Stop and Go: Barriers and Facilitators to Care Home Research.

Barriers to care home research have always existed, but have been thrown into sharp relief by the COVID-19 pandemic. Existing infrastructure failed to deliver the research, or outcomes, which care home residents deserved and we need to look, again, at how these barriers can be taken down. Barriers can be categorised as procedural (encountered before research starts), system (encountered during research) or resident-specific. To tackle these, research regulatory bodies need to adopt a standardised approach to how care home research is developed and designed, reviewed and regulated, and how such approaches can enable recruitment of as wide a range of residents and their representatives as possible, including those without the mental capacity to consent for research. Establishment of local, inter-disciplinary collaborations between universities, general practices, health and social care providers and care homes is another priority. This should be based on pre-existing models such as the 'Living lab' model developed in The Netherlands and now being implemented in the UK and Austria. These changes are critical to develop a sustainable research model. If well designed this will deliver better outcomes for residents and align with the individual and organisational priorities of those who care for them.

Evidence review of physical distancing and partition screens to reduce healthcare acquired SARS-CoV-2.

We review the evidence base for two newly introduced Infection prevention and control strategies within UK hospitals. The new standard infection control precaution of 2 metres physical distancing and the use of partition screens as a means of source control of infection for SARS-CoV-2. Following review of Ovid-MEDLINE and governmental SAGE outputs there is limited evidence to support the use of 2 metres physical distancing and partition screens within healthcare.

First-dose ChAdOx1 and BNT162b2 COVID-19 vaccines and thrombocytopenic, thromboembolic and hemorrhagic events in Scotland.

Reports of ChAdOx1 vaccine-associated thrombocytopenia and vascular adverse events have led to some countries restricting its use. Using a national prospective cohort, we estimated associations between exposure to first-dose ChAdOx1 or BNT162b2 vaccination and hematological and vascular adverse events using a nested incident-matched case-control study and a confirmatory self-controlled case series (SCCS) analysis. An association was found between ChAdOx1 vaccination and idiopathic thrombocytopenic purpura (ITP) (0-27 d after vaccination; adjusted rate ratio (aRR) = 5.77, 95% confidence interval (CI), 2.41-13.83), with an estimated incidence of 1.13 (0.62-1.63) cases per 100,000 doses. An SCCS analysis confirmed that this was unlikely due to bias (RR = 1.98 (1.29-3.02)). There was also an increased risk for arterial thromboembolic events (aRR = 1.22, 1.12-1.34) 0-27 d after vaccination, with an SCCS RR of 0.97 (0.93-1.02). For hemorrhagic events 0-27 d after vaccination, the aRR was 1.48 (1.12-1.96), with an SCCS RR of 0.95 (0.82-1.11). A first dose of ChAdOx1 was found to be associated with small increased risks of ITP, with suggestive evidence of an increased risk of arterial thromboembolic and hemorrhagic events. The attenuation of effect found in the SCCS analysis means that there is the potential for overestimation of the reported results, which might indicate the presence of some residual confounding or confounding by indication. Public health authorities should inform their jurisdictions of these relatively small increased risks associated with ChAdOx1. No positive associations were seen between BNT162b2 and thrombocytopenic, thromboembolic and hemorrhagic events.

Informing the public health response to COVID-19: a systematic review of risk factors for disease, severity, and mortality.

BACKGROUND: Severe Acute Respiratory Syndrome coronavirus-2 (SARS-CoV-2) has challenged public health agencies globally. In order to effectively target government responses, it is critical to identify the individuals most at risk of coronavirus disease-19 (COVID-19), developing severe clinical signs, and mortality. We undertook a systematic review of the literature to present the current status of scientific knowledge in these areas and describe the need for unified global approaches, moving forwards, as well as lessons learnt for future pandemics. METHODS: Medline, Embase and Global Health were searched to the end of April 2020, as well as the Web of Science. Search terms were specific to the SARS-CoV-2 virus and COVID-19. Comparative studies of risk factors from any setting, population group and in any language were included. Titles, abstracts and full texts were screened by two reviewers and extracted in duplicate into a standardised form. Data were extracted on risk factors for COVID-19 disease, severe disease, or death and were narratively and descriptively synthesised. RESULTS: One thousand two hundred and thirty-eight papers were identified post-deduplication. Thirty-three met our inclusion criteria, of which 26 were from China. Six assessed the risk of contracting the disease, 20 the risk of having severe disease and ten the risk of dying. Age, gender and co-morbidities were commonly assessed as risk factors. The weight of evidence showed increasing age to be associated with severe disease and mortality, and general comorbidities with mortality. Only seven studies presented multivariable analyses and power was generally limited. A wide range of definitions were used for disease severity. CONCLUSIONS: The volume of literature generated in the short time since the appearance of SARS-CoV-2 has been considerable. Many studies have sought to document the risk factors for COVID-19 disease, disease severity and mortality; age was the only risk factor based on robust studies and with a consistent body of evidence. Mechanistic studies are required to understand why age is such an important risk factor. At the start of pandemics, large, standardised, studies that use multivariable analyses are urgently needed so that the populations most at risk can be rapidly protected. REGISTRATION: This review was registered on PROSPERO as CRD42020177714 .

