Patient Reported Outcomes of Transperineal Prostate Biopsy With Tumescent Local Anesthesia

OBJECTIVE

To report the outcomes of performing transperineal prostate biopsy in the office setting using the novel anesthetic technique of tumescent local anesthesia. We report anxiety, pain, and embarrassment of patients who underwent this procedure compared to patients who underwent a transrectal prostate biopsy using standard local anesthesia.

MATERIALS AND METHODS

Consecutive patients undergoing either a transperineal prostate biopsy under tumescent local anesthesia or a transrectal prostate biopsy with standard local anesthetic technique were prospectively enrolled. The tumescent technique employed dilute lidocaine solution administered using a self-filling syringe. Patients were asked to rate their pain before, during, and after their procedure using a visual analog scale. Patient anxiety and embarrassment was assessed using the Testing Modalities Index Questionnaire.

RESULTS

Between April 2021 and June 2022, 430 patients underwent a transperineal prostate biopsy using tumescent local anesthesia and 65 patients underwent a standard transrectal prostate biopsy. Patients who underwent a transperineal biopsy had acceptable but significantly higher pain scores than those who underwent a transrectal prostate biopsy (3.9 vs 1.6, P-value <.01). These scores fell to almost zero immediately following their procedure. Additionally, transperineal biopsy patients were more likely to experience anxiety (71% vs 45%, P < .01) and embarrassment (32% vs 15%, P < .01).

CONCLUSION

Transperineal biopsy using local tumescent anesthesia is safe and well-tolerated. Despite the benefits, patients undergoing a transperineal prostate biopsy under tumescent anesthesia still experienced worse procedural pain, anxiety, and embarrassment. Additional studies examining other adjunctive interventions to improve patient experience during transperineal prostate biopsy are needed.

A wearable device-enabled therapeutic approach to improve joint attention in autism spectrum disorder: a prospective pilot study

It has been previously proposed that interventions aimed at integrating and co-activating music processing and motor control systems could have therapeutic potential for priming social skill development in children with autism spectrum disorder (ASD). In this study, we assessed this hypothesis through a wearable sensor platform called Ambulosono ("Ambulo"-walk; "sono"-sound) in which pleasurable children's musical stimuli are contingently linked to effortful motor action (locomotor step size), thus creating a motivational state proposed to be conducive to joint attention (JA) operation. Five participants were recruited from a community-based partner and were assessed by scoring responses following therapist-directed bids for JA. Multiple assessment sessions through a repeated time-series design were conducted to determine baseline and post-intervention scores. The intervention session consisted of approximately 15 min of Ambulosono exposure. Baseline and post-intervention data were aggregated and analyzed using a linear mixed-effect model. The wearable sensor and wireless headphones of the Ambulosono system were tolerated by the participants, and there were no adverse effects associated with the use of the device. We found an increase in the average responses to bids for JA during the Ambulosono intervention phase compared to baseline across participants. This increase did not appear to result from enhanced general arousal. Our pilot data support feasibility and further testing of Ambulosono as a therapeutic aid for integration into community-based ASD programs to augment shared child-therapist social interactions.

Projecting the future incidence and burden of dengue in Southeast Asia

The recent global expansion of dengue has been facilitated by changes in urbanisation, mobility, and climate. In this work, we project future changes in dengue incidence and case burden to 2099 under the latest climate change scenarios. We fit a statistical model to province-level monthly dengue case counts from eight countries across Southeast Asia, one of the worst affected regions. We project that dengue incidence will peak this century before declining to lower levels with large variations between and within countries. Our findings reveal that northern Thailand and Cambodia will show the biggest decreases and equatorial areas will show the biggest increases. The impact of climate change will be counterbalanced by income growth, with population growth having the biggest influence on increasing burden. These findings can be used for formulating mitigation and adaptation interventions to reduce the immediate growing impact of dengue virus in the region.

Childhood-Onset Lupus Nephritis in the Childhood Arthritis and Rheumatology Research Alliance Registry: Short-Term Kidney Status and Variation in Care

OBJECTIVE

The goal was to characterize short-term kidney status and describe variation in early care utilization in a multicenter cohort of patients with childhood-onset systemic lupus erythematosus (cSLE) and nephritis.

METHODS

We analyzed previously collected prospective data from North American patients with cSLE with kidney biopsy-proven nephritis enrolled in the Childhood Arthritis and Rheumatology Research Alliance (CARRA) Registry from March 2017 through December 2019. We determined the proportion of patients with abnormal kidney status at the most recent registry visit and applied generalized linear mixed models to identify associated factors. We also calculated frequency of medication use, both during induction and ever recorded.

RESULTS

We identified 222 patients with kidney biopsy-proven nephritis, with 64% class III/IV nephritis on initial biopsy. At the most recent registry visit at median (interquartile range) of 17 (8-29) months from initial kidney biopsy, 58 of 106 patients (55%) with available data had abnormal kidney status. This finding was associated with male sex (odds ratio [OR] 3.88, 95% confidence interval [95% CI] 1.21-12.46) and age at cSLE diagnosis (OR 1.23, 95% CI 1.01-1.49). Patients with class IV nephritis were more likely than class III to receive cyclophosphamide and rituximab during induction. There was substantial variation in mycophenolate, cyclophosphamide, and rituximab ever use patterns across rheumatology centers.

CONCLUSION

In this cohort with predominately class III/IV nephritis, male sex and older age at cSLE diagnosis were associated with abnormal short-term kidney status. We also observed substantial variation in contemporary medication use for pediatric lupus nephritis between pediatric rheumatology centers. Additional studies are needed to better understand the impact of this variation on long-term kidney outcomes.

