Hospitalization and hospital mortality rates during the first and second waves of the COVID-19 pandemic in Quebec: interrupted time series and decomposition analysis

OBJECTIVES

We investigated hospitalization and hospital mortality rates by cause during the first year of the COVID-19 pandemic in Quebec, Canada.

STUDY DESIGN

Interrupted time series and decomposition analysis.

METHODS

We analyzed hospital mortality during the first (February 25-August 22, 2020) and second waves (August 23, 2020-March 31, 2021), compared with 2019. We identified the cause of death and examined trends using: 1) interrupted time series analysis; 2) log-binomial regression; and 3) decomposition of cause-specific mortality.

RESULTS

Hospitalization rates decreased; however, the proportion of deaths increased from 27.0 per 1000 in 2019 to 35.0 per 1000 in the first wave, for an excess of 8.0 deaths per 1000 admissions. COVID-19 was the cause of a third of excess deaths (2.6 per 1000). Other drivers of excess deaths included respiratory conditions (1.6 deaths per 1000), circulatory disorders (0.6 deaths per 1000), and cancer (0.9 deaths per 1000). COVID-19 was the cause of 58% of excess deaths in the second wave. Interrupted time series regression indicated that the proportion of deaths increased at the outset of the first wave but returned to prepandemic levels before increasing again in the second wave. Compared with 2019, the first wave was associated with 1.31 times (95% confidence interval [CI] 1.28-1.33) and the second wave with 1.17 times (95% CI 1.15-1.19) the risk of death during hospitalization.

CONCLUSIONS

The pandemic was associated with a greater risk of hospital mortality. Excess deaths were driven by COVID-19 but also other causes, including respiratory conditions, circulatory disorders, and cancer.

The impact of using a closed-loop system on food choices and eating practices among people with Type 1 diabetes: a qualitative study involving adults, teenagers and parents

AIMS

We explored whether, how and why moving onto and using a hybrid day-and-night closed-loop system affected people's food choices and dietary practices to better understand the impact of this technology on everyday life and inform recommendations for training and support given to future users.

METHODS

Twenty-four adults, adolescents and parents were interviewed before commencing use of the closed-loop system and following its 3-month use. Data were analysed thematically and longitudinally.

RESULTS

While participants described preparing and/or eating similar meals to those consumed prior to using a closed-loop, many described feeling more normal and less burdened by diabetes in dietary situations. Individuals also noted how the use of this technology could lead to deskilling (less precise carbohydrate counting) and less healthy eating (increased snacking and portion sizes and consumption of fatty, energy-dense foods) because of the perceived ability of the system to deal with errors in carbohydrate counting and address small rises in blood glucose without a corrective dose needing to be administered.

CONCLUSIONS

While there may be quality-of-life benefits to using a closed-loop, individuals might benefit from additional nutritional and behavioural education to help promote healthy eating. Refresher training in carbohydrate counting may also be necessary to help ensure that users are able to undertake diabetes management in situations where the technology might fail or that they take a break from using it.

Broadening the Debate About Post-trial Access to Medical Interventions: A Qualitative Study of Participant Experiences at the End of a Trial Investigating a Medical Device to Support Type 1 Diabetes Self-Management

Increasing ethical attention and debate is focusing on whether individuals who take part in clinical trials should be given access to post-trial care. However, the main focus of this debate has been upon drug trials undertaken in low-income settings. To broaden this debate, we report findings from interviews with individuals (n = 24) who participated in a clinical trial of a closed-loop system, which is a medical device under development for people with type 1 diabetes that automatically adjusts blood glucose to help keep it within clinically recommended ranges. Individuals were recruited from UK sites and interviewed following trial close-out, at which point the closed-loop had been withdrawn. While individuals were stoical and accepting of the requirement to return the closed-loop, they also conveyed varying degrees of distress. Many described having relaxed diabetes management practices while using the closed-loop and having become deskilled as a consequence, which made reverting back to pre-trial regimens challenging. Participants also described unanticipated consequences arising from using a closed-loop. As well as deskilling, these included experiencing psychological and emotional benefits that could not be sustained after the closed-loop had been withdrawn and participants reevaluating their pre- and post-trial life in light of having used a closed-loop and now perceiving this life much more negatively. Participants also voiced frustrations about experiencing better blood glucose control using a closed-loop and then having to revert to using what they now saw as antiquated and imprecise self-management tools. We use these findings to argue that ethical debates about post-trial provisioning need to be broadened to consider potential psychological and emotional harms, and not just clinical harms, that may result from withdrawal of investigated treatments. We also suggest that individuals may benefit from information about potential nonclinical harms to help make informed decisions about trial participation.

