Developing a Data Integrated COVID-19 Tracking System for Decision-Making and Public Use.

INTRODUCTION: The unprecedented COVID-19 pandemic unveiled a strong need for advanced and informative surveillance tools. The Centre for Health Informatics (CHI) at the University of Calgary took action to develop a surveillance dashboard, which would facilitate the education of the public, and answer critical questions posed by local and national government. OBJECTIVES: The objective of this study was to create an interactive method of surveillance, or a "COVID-19 Tracker" for Canadian use. The Tracker offers user-friendly graphics characterizing various aspects of the current pandemic (e.g. case count, testing, hospitalizations, and policy interventions). METHODS: Six publicly available data sources were used, and were selected based on the frequency of updates, accuracy and types of data, and data presentation. The datasets have different levels of granularity for different provinces, which limits the information that we are able to show. Additionally, some datasets have missing entries, for which the "last observation carried forward" method was used. The website was created and hosted online, with a backend server, which is updated on a daily basis. The Tracker development followed an iterative process, as new figures were added to meet the changing needs of policy-makers. RESULTS: The resulting Tracker is a dashboard that visualizes real-time data, along with policy interventions from various countries, via user-friendly graphs with a hover option that reveals detailed information. The interactive features allow the user to customize the figures by jurisdiction, country/region, and the type of data shown. Data is displayed at the national and provincial level, as well as by health regions. CONCLUSION: The COVID-19 Tracker offers real-time, detailed, and interactive visualizations that have the potential to shape crucial decision-making and inform Albertans and Canadians of the current pandemic.

Prevalent high-risk respiratory hygiene practices in urban and rural Bangladesh.

OBJECTIVES: To identify existing respiratory hygiene risk practices, and guide the development of interventions for improving respiratory hygiene. METHODS: We selected a convenience sample of 80 households and 20 schools in two densely populated communities in Bangladesh, one urban and one rural. We observed and recorded respiratory hygiene events with potential to spread viruses such as coughing, sneezing, spitting and nasal cleaning using a standardized assessment tool. RESULTS: In 907 (81%) of 1122 observed events, households' participants coughed or sneezed into the air (i.e. uncovered), 119 (11%) into their hands and 83 (7%) into their clothing. Twenty-two per cent of women covered their coughs and sneezes compared to 13% of men (OR 2.6, 95% CI 1.6-4.3). Twenty-seven per cent of persons living in households with a reported monthly income of >72.6 US$ covered their coughs or sneezes compared to 13% of persons living in households with lower income (OR 3.2, 95% CI 1.6-6.2). In 956 (85%) of 1126 events, school participants coughed or sneezed into the air and 142 (13%) into their hands. Twenty-seven per cent of coughs/sneezes in rural schools were covered compared to 10% of coughs/sneezes in urban schools (OR 2.3, 95% CI 1.5-3.6). Hand washing was never observed after participants coughed or sneezed into their hands. CONCLUSION: There is an urgent need to develop culturally appropriate, cost-effective and scalable interventions to improve respiratory hygiene practices and to assess their effectiveness in reducing respiratory pathogen transmission.

Women's Recovery from Sternotomy-Extension (WREST-E) study: examining long-term pain and discomfort following sternotomy and their predictors.

OBJECTIVE: To examine incision and breast pain and discomfort, and their predictors in women 12 months following sternotomy. DESIGN: Extension survey following participation in a clinical trial. SETTING: 10 Canadian centres. PATIENTS: Women (n = 326) who completed the Women's Recovery from Sternotomy Trial. INTERVENTIONS: None. MAIN OUTCOME MEASURES: Pain and discomfort data (numeric rating scales) collected by standardised interview at 5 days, 12 weeks and 12 months following sternotomy. RESULTS: More patients reported having incision or breast discomfort (46.6%) than pain (18.1%) at 12 months postoperatively. No symptoms at 5 days postoperatively were significantly associated with symptom presence at 12 postoperative months. However, having incision pain and discomfort as well as breast pain and discomfort at 12 postoperative weeks was associated with incision pain (odds ratio (OR) = 3.26, 95% confidence interval (CI) 1.51 to 7.07), incision discomfort (OR = 4.87, 95% CI 3.01 to 7.88), breast pain (OR = 9.36, 95% CI 3.91 to 22.38) and breast discomfort (OR = 6.42, 95% CI 3.62 to 11.37), respectively, at 12 postoperative months. Increasing chest circumference was associated with having ongoing incision pain (OR = 1.12, 95% CI 1.03 to 1.21) and breast pain (OR = 1.10, 95% CI 1.00 to 1.22). Harvesting of bilateral internal mammary arteries (IMAs) was associated with having ongoing incision pain (OR = 4.71, 95% CI 1.54 to 14.3), while harvesting only the left IMA was associated with having ongoing breast pain (OR = 2.78, 95% CI 1.06 to 7.32) and breast discomfort (OR 1.80, 95% CI 1.02 to 3.19). CONCLUSIONS: Patients reported incision and breast pain and discomfort as long as 12 months post-sternotomy. Improved management of postoperative pain and discomfort up to at least 12 weeks following surgery may render reduced long-term pain and discomfort symptoms.

