Insights from the Field: How North Carolina Local Government Climate Communications Compare to IPCC Guidelines

As climate change increasingly threatens the United States, many local governments are implementing programs in response, helping to reduce their communities' contributions to climate change and enhancing their resilience to climate impacts. The purpose of this study is to understand how local governments in North Carolina communicate with residents about their climate change programming. Twelve local government sustainability employees participated in interviews about how they communicated with and received input from residents about such programs. Interview transcripts were coded and analyzed using Atlas.ti 9, and communications approaches were compared to Intergovernmental Panel on Climate Change (IPCC) recommendations. Participants' communications could be characterized as applying some of the IPCC recommendations, and findings suggest opportunities for greater adoption of IPCC strategies in local government communication about climate programs. The Covid-19 pandemic was primarily described as a barrier to communicating about climate programs but also was credited as creating an opportunity for enhanced connections in one community. Additionally, participants described misconceptions about climate change programming expressed by residents, such as initiatives being perceived as impractical when they were in fact feasible. © 2023 Mary Ann Liebert, Inc., publishers.

Development of a Questionnaire on Access to Sickle Cell Disease Care in the Indigenous Tharu Population of Nepal

Purpose of Study Sickle cell disease (SCD) disproportionately affects the Tharu population of Nepal, a marginalized indigenous group concentrated in the Dang district. SCD is a structural hemoglobinopathy resulting in abnormal red blood cells with a tendency to occlude microvasculature. Since 2015, University of British Columbia medical students and a local community partner, Creating Possibilities, have improved access to SCD screening and diagnosis for the Tharu population. However, interviews conducted in 2016- 2017 found that SCD-afflicted community members encounter a number of challenges to obtain treatment once diagnosed. The purpose of this study was to develop a questionnaire on barriers to accessing SCD care in this community. Methods Used The Barriers to Accessing SCD Care Questionnaire was developed from items in existing scales, deductive and inductive item generation, and feedback from expert local partners. Reviewing literature on barriers to accessing healthcare in the Western region of Nepal informed region-specific questionnaire items, while literature on accessing SCD treatment in resource-limited settings informed SCD-specific questionnaire items. We also reviewed the literature on barriers to treatment for various stigmatized chronic health conditions in low-resource settings. Summary of Results Qualitative interviews with SCD-afflicted Tharu individuals in 2016-2017 identified inadequate local medical resources, transportation, financial strain, and limited awareness as barriers to care. Based on the literature review, we organized all survey items under the themes transportation, medical infrastructure, finances, community attitudes, and personal attitudes. The questionnaire includes closed-ended questions using a Likert scale, as well as open-ended interview prompts. It was made in collaboration with local community members to ensure it is culturally appropriate, needs-specific, and easily understandable. The questionnaire received ethics board approval, and interviews will begin once local health authorities lift COVID-19 restrictions. Conclusions Results from the Barriers to Accessing SCD Care questionnaire will guide future community-based interventions.

Access to Sickle Cell Disease Treatment in the Indigenous Tharu Population of Nepal