Patients' and caregivers' experiences of using continuous glucose monitoring to support diabetes self-management: qualitative study

BACKGROUND

Continuous glucose monitoring (CGM) enables users to view real-time interstitial glucose readings and provides information on the direction and rate of change of blood glucose levels. Users can also access historical data to inform treatment decisions. While the clinical and psychological benefits of CGM are well established, little is known about how individuals use CGM to inform diabetes self-management. We explored participants' experiences of using CGM in order to provide recommendations for supporting individuals to make optimal use of this technology.

METHODS

In-depth interviews (n = 24) with adults, adolescents and parents who had used CGM for ≥4 weeks; data were analysed thematically.

RESULTS

Participants found CGM an empowering tool because they could access blood glucose data effortlessly, and trend arrows enabled them to see whether blood glucose was rising or dropping and at what speed. This predicative information aided short-term lifestyle planning and enabled individuals to take action to prevent hypoglycaemia and hyperglycaemia. Having easy access to blood glucose data on a continuous basis also allowed participants to develop a better understanding of how insulin, activity and food impacted on blood glucose. This understanding was described as motivating individuals to make dietary changes and break cycles of over-treating hypoglycaemia and hyperglycaemia. Participants also described how historical CGM data provided a more nuanced picture of blood glucose control than was possible with blood glucose self-monitoring and, hence, better information to inform changes to background insulin doses and mealtime ratios. However, while participants expressed confidence making immediate adjustments to insulin and lifestyle to address impending hypoglycaemia and hypoglycaemia, most described needing and expecting health professionals to interpret historical CGM data and determine changes to background insulin doses and mealtime ratios. While alarms could reinforce a sense of hypoglycaemic safety, some individuals expressed ambivalent views, especially those who perceived alarms as signalling personal failure to achieve optimal glycaemic control.

CONCLUSIONS

CGM can be an empowering and motivational tool which enables participants to fine-tune and optimize their blood glucose control. However, individuals may benefit from psycho-social education, training and/or technological support to make optimal use of CGM data and use alarms appropriately.

Informing climate models with rapid chamber measurements of forest carbon uptake

Models predicting ecosystem carbon dioxide (CO₂ ) exchange under future climate change rely on relatively few real-world tests of their assumptions and outputs. Here, we demonstrate a rapid and cost-effective method to estimate CO₂ exchange from intact vegetation patches under varying atmospheric CO₂ concentrations_. We find that net ecosystem CO₂ uptake (NEE) in a boreal forest rose linearly by 4.7 ± 0.2% of the current ambient rate for every 10 ppm CO₂ increase, with no detectable influence of foliar biomass, season, or nitrogen (N) fertilization. The lack of any clear short-term NEE response to fertilization in such an N-limited system is inconsistent with the instantaneous downregulation of photosynthesis formalized in many global models. Incorporating an alternative mechanism with considerable empirical support - diversion of excess carbon to storage compounds - into an existing earth system model brings the model output into closer agreement with our field measurements. A global simulation incorporating this modified model reduces a long-standing mismatch between the modeled and observed seasonal amplitude of atmospheric CO₂ . Wider application of this chamber approach would provide critical data needed to further improve modeled projections of biosphere-atmosphere CO₂ exchange in a changing climate.

Possible involvement of the phloem lectin in long-distance viroid movement

Incubation with cucumber phloem exudate in vitro results in a dramatic decrease in the electrophoretic mobility of Hop stunt viroid. UV cross-linking and a combination of size exclusion and ion exchange chromatography indicate that this phenomenon reflects a previously unsuspected ability of phloem protein 2, a dimeric lectin and the most abundant component of phloem exudate, to interact with RNA. In light of its demonstrated ability to move from cell to cell via plasmodesmata as well as long distances in the phloem, our results suggest that phloem protein 2 may facilitate the systemic movement of viroids and, possibly, other RNAs in vivo.