Impact of peer-trainer leadership style on uptake of a peer led educational outreach intervention to improve tuberculosis care and outcomes in Malawi: a qualitative study.

BACKGROUND: Little is known about how to build leadership capacity to support implementation of evidence-based practices within health systems. We observed substantial variability across sites in uptake and sustainability of a peer-led educational outreach intervention for lay health workers (LHWs) providing tuberculosis care in Malawi. Feedback from peer-trainers (PTs) suggested that leadership may have contributed to the variation. We sought to assess the impact of PT leadership style on implementation, and to identify leadership traits of more successful PTs, to inform future implementation planning and to identify targets for leadership capacity building. METHODS: Qualitative study employing interviews with PTs and LHWs at high and low implementation sites, and review of study team and quarterly PT meeting notes. High implementation sites achieved high uptake, sustainability and fidelity of implementation including: close adherence to training content and process, high levels of coverage (training most or all eligible LHWs at their site), and outcomes were achieved with high levels of self reported competence with the intervention among both PTs and LHWs. Low implementation sites achieved limited coverage (<= 50% of LHWs trained), and intervention fidelity. RESULTS: Eight PTs and 10 LHWs from eight high and 10 low implementation sites participated in interviews. Leadership traits of more successful PTs included: flexibility in their approach to training, role modeling and provision of supportive supervision to support learning; addressing challenges proactively and as they occurred; collaborative planning; knowledgeable; and availability to support implementation. Traits unique to less successful PTs included: a poor attitude toward their role as PT and a passive-avoidant approach to challenges. CONCLUSION: This study identified leadership traits more common among unit level leaders at sites with higher uptake, sustainability, and fidelity of implementation. These findings provide a starting point for development and evaluation of a leadership capacity building intervention for unit level leaders to support implementation.

Particle-size dependent bactericidal activity of magnesium oxide against Xanthomonas perforans and bacterial spot of tomato.

Bacterial spot, caused by Xanthomonas spp., is a highly destructive disease of tomatoes worldwide. Copper (Cu) bactericides are often ineffective due to the presence of Cu-tolerant strains. Magnesium oxide (MgO) is an effective alternative to Cu bactericides against Xanthomonas spp. However, the effects of particle size on bactericidal activity and fruit elemental levels are unknown. In this study, nano (20 nm) and micron (0.3 and 0.6 µm) size MgO particles were compared for efficacy. Nano MgO had significantly greater in vitro bactericidal activity against Cu-tolerant X. perforans than micron MgO at 25-50 µg/ml. In field experiments nano and micron MgO applied at 200 and 1,000 µg/ml were evaluated for disease control. Nano MgO at 200 µg/ml was the only treatment that consistently reduced disease severity compared to the untreated control. Inductively Coupled Plasma Optical Emission Spectroscopy revealed that nano MgO applications did not significantly alter Mg, Cu, Ca, K, Mn, P and S accumulation compared to fruits from the untreated plots. We demonstrated that although both nano MgO and micron MgO had bactericidal activity against Cu-tolerant strains in vitro, only nano MgO was effective in bacterial spot disease management under field conditions.

Nano-Magnesium Oxide: A Novel Bactericide Against Copper-Tolerant Xanthomonas perforans Causing Tomato Bacterial Spot.

