbA1c levels in patients with diabetes, and high viral loads and low CD4 levels in patients with HIV. The findings highlight the importance of strengthening health systems and care cascades for chronic disease management, which include prevention, screening for and effectively treating comorbidities, and ensuring secure and innovative supplies of medicines in primary healthcare during the COVID­19 pandemic.

Age-stratified utility of NT-proBNP testing as part of a blind Emergency Department shortness of breath orderset (Jan-Dec 2019)

Background: NT-proBNP was added to our emergency department (ED) triage blind 'shortness of breath (SOB) orderset' for presenters aged >70. Evidence-based thresholds for acute heart failure (HF) diagnosis are >900/1800 pg/ml for ages 50-75/>75 respectively (1.2);their utility in contemporary practice is uncertain. Purpose: To assess the relation between blind NT-proBNP testing in this setting and (1) coded discharge diagnosis stratified by age, and (2) all-cause mortality at medium-term follow-up. Methods:We retrieved all ED 'SOB' blood ordersets (1.1.2019-31.12.2019), including NT-proBNP, Hb, electrolytes, creatinine, troponin, CRP, d-dimer, and coded discharge diagnoses. Multivariate logistic regression models for all-cause survival (at 9.9.2021) were assessed. Results: There were 638 presentations (median age 76.1), unexpectedly including 198 <70 years. Modal and median lengths of stay were 0 and 1 day respectively. Stratified by age (<60, 60-69, 70-74, 75-79, 80-84, ≥85y), the proportion with HF coded as primary discharge diagnosis (5, 7, 9, 17, 18, 25% respectively) and all-comer all-cause mortality at 2.2±0.3 years (13, 42, 40, 48, 48, 49%) steadily increased (Table;orderset variables presented as median (inter-quartile range)). Median NT-proBNP was 3672, 2667, and 321 pg/ml when HF was in the primary, secondary, or neither coded discharge diagnosis field respectively;2.2-year-all-cause mortality was 54%, 60%, and 35%. In those with a primary HF discharge code, 77% of 349 presenters ≥75y and 88% of 231 aged 50-74 had NT-proBNP >1800/900 pg/ml respectively. In those without an HF code, 26% in both age cohorts had NT-proBNP >1800/900 pg/ml (dotted lines in Figure, panels A/B, respectively represent NT-proBNP thresholds). Independent predictors of all-cause mortality for patients with a primary or secondary HF code were ln(NT-proBNP) (OR 1.26, 95% CI 1-1.59) and serum Na+ (OR 0.93, 0.88-0.99);for patients without an HF code, these were serum K+ (1.87, 1.21-2.88), ln(NT-proBNP) (1.35, 1.15-1.58), ln(CRP) (1.18, 1.02-1.36), length of stay (1.08, 1.03-1.12), and age (1.03, 1.01-1.06). (Figure Presented) Conclusion: HF detection with NT-proBNP in a blind SOB orderset showed increasing sensitivity with age with the best specificity >75 years. Most presenters stayed ≤1 day, so blind testing at triage facilitates HF detection. NT-proBNP independently predicted 2.2-year-all-cause mortality irrespective of discharge HF coding. This is notable as the commonest non-HF causes of acute SOB are prognostically important at >70 years and follow-up occurred through the Covid-19 pandemic. The findings may reflect disease severity in patients without HF, but also suggest that discharge HF coding status does not identify all those with prognostically relevant HF.

Hybrid Reconnaissance Mission to the 30 October 2020 Aegean Sea Earthquake and Tsunami (Izmir, Turkey & Samos, Greece): Description of Data Collection Methods and Damage

On 30 October 2020, an earthquake of M-w 6.9 hit the Aegean coasts of Turkey and Greece. The epicentre was some 14 km northeast of Avlakia on Samos Island, and 25 km southwest of Seferihisar, Turkey, triggering also a tsunami. The event has been followed by >4,000 aftershocks up to M-w 5.2 The Earthquake Engineering Field Investigation Team (EEFIT) has immediately gathered a team to conduct a hybrid reconnaissance study, bringing together remote and field investigation techniques. The mission took place between 16 November and 17 December, inclusive of three sets of field study carried out by the field crews for building damage assessment in the affected areas in Turkey and Greece under the coordination of the remote team. The mission also aimed to assess the viability of alternative data sources for an appraisal of the future viability of hybrid missions. This paper summarises the mission setup and findings, and discusses the benefits of and difficulties encountered during this hybrid reconnaissance activity.

