Incidence and outcomes of healthcare-associated COVID-19 infections: significance of delayed diagnosis and correlation with staff absence.

BACKGROUND: The sudden increase in COVID-19 admissions in hospitals during the SARS-CoV-2 pandemic of 2020 led to onward transmissions among vulnerable inpatients. AIMS: This study was performed to evaluate the prevalence and clinical outcomes of healthcare-associated COVID-19 infections (HA-COVID-19) during the 2020 epidemic and study factors which may promote or correlate with its incidence and transmission in a Teaching Hospital NHS Trust in London, UK. METHODS: Electronic laboratory, patient and staff self-reported sickness records were interrogated from 1st March to 18th April 2020. HA-COVID-19 was defined as COVID-19 with symptom onset within >14 days of admission. Test performance of a single combined throat and nose swab (CTNS) for patient placement was calculated. The effect of delayed RNA positivity (DRP, defined as >48 h delay), staff self-reported COVID-19 sickness absence, hospital bed occupancy, and community incidence of COVID-19 was compared for HA-COVID-19. The incidence of other significant hospital-acquired bacterial infections (HAB) was compared with previous years. RESULTS: Fifty-eight HA-COVID-19 (7.1%) cases were identified. When compared with community-acquired admitted cases (CA-COVID-19), significant differences were observed in age (P=0.018), ethnicity (P<0.001) and comorbidity burden (P<0.001) but not in 30-day mortality. CTNS-negative predictive value was 60.3%. DRP was associated with greater mortality (P=0.034) and incidence of HA-COVID-19 correlated positively with DRP (R = 0.7108) and staff sickness absence (R = 0.7815). For the study period HAB rates were similar to the previous 2 years. CONCLUSIONS: Early diagnosis and isolation of COVID-19 patients would help to reduce transmission. A single CTNS has limited value in segregating patients into positive and negative pathways.

Testing a model of fear of cancer recurrence or progression: the central role of intrusions, death anxiety and threat appraisal.

We recently proposed a model of cancer-related anxiety to account for the etiology and maintenance of clinically significant anxiety in the context of cancer. This study tested predictions arising from the model to explain fear of cancer recurrence or progression (FCR). Patients with cancer were recruited from a research registry or outpatient hospital clinics (n = 211). In bivariate analyses, FCR was associated with metacognitive beliefs, intolerance of uncertainty, core belief disruption, less meaning in life, social constraints, death anxiety, intrusions, threat appraisal, and coping. A hierarchical regression explained 65% of the variance in FCR. FCR was predicted by younger age, intrusions, death anxiety, threat appraisal and meta-cognitions. The findings highlight the importance of both cognitive processes and content in FCR, including intrusions, fears about death and dying, beliefs about worry, and threat appraisals.

Fear of cancer recurrence and death anxiety.

In 2013, 3 systematic reviews of fear of cancer recurrence (FCR) and its predictors were published. All 3 concurred that FCR is a highly prevalent problem and amongst the largest unmet needs of cancer survivors, even 5 or more years after treatment. However, between them they identified only 1 study that had investigated the relationship between death anxiety and FCR. This is surprising because it is well acknowledged that a diagnosis of cancer, a potentially life-threatening illness, is associated with a number of existential issues that give rise to psychological sequelae such as intrusive thoughts about death and other post-traumatic symptoms. Outside the cancer literature, there has recently been a call to identify death anxiety as a transdiagnostic construct that underlies many anxiety disorders even in healthy people. And yet, the relevance of death anxiety to FCR has not been studied. We explore the barriers to the study of death anxiety and FCR and the reasons that a potential link between the 2 might have important theoretical and clinical implications. We conclude that establishing the relationship between death anxiety, FCR and other existential issues is essential in order to fully understand FCR, particularly in the context of advanced disease. We further conclude that whether death anxiety underlies FCR has important clinical implications which would potentially allow us to optimise currently available evidence-based treatments.

Assessing the influence of topography and canopy structure on Douglas fir throughfall with LiDAR and empirical data in the Santa Cruz mountains, USA.