Individual and area factors associated with general practitioner integration in Australia: a multilevel analysis.

The further integration of primary care within the wider health system is an imperative for reform in all countries. The aim of this paper is to determine the factors associated with general practitioner (GP) integration using the GP Integration Index which has been recently developed and is demonstrating good reliability. The analysis is based on a database derived from an Australia-wide mail questionnaire survey of 1874 GPs drawn from a 20% stratified random sample of 123 Divisions of General Practice (47.8% adjusted response rate). The GP Integration Index measures the level of GPs' integration with the health care system based upon a description of their own behaviour. It consists of nine GP integration factors, and their two associated higher-order factors-Primary Care Management (PCM) and Community Health Role (CHR)-as well as five GP integration enabling factors. A multivariate multilevel analysis was undertaken. An explanatory model for both PCM and CHR was tested based on the GP integration factors as well as general practice, GP and regional characteristics. CHR and PCM were most strongly associated with GP integration enabling factors (mainly at the individual-level) and, for CHR only, with urban-rural location (mainly at the area-level). The most important single explanatory variable for both PCM and CHR was the GP integration enabling factor, "Knowledge of local resources." The important explanatory variables were those reflecting the way GPs work, rather than their broad 'classification' within individual or GP-setting groupings. Based on these results, some revision to the proposed model was necessary. We conclude that processes of care factors (as compared to structure of care factors) are more important in relation to GP integration than previously recognised. Future policy initiatives to promote GP integration should focus on programs to improve GP's knowledge of local resources.

Progression of kidney dysfunction in the community-dwelling elderly.

Despite the high prevalence of chronic kidney disease among the elderly, few studies have described their loss of kidney function. We sought to determine the progression of kidney dysfunction among a community-based cohort of elderly subjects. The cohort included 10 184 subjects 66 years of age or older, who had one or more outpatient serum creatinine measurements during each of two time periods: 1 July to 31 December 2001 and 1 July to 31 December 2003. A mixed effects model, including covariates for age, gender, diabetes mellitus, and comorbidity, was used to determine the rate of decline in estimated glomerular filtration rate (eGFR, in ml/min/1.73 m2) per year over a median follow-up of 2.0 years. Subjects with diabetes mellitus had the greatest decline in eGFR of 2.1 (95% CI 1.8-2.5) and 2.7 (95% CI 2.3-3.1) ml/min/1.73 m2 per year in women and men, respectively. The rate of decline for women and men without diabetes mellitus was 0.8 (95% CI 0.6-1.0) and 1.4 (95% CI 1.2-1.6) ml/min/1.73 m2 per year. Subjects with a study mean eGFR<30 ml/min/1.73 m2, both those with and without diabetes mellitus, experienced the greatest decline in eGFR. In conclusion, we found that the majority of elderly subjects have no or minimal progression of kidney disease over 2 years. Strategies aimed at slowing progression of kidney disease should consider underlying risk factors for progression and the negligible loss of kidney function that occurs in the majority of older adults.

Construction of a GP integration model.

There are frequent calls to improve integration of health services, within and between primary and secondary care sectors. In Australia, general medical practitioners (GPs) are central to these endeavours. This paper aims to better conceptualise GP integration and to develop a model and index based on this. A conceptualisation of integration is proposed based on integration fundamentally as an activity or process not structure. Integration process is the frequency and quality of episodes of information exchange involving the GP and another practitioner or patient and aimed at fulfilling the objectives of the health care system with regard to patient care. These are both direct responses to structural forces and emergent GP capacities and dispositions. The content of this typology was studied using Concept Mapping in 11 groups of GPs, consumers and other practitioners. Clusters of related statements within thematic domains were used as the basis for a provisional model. This was tested using confirmatory factor analysis in a data set derived from a national probability sample of 501 GPs. Some re-specification of the model was necessary, with three integration process factors needing to be subdivided. One factor congeneric model assumptions were used to identify the constituent items for these factors. The result was a model in which 50 items measured nine integration process factors and 20 items measured five enabling factors. Two distinct but correlated higher order factors, relating to individual patient care and public (or community) health--in contrast to a single higher order factor for integration--were identified. The re-specified model was tested with a new sample of 151 GPs and exhibited strong psychometric properties. Reliability and validity were acceptable to this stage of the indices' development. Further testing of the index is necessary to demonstrate factor invariance of the indices in other contexts as well as their utility in cross-structural analysis. That said, the indices have immediate uses.