Lessons for Remote Post-earthquake Reconnaissance from the 14 August 2021 Haiti Earthquake

On 14th August 2021, a magnitude 7.2 earthquake struck the Tiburon Peninsula in the Caribbean nation of Haiti, approximately 150 km west of the capital Port-au-Prince. Aftershocks up to moment magnitude 5.7 followed and over 1,000 landslides were triggered. These events led to over 2,000 fatalities, 15,000 injuries and more than 137,000 structural failures. The economic impact is of the order of US$1.6 billion. The on-going Covid pandemic and a complex political and security situation in Haiti meant that deploying earthquake engineers from the UK to assess structural damage and identify lessons for future building construction was impractical. Instead, the Earthquake Engineering Field Investigation Team (EEFIT) carried out a hybrid mission, modelled on the previous EEFIT Aegean Mission of 2020. The objectives were: to use open-source information, particularly remote sensing data such as InSAR and Optical/Multispectral imagery, to characterise the earthquake and associated hazards;to understand the observed strong ground motions and compare these to existing seismic codes;to undertake remote structural damage assessments, and to evaluate the applicability of the techniques used for future post-disaster assessments. Remote structural damage assessments were conducted in collaboration with the Structural Extreme Events Reconnaissance (StEER) team, who mobilised a group of local non-experts to rapidly record building damage. The EEFIT team undertook damage assessment for over 2,000 buildings comprising schools, hospitals, churches and housing to investigate the impact of the earthquake on building typologies in Haiti. This paper summarises the mission setup and findings, and discusses the benefits, and difficulties, encountered during this hybrid reconnaissance mission.

Comprehensive meta-analysis of COVID-19 mortality rates for 22 cancer subtypes from the Reboot: COVID-Cancer Project, an interactive resource with aggregated data from 21,839 cancer patients

Introduction: The COVID-19 pandemic continues to disproportionately impact people with cancer. Mortality estimates among cancer patients vary and are influenced by numerous factors including cancer type, treatment, disease stage, and patient demographics. To date, attempts to explore these associations have been limited by small cohorts. Methods: Here, we present a meta-analysis of data available through the Reboot: COVID-Cancer Project, a living and freely available resource that includes published clinical studies that report outcomes for cancer patients with COVID-19. Studies were identified using targeted search queries in PubMed, MedRxiv, BioRxiv, and the SSRN eLibrary, followed by rule-based approaches and extensive manual validation and data extraction. The data is updated monthly and can be explored through an interactive dashboard as well as downloaded. Case fatality rates (CFR;the number of deaths per 100 confirmed cases during the study period) were calculated using a random-effects model. Study heterogeneity and sample size bias was assessed using the Egger regression test. Results: As of December 18, 2020, the resource contained 225 publications comprising 21,839 cancer patients with COVID-19. Of these, there was sufficient sample size to quantify CFRs for 22 cancer types across 19,147 patients from 109 publications. The pooled CFR among all cancer patients was 27% (95% CI: 25-30%). For solid tumors and hematological malignancies, the CFRs were 23% (95% CI: 20-25%) and 30% (95% CI: 27-33%), respectively. Within solid tumors, patients with lung (CFR: 32%, 95% CI: 27-36%), prostate (CFR: 30%, 95% CI: 17-43%), and central nervous system (CFR: 27%, 95% CI: 18-36%) malignancies had relatively high CFRs, whereas patients with breast (CFR: 10%, 95% CI: 7-14%) and thyroid (CFR: 5%, 95% CI: 1-11%) malignancies had relatively low CFRs. Among patients with hematological malignancies, CFRs ranged from 10% (95% CI: 3-18%) in patients with chronic myelogenous leukemia to 39% (95% CI: 20-57%) in patients with acute myeloid leukemia. Discussion: We observed significant heterogeneity of COVID-19 CFRs between cancer subtypes. This may in part reflect differences in patient demographics, treatment history, or disease state. Subtype-specific analysis can stratify cancer patients by risk for COVID-19 mortality and advise management strategies. The Reboot: COVID-Cancer Project provides an accessible means to evaluate subtype-specific COVID-19 fatality rates on a by-publication basis.

