Randomized controlled trial of molnupiravir SARS-CoV-2 viral and antibody response in at-risk adult outpatients.

Viral clearance, antibody response and the mutagenic effect of molnupiravir has not been elucidated in at-risk populations. Non-hospitalised participants within 5 days of SARS-CoV-2 symptoms randomised to receive molnupiravir (n = 253) or Usual Care (n = 324) were recruited to study viral and antibody dynamics and the effect of molnupiravir on viral whole genome sequence from 1437 viral genomes. Molnupiravir accelerates viral load decline, but virus is detectable by Day 5 in most cases. At Day 14 (9 days post-treatment), molnupiravir is associated with significantly higher viral persistence and significantly lower anti-SARS-CoV-2 spike antibody titres compared to Usual Care. Serial sequencing reveals increased mutagenesis with molnupiravir treatment. Persistence of detectable viral RNA at Day 14 in the molnupiravir group is associated with higher transition mutations following treatment cessation. Viral viability at Day 14 is similar in both groups with post-molnupiravir treated samples cultured up to 9 days post cessation of treatment. The current 5-day molnupiravir course is too short. Longer courses should be tested to reduce the risk of potentially transmissible molnupiravir-mutated variants being generated. Trial registration: ISRCTN30448031.

Holistic approach supporting mental wellbeing of people in enforced quarantine in South Australia during the COVID-19 pandemic.

OBJECTIVES: To report the experience of quarantine for international arrivals to South Australia requiring quarantine in a medi-hotel setting during the COVID-19 pandemic and to describe the range of evidence-based support services to mitigate the mental health impacts of quarantine. METHODS: A range of services targeted at physical and mental wellbeing were provided. Data from 533 adult respondents out of 721 passengers were included. The Kessler 10 was used to measure psychological distress at two time points. RESULTS: About 7.1% of respondents reported psychological distress at time one, reduced to 2.4% at time two. There was no significant difference in psychological distress by gender at either time point. The mean K10 score at time one was 13.6 (standard deviation=5.2) and the mean score at time two was 11.5 (standard deviation=3.1), with a significant reduction in mean scores (p<0.001) between the two time points. CONCLUSIONS: The level of psychological stress in repatriated Australians was low at arrival and improved further at the time of release from quarantine. Implications for public health: A collaborative multi-sector approach to provide support services for individuals in quarantine can mitigate risks to mental wellbeing.

Decreasing Chlamydial Reinfections in a Female Urban Population.

BACKGROUND: Chlamydia is the most reported bacterial sexually transmitted infection (STI). The rates of chlamydia rose by 19% between 2011 and 2018. The STI National Strategic Plan (2021-2025), encourages coordinated solutions to address STIs and reduce disparities in disadvantaged populations. METHODS: We implemented institutional policy changes, clinical decision support, including a Best Practice Advisory, and defaulted SmartSet with provider and patient education for women's health clinics at a large county health system. The advisory prompted providers to follow best practices when treating Chlamydia trachomatis infections. New C. trachomatis diagnosis cohorts were compared preintervention and postintervention for 6-month reinfection rates and patient and expedited partner treatment (EPT) practices. RESULTS: Five hundred and nineteen women were included in the final analysis. Six-month chlamydia reinfection was lower in the postintervention cohort after adjusting for age (12.3% [26/211] vs 6.5% [20/308], P = 0.02). There was an increase in directly observed therapy of primary patients (17.5% [37/211] vs 77.3% [238/308], P < 0.001), an increase in EPT prescriptions written (4.3% [9/211] vs 79.5% [245/308], P < 0.0001), and a decrease of partners referred out for treatment (61.6% [130/211] vs 5.2% [16/308], P < 0.001) when compared with the control group. The majority of EPT was patient-delivered partner therapy postintervention (3.3% [7/211] vs 69.2% [213/308], P < 0.001). CONCLUSIONS: A multifaceted, streamlined approach was effective in changing provider practices in the treatment of C. trachomatis. Increased rates of directly observed therapy for primary patient treatment and increased rates of patient-delivered partner therapy were observed postimplementation in addition to lower 6-month reinfection rates in a public women's health clinic setting.