Atmospheric inputs to forest ecosystems vary considerably over small spatial scales due to subtle changes in relief and vegetation structure. Relationships between throughfall fluxes (ions that pass through the canopy in water), topographic and canopy characteristics derived from sub-meter resolution light detection and ranging (LiDAR), and field measurements were compared to test the potential utility of LiDAR in empirical models of atmospheric deposition. From October 2012 to May 2013, we measured bulk (primarily wet) deposition and sulfate-S, chloride (Cl(-)), and nitrate-N fluxes beneath eight clusters of Douglas fir trees differing in size and canopy exposure in the Santa Cruz Mountains, California. For all trees sampled, LiDAR data were used to derive canopy surface height, tree height, slope, and canopy curvature, while tree height, diameter (DBH), and leaf area index were measured in the field. Wet season throughfall fluxes to Douglas fir clusters ranged from 1.4 to 3.8 kg S ha(-1), 17-54 kg Cl(-) ha(-1), and 0.2-4 kg N ha(-1). Throughfall S and Cl(-) fluxes were highest under clusters with large trees at topographically exposed sites; net fluxes were 2-18-fold greater underneath exposed/large clusters than all other clusters. LiDAR indices of canopy curvature and height were positively correlated with net sulfate-S fluxes, indicating that small-scale canopy surface features captured by LiDAR influence fog and dry deposition. Although tree diameter was more strongly correlated with net sulfate-S throughfall flux, our data suggest that LiDAR data can be related to empirical measurements of throughfall fluxes to generate robust high-resolution models of atmospheric deposition.

Tropical land-cover change alters biogeochemical inputs to ecosystems in a Mexican montane landscape.

In tropical regions, the effects of land-cover change on nutrient and pollutant inputs to ecosystems remain poorly documented and may be pronounced, especially in montane areas exposed to elevated atmospheric deposition. We examined atmospheric deposition and canopy interactions of sulfate-sulfur (SO4(2-)-S), chloride (Cl-), and nitrate-nitrogen (NO(3-)-N) in three extensive tropical montane land-cover types: clearings, forest, and coffee agroforest. Bulk and fog deposition to clearings was measured as well as throughfall (water that falls through plant canopies) ion fluxes in seven forest and five coffee sites. Sampling was conducted from 2005 to 2008 across two regions in the Sierra Madre Oriental, Veracruz, Mexico. Annual throughfall fluxes to forest and coffee sites ranged over 6-27 kg SO4(2-)-S/ha, 12-69 kg Cl-/ha, and 2-6 kg NO(3-)-N/ha. Sulfate-S in forest and coffee throughfall was higher or similar to bulk S deposition measured in clearings. Throughfall Cl- inputs, however, were consistently higher than Cl- amounts deposited to cleared areas, with net Cl- fluxes enhanced in evergreen coffee relative to semi-deciduous forest plots. Compared to bulk nitrate-N deposition, forest and coffee canopies retained 1-4 kg NO(3-)-N/ha annually, reducing NO(3-)-N inputs to soils. Overall, throughfall fluxes were similar to values reported for Neotropical sites influenced by anthropogenic emissions, while bulk S and N deposition were nine- and eightfold greater, respectively, than background wet deposition rates for remote tropical areas. Our results demonstrate that land-cover type significantly alters the magnitude and spatial distribution of atmospheric inputs to tropical ecosystems, primarily through canopy-induced changes in fog and dry deposition. However, we found that land cover interacts with topography and climate in significant ways to produce spatially heterogeneous patterns of anion fluxes, and that these factors can converge to create deposition hotspots. For land managers, this finding suggests that there is potential to identify species and ecosystems at risk of excess and increasing deposition in montane watersheds undergoing rapid transformation. Our data further indicate that montane ecosystems are vulnerable to air pollution impacts in this and similar tropical regions downwind of urban, industrial, and agricultural emission sources.

In utero progression of mild fetal ventriculomegaly.

