Geographical Dependence of Open Hardware Optimization: Case Study of Solar Photovoltaic Racking

Open-source technological development is well-known for rapid innovation and providing opportunities to reduce costs and thus increase accessibility for a wide range of products. This is done through distributed manufacturing, in which products are produced close to end users. There is anecdotal evidence that these opportunities are heavily geographically dependent, with some locations unable to acquire components to build open hardware at accessible prices because of trade restrictions, tariffs, taxes, or market availability. Supply chain disruptions during the COVID-19 pandemic exacerbated this and forced designers to pivot towards a la carte-style design frameworks for critical system components. To further develop this phenomenon, a case study of free and open-source solar photovoltaic (PV) racking systems is provided. Two similar open-source designs made from different materials are compared in terms of capital costs for their detailed bill of materials throughout ten locations in North, Central and South America. The differences in economic optimization showed that the costs of wood-based racks were superior in North America and in some South American countries, while metal was less costly in Central and South America. The results make it clear that open hardware designs would be best to allow for local optimization based on material availability in all designs. © 2023 by the authors.

Inpatient teledermatology service: baseline review - it works!

Setting up an inpatient teledermatology service over 1 year at our National Health Service-based district general hospital made absolute sense on two grounds: The COVID pandemic and the ever-increasing role of teledermatology enabling dermatology departments, often with limited resources, to 'work smart'. Over a 43-week period, 124 referrals were dealt with on our teledermatology platform (around 12 referrals per month). Average response time to referral was 0.65 days: 56% same-day response, 32% next-day response;and 92% a response within 3 days. Following this, 32% of patients were seen face to face on the wards and 40% were dealt with via remote advice and guidance. Around 10% of referrals were deemed not to be appropriate for dermatology review/advice. Around 12% of referrals were given dermatology face-to-face outpatient appointments rather than review on the wards, and 7% were declined an appointment (pending further information being received) as insufficient information was given for triage/advice and guidance. Initially, just 10% of referrals were sent (first time) with clinical images, but this increased to 54% after 4 months, and although there has been some monthly variation, up to 64% has been achieved (noting that clinical images are not always required for the question being asked). Around 50 different diagnoses were made, illustrating the diversity and complexity of dermatological practice, and the scale of the diagnostic problems facing ward-based teams. Previously published data revealed that around one-third of inpatient dermatology referrals were for 'red legs', which was replicated in the current results, with diagnoses of venous or atopic eczema (14%), drug reactions (12%), skin neoplasia (6%), cellulitis/erysipelas (5%), intertrigo (4%), erythroderma (4%), Gianotti-Crosti syndrome (2.5%), bullous pemphigoid (2.5%), pyoderma gangrenosum (2.5%) and vasculitis (2%). Having an inpatient teledermatology service benefits dermatology departments, enabling efficient working, appropriate triage, training opportunities and ease of second opinions from colleagues. Benefits for referrers are acute ward-based teams including rapid responses to referrals, enabling skin concerns to be dealt with quickly and avoiding delays in investigation, treatment and discharge. Some hospitals where dermatology does not have a permanent base may be able to access dermatology advice and guidance via teledermatology. Overall, patients benefit from teledermatology and it is COVID secure.

First reported case of parvovirus triggering painful widespread livedoid vasculopathy: another virus causing hypercoagulability?

Livedoid vasculopathy (LV) is a noninflammatory thrombotic disease caused by occlusion of dermal small vessels associated with systemic autoimmune disorders and coagulopathies. However, LV is often reported as being 'idiopathic', despite extensive investigation. We report a case of severe LV in an otherwise healthy 27-year-old woman, associated with parvovirus infection. The patient presented with a short history of a livedoid rash initially covering her torso, which spread to acral sites. Burning pains in the lower limb caused reduced mobility;systemically, she remained well and stable throughout. Examination revealed generalized acral skin pallor, livedoid patches of violet erythema and purpura with deep serpiginous ulcerations over extensor aspects of upper and lower limbs with a more broken/racemosa nonulcerated livedoid appearance on the trunk. On admission a transaminitisareas continued to ulcerate. Codeine was present with a creatine kinase of 1569 U L.1, but other blood test results were unremarkable including erythrocyte sedimentation rate, complement, cryoglobulins, antinuclear antibodies, antineutrophil cytoplasmic antibodies, extractable nuclear antigen, rheumatoid factor, myositis screen, antiphospholipid screen and thrombophilia screen. Parvovirus IgG and IgM were both positive and tested for, as the patient's young daughter had recently been diagnosed with 'slapped cheek disease'. Magnetic resonance imaging of the thighs showed a diffuse mild myositis;electromyography, nerve-conduction studies, barium swallow and computed tomography of the chest, abdomen and pelvis were all normal. An incisional skin biopsy was performed, which revealed a blood vessel with organizing (Solimani F, Mansour Y, Didona D et al. Development of severe pemphigus vulgaris following SARS-CoV-2 vaccination with BNT162b2. J Eur Acad Dermatol Venereol 2021;35: e649- 51) have been reported. The main proposed mechanisms for AstraZeneca vaccine-induced pemphigus could be a hyperimmune reaction in genetically predisposed individuals, with eventual formation of anti-desmoglein antibodies. An alternative hypothesis is that vaccine components could act as foreign antigens resulting in a cross-reaction with pemphigus antigens. The close association of COVID-19 vaccination with the acute onset of pemphigus in our patient, as well as exacerbations after subsequent vaccine administration, is more than coincidental. Considering the recent pandemic with COVID-19 and the widespread administration of the COVID-19 vaccine, continued observation and documentation of true adverse events is essential.