Using spatial and population mobility models to inform outbreak response approaches in the Ebola affected area, Democratic Republic of the Congo, 2018-2020

The Democratic Republic of the Congo's (DRC) 10th known Ebola virus disease (EVD) outbreak occurred between August 1, 2018 and June 25, 2020, and was the largest EVD outbreak in the country's history. During this outbreak, the DRC Ministry of Health initiated traveller health screening at points of control (POC, locations not on the border) and points of entry (POE) to minimize disease translocation via ground and air travel. We sought to develop a model-based approach that could be applied in future outbreaks to inform decisions for optimizing POC and POE placement, and allocation of resources more broadly, to mitigate the risk of disease translocation associated with ground-level population mobility. We applied a parameter-free mobility model, the radiation model, to estimate likelihood of ground travel between selected origin locations (including Beni, DRC) and surrounding population centres, based on population size and drive-time. We then performed a road network route analysis and included estimated population movement results to calculate the proportionate volume of travellers who would move along each road segment; this reflects the proportion of travellers that could be screened at a POC or POE. For Beni, the road segments estimated to have the highest proportion of travellers that could be screened were part of routes into Uganda and Rwanda. Conversely, road segments that were part of routes to other population centres within the DRC were estimated to have relatively lower proportions. We observed a posteriori that, in many instances, our results aligned with locations that were selected for actual POC or POE placement through more time-consuming methods. This study has demonstrated that mobility models and simple spatial techniques can help identify potential locations for health screening at newly placed POC or existing POE during public health emergencies based on expected movement patterns. Importantly, we have provided methods to estimate the proportionate volume of travellers that POC or POE screening measures would assess based on their location. This is critical information in outbreak situations when timely decisions must be made to implement public health interventions that reach the most individuals across a network.

Intraarticular steroids as DMARD-sparing agents for juvenile idiopathic arthritis flares: Analysis of the Childhood Arthritis and Rheumatology Research Alliance Registry

BACKGROUND

Children with juvenile idiopathic arthritis (JIA) who achieve a drug free remission often experience a flare of their disease requiring either intraarticular steroids (IAS) or systemic treatment with disease modifying anti-rheumatic drugs (DMARDs). IAS offer an opportunity to recapture disease control and avoid exposure to side effects from systemic immunosuppression. We examined a cohort of patients treated with IAS after drug free remission and report the probability of restarting systemic treatment within 12 months.

METHODS

We analyzed a cohort of patients from the Childhood Arthritis and Rheumatology Research Alliance (CARRA) Registry who received IAS for a flare after a period of drug free remission. Historical factors and clinical characteristics and of the patients including data obtained at the time of treatment were analyzed.

RESULTS

We identified 46 patients who met the inclusion criteria. Of those with follow up data available 49% had restarted systemic treatment 6 months after IAS injection and 70% had restarted systemic treatment at 12 months. The proportion of patients with prior use of a biologic DMARD was the only factor that differed between patients who restarted systemic treatment those who did not, both at 6 months (79% vs 35%, p < 0.01) and 12 months (81% vs 33%, p < 0.05).

CONCLUSION

While IAS are an option for all patients who flare after drug free remission, it may not prevent the need to restart systemic treatment. Prior use of a biologic DMARD may predict lack of success for IAS. Those who previously received methotrexate only, on the other hand, are excellent candidates for IAS.

Inequalities in accessing quality healthcare, does insurance play a role? retrospective analysis of aortic emergencies from national inpatient sample 2019

Background

Aortic emergencies, dissection and rupture, are rare but catastrophic entities, with the cornerstone to survival being prompt diagnosis and treatment. Insurance status often limits access to healthcare, and our study aims to determine if it plays a role in the outcomes of aortic emergencies.

Method

A retrospective analysis of the 2019 Nationwide Inpatient Sample was conducted to identify hospitalization (Age ≥18 & non-elective) with aortic dissection and ruptured aortic aneurysms using ICD-10 codes. Discharge-level weight analysis was used to produce a national estimate. Variables were screened with univariate regression, and intermediate and co-linear variables were screened-out before a multivariable regression analysis model was built and performed to calculate the odds ratio.

Results

A total of 19,685 (0.06%) hospitalizations are identified for aortic emergencies (14965 dissections & 4720 ruptured aneurysms). The mean age was 58.56, 62.7% were males, and ethnic distribution was 65.1% white, 19.5% blacks, 7.6% Hispanics, and others.

11.4% of the hospitalizations underwent diagnostic imaging with either CTA/MRA/TEE/Aortography within 24 hours. Hypotension/shock was present in 32% of these hospitalizations and was a risk factor for mortality OR 3.21 (p&lt;0.00), increasing LOS by an average of 5.1 days and resource utilization by 156,000$. Another risk factor for mortality was stroke/TIA (OR-1.76, p&lt;0.00), increasing LOS and resource utilization by 3.1 days and 80,662$, respectively.

3220 hospitalizations (16.4%) did not survive the course, and the mortality rate in uninsured, Medicare, and Medicaid was 17%, 20%,9% compared with 12% in privately insured. On crude analysis, uninsured and medicare patients appeared to have higher odds of mortality [OR 1.50, p&lt;0.04, and OR 1.83 p-value &lt;0.002 respectively], however upon adjusting for confounders, only uninsured patients showed statistically significant difference (OR 2.13, p&lt;0.002). Similar results were corroborated on analyzing hospitalizations for aortic dissection; however, insurance status did not influence mortality in a ruptured aneurysm.

When comparing hospitalization of median household income of ≥79,000$ with household of median income of 59,000–78,999 $, 46,000–58,999 $ and &lt;46,000$ had higher odds of mortality (OR-1.38, p&lt;0.04), (OR-1.44, p&lt;0.02) and (OR-1.44, p&lt;0.03) respectively. Of all the insurance types, a statistically significant difference compared with private insurance, Medicaid on average, had 2.8 more days and incurred an additional 62,912$ in resource utilization (p&lt;0.00).