Scale-up of filamentous organisms from tubes and shake-flasks into stirred vessels

The choice of small-scale fermentation systems contributes significantly to a successful scale-up. Creasing of flasks and the chosen shaker parameters influence the production of secondary metabolites in a strain- and even compound-specific manner. Using actinomycetes and fungi as model organisms the influence of the small-scale fermentation system on the production of various secondary metabolites is described and the effects on screening success and scale-up are considered.

Glypican-3 (GPC3) expression in human placenta: localization to the differentiated syncytiotrophoblast

The expression of glypican-3 (GPC3), a heparan-sulfate proteoglycan associated with the Simpson-Golabi-Behmel fetal overgrowth syndrome, was studied in normal human placental tissue and cell lines derived from human placentae. Cytotrophoblasts derived from term placentae expressed GPC3 mRNA at low levels in culture. GPC3 mRNA expression increased markedly during trophoblast differentiation. By contrast, fibroblast cell lines derived from normal placentae did not express GPC3 in culture. Similarly, choriocarcinoma cell lines derived from human placentae (BeWo, JAR, and JEG) failed to express GPC3 mRNA. In situ hybridization confirmed the localization of GPC3 mRNA to the syncytiotrophoblast. Furthermore, immunohistochemical staining of paraffin imbedded placental tissue demonstrated intense staining of the syncytiotrophoblast cell layer and less intense staining of cytotrophoblasts. No staining of mesenchymal elements was noted. These data confirm the presence of GPC3 in human placenta and suggest it is expressed by the differentiated syncytiotrophoblast at term.

Secreted proteases from Photorhabdus luminescens: separation of the extracellular proteases from the insecticidal Tc toxin complexes

Photorhabdus luminescens secretes both high molecular weight insecticidal toxin complexes and also a range of extracellular proteases into culture broth. Previous studies by others have suggested that insecticidal activity of the broth is associated with these proteases. However, by gene cloning and targeted knock-out, we have previously shown that oral insecticidal activity is associated with high molecular weight 'toxin complexes' (Tc) encoded by toxin complex or tc genes. Here we further clarify this distinction by biochemically separating the protease fractions away from the oral insecticidal activity of the Tc proteins. We purified three distinct protease fractions from the broth: one consisting of a single species of 55 kDa and two of several putatively related species of approximately 40 kDa. All of these clearly separate from the oral insecticidal activity associated with the high molecular weight Tc proteins and also show no effect on insect weight gain following injection into the haemocoel. Here we examine the substrate preferences and inhibitor profiles of these protease fractions and discuss their relationship with those previously described from other P. luminescens strains and phase variants.

The implementation of a new parallel child health record

After a decade of research, the parent-held Personal Child Health Record was introduced in some parts of the United Kingdom in 1991, coinciding with the enforcement of the Children Act 1989. It was designed as the main record of a child's health and development, to be used until adulthood and to be held by parents. Several Health Care Trusts have since discovered a need to maintain parallel records in the best interests of children. Barnet introduced the 'Joint Professional Record' in 1995 for selected children, such as children on the Child Protection Register. The Joint Professional Record (JPR) is a single, clinic-held, parallel record for multidisciplinary use. We undertook a programme of audit and staff seminars to develop and evaluate use of the JPR. We discuss, below, the impact of this record on professional working relationships and consider the implications of its use as a confidential record and within our policy of working in partnership with parents. In our experience, the JPR has proved a useful adjunct to clinical supervision in the arena of Child Protection and is appropriately used for children in need of protection and those with 'special needs'.

Insecticidal toxins from the bacterium Photorhabdus luminescens

Transgenic plants expressing Bacillus thuringiensis (Bt) toxins are currently being deployed for insect control. In response to concerns about Bt resistance, we investigated a toxin secreted by a different bacterium Photorhabdus luminescens, which lives in the gut of entomophagous nematodes. In insects infected by the nematode, the bacteria are released into the insect hemocoel; the insect dies and the nematodes and bacteria replicate in the cadaver. The toxin consists of a series of four native complexes encoded by toxin complex loci tca, tcb, tcc, and tcd. Both tca and tcd encode complexes with high oral toxicity to Manduca sexta and therefore they represent potential alternatives to Bt for transgenic deployment.

