The Development of a Team-Based, Hybrid Inter-university Graduate Certificate Program Focused on Maternal Child Health Professionals.

INTRODUCTION: Pregnancy, childbirth, and child well-being are identified by Healthy People 2030 as priority topics for improving the health of all Americans. New Mexico is the fifth largest state geographically with most of the state's 33 counties considered rural or frontier. Accessing health care services is challenging in this resource-poor environment. The need to provide maternal and child health (MCH) education in the state was the impetus for developing a graduate certificate in maternal and child public health. METHODS: The hybrid MCH graduate certificate engaged professionals in formal training that included a public health approach to addressing MCH issues in the state's diverse communities. Grant funds paid for the tuition, books and travel for students providing an opportunity to individuals who otherwise could not have pursued graduate education and professional development. RESULTS: Over a 4-year period, two cohorts were recruited, educated, and evaluated. The evaluations reflected an increase in competency knowledge scores for all students. DISCUSSION: This model of MCH education was successful at delivering public health graduate education to MCH practitioners and increasing their knowledge and skills. Listening to students and communities as to what their MCH public health needs are and responding with a flexible educational model provided individuals with information and tools that could be used to improve maternal and child health and reduce health disparities in rural, tribal, and underserved communities.

Reducing broad-spectrum antibiotic use in intensive care unit between first and second waves of COVID-19 did not adversely affect mortality.

BACKGROUND: The COVID-19 pandemic increased the use of broad-spectrum antibiotics due to diagnostic uncertainty, particularly in critical care. Multi-professional communication became more difficult, weakening stewardship activities. AIM: To determine changes in bacterial co-/secondary infections and antibiotics used in COVID-19 patients in critical care, and mortality rates, between the first and second waves. METHODS: Prospective audit comparing bacterial co-/secondary infections and their treatment during the first two waves of the pandemic in a single-centre teaching hospital intensive care unit. Data on demographics, daily antibiotic use, clinical outcomes, and culture results in patients diagnosed with COVID-19 infection were collected over 11 months. FINDINGS: From March 9th, 2020 to September 2nd, 2020 (Wave 1), there were 156 patients and between September 3rd, 2020 and February 1st, 2021 (Wave 2) there were 235 patients with COVID-19 infection admitted to intensive care. No significant difference was seen in mortality or positive blood culture rates between the two waves. The proportion of patients receiving antimicrobial therapy (93.0% vs 81.7%; P < 0.01) and the duration of meropenem use (median (interquartile range): 5 (2-7) vs 3 (2-5) days; P = 0.01) was lower in Wave 2. However, the number of patients with respiratory isolates of Pseudomonas aeruginosa (4/156 vs 21/235; P < 0.01) and bacteraemia from a respiratory source (3/156 vs 20/235; P < 0.01) increased in Wave 2, associated with an outbreak of infection. There was no significant difference between waves with respect to isolation of other pathogens. CONCLUSION: Reduced broad-spectrum antimicrobial use in the second wave of COVID-19 compared with the first wave was not associated with significant change in mortality.

Association of length of hospital stay with delay to surgical fixation of hip fracture.

BACKGROUND: Previous research has shown increases in length of stay (LOS), morbidity and mortality when the standard for surgical fixation of hip fracture of 48 hours is not met. However, few investigators have analyzed LOS as a primary outcome, and most used time of diagnosis as opposed to time of fracture as the reference point. We examined the effect of time to surgical fixation of hip fracture, measured from time of fracture, on length of hospital stay; the secondary outcome was average 1-year mortality. METHODS: We conducted a retrospective cohort study of patients presenting to 1 of 2 tertiary care centres in St. John's, Newfoundland and Labrador, Canada, with a hip fracture from Jan. 1, 2014, to Dec. 31, 2018. We analyzed 3 groups based on timing of surgical fixation after fracture: less than 24 hours (group 1), 24-48 hours (group 2) and more than 48 hours (group 3). We assessed statistical significance using 1-way analysis of variance. RESULTS: Of the 692 patients included in the study, 212 (30.6%) were in group 1, 360 (52.0%) in group 2 and 120 (17.3%) in group 3. A delay to surgical fixation exceeding 48 hours was associated with a significantly longer LOS, by an average of 2.9 and 2.8 days compared to groups 1 and 2, respectively (p = 0.04); there was no significant difference in LOS between groups 1 and 2. A significant difference in average 1-year mortality was observed between groups 1 (11%) and 3 (26%) (p = 0.004), and groups 2 (13%) and 3 (p = 0.009). CONCLUSION: Surgical fixation beyond 48 hours after hip fracture resulted in significantly increased LOS and 1-year mortality. Further research should be conducted to evaluate reasons for delays to surgery and the effects of these delays on time to surgical fixation as measured from time of fracture.

