The Syrian refugee life study: first glance

This paper presents descriptive statistics from the first wave of the Syrian Refugee Life Study (S-RLS), which began in 2020. S-RLS is a longitudinal study that tracks a representative sample of approximately 2,500 registered Syrian refugee households in Jordan. It collects comprehensive data on sociodemographic variables, health and well-being, preferences, social capital, attitudes, and safety and crime perceptions. We use these data to document sociodemographic characteristics of Syrian refugees in Jordan and compare them to representative populations in the 2016 Jordan Labor Market Panel Survey (JLMPS). Our findings point to lags in basic service access, housing quality, and educational attainment for Syrian refugees relative to non-refugees. The impacts of the pandemic may partially explain these disparities. The data also show that most Syrian refugees have not recovered economically after Covid-19 and have larger gender disparities in income, employment, prevalence of child marriage, and gender attitudes than their non-refugee counterparts. Finally, mental health problems were common for Syrian refugees in 2020, with depression indicated among more than 45 per cent of the phone survey sample and 61 per cent of the in-person survey sample. © 2022 The Author(s). Published by Oxford University Press.

The Social Determinants of Loneliness During COVID-19: Personal, Community, and Societal Predictors and Implications for Treatment

Objective The COVID-19 pandemic dramatically altered social determinants of health including work, education, social connections, movement, and perceived control;and loneliness was commonly experienced. This longitudinal study examined how social determinants at the personal (micro), community (meso), and societal (macro) levels predicted loneliness during the pandemic. Methods Participants were 2056 Australian adults surveyed up to three times over 18 months in 2020 and 2021. Multi-level mixed-effect regressions were conducted predicting loneliness from social determinants at baseline and two follow-ups. Results Loneliness was associated with numerous micro determinants: male gender, lifetime diagnosis of a mental health disorder, experience of recent stressful event(s), low income, living alone or couples with children, living in housing with low natural light, noise, and major building defects. Lower resilience and perceived control over health and life were also associated with greater loneliness. At the meso level, reduced engagement with social groups, living in inner regional areas, and living in neighbourhoods with low levels of belongingness and collective resilience was associated with increased loneliness. At the macro level, increased loneliness was associated with State/Territory of residence. Conclusions Therapeutic initiatives must go beyond psychological intervention, and must recognise the social determinants of loneliness at the meso and macro levels. Copyright © The Author(s), 2023. Published by Cambridge University Press on behalf of the Australian Association for Cognitive and Behaviour Therapy.

Changes in ischemic stroke presentations and associated workflow during the first wave of the COVID-19 pandemic: A population study

Background: Pandemics may promote hospital avoidance among patients with emergencies, and added precautions may exacerbate treatment delays. Methods: We used linked administrative data and data from the Quality Improvement and Clinical Research Alberta Stroke Program – a registry capturing stroke-related data on the entire Albertan population(4.3 million) – to identify all patients hospitalized with stroke in the pre-pandemic(01/01/2016-27/02/2020) and COVID-19 pandemic(28/02/2020-30/08/2020) periods. We examined changes in stroke presentation rates and use of thrombolysis and endovascular therapy(EVT), adjusted for age, sex, comorbidities, and pre-admission care needs;and in workflow, stroke severity(National Institutes of Health Stroke Scale/NIHSS), and in-hospital outcomes. Results: We analyzed 19,531 patients with ischemic stroke pre-pandemic versus 2,255 during the pandemic. Hospitalizations/presentations dropped(weekly adjusted-incidence-rate-ratio[aIRR]:0.48,95%CI:0.46-0.50), as did population-level incidence of thrombolysis(aIRR:0.49,0.44-0.56) or EVT(aIRR:0.59,0.49-0.69). However, proportions of presenting patients receiving thrombolysis/EVT did not decline (thrombolysis:11.7% pre-pandemic vs 13.1% during-pandemic, aOR:1.02,0.75-1.38). For out-of-hospital strokes, onset-to-door times were prolonged(adjusted-coefficient:37.0-minutes, 95%CI:16.5-57.5), and EVT recipients experienced greater door-to-reperfusion delays(adjusted-coefficient:18.7-minutes,1.45-36.0). NIHSS scores and in-hospital mortality did not differ. Conclusions: The first COVID-19 wave was associated with a halving of presentations and acute therapy utilization for ischemic stroke at a population level, and greater pre-/in-hospital treatment delays. Our data can inform public health messaging and stroke care in future pandemic waves.