The Utility of Planned Deprescribing in Pandemics and Other Disasters: A Systematic Review

BACKGROUND: How can psychiatrists best provide care in complex, sometimes overwhelming disasters? COVID-19 strained every aspect of health care to the breaking point, from finances to pharmaceutical supply lines. We can expect more challenges to prescribing in the future, as shown by recent hurricanes in Puerto Rico, fires in California, and ice storms in Texas. When medications become scarce or inaccessible, then clinicians need to make difficult prescribing decisions. We suggest that a culture of deprescribing, a systematic approach to reducing or simplifying medications, could be applied to a wide variety of crises. Deprescribing is defined as the planned reduction of medications to improve patient health or to reduce side effects (see deprescribing.org). It has been used to reduce polypharmacy in geriatric and other complex populations. It provides evidence-based guidance for phasing out many classes of medications. It is part of the larger program to reduce waste in health care and to make pharmacy more rational. Disasters and resource scarcity, however, require a different approach. In contrast to routine care focused on individual patients, crisis standards of care (CSC) shift the clinical focus to the community. Instead of deprescribing guidelines for individual clinicians, CSC deprescribing would be national policies addressing shortages of important medications. We did a scoping review looking for studies of deprescribing in a crisis. METHODS/RESULTS: We extracted 1340 references in Google Scholar 2016 to 2021 using (deprescribing) AND (disaster OR crisis OR climate OR pandemic OR supply lines). A scan of texts found 160 references matching our criteria, and only 19 of them addressed deprescribing as a strategy to strengthen health systems or providers in an emergency. Most of those were related to scarce supplies during COVID, and a few addressed the carbon impact of medications. We also reviewed related literatures on medication supply chain vulnerabilities, WHO Essential Medicines, and healthcare rationing. IMPLICATIONS: Deprescribing gained attention during the COVID pandemic, responding to both disrupted supply lines and improving patient safety. Writers concerned with climate change support deprescribing to reduce the carbon impact of medications. Deprescribing as crisis policy could help streamline national stockpiles, supply chains, and manufacturing. Education could make deprescribing second nature for clinicians, potentially decreasing stress and increasing flexibility in future emergencies. Barriers to deprescribing generally include cultural inertia, industry lobbyists, education, and malpractice fears. In a crisis, deprescribing guidelines could provide clinicians with confidence and flexibility while conserving scarce resources. Research is needed to evaluate deprescribing guidelines for crises, especially ensuring equity in how they reduce polypharmacy and save money. FUNDING: No funding.

Planned Deprescribing to Protect Health Systems in Pandemics and Other Disasters: A Scoping Review

BACKGROUND: How can psychiatrists best provide care in complex, sometimes overwhelming disasters? COVID-19 strained every aspect of health care to the breaking point, from finances to pharmaceutical supply lines. We can expect more challenges to prescribing in the future, as shown by recent hurricanes in Puerto Rico, fires in California, and ice storms in Texas. When medications become scarce or inaccessible, then clinicians need to make difficult prescribing decisions. We suggest that a culture of deprescribing, a systematic approach to reducing or simplifying medications, could be applied to a wide variety of crises. Deprescribing is defined as the planned reduction of medications to improve patient health or to reduce side effects (see deprescribing.org). It has been used to reduce polypharmacy in geriatric and other complex populations. It provides evidence-based guidance for phasing out many classes of medications. It is part of the larger program to reduce waste in health care and to make pharmacy more rational. Disasters and resource scarcity, however, require a different approach. In contrast to routine care focused on individual patients, crisis standards of care (CSC) shift the clinical focus to the community. Instead of deprescribing guidelines for individual clinicians, CSC deprescribing would be national policies addressing shortages of important medications. We did a scoping review looking for studies of deprescribing in a crisis. METHODS/RESULTS: We extracted 1340 references in Google Scholar 2016 to 2021 using (deprescribing) AND (disaster OR crisis OR climate OR pandemic OR supply lines ). A scan of texts found 160 references matching our criteria, and only 19 of them addressed deprescribing as a strategy to strengthen health systems or providers in an emergency. Most of those were related to scarce supplies during COVID, and a few addressed the carbon impact of medications. We also reviewed related literatures on medication supply chain vulnerabilities, WHO Essential Medicines, and healthcare rationing. IMPLICATIONS: Deprescribing gained attention during the COVID pandemic, responding to both disrupted supply lines and improving patient safety. Writers concerned with climate change support deprescribing to reduce the carbon impact of medications. Deprescribing as crisis policy could help streamline national stockpiles, supply chains, and manufacturing. Education could make deprescribing second nature for clinicians, potentially decreasing stress and increasing flexibility in future emergencies. Barriers to deprescribing generally include cultural inertia, industry lobbyists, education, and malpractice fears. In a crisis, deprescribing guidelines could provide clinicians with confidence and flexibility while conserving scarce resources. Research is needed to evaluate deprescribing guidelines for crises, especially ensuring equity in how they reduce polypharmacy and save money. FUNDING: No funding.

