Gait Disturbance of Red Herrings, Oranges, and Lemons - A Case of Missed Vitamin C Deficiency and Lessons Learnt.

Vitamin C deficiency resulting in scurvy, is considered to be a rare nutritional disorder in developed countries, thus leading to underdiagnosis with exposure to unnecessary investigations and delay in appropriate treatment. The wide myriad of clinical signs and symptoms with which vitamin C deficiency can present (including haematological, musculoskeletal and vague constitutional symptoms that overlap with other common medical conditions), also contributes to this diagnostic challenge. Despite scurvy being habitually thought to be present in children with neurodevelopmental conditions such as autism spectrum disorder, other important at-risk groups that frequently tend to be forgotten include children with persistent fussy eating behaviour, and children with abnormal vitamin C metabolism. We hereunder present a case of a 10-year-old boy who presented to an acute general hospital for further investigation with gait disturbance. The lack of detailed nutritional assessment on presentation in the first instance led to a missed diagnosis of vitamin C deficiency, thus exposing the child to a wide array of unnecessary investigations and treatments. The added perplexity to the case resulting from false positive results of investigations performed as part of this child's workup, is also discussed.

Adherence to and enforcement of non-pharmaceutical interventions (NPIs) for COVID-19 prevention in Nigeria, Rwanda, and Zambia: A mixed-methods analysis

IntroductionIn the early parts of the COVID-19 pandemic, non-pharmaceutical interventions (NPIs) were implemented worldwide, including in sub-Saharan Africa, to prevent and control SARS-CoV-2 transmission. This mixed-methods study examines adherence to and enforcement of NPIs implemented to curb COVID-19 in Nigeria, Rwanda, and Zambia, leading up to the 10,000th case of laboratory-confirmed COVID-19 in each country. Additionally, we aim to evaluate the relationship between levels and changes of NPIs over time and changes in COVID-19 cases and deaths. MethodsThis mixed-methods analysis utilized semi-structured interviews and a quantitative dataset constructed using multiple open data sources, including the Oxford COVID-19 Government Response Tracker. To understand potential barriers and facilitators in implementing and enforcing NPIs qualitative data were collected from those involved in the COVID-19 response and analyzed using NVivo. Quantitative results were analyzed using descriptive statistics, plots, ANOVA, and post hoc Tukey. ResultsIndividual indicator scores varied with the COVID-19 response in all three countries. Nigeria had sustained levels of strict measures for containment and closure NPIs, while in Rwanda there was substantial variation in NPI score as it transitioned through the different case windows for the same measures. Zambia implemented moderate stringency throughout the pandemic using gathering restrictions and business/school closure measures but maintained low levels of strictness for other containment and closure measures. Rwanda had far more consistent and stringent measures compared to Nigeria and Zambia. Rwandas success in implementing COVID-related measures was partly due to strong enforcement and having a population that generally obeys its government. ConclusionVarious forces either facilitated or hindered adherence and compliance to COVID-19 control measures. This research highlights important lessons, including the need to engage communities early and create buy-in, as well as the need for preparation to ensure that response efforts are proactive rather than reactive when faced with an emergency.

Economic precarity, social isolation, and suicidal ideation during the COVID-19 pandemic