Effects of the Pandemic on Observing the Global Ocean

The years since 2000 have been a golden age in in situ ocean observing with the proliferation and organization of autonomous platforms such as surface drogued buoys and subsurface Argo profiling floats augmenting ship-based observations. Global time series of mean sea surface temperature and ocean heat content are routinely calculated based on data from these platforms, enhancing our understanding of the ocean's role in Earth's climate system. Individual measurements of meteorological, sea surface, and subsurface variables directly improve our understanding of the Earth system, weather forecasting, and climate projections. They also provide the data necessary for validating and calibrating satellite observations. Maintaining this ocean observing system has been a technological, logistical, and funding challenge. The global COVID-19 pandemic, which took hold in 2020, added strain to the maintenance of the observing system. A survey of the contributing components of the observing system illustrates the impacts of the pandemic from January 2020 through December 2021. The pandemic did not reduce the short-term geographic coverage (days to months) capabilities mainly due to the continuation of autonomous platform observations. In contrast, the pandemic caused critical loss to longer-term (years to decades) observations, greatly impairing the monitoring of such crucial variables as ocean carbon and the state of the deep ocean. So, while the observing system has held under the stress of the pandemic, work must be done to restore the interrupted replenishment of the autonomous components and plan for more resilient methods to support components of the system that rely on cruise-based measurements. © 2023 American Meteorological Society.

Who is asking? Requests for antimicrobial prescribing advice received by hospital pharmacists

Doctors are perceived as the primary decision makers in antimicrobial therapy, but prescribing decisions are influenced by the multidisciplinary team. Antimicrobial stewardship (AMS) programs formalise interprofessional advice-giving. No studies capture the advice provided by pharmacists. This study aimed to describe the volume and nature of antimicrobial prescribing advice that healthcare professionals seek from hospital pharmacists. A prospective audit of antimicrobial-related advice requests received by pharmacists (n = 18) at an Australian public hospital was undertaken in July 2020. Antimicrobial advice was sought from 11 pharmacists on 300 occasions. Most requests (80%) were received by the AMS pharmacist. A mean (range) of 30 (17-40) requests per day was recorded and the AMS pharmacist received 24 (16-31) requests daily. Most requests came from the intensive care unit (22.1%), pharmacy (21.4%), and infectious diseases (17.1%). The AMS pharmacist was mostly contacted by consultants and pharmacists, and other pharmacists were contacted by registrars and junior medical officers. Despite COVID-19 adaptations, face-to-face interaction was most common. This audit demonstrates the value of an AMS pharmacist, and indicates the importance of face-to-face interactions and the formalisation of pharmacists' role in prescribing decision-making. Pharmacists provided antimicrobial advice daily to other healthcare professionals. Further research is required to provide insights into the barriers and enablers to effective advice-giving interactions.Copyright © 2022 The Authors. Journal of Pharmacy Practice and Research published by John Wiley & Sons Australia, Ltd on behalf of Society of Hospital Pharmacists of Australia.

Effects of the Covid-19 Pandemic on the nature of bronchiolitis in infants <6 months admitted to a UK District General Hospital

Objectives: In anticipation of increasing rates of bronchiolitis post-easing of Covid restrictions, the UK began "respiratory surge planning". We compared bronchiolitis admissions prior-to (pre-31 March 2020) and peri-pandemic (post 1 April 2020), with the hypothesis of increased severity and volume. Method(s): Retrospective cohort study of infants aged 0-6 months admitted to a UK DGH from 1 April 2016 to 31 January 2022 comparing winter and summer periods. 535 infants met inclusion criteria (mean age 83.5 +/- 31 days). Primary outcome measures: length of stay (LOS), heated-humidified high-flow nasal cannulae oxygen (HHHFNC) use and PICU retrieval. RSV and Covid status were recorded. Parametric data was analysed with Student's t-test. Non-parametric data was evaluated with Chi-square test. pvalues <0.05 were deemed statistically significant (CI 95%). Result(s): Pre-pandemic 92% (408/442) of cases occurred in the winter compared to 61% (57/93) peri-pandemic. Winter mean LOS pre- and peri-pandemic were 2.47+/- 2.2 and 1.89 +/- 2.0 days respectively (p=0.047). Summer mean LOS for pre- and peri-pandemic were 2.62 +/-2.0 and 2.28 +/- 1.8 days respectively (p=0.47). The annual mean LOS pre- and peri-pandemic were 2.48 +/- 2.15 and 2.04 +/- 1.9 days respectively (p=0.05). There was no significant difference in HHHFNC use, with 21% and 22% pre- and peri-pandemic respectively (p=0.84). PICU retrievals were zero to five per 6-months, with no distinct trends. Conclusion(s): We found dramatic decreases in bronchiolitis admissions from April 2020 with a summer spike in 2021;but no overall difference in severity. LOS was shorter peri-pandemic. This may help future service planning.

