COVID-19 wastewater based epidemiology: long-term monitoring of 10 WWTP in France reveals the importance of the sampling context.

SARS-CoV-2 wastewater-based epidemiology (WBE) has been advanced as a relevant indicator of distribution of COVID-19 in communities, supporting classical testing and tracing epidemiological approaches. An extensive sampling campaign, including ten municipal wastewater treatment plants, has been conducted in different cities of France over a 20-week period, encompassing the second peak of COVID-19 outbreak in France. A well-recognised ultrafiltration - RNA extraction - RT-qPCR protocol was used and qualified, showing 5.5 +/- 0.5% recovery yield on heat-inactivated SARS-CoV-2. Importantly the whole, solid and liquid, fraction of wastewater was used for virus concentration in this study. Campaign results showed medium- to strong- correlation between SARS-CoV-2 WBE data and COVID-19 prevalence. To go further, statistical relationships between WWTP inlet flow rate and rainfall were studied and taken into account for each WWTP in order to calculate contextualized SARS-CoV-2 loads. This metric presented improved correlation strengths with COVID-19 prevalence for WWTP particularly submitted and sensitive to rain. Such findings highlighted that SARS-CoV-2 WBE data ultimately require to be contextualized for relevant interpretation.

Obstetric outcomes: A comparison of teenagers and adults in the Cape Coast metropolis, Ghana.

Prevalence of teenage pregnancy is very high in the Central Region of Ghana. Although, pregnant teenagers are perceived to be high-risk mothers, very little has been documented about obstetric outcomes among these mothers in Ghana. This case-control observational study compared maternal and perinatal outcomes between teen and adult mothers in the Cape Coast metropolis. Data on maternal and perinatal outcome variables were collected with a data extraction form from maternal history record and delivery record books of 505 teens and 501 adults. Maternal and perinatal outcomes for the two groups were compared using chi-square or Fisher's exact test and odds ratios at 95% confidence interval. Prenatal services utilization was high among the participants. Prevalence of adverse maternal and perinatal outcomes were low, which is comparable between the two groups. Spontaneous vaginal delivery was higher in the teens with the adults having higher predisposition for caesarean section. The adult mothers were more likely to have preterm delivery and babies with low minute 1 APGAR score, the teens on the other hand had babies with significantly lower birth weight. The favourable and comparable pregnancy outcomes among the participants could be attributed to the high prenatal service utilization. Improved access to prenatal service utilization would produce better pregnancy outcomes.

Microwave- and heat-based decontamination of N95 filtering facepiece respirators: a systematic review.

BACKGROUND: In pandemics such as COVID-19, shortages of personal protective equipment are common. One solution may be to decontaminate equipment such as facemasks for reuse. AIM: To collect and synthesize existing information on decontamination of N95 filtering facepiece respirators (FFRs) using microwave and heat-based treatments, with special attention to impacts on mask function (aerosol penetration, airflow resistance), fit, and physical traits. METHODS: A systematic review (PROSPERO CRD42020177036) of literature available from Medline, Embase, Global Health, and other sources was conducted. Records were screened independently by two reviewers, and data was extracted from studies that reported on effects of microwave- or heat-based decontamination on N95 FFR performance, fit, physical traits, and/or reductions in microbial load. FINDINGS: Thirteen studies were included that used dry/moist microwave irradiation, heat, or autoclaving. All treatment types reduced pathogen load by a log10 reduction factor of at least three when applied for sufficient duration (>30 s microwave, >60 min dry heat), with most studies assessing viral pathogens. Mask function (aerosol penetration <5% and airflow resistance <25 mmH2O) was preserved after all treatments except autoclaving. Fit was maintained for most N95 models, though all treatment types caused observable physical damage to at least one model. CONCLUSIONS: Microwave irradiation and heat may be safe and effective viral decontamination options for N95 FFR reuse during critical shortages. The evidence does not support autoclaving or high-heat (>90°C) approaches. Physical degradation may be an issue for certain mask models, and more real-world evidence on fit is needed.