Bacterial spot caused by Xanthomonas perforans causes significant damage on tomato in Florida. Due to the presence of copper (Cu)-tolerant X. perforans strains, Cu bactericides are not effective in disease management. Hence, there is a critical need to find alternatives for Cu. Antibacterial activity of magnesium oxide (Nano-MgO), and other metal oxide nanoparticles, were evaluated against a Cu-tolerant and -sensitive X. perforans strain. In vitro experiments demonstrated high antibacterial activity of Nano-MgO against both strains compared with the commercial Cu. The minimum inhibitory concentration of Nano-MgO is 25 µg/ml and the minimum bactericidal concentration is 100 µg/ml against a Cu-tolerant X. perforans strain after 4 h of exposure. Structural changes in the bacterial membrane following exposure to Nano-MgO treatments compared with the controls were observed using transmission electron microscopy. In two greenhouse experiments with a Cu-tolerant strain, bacterial spot severity was significantly reduced by Nano-MgO at 200 µg/ml compared with Cu-ethylene bis-dithiocarbamate (grower standard), and the untreated control (P = 0.05). In three field experiments, Nano-MgO at 200 µg/ml significantly reduced disease severity with no negative impact on yield compared with the untreated control. Inductively coupled plasma mass spectrometric analysis of the fruit confirmed that Nano-MgO application did not lead to the accumulation of Mg, Cu, Ca, K, Mn, P, and S. This study is the first to demonstrate the potential of Nano-MgO against bacterial spot of tomato.

Assessing the educational impact of the dementia champions programme in Scotland: Implications for evaluating professional dementia education.

Increasing numbers of people with dementia are living longer with a higher likelihood of requiring hospital care for physical conditions including falls, infections and stroke (Boaden, 2016). However, the literature is replete with descriptions of poor care and hospital care experiences that have fallen well below the expectations of people with dementia, their families and friends. Although poor care is unacceptable, it is unsurprising given that dementia education for health and social care professionals is often inadequate and inconsistent. This results in most healthcare staff being ill-equipped and lacking the confidence to work with people living with dementia. The first of Scotland's National Dementia Strategies committed to "improve the response to dementia in general hospital settings including alternatives to admission and better planning for discharge" (Scottish Government, 2010). The educational response was the commissioning of the Dementia Champions programme. Since 2011, the programme has developed over 800 health and social care professionals working in general hospital and related settings to be change agents in dementia care. This article will outline the theoretical underpinning of the programme and present pooled results from four cohorts (2014-2017) (n = 524). A repeated measure design (pre and post programme) was used to measure attitudes towards people with dementia; self-efficacy and knowledge of dementia. The findings suggest that the education had a statistically significant positive effect on all intended outcomes, indicating the potential for practice change. We discuss these findings in relation to the literature, and respond to the calls for high quality evaluation to measure the effectiveness of dementia education, the challenges and potential directions for measuring educational effectiveness and capturing transfer of learning.

Community characteristics modify the relationship between obesity prevention efforts and dietary intake in children: the Healthy Communities Study.

BACKGROUND: The influence of community characteristics on the effectiveness of childhood obesity prevention efforts is not well understood. OBJECTIVE: Examine the interaction of community characteristics with the relationship between community programmes and policies (CPPs) and dietary intake. METHODS: An observational study of 5138 children in grades K-8 in 130 US communities was conducted in 2013-2015. Key informant interviews identified and characterized CPPs. CPP scores were generated for the number of target behaviours (CPP-Behav) and the number of behaviour change strategies (CPP-Strat) addressed by all CPPs and CPPs with nutrition goals over the prior 6 years in each community. Dietary intake was assessed by dietary screener and included intake of sugar from sugar-sweetened beverages; energy-dense foods; fruits and vegetables; whole grains; and fibre. Multivariate statistical models assessed the interactions between US region, urbanicity, community-level income, and community-level race/ethnicity and CPP scores in relation to dietary intake. RESULTS: CPP-Strat was positively associated with healthier dietary intakes in the Northeast and West, and in high Hispanic communities; the reverse was true in the South, and in high African-American and low-income communities. The CPP-Behav was positively associated with healthier dietary intakes in the South and rural areas, and the reverse was true in the West. CONCLUSION: The relationships between CPP index scores and dietary intake were most strongly influenced by region and urbanicity and to a lesser extent by community-level race/ethnicity and income. Findings suggest that different considerations may be needed for childhood obesity prevention efforts in communities with different characteristics.

