Humanism in the Age of COVID-19: Renewing Focus on Communication and Compassion

The global COVID-19 pandemic has become one of the largest clinical and operational challenges faced by emergency medicine, and our EDs continue to see increased volumes of infected patients, many of whom are not only ill, but acutely aware and fearful of their circumstances and potential mortality. Given this, there may be no more important time to focus on staff-patient communication and expression of compassion.However, many of the techniques usually employed by emergency clinicians to provide comfort to patients and their families are made more challenging or impossible by the current circumstances. Geriatric ED patients, who are at increased risk of severe disease, are particularly vulnerable to the effects of isolation.Despite many challenges, emergency clinicians have at their disposal a myriad of tools that can still be used to express compassion and empathy to their patients. Placing emphasis on using these techniques to maximize humanism in the care of COVID-19 patients during this crisis has the potential to bring improvements to ED patient care well after this pandemic has passed

Genomic surveillance of SARS-CoV-2 using long-range PCR primers

IntroductionWhole Genome Sequencing (WGS) of the SARS-CoV-2 virus is crucial in the surveillance of the COVID-19 pandemic. Several primer schemes have been developed to sequence nearly all of the ~30,000 nucleotide SARS-CoV-2 genome, using a multiplex PCR approach to amplify cDNA copies of the viral genomic RNA. Midnight primers and ARTIC V4.1 primers are the most popular primer schemes that can amplify segments of SARS-CoV-2 (400 bp and 1200 bp, respectively) tiled across the viral RNA genome. Mutations within primer binding sites and primer-primer interactions can result in amplicon dropouts and coverage bias, yielding low-quality genomes with ‘Ns’ inserted in the missing amplicon regions, causing inaccurate lineage assignments, and making it challenging to monitor lineage-specific mutations in Variants of Concern (VoCs).MethodsIn this study we used a set of seven long-range PCR primer pairs to sequence clinical isolates of SARS-CoV-2 on Oxford Nanopore sequencer. These long-range primers generate seven amplicons approximately 4500 bp that covered whole genome of SARS-CoV-2. One of these regions includes the full-length S-gene by using a set of flanking primers. We also evaluated the performance of these long-range primers with Midnight primers by sequencing 94 clinical isolates in a Nanopore flow cell.Results and discussionUsing a small set of long-range primers to sequence SARS-CoV-2 genomes reduces the possibility of amplicon dropout and coverage bias. The key finding of this study is that long range primers can be used in single-molecule sequencing of RNA viruses in surveillance of emerging variants. We also show that by designing primers flanking the S-gene, we can obtain reliable identification of SARS-CoV-2 variants

Influence of freezing and heating conditions on grape seed flavan-3-ol extractability, oxidation, and galloylation pattern

In cool-climate viticulture, the short growing season can influence grape seed maturation by reducing the apparent oxidation of flavan-3-ol monomers and associated increase in seed browning. A reduction in seed maturation increases the potential extraction of flavan-3-ol monomers into wine during maceration operations, heightening bitterness. Here, we carried out a 2 × 2 factorial experiment to test the ability of freezing and heating treatments to advance maturation (decrease flavan-3-ol, improve browning) of (Vitis vinifera L.) Pinot noir and Cabernet Sauvignon seeds over a 24-h incubation period. Only freezing significantly increased seed browning in both cultivars. Subsequent correlations with seed flavan-3-ol monomer concentrations suggest that freezing enhanced the oxidation of these compounds. Interestingly, natural ripening and freezing reduced galloylated flavan-3-ol monomers to a greater extent than non-galloylated ones. This study provides new information regarding the susceptibility of flavan-3-ol monomers to freezing and heating, and also suggests that freezing can advance the maturation the seeds of under-ripe red vinifera grapes

Towards understanding the clinical significance of QT peak prolongation: a novel marker of myocardial ischemia independently demonstrated in two prospective studies

Background: QT peak prolongation identified patients at risk of death or non-fatal MI. We tested the hypothesis that QT peak prolongation might be associated with significant myocardial ischaemia in two separate cohorts to see how widely applicable the concept was. Methods and Results: In the first study, 134 stroke survivors were prospectively recruited and had 12-lead ECGs and Nuclear myocardial perfusion scanning. QT peak was measured in lead I of a 12-lead ECG and heart rate corrected by Bazett’s formula (QTpc). QTpc prolongation to 360ms or more was 92% specific at diagnosing severe myocardial ischaemia. This hypothesis-generating study led us to perform a second prospective study in a different cohort of patients who were referred for dobutamine stress echocardiography. 13 of 102 patients had significant myocardial ischaemia. Significant myocardial ischaemia was associated with QT peak prolongation at rest (mean 354ms, 95% CI 341-367ms, compared with mean 332ms, 95% CI 327-337ms in those without significant ischaemia; p=0.002). QT peak prolongation to 360ms or more was 88% specific at diagnosing significant myocardial ischaemia in the stress echocardiography study. QT peak prolongation to 360ms or more was associated with over 4-fold increase odds ratio of significant myocardial ischaemia. The Mantel- Haenszel Common Odds Ratio Estimate=4.4, 95% CI=1.2-16.0, p=0.023. Conclusion: QT peak (QTpc) prolongation to 360ms or more should make us suspect the presence of significant myocardial ischaemia. Such patients merit further investigations for potentially treatable ischaemic heart disease to reduce their risk of subsequent death or non-fatal MI