Conclusion

Inequalities in accessing healthcare, median household income, and insurance status are risk factors for mortality in aortic emergencies. Efforts are needed to bridge the gap in this particular facet of social determinants of health to find a sustainable and equitable solution for quality healthcare for aall regardless of their insurance status.

Funding Acknowledgement

Type of funding sources: None.

Social determinants of health influence disease activity and functional disability in Polyarticular Juvenile Idiopathic Arthritis

BACKGROUND

Social determinants of health (SDH) greatly influence outcomes during the first year of treatment in rheumatoid arthritis, a disease similar to polyarticular juvenile idiopathic arthritis (pJIA). We investigated the correlation of community poverty level and other SDH with the persistence of moderate to severe disease activity and functional disability over the first year of treatment in pJIA patients enrolled in the Childhood Arthritis and Rheumatology Research Alliance Registry.

METHODS

In this cohort study, unadjusted and adjusted generalized linear mixed effects models analyzed the effect of community poverty and other SDH on disease activity, using the clinical Juvenile Arthritis Disease Activity Score-10, and disability, using the Child Health Assessment Questionnaire, measured at baseline, 6, and 12 months.

RESULTS

One thousand six hundred eighty-four patients were identified. High community poverty (≥20% living below the federal poverty level) was associated with increased odds of functional disability (OR 1.82, 95% CI 1.28-2.60) but was not statistically significant after adjustment (aOR 1.23, 95% CI 0.81-1.86) and was not associated with increased disease activity. Non-white race/ethnicity was associated with higher disease activity (aOR 2.48, 95% CI: 1.41-4.36). Lower self-reported household income was associated with higher disease activity and persistent functional disability. Public insurance (aOR 1.56, 95% CI 1.06-2.29) and low family education (aOR 1.89, 95% CI 1.14-3.12) was associated with persistent functional disability.

CONCLUSION

High community poverty level was associated with persistent functional disability in unadjusted analysis but not with persistent moderate to high disease activity. Race/ethnicity and other SDH were associated with persistent disease activity and functional disability.

130 Paediatric Hand Fractures Requiring Surgery – the Results of a Bespoke Hand Surgery Service

Aim

To evaluate the management of The Royal Devon and Exeter Hospital (RD&E) bespoke hand surgery service on paediatric closed hand fractures. In particular, an assessment against The British Society for Surgery of the Hand (BSSH) closed fracture standards on treatment timelines and national guidance compliance.

Method

A retrospective review of all paediatric patients requiring plastic surgery seen at the RD&E plastics trauma clinic from 1st Nov 2020 to 28th Feb 2021 was performed. This was compared to two previous audit cycles completed during winter 2019 and summer 2020. Health informatics was collated via our IT department and thoroughly reviewed using departmental notes. Exclusion criteria included: all non-fracture injuries, patients &gt; 18 years old and open fractures.

Results

In winter 2020–21 all patients were referred the same day of injury and 92% were seen by a Plastic Surgeon within 24 hours of injury. This was an improvement from the mean time from referral to clinic of 5 days in winter 2019 and 1.33 days in summer 2020 respectively. 85% of cases are now operated within 48 hours of review and 92% of cases were operated within 72 hours of the decision to operate where conservative management had failed.

Conclusions

The introduction of a ‘rapid-access’ musculoskeletal unit with early senior review and a dedicated theatre has created ‘gold-standard’ compliance with national standards for the operative management of closed paediatric fractures. We should continue to focus on improving and increasing capacity of this service as it has likely improved both the patient journey and outcomes.

1018 Did COVID Compromise the Care of Closed Paediatric Hand Fractures?

Aim

To assess the effect of a ‘rapid-access’ musculoskeletal unit, established in March 2020, as part of the Royal Devon & Exeter hospital COVID response, with direct assessment of hand trauma by the Plastic Surgery department staff, on treatment timelines and national guidance compliance for closed paediatric hand fractures.

Method

This was a retrospective review from 1st January to 31st December 2019 and a prospective study from the 1st April to 15th June 2020. The retrospective cases were collated by health informatics. The prospective data was recorded on the department’s database. Exclusion criteria: nail bed injuries with tuft fractures, ligament injuries only, open fractures and patients aged 18 at time of surgery.

Results

In 2019 the majority (73%) of patients (n = 26) were referred within 48hrs but waited a median of 5 days to be seen in clinic by a hand surgeon resulting in significant delays in treatment. After service reconfiguration in 2020, all patients (n = 6) were operated on within 72 hours of the decision to operate - mean time to surgery 1.5 days (range 0-3 days). The mean time from referral to clinic was 1.33 days (range 0-6 days). 4 patients were operated on within 7 days of injury. Of the 2 patients operated on &gt; 7 days, 1 was referred 32 days post injury and 1 failed conservative management.

Conclusions

The introduction of a ‘rapid-access’ musculoskeletal unit with early senior review and a dedicated theatre has created ‘gold-standard’ compliance with national standards for the operative management of closed paediatric fractures.

89 Do Corticosteroid and Local Anaesthetic Hip Injections Administered Proximal or Distal to The Zona Orbicularis Have an Effect on Patient Satisfaction?

Aim

Pubofemoral and ischiofemoral ligaments blend to make zona orbicularis. Zonaorbicularis has been suggested to force fluid from peripheral compartment to central compartment in unidirectional flow. This study aims to assess whether injection of corticosteroid with local anaesthetic injected either proximal or distal to the zona orbicularis has effect on patient satisfaction.