Juneau, Alaska's Successful Response to COVID-19: A Case Study of Adaptive Leadership in a Complex System

Juneau, Alaska, kept COVID-19 deaths lower than in other similar jurisdictions. We argue that adaptive leadership—the early decisions and actions of Juneau's leaders, effective communications, and emergent new collaborative structures—in the context of municipal ownership of key assets enabled Juneau's success. The result of 61 interviews and follow-up research, this case study contributes a better understanding of which institutional design, communication, and collaborative factors mattered in responding to the pandemic. Adaptive leadership provides a better explanation for Juneau's success than alternatives that focus on its isolation, home-rule status, and socio-economic structure.

Initial experience with ex-situ normothermic liver machine perfusion

Background: With the growing acceptance of the role for the expansion of suitable indications for liver transplantation, such as selected cases of hilar cholangiocarcinoma and unresectable colorectal liver metastases, the imbalance between clinical need for liver transplantation and supply of suitable donor organs is likely to widen in Europe for the foreseeable future. Novel organ perfusion technologies are likely to play a fundamental role in maximising utilisation of all donor organs and facilitating the safe transplantation of marginal grafts. Herein we describe the initial experience of implementing Normothermic Machine Perfusion (NMP) in a liver transplant centre just before the onset of the COVID-19 pandemic. Methods: Retrospective analysis of a prospectively-maintained comprehensive database encompassing donor characteristics, perfusion parameters and post-transplantation outcomes. Results: Between February 2020 and October 2021 (20 months), 37 liver grafts were perfused with NMP and 23 proceeded to transplantation. The indications for NMP included logistics - 16 grafts (69%), further assessment of marginal grafts - 5 (22%) livers and facilitation of a predicted difficult hepatectomy (e.g. redo transplant) - 2 livers (9%). Overall, a total of an additional 15 livers, 3 kidneys and one pancreas were transplanted that absolutely could not have been transplanted without NMP (e.g. logistics, unacceptable cold ischaemic time with static cold storage) and a further 7 livers were successfully transplanted that may have been declined without the additional reassurance of dynamic functional assessment and safe prolongation of preservation time. No grafts were lost as a result of perfusion with NMP. Conclusions: NMP is a safe and effective technique for improving graft utilisation in liver transplantation and has become an integral component of routine clinical practice since its introduction in Edinburgh. As collective experience with NMP increases, the prognostic predictive ability of serum (and potentially bile) analysis on the machine is likely to improve graft utilisation further.

Facilitator reflections on online delivery of simulation-based mental health education during COVID-19

Purpose During COVID-19, Maudsley Simulation successfully pivoted to fully online delivery of simulation-based education (SBE) in mental health. In migrating digitally, the simulation faculty experienced a range of new phenomena and challenges. The authors' experiences may be transferable to other specialities and for other educator groups. By sharing the authors' experiences, this study aims to support others adapt to online SBE. Design/methodology/approach This piece represents the authors' collective reflections on the challenges of adapting their facilitation skills to the online environment. It also offers various suggestions on how to improve the learner experience in view of these challenges. Findings Beyond merely platform orientation and operating procedure familiarisation, the team gained insights into ensuring optimal learning, engagement and participant experience during online deliveries. Delivery of online SBE brings several potential barriers to psychological safety and these warrant careful consideration by experienced simulationists. Practical implications Optimising participant engagement and psychological safety remain key considerations despite this novel medium. Facilitators must be willing to adapt accordingly to begin delivering high-quality online SBE. Originality/value From their experience, facilitators must reframe their debriefing expectations and adjust how they engage participants and manage group dynamics given the inherently different nature of this new learning environment.

Repeated transmission of SARS-CoV-2 in an overcrowded Irish emergency department elucidated by whole-genome sequencing.

