Near real-time surveillance of the SARS-CoV-2 epidemic with incomplete data.

Designing public health responses to outbreaks requires close monitoring of population-level health indicators in real-time. Thus, an accurate estimation of the epidemic curve is critical. We propose an approach to reconstruct epidemic curves in near real time. We apply this approach to characterize the early SARS-CoV-2 outbreak in two Spanish regions between March and April 2020. We address two data collection problems that affected the reliability of the available real-time epidemiological data, namely, the frequent missing information documenting when a patient first experienced symptoms, and the frequent retrospective revision of historical information (including right censoring). This is done by using a novel back-calculating procedure based on imputing patients' dates of symptom onset from reported cases, according to a dynamically-estimated "backward" reporting delay conditional distribution, and adjusting for right censoring using an existing package, NobBS , to estimate in real time (nowcast) cases by date of symptom onset. This process allows us to obtain an approximation of the time-varying reproduction number ( R t ) in real-time. At each step, we evaluate how different assumptions affect the recovered epidemiological events and compare the proposed approach to the alternative procedure of merely using curves of case counts, by report day, to characterize the time-evolution of the outbreak. Finally, we assess how these real-time estimates compare with subsequently documented epidemiological information that is considered more reliable and complete that became available later in time. Our approach may help improve accuracy, quantify uncertainty, and evaluate frequently unstated assumptions when recovering the epidemic curves from limited data obtained from public health surveillance systems in other locations.

Self-efficacy toward physical activity and the physical activity behavior of children with and without Developmental Coordination Disorder.

PURPOSE: Affecting 5-6% of children, Developmental Coordination Disorder (DCD) is a prevalent chronic condition. The nature of the disorder - impaired motor coordination - makes avoidance of physical activity (PA) common. The purpose of this study was to examine the effect of barrier and task self-efficacy on PA behavior in children with DCD and a group of typically developing (TD) children. METHODS: Children were compared on their perceived ability to complete different intensities and duration of PA (task efficacy) and their confidence in completing PA when faced with everyday barriers (barrier efficacy). An accelerometer was used to record their activity over the subsequent week. RESULTS: Children with DCD were found to have significantly lower task efficacy and barrier efficacy. They also spent significantly less time in moderate to vigorous physical activity (MVPA). Multivariate analyses revealed that gender modified the relationship for both groups. Separate multivariate regressions, were therefore conducted by gender. A direct effect of DCD on PA was observed for boys, but not for girls. Further analyses showed that neither task efficacy nor barrier efficacy influenced the relationship between DCD and PA. CONCLUSION: Results from this study confirm that children with DCD have lower task and barrier self-efficacy than TD children and that males have lower PA levels than their TD peers; however neither task or barrier self-efficacy mediated the relationship between DCD and PA.

Developmental coordination disorder and overweight and obesity in children aged 9-14 y.

Developmental coordination disorder (DCD) is a significant problem that affects between 5 and 9% of all children. Since children with DCD are less likely than their non-DCD peers to participate in physical activities, they may be at greater risk for overweight and obesity. In this report, we examine the relationship between DCD and overweight and obesity in a sample of 578 children aged 9-14 y. We also examine whether the relationship between DCD and overweight/obesity is the same for boys and girls, taking into account sex and age-appropriate differences in percentage body fat and body mass index (BMI) criteria. Our results show that for boys, DCD may be a risk factor for overweight/obesity in childhood and early adolescence. For girls, there is no difference in the prevalence of overweight/obesity between children with and without the disorder.

Fatal cyst formation after fetal mesencephalic allograft transplant for Parkinson's disease.

OBJECT: In recent years, fetal mesencephalic tissue transplant for the treatment of Parkinson's disease (PD) has been demonstrated to hold promise, but potential complications related to growth of allograft tissue have not been well described. This report explores the development and possible causation of a fatal cyst arising from a fetal transplant in the brain. METHODS: The authors report the case of a 52-year-old woman who underwent bilateral putamenal fetal mesencephalic allograft transplant for PD at another hospital. Twenty-three months later she presented to the authors' institution in a coma. Admission computerized tomography and magnetic resonance (MR) studies revealed a contrast-enhancing mural nodule and associated large cyst arising from the left putamen and causing brainstem compression. Despite surgical decompression of the cyst, the patient did not regain consciousness. Biopsy and autopsy specimens were obtained, along with an analysis of the cyst fluid. Genotyping of the nodule and the patient's peripheral lymphocytes by using polymerase chain reaction-based microsatellite analysis was also performed. Biopsy samples and autopsy histopathological studies showed inflammatory cells, hemosiderin-laden macrophages, and astrocytosis. Scattered neurons and multiple rests of choroid plexus were also noted. The cyst had a thin wall and contained liquid that was identical in composition to cerebrospinal fluid (CSF). Genotyping demonstrated the presence of alleles in the nodule DNA that were not present in lymphocytic DNA, indicating that the nodule contained allograft tissue. CONCLUSIONS: The authors hypothesize that the choroid plexus tissue contained in the allograft resulted in CSF production and cyst formation at the transplant site, ultimately leading to the patient's herniation syndrome. The clinical history and large size of the mural nodule indicate slow growth of this allograft site and cyst over time. This case demonstrates that unusual patterns of tissue growth can occur in the brain after fetal tissue transplant and emphasizes the need for long-term monitoring of posttransplant patients by means of MR imaging. Cell sorting should be considered to ensure transplant of pure neuronal and astroglial populations.