Method

This retrospective study investigated consecutive patients undergoing ultrasound guided hip injections at a single centre in the UK between November 2018 and March 2019. Patients were identified using IMPAX© picture archiving and communications system. Radiographs were assessed to see if radiopaque dye and therefore corticosteroid and local anaesthetic had been injected proximal or distal to the zona orbicularis. Clinic letters were accessed on the electronic patient record and we recorded whether patients had pain relief at 24 hours and 2 weeks following hip injection.

Results

133 Patients were identified during the study period, of which 40 were included. At 24 hours post-injection 72% of patients were satisfied and 28% were unsatisfied, for which there was 76% and 70% satisfaction for proximal and distal injections respectively (p = 0.63). At 2 weeks post-injection 45% of patients were satisfied and 55% of patients unsatisfied, for which there was 47% and 44% satisfaction for proximal and distal injections respectively (p = 0.9).

Conclusions

Overall patient satisfaction is high following hip corticosteroid and local anaesthetic injection. No difference was found between injections proximal and distal to the zona orbicularis. Further research is needed to quantify the association between proximal and distal injections.

Emergence and spread of SARS-CoV-2 lineage B.1.620 with variant of concern-like mutations and deletions

Distinct SARS-CoV-2 lineages, discovered through various genomic surveillance initiatives, have emerged during the pandemic following unprecedented reductions in worldwide human mobility. We here describe a SARS-CoV-2 lineage - designated B.1.620 - discovered in Lithuania and carrying many mutations and deletions in the spike protein shared with widespread variants of concern (VOCs), including E484K, S477N and deletions HV69Δ, Y144Δ, and LLA241/243Δ. As well as documenting the suite of mutations this lineage carries, we also describe its potential to be resistant to neutralising antibodies, accompanying travel histories for a subset of European cases, evidence of local B.1.620 transmission in Europe with a focus on Lithuania, and significance of its prevalence in Central Africa owing to recent genome sequencing efforts there. We make a case for its likely Central African origin using advanced phylogeographic inference methodologies incorporating recorded travel histories of infected travellers.

Tracking the international spread of SARS-CoV-2 lineages B.1.1.7 and B.1.351/501Y-V2 with grinch

Late in 2020, two genetically-distinct clusters of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) with mutations of biological concern were reported, one in the United Kingdom and one in South Africa. Using a combination of data from routine surveillance, genomic sequencing and international travel we track the international dispersal of lineages B.1.1.7 and B.1.351 (variant 501Y-V2). We account for potential biases in genomic surveillance efforts by including passenger volumes from location of where the lineage was first reported, London and South Africa respectively. Using the software tool grinch (global report investigating novel coronavirus haplotypes), we track the international spread of lineages of concern with automated daily reports, Further, we have built a custom tracking website (cov-lineages.org/global_report.html) which hosts this daily report and will continue to include novel SARS-CoV-2 lineages of concern as they are detected.

Emergence of an early SARS-CoV-2 epidemic in the United States

The emergence of the COVID-19 epidemic in the United States (U.S.) went largely undetected due to inadequate testing. New Orleans experienced one of the earliest and fastest accelerating outbreaks, coinciding with Mardi Gras. To gain insight into the emergence of SARS-CoV-2 in the U.S. and how large-scale events accelerate transmission, we sequenced SARS-CoV-2 genomes during the first wave of the COVID-19 epidemic in Louisiana. We show that SARS-CoV-2 in Louisiana had limited diversity compared to other U.S. states and that one introduction of SARS-CoV-2 led to almost all of the early transmission in Louisiana. By analyzing mobility and genomic data, we show that SARS-CoV-2 was already present in New Orleans before Mardi Gras, and the festival dramatically accelerated transmission. Our study provides an understanding of how superspreading during large-scale events played a key role during the early outbreak in the U.S. and can greatly accelerate epidemics.

Tracking the international spread of SARS-CoV-2 lineages B.1.1.7 and B.1.351/501Y-V2

Late in 2020, two genetically-distinct clusters of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) with mutations of biological concern were reported, one in the United Kingdom and one in South Africa. Using a combination of data from routine surveillance, genomic sequencing and international travel we track the international dispersal of lineages B.1.1.7 and B.1.351 (variant 501Y-V2). We account for potential biases in genomic surveillance efforts by including passenger volumes from location of where the lineage was first reported, London and South Africa respectively. Using the software tool grinch (global report investigating novel coronavirus haplotypes), we track the international spread of lineages of concern with automated daily reports, Further, we have built a custom tracking website (cov-lineages.org/global_report.html) which hosts this daily report and will continue to include novel SARS-CoV-2 lineages of concern as they are detected.

Wildland Fire Emission Sampling at Fishlake National Forest, Utah Using an Unmanned Aircraft System

Emissions from a stand replacement prescribed burn were sampled using an unmanned aircraft system (UAS, or "drone") in Fishlake National Forest, Utah, U.S.A. Sixteen flights over three days in June 2019 provided emission factors for a broad range of compounds including carbon monoxide (CO), carbon dioxide (CO₂), nitric oxide (NO), nitrogen oxide (NO₂), particulate matter < 2.5 microns in diameter (PM_2.5), volatile organic compounds (VOCs) including carbonyls, black carbon, and elemental/organic carbon. To our knowledge, this is the first UAS-based emission sampling for a fire of this magnitude, including both slash pile and crown fires resulting in wildfire-like conditions. The burns consisted of drip torch ignitions as well as ground-mobile and aerial helicopter ignitions of large stands comprising over 1,000 ha, allowing for comparison of same-species emission factors burned under different conditions. The use of a UAS for emission sampling minimizes risk to personnel and equipment, allowing flexibility in sampling location and ensuring capture of representative, fresh smoke constituents. PM_2.5 emission factors varied 5-fold and, like most pollutants, varied inversely with combustion efficiency resulting in lower emission factors from the slash piles than the crown fires.

