Nowcasting the 2022 mpox outbreak in England.

In May 2022, a cluster of mpox cases were detected in the UK that could not be traced to recent travel history from an endemic region. Over the coming months, the outbreak grew, with over 3000 total cases reported in the UK, and similar outbreaks occurring worldwide. These outbreaks appeared linked to sexual contact networks between gay, bisexual and other men who have sex with men. Following the COVID-19 pandemic, local health systems were strained, and therefore effective surveillance for mpox was essential for managing public health policy. However, the mpox outbreak in the UK was characterised by substantial delays in the reporting of the symptom onset date and specimen collection date for confirmed positive cases. These delays led to substantial backfilling in the epidemic curve, making it challenging to interpret the epidemic trajectory in real-time. Many nowcasting models exist to tackle this challenge in epidemiological data, but these lacked sufficient flexibility. We have developed a nowcasting model using generalised additive models that makes novel use of individual-level patient data to correct the mpox epidemic curve in England. The aim of this model is to correct for backfilling in the epidemic curve and provide real-time characteristics of the state of the epidemic, including the real-time growth rate. This model benefited from close collaboration with individuals involved in collecting and processing the data, enabling temporal changes in the reporting structure to be built into the model, which improved the robustness of the nowcasts generated. The resulting model accurately captured the true shape of the epidemic curve in real time.

Identifying employee, workplace and population characteristics associated with COVID-19 outbreaks in the workplace: a population-based study.

OBJECTIVES: To identify risk factors that contribute to outbreaks of COVID-19 in the workplace and quantify their effect on outbreak risk. METHODS: We identified outbreaks of COVID-19 cases in the workplace and investigated the characteristics of the individuals, the workplaces, the areas they work and the mode of commute to work, through data linkages based on Middle Layer Super Output Areas in England between 20 June 2021 and 20 February 2022. We estimated population-level associations between potential risk factors and workplace outbreaks, adjusting for plausible confounders identified using a directed acyclic graph. RESULTS: For most industries, increased physical proximity in the workplace was associated with increased risk of COVID-19 outbreaks, while increased vaccination was associated with reduced risk. Employee demographic risk factors varied across industry, but for the majority of industries, a higher proportion of black/African/Caribbean ethnicities and living in deprived areas, was associated with increased outbreak risk. A higher proportion of employees in the 60-64 age group was associated with reduced outbreak risk. There were significant associations between gender, work commute modes and staff contract type with outbreak risk, but these were highly variable across industries. CONCLUSIONS: This study has used novel national data linkages to identify potential risk factors of workplace COVID-19 outbreaks, including possible protective effects of vaccination and increased physical distance at work. The same methodological approach can be applied to wider occupational and environmental health research.

Global effects of land use on local terrestrial biodiversity.

Human activities, especially conversion and degradation of habitats, are causing global biodiversity declines. How local ecological assemblages are responding is less clear--a concern given their importance for many ecosystem functions and services. We analysed a terrestrial assemblage database of unprecedented geographic and taxonomic coverage to quantify local biodiversity responses to land use and related changes. Here we show that in the worst-affected habitats, these pressures reduce within-sample species richness by an average of 76.5%, total abundance by 39.5% and rarefaction-based richness by 40.3%. We estimate that, globally, these pressures have already slightly reduced average within-sample richness (by 13.6%), total abundance (10.7%) and rarefaction-based richness (8.1%), with changes showing marked spatial variation. Rapid further losses are predicted under a business-as-usual land-use scenario; within-sample richness is projected to fall by a further 3.4% globally by 2100, with losses concentrated in biodiverse but economically poor countries. Strong mitigation can deliver much more positive biodiversity changes (up to a 1.9% average increase) that are less strongly related to countries' socioeconomic status.

Pilot Study of Sacroiliac Joint Dysfunction Treated with a Single Session of Fascial Manipulation® Method: Clinical Implications for Effective Pain Reduction.