Activity levels and the relationship to lung function and nutritional status in children with cystic fibrosis.

Cystic fibrosis is characterized by chronic obstructive lung disease and malnutrition. Previous studies have shown that nutritional status and lung function are limiting factors for exercise capacity. A reduced exercise capacity may in turn diminish activity levels. We evaluated whether the total time spent somewhat active (e.g., walking) or active (e.g., biking), as reported by the Habitual Activity Estimation Scale, was related to lung function, as evaluated by forced expiratory volume in one second (%predicted FEV1), and nutritional status, measured as body mass percentile, in 36 children with cystic fibrosis, aged 6 to 16 years. The Habitual Activity Estimation Scale questionnaires were completed by the parents for children younger than 12 years of age and by both the parent and the child, independently, for those 12 years and older. Patients had a body mass percentile of 99 +/- 15.2% and % predicted FEV1 of 85.7 +/- 20, with no differences between boys (15/36) and girls (21/36). Boys spent 8.1 hours and girls spent 7.5 hours (P > 0.1) being at least somewhat active. These values are similar to those reported for healthy boys and girls. In patients with significant lung disease (%predicted FEV1, < or = 75; n = 11), activity level (the time spent somewhat active or active) was related to nutritional status (r = 0.675; P = 0.02) but not to lung function (r = 0.21; P > 0.1). Activity level reported by patients 12 years of age and older was on average 24.1% higher (P < 0.05) than that reported by their parents, but the two reportings were related (r = 0.758; P = 0.004). These results suggest that activity level may be restricted by nutritional status in those patients with significant air flow limitation. We suggest that improving the nutritional status of cystic fibrosis patients may prevent decreases in activity levels and quality of life of these affected children.

Prospective evaluation of a clinical guideline recommending hospital length of stay in upper gastrointestinal tract hemorrhage.

CONTEXT: Upper gastrointestinal tract hemorrhage (UGIH) is a common and potentially life-threatening disorder. Resource utilization can vary without adverse effect on patient outcome. Clinical practice guidelines are a potential solution to reduce variation in practice while improving patient outcomes. OBJECTIVE: To validate prospectively the safety, acceptability, and impact of a clinical practice guideline defining the medically appropriate length of stay (LOS) for patients hospitalized with UGIH. DESIGN: Prospective, controlled time-series study with an alternate-month design. Outcome surveyors and patients were blinded to study group allocation. GUIDELINE: A retrospectively validated scoring system using 4 independent variables: hemodynamics, time from bleeding, comorbidity, and esophagogastroduodenoscopy (EGD) findings to predict risk of adverse events. The quantitative risk for the low-risk subset was 0.6% (95% confidence interval [CI], 0.0%-2.0%) for subsequent complications and 0% (95% CI, 0.0%-0.9%) for life-threatening complications from this retrospective evaluation. SETTING: A 1000-bed, not-for-profit, university-affiliated teaching hospital. PATIENTS: Consecutive adult patients hospitalized for acute UGIH. INTERVENTION: Concurrent feedback of guideline recommendation (same-day hospital discharge) to physicians caring for patients at low risk for complication. No risk information was provided during control months. RESULTS: Seventy percent (209/299) of UGIH patients achieved low-risk status according to the guideline and were therefore potentially suitable for early discharge from the hospital. Providing real-time quantitative risk information (intervention group only) was associated with an increase in guideline compliance from 30% to 70% (P<.001) and a decrease in mean (SD) LOS from 4.6 (3.5) days to 2.9 (1.3) days (mean reduction of 1.7 days per patient; P<.001). No differences in complications, patient health status, or patient satisfaction were found when measured 1 month after discharge. An independent variable predicting decreased hospital LOS for low-risk UGIH patients was early EGD. CONCLUSIONS: Implementation of the clinical practice guideline safely reduced hospital LOS for selected low-risk patients with acute UGIH. Further prospective validation in other settings is warranted.

Upper gastrointestinal hemorrhage clinical--guideline determining the optimal hospital length of stay.