Establishment and lineage dynamics of the SARS-CoV-2 epidemic in the UK

The United Kingdom's COVID-19 epidemic during early 2020 was one of world's largest and was unusually well represented by virus genomic sampling. We determined the fine-scale genetic lineage structure of this epidemic through analysis of 50,887 severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) genomes, including 26,181 from the UK sampled throughout the country's first wave of infection. Using large-scale phylogenetic analyses combined with epidemiological and travel data, we quantified the size, spatiotemporal origins, and persistence of genetically distinct UK transmission lineages. Rapid fluctuations in virus importation rates resulted in >1000 lineages; those introduced prior to national lockdown tended to be larger and more dispersed. Lineage importation and regional lineage diversity declined after lockdown, whereas lineage elimination was size-dependent. We discuss the implications of our genetic perspective on transmission dynamics for COVID-19 epidemiology and control.

Emergence of an early SARS-CoV-2 epidemic in the United States

The emergence of the early COVID-19 epidemic in the United States (U.S.) went largely undetected, due to a lack of adequate testing and mitigation efforts. The city of New Orleans, Louisiana experienced one of the earliest and fastest accelerating outbreaks, coinciding with the annual Mardi Gras festival, which went ahead without precautions. To gain insight into the emergence of SARS-CoV-2 in the U.S. and how large, crowded events may have accelerated early transmission, we sequenced SARS-CoV-2 genomes during the first wave of the COVID-19 epidemic in Louisiana. We show that SARS-CoV-2 in Louisiana initially had limited sequence diversity compared to other U.S. states, and that one successful introduction of SARS-CoV-2 led to almost all of the early SARS-CoV-2 transmission in Louisiana. By analyzing mobility and genomic data, we show that SARS-CoV-2 was already present in New Orleans before Mardi Gras and that the festival dramatically accelerated transmission, eventually leading to secondary localized COVID-19 epidemics throughout the Southern U.S.. Our study provides an understanding of how superspreading during large-scale events played a key role during the early outbreak in the U.S. and can greatly accelerate COVID-19 epidemics on a local and regional scale.

Air Passenger Travel and International Surveillance Data Predict Spatiotemporal Variation in Measles Importations to the United States

Measles incidence in the United States has grown dramatically, as vaccination rates are declining and transmission internationally is on the rise. Because imported cases are necessary drivers of outbreaks in non-endemic settings, predicting measles outbreaks in the US depends on predicting imported cases. To assess the predictability of imported measles cases, we performed a regression of imported measles cases in the US against an inflow variable that combines air travel data with international measles surveillance data. To understand the contribution of each data type to these predictions, we repeated the regression analysis with alternative versions of the inflow variable that replaced each data type with averaged values and with versions of the inflow variable that used modeled inputs. We assessed the performance of these regression models using correlation, coverage probability, and area under the curve statistics, including with resampling and cross-validation. Our regression model had good predictive ability with respect to the presence or absence of imported cases in a given state in a given year (area under the curve of the receiver operating characteristic curve (AUC) = 0.78) and the magnitude of imported cases (Pearson correlation = 0.84). By comparing alternative versions of the inflow variable averaging over different inputs, we found that both air travel data and international surveillance data contribute to the model's ability to predict numbers of imported cases and individually contribute to its ability to predict the presence or absence of imported cases. Predicted sources of imported measles cases varied considerably across years and US states, depending on which countries had high measles activity in a given year. Our results emphasize the importance of the relationship between global connectedness and the spread of measles. This study provides a framework for predicting and understanding imported case dynamics that could inform future studies and outbreak prevention efforts.

Modelling airport catchment areas to anticipate the spread of infectious diseases across land and air travel

Air travel is an increasingly important conduit for the worldwide spread of infectious diseases. However, methods to identify which airports an individual may use to initiate travel, or where an individual may travel to upon arrival at an airport is not well studied. This knowledge gap can be addressed by estimating airport catchment areas: the geographic extent from which the airport derives most of its patronage. While airport catchment areas can provide a simple decision-support tool to help delineate the spatial extent of infectious disease spread at a local scale, observed data for airport catchment areas are rarely made publicly available. Therefore, we evaluated a probabilistic choice behavior model, the Huff model, as a potential methodology to estimate airport catchment areas in the United States in data-limited scenarios. We explored the impact of varying input parameters to the Huff model on estimated airport catchment areas: distance decay exponent, distance cut-off, and measures of airport attractiveness. We compared Huff model catchment area patterns for Miami International Airport (MIA) and Harrisburg International Airport (MDT). We specifically compared our model output to observed data sampled for MDT to align model parameters with an established, observed catchment area. Airport catchment areas derived using the Huff model were highly sensitive to changes in model parameters. We observed that a distance decay exponent of 2 and a distance cut-off of 500 km represented the most realistic spatial extent and heterogeneity of the MIA catchment area. When these parameters were applied to MDT, the Huff model produced similar spatial patterns to the observed MDT catchment area. Finally, our evaluation of airport attractiveness showed that travel volume to the specific international destinations of interest for infectious disease importation risks (i.e., Brazil) had little impact on the predicted choice of airport when compared to all international travel. Our work is a proof of concept for use of the Huff model to estimate airport catchment areas as a generalizable decision-support tool in data-limited scenarios. While our work represents an initial examination of the Huff model as a method to approximate airport catchment areas, an essential next step is to conduct a quantitative calibration and validation of the model based on multiple airports, possibly leveraging local human mobility data such as call detail records or online social network data collected from mobile devices. Ultimately, we demonstrate how the Huff model could be potentially helpful to improve the precision of early warning systems that anticipate infectious disease spread, or to incorporate when local public health decision makers need to identify where to mobilize screening infrastructure or containment strategies at a local level.