Efficacy and safety of disinfectants for decontamination of N95 and SN95 filtering facepiece respirators: a systematic review.

BACKGROUND: Decontaminating and reusing filtering facepiece respirators (FFRs) for healthcare workers is a potential solution to address inadequate FFR supply during a global pandemic. AIM: The objective of this review was to synthesize existing data on the effectiveness and safety of using chemical disinfectants to decontaminate N95 FFRs. METHODS: A systematic review was conducted on disinfectants to decontaminate N95 FFRs using Embase, Medline, Global Health, Google Scholar, WHO feed, and MedRxiv. Two reviewers independently determined study eligibility and extracted predefined data fields. Original research reporting on N95 FFR function, decontamination, safety, or FFR fit following decontamination with a disinfectant was included. FINDINGS AND CONCLUSION: A single cycle of vaporized hydrogen peroxide (H2O2) successfully removes viral pathogens without affecting airflow resistance or fit, and maintains an initial filter penetration of <5%, with little change in FFR appearance. Residual hydrogen peroxide levels following decontamination were within safe limits. More than one decontamination cycle of vaporized H2O2 may be possible but further information is required on how multiple cycles would affect FFR fit in a real-world setting before the upper limit can be established. Although immersion in liquid H2O2 does not appear to adversely affect FFR function, there is no available data on its ability to remove infectious pathogens from FFRs or its impact on FFR fit. Sodium hypochlorite, ethanol, isopropyl alcohol, and ethylene oxide are not recommended due to safety concerns or negative effects on FFR function.

Decontamination interventions for the reuse of surgical mask personal protective equipment: a systematic review.

BACKGROUND: The high demand for personal protective equipment during the novel coronavirus outbreak has prompted the need to develop strategies to conserve supply. Little is known regarding decontamination interventions to allow for surgical mask reuse. AIM: To identify and synthesize data from original research evaluating interventions to decontaminate surgical masks for the purpose of reuse. METHODS: MEDLINE, Embase, CENTRAL, Global Health, the WHO COVID-19 database, Google Scholar, DisasterLit, preprint servers, and prominent journals from inception to April 8th, 2020, were searched for prospective original research on decontamination interventions for surgical masks. Citation screening was conducted independently in duplicate. Study characteristics, interventions, and outcomes were extracted from included studies by two independent reviewers. Outcomes of interest included impact of decontamination interventions on surgical mask performance and germicidal effects. FINDINGS: Seven studies met eligibility criteria: one evaluated the effects of heat and chemical interventions applied after mask use on mask performance, and six evaluated interventions applied prior to mask use to enhance antimicrobial properties and/or mask performance. Mask performance and germicidal effects were evaluated with heterogeneous test conditions. Safety outcomes were infrequently evaluated. Mask performance was best preserved with dry heat decontamination. Good germicidal effects were observed in salt-, N-halamine-, and nanoparticle-coated masks. CONCLUSION: There is limited evidence on the safety or efficacy of surgical mask decontamination. Given the heterogeneous methods used in studies to date, we are unable to draw conclusions on the most efficacious and safe intervention for decontaminating surgical masks.

Decontaminating N95 and SN95 masks with ultraviolet germicidal irradiation does not impair mask efficacy and safety.