What is in? What is out? Updating the British Society for Cutaneous Allergy facial series.

BACKGROUND: Allergic contact dermatitis (ACD) to cosmetics is widely reported. To ensure we are accurately diagnosing ACD, patch test series should be continually reviewed to identify relevant and emerging allergens and highlight those that are outdated. The current British Society for Cutaneous Allergy (BSCA) facial series recommends 26 allergens and was last modified in 2012. OBJECTIVES: To review and update the BSCA facial series. METHODS: We retrospectively reviewed the results from 12 UK and Ireland patch test centres' facial series from January 2016 to December 2017. We recorded the number of allergens tested in each centre and the detection rate for each allergen. Using a 0·3% positive rate as the inclusion threshold, we established which allergens in the BSCA facial series had positive patch test rates < 0·3% and > 0·3%. Allergens not in the BSCA facial series that had a positive patch test rate > 0·3% were identified. RESULTS: Overall, 4224 patients were patch tested to the facial series. The number of allergens included in individual centres' facial series ranged from 24 to 66, with a total of 103 allergens tested across all centres. Twelve of the 26 allergens in the BSCA facial series had a positive patch test rate < 0·3% and 14 had a rate > 0·3%. Twenty-five allergens not recommended in the BSCA facial series had a positive patch test rate > 0·3%. CONCLUSIONS: This audit has highlighted the significant variation in practice that exists among patch test centres, despite a recommended facial series. The BSCA facial series has been updated and now contains 24 allergens. Fifteen allergens remain, 11 allergens have been dropped and nine new allergens have been added.

A novel cohorting and isolation strategy for suspected COVID-19 cases during a pandemic.

BACKGROUND: The COVID-19 pandemic presents a significant infection prevention and control challenge. The admission of large numbers of patients with suspected COVID-19 disease risks overwhelming the capacity to protect other patients from exposure. The delay between clinical suspicion and confirmatory testing adds to the complexity of the problem. METHODS: We implemented a triage tool aimed at minimizing hospital-acquired COVID-19 particularly in patients at risk of severe disease. Patients were allocated to triage categories defined by likelihood of COVID-19 and risk of a poor outcome. Category A (low-likelihood; high-risk), B (high-likelihood; high-risk), C (high-likelihood; low-risk) and D (low-likelihood; low-risk). This determined the order of priority for isolation in single-occupancy rooms with Category A the highest. Patients in other groups were cohorted when isolation capacity was limited with additional interventions to reduce transmission. RESULTS: Ninety-three patients were evaluated with 79 (85%) receiving a COVID-19 diagnosis during their admission. Of those without a COVID-19 diagnosis: 10 were initially triaged to Category A; 0 to B; 1 to C and 4 to D. All high-risk patients requiring isolation were, therefore, admitted to single-occupancy rooms and protected from exposure. Twenty-eight (30%) suspected COVID-19 patients were evaluated to be low risk (groups C and D) and eligible for cohorting. No symptomatic hospital-acquired infections were detected in the cohorted patients. DISCUSSION: Application of a clinical triage tool to guide isolation and cohorting decisions may reduce the risk of hospital-acquired transmission of COVID-19 especially to individuals at the greatest of risk of severe disease.

Morbidity and mortality following pelvic ramus fractures in an older Atlantic Canadian cohort

