Impact of the COVID-19 pandemic on the management of open fractures in a major trauma centre.

INTRODUCTION: The Coronavrius-19 (COVID-19) pandemic has presented the biggest challenge that the National Health Service (NHS) has ever seen. As one of the worst affected regions, Orthopaedic service provision and delivery in London, changed dramatically. Our hypothesis is that these restrictions adversely impacted the care of open fractures in our major trauma unit in London. METHODS: This is a prospective case control study comparing the management of patients presenting pre-COVID, to those presenting during the height of the COVID pandemic in London. The pre-COVID, control cohort presented between the 1st October and the November 30, 2019. The COVID cohort presented between the April 1, 2020 and the May 31, 2020. Data was collected that related to the 11 clinical domains of the British Orthopaedic Association Standards of Trauma (BOAST) 4 guidance, as well as early complications. RESULTS: Of the 11 domains, 100 % compliance was achieved in 6 components, across both groups where applicable. During pre-COVID times, the timing to initial debridement was within 12 h for High energy trauma in 16/28 (57.1 %), dropping to 7/22 (31.8 %) during COVID, (p = 0.004). Definitive soft tissue closure within 72 h If not achievable at initial debridement dropped from 9/10 (90.0%) to 4/6 (66.7 %), (p = 0.006). There was no significant difference in early complication rates. CONCLUSION: Coronavirus has changed the landscape of healthcare worldwide and impacted open fracture care by increasing time to theatre. This had no effect on early complication rate but longer term effects remain to be seen.

Type IV Pili Can Mediate Bacterial Motility within Epithelial Cells.

Pseudomonas aeruginosa is among bacterial pathogens capable of twitching motility, a form of surface-associated movement dependent on type IV pili (T4P). Previously, we showed that T4P and twitching were required for P. aeruginosa to cause disease in a murine model of corneal infection, to traverse human corneal epithelial multilayers, and to efficiently exit invaded epithelial cells. Here, we used live wide-field fluorescent imaging combined with quantitative image analysis to explore how twitching contributes to epithelial cell egress. Results using time-lapse imaging of cells infected with wild-type PAO1 showed that cytoplasmic bacteria slowly disseminated throughout the cytosol at a median speed of >0.05 µm s-1 while dividing intracellularly. Similar results were obtained with flagellin (fliC) and flagellum assembly (flhA) mutants, thereby excluding swimming, swarming, and sliding as mechanisms. In contrast, pilA mutants (lacking T4P) and pilT mutants (twitching motility defective) appeared stationary and accumulated in expanding aggregates during intracellular division. Transmission electron microscopy confirmed that these mutants were not trapped within membrane-bound cytosolic compartments. For the wild type, dissemination in the cytosol was not prevented by the depolymerization of actin filaments using latrunculin A and/or the disruption of microtubules using nocodazole. Together, these findings illustrate a novel form of intracellular bacterial motility differing from previously described mechanisms in being directly driven by bacterial motility appendages (T4P) and not depending on polymerized host actin or microtubules.IMPORTANCE Host cell invasion can contribute to disease pathogenesis by the opportunistic pathogen Pseudomonas aeruginosa Previously, we showed that the type III secretion system (T3SS) of invasive P. aeruginosa strains modulates cell entry and subsequent escape from vacuolar trafficking to host lysosomes. However, we also showed that mutants lacking either type IV pili (T4P) or T4P-dependent twitching motility (i) were defective in traversing cell multilayers, (ii) caused less pathology in vivo, and (iii) had a reduced capacity to exit invaded cells. Here, we report that after vacuolar escape, intracellular P. aeruginosa can use T4P-dependent twitching motility to disseminate throughout the host cell cytoplasm. We further show that this strategy for intracellular dissemination does not depend on flagellin and resists both host actin and host microtubule disruption. This differs from mechanisms used by previously studied pathogens that utilize either host actin or microtubules for intracellular dissemination independently of microbe motility appendages.

Association of Race, Ethnicity and Language with Participation in Mental Health Research Among Adult Patients in Primary Care.

Racial and ethnic minorities remain underrepresented in clinical psychiatric research, but the reasons are not fully understood and may vary widely between minority groups. We used the Z-test of independent proportions and binary logistic regression to examine the relationship between race, ethnicity or primary language and participation in screening as well as interest in further research participation among primary care patients being screened for a depression study. Minorities were less likely than non-Hispanic Whites to complete the initial screening survey. Latinos and Blacks were more likely to agree to be contacted for research than non-Hispanic Whites. Among Latinos, primary language was associated with willingness to be contacted for research. Associations between research participation and race, ethnicity and language are complex and vary across different enrollment steps. Future research should consider stages of the research enrollment process separately to better understand barriers and identify targets for intervention.