Purpose of Study: Sickle cell disease (SCD) is a hemoglobinopathy that disproportionately affects the indigenous Tharu population of Nepal, a marginalized ethnic group concentrated in the Dang district. There are significant global disparities in the prognosis of SCD;in low-income countries, which lack screening and management infrastructure, up to 80% of those born with SCD are undiagnosed and less than half survive beyond 5 years of age. Since 2015, University of British Columbia medical student teams have collaborated with a local community partner, Creating Possibilities (CP), to improve SCD awareness, screening, diagnosis, and management for the Tharu population in and around Dang. Community members with SCD have previously expressed numerous challenges in obtaining treatment once diagnosed. This study aims to better understand difficulties in accessing SCD care for this community. Methods Used: The Access to SCD Care Questionnaire was developed from items in existing scales, deductive and inductive item generation, and feedback from expert local partners to ensure it is culturally appropriate, needs-specific, and easily understandable. The questionnaire includes closed-ended questions using a Likert scale and open-ended interview prompts. It centers around five core themes: personal beliefs, community attitudes, finances, transportation, and medical infrastructure. Interviews were conducted in Tharu (local dialect) by CP staff members in January to March 2022. Themes and sub-themes were qualitatively analyzed. Summary of Results: Participants aged from 14 to 42 with an equal sex ratio, a total of 12 interviews were conducted before study saturation was reached. All participants reported at least one minor or major problem with access to SCD care in each of the five core themes of the questionnaire. Inadequate healthcare infrastructure was the most frequently reported barrier, with participants reporting lack of local medication accessibility and low supplies at further district hospitals. Additionally, despite government funding for treatment coverage, participants reported difficulties obtaining the necessary legal documents to prove eligibility. The second largest perceived barrier to care was transportation, which was reported to be costly, time-consuming, and not readily available. Regardless of sub-theme, participants reported that system-wide effects from COVID-19 perpetuated these issues. Conclusion(s): Results from the Access to SCD Care Questionnaire demonstrate that availability and accessibility to medications and transportation services are the primary challenges to receiving SCD care in this indigenous community. Therefore, future interventions for this community should focus on these findings. In contrast with previous literature, community stigma and personal beliefs were not often reported as hindering SCD treatment. This may be attributed to successful education campaigns within this specific community or due to participation bias.

University of British Columbia Nepal Sickle Cell Project Status Report 2015-2020

Purpose of Study In 2015 the University of British Columbia partnered with Creating Possibilities (CP), a charitable organization located in Dang, Nepal. Each year, a team of medical students is sent to assist CP in the long term management of sickle cell disease (SCD) in rural Western Nepal. Due to COVID-19 limitations, we were unable to travel to Nepal this year for the field component of our project. Instead, we took this opportunity to reflect on the project as a whole and create a project status report, outlining the past five years of work. The purpose of this report included: summarizing overall project progress, identifying future project directions, and improving communication amongst project stakeholders. Methods Used To create the project status report, our team reviewed all project documents since 2015. We also conducted virtual interviews with previous team leads to clarify questions and fill in gaps. Project progress was assessed by comparing activities completed to date to the project's initial three main objectives. Summary of Results The first objective of characterizing the prevalence of SCD among the Tharu population is currently ongoing. Since 2015, we have conducted large-scale screening of the Tharu population, with 4483 individuals having been screened by our team. Thus far, a hemoglobin S prevalence of 9.3% has been estimated. Our second objective of identifying barriers to SCD management is also ongoing. Since 2016, yearly focus groups and needs assessments have been conducted with community members and health workers. Common themes of barriers included accessibility, financial limitations, and education. Finally, our third objective of implementing sustainable solutions for long term detection and management of SCD still needs to be addressed. Conclusions Screening and needs assessments will continue as we progress toward addressing our first two objectives. Following consultation with experts and a literature review, we have identified a pilot newborn screening program for SCD as the first step in addressing our third objective.

Improving screening for cystic fibrosis-related diabetes in a pediatric cystic fibrosis clinic