PURPOSE: Physicians lack objective outcome data to define the medically appropriate length of stay (LOS) for patients hospitalized with acute upper gastrointestinal hemorrhage (UGIH), resulting in wide variations in resource utilization and quality of care. A clinical practice guideline with the ability to assign relative risk for adverse events is proposed. METHODS: A comprehensive scoring system was derived from the literature by using four variables; hemodynamics, time from bleeding, comorbidity, and esophagoduodenoscopy findings. The discriminatory ability, potential safety, and impact on resource utilization of the clinical practice guideline was measured in a retrospective, observational study. RESULTS: Seventy percent of UGIH patients (349 of 500) achieved low-risk status according to the guideline, and, were therefore potentially suitable for early discharge from the hospital. If low-risk patients were discharged based upon the guideline, mean (+/- SD) hospital LOS would have been decreased from 4.8 +/- 2.4 days to 2.7 +/- 1.4 days; mean reduction was 2.1 bed-days per patient (95% CI 1.8 to 2.3, P <0.001). LOS would have increased in 4% of cases. Adopting the guideline's recommendation of early discharge would have resulted in a 0.6% (95% CI 0.07 to 2.1) complication rate, with no worsening of quality of care, as judged by implicit review. CONCLUSIONS: The proposed clinical practice guideline may safely reduce hospital LOS for selected low-risk patients with acute UGIH. Moreover, it also may reduce premature discharge of high-risk patients prone to life-threatening events.

Investigating the development of self-evaluation skills in a problem-based tutorial course.

PURPOSE: To compare students' self-evaluations of their performances with the evaluations they received from their tutors in a problem-based course. METHOD: In the Occupational Therapy and Physiotherapy Programme of the McMaster University Faculty of Health Sciences in 1993-94, a study was conducted of the self-evaluation skills of 30 students in five tutorial groups. Repeated-measures analyses of variance, factor analyses, and Pearson correlations were used to examine the student's self-evaluations in comparison with their tutors' evaluations on six consecutive occasions over a 14-week period. RESULTS: Significant (p < .01) increases were found for both students' and tutors' evaluation scores over the six evaluations. A significant interaction was also found, with the tutors' evaluations being initially lower but eventually higher than the students' self-evaluations. Correlations between students' and tutors' evaluations rose in a sawtooth manner from .49 on the first evaluation to .84 by the sixth evaluation. There was a pattern of diminishing oscillations in the interobserver correlations over the six evaluations. CONCLUSION: When combined with the steady increase in evaluation scores, the pattern of diminishing oscillations in interobserver correlations was interpreted more as evidence of a negotiation process between students and their tutors than as evidence of improvement in self-evaluation skills.

Male occupational therapists in Ontario: a survey of work-related issues.

Job satisfaction greatly influences an individual's decision to remain in his or her work situation. In many studies, one of the primary reasons for men leaving the profession of occupational therapy was due to job dissatisfaction. The purpose of this study was to further investigate the issue of job satisfaction in male occupational therapists. In March 1992, a survey was mailed to all (n = 82) male occupational therapists practicing in Ontario. A 67% (n = 55) response rate was obtained. This study addressed several factors pertaining to job satisfaction and other work-related issues. When using the median years of OT work experience (ie. seven) to divide the sample, two items were found to be significantly different when using one-way analyses of variance (ANOVA's): "satisfaction with the standing of the profession" and cumulative "satisfaction variable" items. In this study, less experienced male occupational therapists reported themselves to be less satisfied, more inclined to leave the profession or pursue another profession, but did not feel more isolated than their more experienced counterparts. The means of all items revealed a feeling of dissatisfaction on the Likert-scale used in this survey. Although no statistical significance could be achieved, a clear trend existed toward a lower level of satisfaction among the less experienced group.

Voluntary dehydration and heat intolerance in cystic fibrosis.

Although exercise may be beneficial in cystic fibrosis (CF), patients' low tolerance to climatic heat stress means that physical exertion can increase morbidity and mortality. We postulated that the high salt content of CF patients' sweat and the consequent absence of body-fluid hyperosmolality during a long episode of sweating might deprive such patients of a thirst stimulus. Eight children with CF (four boys, four girls; aged 9.5-14.1 years) and eight controls, matched for age and sex, attended two randomly ordered sessions of exercise (cycling) in a chamber at 31-33 degrees C, relative humidity 43-47%. 20 min bouts of exercise (at 45% of predetermined maximum oxygen uptake) were interspersed with 25 min rest periods. At one session, chilled water was given every 15-20 min to replace fluid lost; at the other, drinking was guided by the child's thirst. At the thirst-guided session, CF patients drank much less than the controls did (0.80% vs 1.73% initial body weight) and lost twice as much fluid (1.57% vs 0.78% initial body weight). The recovery of heart rate after exercise was slower in CF patients, but there were no other signs of heat strain. The groups did not differ in any variable during the forced drinking session. We conclude that children with CF underestimate their fluid needs and undergo excessive dehydration during extended exposure to hot conditions.

Genetic markers in Australian Caucasian subjects with coeliac disease.

A group of 69 unrelated Australian coeliac subjects (41 adult onset and 28 childhood onset) were typed for for HLA-A, B, DR and DQ antigens. Immunoglobulin allotypes were also determined in 36 of these patients. An association between coeliac disease and the antigens DR3, DR7 and DQw2 was confirmed in this population. There was no significant difference in antigen frequencies between childhood and adult onset coeliac disease, although the association with DR7 was stronger in the childhood group. All coeliac patients who did not carry DR3 or DR7 were found to be DR4 positive. No association was demonstrated between coeliac disease and any immunoglobulin allotype, either in the absence of HLA antigens B8 and DR3 or in male coeliac patients.