Estimating internationally imported cases during the early COVID-19 pandemic

Early in the COVID-19 pandemic, predictions of international outbreaks were largely based on imported cases from Wuhan, China, potentially missing imports from other cities. We provide a method, combining daily COVID-19 prevalence and flight passenger volume, to estimate importations from 18 Chinese cities to 43 international destinations, including 26 in Africa. Global case importations from China in early January came primarily from Wuhan, but the inferred source shifted to other cities in mid-February, especially for importations to African destinations. We estimate that 10.4 (6.2 - 27.1) COVID-19 cases were imported to these African destinations, which exhibited marked variation in their magnitude and main sources of importation. We estimate that 90% of imported cases arrived between 17 January and 7 February, prior to the first case detections. Our results highlight the dynamic role of source locations, which can help focus surveillance and response efforts.

Estimating internationally imported cases during the early COVID-19 pandemic

Early in the COVID-19 pandemic, predictions of international outbreaks were largely based on imported cases from Wuhan, China, potentially missing imports from other cities. We provide a method, combining daily COVID-19 prevalence and flight passenger volume, to estimate importations from 18 Chinese cities to 43 international destinations, including 26 in Africa. Global case importations from China in early January came primarily from Wuhan, but the inferred source shifted to other cities in mid-February, especially for importations to African destinations. We estimate that 10.4 (6.2 - 27.1) COVID-19 cases were imported to these African destinations, which exhibited marked variation in their magnitude and main sources of importation. We estimate that 90% of imported cases arrived between 17 January and 7 February, prior to the first case detections. Our results highlight the dynamic role of source locations, which can help focus surveillance and response efforts.

Potential for inter-state spread of Covid-19 from Arizona, USA: analysis of mobile device location and commercial flight data

A significant rise of SARS-CoV-2 transmission in Arizona in June 2020 prompted the need to evaluate potential dispersion to other regions in the United States. We evaluate the potential for domestic dissemination of SARS-CoV-2 from Arizona using mobile device-location and scheduled flights data.

Estimating internationally imported cases during the early COVID-19 pandemic

Early in the COVID-19 pandemic, when cases were predominantly reported in the city of Wuhan, China, local outbreaks in Europe, North America, and Asia were largely predicted from imported cases on flights from Wuhan, potentially missing imports from other key source cities. Here, we account for importations from Wuhan and from other cities in China, combining COVID-19 prevalence estimates in 18 Chinese cities with estimates of flight passenger volume to predict for each day between early December 2019 to late February 2020 the number of cases exported from China. We predict that the main source of global case importation in early January was Wuhan, but due to the Wuhan lockdown and the rapid spread of the virus, the main source of case importation from mid February became Chinese cities outside of Wuhan. For destinations in Africa in particular, non-Wuhan cities were an important source of case imports (1 case from those cities for each case from Wuhan, range of model scenarios: 0.1-9.8). Our model predicts that 18.4 (8.5 - 100) COVID-19 cases were imported to 26 destination countries in Africa, with most of them (90%) predicted to have arrived between 7th January (±10 days) and 5th February (±3 days), and all of them predicted prior to the first case detections. We finally observed marked heterogeneities in expected imported cases across those locations. Our estimates shed light on shifting sources and local risks of case importation which can help focus surveillance efforts and guide public health policy during the final stages of the pandemic. We further provide a time window for the seeding of local epidemics in African locations, a key parameter for estimating expected outbreak size and burden on local health care systems and societies, that has yet to be defined in these locations.

Routes for COVID-19 importation in Brazil

The global outbreak caused by the severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) has been declared a pandemic by the World Health Organization. As the number of imported SARS-CoV-2 cases is on the rise in Brazil, we use incidence and historical air travel data to estimate the most important routes of importation into the country.

Pneumonia of unknown aetiology in Wuhan, China: potential for international spread via commercial air travel

There is currently an outbreak of pneumonia of unknown aetiology in Wuhan, China. Although there are still several unanswered questions about this infection, we evaluate the potential for international dissemination of this disease via commercial air travel should the outbreak continue.

Pneumonia of unknown aetiology in Wuhan, China: potential for international spread via commercial air travel

There is currently an outbreak of pneumonia of unknown aetiology in Wuhan, China. Although there are still several unanswered questions about this infection, we evaluate the potential for international dissemination of this disease via commercial air travel should the outbreak continue.

Potential for global spread of a novel coronavirus from China

An epidemic of a novel coronavirus emerged from Wuhan, China, in late December 2019 and has since spread to several large Chinese cities. Should a scenario arise where this coronavirus spreads more broadly across China, we evaluate how patterns of international disease transmission could change.

Assessing spread risk of Wuhan novel coronavirus within and beyond China, January-April 2020: a travel network-based modelling study

Background

A novel coronavirus (2019-nCoV) emerged in Wuhan City, China, at the end of 2019 and has caused an outbreak of human-to-human transmission with a Public Health Emergency of International Concern declared by the World Health Organization on January 30, 2020.

Aim

We aimed to estimate the potential risk and geographic range of Wuhan novel coronavirus (2019-nCoV) spread within and beyond China from January through to April, 2020.

Methods

A series of domestic and international travel network-based connectivity and risk analyses were performed, by using de-identified and aggregated mobile phone data, air passenger itinerary data, and case reports.

Results

The cordon sanitaire of Wuhan is likely to have occurred during the latter stages of peak population numbers leaving the city before Lunar New Year (LNY), with travellers departing into neighbouring cities and other megacities in China. We estimated that 59,912 air passengers, of which 834 (95% UI: 478 - 1349) had 2019-nCoV infection, travelled from Wuhan to 382 cities outside of mainland China during the two weeks prior to Wuhan's lockdown. The majority of these cities were in Asia, but major hubs in Europe, the US and Australia were also prominent, with strong correlation seen between predicted importation risks and reported cases. Because significant spread has already occurred, a large number of airline travellers (3.3 million under the scenario of 75% travel reduction from normal volumes) may be required to be screened at origin high-risk cities in China and destinations across the globe for the following three months of February to April, 2020 to effectively limit spread beyond its current extent.