OBJECTIVE: To evaluate the progression in utero of mild isolated fetal ventriculomegaly (defined as a transverse diameter of the atrium of the lateral ventricle measuring between 10 and 15 mm), and to estimate the proportion of fetuses that normalize (diameter decreasing to less than 10mm), stabilize (remaining between 10 and 15 mm), or progress to more severe ventriculomegaly (becoming greater than 15 mm). METHODS: The obstetric databases of 3 institutions were queried for any studies mentioning ventriculomegaly or hydrocephalus. Reports and original images were reviewed to verify cases of isolated mild ventriculomegaly, with no other anomalies on comprehensive ultrasonographic examination. Fetuses that had 2 or more evaluations more than 3 weeks apart were included. RESULTS: A total of 63 fetuses met the criteria for isolated mild ventriculomegaly. The mean gestational age and ventricular measurements were 24.7+/-3.7 weeks and 11.8+/-1.1mm, respectively, at the initial scan and 34+/-2.9 weeks and 12.1 +/-3.8mm, respectively, at the final scan. The mean number of scans was 3.75 per fetus (range, 2-6). Amniocentesis revealed the deletion of 5p, which causes the cri du chat, in 1 of 21 fetuses; 26 fetuses (41%) showed normalization of the lateral ventricles; 10 fetuses (16%) showed progression; and 27 (43%) appeared stable. shows the statistics of the individual groups. Three of the fetuses that "stabilized" improved from 15 mm to 11, 11.5, and 11.7 mm, respectively. Two worsened from 10.2 to 14 mm and from 11.4 to 13 mm. CONCLUSIONS: More than 40% of the cases of mild isolated fetal ventriculomegaly resolved in utero. The significant overlap in measurements for the different groups precludes prediction in individual cases. However, of the 13 cases where the transverse diameter measured 13 mm or more, only 1 normalized, while 9 of the remaining 12 cases stabilized and 3 progressed.

Lowland forest loss in protected areas of Indonesian Borneo.

The ecology of Bornean rainforests is driven by El Niño-induced droughts that trigger synchronous fruiting among trees and bursts of faunal reproduction that sustain vertebrate populations. However, many of these species- and carbon-rich ecosystems have been destroyed by logging and conversion, which increasingly threaten protected areas. Our satellite, Geographic Information System, and field-based analyses show that from 1985 to 2001, Kalimantan's protected lowland forests declined by more than 56% (>29,000 square kilometers). Even uninhabited frontier parks are logged to supply international markets. "Protected" forests have become increasingly isolated and deforested and their buffer zones degraded. Preserving the ecological integrity of Kalimantan's rainforests requires immediate transnational management.

Prevalence of HIV, hepatitis B, and hepatitis C antibodies in prisoners in England and Wales: a national survey.

Prisoners in eight of the 135 prisons in England and Wales were surveyed in 1997 and 1998 to study the prevalence of and risk factors for transmission of bloodborne viruses in prison. Subjects voluntarily completed a risk factor questionnaire and provided oral fluid specimens for unlinked anonymous testing for the presence of antibodies to HIV, hepatitis C virus (HCV), and the core antigen of hepatitis B virus (HBc). Almost 8% (4778) of the total of 60,561 prisoners were eligible and four fifths (3942) of those eligible took part. Among all those tested (3930) 0.4% (14) were positive for anti-HIV, 8% (308) for anti-HBc, and 7% (293) for anti-HCV (the anti-HBc and anti-HCV prevalences were not adjusted for assay sensitivities of 82% and 80%, respectively). Twenty-four per cent (777/3176) of adult prisoners reported ever having injected drugs, 30% of whom (224/747) reported having injected in prison. Three quarters of those who injected in prison (167/224) shared needles or syringes. Among adult injecting drug users, 0.5% (4/775) had anti-HIV, 31% (240/775) anti-HCV, and 20% (158/775) anti-HBc. The presence of anti-HCV and anti-HBc was associated with injecting inside prison and number of previous times in prison. The results suggest that hepatitis viruses are probably being transmitted in prisons through sharing non-sterile injecting equipment and that a risk of HIV transmission exists. Harm minimisation measures for the 6% of prisoners who continue to inject while in prison should be strengthened.

Alpha-Bungarotoxin binding to human muscle acetylcholine receptor: measurement of affinity, delineation of AChR subunit residues crucial to binding, and protection of AChR function by synthetic peptides.

