bluuebunny/crossref_metadata_2025 huggingface dataset:
Target student mental well-being
Authors: Leshner Alan I.
Published: January 2021

Mental health and well-being are critical to student success in higher education and beyond but rarely get the attention they need. Colleges and universities in the United States have been seeing increases in mental illness and emotional distress among students for decades. Unfortunately, the COVID-19 pandemic and its social and economic consequences are accelerating these trends. Furthermore, renewed focus on systemic racism in many spheres of American life is highlighting the stresses and mental health consequences faced by students from traditionally underrepresented groups and by women who continue to suffer the lingering effects of sexism. The damaging consequences of these problems for students, their institutions, and a modern world that depends on a well-educated, healthy workforce demand a much better response. Promoting student mental health and emotional well-being on campus requires more than a well-functioning counseling center. It calls for a campus-wide commitment and coordinated action plan. For many institutions, accomplishing this will involve a major rethinking of their responsibilities to students.
Interactions with Commensal and Pathogenic Bacteria Induce HIV-1 Latency in Macrophages through Altered Transcription Factor Recruitment to the Long Terminal Repeat
Authors: Viglianti Gregory A. , Planelles Vicente , Hanley Timothy M.
Published: January 2021

The major barrier toward the eradication of HIV-1 infection is the presence of a small reservoir of latently infected cells, which include CD4+T cells and macrophages that escape immune-mediated clearance and the effects of antiretroviral therapy. There remain crucial gaps in our understanding of the molecular mechanisms that lead to transcriptionally silent or latent HIV-1 infection of macrophages.
Reovirus RNA Recombination Is Sequence Directed and Generates Internally Deleted Defective Genome Segments during Passage
Authors: Smith Sydni Caet , Gribble Jennifer , Diller Julia R. , Wiebe Michelle A. , Thoner Timothy W. , Denison Mark R. , Ogden Kristen M.
Published: January 2021

Viruses in the
Reoviridae
family include important pathogens of humans and other animals and have segmented RNA genomes. Recombination in RNA virus populations can facilitate novel host exploration and increased disease severity.
Cellular and Viral Determinants of Herpes Simplex Virus 1 Entry and Intracellular Transport toward the Nuclei of Infected Cells
Authors: Musarrat Farhana , Chouljenko Vladimir , Kousoulas Konstantin G.
Published: January 2021

Herpes simplex virus 1 viruses enter either via fusion at the plasma membranes or endocytosis depositing the virion capsids into the cytoplasm of infected cells. The viral capsids utilize the dynein motor complex to move toward the nuclei of infected cells by using the microtubular network.
Fingerprinting sand from Asian rivers to the deep central South China Sea since the Late Miocene
Authors: Cao Licheng , Jiang Tao , He Jingke
Published: January 2021

The complex sedimentary processes from source to sink lead to a substantial fractionation of sediment size and composition. Relatively coarse-grained, continent-derived detritus is rarely transported and deposited in the deep ocean, and the terminus of this sediment routing system is poorly understood. Sandy turbidite deposits within the Upper Miocene–Pleistocene strata drilled in the deep central South China Sea during the International Ocean Discovery Program (IODP) Expedition 349 provide valuable samples for evaluating the evolution of sediment contributions from different Asian landmasses. This study reconstructs this ancient source-to-sink system based on an integration of heavy mineral and detrital zircon analyses (including U-Pb age, trace element, grain size and shape), obtained from IODP sites U1431 and U1432, as well as a zircon age-based mixture modeling of well-defined provenance end-members. The results show several provenance shifts that correspond to more complex and dynamic source-to-sink scenarios than previously envisaged. Certain source areas, like East Vietnam, present a different provenance signature than that of today. Multiple provenances have been mixed and diluted during sediment transport, exhibiting a large regional variability. We interpret that siliciclastic turbidite deposits in the central South China Sea were mainly derived from East Vietnam during the early Late Miocene and Pliocene, and the Pearl River Basin during the late Late Miocene and Pleistocene. Additional, but less significant, contributions from the Red and Mekong river basins and coastal Southeast China are also observed.
Supplemental Material: No ring fracture in Mono Basin, California
Authors: Hildreth Wes , Fierstein Judy
Published: January 2021

Table S1: Chemical data for the three plutons in the area investigated.
Associations between family presence and neonatal intubation outcomes: a report from the National Emergency Airway Registry for Neonates: NEAR4NEOS
Authors: Brei Brianna K , Sawyer Taylor , Umoren Rachel , Gray Megan M , Krick Jeanne , Foglia Elizabeth E , Ades Anne , Glass Kristen , Kim Jae H , Singh Neetu , Jung Philipp , Johnston Lindsay , Moussa Ahmed , Napolitano Natalie , Barry James , Zenge Jeanne , Quek Binhuey , DeMeo Stephen D , Shults Justine , Unrau Jennifer , Nadkarni Vinay , Nishisaki Akira
Published: January 2021

Objective

Describe the current practice of family presence during neonatal tracheal intubations (TIs) across neonatal intensive care units (NICUs) and examine the association with outcomes.

Design

Retrospective analysis of TIs performed in NICUs participating in the National Emergency Airway Registry for Neonates (NEAR4NEOS).

Setting

Thirteen academic NICUs.

Patients

Infants undergoing TI between October 2014 and December 2017.

Main outcome measures

Association of family presence with TI processes and outcomes including first attempt success (primary outcome), success within two attempts, adverse TI-associated events (TIAEs) and severe oxygen desaturation ≥20% from baseline.