ImportanceThe US population faces stressors associated with suicide brought on by the COVID-19 pandemic. Understanding the relationship between stressors and suicidal ideation may inform policies and programs to prevent suicide. ObjectiveTo evaluate the relationship between stressors and suicidal ideation during the COVID-19 pandemic. DesignWe compared suicidal ideation in 2017-2018 to suicidal ideation in 2020. We estimated the association between stressors and suicidal ideation in bivariable and multivariable Poisson regression models with robust variance. SettingUnited States ParticipantsParticipants were from two, nationally representative surveys of US adults: The 2017-2017 National Health and Nutrition Examination Survey and the 2020 COVID-19 and Life Stressors Impact on Mental Health and Well-being study (conducted March 31 to April 13), analyzed April 28 to September 30, 2020. ExposuresEconomic precarity as measured through job loss or difficulty paying rent and social isolation based on reporting "feeling alone." Main outcome measureSuicidal ideation based on reporting "Thoughts that you would be better off dead or of hurting yourself in some way" over the past two weeks. ResultsSuicidal ideation increased more than fourfold, from 3.4% in the 2017-2018 NHANES to 16.3% in the 2020 CLIMB survey, and from 5.8% to 26.4% among participants in low-income households. Suicidal ideation was more prevalent among people facing difficulty paying rent (31.5%), job loss (24.1%), and loneliness (25.1%), with each stressor associated with suicidal ideation in bivariable models. In the multivariable model, difficulty paying rent was associated with suicidal ideation (aPR: 1.5, 95% CI: 1.2 to 2.1), while losing a job was not (aPR: 0.9, 95% CI: 0.6 to 1.2). Feeling alone was associated with suicidal ideation (aPR: 1.9, 95% CI: 1.5 to 2.4). Conclusions and relevanceSuicidal ideation increased more than fourfold during the COVID-19 pandemic. Difficulty paying rent and loneliness were most associated with suicidal ideation. Policies and programs to support people experiencing economic precarity and loneliness may contribute to suicide prevention.

Serological testing in addition to PCR screening for the re-opening of American colleges and universities: potential for cost-savings without compromising pandemic mitigation

ImportanceThe addition of a serological testing could reduce the overall testing costs of a PCR-based SARS-CoV-2 testing reopening plan for colleges/universities in the United States, without compromising the efficacy of the testing plan. ObjectivesTo determine whether a college/university reopening SARS-CoV-2 testing plan that includes serological testing can be cost-saving compared to a PCR-only testing. Design, Setting, and ParticipantsWe assessed costs of serological testing in addition to PCR testing under various scenarios of university sizes (2000, 10,000, and 40,000) and epidemic conditions (initial antibody prevalence 2.5-15%; cumulative SARS-CoV-2 incidence during the school year 5-30%) of SARS-CoV-2 in the United States. We estimated total testing costs and relative percentage of cost-savings of different screening (i.e. targeted/ universal) and testing (i.e. in-sourcing/out-sourcing) scenarios between September 2020-May 2021. Main Outcomes and MeasuresTesting costs of serological testing and PCR testing, Relative percentage of cost saving by including serology testing in addition to PCR testing. ResultsIncluding baseline serology testing alongside routine regular PCR testing can reduce total test volumes and related costs throughout the school year. While the total testing cost is likely much lower if regular PCR testing is insourced compared to outsourced ($5 million vs $34 million for university size 10,000), including serologic testing could achieve the up to 20% cost-savings relative to PCR testing alone. The insourcing of serological testing when PCR testing is insourced can achieve greater cost-savings under high initial antibody prevalence (>5%) and cumulative incidence throughout the school year (>10%) at medium and large sized universities. If PCR testing is outsourced, however, the inclusion of serological testing becomes always preferred in most university sizes and epidemic conditions. Conclusions and RelevanceWhile regular PCR testing alone is the preferred strategy for containing epidemics, including serology testing may help achieve cost-savings if outbreaks are anticipated, or if baseline seropositivity is high. Key Points (96/100)O_ST_ABSQuestionC_ST_ABSCan the addition of a serological testing reduce the overall testing costs of a PCR-based SARS-CoV-2 testing reopening plan for universities in the United States? FindingsThis costing study suggested that inclusion of serological testing in addition to outsourced PCR testing as part of a university re-opening strategy could achieve cost savings of up to 20%. The amount of savings, or additional costs, is dependent on insourcing or outsourcing of testing, epidemic conditions and university size. MeaningThe relative cost-savings depend strongly on whether PCR and/or serology are being insourced or outsourced, university sizes and cumulative incidence.

Neighborhood income and physical distancing during the COVID-19 pandemic in the U.S.