3D printed models decentralise surgical skills training for retrograde intrarenal surgery and percutaneous nephrolithotomy in the COVID-19 era

Introduction & Objectives: Imparting the required psychomotor skills for trainees to become proficient in Percutaneous Nephrolithotomy (PCNL) and Retrograde Intrarenal Surgery (RIRS) is tricky for surgical educators, due to the challenging nature of the procedures and the lack of realistic simulators. The current COVID-19 pandemic has compounded these issues by reducing learning opportunities for trainees through reduced case numbers and availability of surgical skills courses. To address these contemporaneous issues, we have developed 3D printed inexpensive combined RIRS and PCNL training models for both in-person and video conference skills training. Materials & Methods: Anonymised Computed Tomography data was used to develop the training model, using medical image processing software (3D Slicer, version 4.12, Harvard, USA). The model was 3D printed using flesh-coloured resin which best approximated the appearance of the collecting system during ureteroscopy. The face validity of the simulator was assessed by surgical educators for its suitability for both in-person and remote training. Results: The RIRS and PCNL training model was evaluated by expert Urologists involved in the national training of the procedures and found to be more realistic and affordable when compared to available alternatives. The 3D printed model was developed for under €3, allowing multiple identical copies to be 3D printed for both in-person courses and scheduled video conferencing workshops with the models distributed to each participating centre beforehand. This “hub and spoke” method of surgical skills training is greatly facilitated by the affordability of the 3D printed models. Conclusions: We have developed an inexpensive combined RIRS and PCNL training model for both in-person and remote training at USANZ and other international training courses. 3D printed simulators have great future potential in the training of endourological and other urological procedures, enhancing connectivity and facilitating the decentralisation of training courses for the acquisition of key surgical skills.

Russia after 2020: Looking ahead after two decades of Putin

This book presents a comprehensive survey of the current state of Russia and how Russia is likely to develop in the immediate future. Not always sticking to the mainstream narrative, it covers political events including Putin's constitutional reforms of January 2020 and their likely consequences, economic developments, Russia's international relations and military activities, and changes and issues in Russian society, including in education, the place of women, health care and religion. Special attention is paid to manifestations of the COVID-19 pandemic. The book's overall conclusion is that events of 2020 may compel Putin to 'think again' before he decides whether to run for office in 2024. © 2022 J. L. Black. All rights reserved.

Ports and intermodal transport - Institutions and organisations: The Setō Inland Sea, Japan, from archaic times to the present

Port planning and development requires a complete understanding of institutional arrangements, regulatory frameworks and stakeholder interests all within a broader context of global trade and investment. Historical investigations have revealed key events and players that have changed institutional and organisational administration in commercial ports. This paper is a descriptive analysis of major “tipping point” events, the key players and whether institutions or organisations dominated, with particular reference to ports in the Ōsaka Bay region of Japan from archaic times to the present day. The theoretical framework is provided by the New Institutional Economics and a case study approach is adopted using ports at the eastern end of the Setō Inland Sea, Japan. The methodology involves a literature search and an interpretation of the relevant material in English and Japanese, site visits and interviews with port officers on how and when transformations occurred, noting, in the conclusions, implications for reform in post-COVID 19 Japan. Copyright © 2021 Inderscience Enterprises Ltd.

Football is "the most important of the least important things": the illusion of sport and COVID-19. (Special Issue: Leisure in the time of Covid-19.)

In his book, On the Pleasure Principle in Culture (2014), Robert Pfaller argued that our relationship to sport is one grounded in "illusion". Simply put, our interest in and enjoyment of sport occurs through a process of "knowing better". Here, one's knowledge of the unimportance of sport is achieved by associating the illusion of sport with a naive observer - i.e. someone who does believe in sport's importance. In the wake of the global pandemic, COVID-19, it would seem that Pfaller's remarks have taken on an added significance. With major sporting events and domestic competitions being indefinitely postponed or canceled, Liverpool manager, Jurgen Klopp, commented that football was "the most important of the least important things". In light of these remarks, this paper will critically locate sport's sudden unimportance in relation to Pfaller's contention that sport reflects an "illusion without owner".