Inadequate supply of filtering facepiece respirators (FFRs) for healthcare workers during a pandemic such as the novel coronavirus outbreak (SARS-CoV-2) is a serious public health issue. The aim of this study was to synthesize existing data on the effectiveness of ultraviolet germicidal irradiation (UVGI) for N95 FFR decontamination. A systematic review (PROSPERO CRD42020176156) was conducted on UVGI in N95 FFRs using Embase, Medline, Global Health, Google Scholar, WHO feed, and MedRxiv. Two reviewers independently determined eligibility and extracted predefined variables. Original research reporting on function, decontamination, or mask fit following UVGI were included. Thirteen studies were identified, comprising 54 UVGI intervention arms and 58 N95 models. FFRs consistently maintained certification standards following UVGI. Aerosol penetration averaged 1.19% (0.70-2.48%) and 1.14% (0.57-2.63%) for control and UVGI arms, respectively. Airflow resistance for the control arms averaged 9.79 mm H2O (7.97-11.70 mm H2O) vs 9.85 mm H2O (8.33-11.44 mm H2O) for UVGI arms. UVGI protocols employing a cumulative dose >20,000 J/m2 resulted in a 2-log reduction in viral load. A >3-log reduction was observed in seven UVGI arms using >40,000 J/m2. Impact of UVGI on fit was evaluated in two studies (16,200; 32,400 J/m2) and no evidence of compromise was found. Our findings suggest that further work in this area (or translation to a clinical setting) should use a cumulative UV-C dose of 40,000 J/m2 or greater, and confirm appropriate mask fit following decontamination.

Service users' experiences of receiving a diagnosis of borderline personality disorder: A systematic review.

There is ongoing controversy regarding the borderline personality disorder (BPD) diagnosis. Whilst the experiences of people living with BPD have been widely acknowledged, the process of receiving the diagnosis is poorly described. This systematic review aimed to synthesize the existing research exploring people's experiences of receiving a diagnosis of BPD, as well as examining what is considered best practice in the diagnostic delivery process. The findings from 12 qualitative studies were synthesized using thematic analysis, generating two overarching themes: negative and positive experiences of receiving a diagnosis of BPD. These themes were described using the following sub-themes: the communication of diagnosis and meaning made of it, validity around diagnosis and attitudes of others. Results indicate that there is a substantial difference between a well-delivered and poorly delivered diagnosis. The diagnostic delivery process is fundamental to how people understand and interpret the BPD diagnosis. The way in which the BPD diagnosis is shared with people can ultimately shape their views about hope for recovery and their subsequent engagement with services. © 2020 John Wiley & Sons, Ltd.

Determinants of diagnostic discordance for non-diabetic hyperglycaemia and Type 2 diabetes using paired glycated haemoglobin measurements in a large English primary care population: cross-sectional study.

AIM: To investigate factors influencing diagnostic discordance for non-diabetic hyperglycaemia and Type 2 diabetes. METHODS: Some 10 000 adults at increased risk of diabetes were screened with HbA1c and fasting plasma glucose (FPG). The 2208 participants with initial HbA1c ≥ 42 mmol/mol (≥ 6.0%) or FPG ≥ 6.1 mmol/l were retested after a median 40 days. We compared the first and second HbA1c results, and consequent diagnoses of non-diabetic hyperglycaemia and Type 2 diabetes, and investigated predictors of discordant diagnoses. RESULTS: Of 1463 participants with non-diabetic hyperglycaemia and 394 with Type 2 diabetes on first testing, 28.4% and 21.1% respectively had discordant diagnoses on repeated testing. Initial diagnosis of non-diabetic hyperglycaemia and/or impaired fasting glucose according to both HbA1c and FPG criteria, or to FPG only, made reclassification as Type 2 diabetes more likely than initial classification according to HbA1c alone. Initial diagnosis of Type 2 diabetes according to both HbA1c and FPG criteria made reclassification much less likely than initial classification according to HbA1c alone. Age, and anthropometric and biological measurements independently but inconsistently predicted discordant diagnoses and changes in HbA1c . CONCLUSIONS: Diagnosis of non-diabetic hyperglycaemia or Type 2 diabetes with a single measurement of HbA1c in a screening programme for entry to diabetes prevention trials is unreliable. Diagnosis of non-diabetic hyperglycaemia and Type 2 diabetes should be confirmed by repeat testing. FPG results could help prioritise retesting. These findings do not apply to people classified as normal on a single test, who were not retested.

Managing hyperglycaemia during antenatal steroid administration, labour and birth in pregnant women with diabetes.