Results

Of the 2570 TIs, 242 (9.4%) had family presence, which varied by site (median 3.6%, range 0%–33%; p<0.01). Family member was more often present for older infants and those with chronic respiratory failure. Fewer TIs were performed by residents when family was present (FP 10% vs no FP 18%, p=0.041). Among TIs with family presence versus without family presence, the first attempt success rate was 55% vs 49% (p=0.062), success within two attempts was 74% vs 66% (p=0.014), adverse TIAEs were 18% vs 20% (p=0.62) and severe oxygen desaturation was 49% vs 52%, (p=0.40). In multivariate analyses, there was no independent association between family presence and intubation success, adverse TIAEs or severe oxygen desaturation.

Conclusion

Family are present in less than 10% of TIs, with variation across NICUs. Even after controlling for important patient, provider and site factors, there were no significant associations between family presence and intubation success, adverse TIAEs or severe oxygen desaturation.
Neurodevelopmental outcomes following neonatal late-onset sepsis and blood culture-negative conditions
Authors: Mukhopadhyay Sagori , Puopolo Karen M , Hansen Nellie I , Lorch Scott A , DeMauro Sara B , Greenberg Rachel G , Cotten C Michael , Sanchez Pablo J , Bell Edward F , Eichenwald Eric C , Stoll Barbara J
Published: January 2021

Objective

Determine risk of death or neurodevelopmental impairment (NDI) in infants with late-onset sepsis (LOS) versus late-onset, antibiotic-treated, blood culture-negative conditions (LOCNC).

Design

Retrospective cohort study.

Setting

24 neonatal centres.

Patients

Infants born 1/1/2006–31/12/2014, at 22–26 weeks gestation, with birth weight 401–1000 g and surviving >7 days were included. Infants with early-onset sepsis, necrotising enterocolitis, intestinal perforation or both LOS and LOCNC were excluded.

Exposures

LOS and LOCNC were defined as antibiotic administration for ≥5 days with and without a positive blood/cerebrospinal fluid culture, respectively. Infants with these diagnoses were also compared with infants with neither condition.

Outcomes

Death or NDI was assessed at 18–26 months corrected age follow-up. Modified Poisson regression models were used to estimate relative risks adjusting for covariates occurring ≤7 days of age.

Results

Of 7354 eligible infants, 3940 met inclusion criteria: 786 (20%) with LOS, 1601 (41%) with LOCNC and 1553 (39%) with neither. Infants with LOS had higher adjusted relative risk (95% CI) for death/NDI (1.14 (1.05 to 1.25)) and death before follow-up (1.71 (1.44 to 2.03)) than those with LOCNC. Among survivors, risk for NDI did not differ between the two groups (0.99 (0.86 to 1.13)) but was higher for LOCNC infants (1.17 (1.04 to 1.31)) compared with unaffected infants.

Conclusions

Infants with LOS had higher risk of death, but not NDI, compared with infants with LOCNC. Surviving infants with LOCNC had higher risk of NDI compared with unaffected infants. Improving outcomes for infants with LOCNC requires study of the underlying conditions and the potential impact of antibiotic exposure.
NeoBeat offers rapid newborn heart rate assessment
Authors: Bush Jessica Brittany , Cooley Victoria , Perlman Jeffrey , Chang Catherine
Published: January 2021

Background

Heart rate (HR) is used to guide interventions during delivery room (DR) neonatal resuscitation. Dry electrode ECG (NeoBeat) may detect HR more rapidly than pulse oximetry (PO) and portable ECG, but real-time comparisons of these devices are lacking.

Design/methods

PO, ECG and NeoBeat were placed sequentially on newborns in the DR. Time for device placement and time to accurate HR acquisition were noted.

Results

DR resuscitations of 28 preterm/term infants were observed. The NeoBeat was placed faster (ie, 3 s) than PO (20 s, p=<0.0001) and ECG (16 s, p=<0.0001). Total time from initiation of device placement to HR acquisition was fastest with NeoBeat (13 s) versus ECG (42 s, p<0.0001) and PO (105 s, p<0.0001) (duration values=median).

Conclusions

These observations in a small cohort of relatively well neonates demonstrate that the NeoBeat is significantly faster to place and consistently acquires HR faster than PO and ECG.
Effect of tocilizumab on clinical outcomes at 15 days in patients with severe or critical coronavirus disease 2019: randomised controlled trial
Authors: Veiga Viviane C , Prats João A G G , Farias Danielle L C , Rosa Regis G , Dourado Leticia K , Zampieri Fernando G , Machado Flávia R , Lopes Renato D , Berwanger Otavio , Azevedo Luciano C P , Avezum Álvaro , Lisboa Thiago C , Rojas Salomón S O , Coelho Juliana C , Leite Rodrigo T , Carvalho Júlio C , Andrade Luis E C , Sandes Alex F , Pintão Maria C T , Castro Claudio G , Santos Sueli V , de Almeida Thiago M L , Costa André N , Gebara Otávio C E , de Freitas Flávio G Rezende , Pacheco Eduardo S , Machado David J B , Martin Josiane , Conceição Fábio G , Siqueira Suellen R R , Damiani Lucas P , Ishihara Luciana M , Schneider Daniel , de Souza Denise , Cavalcanti Alexandre B , Scheinberg Phillip
Published: January 2021

Objective

To determine whether tocilizumab improves clinical outcomes for patients with severe or critical coronavirus disease 2019 (covid-19).

Design

Randomised, open label trial.

Setting

Nine hospitals in Brazil, 8 May to 17 July 2020.

