A quantitative evaluation of aerosol generation during tracheal intubation and extubation

The potential aerosolised transmission of severe acute respiratory syndrome coronavirus‐2 is of global concern. Airborne precaution personal protective equipment and preventative measures are universally mandated for medical procedures deemed to be aerosol generating. The implementation of these measures is having a huge impact on healthcare provision. There is currently a lack of quantitative evidence on the number and size of airborne particles produced during aerosol‐generating procedures to inform risk assessments. To address this evidence gap, we conducted real‐time, high‐resolution environmental monitoring in ultraclean ventilation operating theatres during tracheal intubation and extubation sequences. Continuous sampling with an optical particle sizer allowed characterisation of aerosol generation within the zone between the patient and anaesthetist. Aerosol monitoring showed a very low background particle count (0.4 particles.l⁻¹) allowing resolution of transient increases in airborne particles associated with airway management. As a positive reference control, we quantitated the aerosol produced in the same setting by a volitional cough (average concentration, 732 (418) particles.l⁻¹, n = 38). Tracheal intubation including facemask ventilation produced very low quantities of aerosolised particles (average concentration, 1.4 (1.4) particles.l⁻¹, n = 14, p < 0.0001 vs. cough). Tracheal extubation, particularly when the patient coughed, produced a detectable aerosol (21 (18) l⁻¹, n = 10) which was 15‐fold greater than intubation (p = 0.0004) but 35‐fold less than a volitional cough (p < 0.0001). The study does not support the designation of elective tracheal intubation as an aerosol‐generating procedure. Extubation generates more detectable aerosol than intubation but falls below the current criterion for designation as a high‐risk aerosol‐generating procedure. These novel findings from real‐time aerosol detection in a routine healthcare setting provide a quantitative methodology for risk assessment that can be extended to other airway management techniques and clinical settings. They also indicate the need for reappraisal of what constitutes an aerosol‐generating procedure and the associated precautions for routine anaesthetic airway management.

Midwifery leadership, advocacy and action to improve maternal health in PNG

Background

The SDG target for maternal mortality is less than 70 per 100,000 live births; in Papua New Guinea, it is estimated to be 145. PNG will require significant resources and strong leadership to meet the 2030 target. The PNG Midwifery Leadership Buddy Program (Buddy Program), funded and coordinated by Rotary, offers an innovative model to improve maternal health, which may be transferable to other low-middle-income countries.

Objectives

The Buddy Program aims to build midwifery leadership resulting in improved outcomes in PNG. As partners, midwives from PNG and Australia undertake leadership training in Port Moresby and enter a reciprocal peer support relationship. Over 12 months, they support each other in their professional roles and progress a quality improvement project.

Results

Three cohorts of midwives (18 from each country), have participated in the leadership training and the first group has completed 12 months of peer support. Participants have reported increased confidence for leadership, action and advocacy. There has been some communication challenges and variation in expectations, predominately due to cultural differences. The Buddy Program has resulted in a number of tangible projects including the introduction of family planning education at a local school and University, introduction of respectful care in pregnancy charter and increased surveillance and treatment of pregnant women with anaemia. Interestingly, a number of participants have continued to support each other beyond the initial 12-month commitment.

Conclusions

Supportive partnerships that grow midwifery leadership hold significant potential to increase the quality of maternity care and reduce preventable maternal deaths in low-middle-income countries.

Key messages

Midwifery leadership plays a vital role in addressing the SDG targets for maternal health. The Buddy Program offers an innovative model to progress the agenda for universal access to quality maternity care.

The Use of Traffic Sounds to Make Street Crossings by Persons who are Visually Impaired

Orientation and mobility O&M specialists are concerned with the ability of a person who is visually impaired to use hearing as well as vision in independent travel. Yet, there is no published research on the auditory requirements for making effective street crossings by individuals who are visually impaired or by individuals who are both visually and hearing impaired. Thus, this article presents the frequency and intensity measurements for traffic sounds under different conditions. It then compares these measurements to audiograms to illustrate how, given certain limitations and cautions, O&M specialists can estimate a traveler's ability to make safe traffic crossings.