Background and Objectives: Sacroiliac joint dysfunction (SIJD) generally refers to pain in the lower back due to abnormal sacroiliac joint movement, either from hypomobility or hypermobility. It is considered to be the principal cause in up to 40% of low back pain cases. In literature, it emerges that the "fascia", by its anatomical continuity, if altered or densified in different regions of the body with respect to the sacroiliac joint and its surroundings, may have a fundamental role in the genesis of SIJD and low back pain. The purpose of the present study is to evaluate the effectiveness of incorporating a single session of Fascial Manipulation®-Stecco method®, treating the muscular fasciae at distance from the painful region. Materials and Methods: Twenty patients with acute and chronic sacroiliac joint dysfunction (SIJD) were recruited (16 males and 4 females, mean age of 46.6 ± 12.98 years). Patients underwent a predefined assessment protocol, followed by an evaluation of myofascial pain and subsequent manipulation of the fascia at points at least 20 cm away from the posterior inferior iliac spines (PIIS). Each patient underwent three pain evaluations: pre-treatment (t0), post-treatment (t1), and at a 1-month follow-up (t2). For the evaluation in t0, t1 the numerical rating scale (NRS) for the intensity of pain and the algometer for the pain threshold at the PIIS were used; in t2 only the NRS scale. Results: The results obtained by comparing the algometer measurements with the NRS values between t0 and t1 were in both cases statistically significant (p < 0.0001), whereas the comparison between the NRS values at t1 and at t2 was not statistically significant (p > 0.05). Conclusions: A single Fascial Manipulation treatment, even when applied at least 20 cm from the PIIS, can potentially decrease pain around the SIJ. The inclusion of this type of approach in SIJD can allow for improved patient management, better tolerance for other treatments and a more rapid application of pain-free exercise programs.

The cost of sustaining a patient-centered medical home: experience from 2 states.

PURPOSE: As medical practices transform to patient-centered medical homes (PCMHs), it is important to identify the ongoing costs of maintaining these "advanced primary care" functions. A key required input is personnel effort. This study's objective was to assess direct personnel costs to practices associated with the staffing necessary to deliver PCMH functions as outlined in the National Committee for Quality Assurance Standards. METHODS: We developed a PCMH cost dimensions tool to assess costs associated with activities uniquely required to maintain PCMH functions. We interviewed practice managers, nurse supervisors, and medical directors in 20 varied primary care practices in 2 states, guided by the tool. Outcome measures included categories of staff used to perform various PCMH functions, time and personnel costs, and whether practices were delivering PCMH functions. RESULTS: Costs per full-time equivalent primary care clinician associated with PCMH functions varied across practices with an average of $7,691 per month in Utah practices and $9,658 in Colorado practices. PCMH incremental costs per encounter were $32.71 in Utah and $36.68 in Colorado. The average estimated cost per member per month for an assumed panel of 2,000 patients was $3.85 in Utah and $4.83 in Colorado. CONCLUSIONS: Identifying costs of maintaining PCMH functions will contribute to effective payment reform and to sustainability of transformation. Maintenance and ongoing support of PCMH functions require additional time and new skills, which may be provided by existing staff, additional staff, or both. Adequate compensation for ongoing and substantial incremental costs is critical for practices to sustain PCMH functions.

Diagnosing and managing venous leg ulcers in patients in the community.

Venous leg ulcers (VLUs) are a chronic condition affecting between 0.1% and 0.3% of the population in the UK. Healing rates are variable and recurrence rates are high. The diagnosis, assessment, and management of this patient group is primarily carried out in the community. Assessment of this patient group requires skill and competence to ensure a correct diagnosis is made. When carrying out the assessment, it is important to consider the patient's past medical history, medication, and allergies, as well as to record the ankle brachial pressure index (ABPI), pain level, palpation of pulses, and ankle joint movement, among other aspects of the assessment. VLUs heal with compression therapy, and practitioners should be knowledgeable about the various compression systems available in order to offer patients the most suitable and informed choices.

A global model of the response of tropical and sub-tropical forest biodiversity to anthropogenic pressures.

Habitat loss and degradation, driven largely by agricultural expansion and intensification, present the greatest immediate threat to biodiversity. Tropical forests harbour among the highest levels of terrestrial species diversity and are likely to experience rapid land-use change in the coming decades. Synthetic analyses of observed responses of species are useful for quantifying how land use affects biodiversity and for predicting outcomes under land-use scenarios. Previous applications of this approach have typically focused on individual taxonomic groups, analysing the average response of the whole community to changes in land use. Here, we incorporate quantitative remotely sensed data about habitats in, to our knowledge, the first worldwide synthetic analysis of how individual species in four major taxonomic groups--invertebrates, 'herptiles' (reptiles and amphibians), mammals and birds--respond to multiple human pressures in tropical and sub-tropical forests. We show significant independent impacts of land use, human vegetation offtake, forest cover and human population density on both occurrence and abundance of species, highlighting the value of analysing multiple explanatory variables simultaneously. Responses differ among the four groups considered, and--within birds and mammals--between habitat specialists and habitat generalists and between narrow-ranged and wide-ranged species.

Wildfire exposure and fuel management on western US national forests.