Participants

Adults with confirmed covid-19 who were receiving supplemental oxygen or mechanical ventilation and had abnormal levels of at least two serum biomarkers (C reactive protein, D dimer, lactate dehydrogenase, or ferritin). The data monitoring committee recommended stopping the trial early, after 129 patients had been enrolled, because of an increased number of deaths at 15 days in the tocilizumab group.

Interventions

Tocilizumab (single intravenous infusion of 8 mg/kg) plus standard care (n=65) versus standard care alone (n=64).

Main outcome measure

The primary outcome, clinical status measured at 15 days using a seven level ordinal scale, was analysed as a composite of death or mechanical ventilation because the assumption of odds proportionality was not met.

Results

A total of 129 patients were enrolled (mean age 57 (SD 14) years; 68% men) and all completed follow-up. All patients in the tocilizumab group and two in the standard care group received tocilizumab. 18 of 65 (28%) patients in the tocilizumab group and 13 of 64 (20%) in the standard care group were receiving mechanical ventilation or died at day 15 (odds ratio 1.54, 95% confidence interval 0.66 to 3.66; P=0.32). Death at 15 days occurred in 11 (17%) patients in the tocilizumab group compared with 2 (3%) in the standard care group (odds ratio 6.42, 95% confidence interval 1.59 to 43.2). Adverse events were reported in 29 of 67 (43%) patients who received tocilizumab and 21 of 62 (34%) who did not receive tocilizumab.

Conclusions

In patients with severe or critical covid-19, tocilizumab plus standard care was not superior to standard care alone in improving clinical outcomes at 15 days, and it might increase mortality.

Trial registration

ClinicalTrials.gov
NCT04403685
.
Estimating the burden of cardiovascular risk in community dwellers over 40 years old in South Africa, Kenya, Burkina Faso and Ghana
Authors: Wagner Ryan G , Crowther Nigel J , Micklesfield Lisa K , Boua Palwende Romauld , Nonterah Engelbert A , Mashinya Felistas , Mohamed Shukri F , Asiki Gershim , Tollman Stephen , Ramsay Michèle , Davies Justine I
Published: January 2021

Introduction

Cardiovascular disease (CVD) risk factors are increasing in sub-Saharan Africa. The impact of these risk factors on future CVD outcomes and burden is poorly understood. We examined the magnitude of modifiable risk factors, estimated future CVD risk and compared results between three commonly used 10-year CVD risk factor algorithms and their variants in four African countries.

Methods

In the Africa-Wits-INDEPTH partnership for Genomic studies (the AWI-Gen Study), 10 349 randomly sampled individuals aged 40–60 years from six sites participated in a survey, with blood pressure, blood glucose and lipid levels measured. Using these data, 10-year CVD risk estimates using Framingham, Globorisk and WHO-CVD and their office-based variants were generated. Differences in future CVD risk and results by algorithm are described using kappa and coefficients to examine agreement and correlations, respectively.

Results

The 10-year CVD risk across all participants in all sites varied from 2.6% (95% CI: 1.6% to 4.1%) using the WHO-CVD lab algorithm to 6.5% (95% CI: 3.7% to 11.4%) using the Framingham office algorithm, with substantial differences in risk between sites. The highest risk was in South African settings (in urban Soweto: 8.9% (IQR: 5.3–15.3)). Agreement between algorithms was low to moderate (kappa from 0.03 to 0.55) and correlations ranged between 0.28 and 0.70. Depending on the algorithm used, those at high risk (defined as risk of 10-year CVD event >20%) who were under treatment for a modifiable risk factor ranged from 19.2% to 33.9%, with substantial variation by both sex and site.

Conclusion

The African sites in this study are at different stages of an ongoing epidemiological transition as evidenced by both risk factor levels and estimated 10-year CVD risk. There is low correlation and disparate levels of population risk, predicted by different risk algorithms, within sites. Validating existing risk algorithms or designing context-specific 10-year CVD risk algorithms is essential for accurately defining population risk and targeting national policies and individual CVD treatment on the African continent.
Learning from changes concurrent with implementing a complex and dynamic intervention to improve urban maternal and perinatal health in Dar es Salaam, Tanzania, 2011-2019
Authors: Sequeira Dmello Brenda , Sellah Ziada , Magembe Grace , Housseine Natasha , Maaløe Nanna , van den Akker Thomas , Meyrowitsch Dan W , Mushi Timothy , Masweko Mangalu , Jidayi Dorcas , van Roosmalen Jos , Kidanto Hussein L
Published: January 2021

Introduction

Rapid urbanisation in Dar es Salaam, the main commercial hub in Tanzania, has resulted in congested health facilities, poor quality care, and unacceptably high facility-based maternal and perinatal mortality. Using a participatory approach, the Dar es Salaam regional government in partnership with a non-governmental organisation, Comprehensive Community Based Rehabilitation in Tanzania, implemented a complex, dynamic intervention to improve the quality of care and survival during pregnancy and childbirth. The intervention was rolled out in 22 public health facilities, accounting for 60% of the city’s facility births.

Methods

Multiple intervention components addressed gaps across the maternal and perinatal continuum of care (training, infrastructure, routine data quality strengthening and utilisation). Quality of care was measured with the Standards-Based Management and Recognition tool. Temporal trends from 2011 to 2019 in routinely collected, high-quality data on facility utilisation and facility-based maternal and perinatal mortality were analysed.