Did destructive leadership help create the conditions for the spread of Covid-19, and what are the early warning signs?

This research asks: ‘were there any objectively identifiable signals in the words leaders used in the early stages of the Covid-19 pandemic that can be associated with ineffective management of the crisis?' We chose to focus on the leaders of the two English-speaking nations that fared worst and best in the pandemic, the United States and New Zealand. By way of background and in order to contextualise the research, we compared and contrasted Trump's and Ardern's leaderships using the toxic triangle framework of destructive leadership. We then focused on the leader behaviour element of the triangle by using computerised text analysis (CTA) to analyse Trump's and Ardern's public pronouncements during the critical early stages of the pandemic. Based on a similarity index (S), we identified linguistic markers associated with destructive leader behaviours and negative outcomes (Trump) and non-destructive leader behaviours and positive outcomes (Ardern). We discuss future applications of these linguistic markers for the diagnosis both of incumbent and potential leaders' responses to crises management. © The Author(s) 2022.

Diagnostic Test Kinetics, Infectivity, and Immunological Responses Among Unvaccinated Adults During Acute SARS-CoV-2 Infection

Background. Appropriate diagnostic testing can be used to inform infection control measures and reduce SARS-CoV-2 transmission, yet the test kinetics, infectivity, and immunological responses during acute, non-severe SARS-CoV-2 infection need clarity. Methods. We conducted a prospective cohort study between Nov 2020-July 2021 in Seattle, Washington of 95 unvaccinated, immunocompetent adults with no prior SARS-CoV-2 infection. Nasal swabs (nasopharyngeal and anterior) and blood serum samples were serially collected at six visits over two months. Viral RNA, N and S antigen concentrations, and viral growth/infectivity were measured from nasal samples. Anti-S total antibody and IgG assays were performed on serum. We fit loess curves to quantitative data corresponding to each testing modality by days since symptom onset (DSSO) and compared qualitative test results across time points to demonstrate timedependent agreement of PCR, N antigen, and culture results. Generalized estimating equations were used to approximate relative risk of culture positivity (a proxy for infectiousness) for positive vs. negative test results (antigen and PCR), stratified by presence/ absence of symptoms and DSSO. Sampling Schema Nasal swabs and venous blood were collected at visits 1-4;venous blood only at visits 5-6. All participants were enrolled within 14 days of symptom onset (median: 6) and 7 days of a positive test (median: 4). Results. Infections in this cohort (median age: 29y) were mild (no hospitalization). Median (IQR) time to negative result was 11 (4), 13 (6), and 20 (7) DSSO for culture growth, N antigen, and PCR tests, respectively. Viral RNA quantities declined more slowly than antigen and culturable virus;antibody titers rose rapidly 5-15 DSSO and plateaued 20-30 DSSO. All culture-positive samples collected 0-5 DSSO were positive by PCR, but relative risk of culture positivity (infectiousness) for positive vs. negative PCR results declined 6-10 DSSO. Relative risk of culture positivity for positive vs. negative antigen results was consistently high 0-10 DSSO, with similar results when stratified by presence of symptoms. Diagnostic test kinetics and immunological responses Diagnostic test kinetics and immunological responses measured in adults with non-severe, symptomatic SARS-CoV-2 infection: loess trendlines and 95% confidence intervals are given for SARS-CoV-2 viral load (calculated from PCR Ct value using a calibration curve), TCID50 from viral culture, mean concentrations of nucleocapsid and spike antigen proteins, and anti-S total and IgG antibody concentrations. Conclusion. The results reinforce the importance of molecular PCR testing as a highly sensitive diagnostic tool but with limited utility as an indicator of viral culturability and likely infectiousness. N antigen testing may be a preferable diagnostic test within two weeks of symptom onset, especially 6-10 DSSO, because it more closely correlates with culture growth over the course of infection.