Substantial investments in fuel management activities on national forests in the western US are part of a national strategy to reduce human and ecological losses from catastrophic wildfire and create fire resilient landscapes. Prioritizing these investments within and among national forests remains a challenge, partly because a comprehensive assessment that establishes the current wildfire risk and exposure does not exist, making it difficult to identify national priorities and target specific areas for fuel management. To gain a broader understanding of wildfire exposure in the national forest system, we analyzed an array of simulated and empirical data on wildfire activity and fuel treatment investments on the 82 western US national forests. We first summarized recent fire data to examine variation among the Forests in ignition frequency and burned area in relation to investments in fuel reduction treatments. We then used simulation modeling to analyze fine-scale spatial variation in burn probability and intensity. We also estimated the probability of a mega-fire event on each of the Forests, and the transmission of fires ignited on national forests to the surrounding urban interface. The analysis showed a good correspondence between recent area burned and predictions from the simulation models. The modeling also illustrated the magnitude of the variation in both burn probability and intensity among and within Forests. Simulated burn probabilities in most instances were lower than historical, reflecting fire exclusion on many national forests. Simulated wildfire transmission from national forests to the urban interface was highly variable among the Forests. We discuss how the results of the study can be used to prioritize investments in hazardous fuel reduction within a comprehensive multi-scale risk management framework.

Quality, satisfaction, and financial efficiency associated with elements of primary care practice transformation: preliminary findings.

PURPOSE: We examined quality, satisfaction, financial, and productivity outcomes associated with implementation of Care by Design (CBD), the University of Utah's version of the patient-centered medical home. METHODS: We measured the implementation of individual elements of CBD using a combination of observation, chart audit, and collection of data from operational reports. We assessed correlations between level of implementation of each element and measures of quality, patient and clinician satisfaction, financial performance, and efficiency. RESULTS: Team function elements had positive correlations (P ≤.05) with 6 quality measures, 4 patient satisfaction measure, and 3 clinician satisfaction measures. Continuity elements had positive correlations with 2 satisfaction measures and 1 quality measure. Clinician continuity was the key driver in the composite element of appropriate access. Unexpected findings included the negative correlation of use of templated questionnaires with 3 patient satisfaction measures. Trade-offs were observed for performance of blood draws in the examination room and the efficiency of visits, with some positive and some negative correlations depending on the outcome. CONCLUSIONS: Elements related to care teams and continuity appear to be key elements of CBD as they influence all 3 CBD organizing principles: appropriate access, care teams, and planned care. These relationships, as well as unexpected, unfavorable ones, require further study and refined analyses to identify causal associations.

Fascial manipulation as an adjunct to physiotherapy management in obstetric brachial plexus palsy: A case report.

The integrity of connective tissue sheaths surrounding the nerves influences both the severity and the potential for recovery of brachial plexus lesions. This study presents an innovative, early onset, multidisciplinary approach to obstetric brachial plexus palsy. This approach is aimed at functional recovery of the nerve lesion and includes mobilization of the fascia using the Fascial Manipulation® method. This case study discusses how, in addition to conventional treatment, interventions aimed at the fascial system can potentially affect tension around the neural sheaths, enhance proprioceptive input and facilitate movement to influence obstetric brachial plexus palsy outcomes.

Space-time clustering of elevated thyroid stimulating hormone levels.

Previous studies of congenital hypothyroidism (CHT) have reported an increasing incidence which may suggest that environmental factors play an aetiological role. If so, then cases may exhibit space-time clustering, where cases occur at similar times and close proximities to other cases. In this study we investigated whether space-time clustering of elevated thyroid stimulating hormone (TSH) in newborns exists. All infants born in the Northern Region of England are screened by measuring levels of circulating TSH using a blood spot assay. Data on 207 cases of elevated TSH values, as a proxy for CHT, in newborns born from 1994 to 2006 inclusive were available and analysed using rigorous space-time clustering statistical methods. Analysis showed statistically significant evidence of space-time clustering. The strength of clustering was most marked for cases born within 0.1-0.7 year (1-8 months) of one another. This is the first study to find significant space-time clustering of cases of elevated TSH levels in newborns, a surrogate for space-time clustering of CHT. Whilst the reasons for the clustering are unclear, it would appear from this analysis that transient environmental exposures are likely to be involved, although environmental determinants of genetic mutations and epigenetic factors cannot be ruled out. Further research is required to a) validate these results in other populations and b) to assess in more detail the potential environmental determinants of increased CHT risk.

Advancing effects analysis for integrated, large-scale wildfire risk assessment.

