The effects of implementing a point-of-care electronic template to prompt routine anxiety and depression screening in patients consulting for osteoarthritis (the Primary Care Osteoarthritis Trial): A cluster randomised trial in primary care

Background This study aimed to evaluate whether prompting general practitioners (GPs) to routinely assess and manage anxiety and depression in patients consulting with osteoarthritis (OA) improves pain outcomes. Methods and findings We conducted a cluster randomised controlled trial involving 45 English general practices. In intervention practices, patients aged ≥45 y consulting with OA received point-of-care anxiety and depression screening by the GP, prompted by an automated electronic template comprising five questions (a two-item Patient Health Questionnaire–2 for depression, a two-item Generalized Anxiety Disorder–2 questionnaire for anxiety, and a question about current pain intensity [0–10 numerical rating scale]). The template signposted GPs to follow National Institute for Health and Care Excellence clinical guidelines for anxiety, depression, and OA and was supported by a brief training package. The template in control practices prompted GPs to ask the pain intensity question only. The primary outcome was patient-reported current pain intensity post-consultation and at 3-, 6-, and 12-mo follow-up. Secondary outcomes included pain-related disability, anxiety, depression, and general health. During the trial period, 7,279 patients aged ≥45 y consulted with a relevant OA-related code, and 4,240 patients were deemed potentially eligible by participating GPs. Templates were completed for 2,042 patients (1,339 [31.6%] in the control arm and 703 [23.1%] in the intervention arm). Of these 2,042 patients, 1,412 returned questionnaires (501 [71.3%] from 20 intervention practices, 911 [68.0%] from 24 control practices). Follow-up rates were similar in both arms, totalling 1,093 (77.4%) at 3 mo, 1,064 (75.4%) at 6 mo, and 1,017 (72.0%) at 12 mo. For the primary endpoint, multilevel modelling yielded significantly higher average pain intensity across follow-up to 12 mo in the intervention group than the control group (adjusted mean difference 0.31; 95% CI 0.04, 0.59). Secondary outcomes were consistent with the primary outcome measure in reflecting better outcomes as a whole for the control group than the intervention group. Anxiety and depression scores did not reduce following the intervention. The main limitations of this study are two potential sources of bias: an imbalance in cluster size (mean practice size 7,397 [intervention] versus 5,850 [control]) and a difference in the proportion of patients for whom the GP deactivated the template (33.6% [intervention] versus 27.8% [control]). Conclusions In this study, we observed no beneficial effect on pain outcomes of prompting GPs to routinely screen for and manage comorbid anxiety and depression in patients presenting with symptoms due to OA, with those in the intervention group reporting statistically significantly higher average pain scores over the four follow-up time points than those in the control group. Trial registration ISRCTN registry ISRCTN4072198

Improving Fluorometry as a Source Tracking Method to Detect Human Fecal Contamination in Georgia Waters

Proceedings of the 2007 Georgia Water Resources Conference, March 27-29, 2007, Athens, Georgia.In a continuing effort to develop inexpensive source tracking methods to detect human fecal contamination in environmental waters, we combined targeted sampling with fluorometry. Targeted sampling works by identifying hotspots of fecal contamination through multiple samplings over ever decreasing distances. Fluorometry identifies human fecal contamination by detecting optical brighteners, primarily from laundry detergents. On St. Simons Island, targeted sampling and fluorometry identified two hotspots of fecal contamination. One hotspot was confirmed as fecal contamination from humans, but the other was not, most likely because of background organic matter fluorescence. Adding a 436-nm emission filter to the fluorometer reduced this background fluorescence by >50%, and with this filter in place, the second hotspot was identified as fecal contamination from birds. As long as a fluorometer is equipped with a 436-nm emission filter, targeted sampling combined with fluorometry may be a relatively inexpensive method to identify human fecal contamination in water.Sponsored and Organized by: U.S. Geological Survey, Georgia Department of Natural Resources, Natural Resources Conservation Service, The University of Georgia, Georgia State University, Georgia Institute of TechnologyThis book was published by the Institute of Ecology, The University of Georgia, Athens, Georgia 30602-2202. The views and statements advanced in this publication are solely those of the authors and do not represent official views or policies of The University of Georgia, the U.S. Geological Survey, the Georgia Water Research Institute as authorized by the Water Resources Research Act of 1990 (P.L. 101-397) or the other conference sponsors

Combining targeted sampling and bacterial source tracking (bst) during calm and stormy conditions

In April 2004, high numbers of fecal enterococci triggered a beach advisory on Sea Island, GA. Targeted sampling, which finds fecal contamination much like the children’s game of “hot” and “cold,” was combined with three bacterial source tracking (BST) methods: Enterococcus speciation, the presence or absence of a human virulence factor in Enterococcus faecium, and fluorometry. During calm (i.e non-runoff) conditions, the likely contamination sources were wildlife feces and leaking sewer lines located on a creek of St. Simons Island, GA. Fluorometry quickly identified malfunctioning sewer lines. A test for human virulence factor was positive. During stormflow (i.e. runoff) conditions, the likely contamination sources were wildlife feces and effluent from two pipes. A test for human virulence factor was negative. Because the percentage of Ent. faecalis from the pipes was high (>30%), fecal contamination from wild birds was likely. This is the first report of targeted sampling during stormy conditions, and the first time fluorometry has been combined with targeted sampling.Sponsored by: Georgia Environmental Protection Division U.S. Geological Survey, Georgia Water Science Center U.S. Department of Agriculture, Natural Resources Conservation Service Georgia Institute of Technology, Georgia Water Resources Institute The University of Georgia, Water Resources Facult