Alpha-Bungarotoxin (alpha-BuTx) binds with high affinity to the nicotinic acetylcholine receptor (AChR) of most species, mainly to sequences around the two cysteines at positions 192 and 193 of the alpha-subunit, but other sequences of the alpha-subunit and of the adjacent gamma- or epsilon- and delta-subunits are also important in the native molecule. Alpha-BuTx binds strongly to human AChR but the short alpha neurotoxins, for instance Erabutoxin B, are relatively ineffective at the human neuromuscular junction. In this article we compare the affinity of 125I-alpha-BuTx for Torpedo and human muscle AChR and the ability of neurotoxins to inhibit this binding. We examine the contribution to alpha-BuTx binding of the three amino acids that differ between human and Torpedo AChR alpha-185-196. In addition, we show that an alpha-185-199, peptide that binds strongly to 125I-alpha-BuTx and can inhibit its binding in solution, is also capable of protecting the AChR on a cell line or at the neuromuscular junction. Such peptides might be useful in the treatment of acute envenoming or the autoantibody-mediated block of AChR function that can occur in human disorders.

Superior exercise performance in lifelong Tibetan residents of 4,400 m compared with Tibetan residents of 3,658 m.

Few environments challenge human populations more than high altitude, since the accompanying low oxygen pressures (hypoxia) are pervasive and impervious to cultural modification. Work capacity is an important factor in a population's ability to thrive in such an environment. The performance of work or exercise is a measure of the integrated functioning of the O2 transport system, with maximal O2 uptake (.VO2max) a convenient index of that function. Hypoxia limits the ability to transport oxygen: maximal O2 uptake decreases with ascent to high altitude, and years of high altitude residence do not restore sea level .VO2max values. Since Tibetans live and work at some of the highest altitudes in the world, their ability to exercise at very high altitude (>4,000 m) may define the limits of human adaptation to hypoxia. We transported 20 Tibetan lifelong residents of > or =4,400 m down to 3,658 m in order to compare them with 16 previously studied Tibetan residents of Lhasa (3,658 m). The two groups of Tibetans were matched for age, weight, and height. All studies were performed in Lhasa within 3 days of the 4,400 m Tibetans' arrival. Standard test protocol and criteria were used for attaining .VO2max on a Monark bicycle ergometer, while measuring oxygen uptake (.VO2, ml/kg - min STPD), heart rate (bpm), minute ventilation (VE, 1/min BTPS), and arterial oxygen saturation (SaO2, %). The 4,400 m compared with 3,658 m residents had, at maximal effort, similar .VO2 (48.5 +/- 1.2 vs. 51.2 +/- 1.4 ml/kg - min, P = NS), higher workload attained (211 +/- 6 vs. 177 +/- 7 watts, P < 0.01), lower heart rate(176 +/- 2 vs. 191 +/- 2 bpm, P < 0.01), lower ventilation (127 +/- 5 vs. 149 +/- 5 l/min BTPS, P < 0.01), and similar SaO2(81.9 +/- 1.0 vs. 83.7 +/- 1.2%, P = NS). Furthermore, over the range of submaximal workloads, 4,400 m compared with 3,658 m Tibetans had lower .VO2 (P < 0.01), lower heart rates (P < 0.01), and lower ventilation (P < 0.01) and SaO2 (P < 0.05). We conclude that Tibetans living at 4,400 m compared with those residing at 3,658 m achieve greater work performance for a given .VO2 at submaximal and maximal workloads with less cardiorespiratory effort.

Ventilation and hypoxic ventilatory responsiveness in Chinese-Tibetan residents at 3,658 m.