IntroductionAlthough physical distancing has been the primary strategy to reduce the spread of COVID-19 in the U.S., peoples ability to distance may vary by socioeconomic characteristics, leading to higher transmission risk in low-income neighborhoods. MethodsWe used mobility data from a large, anonymized sample of smartphone users to assess the relationship between neighborhood median household income and physical distancing during the COVID-19 epidemic. We assessed changes in several behaviors including: spending the day entirely at home; working outside the home; and visits to supermarkets, parks, hospitals, and other locations. We also assessed differences in effects of state policies on physical distancing across neighborhood income levels. ResultsWe found a strong gradient between neighborhood income and physical distancing. Compared to January and February 2020, the proportion of individuals spending the day entirely at home in April 2020 increased by 10.9 percentage points in low-income neighborhoods and by 27.1 percentage points in high-income neighborhoods. During April 2020, people in low-income neighborhoods were more likely to work outside the home, compared to people in higher-income neighborhoods, but not more likely to visit non-work locations. State physical distancing orders were associated with a 1.5 percentage-point increase (95% CI [0.9, 2.1], p < 0.001) in staying home in low-income neighborhoods and a 2.4 percentage point increase (95% CI [1.4, 3.4], p < 0.001) in high-income neighborhoods. DiscussionPeople in lower-income neighborhoods have faced barriers to physical distancing, particularly the need to work outside the home. State physical distancing policies have not mitigated these disparities.

An evaluation of the use of oral contrast media in abdominopelvic CT.

OBJECTIVES: To evaluate the diagnostic efficacy of different oral contrast media (OCM) for abdominopelvic CT examinations performed for follow-up general oncological indications. The objectives were to establish anatomical image quality criteria for abdominopelvic CT; use these criteria to evaluate and compare image quality using positive OCM, neutral OCM and no OCM; and evaluate possible benefits for the medical imaging department. METHODS: Forty-six adult patients attending a follow-up abdominopelvic CT for general oncological indications and who had a previous abdominopelvic CT with positive OCM (n = 46) were recruited and prospectively placed into either the water (n = 25) or no OCM (n = 21) group. Three radiologists performed absolute visual grading analysis (VGA) to assess image quality by grading the fulfilment of 24 anatomical image quality criteria. RESULTS: Visual grading characteristics (VGC) analysis of the data showed comparable image quality with regards to reproduction of abdominal structures, bowel discrimination, presence of artefacts, and visualization of the amount of intra-abdominal fat for the three OCM protocols. CONCLUSION: All three OCM protocols provided similar image quality for follow-up abdominopelvic CT for general oncological indications. KEY POINTS: • Positive oral contrast media are routinely used for abdominopelvic multidetector computed tomography • Experimental study comparing image quality using three different oral contrast materials • Three different oral contrast materials result in comparable CT image quality • Benefits for patients and medical imaging department.

Availability of essential health services in post-conflict Liberia

Objective:To assess the availability of essential health services in northern Liberia in 2008; five years after the end of the civil war. Methods We carried out a population-based household survey in rural Nimba county and a health facility survey in clinics and hospitals nearest to study villages. We evaluated access to facilities that provide index essential services: artemisinin combination therapy for malaria; integrated management of childhood illness; human immunodeficiency virus (HIV) counselling and testing; basic emergency obstetric care and treatment of mental illness. Findings Data were obtained from 1405 individuals (98response rate) selected with a three-stage population- representative sampling method; and from 43 of Nimba county's 49 health facilities selected because of proximity to the study villages. Respondents travelled an average of 136 minutes to reach a health facility. All respondents could access malaria treatment at the nearest facility and 55.9could access HIV testing. Only 26.8; 14.5; and 12.1could access emergency obstetric care; integrated management of child illness and mental health services; respectively. Conclusion Although there has been progress in providing basic services; rural Liberians still have limited access to life-saving health care. The reasons for the disparities in the services available to the population are technical and political. More frequently available services (HIV testing; malaria treatment) were less complex to implement and represented diseases favoured by bilateral and multilateral health sector donors. Systematic investments in the health system are required to ensure that health services respond to current and future health priorities