Associations of community programs and policies with children's dietary intakes: the Healthy Communities Study.

BACKGROUND: The impact of community-based obesity prevention efforts on child nutrition has not been adequately studied. OBJECTIVE: Examine relationships between number, type and intensity of community programs and policies (CPPs) and child nutrition. METHODS: An observational study of 5138 children (grades K-8) in 130 U.S. communities was conducted in 2013-2015. CPPs were identified by 10-14 key informant interviews per community. CPPs were characterized based on: count, intensity, number of different strategies used and number of different behaviours targeted. Scores for the prior 6 years were calculated separately for CPPs that addressed primarily nutrition, primarily physical activity (PA) or total combined. Child intakes were calculated from a dietary screener and dietary behaviours were based on survey responses. Multi-level statistical models assessed associations between CPP indices and nutrition measures, adjusting for child and community-level covariates. RESULTS: Implementing more types of strategies across all CPPs was related to lower intakes of total added sugar (when CPPs addressed primarily PA), sugar-sweetened beverages (for nutrition and PA CPPs) and energy-dense foods of minimal nutritional value (for total CPPs). Addressing more behaviours was related to higher intakes of fruit and vegetables (for nutrition and total CPPs) and fibre (total CPPs). Higher count and intensity (PA and total CPPs) were related to more consumption of lower fat compared with higher fat milk. A higher count (PA CPPs) was related to fewer energy-dense foods and whole grains. No other relationships were significant at P < 0.05. CONCLUSION: Multiple characteristics of CPPs to prevent obesity appear important to improve children's diets.

Objectives of community policies and programs associated with more healthful dietary intakes among children: findings from the Healthy Communities Study.

BACKGROUND: Rational planning of community policies and programs (CPPs) to prevent obesity requires an understanding of CPP objectives associated with dietary behaviours. OBJECTIVE: The objective of the study is to identify objectives of CPPs associated with healthful dietary behaviours. METHODS: An observational study identified 4026 nutrition CPPs occurring in 130 communities in the prior 6 years. Dietary intakes of fruits and vegetables, added sugar and sugar-sweetened beverages, among others, were reported among 5138 children 4-15 years of age from the communities, using a Dietary Screener Questionnaire with children age 9 years and older (parent assisted) or parent proxies for younger children. CPPs were documented through key informant interviews and characterized by their intensity, count, and objectives including target dietary behaviour and food environment change strategy. Associations between dietary intakes and CPP objectives were assessed using hierarchical statistical models. RESULTS: CPPs with the highest intensity scores that targeted fast food or fat intake or provided smaller portions were associated with greater fruit and vegetable intake (0.21, 0.19, 0.23 cup equivalents/day respectively with p values <0.01, 0.04, 0.03). CPPs with the highest intensity scores that restricted the availability of less healthful foods were associated with lower child intakes of total added sugar (-1.08 tsp/day, p < 0.01) and sugar from sugar-sweetened beverages (-1.63 tsp/day, p = 0.04). Similar associations were observed between CPP count and dietary outcomes. No other significant associations were found between CPP target behaviours or environmental strategies and dietary intakes/behaviours. CONCLUSION: CPPs that targeted decreases in intakes of less healthful foods and/or aimed to modify the availability of less healthful foods and portions were associated with healthier child dietary behaviours.

The longitudinal relationship between community programmes and policies to prevent childhood obesity and BMI in children: the Healthy Communities Study.

BACKGROUND: Although a national epidemic of childhood obesity is apparent, how community-based programmes and policies (CPPs) affect this outcome is not well understood. OBJECTIVES: This study examined the longitudinal relationship between the intensity of CPPs in 130 communities over 10 years and body mass index (BMI) of resident children. We also examined whether these relationships differ by key family or community characteristics. METHODS: Five thousand one hundred thirty-eight children in grades K-8 were recruited through 436 schools located within 130 diverse US communities. Measures of height, weight, nutrition, physical activity and behavioural and demographic family characteristics were obtained during in-home visits. A subsample of families consented to medical record review; these weight and height measures were used to calculate BMI over time for 3227 children. A total of 9681 CPPs were reported during structured interviews of 1421 community key informants, and used to calculate a time series of CPP intensity scores within each community over the previous decade. Linear mixed effect models were used to assess longitudinal relationships between childhood BMI and CPP intensity. RESULTS: An average BMI difference of 1.4 kg/m2 (p-value < 0.01) was observed between communities with the highest and lowest observed CPP intensity scores, after adjusting for community and child level covariates. BMI/CPP relationships differed significantly by child grade, race/ethnicity, family income and parental education; as well as community-level race/ethnicity. CONCLUSIONS: These results indicate that, over time, more intense CPP interventions are related to lower childhood BMI, and that there are disparities in this association by sociodemographic characteristics of families and communities.