Optimal glycaemic control before and during pregnancy improves both maternal and fetal outcomes. This article summarizes the recently published guidelines on the management of glycaemic control in pregnant women with diabetes on obstetric wards and delivery units produced by the Joint British Diabetes Societies for Inpatient Care and available in full at www.diabetes.org.uk/joint-british-diabetes-society and https://abcd.care/joint-british-diabetes-societies-jbds-inpatient-care-group. Hyperglycaemia following steroid administration can be managed by variable rate intravenous insulin infusion (VRIII) or continuous subcutaneous insulin infusion (CSII) in women who are willing and able to safely self-manage insulin dose adjustment. All women with diabetes should have capillary blood glucose (CBG) measured hourly once they are in established labour. Those who are found to be higher than 7 mmol/l on two consecutive occasions should be started on VRIII. If general anaesthesia is used, CBG should be monitored every 30 min in the theatre. Both the VRIII and CSII rate should be reduced by at least 50% once the placenta is delivered. The insulin dose needed after delivery in insulin-treated Type 2 and Type 1 diabetes is usually 25% less than the doses needed at the end of first trimester. Additional snacks may be needed after delivery especially if breastfeeding. Stop all anti-diabetes medications after delivery in gestational diabetes. Continue to monitor CBG before and 1 h after meals for up to 24 h after delivery to pick up any pre-existing diabetes or new-onset diabetes in pregnancy. Women with Type 2 diabetes on oral treatment can continue to take metformin after birth.

Young people's experiences of managing Type 1 diabetes at university: a national study of UK university students.

AIM: Little is known about the challenges of transitioning from school to university for young people with Type 1 diabetes. In a national survey, we investigated the impact of entering and attending university on diabetes self-care in students with Type 1 diabetes in all UK universities. METHODS: Some 1865 current UK university students aged 18-24 years with Type 1 diabetes, were invited to complete a structured questionnaire. The association between demographic variables and diabetes variables was assessed using logistic regression models. RESULTS: In total, 584 (31%) students from 64 hospitals and 37 university medical practices completed the questionnaire. Some 62% had maintained routine diabetes care with their home team, whereas 32% moved to the university provider. Since starting university, 63% reported harder diabetes management and 44% reported higher HbA1c levels than before university. At university, 52% had frequent hypoglycaemia, 9.6% reported one or more episodes of severe hypoglycaemia and 26% experienced diabetes-related hospital admissions. Female students and those who changed healthcare provider were approximately twice as likely to report poor glycaemic control, emergency hospital admissions and frequent hypoglycaemia. Females were more likely than males to report stress [odds ratio (OR) 4.78, 95% confidence interval (CI) 3.19-7.16], illness (OR 3.48, 95% CI 2.06-5.87) and weight management issues (OR 3.19, 95% CI 1.99-5.11) as barriers to self-care. Despite these difficulties, 91% of respondents never or rarely contacted university support services about their diabetes. CONCLUSION: The study quantifies the high level of risk experienced by students with Type 1 diabetes during the transition to university, in particular, female students and those moving to a new university healthcare provider.

Spatial assessment of soil contamination by heavy metals from informal electronic waste recycling in Agbogbloshie, Ghana.

OBJECTIVES: This study examined the spatial distribution and the extent of soil contamination by heavy metals resulting from primitive, unconventional informal electronic waste recycling in the Agbogbloshie e-waste processing site (AEPS) in Ghana. METHODS: A total of 132 samples were collected at 100 m intervals, with a handheld global position system used in taking the location data of the soil sample points. Observing all procedural and quality assurance measures, the samples were analyzed for barium (Ba), cadmium (Cd), cobalt (Co), chromium (Cr), copper (Cu), mercury (Hg), nickel (Ni), lead (Pb), and zinc (Zn), using X-ray fluorescence. Using environmental risk indices of contamination factor and degree of contamination (Cdeg), we analyzed the individual contribution of each heavy metal contamination and the overall Cdeg. We further used geostatistical techniques of spatial autocorrelation and variability to examine spatial distribution and extent of heavy metal contamination. RESULTS: Results from soil analysis showed that heavy metal concentrations were significantly higher than the Canadian Environmental Protection Agency and Dutch environmental standards. In an increasing order, Pb>Cd>Hg>Cu>Zn>Cr>Co>Ba>Ni contributed significantly to the overall Cdeg. Contamination was highest in the main working areas of burning and dismantling sites, indicating the influence of recycling activities. Geostatistical analysis also revealed that heavy metal contamination spreads beyond the main working areas to residential, recreational, farming, and commercial areas. CONCLUSIONS: Our results show that the studied heavy metals are ubiquitous within AEPS and the significantly high concentration of these metals reflect the contamination factor and Cdeg, indicating soil contamination in AEPS with the nine heavy metals studied.