Integration from the Australian GP's perspective.

OBJECTIVE: To report on what general practitioners' perceptions are about their role in relation to activities that support integration and what they are doing. METHOD: General practitioner perceived integrative behaviour was measured using a survey containing 114 statements about, 'what constitutes a well integrated GP'. Four hundred and forty-eight GPs were randomly sampled from the Health Insurance Commission (HIC) Medicare billing database in 1996. A response rate of 47% was obtained, yielding 208 surveys for analysis. RESULTS: General practitioners reported integrative activities such as being accessible to patients and working within a multidisciplinary team as currently occurring optimally. Not occurring optimally were: hospital and community involvement; participation in local projects; student education; and payment for working with others. Rural practitioners reported significantly more hospital and community involvement compared with metropolitan practitioners. Less than one-third of GPs reported that they were linked to other services by computer and used a computer for storage/communication of patient information. DISCUSSION: There are many obstacles preventing integrative activities in daily general practice. Policy and attitudinal changes as well as financial incentives are required to enable GPs to practise in an integrated manner. Infrastructure support to encourage GP education, training and information technology are essential to improve GP integration. Many such initiatives are currently in progress, and will require future evaluation. Findings from this 1996 survey will provide some useful baseline information assisting with future evaluation studies.

General practice integration in Australia. Primary health services provider and consumer perceptions of barriers and solutions.

OBJECTIVE: To identify practical examples of barriers and possible solutions to improve general practice integration with other health service providers. METHOD: Twelve focus groups, including one conducted by teleconference, were held across Australia with GPs and non GP primary health service providers between May and September, 1996. Focus groups were embedded within concept mapping sessions, which were used to conceptually explore the meaning of integration in general practice. Data coding, organising and analysis were based on the techniques documented by Huberman and Miles. RESULTS: Barriers to integration were perceived to be principally due to the role and territory disputes between the different levels of government and their services, the manner in which the GP's role is currently defined, and the system of GP remuneration. Suggestions on ways to improve integration involved two types of strategies. The first involves initiatives implemented 'top down' through major government reform to service structures, including the expansion of the role of divisions of general practice, and structural changes to the GP remuneration systems. The second type of strategy suggested involves initiatives implemented from the 'bottom up' involving services such as hospitals (e.g. additional GP liaison positions) and the use of information technology to link services and share appropriate patient data. CONCLUSION: The findings support the need for further research and evaluation of initiatives aimed at achieving general practice integration at a systems level. There is little evidence to suggest which types of initiatives improve integration. However, general practice has been placed in the centre of the health care debate and is likely to remain central to the success of such initiatives. Clarification of the future role and authority of general practice will therefore be required if such integrative strategies are to be successful at a wider health system level.

Rapid onset of control with budesonide Turbuhaler in patients with mild-to-moderate asthma.

BACKGROUND: Budesonide (Pulmicort) is an inhaled corticosteroid with high topical potency but low systemic activity. Turbuhaler is a novel breath-actuated, multi-dose, dry-powder inhaler. OBJECTIVES: This study was conducted to determine the efficacy and safety of two different dose regimens of budesonide Turbuhaler, compared with placebo, in adult patients with mild-to-moderate asthma not well-controlled with bronchodilator therapy. METHODS: This double-blind, randomized, placebo-controlled, parallel-group, multicenter study compared the efficacy and safety of 200 microg and 400 microg of budesonide, administered twice daily via Turbuhaler, with placebo, in 273 adult patients (aged 19 to 70 years) with mild-to-moderate asthma (FEV1 67% of predicted normal), not well-controlled with bronchodilator therapy. Efficacy was assessed by pulmonary function tests and patient assessments of asthma symptom control. Safety was assessed in terms of adverse events, laboratory evaluations, and physical examinations. RESULTS: Two hundred and 400 microg of budesonide bid were significantly more effective than placebo at improving morning PEF (mean differences from placebo of 43.63 L/min and 40.10 L/min, respectively; P < .001) and FEV1 (mean differences from placebo of 0.44 L, and 0.50 L, respectively; P < .001) over the 12-week treatment period. Onset of action as assessed by morning PEF was within two days. Basal and stimulated plasma cortisol concentrations were not significantly affected by budesonide treatment compared with placebo. CONCLUSIONS: Treatment of adults suffering from mild-to-moderate asthma with budesonide Turbuhaler is well tolerated and results in a rapid onset of asthma control which is maintained over time.