Background: Cystic fibrosis-related diabetes (CFRD) is the most common comorbidity in people with cystic fibrosis (CF), affecting approximately 20% of adolescents and 40% to 50% of adults [1]. CF care guidelines recommend screening for CFRD using the 75-gram 2-hour oral glucose tolerance test (OGTT) yearly beginning at 10 years old. Our CF center had a below-average percentage of eligible patients adequately screened for CFRD (65% total screened [only 36% with recommended OGTT] vs ~63% nationally) because of use of a non-preferred screening method and a wide clinic catchment area.We initiated a quality improvement project to increase the percentage of eligible people with CF appropriately screened according to recommended CF care guidelines. Method(s): We began in 2019 by reviewing current data and processes to understand our baseline, goals, and anticipated barriers. We then established the goals of our project with proposed interventions and obtained institutional reviewboard approval. The three goals of our project were to fully eliminate use of the non-preferred screening method by the end of 2020, streamline local OGTT location options for families that live far from our CF center, and increase the percentage of eligible patients screened via OGTT by 20% by the end of 2020.We accomplished these goals by educating families regarding the recommended CFRD screening by OGTT in our CF newsletter;surveying families on how, when, and where they would like to complete their OGTT;and creating an OGTT informational brochure including three selected locations across our clinic geographical coverage area where OGTT can be reliably obtained. An additional goal was added in January 2022 because our percentage of appropriately screened patients dropped in 2021.We aimed to increase our percentage of eligible patients screened by 10% for the year. We are doing this by changing the location of an outlying OGTT facility after receiving negative feedback from our patients. Result(s):We fully eliminated use of the non-preferred screening method by 2020;all patients screened in 2020 were done by OGTT. We increased our total screening percentage from 65% in 2019 to 86% percent in 2020, despite difficulties created by the COVID pandemic. Our screening percentage dropped to 78% in 2021, but we have worked to offer OGTT at one of our associated pediatric clinic locations to better serve families. Conclusion(s): Using traditional quality improvement methods and processes, we eliminated use of a non-preferred CFRD screening method in our pediatric CF clinic. We have increased our screening rates to above the national average and continue to work on improving the CFRD screening process for our patients and families.Copyright © 2022, European Cystic Fibrosis Society. All rights reserved

A Systems Approach to Understanding Barriers and Facilitators to Faculty Retention at Paediatric Epilepsy Training Courses

Objectives: The British Paediatric Neurology Association delivers three Paediatric Epilepsy Training courses (PET) to improve epilepsy care. It uses a global volunteer trained faculty of 400 trainers across 15 countries. The move to online courses, partially driven by COVID-19, has further focussed attention on faculty retention. This study used the Systems Engineering Initiative for Patient Safety (SEIPS) model to identify barriers and facilitators for faculty trainers, comparing face-to-face and online course delivery. Method(s): A questionnaire was distributed to 375 UK and international faculty members (n = 55) and participants were invited to follow-up semi-structured interviews (SSI) (n = 5). Questionnaire responses allowed quantitative analysis and comparison with a 2016 BPNA internal Faculty Motivation Report. Thematic analysis using the six elements of the SEIPS model was utilised for SSIs and questionnaire free text. Result(s): Faculty across countries stated their primary motivation to improve care of children with epilepsy, as in 2016. Most faculty trainers preferred face-to-face courses, with one country faculty the exception. Facilitators to retention at face-to-face courses were 'internal environment', 'tasks', and 'persons'. Faculty appreciated the environment, which facilitated networking and questions, additionally enhancing their own practice. Barriers were 'organisation', and 'tasks', primarily time demands, and the burden of travel. At online courses, barriers of time and travel were lessened, facilitating teaching. However, some found technology challenging, particularly those with less online experience. 'Internal environment' online was a barrier, with less connection to colleagues and learners. Some found that while courses remained valuable, they were less enjoyable. Conclusion(s): While PET courses run online appear to be popular with participants, the same may not be as true for faculty trainers. This may have implication for future faculty retention upon which the BPNA short courses are reliant.

Hemodynamic changes in patients with SARS-CoV-2 infection presenting for cesarean delivery under spinal anesthesia: a retrospective case-control study.