Recombination and its impact on the genome of the haplodiploid parasitoid wasp Nasonia

Homologous meiotic recombination occurs in most sexually reproducing organisms, yet its evolutionary advantages are elusive. Previous research explored recombination in the honeybee, a eusocial hymenopteran with an exceptionally high genome-wide recombination rate. A comparable study in a non-social member of the Hymenoptera that would disentangle the impact of sociality from Hymenoptera-specific features such as haplodiploidy on the evolution of the high genome-wide recombination rate in social Hymenoptera is missing. Utilizing single-nucleotide polymorphisms (SNPs) between two Nasonia parasitoid wasp genomes, we developed a SNP genotyping microarray to infer a high-density linkage map for Nasonia. The map comprises 1,255 markers with an average distance of 0.3 cM. The mapped markers enabled us to arrange 265 scaffolds of the Nasonia genome assembly 1.0 on the linkage map, representing 63.6% of the assembled N. vitripennis genome. We estimated a genome-wide recombination rate of 1.4-1.5 cM/Mb for Nasonia, which is less than one tenth of the rate reported for the honeybee. The local recombination rate in Nasonia is positively correlated with the distance to the center of the linkage groups, GC content, and the proportion of simple repeats. In contrast to the honeybee genome, gene density in the parasitoid wasp genome is positively associated with the recombination rate; regions of low recombination are characterized by fewer genes with larger introns and by a greater distance between genes. Finally, we found that genes in regions of the genome with a low recombination frequency tend to have a higher ratio of non-synonymous to synonymous substitutions, likely due to the accumulation of slightly deleterious non-synonymous substitutions. These findings are consistent with the hypothesis that recombination reduces interference between linked sites and thereby facilitates adaptive evolution and the purging of deleterious mutations. Our results imply that the genomes of haplodiploid and of diploid higher eukaryotes do not differ systematically in their recombination rates and associated parameters.Publisher PDFPeer reviewe

Exercise and diet support in breast and prostate cancer survivors: Findings from focus groups

Purpose: Cancer survival is improving, making optimal management of long-term treatment-related adverse effects increasingly important. Exercise and a healthy diet are beneficial and regularly recommended in cancer survivorship guidelines; however, few cancer survivors meet these recommendations so there is a need to explore why. This study aimed to understand experiences receiving exercise and diet support among Australian breast and prostate cancer survivors during and following treatment, and to explore what support they would like to receive. Methods: Adults who completed active treatment for breast or prostate cancer were recruited via a private cancer care centre. Using a qualitative descriptive study design, participants attended in-person focus groups that were recorded, transcribed, then analysed using reflexive thematic analysis. Results: In total, 26 cancer survivors (15 breast, 11 prostate) participated in one of seven focus groups (4 breast, 3 prostate). Two themes were developed: 1) It was just brushed over, and 2) Wanting more. Theme 1 reports that exercise, and especially diet, were rarely discussed. If they were, it was often limited to general recommendations. Theme 2 shows that participants wanted more specific and personalised support, and information about how exercise and/or diet could benefit their cancer treatment. Conclusion: Despite strong interest in receiving personalised exercise and diet support, neither are routinely provided to Western Australian breast and prostate cancer survivors. If support was provided, there was inconsistency in the level and type of support provided. These findings identify important gaps in exercise and diet support provision to cancer survivors and will inform future strategies aiming to improve cancer survivorship care

Constraints on the SU(3) Electroweak Model

We consider a recent proposal by Dimopoulos and Kaplan to embed the electroweak SU(2)_L X U(1)_Y into a larger group SU(3)_W X SU(2) X U(1) at a scale above a TeV. This idea is motivated by the prediction for the weak mixing angle sin^2 theta_W = 1/4, which naturally appears in these models so long as the gauge couplings of the high energy SU(2) and U(1) groups are moderately large. The extended gauge dynamics results in new effective operators that contribute to four-fermion interactions and Z pole observables. We calculate the corrections to these electroweak precision observables and carry out a global fit of the new physics to the data. For SU(2) and U(1) gauge couplings larger than 1, we find that the 95% C.L. lower bound on the matching (heavy gauge boson mass) scale is 11 TeV. We comment on the fine-tuning of the high energy gauge couplings needed to allow matching scales above our bounds. The remnants of SU(3)_W breaking include multi-TeV SU(2)_L doublets with electric charge (+-2,+-1). The lightest charged gauge boson is stable, leading to cosmological difficulties.Comment: 17 pages, LaTeX, 4 figures embedded, uses JHEP.cl