The concept mapping method. An alternative to focus group inquiry in general practice.

BACKGROUND: The concept mapping rationale and process are explained step by step. The concept mapping method produces a two dimensional conceptual map of ideas produced by the group which can be analysed at the level of individual statements, clusters of statements, and groups of similar clusters. An example of concept mapping conducted with four general practitioner (GP) groups from different practice types and demographic locations is provided. A total of 51 participating GPs were asked to complete an 'evaluation questionnaire' at the end of each group session. The majority of GP participants (68%) rated the method as highly useful. OBJECTIVE: To describe the concept mapping method and its interpretation for use in general practice research. To report on its perceived usefulness and acceptability by general practitioners. DISCUSSION: Concept mapping is a very useful method combining benefits from qualitative and quantitative approaches for exploring the breadth of a topic in its entirety, especially for abstract concepts. GPs found the concept mapping method to be efficient for group inquiry, rating it high on utility. There is scope to refine the method, reducing time spent in some stages of the session, and substituting more time on final analysis.

Zafirlukast improves asthma symptoms and quality of life in patients with moderate reversible airflow obstruction.

BACKGROUND: Previous trials demonstrated the effectiveness of the leukotriene receptor antagonist zafirlukast in patients with mild-to-moderate asthma. OBJECTIVES: We sought to assess the efficacy and safety of zafirlukast and its effect on patients' quality of life (QOL) during a 13-week, double-blind, placebo-controlled, multicenter trial in adults and adolescents with moderate reversible airflow obstruction. METHODS: Patients (age range, 12 to 68 years) with total daytime asthma symptoms scores of 10 or greater over 7 consecutive days (maximum, 21/wk), FEV1 45% or greater but less than or equal to 80% of predicted value (>/=6 hours after beta2 -agonist), and reversible airway disease were randomized to 20 mg zafirlukast twice daily (nZ = 231) or placebo twice daily (nP = 223). Efficacy was assessed from changes in daytime and nocturnal symptoms, beta2 -agonist use, nasal congestion score, and pulmonary function. QOL was evaluated with a disease-specific Asthma Quality of Life Questionnaire. Safety was determined from adverse event information and clinical laboratory test results. RESULTS: Zafirlukast was significantly (P <.001) more effective than placebo, with reductions from baseline in the daytime asthma symptoms score (-23%), nighttime awakenings with asthma (-19%), and beta2 -agonist use (-24%) and improvements from baseline in morning (+25 L/min) and evening (+18 L/min) peak expiratory flow rates. Compared with placebo, zafirlukast significantly (P /=0.5-unit change from baseline; P

Hematologic effects of thrombophilia.

The hematologic effects of thrombophilia are subtle, and when recognized may provide clues for the diagnosis of hypercoagulation in patients. This article identifies aberrant, routine test results associated with the diagnosis of thrombophilia. The future expansion of laboratory testing for thrombophilia detection is presented in summation.

Dose ranging study of mometasone furoate (Nasonex) in seasonal allergic rhinitis.

BACKGROUND: Topical nasal corticosteroids are rapidly gaining acceptance as first-line therapy for seasonal allergic rhinitis, but there is a desire for effective corticosteroids with an improved safety profile over existing products. OBJECTIVE: A multicenter, double-blind dose ranging study was conducted to compare the activity and tolerance of four doses of mometasone furoate nasal spray (tradename Nasonex) and placebo in adult patients with seasonal allergic rhinitis. METHODS: Four hundred eighty patients with seasonal allergic rhinitis were enrolled and randomized to receive mometasone furoate nasal spray 50 micrograms (n = 96), 100 micrograms (n = 95), 200 micrograms (n = 98) or 800 micrograms (n = 95), or placebo vehicle (n = 95) once daily for 28 days. RESULTS: All of the doses of mometasone furoate nasal spray showed activity in reducing the severity of rhinitis. The 200-microgram dose reduced total nasal symptom scores and total symptom scores throughout the study (P < .05 versus placebo vehicle). The 50-microgram dose and the 100-microgram dose showed less consistent activity at early timepoints (days 3 and 7), while the 800 microgram dose did not provide significant additional benefits over the 200-microgram dose. All dose levels were well tolerated CONCLUSION: The results of this trial indicate that 200 micrograms once daily is the optimum dose of mometasone furoate nasal spray for the treatment of seasonal allergic rhinitis.