Snapshot of Delaware Senior Centers:COVID-19 Restrictions, Challenges and Successes

Senior centers provide recreational and social opportunities to millions of older adults. As a result of COVID-19, many senior center directors were forced to adapt and provide new physical distancing opportunities for their members quickly. The study aimed to identify restrictions, challenges, and successes that Delaware senior center administrators faced during the COVID-19 pandemic. Interviews with 15 senior center administrators revealed that many sites relied upon state or federal guidelines for their policies while significantly reducing their specific class and activity offerings. These senior center administrators indicated a lack of guidance on openings, financial hardships, and lack of volunteers and employees as challenges they faced. Policies and frameworks should be developed to assist these organizations when adapting to future disasters.

The International Education Index: A global approach to education policy analysis, performance and sustainable development

Before the COVID-19 pandemic, the world struggled to address growing educational inequalities and fulfil the commitment to Sustainable Development Goal 4, which seeks to ensure inclusive and equitable quality education and promote lifelong learning opportunities for all. The pandemic has exacerbated these inequalities and changed how education functions, moving to online and hybrid methods. The challenges in global education highlighted and worsened by the pandemic make it necessary to re-evaluate education systems and the policies in place to support access, quality and equal opportunity. This article focuses on analysing education policies at a national level. It tests a pilot policy analysis tool, the International Education Index (IEI), developed as a starting point to begin this reconsideration and create an accessible and comprehensive way to evaluate national education systems to inform decision-making and policies in the new context. This research uses Ireland and Northern Ireland to test the IEI pilot tool. The IEI consists of 54 questions across nine indicators, including institutional frameworks, education strategies, digital skills and infrastructure, twenty-first century skills, access to basic social services, adherence to international standards, legal frameworks, data gathering and availability and international partnerships. Countries can score 108 points to be categorised as having developed, emerging or nascent national education systems. Ireland scored 94 and Northern Ireland 81, indicating that they have developed national education systems.

Improving Intranasal Naloxone Distribution for Harm Reduction in Emergency Departments

Introduction: The COVID19 pandemic has exacerbated the opioid epidemic in Ohio, with increased numbers of opioid overdoses recentl recorded. Emergency departments (EDs) commonly serve as a first point of medical contact for those with opioid overdose and those at risk for overdose. Access to addiction treatment and harm reduction resources within EDs is critical in preventing opioid overdoses and related deaths. Nationwide efforts to increase medication for opioid use disorder (MOUD) access have been underway largely through the use of buprenorphine-based medications;other strategies such as distribution of intranasal naloxone kits (i.e. Narcan) in the ED have not received as much attention. Since 2015, The Ohio State University Wexner Medical Center (OSU) at both its community and main campus hospitals has sought to increase the distribution of intranasal naloxone kits to those at risk of opioid overdose. Due to low distribution rates at these sites, in 2019 these kits were provided free-of-charge through the Ohio Department of Health Project DAWN (Deaths Avoided with Naloxone) initiative. Despite education efforts and staff training, these resources remain severely underutilized, with the community hospital outperforming the main hospital. Method(s): In a medical student driven project, the frequency of intranasal naloxone distribution to qualifying patients was tracked over a six-month period from January to June 2021. Inclusion criteria for eligible patients included those presenting with a chief complaint of opioid overdose, withdrawal, or those with history of OUD. In an effort to determine why distribution remains underutilized, a qualitative internet-based survey was deployed to nursing staff and prescribers (advanced practice practitioners, resident and attending physicians). To determine the perception of intranasal naloxone use for harm reduction and barriers to distribution, the survey queried the importance, perceived need, indications, and ability to distribute intranasal naloxone in a combination of yes/no and free-text responses. Result(s): Over the six-month study period, < 10% of more than 500 eligible patients received intranasal naloxone kits at both campuses. In total, 72 providers were interviewed, 27 of whom were prescribers and 45 were nurses. All participants completed the survey in its entirety. Survey results indicated that despite an adequate knowledge base, significant logistical barriers to distribution remained. This included not knowing the process required to order and dispense kits, a lack of clearly defined roles in the distribution process, and logistical issues in the physical location of kits throughout the ED. Conclusion(s): Despite willing and knowledgeable providers, logistical issues slowed intranasal naloxone distribution in a patient population more likely to leave against medical advice and less likely to interact with medical providers. This implies that even for those for whom a kit is ordered they may not have it in hand when leaving the ED, missing a rare opportunity to provide harm reduction devices to those most in need. Efforts are underway to improve distribution of the intranasal naloxone kits, including additional orientation for off-service interns, the development of a best practice advisory, and the utilization of standing orders.