A quality improvement project to increase self-administration of medicines in an acute hospital.

QUALITY PROBLEM OR ISSUE: A patient survey found significantly fewer patients reported they had self-administered their medicines while in hospital (20% of 100 patients) than reported that they would like to (44% of 100). We aimed to make self-administration more easily available to patients who wanted it. INITIAL ASSESSMENT: We conducted a failure, modes and effects analysis, collected baseline data on four wards and carried out observations. CHOICE OF SOLUTION: Our initial assessment suggested that the main areas we should focus on were raising patient awareness of self-administration, changing the patient assessment process and creating a storage solution for medicines being self-administered. We developed new patient information leaflets and posters and a doctor's assessment form using Plan-Do-Study-Act cycles. We developed initial designs for a storage solution. IMPLEMENTATION: We piloted the new materials on three wards; the fourth withdrew due to staff shortages. EVALUATION: Following collection of baseline data, we continued to collect weekly data. We found that the proportion of patients who wished to self-administer who reported that they were able to do so, significantly increased from 41% (of 155 patients) to 66% (of 118 patients) during the study, despite a period when the hospital was over capacity. LESSONS LEARNED: Raising and maintaining healthcare professionals' awareness of self-administration can greatly increase the proportion of patients who wish to self-administer who actually do so. Healthcare professionals prefer multi-disciplinary input into the assessment process.

Validation of a national hand hygiene proxy measure in NHS Scotland.

The Scottish national hand hygiene proxy measure uses the volume of alcohol-based hand rub (ABHR) purchased by NHS Scotland boards as an indicator of the number of hand hygiene moments being performed per patient-bed-day. The proxy measure calculation is based on the assumption that 3 mL of ABHR is used per hand hygiene moment. This study aimed to validate the volume of ABHR being used per hand hygiene moment. It found that the median volume of ABHR being used in practice is approximately 1 mL per hand hygiene moment, and that using this validated volume in the calculation substantially increases the proxy measure of hand hygiene compliance.

Advanced Copper Composites Against Copper-Tolerant Xanthomonas perforans and Tomato Bacterial Spot.

Bacterial spot, caused by Xanthomonas spp., is a widespread and damaging bacterial disease of tomato (Solanum lycopersicum). For disease management, growers rely on copper bactericides, which are often ineffective due to the presence of copper-tolerant Xanthomonas strains. This study evaluated the antibacterial activity of the new copper composites core-shell copper (CS-Cu), multivalent copper (MV-Cu), and fixed quaternary ammonium copper (FQ-Cu) as potential alternatives to commercially available micron-sized copper bactericides for controlling copper-tolerant Xanthomonas perforans. In vitro, metallic copper from CS-Cu and FQ-Cu at 100 µg/ml killed the copper-tolerant X. perforans strain within 1 h of exposure. In contrast, none of the micron-sized copper rates (100 to 1,000 µg/ml) from Kocide 3000 significantly reduced copper-tolerant X. perforans populations after 48 h of exposure compared with the water control (P < 0.05). All copper-based treatments killed the copper-sensitive X. perforans strain within 1 h. Greenhouse studies demonstrated that all copper composites significantly reduced bacterial spot disease severity when compared with copper-mancozeb and water controls (P < 0.05). Although there was no significant impact on yield, copper composites significantly reduced disease severity when compared with water controls, using 80% less metallic copper in comparison with copper-mancozeb in field studies (P < 0.05). This study highlights the discovery that copper composites have the potential to manage copper-tolerant X. perforans and tomato bacterial spot.

Weight gain in pregnancy and child weight status from birth to adulthood in the United States.