Results

Significant improvements were observed in the 22 health facilities: 41% decongestion in the three most overcrowded hospitals and comparable increase in use of lower level facilities, sixfold increase in quality of care, and overall reductions in facility-based maternal mortality ratio (47%) and stillbirth rate (19%).

Conclusions

This collaborative, multipartner, multilevel real-world implementation, led by the local government, leveraged structures in place to strengthen the urban health system and was sustained through a decade. As depicted in the theory of change, it is highly plausible that this complex intervention with the mediators and confounders contributed to improved distribution of workload, quality of maternity care and survival at birth.
Navigating inequities: a roadmap out of the pandemic
Authors: Ismail Shainoor J , Tunis Matthew C , Zhao Linlu , Quach Caroline
Published: January 2021

The COVID-19 pandemic has exposed social inequities that rival biological inequities in disease exposure and severity. Merely identifying some inequities without understanding all of them can lead to harmful misrepresentations and deepening disparities. Applying an ‘equity lens’ to bring inequities into focus without a vision to extinguish them is short-sighted. Interventions to address inequities should be as diverse as the pluralistic populations experiencing them. We present the first validated equity framework applied to COVID-19 that sheds light on the full spectrum of health inequities, navigates their sources and intersections, and directs ethically just interventions. The Equity Matrix also provides a comprehensive map to guide surveillance and research in order to unveil epidemiological uncertainties of novel diseases like COVID-19, recognising that inequities may exist where evidence is currently insufficient. Successfully applied to vaccines in recent years, this tool has resulted in the development of clear, timely and transparent guidance with positive stakeholder feedback on its comprehensiveness, relevance and appropriateness. Informed by evidence and experience from other vaccine-preventable diseases, this Equity Matrix could be valuable to countries across the social gradient to slow the spread of SARS-CoV-2 by abating the spread of inequities. In the race to SARS-CoV-2 vaccines, this urgently needed roadmap can effectively and efficiently steer global leadership towards equitable allocation with diverse strategies for diverse inequities. Such a roadmap has been absent from discussions on managing the COVID-19 pandemic, and is critical for our passage out of it.
Respectful maternity care delivered within health facilities in Bangladesh, Ghana and Tanzania: a cross-sectional assessment preceding a quality improvement intervention
Authors: Manu Alexander , Zaka Nabila , Bianchessi Christina , Maswanya Edward , Williams John , Arifeen Shams E
Published: January 2021

Objective

To assess respectful maternity care (RMC) in health facilities.

Design

Cross-sectional study.

Setting

Forty-three (43) facilities across 15 districts in Bangladesh, 16 in Ghana and 12 in Tanzania.

Participants

Facility managers; 325 providers (nurses/midwives/doctors)—Bangladesh (158), Ghana (86) and Tanzania (81); and 849 recently delivered women—Bangladesh (295), Ghana (381) and Tanzania (173)—were interviewed. Observation of 641 client–provider interactions was conducted—Bangladesh (387), Ghana (134) and Tanzania (120).

Assessment

Trained social scientists and clinicians assessed infrastructure, policies, provision and women’s experiences of RMC (emotional support, respectful care and communication).

Primary outcome

RMC provided and/or experienced by women.

Results

Three (20%) facilities in Bangladesh, four (25%) in Ghana and three (25%) in Tanzania had no maternity clients’ toilets and one-half had no handwashing facilities. Policies for RMC such as identification of client abuses were available: 81% (Ghana), 73% (Bangladesh) and 50% (Tanzania), but response was poor. Ninety-four (60%) Bangladeshi, 26 (30%) Ghanaian and 20 (25%) Tanzanian providers were not RMC trained. They provided emotional support during labour care to 107 (80%) women in Ghana, 95 (79%) in Tanzania and 188 (48.5%) in Bangladesh, and were often courteous with them—236 (61%) in Bangladesh, 119 (89%) in Ghana and 108 (90%) in Tanzania. Due to structural challenges, 169 (44%) women in Bangladesh, 49 (36%) in Ghana and 77 (64%) in Tanzania had no privacy during labour. Care was refused to 13 (11%) Tanzanian and 2 Bangladeshi women who could not pay illegal charges. Twenty-five (7%) women in Ghana, nine (6%) in Bangladesh and eight (5%) in Tanzania were verbally abused during care. Providers in all countries highly rated their care provision (95%–100%), and 287 (97%) of Bangladeshi women, 368 (97%) Ghanaians and 152 (88%) Tanzanians reported ‘satisfaction’ with the care they received. However, based on their facility experiences, significant (p<0.001) percentages—20% (Ghana) to 57% (Bangladesh)—will not return to the same facilities for future childbirth.

Conclusions

Facilities in Bangladesh, Ghana and Tanzania have foundational systems that facilitate RMC. Structural inadequacies and policy gaps pose challenges. Many women were, however, unwilling to return to the same facilities for future deliveries although they (and providers) highly rated these facilities.
Hypertension knowledge and treatment initiation, adherence, and discontinuation among adults in Chennai, India: a cross-sectional study
Authors: Sudharsanan Nikkil , Ali Mohammed K , McConnell Margaret
Published: January 2021

Introduction

A substantial share of urban Indians with diagnosed hypertension do not take regular treatment, potentially due to poor knowledge of hypertension consequences and treatment options. We describe hypertension knowledge and beliefs, treatment patterns, and reported reasons for treatment non-use among adults with diagnosed hypertension in Chennai, India.

Methods

We collected data on 833 adults ages 30+ with physician diagnosed hypertension using a door-to-door household survey within randomly selected wards of Chennai. We described the proportion of individuals who were not taking daily medications and their reported reasons for not doing so. Next, we described individuals’ knowledge of hypertension consequences and how to control blood pressure (BP) and assessed the association between knowledge and daily treatment use.