Conclusion

Further spread of 2019-nCoV within China and international exportation is likely to occur. All countries, especially vulnerable regions, should be prepared for efforts to contain the 2019-nCoV infection.

Factors Affecting Pre-Travel Health Seeking Behaviour and Adherence to Pre-Travel Health Advice: A Systematic Review

BACKGROUND

Recent years have seen unprecedented growth in international travel. Travellers are at high risk for acquiring infections while abroad and potentially bringing these infections back to their home country. There are many ways to mitigate this risk by seeking pre-travel advice (PTA), including receiving recommended vaccinations and chemoprophylaxis, however many travellers do not seek or adhere to PTA. We conducted a systematic review to further understand PTA-seeking behaviour with an ultimate aim to implement interventions that improve adherence to PTA and reduce morbidity and mortality in travellers.

METHODS

We conducted a systematic review of published medical literature selecting studies that examined reasons for not seeking PTA and non-adherence to PTA over the last ten years. 4484 articles were screened of which 56 studies met our search criteria after full text review.

RESULTS

The major reason for not seeking or non-adherence to PTA was perceived low risk of infection while travelling. Side effects played a significant role for lack of adherence specific to malaria prophylaxis.

CONCLUSIONS

These data may help clinicians and public health providers to better understand reasons for non-adherence to PTA and target interventions to improve travellers understanding of potential and modifiable risks. Additionally, we discuss specific recommendations to increase public health education that may enable travellers to seek PTA.

Travel Surveillance and Genomics Uncover a Hidden Zika Outbreak during the Waning Epidemic

The Zika epidemic in the Americas has challenged surveillance and control. As the epidemic appears to be waning, it is unclear whether transmission is still ongoing, which is exacerbated by discrepancies in reporting. To uncover locations with lingering outbreaks, we investigated travel-associated Zika cases to identify transmission not captured by reporting. We uncovered an unreported outbreak in Cuba during 2017, a year after peak transmission in neighboring islands. By sequencing Zika virus, we show that the establishment of the virus was delayed by a year and that the ensuing outbreak was sparked by long-lived lineages of Zika virus from other Caribbean islands. Our data suggest that, although mosquito control in Cuba may initially have been effective at mitigating Zika virus transmission, such measures need to be maintained to be effective. Our study highlights how Zika virus may still be "silently" spreading and provides a framework for understanding outbreak dynamics. VIDEO ABSTRACT.

Zika virus transmission in Angola and the potential for further spread to other African settings

Background

Cases of Zika virus were recently detected in Luanda, Angola, a major travel hub in Africa. The risk of Zika virus transmission throughout the continent from Angola is evaluated.

Methods

Travel volumes were assessed using monthly passenger-level flight data from Luanda to all locations throughout Africa. Travel data was superimposed onto seasonal environmental suitability maps that predict the potential for subsequent Zika virus transmission.

Results and Conclusions

Windhoek, Maputo, Durban and Kinshasa have the greatest potential for Zika virus introduction and transmission during the southern hemisphere summer months, and Nairobi during the northern hemisphere summer months.

Closure of the perineal defect after abdominoperineal excision for rectal adenocarcinoma - ACPGBI Position Statement

BACKGROUND

Perineal wound morbidity is common following abdominoperineal excision of the rectum (APE). There is no consensus on the optimum perineal reconstruction method after APE, and in particular 'extra-levator APE' (ELAPE).

METHODS

A systematic review of the PubMed, Embase and Cochrane databases was performed. This position statement formulated clinical questions and graded the evidence to make recommendations.

RESULTS

Perineal wound complications may be higher following ELAPE compared to 'conventional APE (cAPE)' however there is insufficient evidence to recommend cAPE over ELAPE with regards to the impact upon perineal wound healing. The majority of cAPE studies have used primary closure with varying complication rates reported. Where concerns regarding perineal wound healing exist, myocutaneous flap closure may be considered as an alternative method. There is minimal available evidence on perineal mesh reconstruction following cAPE. Primary closure, mesh use and myocutaneous flap reconstruction following ELAPE has been reported although variations in definitions and low-quality of available evidence limit comparison. There is insufficient evidence to recommend one particular method of perineal closure after ELAPE. Primary perineal closure is likely to have a higher risk of perineal herniation. Myocutaneous flaps and biological mesh have been effectively used in ELAPE closure. There is insufficient evidence to support one particular type of flap or mesh. Perineal wound complication rates are significantly increased when neo-adjuvant radiotherapy is delivered, regardless of surgical technique. There is no evidence that laparoscopy reduces APE perineal wound complications.

CONCLUSION

This position statement updates clinicians on current evidence around perineal closure after APE surgery.

Differentiating cognitive or motor dimensions associated with the perception of fall-related self-efficacy in Parkinson's disease

In Parkinson's disease (PD), concurrent declines in cognitive and motor domain function can severely limit an individual's ability to conduct daily tasks. Current diagnostic methods, however, lack precision in differentiating domain-specific contributions of cognitive or motor impairments based on a patients' clinical manifestation. Fear of falling (FOF) is a common clinical manifestation among the elderly, in which both cognitive and motor impairments can lead to significant barriers to a patients' physical and social activities. The present study evaluated whether a set of analytical and machine-learning approaches could be used to help delineate boundary conditions and separate cognitive and motor contributions to a patient's own perception of self-efficacy and FOF. Cognitive and motor clinical scores, in conjunction with FOF, were collected from 57 Parkinson's patients during a multi-center rehabilitation intervention trial. Statistical methodology was used to extract a subset of uncorrelated cognitive and motor components associated with cognitive and motor predictors, which were then used to independently identify and visualize cognitive and motor dimensions associated with FOF. We found that a central cognitive process, extracted from tests of executive, attentional, and visuoperceptive function, was a unique and significant independent cognitive predictor of FOF in PD. In addition, we provide evidence that the approaches described here may be used to computationally discern specific types of FOF based on separable cognitive or motor models. Our results are consistent with a contemporary model that the deterioration of a central cognitive mechanism that modulates self-efficacy also plays a critical role in FOF in PD.