Background: Pelvic ramus fractures in older patients are associated with substantial morbidity and mortality. There is a paucity of literature on fractures of the pelvis in this age group. The purpose of this study was to report mortality rates following such injuries. In addition, we aimed to describe and quantify the important resultant morbidity in this vulnerable population. Methods: We performed a retrospective chart review of all low-energy pelvic ramus fractures in patients more than age 60 years that occurred between January 2000 and December 2005. Data on survival, hospital length of stay, ambulatory status and place of residence were recorded. For comparison, we calculated the mortality rate for a surrogate age- and sex-matched group using Statistics Canada survival data for use as an uninjured control group. Results: We identified 43 patients (32 women [74%]; mean age 79.4 yr) with isolated low-energy pelvic ramus fractures over the study period. The 1- and 5-year mortality rates were 16.3% (95% confidence interval [CI] 7.8%­30.3%) and 58.1% (95% CI 43.3%­71.6%), respectively, both significantly higher than the point estimates for the control group (6.6% and 31.3%, respectively). Following injury, 14/39 patients (36%) permanently required increased ambulatory aids, and 8 (20%) required a permanent increase in everyday level of care. Conclusion: The results suggest that there may be increased mortality and morbidity following low-energy pattern pelvic ramus fractures in an older population compared to age- and sex-matched uninjured control subjects.

Contexte: Les fractures du bassin chez les personnes âgées sont associées à une morbidité et une mortalité substantielles. La littérature sur les fractures du bassin dans ce groupe d'âge est peu abondante. Le but de cette étude était donc de faire état des taux de mortalité suite à de telles blessures. Nous avons aussi voulu décrire et quantifier l'importante morbidité qui en résulte chez cette population vulnérable. Méhodes: Nous avons effectué une revue rétrospective de tous les cas de fractures du bassin consécutives à un traumatisme de faible énergie chez des patients de plus de 60 ans survenues entre janvier 2000 et décembre 2005. Les données de survie, la durée de l'hospitalisation, le statut ambulatoire et le lieu de résidence ont été notées. À des fins de comparaison, nous avons calculé le taux de mortalité pour un groupe témoin indemme assorti selon l'âge et le sexe en nous servant des données de survie de Statistique Canada. Résultats: Nous avons recensé 43 patients (32 femmes [74 %]; âge moyen 79,4 ans) porteurs de fractures du bassin isolées consécutives à un traumatisme de faible énergie pour la période de l'étude. Les taux de mortalité à 1 an et à 5 ans ont été de 16,3 % (intervalle confiance [IC] de 95 % 7,8 %­30,3 %) et 58,1 % (IC de 95 % 43,3 %­71,6 %), respectivement, tous deux significativement plus élevés que les estimations ponctuelles pour le groupe témoin (6,6 % et 31,3 %, respectivement). Après le traumatisme, 14 patients sur 39 (36 %) ont eu besoin de façon permanente et croissante de dispositifs d'aide à la marche et 8 (20 %) ont eu besoin de façon permanente d'un niveau de soins quotidiens accru. Conclusion: Les résultats donnent à penser que la mortalité et la morbidité pourraient être plus marquées après une fracture de la hanche consécutive à un traumatisme de faible énergie chez la population âgée, comparativement à des témoins assortis selon l'âge et le sexe.

A systematic review of cannabidiol dosing in clinical populations.

AIMS: Cannabidiol (CBD) is a cannabis-derived medicinal product with potential application in a wide-variety of contexts; however, its effective dose in different disease states remains unclear. This review aimed to investigate what doses have been applied in clinical populations, in order to understand the active range of CBD in a variety of medical contexts. METHODS: Publications involving administration of CBD alone were collected by searching PubMed, EMBASE and ClinicalTrials.gov. RESULTS: A total of 1038 articles were retrieved, of which 35 studies met inclusion criteria covering 13 medical contexts. Twenty-three studies reported a significant improvement in primary outcomes (e.g. psychotic symptoms, anxiety, seizures), with doses ranging between <1 and 50 mg/kg/d. Plasma concentrations were not provided in any publication. CBD was reported as well tolerated and epilepsy was the most frequently studied medical condition, with all 11 studies demonstrating positive effects of CBD on reducing seizure frequency or severity (average 15 mg/kg/d within randomised controlled trials). There was no signal of positive activity of CBD in small randomised controlled trials (range n = 6-62) assessing diabetes, Crohn's disease, ocular hypertension, fatty liver disease or chronic pain. However, low doses (average 2.4 mg/kg/d) were used in these studies. CONCLUSION: This review highlights that CBD has a potential wide range of activity in several pathologies. Pharmacokinetic studies as well as conclusive phase III trials to elucidate effective plasma concentrations within medical contexts are severely lacking and highly encouraged.

Recommendation to include hydroxyethyl (meth)acrylate in the British baseline patch test series.