Results

Over one quarter (28% (95% CI 25% to 31%)) of diagnosed individuals reported not taking daily treatment. The largest proportion (18% (95% CI 16% to 21%)) were individuals who had discontinued prior treatment use. The primary reason individuals reported for non-daily use was that their BP had returned to normal. Just 23% (95% CI 20% to 26%) of individuals listed BP medications as the most effective way to reduce BP; however, these individuals were 11% points (95% CI 4% to 19%) more likely to take daily medications. Conversely, 43% (95% CI 40% to 47%) of individuals believed that BP medications should be stopped from time to time and these individuals were 15% points (95% CI −0.21 to –0.09) less likely to take daily treatment. While awareness of the consequences of hypertension was poor, we found no evidence that it was associated with taking daily medications.

Conclusions

There were large gaps in consistency of BP medication use which were strongly associated with knowledge about BP medications. Further research is needed to identify whether addressing beliefs can improve daily treatment use among individuals with diagnosed hypertension.
COVID-19 among the inhabitants of the slums in the city of Buenos Aires: a population-based study
Authors: Macchia Alejandro , Ferrante Daniel , Battistella Gabriel , Mariani Javier , González Bernaldo de Quirós Fernán
Published: January 2021

Objective

To summarise the unfolding of the COVID-19 epidemic among slum dwellers and different social strata in the city of Buenos Aires during the first 20 weeks after the first reported case.

Design

Observational study using a time-series analysis. Natural experiment in a big city.

Setting

Population of the city of Buenos Aires and the integrated health reporting system records of positive RT-PCR for COVID-19 tests.

Participants

Records from the Argentine Integrated Health Reporting System for all persons with suspected and RT-PCR-confirmed diagnosis of COVID-19 between 31 January and 14 July 2020.

Outcomes

To estimate the effects of living in a slum on the standardised incidence rate of COVID-19, corrected Poisson regression models were used. Additionally, the impact of socioeconomic status was performed using an ecological analysis at the community level.

Results

A total of 114 052 people were tested for symptoms related with COVID-19. Of these, 39 039 (34.2%) were RT-PCR positive. The incidence rates for COVID-19 towards the end of the 20th week were 160 (155 to 165) per 100 000 people among the inhabitants who did not reside in the slums (n=2 841 997) and 708 (674 to 642) among slums dwellers (n=233 749). Compared with the better-off socioeconomic quintile (1.00), there was a linear gradient on incidence rates: 1.36 (1.25 to 1.46), 1.61 (1.49 to 1.74), 1.86 (1.72 to 2.01), 2.94 (2.74 to 3.16) from Q2 to Q5, respectively. Slum dwellers were associated with an incidence rate of 14.3 (13.4 to 15.4).

Conclusions

The distribution of the epidemic is socially conditioned. Slum dwellers are at a much higher risk than the rest of the community. Slum dwellers should not be considered just another risk category but an entirely different reality that requires policies tailored to their needs.
Frontline healthcare workers’ experiences with personal protective equipment during the COVID-19 pandemic in the UK: a rapid qualitative appraisal
Authors: Hoernke Katarina , Djellouli Nehla , Andrews Lily , Lewis-Jackson Sasha , Manby Louisa , Martin Sam , Vanderslott Samantha , Vindrola-Padros Cecilia
Published: January 2021

Objectives

To report frontline healthcare workers’ (HCWs) experiences with personal protective equipment (PPE) during the COVID-19 pandemic in the UK. To understand HCWs’ fears and concerns surrounding PPE, their experiences following its guidance and how these affected their perceived ability to deliver care during the COVID-19 pandemic.

Design

A rapid qualitative appraisal study combining three sources of data: semistructured in-depth telephone interviews with frontline HCWs (n=46), media reports (n=39 newspaper articles and 145 000 social media posts) and government PPE policies (n=25).

Participants

Interview participants were HCWs purposively sampled from critical care, emergency and respiratory departments as well as redeployed HCWs from primary, secondary and tertiary care centres across the UK.

Results

A major concern was running out of PPE, putting HCWs and patients at risk of infection. Following national level guidance was often not feasible when there were shortages, leading to reuse and improvisation of PPE. Frequently changing guidelines generated confusion and distrust. PPE was reserved for high-risk secondary care settings and this translated into HCWs outside these settings feeling inadequately protected. Participants were concerned about differential access to adequate PPE, particularly for women and Black, Asian and Minority Ethnic HCWs. Participants continued delivering care despite the physical discomfort, practical problems and communication barriers associated with PPE use.

Conclusion

This study found that frontline HCWs persisted in caring for their patients despite multiple challenges including inappropriate provision of PPE, inadequate training and inconsistent guidance. In order to effectively care for patients during the COVID-19 pandemic, frontline HCWs need appropriate provision of PPE, training in its use as well as comprehensive and consistent guidance. These needs must be addressed in order to protect the health and well-being of the most valuable healthcare resource in the COVID-19 pandemic: our HCWs.
192 Primary care streaming in emergency departments- contexts and mechanisms associated with perceived effectiveness outcomes: a realist evaluation
Authors: Edwards Michelle , Edwards Michelle , Cooper Alison , Davies Freya , Stevens Andrew Carson , Hughes Thomas , Anderson Pippa , Edwards Adrian
Published: January 2021