When breathing ambient air at rest at 3,658 m altitude, Tibetan lifelong residents of 3,658 m ventilate as much as newcomers acclimatized to high altitude; they also ventilate more and have greater hypoxic ventilatory responses (HVRs) than do Han ("Chinese") long-term residents at 3,658 m. This suggests that Tibetan ancestry is advantageous in protecting resting ventilation levels during years of hypoxic exposure and is of interest in light of the permissive role of hypoventilation in the development of chronic mountain sickness, which is nearly absent among Tibetans. The existence of individuals with mixed Tibetan-Chinese ancestry (Han-Tibetans) residing at 3,658 m affords an opportunity to test this hypothesis. Eighteen men born in Lhasa, Tibet, China (3,658 m) to Tibetan mothers and Han fathers were compared with 27 Tibetan men and 30 Han men residing at 3,658 m who were previously studied. We used the same study procedures (minute ventilation was measured with a dry-gas flowmeter during room air breathing and hyperoxia and with a 13-liter spirometer-rebreathing system during the hypoxic and hypercapnic tests). During room air breathing at 3,658 m (inspired O2 pressure = 93 Torr), Han-Tibetans resembled Tibetans in ventilation (12.1 +/- 0.6 vs. 11.5+/- 0.5 l/min BTPS, respectively) but had HVR that were blunted (63 +/- 16 vs. 121 +/- 13, respectively, for HVR shape parameter A) and declined with increasing duration of high-altitude residence. During administered hyperoxia (inspired O2 pressure = 310 Torr) at 3,658 m, the paradoxical hyperventilation previously seen in Tibetan but not Han residents at 3,658 m (11.8 +/- 0.5 vs. 10.1 +/- 0.5 l/min BTPS) was absent in these Han-Tibetans (9.8 +/- 0.6 l/min BTPS). Thus, although longer duration of high-altitude residence appears to progressively blunt HVR among Han-Tibetans born and residing at 3, 658 m, their Tibetan ancestry appears protective in their maintenance of high resting ventilation levels despite diminished chemosensitivity.

Hypoxic ventilatory responses in Tibetan residents of 4400 m compared with 3658 m.

Lifelong Tibetan residents of 3658 m ventilate as much and have hypoxic and hypercapnic ventilatory responsiveness as least as great as acclimatized newcomers, and likely greater than lifelong North or South American high-altitude residents. To determine whether Tibetans residing at altitudes > 3658 m maintained similar levels of ventilation, hypoxic and hypercapnic ventilatory responses, we transported 20 lifelong residents of > or = 4400 m to 3658 m for comparison with 27 similarly-aged male Tibetan residents of 3658 m. At 3658 m, the 4400 m compared with the 3658 m Tibetans had similar levels of minute ventilation and arterial O2 saturation, higher respiratory quotients but lower hypoxic ventilatory responses. We conclude that Tibetan residents of > or = 4400 m ventilate as much as Tibetan residents of 3658 m despite an altitude-associated blunting of their hypoxic ventilatory responses. Thus, factors other than hypoxic ventilatory chemosensitivity are likely to be important contributors to resting ventilation among Tibetan high altitude residents.

'Organic phase buffers' control biocatalyst activity independent of initial aqueous pH.

Combinations of triisooctylamine with its hydrochloride, or of triphenylacetic acid with its Na+ salt, can function as buffers for use during biocatalysis in organic media. They can control the pH of an adjacent aqueous phase, even though both forms of each buffer remain in the organic phase. With 0.1 M aqueous NaCl, the mid-point pH values obtained with the two buffer systems are around pH 4.5 and 7.0, respectively. The activity of an immobilized subtilisin Carlsberg shows a strong dependence on the ratio of the two forms of the triphenylacetic acid buffer system. Without the buffer, the rate shows the normal dependence on the pH of the aqueous solution before drying; however, this is almost eliminated if the buffer is used. The amine buffer system can similarly affect the activity of an immobilized Rhizomucor miehei lipase.

Zocor, the postmarketing experience.

The aim of this study was to develop and test a descriptive, intensive drug surveillance methodology in order to examine the effectiveness and safety of new drugs in the immediate postmarketing period. The HMG-CoA reductase inhibitor, simvastatin (Zocor), was chosen as the test drug. Data were collected from 100 randomly chosen cardiologists, specialist physicians and general practitioners practising in the six main centres of South Africa. A 66% doctor response rate was achieved and 438 patients were enrolled in the study. The overall effectiveness expressed as a percentage decrease (from baseline) in total cholesterol levels was 20.5% for the 251 patients who started on a 10 mg daily dose of the drug and 27.6% for the 42 patients who started on 10 mg but changed to 20 mg/d. The safety profile of simvastatin was comparable with the premarketing clinical trial data, and patient non-compliance appeared to be dose-related. The methodology employed was found to be suitable for the collection of safety and effectiveness data in the postmarketing period and simvastatin was shown to be effective with few adverse events reported.