The importance of children and young person involvement in scoping the need for a paediatric glucocorticoid-associated patient reported outcome measure.

BACKGROUND: For many children and young people (CYP) with paediatric rheumatic conditions, glucocorticoid medications and their associated side-effects have a substantial impact on disease experience. Whilst there are physician-rated measures of glucocorticoid toxicity, no parallel patient reported measure has been developed to date for CYP with rheumatic disease. This manuscript describes a series of public patient involvement (PPI) events to inform the development of a future paediatric glucocorticoid-associated patient reported outcome measure (PROM). METHODS: One large group PPI event was advertised to CYP with experience of glucocorticoid medication use and their parents through clinicians, charities and existing PPI groups. This featured education on the team's research into glucocorticoid medication and interactive polls/structured discussion to help participants share their experiences. Further engagement was sought for PPI group work to co-develop future glucocorticoid studies, including development of a glucocorticoid associated PROM. Quantitative and qualitative feedback was collected from online questionnaires. The initiative was held virtually due to the Covid-19 pandemic. RESULTS: Nine families (n = 15) including 6 CYP joined the large group PPI event. Online pre-attendance and post-attendance questionnaires showed improvement in mean self-reported confidence [1 = not at all confident, 5 = very confident] in the following: what steroid medications are (pre = 3.9, post = 4.8), steroid side effects (pre = 3.8, post = 4.6), patient-reported outcome measures (pre = 2.0, post = 4.5), available research on steroids (pre = 2.2, post = 3.5). Five families (n = 7) were involved in a monthly PPI group who worked alongside the research team to identify priorities in glucocorticoid research, produce age-appropriate study materials, identify barriers to study participation (e.g. accessibility & convenience) and recommend appropriate modalities for dissemination. The participants found discussing shared experiences and learning about research to be the most enjoyable aspects of the initiative. CONCLUSIONS: This PPI initiative provided a valuable forum for families, including young children, to share their perspectives. Here, the authors explore the effective use of PPI in a virtual setting and provide a unique case study for the involvement of CYP in PROM development. The monthly PPI group also identified a need for the development of a new PROM related to glucocorticoid medication use and provided unique insights into how such a study could be structured.

The Syrian refugee life study: first glance

This paper presents descriptive statistics from the first wave of the Syrian Refugee Life Study (S-RLS), which began in 2020. S-RLS is a longitudinal study that tracks a representative sample of approximately 2,500 registered Syrian refugee households in Jordan. It collects comprehensive data on sociodemographic variables, health and well-being, preferences, social capital, attitudes, and safety and crime perceptions. We use these data to document sociodemographic characteristics of Syrian refugees in Jordan and compare them to representative populations in the 2016 Jordan Labor Market Panel Survey (JLMPS). Our findings point to lags in basic service access, housing quality, and educational attainment for Syrian refugees relative to non-refugees. The impacts of the pandemic may partially explain these disparities. The data also show that most Syrian refugees have not recovered economically after Covid-19 and have larger gender disparities in income, employment, prevalence of child marriage, and gender attitudes than their non-refugee counterparts. Finally, mental health problems were common for Syrian refugees in 2020, with depression indicated among more than 45 per cent of the phone survey sample and 61 per cent of the in-person survey sample.