Aims/Objectives/Background

Recent policy has encouraged emergency departments (EDs) to deploy nurses to stream patients from the ED front door to GPs working in a separate GP service operating within or alongside an ED. We aim to describe mechanisms relating to effectiveness of streaming in different primary care service models identified in emergency departments. We explored whether patients were appropriately streamed to emergency care, primary care, other hospital services or community primary care services; patient flow (including effects on waiting times and length of stay in the emergency department); and safe streaming outcomes. We sought suggestions for quality improvements relating to streaming

Methods/Design

A realist evaluation methodology was used to explore perceived streaming effectiveness. We visited 13 emergency departments (purposively selected across England & Wales; 8 streamed primary care patients to a primary care clinician) and carried out observations of triage/streaming and patient flow and interviews with key members of staff (consultants, GPs, nurses).Field notes from observations and audio-recorded interviews were transcribed verbatim and were analysed by creating context, mechanism and outcome configurations to refine and develop theories relating to streaming effectiveness.

Results/Conclusions

We identified five contexts (nurses’ knowledge and experience, streaming guidance, teamwork and communication, operational management and strategic management) that facilitated mechanisms that influenced the effectiveness of streaming (streaming to an appropriate service, patient flow, delivering safe care). We integrated a middle range psychological theory with our findings to recommend a focus for training nurses in streaming and service improvements. We recommend a collaborative approach to service development, guidance and training (including input from emergency department clinicians, primary care clinicians) and a range of training strategies that are suitable for less experienced junior nurses and more experienced senior nurses and nurse practitioners.
133 Palliative care in the emergency department – a scoping review
Authors: Barham Ffion , King Samuel , Hawksley Jessica
Published: January 2021

Aims/Objectives/Background

The World Health Organisation (WHO) estimate that 40 million people a year globally require palliative care, and this need is expanding. The needs of palliative patients are not optimally met in the Emergency Department (ED), in part due to crowding and exit-block. This is further compounded in an ageing population with increasingly complex chronic diseases. Palliative care in the ED is one of the top five research priorities from the Royal College of Emergency Medicine and is often an underestimated part of the ED workload. These patients need to be recognised early and their care considered holistically. This project aims to define the scale of palliative care demand on EDs, describe the care these patients receive, and consider whether we provide truly palliative care for these patients.

Methods/Design

Data were collected from electronic and written ED records for all patients meeting the inclusion criteria who attended over a 14-day period. Patient records were identified by manually reviewing all electronic records and identifying coding that corresponded to the WHO list of palliative conditions. Demographic, attendance and clinical data were anonymised and analysed descriptively.

Results/Conclusions

Over the study period, 5% (208/4126) of all ED attendances presented with palliative conditions. This figure is likely to be an underestimate, as electronic systems in this department are not linked to e-notes and written records accompany the patient’s hospital journey. Average time in department was 461 minutes (IQR 274.5 – 621.5). 77% (93/121) of these patients were admitted to hospital, with 96% of those admitted to the Medical Assessment Unit. Only 7% (8/121) left the department with a completed Treatment Escalation Plan (2 of these were pre-existing). This scoping data shows that a small but significant proportion of ED patients have incurable conditions and it may be worth targeting quality, not quantity, of life.
251 The frailty in major trauma study (FRAIL-T): feasibility of nurse lead frailty assessment in elderly trauma and the impact on outcomes
Authors: Jarman Heather , Crouch Robert , Baxter Mark , Dillane Bebhinn , Wang Chao , Cole Elaine
Published: January 2021

Aims/Objectives/Background

Frailty screening for major trauma patients has recently become part of the best practice commissioning tariff within NHS England, yet there is no consensus as to who should carry out this assessment or which tool best identifies frailty in the Emergency Department (ED). As the trauma population ages there is a need for accurate early identification of frailty in the ED to underpin frailty specific major trauma pathways. The primary aim of this study was to determine the feasibility and accuracy of ED nurse-led frailty assessment in patients ≥ 65 years admitted to Major Trauma Centres (MTCs).

Methods/Design

A prospective observational study was conducted across five UK MTCs, enrolling 370 participants over nine months. Eligible patients were aged 65 or more requiring trauma team activation. Frailty was assessed in the ED using three different tools: Trauma Specific Frailty Index (TSFI); Clinical Frailty Scale (CFS); PRISMA-7. ED nurse frailty assessment was correlated with Geriatrician assessment within 72 hours of admission using Spearman’s correlation coefficient and kappa statistic for measuring the interrater agreement.

Results/Conclusions

Complete frailty assessments were calculated for CFS in 99.4% of patients, PRISMA7 in 95.9% and TSFI in 37.58%. Rates of frailty differed between tools: CFS 32%, PRISMA7 57% and TSFI 92% whilst Geriatrician determined frailty was 37%. In all tools frail patients were older (p<0.001) and falls <2 m were the leading mechanism of injury (p<0.05). CFS showed both strong correlation (rs 0.639,p<0.001) and substantial agreement (kappa 0.637,p<0.001) with Geriatrician assessment within 72 hours of admission.

ED nurses can accurately assess older major trauma patients for frailty using the Clinical Frailty Scale. These findings support assessment of frailty in the ED in order to identify patients who would benefit from early frailty specific care.
191 A classification of primary care pathways in emergency departments: a multi-methods study comprising cross-sectional survey; site visits with observations; semi-structured and informal interviews
Authors: Edwards Michelle , Cooper Alison , Freya Davies , Carson-Stevens Andrew , Hughes Thomas , Siriwardena Niro , Snooks Helen , Edwards Adrian
Published: January 2021

Aims/Objectives/Background

We aim to describe and classify the predominant streaming pathways on arrival in Emergency Departments (EDs) in England and Wales and explain how they operate in different models of emergency department primary care services. Recent policy has encouraged a method whereby nurses stream from the emergency department front door to GPs working in a separate GP service operating within or alongside an ED. However, there is variation in methods of assessing and streaming patients on arrival at EDs. Conflated terminology causes difficulties in assessing relative performance, improving quality or gathering evidence about safety, clinical effectiveness. Our findings present a new classification of current streaming pathways from emergency departments to primary care services.