Repatriation operation in South Australia during the COVID-19 pandemic: initial planning and preparedness.

ABSTRACT: With COVID-19 affecting millions of people around the globe, quarantine of international arrivals is a critical public health measure to prevent further disease transmission in local populations. This measure has also been applied in the repatriation of citizens, undertaken by several countries as an ethical obligation and legal responsibility. This article describes the process of planning and preparing for the repatriation operation in South Australia during the COVID-19 pandemic. Interagency collaboration, development of a COVID-19 testing and quarantining protocol, implementing infection prevention and control, and building a specialised health care delivery model were essential aspects of the repatriation operational planning, with a focus on maintaining dignity and wellbeing of the passengers as well as on effective prevention of COVID-19 transmission. From April 2020 to mid-February 2021, more than 14,000 international arrivals travellers have been repatriated under the South Australian repatriation operations. This paper has implications to inform ongoing repatriation efforts in Australia and overseas in a pandemic situation.

Identifying the at-risk General Practice trainee: a retrospective cohort meta-analysis of General Practice registrar flagging.

A central principle of programmatic assessment is that the final decision is not a surprise to the learner. To achieve this, assessments must demonstrate predictive and consequential validity, however, to date, research has only focussed on the former. The present study attempts to address this gap by examining the predictive and consequential validity of flagging systems used by Australian General Practice regional training organisations (RTOs) in relation to Fellowship examinations. Informed by unstructured interviews with Senior Medical Educators to understand the flagging system of each RTO, meta-analyses of routinely-collected flagging data were used to examine the predictive validity of flagging at various points in training and exam performance. Additionally, flagging system features identified from the interviews were used to inform exploratory subgroup analyses and meta-regressions to further assess the predictive and consequential validity of these systems. Registrars flagged near the end of their training were two to four times more likely to fail Fellowship exams than their non-flagged counterparts. Regarding flagging system features, having graded (i.e. ordinal) flagging systems was associated with higher accuracy, whilst involving the assigned medical educator in remediation and initiating a formal diagnostic procedure following a flag improved registrars' chances of passing exams. These results demonstrate both predictive and consequential validity of flagging systems. We argue that flagging is most effective when initiated early in training in conjunction with mechanisms to maximise diagnostic accuracy and the quality of remediation programs.

Workplace-based assessments in postgraduate medical education: A hermeneutic review.

OBJECTIVES: Since their introduction, workplace-based assessments (WBAs) have proliferated throughout postgraduate medical education. Previous reviews have identified mixed findings regarding WBAs' effectiveness, but have not considered the importance of user-tool-context interactions. The present review was conducted to address this gap by generating a thematic overview of factors important to the acceptability, effectiveness and utility of WBAs in postgraduate medical education. METHOD: This review utilised a hermeneutic cycle for analysis of the literature. Four databases were searched to identify articles pertaining to WBAs in postgraduate medical education from the United Kingdom, Canada, Australia, New Zealand, the Netherlands and Scandinavian countries. Over the course of three rounds, 30 published articles were thematically analysed in an iterative fashion to deeply engage with the literature in order to answer three scoping questions concerning acceptability, effectiveness and assessment training. As each round was coded, themes were refined and questions added until saturation was reached. RESULTS: Stakeholders value WBAs for permitting assessment of trainees' performance in an authentic context. Negative perceptions of WBAs stem from misuse due to low assessment literacy, disagreement with definitions and frameworks, and inadequate summative use of WBAs. Effectiveness is influenced by user (eg, engagement and assessment literacy) and tool attributes (eg, definitions and scales), but most fundamentally by user-tool-context interactions, particularly trainee-assessor relationships. Assessors' assessment literacy must be combined with cultural and administrative factors in organisations and the broader medical discipline. CONCLUSIONS: The pivotal determinants of WBAs' effectiveness and utility are the user-tool-context interactions. From the identified themes, we present 12 lessons learned regarding users, tools and contexts to maximise WBA utility, including the separation of formative and summative WBA assessors, use of maximally useful scales, and instituting measures to reduce competitive demands.