COVID vaccine uptake in young persons on immunosuppression under the care of tertiary paediatric rheumatology service

Introduction/Background: COVID-19 disease, caused by SARS-CoV-2 virus, first emerged as a presentation of severe respiratory disease in 2019. Although children exhibit mild disease, concerns were raised about serious infection in immunocompromised children. The current national guidance recommends that immunocompromised children between 12 and 18 years of age should be offered three primary doses of the Pfizer BioNTech vaccine, 8 weeks apart, followed by a booster dose within 3 months. This audit looked at the awareness and uptake of this regime in young persons on immunosuppression. This information was disseminated to families during clinical contacts and automatic replies sent out from the team mailbox. Description/Method: To collect the data for the audit, we used an anonymous questionnaire to capture the following information:• Diagnosis• Immunomodulatory/Immunosuppressive treatment• Their awareness of the regime for COVID vaccine (number of doses and interval)• Number of vaccines taken• If not taken, why?The questionnaires were handed out to 31 patients attending Paediatric Rheumatology day-care and outpatient clinics over a two-week period for their response. There were no non-responders. Patients who were not on any immunosuppressant medication were excluded.The split of their diagnoses and medications are summarised in tables 1 and 2:Patients with JIA (55%) unsurprisingly dominated the cohort, followed by JSLE, JDM and scleroderma. Only 3/31 patients (10%) were on any form of systemic steroid therapy (all on oral Prednisolone less than 0.5 mg/kg). Majority of the patients (21/31 – 68%) were on Methotrexate, either on its own, or in combination with one of the biologic agents (one scleroderma patient was on MTX + MMF). 14/21 (45%) patients were on one of the biologic agents, of which only one patient was on Rituximab.P69 Table 1:Patients' diagnosesDiagnosisNumber of respondentsJuvenile Idiopathic Arthritis (JIA)17 (2 – uveitis) – 55%Juvenile Systemic Lupus Erythematosus (JSLE)5 – 16%Juvenile Dermatomyositis (JDM)3 – 10%Localised scleroderma / Systemic Sclerosis3 – 10%ANCA Associated Vasculitis (AAV)1 – 3 %Systemic Autoinflammatory Disease2 (both Mevalonate Kinase deficiency) – 6%P69 Table 2:Patients' medicationsMedicationsNumber of respondentsSystemic steroids (on top of other medicines)3 (10%)Methotrexate (MTX)11 (35%)Methotrexate + Adalimumab6 (19%)Mycophenolate Mofetil (MMF)4 (13%)MTX + MMF1 (3%)Adalimumab3 (10%)MTX + Infliximab3 (10%)Canakinumab 2 (6%)Cyclophosphamide1 (3%) Discussion/Results: The results showed that only 6/31 (19%) of patients/their carers knew the correct number (3 + 1) of COVID vaccines recommended in this cohort. 18/31 (58%) patients had received the vaccine, of which 4 patients refused further doses due to side effects they had experienced following the first dose. Of the 13 young people who did not take the vaccine, 9 patients (29%) were unsure whether they need the vaccine. They did not know the benefits of the vaccine and were afraid it either could have a negative effect on immunocompromised children or just were not aware of the guidelines. The other 4 (13%) participants did not want to take the vaccine due to their own personal beliefs.Although concerns were raised about serious COVID-19 infection in immunocompromised children, there is currently very little evidence to suggest that the infection rate and severity of COVID-19 infection in children treated with Methotrexate or biologic agents is higher or the treatment needs to be discontinued or the doses adjusted. There is some emerging evidence to suggest that adults on Rituximab and to a lesser extend Mycophenolate may have increased risk of developing severe outcomes from COVID-19, which has not been replicated in children. The recommendation for third primary dose is based on preliminary results from UK studies of real-world vaccine effectiveness (VE) in persons who are immunosuppressed, suggesting a modest reduction in VE against symptomatic COVID-19. There is also emerging evidence hat COVID vaccination significantly reduces the risk of Paediatric Inflammatory Multisystem Syndrome (PIMS-TS) in 12 – 18 year olds. Key learning points/Conclusion: Despite the notion that the team had disseminated information on the vaccine regime to patients, only one fifth of the patients/carers knew the exact regime for COVID vaccine recommended in this group of young people.Just under 60% of the patients took the vaccine, with the rest choosing not to have it due to a mixture of lack of information and personal choice.The action plan was drawn up to:1. enquire about and document vaccination status, and provide advice and information during every clinical contact;2. include COVID vaccine in education sessions by nursing team;3. include the information as default in all clinic letters;4. reaudit in six months.