BACKGROUND: (Meth)acrylates are potent sensitizers and a common cause of allergic contact dermatitis (ACD). The frequency of (meth)acrylate ACD has increased with soaring demand for acrylic nails. A preliminary audit has suggested a significant rate of positive patch tests to (meth)acrylates using aimed testing in patients providing a clear history of exposure. To date, (meth)acrylates have not been routinely tested in the baseline patch test series in the U.K. and Europe. OBJECTIVES: To determine whether inclusion of 2-hydroxyethyl methacrylate (2-HEMA) 2% in petrolatum (pet.) in the baseline series detects cases of treatable (meth)acrylate ACD. METHODS: During 2016-2017, 15 U.K. dermatology centres included 2-HEMA in the extended baseline patch test series. Patients with a history of (meth)acrylate exposure, or who tested positive to 2-HEMA, were selectively tested with a short series of eight (meth)acrylate allergens. RESULTS: In total 5920 patients were consecutively patch tested with the baseline series, of whom 669 were also tested with the (meth)acrylate series. Overall, 102 of 5920 (1·7%) tested positive to 2-HEMA and 140 (2·4%) to at least one (meth)acrylate. Had 2-HEMA been excluded from the baseline series, (meth)acrylate allergy would have been missed in 36 of 5920 (0·6% of all patients). The top (meth)acrylates eliciting a positive reaction were 2-HEMA (n = 102, 1·7%), 2-hydroxypropyl methacrylate (n = 61, 1·0%) and 2-hydroxyethyl acrylate (n = 57, 1·0%). CONCLUSIONS: We recommend that 2-HEMA 2% pet. be added to the British baseline patch test series. We also suggest a standardized short (meth)acrylate series, which is likely to detect most cases of (meth)acrylate allergy.

A two-dimensional finite element model of cyclic adenosine monophosphate (cAMP) intracellular signaling.

In this work, we present a two-dimensional finite element analysis (FEA) model that describes fundamental intracellular signals of cyclic adenosine monophosphate (cAMP) in a general fashion. The model was subsequently solved numerically and the results were displayed in forms of time-course plots of cAMP concentration at a cellular location or color-filled contour maps of cAMP signal distribution within the cell at specific time points. Basic intracellular cAMP signaling was described in this model so it can be numerically validated by verifying its numerical results against available analytical solutions and against results obtained from other numerical techniques reported in the literature. This is the first important step before the model can be expanded in future work. Model simulations demonstrate that under certain conditions, sustained cAMP concentrations can be formed within endothelial cells (ECs), similar to those observed in rat pulmonary microvascular ECs. Spatial and temporal cAMP dynamic simulations indicated that the proposed FEA model is an effective tool for the study of the kinetics and spatial spread of second messenger signaling and can be expanded to simulate second messenger signals in the pulmonary vasculature.

Prolonged and large outbreak of invasive group A Streptococcus disease within a nursing home: repeated intrafacility transmission of a single strain.

OBJECTIVES: Multiple invasive group A Streptococcus (GAS) infections were reported to public health by a skilled nursing facility (facility A) in Illinois between May 2014 and August 2016. Cases continued despite interventions including antibiotic prophylaxis for all residents and staff. Two other geographically close facilities reported contemporaneous outbreaks of GAS. We investigated potential reasons for ongoing transmission. METHODS: We obtained epidemiologic data from chart review of cases and review of facility and public health records from previous investigations into the outbreak. Infection control practices at facility A were observed and evaluated. Whole genome sequencing followed by phylogenetic analysis was performed on available isolates from the three facilities. RESULTS: From 2014 to 2016, 19 invasive and 60 noninvasive GAS infections were identified at facility A occurring in three clusters. Infection control evaluations during clusters 2 and 3 identified hand hygiene compliance rates of 14% to 25%, appropriate personal protective equipment use in only 33% of observed instances, and deficient wound-care practices. GAS isolates from residents and staff of all three facilities were subtype emm89.0; on phylogenetic analysis, facility A isolates were monophyletic and distinct. CONCLUSIONS: Inadequate infection control and improper wound-care practices likely led to this 28-month-long outbreak of severe infections in a skilled nursing facility. Whole genome sequencing and phylogenetic analysis suggested that intrafacility transmission of a single highly transmissible GAS strain was responsible for the outbreak in facility A. Integration of genomic epidemiology tools with traditional epidemiology and infection control assessments was helpful in investigation of a facility-wide outbreak.