Psychiatry on a shoestring: developing new standards of care for a severe, prolonged, and widespread emergency

Study Objective. The COVID-19 crisis has severely stressed our healthcare system and pushed our economy to the brink. This long emergency will probably cause years of severe suffering in every region. Health expenses greatly increased, supply chains were disrupted, and governments coped with much less revenue. Good clinicians plan for ALL contingencies, and we need to consider that the current disaster may get much worse. How can we adapt psychiatry to a long emergency? This goes far beyond previous work on crisis standards of care because the emergency is severe, prolonged, and widespread. If we had to spend much less on psychotropics, which meds stay on the formulary? If we have to close hospitals, which patients get a bed? What adaptations could be used if demand exceeds the supply of providers? Very little is known about how to make severe, permanent cuts to healthcare. Our previous systematic review found no scholarship addressing the ethics of severe and prolonged healthcare rationing. Global catastrophes need a global health policy, but this one has no experts. The present study starts the project by surveying experts with related experience that could be useful in future plans. Method. We used purposive sampling to find 18 professionals with experience in healthcare rationing from underserved, indigenous communities, homeless programs, and African nations. We also interviewed ethicists, pharmacists, administrators, NGO clinicians, and military. Interviews were transcribed and coded using basic inductive techniques. Because so little is known about this topic, we used grounded theory, an iterative approach to guide further sampling, refine interviews, and make some preliminary conclusions. Results. Participants all agreed this crisis planning is extremely important and complex. They described diverse concerns regarding ethical decision making, with some having confidence with top-down government policy, and others recommending a grassroots approach. Minority participants had less confidence in government. There was no consensus on any best ethical framework. Most had confidence that clinicians will ultimately do the right thing. Native American leaders had confidence in a holistic, preventive approach. All agreed that social justice should be central in measuring economic impact of long emergencies and choosing ethical options. We collected suggestions for innovative approaches to rationing. Conclusions. This research program illuminates the difficult ethical questions about adapting psychiatry to a prolonged,widespread, and severe emergency. Our interviews identify areas where severe but ethical cuts can be made in medications, hospitals, clinical staff, and administration. Next steps include evidence-based formularies, utilitarian staff cuts, and ethical standards for closing beds or revamping state hospitals.Underserved and diverse communitieswith rationing experience must have a voice in the discussion.

Impact of Covid-19 on farming systems in Europe through the lens of resilience thinking.

Context: Resilience is the ability to deal with shocks and stresses, including the unknown and previously unimaginable, such as the Covid-19 crisis. Objective: This paper assesses (i) how different farming systems were exposed to the crisis, (ii) which resilience capacities were revealed and (iii) how resilience was enabled or constrained by the farming systems' social and institutional environment. Methods: The 11 farming systems included have been analysed since 2017. This allows a comparison of pre-Covid-19 findings and the Covid-19 crisis. Pre-Covid findings are from the SURE-Farm systematic sustainability and resilience assessment. For Covid-19 a special data collection was carried out during the early stage of lockdowns. Results and conclusions: Our case studies found limited impact of Covid-19 on the production and delivery of food and other agricultural products. This was due to either little exposure or the agile activation of robustness capacities of the farming systems in combination with an enabling institutional environment. Revealed capacities were mainly based on already existing connectedness among farmers and more broadly in value chains. Across cases, the experience of the crisis triggered reflexivity about the operation of the farming systems. Recurring topics were the need for shorter chains, more fairness towards farmers, and less dependence on migrant workers. However, actors in the farming systems and the enabling environment generally focused on the immediate issues and gave little real consideration to long-term implications and challenges. Hence, adaptive or transformative capacities were much less on display than coping capacities. The comparison with pre-Covid findings mostly showed similarities. If challenges, such as shortage of labour, already loomed before, they persisted during the crisis. Furthermore, the eminent role of resilience attributes was confirmed. In cases with high connectedness and diversity we found that these system characteristics contributed significantly to dealing with the crisis. Also the focus on coping capacities was already visible before the crisis. We are not sure yet whether the focus on short-term robustness just reflects the higher visibility and urgency of shocks compared to slow processes that undermine or threaten important system functions, or whether they betray an imbalance in resilience capacities at the expense of adaptability and transformability. Significance: Our analysis indicates that if transformations are required, e.g. to respond to concerns about transnational value chains and future pandemics from zoonosis, the transformative capacity of many farming systems needs to be actively enhanced through an enabling environment.