Regulation of dopa decarboxylase expression during colour pattern formation in wild-type and melanic tiger swallowtail butterflies

The eastern tiger swallowtail butterfly Papilio glaucus shows a striking example of Batesian mimicry. In this species, females are either wild type (yellow and black) or melanic (where most of the yellow colour is replaced by black). In order to understand how these different colour patterns are regulated, we examined the temporal order of wing pigment synthesis via precursor incorporation studies, enzyme assays, and in situ hybridisation to mRNA encoding a key enzyme, dopa decarboxylase. We show that dopa decarboxylase provides dopamine to both of the two major colour pigments, papiliochrome (yellow) and melanin (black). Interestingly, however, dopa decarboxylase activity is spatially and temporally regulated, being utilised early in presumptive yellow tissues and later in black. Further, in melanic females, both dopa decarboxylase activity and early papiliochrome synthesis are suppressed in the central forewing and this normally yellow area is later melanised. These results show that the regulation of enzyme synthesis observed in the yellow/black pattern of a single wing, is similar to that involved in melanism. We infer that dopa decarboxylase activity must be regulated in concert with downstream enzymes of either the melanin and/or the papiliochrome specific pathways, forming part of a developmental switch between yellow or black. This modification of multiple enzyme activities in concert is consistent with a model of melanisation involving coordinate regulation of the underlying synthetic pathways by a single Y-linked (female) factor.

'Sexuality, disability and abuse: advice for life ... not just for kids'!

This annotation addresses the debate about the availability, taboos, choices and risks concerning the sexuality and abuse of young disabled people. It highlights the vulnerability of some disabled young people and discusses the dilemmas of maintaining the disabled person's dignity, safeguarding his/her independence and recognizing the need for appropriate sex education while providing protection from abuse. It is suggested that statutory agencies as well as legislation should assume greater responsibility for protecting and safeguarding the interests of disabled youngsters, some of whom may risk physical, emotional and sexual abuse beyond childhood. The manner in which sexuality and abuse are dealt with often reflects the way disabled people are regarded by the society. This paper attempts to address some of the legal and conceptual issues surrounding this area.

Adults with spina bifida and/or hydrocephalus

Recent advances in medical technology enable many children with complex disabilities to survive into adulthood and to have certain expectations of life. One of these expectations is the continuity of specialist health care in an adult setting. This paper describes a new out-patient service which aims to provide optimum care, continuity and consistency of service for adults with spina bifida and/or hydrocephalus. The need for specialist health input into this service, in order to monitor the neurological, urological and psychosocial complications often associated with spina bifida and/or hydrocephalus is recognised. In one year (1992), 86 young adults with spina bifida and/or hydrocephalus attended for annual or more frequent assessment, either independently or with their families or carers. A variety of health and social problems were treated. In response to demand, a multi-disciplinary assessment unit, which includes the services of both medical and nursing specialists, occupational and physiotherapists, psychologists and access to specialist surgical opinions has recently opened at the Chelsea and Westminster Hospital. This new service attempts to meet some of the needs described in the outpatient audit. Adults with other disabilities are requesting to use this service. A longitudinal study to monitor quality, and outcome is indicated from this initial survey.

Physiological responses to 90 min of simulated dinghy sailing

A dinghy sailing race protocol was developed from video analysis of elite Laser class sailors competing in fairly windy (> 12 knots) national level races. A dinghy sailing ergometer was constructed for use with a 90 min protocol. Subjects watched a video of a Laser dinghy skipper sailing (on-water) according to the protocol while themselves hiking (leaning out) from the ergometer and simulating their normal on-water movements in tandem with the video. This simulation was used to examine physiological responses to dinghy sailing and factors correlated with hiking performance in 10 of Australia's top 30 Laser dinghy sailors. Simulated dinghy sailing elicited a large blood pressure response but a low rate of aerobic and anaerobic metabolism. During the 20 min upwind legs, the mean (+/- S.E.M.) systolic and diastolic blood pressures were 172 +/- 18 and 100 +/- 14 mmHg respectively, and mean arterial blood pressure (MABP) was 123 +/- 14 mmHg. Oxygen uptake during the simulated upwind legs was 1.12 +/- 0.22 1 min-1. Both blood pressure and VO2 were significantly lower during the 12 min reaching legs. The mean of the blood lactate concentrations measured 1 min following each of the upwind legs was 2.32 +/- 0.81 mM. Isometric knee extension strength (at 130 degrees) and the length to which subjects set the hiking strap on the ergometer were moderately related to upwind hiking performance (knee extension strength and upwind hiking strap tension, r = 0.62; hiking strap length and upwind righting moment, r = 0.66; both P < 0.05).(ABSTRACT TRUNCATED AT 250 WORDS)