Clinical clerkships in neurosurgery and neurology at United States medical schools.

The neurology and neurosurgery clinical clerkship experience (excluding lectures and conferences) of the students in U.S. allopathic medical schools during one of the academic years 1986 to 1987 or 1987 to 1988 was surveyed. Almost all schools have at least some students taking these clerkships. The majority of students (78%) have clinical exposure to neurology, but only a minority (28%) take a neurosurgical clerkship; however, far more schools require their students to take neurology clerkships (54%) than neurosurgical clerkships (12%). A few require that either be taken. Overall, 81% of schools require all students to take at least one of these clerkships. For the most part, students taking a clerkship in either specialty do not do so again. The initial and usually unique exposure averages 3.5 weeks in neurology and 2.4 weeks in neurosurgery. For each specialty, required clerkships tended to be shorter than selective clerkships, which in turn were shorter than elective ones. Furthermore, first clerkships offered in the fourth year, whether they were required, selective, or elective, tended to be longer than the corresponding third-year first clerkships at other schools. Whereas the average length of a first clinical clerkship in neurology is almost as long for schools requiring it (3.4 wk) as for those that offer it as an elective or selective (4.0 wk), required neurosurgical clerkships are much shorter (1.5 wk) than elective or selective rotations (3.1 wk). Schools with residency training programs more frequently required students to a clerkship and, consequently, had greater numbers of students taking a clerkship in the corresponding specialty.(ABSTRACT TRUNCATED AT 250 WORDS)

HIV counselling in prisons.

HIV presents particular problem in penal establishments: the nature of the population; conditions in prison; media attention and misinformation; the possibility of transmission within and beyond the prison population; the extra issues that apply to female prisoners. These are discussed in the context of prison policy regarding HIV and the broad strategic approach which is being adopted to manage the problem of HIV within penal institutions. Counselling has a key role in the overall strategy. Pre- and post-test counselling with prisoners is described and the particular problems presented by inmates are discussed and illustrated by reference to case histories. Developments in counselling provision for inmates are outlined.

PIP: This paper explores on HIV counseling in prisons. HIV infection presents particular problems in penal establishments including the nature of prison conditions, attention and misinformation by the media, transmission of HIV infection with prisoners and outsiders, and the extra issues that apply to female prisoners. All these are discussed in the context of prison service policy regarding HIV infection and the broad strategic approach employed to manage the problem within penal establishments where counseling played a key role. Moreover, this article features the pre-test and post-test counseling and problems presented by inmates, which are discussed and illustrated with reference to several case histories. Also outlined are developments in counseling provision for prisoners. Pre-test counseling, which is performed to ensure knowledge of the test, presents additional problems in the penal setting because of difficulties in maintaining absolute confidentiality of results, mismatch of counseling expectations and motivations with counseling aims, and unique problems for the development of safer behavior. Meanwhile, post-test counseling with HIV-positive inmates is problematic and requires particular skills of the counselors. It should be recognized that prison could represent an opportunity to offer education and counseling to a unique and vulnerable population.

Fibrinolysis in systemic lupus erythematosus: effect of desamino D-arginine vasopressin infusion.

In systemic lupus erythematosus (SLE) the lupus anticoagulant is known to be associated with thrombosis. However, this anticoagulant only occurs in a small percentage of patients. Histopathological studies suggest a more generalized thrombotic tendency with platelets and fibrin within the microvasculature. Fibrinogen is elevated in SLE and this may lead to the fibrin deposition described. We wondered if decreased fibrinolysis contributed to this and we infused desamino D-arginine vasopressin (DDAVP) into ten patients with SLE and eight controls. DDAVP stimulates endothelial production of plasminogen activator (PA) and factor VIII. Baseline results showed a significant decrease in PA activity with a concomitant increase in fibrinogen in SLE. The t-PA and inhibitor levels were normal but factor VIII was increased. After infusion of DDAVP, results indicated that, despite baseline results, SLE patients were able to respond to stimulation and the increase in PA activity produced a decrease in plasma fibrinogen levels. These findings may have therapeutic implications.