Severe envenomation by the taipan (Oxyuranus scutellatus)

We describe cases of five patients with taipan envenomation which indicate that patients with paresis benefit from repeated doses of antivenom, even if given long after the bite, and that fresh frozen plasma should be given to correct coagulopathy that persists after reversal of neuromuscular blockade. We reiterate the importance of compression bandages.

Efficacy of once daily extended-release theophylline in decreasing the use of inhaled beta 2-agonists in stable, mild-to-moderate asthma patients.

BACKGROUND/OBJECTIVE: The purpose of this study was to determine whether the addition of extended-release theophylline to the daily treatment regimen of inhaled beta 2-agonist users would result in decreased use of beta 2-agonist while maintaining similar efficacy for treatment of asthma. METHODS: This was a single-blind, multicenter (six sites) study. Sixty-one patients with a history of mild-to-moderate asthma treated with inhaled beta 2-agonist were randomized to treatment with Theo-24 (anhydrous extended-release capsules) plus inhaled beta 2-agonist or placebo plus beta 2-agonist. Patients kept daily symptom diaries, measured peak flow rates, recorded puffs of inhaled beta 2-agonist, and adverse events during a 4-week treatment period. RESULTS: Fifty-five patients were included in the efficacy analysis. The primary efficacy variable in this study was the mean number of puffs (adjusted for baseline differences) of beta 2-agonist inhaled per day. In this study, the addition of theophylline to the daily regimen of inhaled beta 2-agonist for 4 weeks significantly reduced the total daily dose of inhaled beta 2-agonist at weeks 3 and 4 of treatment compared with placebo. The differences were significant at the P < .05 level. For patients in the theophylline group, the number of puffs decreased from an unadjusted mean of 9.81 at baseline to an adjusted mean of 6.78 after 4 weeks of treatment compared with 9.91 at baseline and 8.17 for the placebo group. There were no unexpected or serious adverse events. CONCLUSIONS: In this study, the addition of once daily, extended-release theophylline to the daily regimen of inhaled beta 2-agonist for 4 weeks significantly reduced the total daily dose of inhaled beta 2-agonist at weeks 3 and 4 of treatment compared with placebo, while maintaining acceptable asthma symptom scores.

Genome reorganization from polyteny to polyploidy in the nurse cells found in onion fly (Delia antiqua) and cabbage root fly (Delia radicum) ovaries (Diptera, Anthomyiidae).

The material required to ensure successful embryogenesis in the onion fly (Delia antiqua) and the cabbage root fly (Delia radicum) (Diptera, Anthomyiidae) is supplied by 15 nurse cells, while the oocyte chromosomes enter a quiescent stage during prophase I of meiosis. This level of transcription is achieved by the polyploidization of the nurse cell DNA. Elongate polytene chromosomes form in both species, but lack the banding and conspicuous puffing commonly seen in other dipteran tissues. The polytene chromosomes contract until they finally appear as small, densely staining spheres. These fragment into large numbers of endochromosomes that are much smaller than their mitotic counterparts, which then despiralize, resulting in the flocculate appearance of the nurse cell nucleus. Photodensitometry revealed a gradient of DNA values between nurse cells near the oocytes and those further away. Final DNA values 1000 times the haploid level were recorded in the nurse cell nearest to the oocyte compared with 336 times the C-value in the most distal cell. At lower temperatures (< 10 degrees C), the polytene chromosomes become banded and longer. None of the onion flies kept in these conditions produced viable eggs, though there was some reproductive success among the cabbage root flies.

Female meiosis in the onion fly and cabbage root fly (Diptera: Anthomyiidae).

The sequence of female meiosis was investigated in two populations of the cabbage root fly (Delia radicum) and three populations of the onion fly (D. antiqua). In contrast with the completely achiasmate males, both species showed high levels of recombination in females. However, significant differences in chiasma frequency occurred between individuals within populations and between the populations. It was not uncommon to find aneuploidy of the X chromosomes. The autosomes occasionally showed asynapsis or desynapsis, but normal disjunction of univalents was facilitated by distance pairing.