Impact of a culturally focused psychiatric consultation on depressive symptoms among Latinos in primary care.

OBJECTIVE: A culturally focused psychiatric (CFP) consultation service was implemented to increase engagement in mental health care and reduce depressive symptoms among adult Latino primary care patients. The aim of this study was to assess preliminary efficacy of the CFP consultation service to reduce depressive symptoms. METHODS: In a randomized controlled study, primary care clinics were randomly selected to provide either the two-session CFP intervention or enhanced usual care. For CFP intervention participants, study clinicians (psychologists or psychiatrists) provided a psychiatric assessment, psychoeducation, cognitive-behavioral tools, and tailored treatment recommendations; primary care providers were provided a consultation summary. Depressive symptoms (as measured by the Quick Inventory of Depressive Symptomatology-Self Rated [QIDS-SR]) were assessed at baseline and six-month follow-up. Multiple regression analysis was conducted to evaluate whether CFP intervention participants showed greater improvement in depressive symptoms at follow-up, with control for baseline depression, clinic site, and significant covariates. RESULTS: Participants (N=118) were primarily Spanish-monolingual speakers (64%). Although depressive symptoms remained in the moderate range for both groups from baseline to six months, symptom reduction was greater among CFP intervention participants (mean±SD change in QIDS-SR score=3.46±5.48) than those in usual care (change=.09±4.43). The final multiple regression model indicated that participation in the CFP intervention predicted lower depressive symptoms at follow-up (unstandardized beta=-3.09, p=.008), independent of baseline depressive symptoms, clinic site, age, gender, and employment status. CONCLUSIONS: Results suggest that Latinos experiencing depressive symptoms may benefit from a short-term CFP consultation. Findings also support the integration of psychiatric interventions for Latinos in the primary care setting.

Evaluating patient acceptability of a culturally focused psychiatric consultation intervention for Latino Americans with depression.

Significant disparities exist in both access to and quality of mental health care for Latino Americans with depression compared to Caucasians, resulting in a greater burden of disability in this underserved population. Our aim is to evaluate participant acceptability of a Culturally Focused Psychiatric (CFP) consultation program for depressed Latino Americans. Latino American adult primary care patients endorsing depressive symptoms on a screening questionnaire were targeted in their primary care clinic. The intervention addressed participants' depressive symptoms using culturally adapted clinical assessments and toolkits. Acceptability was evaluated using a treatment satisfaction scale and in-depth semi-structured interviews. Overall, 85% of participants responded positively to all questions of the satisfaction scale. In in-depth interviews, the vast majority of participants reported the program met expectations, all stated providers were culturally sensitive, and most stated recommendations were culturally sensitive. The CFP program was found to be acceptable to a group of depressed Latino American primary care patients. Further research is needed to evaluate if the CFP intervention can improve depressive symptoms and outcomes.

Governing peripherally inserted central venous catheters by combining continuous performance improvement and computerized physician order entry.

OBJECTIVE: Seattle Children's in Seattle, Washington sought to establish governance over peripherally inserted central catheters. Preventing overuse and creating an efficient placement process were of paramount importance. METHODOLOGY: We describe a process by which the marriage of continuous performance-improvement projects and computerized physician order entry has led to a reproducible reduction in peripherally inserted central catheter volumes and an increase in overall provider satisfaction with the ordering process. This was accomplished by increasing daily awareness of central venous catheters, establishing peripherally inserted central catheter-specific insertion criteria, establishing a governing vascular-access service, and creation of a peripherally inserted central catheter-specific computerized order set. RESULTS: After implementation of these measures, peripherally inserted central catheter insertion volumes decreased by 33.4%; these results have been sustained over a period of 19 months. From August 2006 to October 2006, 48% of peripherally inserted central catheters were placed on the same calendar day of order entry, 37% within 24 hours of order entry, and 15% within 48 to 72 hours. Overall, provider satisfaction with the ordering process improved according to a Likert scale. Scores increased from 2.68 of 5 to 3.55 of 5 over a 9-month period. This result was statistically significant at the 95th percentile level according to the t-test method. CONCLUSIONS: We conclude that properly constructed computerized order sets can be effective in altering physician ordering practices through standardization.

Modifying the Toyota Production System for continuous performance improvement in an academic children's hospital.

The Toyota Production System (TPS) has become a successful model for improving efficiency and eliminating errors in manufacturing processes. In an effort to provide patients and families with the highest quality clinical care, our academic children's hospital has modified the techniques of the TPS for a program in continuous performance improvement (CPI) and has expanded its application to educational and research programs. Over a period of years, physicians, nurses, residents, administrators, and hospital staff have become actively engaged in a culture of continuous performance improvement. This article provides background into the methods of CPI and describes examples of how we have applied these methods for improvement in clinical care, resident teaching, and research administration.