BACKGROUND: Coronavirus disease 2019 (COVID-19) is associated with adverse maternal and neonatal outcomes. Early studies suggested that COVID-19 was associated with a higher incidence of hypotension following neuraxial anesthesia in parturients. We explored the hemodynamic response to spinal anesthesia for cesarean delivery in pregnant severe respiratory distress syndrome-coronavirus-2 (SARS-CoV-2) positive patients, using a retrospective case-control design. METHODS: We searched our electronic medical records for patients who received spinal anesthesia for cesarean delivery, and were SARS-CoV-2 positive or recovered at delivery, and used historical and SARS-CoV-2 negative controls from two tertiary care hospitals. We compared the demographic, clinical, and hemodynamic variables between patients who were SARS-CoV-2 positive at delivery, those who were positive during pregnancy and recovered before delivery, and controls. Analyses were stratified by normotensive versus hypertensive status of the patients at delivery. RESULTS: We identified 22 SARS-CoV-2 positive, 73 SARS-CoV-2 recovered, and 1517 controls. The SARS-CoV-2 positive, and recovered pregnant patients, had on average 5.6 and 2.2 mmHg, respectively, higher post-spinal mean arterial pressures (MAPs) than control patients, adjusting for covariates. Additionally, the lowest post-spinal MAP was negatively correlated with the number of daysbetween the onset of COVID-19 symptoms and delivery in patients with hypertension (correlation -0.55, 95% CI -0.81 to -0.09). CONCLUSIONS: Patients with SARS-CoV-2 infection during pregnancy exhibit less spinal hypotension than non-infected patients. While the clinical significance of this finding is unknown, it points to important cardiovascular effects of the virus.

Longitudinal outcomes of adults and children with cystic fibrosis during the COVID-19 pandemic

Background: The onset of the COVID-19 pandemic was associated with restricted community movement, including limited access to health care facilities, resulting in a change in clinical service delivery to people with cystic fibrosis (CF). The aim of this study was to determine clinical outcomes of Australian adults and children with CF in the 12 months after the onset of the COVID-19 pandemic. Method(s): This longitudinal cohort study used prospectively entered national registry data. Primary outcomes were 12-month change in percentage predicted forced expiratory volume in one second (FEV1pp), body mass index (BMI) in adults, and BMI z-scores in children. A piecewise linear mixed-effects model was used to determine trends in outcomes in the 24 months before and 12 months after the onset of the pandemic. Comparative analysis of hospitalization and service delivery data before and after the onset of the pandemic was conducted. Result(s): Data were available for 3,662 individuals (median age 19.6, range 0-82). Overall registry data completeness was 95%. When trends in outcomes before and after pandemic onset were compared;FEV1pp went from a mean annual change of -0.13% (95% CI, -0.39 to 0.13) to a mean improvement of 1.73% (95% CI, 1.29-2.17). Annual mean annual change in BMI improved from 0.01 kg/m2 (95% CI, -0.07-0.09 kg/m2) to 0.33 kg/m2 (95% CI, 0.23-0.43 kg/m2). Therewas no change in BMI z-scores. Number of hospitalizations decreased from 2,656 to 1,957 ( p < 0.01). Virtual outpatient consultations increased from 8% of toal outpatient consultations before pandemic onset to 47% during the pandemic. Therewas an increase in average number of consultations per patient from a median of 4 (interquartile range 2-5) to 5 (interquartile range 3-6) ( p < 0.01). Conclusion(s): In the 12 months after the onset of the COVID-19 pandemic, improvement was observed in the clinical outcomes of people with CF and the model of care delivery changed from the pre-pandemic period. Health care teams must consider how best to deliver care in light of improved outcomes observed during the COVID-19 pandemic. Acknowledgements: This study was supported by a Health Service Research Grant from the HCF Research Foundation Copyright © 2022, European Cystic Fibrosis Society. All rights reserved

Home schooling during the COVID-19 pandemic in the United Kingdom: The experience of families of children with neurodevelopmental conditions