Laparoscopic versus open colorectal surgery in the acute setting (LaCeS trial): a multicentre randomized feasibility trial

BACKGROUND

Approximately 30 000 people undergo major emergency abdominal gastrointestinal surgery annually, and 36 per cent of these procedures (around 10 800) are carried out for emergency colorectal pathology. Some 14 per cent of all patients requiring emergency surgery have a laparoscopic procedure. The aims of the LaCeS (laparoscopic versus open colorectal surgery in the acute setting) feasibility trial were to assess the feasibility, safety and acceptability of performing a large-scale definitive phase III RCT, with a comparison of emergency laparoscopic versus open surgery for acute colorectal pathology.

METHODS

LaCeS was designed as a prospective, multicentre, single-blind, parallel-group, pragmatic feasibility RCT with an integrated qualitative study. Randomization was undertaken centrally, with patients randomized on a 1 : 1 basis between laparoscopic or open surgery.

RESULTS

A total of 64 patients were recruited across five centres. The overall mean steady-state recruitment rate was 1·2 patients per month per site. Baseline compliance for clinical and health-related quality-of-life data was 99·8 and 93·8 per cent respectively. The conversion rate from laparoscopic to open surgery was 39 (95 per cent c.i. 23 to 58) per cent. The 30-day postoperative complication rate was 27 (13 to 46) per cent in the laparoscopic arm and 42 (25 to 61) per cent in the open arm.

CONCLUSION

Laparoscopic emergency colorectal surgery may have an acceptable safety profile. Registration number: ISRCTN15681041 ( http://www.controlled-trials.com).

Assessing resilience of healthcare infrastructure exposed to COVID-19: emerging risks, resilience indicators, interdependencies and international standards

In the moment of preparation of this paper, the world is still globally in grip of the Corona (COVID-19) crisis, and the need to understand the broader overall framework of the crisis increases. As in similar cases in the past, also with this one, the main interest is on the “first response”. Fully appreciating the efforts of those risking their lives facing pandemics, this paper tries to identify the main elements of the larger, possibly global, framework, supported by international standards, needed to deal with new (emerging) risks resulting from threats like Corona and assess the resilience of systems affected. The paper proposes that future solutions should include a number of new elements, related to both risk and resilience. That should include broadening the scope of attention, currently focused onto preparation and response phases, to the phases of “understanding risks”, including emerging risks, and transformation and adaptation. The paper suggests to use resilience indicators in this process. The proposed approach has been applied in different cases involving critical infrastructures in Europe (energy supply, water supply, transportation, etc., exposed to various threats), including the health system in Austria. The detailed, indicator-based, resilience analysis included mapping resilience, resilience stress-testing, visualization, etc., showing, already before the COVID-19, the resilience (stress-testing) limits of the infrastructures. A simpler (57 indicator based) analysis has, then been done for 11 countries (including Austria). The paper links these results with the options available in the area of policies, standards, guidelines and tools (such as the RiskRadar), with focus on interdependencies and global standards—especially the new ISO 31,050, linking emerging risks and resilience.

A randomized phase II evaluation of weekly gemcitabine plus pazopanib versus weekly gemcitabine alone in the treatment of persistent or recurrent epithelial ovarian, fallopian tube or primary peritoneal carcinoma

OBJECTIVE

Angiogenesis inhibition is a valuable strategy for ovarian cancer (EOC). Pazopanib (paz) is a potent small molecular inhibitor of VEGF-1, -2, -3, PDGFR, c-kit, and has activity as a single agent in ovarian cancer. We designed a trial to assess the benefit of adding paz to gemcitabine (gem) in patients with recurrent EOC.

METHODS

An open-label, randomized, multi-site, phase 2 trial was conducted (NCT01610206) including patients with platinum resistant or sensitive disease, ≤ 3 prior lines of chemotherapy, and measurable/evaluable disease. Patients were randomly assigned to weekly gem 1000 mg/m² on days 1 and 8 of a 21 day cycle, with or without paz 800 mg QD, stratified by platinum sensitivity and number of prior lines (1 vs 2 or 3). The primary endpoint was PFS.