In this article, we describe the design and development of a quantitative, geospatial risk assessment tool intended to facilitate monitoring trends in wildfire risk over time and to provide information useful in prioritizing fuels treatments and mitigation measures. The research effort is designed to develop, from a strategic view, a first approximation of how both fire likelihood and intensity influence risk to social, economic, and ecological values at regional and national scales. Three main components are required to generate wildfire risk outputs: (1) burn probability maps generated from wildfire simulations, (2) spatially identified highly valued resources (HVRs), and (3) response functions that describe the effects of fire (beneficial or detrimental) on the HVR. Analyzing fire effects has to date presented a major challenge to integrated risk assessments, due to a limited understanding of the type and magnitude of changes wrought by wildfire to ecological and other nonmarket values. This work advances wildfire effects analysis, recognizing knowledge uncertainty and appropriately managing it through the use of an expert systems approach. Specifically, this work entailed consultation with 10 fire and fuels program management officials from federal agencies with fire management responsibilities in order to define quantitative resource response relationships as a function of fire intensity. Here, we demonstrate a proof-of-concept application of the wildland fire risk assessment tool, using the state of Oregon as a case study.

Prevalence of chronic kidney disease in adults in England: comparison of nationally representative cross-sectional surveys from 2003 to 2016.

OBJECTIVES: To identify recent trends in chronic kidney disease (CKD) prevalence in England and explore their association with changes in sociodemographic, behavioural and clinical factors. DESIGN: Pooled cross-sectional analysis. SETTING: Health Survey for England 2003, 2009/2010 combined and 2016. PARTICIPANTS: 17 663 individuals (aged 16+) living in private households. PRIMARY AND SECONDARY OUTCOME MEASURES: Prevalence of estimated glomerular filtration rate (eGFR) <60 mL/min/1.73 m2 and albuminuria (measured by albumin-creatinine ratio) during 2009/2010 and 2016 and trends in eGFR between 2003 and 2016. eGFR was estimated using serum creatinine Chronic Kidney Disease Epidemiology Collaboration and Modification of Diet in Renal Disease equations. RESULTS: GFR <60 mL/min/1.73 m2 prevalence was 7.7% (95% CI 7.1% to 8.4%), 7.0% (6.4% to 7.7%) and 7.3%(6.5% to 8.2%) in 2003, 2009/2010 and 2016, respectively. Albuminuria prevalence was 8.7% (8.1% to 9.5%) in 2009/2010 and 9.8% (8.7% to 10.9%) in 2016. Prevalence of CKD G1-5 (eGFR <60 mL/min/1.73 m2 or albuminuria) was 12.6% (11.8% to 13.4%) in 2009/2010 and 13.9% (12.8% to 15.2%) in 2016. Prevalence of diabetes and obesity increased during 2003-2016 while prevalence of hypertension and smoking fell. The age-adjusted and gender-adjusted OR of eGFR <60 mL/min/1.73 m2 for 2016 versus 2009/2010 was 0.99 (0.82 to 1.18) and fully adjusted OR was 1.13 (0.93 to 1.37). There was no significant period effect on the prevalence of albuminuria or CKD G1-5 from 2009/2010 to 2016 in age and gender or fully adjusted models. CONCLUSION: The fall in eGFR <60 mL/min/1.73 m2 seen from 2003 to 2009/2010 did not continue to 2016. However, absolute CKD burden is likely to rise with population growth and ageing, particularly if diabetes prevalence continues to increase. This highlights the need for greater CKD prevention efforts and continued surveillance.

Case studies evaluating 3M's two-layer compression system: Coban 2.

Compression therapy is the cornerstone of venous leg ulcer management. In this evaluation of a Two-layer compression bandage system, the article focuses upon the performance of the bandage together with the patients' perspective regarding comfort and acceptability when carrying out normal daily activities. Twenty patients were recruited into the evaluation, and four case studies are presented here as an example of the evaluation.

The database of the PREDICTS (Projecting Responses of Ecological Diversity In Changing Terrestrial Systems) project.

The PREDICTS project-Projecting Responses of Ecological Diversity In Changing Terrestrial Systems (www.predicts.org.uk)-has collated from published studies a large, reasonably representative database of comparable samples of biodiversity from multiple sites that differ in the nature or intensity of human impacts relating to land use. We have used this evidence base to develop global and regional statistical models of how local biodiversity responds to these measures. We describe and make freely available this 2016 release of the database, containing more than 3.2 million records sampled at over 26,000 locations and representing over 47,000 species. We outline how the database can help in answering a range of questions in ecology and conservation biology. To our knowledge, this is the largest and most geographically and taxonomically representative database of spatial comparisons of biodiversity that has been collated to date; it will be useful to researchers and international efforts wishing to model and understand the global status of biodiversity.