Distribution and relative abundance of scalloped (Sphyrna lewini) and Carolina (S. gilberti) hammerheads in the western North Atlantic Ocean

The scalloped hammerhead (Sphyrna lewini) and its cryptic congener, Carolina hammerhead (S. gilberti), are sympatrically distributed in the western North Atlantic Ocean. Because the species are indistinguishable based on external morphology, little research focused on Carolina hammerheads exists. In this study, the distribution of Carolina hammerheads in waters of the United States off the east coast (U.S. Atlantic) and Gulf of Mexico (Gulf) was examined and their abundance relative to scalloped hammerheads assessed by genetically identifying 1231 individuals using diagnostic single nucleotide polymorphisms. Both species were found in the U.S. Atlantic, where 27 % of individuals were Carolina hammerheads, but only scalloped hammerheads were identified in the Gulf. In Bulls Bay, SC, a well-known hammerhead nursery, assessment of relative abundance from May to September showed scalloped hammerheads were more abundant May-June and Carolina hammerheads more abundant July-September. Results of this study suggest Carolina hammerheads have a spatially limited distribution in the western North Atlantic and highlight the importance of Bulls Bay as a nursery for the species. In addition, the results suggest Carolina hammerheads may comprise a non-trivial proportion of what is considered the U.S. Atlantic scalloped hammerhead stock and should be considered in future decisions regarding management of the hammerhead complex

The revised Approved Instructional Resources score:An improved quality evaluation tool for online educational resources

BACKGROUND: Free Open-Access Medical education (FOAM) use among residents continues to rise. However, it often lacks quality assurance processes and residents receive little guidance on quality assessment. The Academic Life in Emergency Medicine Approved Instructional Resources tool (AAT) was created for FOAM appraisal by and for expert educators and has demonstrated validity in this context. It has yet to be evaluated in other populations.OBJECTIVES: We assessed the AAT's usability in a diverse population of practicing emergency medicine (EM) physicians, residents, and medical students; solicited feedback; and developed a revised tool.METHODS: As part of the Medical Education Translational Resources: Impact and Quality (METRIQ) study, we recruited medical students, EM residents, and EM attendings to evaluate five FOAM posts with the AAT and provide quantitative and qualitative feedback via an online survey. Two independent analysts performed a qualitative thematic analysis with discrepancies resolved through discussion and negotiated consensus. This analysis informed development of an initial revised AAT, which was then further refined after pilot testing among the author group. The final tool was reassessed for reliability.RESULTS: Of 330 recruited international participants, 309 completed all ratings. The Best Evidence in Emergency Medicine (BEEM) score was the component most frequently reported as difficult to use. Several themes emerged from the qualitative analysis: for ease of use-understandable, logically structured, concise, and aligned with educational value. Limitations include deviation from questionnaire best practices, validity concerns, and challenges assessing evidence-based medicine. Themes supporting its use include evaluative utility and usability. The author group pilot tested the initial revised AAT, revealing a total score average measure intraclass correlation coefficient (ICC) of moderate reliability (ICC = 0.68, 95% confidence interval [CI] = 0 to 0.962). The final AAT's average measure ICC was 0.88 (95% CI = 0.77 to 0.95).CONCLUSIONS: We developed the final revised AAT from usability feedback. The new score has significantly increased usability, but will need to be reassessed for reliability in a broad population.</p

Age and frailty are independently associated with increased COVID-19 mortality and increased care needs in survivors: results of an international multi-centre study

Introduction: Increased mortality has been demonstrated in older adults with coronavirus disease 2019 (COVID-19), but the effect of frailty has been unclear. Methods: This multi-centre cohort study involved patients aged 18 years and older hospitalised with COVID-19, using routinely collected data. We used Cox regression analysis to assess the impact of age, frailty and delirium on the risk of inpatient mortality, adjusting for sex, illness severity, inflammation and co-morbidities. We used ordinal logistic regression analysis to assess the impact of age, Clinical Frailty Scale (CFS) and delirium on risk of increased care requirements on discharge, adjusting for the same variables. Results: Data from 5,711 patients from 55 hospitals in 12 countries were included (median age 74, interquartile range [IQR] 54–83; 55.2% male). The risk of death increased independently with increasing age (>80 versus 18–49: hazard ratio [HR] 3.57, confidence interval [CI] 2.54–5.02), frailty (CFS 8 versus 1–3: HR 3.03, CI 2.29–4.00) inflammation, renal disease, cardiovascular disease and cancer, but not delirium. Age, frailty (CFS 7 versus 1–3: odds ratio 7.00, CI 5.27–9.32), delirium, dementia and mental health diagnoses were all associated with increased risk of higher care needs on discharge. The likelihood of adverse outcomes increased across all grades of CFS from 4 to 9. Conclusion: Age and frailty are independently associated with adverse outcomes in COVID-19. Risk of increased care needs was also increased in survivors of COVID-19 with frailty or older age.</p