RESULTS

148 patients were enrolled 2012-2017. Median age was 63 years (30-82); 60% were platinum resistant; median surveillance was 13 months (0.4-54 months). Median PFS was 5.3 (95% CI, 4.2-5.8) vs 2.9 months (95% CI, 2.1-4.1) in the gem arm. The PFS effect was most pronounced in the platinum resistant group (5.32 vs 2.33 months Tarone-Ware p < 0.001). There was no difference in OS. Overall RR (PR 20% vs 11%, Chi-squre p = 0.02) and DCR (80% vs 60%, Chi-square p < 0.001) were higher in the combination. High grade AEs in the combination arm included ≥ Grade 3: hypertension (15%), neutropenia (35%), and thrombocytopenia (12%).

CONCLUSIONS

The addition of paz to gem enhanced anti-tumor activity; those with platinum-resistant disease derived the most benefit from combination therapy, even in the setting of receiving prior bevacizumab.

Excited-state electronic structure of molecules using many-body Green's functions: Quasiparticles and electron-hole excitations with VOTCA-XTP

We present the open-source VOTCA-XTP software for the calculation of the excited-state electronic structure of molecules using many-body Green's function theory in the GW approximation with the Bethe-Salpeter equation (BSE). This work provides a summary of the underlying theory and discusses the details of its implementation based on Gaussian orbitals, including resolution-of-identity techniques and different approaches to the frequency integration of the self-energy or acceleration by offloading compute-intensive matrix operations using graphics processing units in a hybrid OpenMP/Cuda scheme. A distinctive feature of VOTCA-XTP is the capability to couple the calculation of electronic excitations to a classical polarizable environment on an atomistic level in a coupled quantum- and molecular-mechanics (QM/MM) scheme, where a complex morphology can be imported from Molecular Dynamics simulations. The capabilities and limitations of the GW-BSE implementation are illustrated with two examples. First, we study the dependence of optically active electron-hole excitations in a series of diketopyrrolopyrrole-based oligomers on molecular-architecture modifications and the number of repeat units. Second, we use the GW-BSE/MM setup to investigate the effect of polarization on localized and intermolecular charge-transfer excited states in morphologies of low-donor content rubrene-fullerene mixtures. These showcases demonstrate that our implementation currently allows us to treat systems with up to 2500 basis functions on regular shared-memory workstations, providing accurate descriptions of quasiparticle and coupled electron-hole excited states of various characters on an equal footing.

Information flow in finite flocks

We explore information flow in finite active matter flocks by simulating the canonical Vicsek model and estimating the flow of information as a function of noise (the variability in the extent to which each animal aligns with its neighbours). We show that the global transfer entropy for finite flocks not only fails to peak near the phase transition, as demonstrated for the canonical 2D Ising model, but remains constant from the transition throughout the entire ordered regime to very low noise values. This provides a foundation for future study regarding information flow in more complex models and real-world flocking data.

Deliberate practice as an educational method for learning to interpret the prepubescent female genital examination

BACKGROUND

Correct interpretation of the prepubescent female genital examination is a critical skill; however, physician skill in this area is limited.

OBJECTIVE

To complement the bedside learning of this examination, we developed a learning platform for the visual diagnosis of the prepubescent female genital examination and examined the amount and rate of skill acquisition.

PARTICIPANTS AND SETTING

Medical students, residents, and fellows and attendings participated in an on-line learning platform.

METHODS

This was a multicenter prospective cross-sectional study. Study participants deliberately practiced 158 prepubescent female genital examination cases hosted on a computer-based learning and assessment platform. Participants assigned the case normal or abnormal; if abnormal, they identified the location of the abnormality and the specific diagnosis. Participants received feedback after every case.

RESULTS

We enrolled 107 participants (26 students, 31 residents, 24 fellows and 26 attendings). Accuracy (95 % CI) increased by 10.3 % (7.8, 12.8), Cohen's d-effect size of 1.17 (1.14, 1.19). The change in specificity was +16.8 (14.1, 19.5) and sensitivity +2.4 (-0.9, 5.6). It took a mean (SD) 46.3 (32.2) minutes to complete cases. There was no difference between learner types with respect to initial (p = 0.2) or final accuracy (p = 0.4) scores.

CONCLUSIONS

This study's learning intervention led to effective and feasible skill improvement. However, while participants improved significantly with normal cases, which has relevance in reducing unnecessary referrals to child protection teams, learning gains were not as evident in abnormal cases. All levels of learners demonstrated a similar performance, emphasizing the need for this education even among experienced clinicians.