Are mental health services getting better at responding to abuse, assault and neglect?

OBJECTIVE: To determine whether staff responses to abuse disclosures had improved since the introduction of a trauma policy and training programme. METHOD: The files of 250 clients attending four New Zealand mental health centres were audited. RESULTS: There was a significant improvement, compared to an audit prior to the introduction of the policy and training, in the proportion of abuse cases included in formulations, and, to a lesser extent, in treatment plans. There was no significant improvement in the proportion referred for relevant treatment, which remained at less than 25% across abuse categories. The proportion of neglect disclosures responded to was significantly lower than for abuse cases. Fifty percent of the files in which abuse/neglect was recorded noted whether the client had been asked about previous disclosure, and 22% noted whether the client thought there was any connection between the abuse/neglect and their current problems. Less than 1% of cases were reported to legal authorities. People diagnosed with a psychotic disorder were significantly less likely to be responded to appropriately. CONCLUSION: Future training may need to focus on responding well to neglect and people diagnosed with psychosis, on making treatment referrals, and on initiating discussions about reporting to authorities.

Childhood adversity and psychosis: generalised or specific effects?

BACKGROUND: This study examines relationships between childhood adversity and the presence of characteristic symptoms of schizophrenia. It was hypothesised that total adversity exposures would be significantly higher in individuals exhibiting these symptoms relative to patients without. Recent proposals that differential associations exist between specific psychotic symptoms and specific adversities was also tested, namely: sexual abuse and hallucinations, physical abuse and delusions, and fostering/adoption and delusions. METHOD: Data were collected through auditing 251 randomly selected medical records, drawn from adult patients in New Zealand community mental health centres. Information was extracted on presence and subtype of psychotic symptoms and exposure to ten types of childhood adversity, including five types of abuse and neglect. RESULTS: Adversity exposure was significantly higher in patients experiencing hallucinations in general, voice hearing, command hallucinations, visions, delusions in general, paranoid delusions and negative symptoms than in patients without these symptoms. There was no difference in adversity exposure in patients with and without tactile/olfactory hallucinations, grandiose delusions or thought disorder. Indication of a dose-response relationship was detected, in that total number of adversities significantly predicted total number of psychotic symptoms. Although fostering/adoption was associated with paranoid delusions, the hypothesised specificity between sexual abuse and hallucinations, and physical abuse and delusions, was not found. The two adversities showing the largest number of associations with psychotic symptoms were poverty and being fostered/adopted. CONCLUSIONS: The current data are consistent with a model of global and cumulative adversity, in which multiple exposures may intensify psychosis risk beyond the impact of single events. Implications for clinical intervention are discussed.

National survey of the management of Diabetic Ketoacidosis (DKA) in the UK in 2014.