International travel between global urban centres vulnerable to yellow fever transmission

OBJECTIVE

To examine the potential for international travel to spread yellow fever virus to cities around the world.

METHODS

We obtained data on the international flight itineraries of travellers who departed yellow fever-endemic areas of the world in 2016 for cities either where yellow fever was endemic or which were suitable for viral transmission. Using a global ecological model of dengue virus transmission, we predicted the suitability of cities in non-endemic areas for yellow fever transmission. We obtained information on national entry requirements for yellow fever vaccination at travellers' destination cities.

FINDINGS

In 2016, 45.2 million international air travellers departed from yellow fever-endemic areas of the world. Of 11.7 million travellers with destinations in 472 cities where yellow fever was not endemic but which were suitable for virus transmission, 7.7 million (65.7%) were not required to provide proof of vaccination upon arrival. Brazil, China, India, Mexico, Peru and the United States of America had the highest volumes of travellers arriving from yellow fever-endemic areas and the largest populations living in cities suitable for yellow fever transmission.

CONCLUSION

Each year millions of travellers depart from yellow fever-endemic areas of the world for cities in non-endemic areas that appear suitable for viral transmission without having to provide proof of vaccination. Rapid global changes in human mobility and urbanization make it vital for countries to re-examine their vaccination policies and practices to prevent urban yellow fever epidemics.

Effect of sodium molybdate supplementation on high concentrations of Cu in liver of yearling bulls

AIM

To determine the impact of sodium molybdate treatment, given weekly, on concentrations of Cu in liver, activity of liver enzymes, and weight gain over 4 weeks, in yearling bulls with elevated concentrations of Cu in liver.

METHODS

The study was carried on two commercial grazing farms in the Otago region of New Zealand in yearling Friesian bulls (n=150 on Farm A and n=49 on Farm B) with mean concentration of Cu in liver >3,000 µmol/kg fresh weight. On Day 0, all animals were weighed and half were systematically allocated to treatment with sodium molybdate (3 mg/kg liveweight on Farm A and 7 mg/kg liveweight on Farm B); the remainder received no treatment (Control). Sodium molybdate was given as a drench weekly for 4 weeks and all animals were weighed again on Day 28. Ten animals on each farm (five from each treatment group) were systematically selected for blood sampling and liver biopsies on Days 0 and 28. Samples were analysed for concentrations of Cu in plasma, vitamin B₁₂ in serum, activities of γ-glutamyl transferase, aspartate aminotransferase and glutamate dehydrogenase in serum, and concentrations of Cu and vitamin B₁₂ in liver. Separate multivariable linear models were used to compare the change in outcome variables between Days 0 and 28 between bulls that had been drenched with sodium molybdate or not.

RESULTS

On Farm A, mean concentrations of Cu in liver on Day 28, as a percentage of concentrations on Day 0, for the control group was 55 (95% CI=40-73)% and for the treatment group was 73 (95% CI=43-111)%. On Farm B, the equivalent mean for the control group was 75 (95% CI=42-131)% and for the treatment group was 85 (95% CI=38-134)%. The multivariable linear models indicated that the changes in concentrations of Cu in liver, activities of liver enzymes and weight gain between Days 0 and 28 did not differ between the bulls treated or not with sodium molybdate (p>0.18).

CONCLUSIONS AND CLINICAL RELEVANCE

Treatment with sodium molybdate in one bolus at weekly intervals for 4 weeks did not affect concentrations of Cu in liver, activity of liver enzymes or weight gain in animals with high concentrations of Cu liver on two farms.

Infectious disease implications of large-scale migration of Venezuelan nationals

Background

The ongoing economic and political crisis in Venezuela has resulted in a collapse of the healthcare system and the re-emergence of previously controlled or eliminated infectious diseases. There has also been an exodus of Venezuelan international migrants in response to the crisis. We sought to describe the infectious disease risks faced by Venezuelan nationals and assess the international mobility patterns of the migrant population.

Methods

We synthesized data on recent infectious disease events in Venezuela and among international migrants from Venezuela, as well as on current country of residence among the migrant population. We used passenger-level itinerary data from the International Air Transport Association to evaluate trends in outbound air travel from Venezuela over time. We used two parameter-free mobility models, the radiation and impedance models, to estimate the expected population flows from Venezuelan cities to other major Latin American and Caribbean cities.

Results

Outbreaks of measles, diphtheria and malaria have been reported across Venezuela and other diseases, such as HIV and tuberculosis, are resurgent. Changes in migration in response to the crisis are apparent, with an increase in Venezuelan nationals living abroad, despite an overall decline in the number of outbound air passengers. The two models predicted different mobility patterns, but both highlighted the importance of Colombian cities as destinations for migrants and also showed that some migrants are expected to travel large distances. Despite the large distances that migrants may travel internationally, outbreaks associated with Venezuelan migrants have occurred primarily in countries proximate to Venezuela.

Conclusions

Understanding where international migrants are relocating is critical, given the association between human mobility and the spread of infectious diseases. In data-limited situations, simple models can be useful for providing insights into population mobility and may help identify areas likely to receive a large number of migrants.