Impact of Covid-19 on Timeliness of Nutrition Care in Outpatient Gastroenterology

Background: The COVID-19 pandemic has disrupted health care systems worldwide. Access to nutrition care is vital, especially considering the unique nutrition needs of patients with gastrointestinal conditions. In this study, we aimed to determine local effects of the COVID-19 pandemic, with respect to nutrition care. Method(s): We performed a retrospective descriptive review of internal operational data at Dayton Children's Hospital. We captured data on the number of new patient office visits for malnutrition-related diagnoses and the number of stand-alone nutrition visits completed in-person and via telehealth. We hypothesized need for malnutrition-related visits would increase and telehealth visits would be underutilized, leading to gaps in care during the COVID-19 pandemic. Result(s): Numbers of total stand-alone nutrition visits declined in 2020 from 41 in January to less than 10 in April. Numbers of telephone visits did not rise above 10 for any month in 2020. Volumes of new patient visits for malnutrition-related conditions in 2020 declined to as low as 56 visits per month in April, rising to over 100 by June. Conclusion(s): While volumes of new patient office visits with malnutrition-related diagnoses rose, volumes of stand-alone nutrition visits declined. We found gaps in care as stand-alone nutrition telehealth visits were underutilized during this time period. Opportunities exist to expand the use of telehealth technology to nutrition professionals and prevent future gaps in care. .

Testing for SARS-CoV-2 Infection in Care Home Residents and Staff in English Care Homes: A Service Evaluation

Context: COVID-19 is especially dangerous to older adults living in residential care. Objective: To evaluate the usefulness of a nurse-led Enhanced Care Home Team (ECHT) SARS-CoV-2 testing strategy to identify resident cases early, identify typical illness presentation residents, and correctly attribute cause of death in care home settings in Norfolk, UK. Method: Residents and staff received nose and throat swab tests (7 April to 29 June 2020). Resident test results were linked with symptoms on days 0–14 after test and mortality to 13 July 2020. The data collected were used to evaluate service performance. Findings: Residents (n = 521) and staff (estimated n = 340) in 44 care homes were tested in the ECHT service. SARS-CoV-2 positivity was identified in 103 residents in 14 homes and 49 staff in 7 homes. Of 103 SARS-CoV-2+ residents, just 37 had what were understood to be typical COVID-19 symptom(s). Among 51 residents without symptoms when initially tested, 13 (25%) developed symptoms within 14 days. Many SARS-CoV-2+ residents lacked typical symptoms but presented rather as ‘generally unwell’ (n = 16). Of 39 resident deaths during the monitoring period, 20 (51%) were initially attributed to SARS-CoV-2, all of whom tested SARS-CoV-2+. One deceased person not initially attributed to SARS-CoV-2 tested positive through a different monitoring programme. Of all staff tests, 9% were positive. Implications: A locally designed and integrated joint nursing and social care team approach successfully identified asymptomatic and pre-symptomatic SARS-CoV-2+ residents and staff. Being ‘generally unwell’ was common amongst symptomatic residents and indicated SARS-CoV-2 infection in older people in the absence of more ‘typical’ symptoms. The service supported correct attribution of cause of death. © 2022 The Author(s).

Economic MAD as Middle Powers' Strategic Tool in the Great Power Rivalry

The Cold War theory of mutually assured destruction (MAD), which described the reciprocal damage resulting from the use of nuclear weapons, can be expanded in the 21st century to include more dimensions including climate and the economy. The economic dimension of MAD (dubbed as EMAD) is a situation where one country is incapable of disrupting trade with a target country without also causing itself significant economic d[amage. This can occur given the presence of a specific economic advantage on which the coercing power relies. How can the presence of EMAD help afford middle powers more leeway in their alignment decisions within this strategic dilemma? What economic advantages create a stronger situation of EMAD? In line with these inquiries, this article investigates three cases, each with differing degrees of economic MAD: the 2016 Korea-China dispute over THAAD deployment;the 2020 Australia-China dispute over Covid-19;and the 2022 case of Korea's participation in IPEF. After all, middle powers need to develop a 'collective security-type arrangement' where China's wielding of economic muscle against any middle power state is considered an aggression against all other middle powers, which act together or collectively assist the target state to make the most of EMAD vis-a-vis China. For this, it is reasonable and realistic to promote the democratic liberal international order (LIO) by aligning with U.S.-led minilateral and multilateral initiatives or mechanisms. Yet, it is also important to identify areas and ways to engage with China rather than alienating or excluding it on the international stage.