AIM: To examine, in a national survey, the outcomes of adult patients presenting with DKA in 2014, mapped against accepted UK national guidance. METHODS: Data were collected in a standardized form covering clinical and biochemical outcomes, risk and discharge planning. The form was sent to all UK diabetes specialist teams (n = 220). Anonymized data were collected on five consecutive patients admitted with DKA between 1 May 2014 and 30 November 2014. RESULTS: A total of 283 forms were received (n = 281 patients) from 72 hospitals, of which 71.4% used the national guidelines. The results showed that 7.8% of cases occurred in existing inpatients, 6.1% of admissions were newly diagnosed diabetes and 33.7% of patients had had at least one episode of DKA in the preceding year. The median times to starting 0.9% sodium chloride and intravenous insulin were 41.5 and 60 min, respectively. The median time to resolution was 18.7 h and the median length of hospital stay was 2.6 days. Significant adverse biochemical outcomes occurred, with 27.6% of patients developing hypoglycaemia and 55% reported as having hypokalaemia. There were also significant issues with care processes. Initial nurse-led observations were carried out well, but subsequent patient monitoring remained suboptimal. Most patients were not seen by a member of the diabetes specialist team during the first 6 h, but 95% were seen before discharge. A significant minority of discharge letters to primary care did not contain necessary information. CONCLUSION: Despite widespread adoption of national guidance, several areas of management of DKA are suboptimal, being associated with avoidable biochemical and clinical risk.

Lipoprotein Particles in Adolescents and Young Women With PCOS Provide Insights Into Their Cardiovascular Risk.

CONTEXT: Adult women with polycystic ovarian syndrome (PCOS) have an increased risk for cardiovascular disease, but the evidence for this is controversial in adolescents and young women with PCOS. Measurement of low-density lipoprotein (LDL) particle number, measured by nuclear magnetic resonance spectroscopy is a novel technology to assess cardiovascular risk. OBJECTIVE: The objective of the study was to evaluate lipoprotein particle number and size in young women with PCOS and its relationship with insulin resistance and hyperandrogenism. DESIGN: This was a cross-sectional case control study. SETTING: The study was conducted at a clinical research center. PARTICIPANTS: Women with PCOS (n = 35) and normal controls (n = 20) participated in the study. INTERVENTIONS: Blood samples and anthropometric measures were obtained. MAIN OUTCOME MEASURES: LDL particle size and number were measured using nuclear magnetic resonance spectroscopy. A secondary outcome was to investigate the correlation of LDL particle number with high-sensitivity C-reactive protein, waist to hip ratio, hyperandrogenism, insulin resistance, and adiponectin. RESULTS: Women with PCOS had higher LDL particle number when compared with healthy controls (935 ± 412 vs 735 ± 264, P = .032); LDL particle number correlated strongly with high-sensitivity C-reactive protein (r = 0.37, P = .006) and waist-to-hip (r = 0.57, P = .0003). The higher LDL particle number was driven mainly due to differences in the small LDL particle number (sLDLp), with PCOS patients having more sLDLp (348 ± 305 vs 178 ± 195, P = .015). The sLDLp correlated with the Matsuda index (r = -0.51, P = .0001), homeostasis model assessment index of insulin resistance (r = 0.41, P = .002), and adiponectin (r = -0.46, P = .0004) but not with T. CONCLUSION: Adolescent and young women with PCOS have an atherogenic lipoprotein profile suggestive of increased cardiovascular risk that appears to be driven by the degree of visceral adiposity and insulin resistance.

Season's appreciations.

To follow the tradition set by the late Franz Halberg, highlights of research performed over the last year from his Minnesota Center are summarized. They illustrate the broad international cooperation enjoyed by his center and the diversity of applications of the discipline he founded. The results briefly summarized herein in the form of an annotated bibliography are a testimony that his legacy continues to live on and constitutes a tribute to his memory.

Imaging features of spinal trauma: what the radiologist needs to know.

Traumatic spinal fractures typically occur in a young subset of patients following a high-energy motor vehicle accident (MVA) or a fall from height. Upon recognizing the spinal injury, the radiologist should be able to describe the fracture pattern based on conventional nomenclature and to deduce the likely mechanism of injury. This will enable the provision of a more clinically relevant report and will help the radiologist to appreciate the likelihood of associated ligamentous and neurological injury. Vertebral trauma often follows a recognizable pattern based on a specific mechanism of injury. These predictable types of fracture have been referred to as the "fingerprints" of the injury.(1) This review depicts the variety of vertebral column fractures seen in a cohort of 781 patients admitted to our level 1 trauma centre over 1 year.