BACKGROUND: High weight gain in pregnancy has been associated with child adiposity, but few studies have assessed the relationship across childhood or in racially/ethnically diverse populations. OBJECTIVES: The objectives of the study are to test if weight gain in pregnancy is associated with high birthweight and overweight/obesity in early, middle and late childhood and whether these associations differ by maternal race/ethnicity. METHODS: Mother-child dyads (n = 7539) were included from the National Longitudinal Survey of Youth 1979, a nationally representative cohort study in the USA (1979-2012). Log-binomial regression models were used to analyse associations between weight gain and the outcomes: high birthweight (>4000 g) and overweight/obesity at ages 2-5, 6-11 and 12-19 years. RESULTS: Excessive weight gain was positively associated, and inadequate weight gain was negatively associated with high birthweight after confounder adjustment (P < 0.05). Only excessive weight gain was associated with overweight in early, middle and late childhood. These associations were not significant in Hispanics or Blacks although racial/ethnic interaction was only significant ages 12-19 years (P = 0.03). CONCLUSIONS: Helping pregnant women gain weight within national recommendations may aid in preventing overweight and obesity across childhood, particularly for non-Hispanic White mothers.

Epidemiology and management of bacterial leaf spot on watermelon caused by Pseudomonas syringae.

Bacterial leaf spot of watermelon caused by Pseudomonas syringae has been an emerging disease in the southeastern United States in recent years. Disease outbreaks in Florida were widespread from 2013 to 2014 and resulted in foliar blighting at the early stages of the crop and transplant losses. We conducted a series of field trials at two locations over the course of two years to examine the chemical control options that may be effective in management of this disease, and to investigate the environmental conditions conducive for bacterial leaf spot development. Weekly applications of acibenzolar-S-methyl (ASM) foliar, ASM drip, or copper hydroxide mixed with ethylene bis-dithiocarbamate were effective in reducing the standardized area under the disease progress curve (P < 0.05). Pearson's correlation test demonstrated a negative relationship between the average weekly temperature and disease severity (-0.77, P = 0.0002). When incorporated into a multiple regression model with the square root transformed average weekly rainfall, these two variables accounted for 71% of the variability observed in the weekly disease severity (P < 0.0001). This information should be considered when choosing the planting date for watermelon seedlings as the cool conditions often encountered early in the spring season are conducive for bacterial leaf spot development.

The differential effects of norepinephrine and dopamine on cerebrospinal fluid pressure and spinal cord perfusion pressure after acute human spinal cord injury.

STUDY DESIGN: Prospective vasopressor cross-over interventional studyObjectives:To examine how two vasopressors used in acute traumatic spinal cord injury (SCI) affect intrathecal cerebrospinal fluid pressure and the corresponding spinal cord perfusion pressure (SCPP). SETTING: Vancouver, British Columbia, Canada. METHODS: Acute SCI patients over the age of 17 with cervical or thoracic ASIA Impairment Scale (AIS). A, B or C injuries were enrolled in this study. Two vasopressors, norepinephrine and dopamine, were evaluated in a 'crossover procedure' to directly compare their effect on the intrathecal pressure (ITP). The vasopressor cross-over procedures were performed in the intensive care unit where ITP, mean arterial pressure (MAP) and heart rate were being continuously measured. The SCPP was calculated as the difference between MAP and ITP. RESULTS: A total of 11 patients were enrolled and included in our analysis. There were 6 patients with AIS A, 3 with AIS B and 2 with AIS C injuries at baseline. We performed 24 cross-over interventions in these 11 patients. There was no difference in MAP with the use of norepinephrine versus dopamine (84±1 mm Hg for both; P=0.33). Conversely, ITP was significantly lower with the use of norepinephrine than with dopamine (17±1 mm Hg vs 20±1 mm Hg, respectively, P<0.001). This decrease in ITP with norepinephrine resulted in an increased SCPP during the norepinephrine infusion when compared with dopamine (67±1 mm Hg vs 65±1 mm Hg respectively, P=0.0049). CONCLUSION: Norepinephrine was able to maintain MAP with a lower ITP and a correspondingly higher SCPP as compared with dopamine in this study. These results suggest that norepinephrine may be preferable to dopamine if vasopressor support is required post SCI to maintain elevated MAPs in accordance with published guidelines.