Methods/Design

We used a multi-stage method approach, including an online survey completed by 77 EDs across England & Wales, interviews with 21 clinical leads, and finally, undertaking case studies of 13 EDs. Qualitative data were triangulated and analysed using a framework analysis approach.

Results/Conclusions

The most common ED pathways to primary care services were: front door streaming before ED registration; streaming inside the ED; or without streaming but GPs selecting patients. Pathways were often adapted, to suit local circumstances such as department layout, patient demand levels, skill mix and interests of GPs practitioners and the accessibility of community primary care services. Pathways to redirect patients with non-urgent primary care problems to community primary care services were also used, with local variation in protocols based on staffing, patient demand and links to community primary care services. Local clinical leads and managers need to consider which pathway(s) may best suit their local context and needs. Consistency of terminology used to describe pathways between EDs and primary care services is necessary for multi-site evaluation, quality improvement and performance measurement.
332 The diagnostic role of shunt series radiographs (SSR) in children presenting to the children’s emergency department (CED) with suspected ventriculoperitoneal (VP) shunt failure
Authors: Griffiths Angharad , Okafor Ikechukwu , Beattie Thomas
Published: January 2021

Aims/Objectives/Background

VP shunts are used to drain CSF from the cranial vault because of a wide range of pathologies and, like any piece of hardware, can fail. Traditionally investigations include SSR and CT. This project examines the role of SSR in evaluating children with suspected VP shunt failure.

Primary outcome: Sensitivity and specificity of SSR in children presenting to the CED with concern for shunt failure.

Methods/Design

Conducted in a single centre, tertiary CED of the national Irish Neurosurgical(NS) referral centre (ED attendance:>50,000 patients/year). 100 sequential SSR requested by the CED were reviewed. Clinical information was extracted from electronic requests. Shunt failure was defined by the need for NS intervention(Revision).

Abstract 332 Figure 1Abstract 332 Figure 2

Results/Conclusions

Sensitivity and specificity is presented in figure 1 (two by two table).

100 radiographs performed in 84 children.

22% shunts revised (see flow diagram).

7 SSR’s were abnormal.

85% (n=6) shunts revised. [5 following abnormal CT].

Of the normal SSR’s; 16 had abnormal CT and revised.

85/100 received CT.

64 of 85 CT’s (75%) were normal.

□

6 of the 64 had focal shunt concern.

SSR’s shouldn’t be used in isolation. NPV&PPV, Sensitivity&Specificity is low.

SSR’s are beneficial where there’s concern over focal shunt problems (injury/pain/swelling) or following abnormal CT.

VP shunt failure is not well investigated with SSR alone.

SSR’s could be omitted where there is no focal shunt concern/after normal CT (without impacting clinical outcome) reducing radiation exposure and reduce impact on CED’s.

59 SSR’s could have been avoided without adverse clinical outcome.
Two-dimensional shear wave elastography predicts survival in advanced chronic liver disease
Authors: Trebicka Jonel , Gu Wenyi , de Ledinghen Victor , Aubé Christophe , Krag Aleksander , Praktiknjo Michael , Castera Laurent , Dumortier Jerome , Bauer David Josef Maria , Friedrich-Rust Mireen , Pol Stanislas , Grgurevic Ivica , Zheng Rongqin , Francque Sven , Gottfriedovà Halima , Mustapic Sanda , Sporea Ioan , Berzigotti Annalisa , Uschner Frank Erhard , Simbrunner Benedikt , Ronot Maxime , Cassinotto Christophe , Kjaergaard Maria , Andrade Filipe , Schulz Martin , Semmler Georg , Drinkovic Ida Tjesic , Chang Johannes , Brol Maximilian Joseph , Rautou Pierre Emmanuel , Vanwolleghem Thomas , Strassburg Christian P , Boursier Jerome , Ferstl Philip Georg , Rasmussen Ditlev Nytoft , Reiberger Thomas , Vilgrain Valerie , Guibal Aymeric , Guillaud Olivier , Zeuzem Stefan , Vassord Camille , Lu Xue , Vonghia Luisa , Senkerikova Renata , Popescu Alina , Margini Cristina , Wang Wenping , Thiele Maja , Jansen Chrisitan
Published: January 2021

Objective

Liver stiffness measurement (LSM) is a tool used to screen for significant fibrosis and portal hypertension. The aim of this retrospective multicentre study was to develop an easy tool using LSM for clinical outcomes in advanced chronic liver disease (ACLD) patients.

Design

This international multicentre cohort study included a derivation ACLD patient cohort with valid two-dimensional shear wave elastography (2D-SWE) results. Clinical and laboratory parameters at baseline and during follow-up were recorded. LSM by transient elastography (TE) was also recorded if available. The primary outcome was overall mortality. The secondary outcome was the development of first/further decompensation.