The declining marital-status earnings differential

"Earnings differentials between married and unmarried [U.S.] men have been declining since the late 1960s. We consider two possible explanations for this decline: changes in the nature of selection into marriage; and changes in role specialization within marriage. Our analysis of changes in marriage differentials within cohorts supports only a small contribution of changes in selection. There is some evidence that differences in human-capital investment between married and unmarried men have fallen over time, but this effect has apparently been largely offset by increases in the return to that human capital." This is a revised version of a paper originally presented at the 1991 Annual Meeting of the Population Association of America.

Pharmacokinetics of prednisolone in children with acute lymphoblastic leukaemia

The pharmacokinetics of soluble oral prednisolone were studied during induction therapy in six children with acute lymphoblastic leukaemia. There was a three- to four-fold variation in the pharmacokinetics of total and free prednisolone. For total prednisolone, the mean elimination half-life was relatively short (1.37 h) and the total clearance, relatively high (15.1 ml min-1 kg-1). The mean free fraction was high (0.37).

An investigation of factors affecting progress of patients on a stroke unit

The aim of the study was to identify factors affecting the progress in physical abilities and activities of daily living of patients admitted to a stroke unit. A series of 70 patients admitted consecutively were assessed on a series of tests of motor, functional and cognitive abilities at admission. They were assessed for level of motor abilities and activities of daily living at discharge and 9 months after stroke. Predictive equations were developed which account for between 61% and 33% of the variance in motor abilities and activities of daily living at discharge and at 9 months after stroke. The most important factor influencing outcome was the degree of motor loss.

Gender differences in peak acetaldehyde concentration after an acute dose of ethanol

Acetaldehyde, the first metabolite of ethyl alcohol, is found in higher concentrations in alcoholics and heavy drinkers after alcohol ingestion than in social drinkers or abstainers. This experiment investigated gender differences related to acetaldehyde. Seventy-nine adult social drinkers (38 females and 41 males) were tested after an overnight fast and at least 4 hours food deprived with 0.52 g/kg ethanol in water (20% alcohol by volume). Blood alcohol and acetaldehyde concentrations from breath samples were determined every 5 minutes post-drink for 40 minutes with a gas chromatograph. The drink was consumed over a 5-minute period. Half of each group ran 30-140 miles per week. The other half were controls. A significant overall gender difference in peak acetaldehyde concentration was obtained (p less than 0.5), with males showing higher values than females. Among athletes, these gender differences were greater (p less than 0.002). Among controls the gender differences were in the same direction but they were not significant. Groups did not differ reliably on age (M = 32.88 years, F = 31.13 years), drinking history (M = 2.07, F = 1.92) or lean body mass (M = 43.1, F = 43.1). Groups did not differ on time to peak blood alcohol concentrations (M = 30.98 min, F = 31.58 min). The results have implications for gender differences in alcoholism and biological sensitivity to alcohol.

Inability to demonstrate hydroxylation of tyrosine by murine melanoma "tyrosinase" (L-DOPA oxidase), using the tritiated water assay technique

Validity of the tritiated water assay technique for tyrosine hydroxylase activity as a qualitative method was demonstrated with mushroom tyrosinase. Using this method, isolated murine melanoma "tyrosinase" (L-dopa oxidase) showed no tyrosine hydroxylase activity. This finding supports previous studies in our laboratory which used a variety of histochemical and biochemical methods. The nonenzymatic production of tritiated water caused by tritium exchange with hydrogen peroxide complicates the use of the tritiated water assay technique with crude systems, since hydrogen peroxide is generated by a variety of oxidase reactions. For this reason, previous studies using the tritiated water assay technique with crude systems are ambiguous.