AIM: To provide a detailed genomic-epidemiological description of a complex multi-ward SARS-CoV-2 outbreak, which originated in the crowded emergency department (ED) in our hospital during the third wave of the COVID-19 pandemic, and was elucidated promptly by local whole-genome sequencing (WGS). METHODS: SARS-CoV-2 was detected by reverse transcriptase real-time polymerase chain reaction on viral RNA extracted from nasopharyngeal swabs. WGS was performed using an Oxford MinION Mk1C instrument following the ARTIC v3 sequencing protocol. High-quality consensus genomes were assembled with the artic-ncov2019 bioinformatics pipeline and viral phylogenetic trees were built, inferred by maximum-likelihood. Clusters were defined using a threshold of 0-1 single nucleotide polymorphisms (SNPs) between epidemiologically linked sequences. RESULTS: In April 2021, outbreaks of COVID-19 were declared on two wards at University Hospital Limerick after 4 healthcare-associated SARS-CoV-2 infections were detected by post-admission surveillance testing. Contact tracing identified 12 further connected cases; all with direct or indirect links to the ED 'COVID Zone'. All sequences were assigned to the Pangolin B.1.1.7 lineage by WGS, and SNP-level analysis revealed two distinct but simultaneous clusters of infections. Repeated transmission in the ED was demonstrated, involving patients accommodated on trolleys in crowded areas, resulting in multiple generations of infections across three inpatient hospital wards and subsequently to the local community. These findings informed mitigation efforts to prevent cross-transmission in the ED. CONCLUSION: Cross-transmission of SARS-CoV-2 occurred repeatedly in an overcrowded emergency department. Viral WGS elucidated complex viral transmission networks in our hospital and informed infection, prevention and control practice.

Association between tocilizumab treatment of hyperinflammatory patients with COVID-19 in a critical care setting and elevated incidence of hospital-acquired bacterial and invasive fungal infections.

BACKGROUND: Tocilizumab is an interleukin-6 inhibitor that reduces mortality and the need for invasive mechanical ventilation, while increasing the possibility of successful hospital discharge for hyperinflammatory patients with severe coronavirus disease 2019 (COVID-19). No increase in adverse events or serious infections has been reported previously. AIM: To describe the characteristics and outcomes of patients with severe COVID-19 in critical care who received tocilizumab, and to compare mortality and length of hospital stay for patients who received tocilizumab (N=41) with those who did not (N=33). METHODS: Retrospective review of data related to patients with COVID-19 who received tocilizumab in a critical care setting from 1st January to 31st December 2021. FINDINGS: Amongst COVID-19 survivors, those who had received tocilizumab had longer intensive care unit (ICU) stays (median length 21 vs 9 days) and hospital stays (45 vs 34 days) compared with those who had not received tocilizumab. Thirty-day mortality (29% vs 36%; P=0.5196) and 60-day mortality (37% and 42%; P=0.6138) were not significantly lower in patients who received tocilizumab. Serious bacterial and fungal infections occurred at higher frequency amongst patients who received tocilizumab [odds ratio (OR) 2.67, 95% confidence interval (CI) 1.04-6.86; P=0.042], and at significantly higher frequency than in non-COVID-19 ICU admissions (OR 5.26, 95% CI 3.08-9.00; P<0.0001). CONCLUSIONS: In this single-centre study, patients in critical care with severe COVID-19 who received tocilizumab had a greater number of serious bacterial and fungal infections, but this may not have been a direct effect of tocilizumab treatment.

Assessing Craniofacial Team Functioning During Virtual Multidisciplinary Team Meetings

Background/Purpose: The craniofacial team meeting represents a critical timepoint at which a diverse group of disciplines assemble in quorum to discuss the complex medical and psychosocial issues facing their patients and create treatment plans to address them. Professionals from not only different disciplines but from entirely different fields must efficiently amalgamate their expertise to create one intricate plan for their unique patient population. It is this diversity of disciplines represented and the complexity of subject matter that makes craniofacial team meetings ideal for studying team functioning during multidisciplinary meetings. The global pandemic necessitated a shift of these complex meetings to the virtual setting. While providing direct patient care (i.e. tele-health) has been studied extensively, the literature on virtual team meetings is lacking. The authors of this study evaluated the team functioning of one craniofacial team by studying their virtual team meetings. Methods/Description: Ten virtual team meetings, including 94 patient case discussions, from a 3-month period in late 2020 were recorded and scored individually by three members of the research team using modified versions of the standardized multidisciplinary team Meeting Observational Tool (MOT) and the Metric of Decision-Making (MODe). The mean score amongst the three observers for each category of team functioning was used for analysis. Participants' subjective assessments of team meetings were elicited through monthly Qualtrics surveys. Results: Our results indicate that team functioning during virtual team meetings was high for providing case history, exhibiting optimal team behavior, and providing a treatment plan for individual case discussions. Patient-centered and psychosocial categories received lower scores. Survey respondents generally regarded their team as highly functioning during team meetings, with lower marks given only for decision-making efficiency and full participation from all disciplines. The meeting technology and equipment received a high score on average. Additionally, participants indicated that the virtual format did not enhance or hinder team functioning during team meetings. Conclusions: Amidst the ongoing COVID-19 pandemic it is important to study the effectiveness of multidisciplinary team meetings held in a virtual format. Our findings suggest that virtual setting allows for high team functioning as measured by both objective and subjective assessments and should therefore be considered a viable alternative to in-person meetings. The team performed best in discussing clinical topics, generating treatment plans, and team behavior, including equality among disciplines. Psychosocial matters and patient perspectives were not discussed as extensively as clinical topics and the team overestimated their coverage of both psychosocial matters and patient perspectives, consistent with previous studies on team functioning.