Results

After screening 2148 patients (16 centres), 1827 patients (55 years, 62.4% men) were included in the 2D-SWE cohort, with median liver SWE (L-SWE) 11.8 kPa and a model for end stage liver disease (MELD) score of 8. Combination of MELD score and L-SWE predict independently of mortality (AUC 0.8). L-SWE cut-off at ≥20 kPa combined with MELD ≥10 could stratify the risk of mortality and first/further decompensation in ACLD patients. The 2-year mortality and decompensation rates were 36.9% and 61.8%, respectively, in the 305 (18.3%) high-risk patients (with L-SWE ≥20 kPa and MELD ≥10), while in the 944 (56.6%) low-risk patients, these were 1.1% and 3.5%, respectively. Importantly, this M10LS20 algorithm was validated by TE-based LSM and in an additional cohort of 119 patients with valid point shear SWE-LSM.

Conclusion

The M10LS20 algorithm allows risk stratification of patients with ACLD. Patients with L-SWE ≥20 kPa and MELD ≥10 should be followed closely and receive intensified care, while patients with low risk may be managed at longer intervals.
Large granular lymphocyte leukaemia study at the University Hospital of Donostia
Authors: Uranga Alasne , González Carmen , Furundarena J R , Robado Naiara , Rey Mercedes , Aragon Larraitz , Urreta Iratxe , Aranbarri Ane , De Juan Maria Dolores , Araiz Maria
Published: January 2021

Introduction

Large granular lymphocyte (LGL) leukaemia is considered a mature T-cell or natural killer (NK) cell neoplasm, characterised by a clonal proliferation of LGL.

Aims

To analyse the characteristics and to establish (if possible) the prognostic parameters of these patients diagnosed in a single centre: University Hospital of Donostia.

Methods

We retrospectively studied data about 308 patients with LGL leukaemia diagnosed in our centre.

Results

The frequency of T-LGL leukaemia and chronic lymphoproliferative disorder of NK cells was 89% and 6.8% respectively, and no aggressive NK-LGL leukaemia was seen in our population. The median age at diagnosis was 65.7 years and male-to-female ratio was 1.08. 59% of our patients were asymptomatic at the time of diagnosis. Most patients presented lymphocytosis and 63.6% more than 20% LGLs in the peripheral blood count, but it has to be taken into account that these results may be influenced by the selection bias of our study, as we recognised these patients as ‘alarms of the laboratory analysers’. Neutropenia was the most common cytopenia, and autoimmune disorders were described in 16.5% of the patients. Only 12 patients (3.9%) required treatment, a much lower percentage that the one reported in the literature, and this is consistent with the fact that patients were less symptomatic than in other series, as we expected. The 5-year and 15-year overall survival was 92% and 87%, respectively.

Conclusions

Our patients may represent the even more benign end of the spectrum of clonal T LGL and NK proliferations.
Trial to evaluate the immunogenicity and safety of a melanoma helper peptide vaccine plus incomplete Freund’s adjuvant, cyclophosphamide, and polyICLC (Mel63)
Authors: Slingluff, Jr. Craig L , Petroni Gina R , Chianese-Bullock Kimberly A , Wages Nolan A , Olson Walter C , Smith Kelly T , Haden Kathleen , Dengel Lynn T , Dickinson Anna , Reed Caroline , Gaughan Elizabeth M , Grosh William W , Kaur Varinder , Varhegyi Nikole , Smolkin Mark , Galeassi Nadejda V , Deacon Donna , Hall Emily H
Published: January 2021

Background

Peptide vaccines designed to stimulate melanoma-reactive CD4+ T cells can induce T cell and antibody (Ab) responses, associated with enhanced overall survival. We hypothesized that adding toll-like receptor 3 agonist polyICLC to an incomplete Freund’s adjuvant (IFA) would be safe and would support strong, durable CD4+ T cell and Ab responses. We also hypothesized that oral low-dose metronomic cyclophosphamide (mCy) would be safe, would reduce circulating regulatory T cells (T-regs) and would further enhance immunogenicity.

Participants and methods

An adaptive design based on toxicity and durable CD4+ T cell immune response (dRsp) was used to assign participants with resected stage IIA-IV melanoma to one of four study regimens. The regimens included a vaccine comprising six melanoma peptides restricted by Class II MHC (6MHP) in an emulsion with IFA alone (Arm A), with IFA plus systemic mCy (Arm B), with IFA+ local polyICLC (Arm C), or with IFA+ polyICLC+ mCy (Arm D). Toxicities were recorded (CTCAE V.4.03). T cell responses were measured by interferon γ ELIspot assay ex vivo. Serum Ab responses to 6MHP were measured by ELISA. Circulating T-regs were assessed by flow cytometry.

Results

Forty-eight eligible participants were enrolled and treated. Early data on safety and dRsp favored enrollment on arm D. Total enrollment on Arms A-D were 3, 7, 6, and 32, respectively. Treatment-related dose-limiting toxicities (DLTs) were observed in 1/7 (14%) participants on arm B and 2/32 (6%) on arm D. None exceeded the 25% DLT threshold for early closure to enrollment for any arm. Strong durable T cell responses to 6MHP were detected ex vivo in 0%, 29%, 67%, and 47% of participants on arms A-D, respectively. IgG Ab responses were greatest for arms C and D. Circulating T-regs frequencies were not altered by mCy.

Conclusions

6MHP vaccines administered with IFA, polyICLC, and mCy were well tolerated. The dRsp rate for arm D of 47% (90% CI 32 to 63) exceeded the 18% (90% CI 11 to 26) rate previously observed with 6MHP in IFA alone. Vaccination with IFA+ polyICLC (arm C) also showed promise for enhancing T cell and Ab responses.