The COVID-19 outbreak, and associated school restrictions affected the learning experience of students worldwide. The current study focused on the learning experiences of United Kingdom children with neurodevelopmental conditions, including autism and/or intellectual disability. Specifically, the aim was to examine families' experience with school support for home schooling, families' resources, and level of satisfaction with schools among families whose children engaged with home schooling, hybrid learning, and school-based learning during the pandemic. An online survey took place in 2021, approximately 1 year since the start of the COVID-19 pandemic in the United Kingdom. Participants were recruited mostly through social media with support via several charities across the United Kingdom. Participants were 809 parents/carers of children with autism and/or intellectual disability aged 5 - 15 years. Of these, 59% were learning from home daily during home schooling, 19% spent some days in school (hybrid learning), and 22% were going to school daily during school restrictions. Parents/carers reported on the support received from schools, the resources accessed, and the resources needed but not accessed to facilitate learning. They also reported on their level of satisfaction with school support and school management of COVID-19 risks. Results indicated that learning during the COVID-19 pandemic was mostly via school-provided worksheets, in the home and hybrid learning group. Families had access to the internet/data and a laptop, computer, or tablet to facilitate learning. However, in both learning groups (i.e., home and hybrid learning) they needed but did not have access to special equipment, special software, and a printer. Importantly, 11% of families in home and hybrid learning groups reported not having access to a desk/table. Satisfaction with school support was low in the home and hybrid learning groups. Satisfaction with COVID-19 management was higher for families of children attending school daily (i.e., the school-based learning group). Future education policy decisions during public health crises should take into consideration the needs of children with neurodevelopmental conditions including autism and/or intellectual disability.

Use, and acceptability, of digital health technologies in musculoskeletal physical therapy: A survey of physical therapists and patients.

OBJECTIVES: Determine (a) frequency of digital health use to obtain/record clinical information (pre-COVID-19); (b) willingness to use digital technologies among physical therapists and patients with musculoskeletal conditions. METHODS: 102 physical therapists, and 103 patients were recruited in Australia. An electronic survey ascertained (a) demographic/clinical characteristics, (b) frequency of methods to obtain and record clinical information; (c) willingness to use digital technologies to support musculoskeletal care. RESULTS: Physical therapists mostly used non-digital methods to obtain subjective (e.g., face-to-face questioning, n = 98; 96.1%) and objective information (e.g., visual estimation, n = 95; 93.1%). The top three digital health technologies most frequently used by therapists: photo-based image capture (n = 19; 18.6%), accessing information logged/tracked by patients into a mobile app (n = 14; 13.7%), and electronic systems to capture subjective information that the patient fills in (n = 13; 12.7%). The top three technologies used by patients: activity trackers (n = 27; 26.2%), logging/tracking health information on mobile apps or websites (n = 12; 11.7%), and entering information on a computer (n = 12; 7.8%). Physical therapists were most willing to use technologies for: receiving diagnostic imaging results (n = 99; 97.1%), scheduling appointments (n = 92; 90.2%) and capturing diagnostic results (n = 92; 90.2%). Patients were most willing to use technologies for receiving notifications about health test results (n = 91; 88.4%), looking up health information (n = 83; 80.6%) and receiving personalised alerts/reminders (n = 80; 77.7%). CONCLUSIONS: Physical therapists and patients infrequently use digital health technologies to support musculoskeletal care, but expressed some willingness to consider using them for select functions.

SARS-CoV-2 Genome Sequencing Methods Differ in Their Abilities To Detect Variants from Low-Viral-Load Samples.

Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) genomic surveillance has been vital in understanding the spread of coronavirus disease 2019 (COVID-19), the emergence of viral escape mutants, and variants of concern. However, low viral loads in clinical specimens affect variant calling for phylogenetic analyses and detection of low-frequency variants, important in uncovering infection transmission chains. We systematically evaluated three widely adopted SARS-CoV-2 whole-genome sequencing methods for their sensitivity, specificity, and ability to reliably detect low-frequency variants. Our analyses reveal that the ARTIC v3 protocol consistently displays high sensitivity for generating complete genomes at low viral loads compared with the probe-based Illumina Respiratory Viral Oligo panel and a pooled long-amplicon method. We show substantial variability in the number and location of low-frequency variants detected using the three methods, highlighting the importance of selecting appropriate methods to obtain high-quality sequence data from low-viral-load samples for public health and genomic surveillance purposes.