Chest trauma: an experience of a Respiratory Support Unit with level 2 care in the North East of England

IntroductionFalls cause 75% of trauma in patients above 65 years of age and thoracic trauma is the second commonest injury;rib fractures are the commonest thoracic injury. There is wide variation in care. Older trauma patients are less likely to have trauma assessments. Rib fractures carry up to 12% mortality with up to 31% developing pneumonia.1 The number of fractures correlates with morbidity. Northumbria Healthcare has a team of respiratory consultants, physiotherapists, specialist nurses and anaesthetists for rib fracture management on a respiratory support unit.MethodsWith Caldicott approval, basic demographics and clinical outcomes of patients admitted with thoracic trauma between Aug 20-Apr 21 were analysed. Descriptive statistical methodology was applied.Results119 patients were identified. Mean age was 71.1 years (range 23–97). 53 were male, 66 female. Mechanism of injury were falls from standing (65), falls down stairs/bed or in the bath (18), ladders (4), cycling (12), assault (3), road accidents (8) and 9 others (for example off horses). LOS was 7.3 days (range 1–54). 85 patients had more than 1 co-morbidity. 26 had a full trauma assessment and 75 had pan CTs. Mean number of rib fractures was 3.6. 31 (26%) had a pneumothorax and/or haemothorax. 18 chest drains were inserted (all small bore) and 1 needle aspiration done. No cardiothoracic input was required. Isolated chest trauma was present only in 45 patients. All had pain team review, 22 erector spinae catheters were inserted with 2 paravertebral blocks. 82 patients did not require oxygen, 1 required CPAP and 1 HFNC. 7 needed intensive care transfer. 20 (17%) developed pneumonias.16 (14%) deaths occurred within 30 days (1 heart failure and cancer progression, 2 Covid and 14 pneumonias)- all were in those with falls from standing. There was no correlation between number of fractured ribs, length of stay and mortality.ConclusionsHigh level care for thoracic trauma can be performed by the respiratory team with analgesia managed by the pain team. 42% of pneumothoraces/haemothoraces were observed. Falls from standing are associated with significant mortality and morbidity. The service is now complemented by a frailty assessment service.Referencehttps://academic.oup.com/ageing/article/49/2/161/5673134

Impact of the COVID-19 pandemic on maternal mental heath

IntroductionAs countries adopt strict quarantines and lockdowns, increasing attention has been given to the impact on mental wellbeing. The influence of this on perinatal mental health and service provision is important to consider, as these women may be particularly vulnerable to the negative effects already seen in general and psychiatric populations.ObjectivesThe impact on global mental health of Covid-19, and the isolation measures used to combat it’s spread, is increasingly acknowledged. We were interested in the effect the pandemic has had specifically on the mental health of women in the peripartum period. By reflecting on our experiences, we hope to generate ideas to improve services.MethodsWe considered the effects of the pandemic in this high-risk population during each stage of contact with services. This included pre-conception, antenatal and postnatal periods, as well as the potential longitudinal and service effects. Recent case examples were identified and described from our busy and diverse South London perinatal psychiatry service.ResultsRecent referrals to our service suggest the current crisis has been a key trigger for the deterioration of many women’s mental health. This includes women who have been impacted by various factors related to the pandemic, at all stages of the perinatal period.ConclusionsIt is vital to maintain equality of access to perinatal services and to continue to consider how to deliver best care. This will involve adapting to the new working environment, and optimising care delivery using remote technologies where appropriate, in a way that is safe, accessible and acceptable to service users.

A Real-World Evidence Framework for Optimizing Dosing in All Patients With COVID-19.

Potential treatments for coronavirus disease 2019 (COVID-19) are being investigated at unprecedented speed, and successful treatments will rapidly be used in tens or hundreds of thousands of patients. To ensure safe and effective use in all those patents it is essential also to develop, at unprecedented speed, a means to provide frequently updated, optimal dosing information for all patient subgroups. Success will require immediate collaboration between drug developers, academics, and regulators.