Barriers and benefits: implications of artificial night-lighting for the distribution of common bats in Britain and Ireland.

Artificial lighting is a particular problem for animals active at night. Approximately 69% of mammal species are nocturnal, and one-third of these are bats. Due to their extensive movements-both on a nightly basis to exploit ephemeral food supplies, and during migration between roosts-bats have an unusually high probability of encountering artificial light in the landscape. This paper reviews the impacts of lighting on bats and their prey, exploring the direct and indirect consequences of lighting intensity and spectral composition. In addition, new data from large-scale surveys involving more than 265 000 bat calls at more than 600 locations in two countries are presented, showing that prevalent street-lighting types are not generally linked with increased activity of common and widespread bat species. Such bats, which are important to ecosystem function, are generally considered 'light-attracted' and likely to benefit from the insect congregations that form at lights. Leisler's bat (Nyctalus leisleri) may be an exception, being more frequent in lit than dark transects. For common pipistrelle bats (Pipistrellus pipistrellus), lighting is negatively associated with their distribution on a landscape scale, but there may be local increases in habitats with good tree cover. Research is now needed on the impacts of sky glow and glare for bat navigation, and to explore the implications of lighting for habitat matrix permeability.

Exploration of chronic kidney disease prevalence estimates using new measures of kidney function in the health survey for England.

BACKGROUND: Chronic kidney disease (CKD) diagnosis relies on glomerular filtration rate (eGFR) estimation, traditionally using the creatinine-based Modification of Diet in Renal Disease (MDRD) equation. The Chronic Kidney Disease Epidemiology Collaboration (CKDEPI) equation performs better in estimating eGFR and predicting mortality and CKD progression risk. Cystatin C is an alternative glomerular filtration marker less influenced by muscle mass. CKD risk stratification is improved by combining creatinine eGFR with cystatin C and urinary albumin to creatinine ratio (uACR). We aimed to identify the impact of introducing CKDEPI and cystatin C on the estimated prevalence and risk stratification of CKD in England and to describe prevalence and associations of cystatin C. METHODS AND FINDINGS: Cross sectional study of 5799 people in the nationally representative 2009 and 2010 Health Surveys for England. PRIMARY OUTCOME MEASURES: prevalence of MDRD, CKDEPI and cystatin C-defined eGFR<60 ml/min/1.73 m(2); prevalence of CKD biomarker combinations (creatinine, cystatin C, uACR). Using CKDEPI instead of MDRD reduced the prevalence of eGFR<60 ml/min/1.73 m(2) from 6.0% (95% CI 5.4-6.6%) to 5.2% (4.7-5.8%) equivalent to around 340,000 fewer individuals in England. Those reclassified as not having CKD evidenced a lower risk profile. Prevalence of cystatin C eGFR<60 ml/min/1.73 m(2) was 7.7% and independently associated with age, lack of qualifications, being an ex-smoker, BMI, hypertension, and albuminuria. Measuring cystatin C in the 3.9% people with CKDEPI-defined eGFR<60 ml/min/1.73 m(2) without albuminuria (CKD Category G3a A1) reclassified about a third into a lower risk group with one of three biomarkers and two thirds into a group with two of three. Measuring cystatin C in the 6.7% people with CKDEPI eGFR >60 ml/min/1.73 m(2) with albuminuria (CKD Category G1-2) reclassified almost a tenth into a higher risk group. LIMITATIONS: Cross sectional study, single eGFR measure, no measured ('true') GFR. CONCLUSIONS: Introducing the CKDEPI equation and targeted cystatin C measurement reduces estimated CKD prevalence and improves risk stratification.

Impact of an integrated transition management program in primary care on hospital readmissions.

Poorly executed transitions in care from hospital to home are associated with increased vulnerability to adverse medication events and hospital readmissions, and also excess healthcare costs. Efforts to improve care coordination on hospital discharge have been shown to reduce hospital readmission rates but often rely on interventions that are not fully integrated within the primary care setting. The Patient Centered Medical Home (PCMH) model, whose core principles include care coordination in the posthospital setting, is an approach that addresses transitions in care in a more integrated fashion. We examined the impact of multicomponent transition management (TM) services on hospital readmission rates and time to hospital readmission among 118 patients enrolled in a TM program that is part of Care By Design, the University of Utah Community Clinics' version of the PCMH. We conducted a retrospective analysis comparing outcomes for patients before receiving TM services with outcomes for the same patients after receiving TM services. The all-cause 30-day hospital readmission rate decreased from 17.9% to 8.0%, and the mean time to hospital readmission within 180 days was delayed from 95 to 115 days. These findings support the effectiveness of TM activities integrated within the primary care setting.