Change in the presentation and outcome of diabetic foot ulcers (DFU) during covid-19, despite multi-disciplinary foot team (MDFT) adaptions of clinical practice

Aims: To explore the effect of the covid-19 pandemic on referral patterns, ulcer presentation and outcome. Methods: During covid-19 clinical pathways were adapted allowing patients to access maintenance DFU care in community settings, while maintaining rapid access to the MDFT service. The commissioned integrated digital imaging/wound management system allowed treatment and monitoring DFUs in community settings. We describe the changes in ulcer presentation and outcome despite this from March to October 2020. Results: A total of 157 (24%) fewer new patients were referred to MDFT compared to the same period in the 2019 and more (19%) came from GP/practice nurses than usual. Baseline SINBAD scores March-October 2020 versus 2015-18 NDFA data showed more larger ulcers (37% > 1cm2 vs. 35.5%), more were infected (45% vs. 42.6%) and more were deep to tendon or bone (14% vs. 10.3%). Time to first referral also increased;12% were seen >14 days to 2 months compared with 8.4% in 2015-2018. In 2015-2018 10 (1.4% of 695 ulcers) major amputations occurred within 6 months of referral (local NDFA data) whereas we have seen 12 major amputations in patients known to the MDFT from March to October 2020. Conclusions: Integrated community follow-up enabled adequate capacity in the MDFT and allowed usual care to be continued. However during the first wave of covid-19 cases fewer patients overall were referred to the MDFT and those that were had larger, deeper, more infected ulcers and were referred later. This is of concern and needs to be further explored.

Threat of racial and economic inequality increases preference for algorithm decision-making

Artificial intelligence (AI) algorithms hold promise to reduce inequalities across race and socioeconomic status. One of the most important domains of racial and economic inequalities is medical outcomes;Black and low-income people are more likely to die from many diseases. Algorithms can help reduce these inequalities because they are less likely than human doctors to make biased decisions. Unfortunately, people are generally averse to algorithms making important moral decisions—including in medicine—undermining the adoption of AI in healthcare. Here we use the COVID-19 pandemic to examine whether the threat of racial and economic inequality increases the preference for algorithm decision-making. Four studies (N = 2819) conducted in the United States and Singapore show that emphasizing inequality in medical outcomes increases the preference for algorithm decision-making for triage decisions. These studies suggest that one way to increase the acceptance of AI in healthcare is to emphasize the threat of inequality and its negative outcomes associated with human decision-making. © 2021 Elsevier Ltd

Revealing COVID-19 transmission in Australia by SARS-CoV-2 genome sequencing and agent-based modeling

In January 2020, a novel betacoronavirus (family Coronaviridae), named severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), was identified as the etiological agent of a cluster of pneumonia cases occurring in Wuhan City, Hubei Province, China. The disease arising from SARS-CoV-2 infection, coronavirus disease 2019 (COVID-19), subsequently spread rapidly causing a worldwide pandemic. Here we examine the added value of near real-time genome sequencing of SARS-CoV-2 in a subpopulation of infected patients during the first 10 weeks of COVID-19 containment in Australia and compare findings from genomic surveillance with predictions of a computational agent-based model (ABM). Using the Australian census data, the ABM generates over 24 million software agents representing the population of Australia, each with demographic attributes of an anonymous individual. It then simulates transmission of the disease over time, spreading from specific infection sources, using contact rates of individuals within different social contexts. We report that the prospective sequencing of SARS-CoV-2 clarified the probable source of infection in cases where epidemiological links could not be determined, significantly decreased the proportion of COVID-19 cases with contentious links, documented genomically similar cases associated with concurrent transmission in several institutions and identified previously unsuspected links. Only a quarter of sequenced cases appeared to be locally acquired and were concordant with predictions from the ABM. These high-resolution genomic data are crucial to track cases with locally acquired COVID-19 and for timely recognition of independent importations once border restrictions are lifted and trade and travel resume.