Impact of vascular screening interventions on perceived threat, efficacy beliefs and behavioural intentions: A systematic narrative review

Health-related behaviours contribute to the global burden of cardiovascular disease (CVD). Cardiovascular imaging can be used to screen asymptomatic individuals for increased risk of CVD to enable earlier interventions to promote health-related behaviours to prevent or reduce CVD risk. Some theories of behaviour and behaviour change assume that engagement in a given behaviour is a function of individual threat appraisals, beliefs regarding the performance of behaviour, self-efficacy for performing the desired behaviour and/or dispositions to act (e.g. behavioural intentions). To date, little is known about the impact of cardiovascular imaging interventions on these constructs. This article summarises evidence related to perceived threat, efficacy beliefs, and behavioural intentions after CVD screening. We identified 10 studies (2 RCTs and 8 non-randomised studies, n = 2498) through a combination of screening citations from published systematic reviews and meta-analyses and searching electronic databases. Of these, 7 measured behavioural intentions and perceived susceptibility and 3 measured efficacy beliefs. Findings showed largely encouraging effects of screening interventions on bolstering self-efficacy beliefs and strengthening behavioural intentions. Imaging results that suggest the presence of coronary or carotid artery disease also increased perceived susceptibility to CVD. However, the review also identified some gaps in the literature, such as a lack of guiding theoretical frameworks and assessments of critical determinants of health-related behaviours. By carefully considering the key issues highlighted in this review, we can make significant strides towards reducing CVD risks and improving population health

Risk factors for rehospitalization for acute coronary syndromes and unplanned revascularization following acute myocardial infarction

Background Rehospitalizations for acute coronary syndromes (ACS) and coronary revascularization after an acute myocardial infarction (AMI) are not only common and costly but can also impact patients’ quality of life. In contrast to mortality and all‐cause readmissions, little insight is available into risk factors associated with ACS and revascularization after AMI. Methods and Results In a multicenter AMI registry, we examined the rates and predictors of rehospitalizations for ACS and revascularization within the year after AMI among 3283 patients. Staged revascularization procedures were excluded. Kaplan–Meier estimated rates of rehospitalization due to ACS and revascularization were 6.8% and 4.1%, respectively. In hierarchical, multivariable models, the strongest predictors of rehospitalization for ACS were coronary artery bypass graft prior to AMI hospitalization (hazard ratio [HR] 2.12, 95% CI 1.45 to 3.10), female sex (HR 1.67, 95% CI 1.23 to 2.25), and in‐hospital PCI (HR 1.85, 95% CI 1.28 to 2.69). The strongest predictors of subsequent revascularization were multivessel disease (HR 2.89, 95% CI 1.90 to 4.39) and in‐hospital percutaneous coronary intervention with a bare metal stent (HR 2.08, 95% CI 1.19 to 3.63). The Global Registry of Acute Coronary Events mortality risk score was not associated with the risk of rehospitalization for ACS or revascularization. Conclusions Unique characteristics are associated with admissions for ACS and revascularization, as compared with survival. These multivariable risk predictors may help identify patients at high risk for ACS and revascularization, in whom intensification of secondary prevention therapies or closer post‐AMI follow‐up may be warranted

Development and implementation of a mobile device-based pediatric electronic decision support tool as part of a national practice standardization project

OBJECTIVE: Implementing evidence-based practices requires a multi-faceted approach. Electronic clinical decision support (ECDS) tools may encourage evidence-based practice adoption. However, data regarding the role of mobile ECDS tools in pediatrics is scant. Our objective is to describe the development, distribution, and usage patterns of a smartphone-based ECDS tool within a national practice standardization project. MATERIALS AND METHODS: We developed a smartphone-based ECDS tool for use in the American Academy of Pediatrics, Value in Inpatient Pediatrics Network project entitled Reducing Excessive Variation in the Infant Sepsis Evaluation (REVISE). The mobile application (app), PedsGuide, was developed using evidence-based recommendations created by an interdisciplinary panel. App workflow and content were aligned with clinical benchmarks; app interface was adjusted after usability heuristic review. Usage patterns were measured using Google Analytics. RESULTS: Overall, 3805 users across the United States downloaded PedsGuide from December 1, 2016, to July 31, 2017, leading to 14 256 use sessions (average 3.75 sessions per user). Users engaged in 60 442 screen views, including 37 424 (61.8%) screen views that displayed content related to the REVISE clinical practice benchmarks, including hospital admission appropriateness (26.8%), length of hospitalization (14.6%), and diagnostic testing recommendations (17.0%). Median user touch depth was 5 [IQR 5]. DISCUSSION: We observed rapid dissemination and in-depth engagement with PedsGuide, demonstrating feasibility for using smartphone-based ECDS tools within national practice improvement projects. CONCLUSIONS: ECDS tools may prove valuable in future national practice standardization initiatives. Work should next focus on developing robust analytics to determine ECDS tools\u27 impact on medical decision making, clinical practice, and health outcomes