Value of Electronic Health Records Measured Using Financial and Clinical Outcomes: Quantitative Study

BACKGROUND

The Health Information Technology for Economic and Clinical Health Act of 2009 was legislated to reduce health care costs, improve quality, and increase patient safety. Providers and organizations were incentivized to exhibit meaningful use of certified electronic health record (EHR) systems in order to achieve this objective. EHR adoption is an expensive investment, given the resources and capital that are invested. Due to the cost of the investment, a return on the EHR adoption investment is expected.

OBJECTIVE

This study performed a value analysis of EHRs. The objective of this study was to investigate the relationship between EHR adoption levels and financial and clinical outcomes by combining both financial and clinical outcomes into one conceptual model.

METHODS

We examined the multivariate relationships between different levels of EHR adoption and financial and clinical outcomes, along with the time variant control variables, using moderation analysis with a longitudinal fixed effects model. Since it is unknown as to when hospitals begin experiencing improvements in financial outcomes, additional analysis was conducted using a 1- or 2-year lag for profit margin ratios.

RESULTS

A total of 5768 hospital-year observations were analyzed over the course of 4 years. According to the results of the moderation analysis, as the readmission rate increases by 1 unit, the effect of a 1-unit increase in EHR adoption level on the operating margin decreases by 5.38%. Hospitals with higher readmission payment adjustment factors have lower penalties.

CONCLUSIONS

This study fills the gap in the literature by evaluating individual relationships between EHR adoption levels and financial and clinical outcomes, in addition to evaluating the relationship between EHR adoption level and financial outcomes, with clinical outcomes as moderators. This study provided statistically significant evidence (P<.05), indicating that there is a relationship between EHR adoption level and operating margins when this relationship is moderated by readmission rates, meaning hospitals that have adopted EHRs could see a reduction in their readmission rates and an increase in operating margins. This finding could further be supported by evaluating more recent data to analyze whether hospitals increasing their level of EHR adoption would decrease readmission rates, resulting in an increase in operating margins. Hospitals would incur lower penalties as a result of improved readmission rates, which would contribute toward improved operating margins.

Management of Acute Carpal Tunnel Syndrome: A Systematic Review

Purpose

This review aims to compare recovery outcomes of conservative, early operative, and a combination of conservative and operative management for acute carpal tunnel syndrome (ACTS).

Methods

A literature search of PubMed, Scopus, and CINAHL from 1970 to 2022 was conducted using the keywords carpal tunnel syndrome and acute nerve compression. ACTS was defined as a case within 12 weeks of symptom onset. Primary data extracted included causes (traumatic or atraumatic), symptom duration (<1 day, 1-7 days, or 8-84 days), intervention (surgical, conservative, or conservative then surgical), follow-up duration, and outcome (full recovery or non-full recovery). Logistic regression analyses and χ2 tests were performed to investigate associations among these variables.

Results

A total of 197 patients involving 127 (64.5%) traumatic and 70 (35.3%) atraumatic cases were included. Forty-seven percent of patients were managed conservatively followed by surgery, 30% conservative only, and 23% surgery only. The traumatic group was associated with better recovery than the atraumatic group. Recovery outcomes were not associated with symptom duration or follow-up time. The choice of intervention was not associated with traumatic or atraumatic etiology, nor did it affect recovery outcomes in either group.

Conclusions

Traumatic ACTS is associated with better recovery outcomes than atraumatic etiologies. Surgical intervention was not found to be associated with better outcomes than conservative management, regardless of the etiologies. Further prospective studies are warranted to compare surgical versus conservative management.

Clinical Relevance

Currently, there are no guidelines for the best management of ACTS, and it is not known if early or delayed surgical treatment is optimal. This review compiles the current evidence and identifies gaps in the literature, highlighting the need for further investigation to provide the best clinical practice.

Pandemic Responsiveness in an Acute Care Setting: A Community Hospital's Utilization of Operational Resources During COVID-19

Background

To ensure continuity of services while mitigating patient surge and nosocomial infections during the coronavirus disease 2019 (COVID-19) pandemic, acute care hospitals have been required to make significant operational adjustments. Here, we identify and discuss key administrative priorities and strategies utilized by a large community hospital located in Ontario, Canada.

Methods

Guided by a qualitative descriptive approach, we performed a thematic analysis of all COVID-19-related documentation discussed by the hospital’s emergency operation centre (EOC) during the pandemic’s first wave. We then solicited operational strategies from a multidisciplinary group of hospital leaders to construct a narrative for each theme.

Results

Seven recurrent themes critical to the hospital’s pandemic response emerged: 1) Organizational structure: a modified EOC structure was adopted to increase departmental interoperability and situational awareness; 2) Capacity planning: Design Thinking guided rapid infrastructure decisions to meet surge requirements; 3) Occupational health and workplace safety: a multidisciplinary team provided respirator fit-testing, critical absence adjudication, and wellness needs; 4) Human resources/workforce planning: new workforce planning, recruitment, and redeployment strategies addressed staffing shortages; 5) Personal protective equipment (PPE): PPE conservation required proactive sourcing from traditional and non-traditional suppliers; 6) Community response: local partnerships were activated to divert patients through a non-referral-based assessment and treatment centre, support long-term care and retirement homes, and establish a 70-bed field hospital; and 7) Corporate communication: a robust communication strategy provided timely and transparent access to rapidly evolving information.

Conclusion

A community hospital’s operational preparedness for COVID-19 was supported by inter-operability, leveraging internal and external expertise and partnerships, creative problem solving, and developing novel tools to support occupational health and community initiatives.

The Development, Implementation, and Feasibility of a Circadian, Light, and Sleep Skills Program for Shipboard Military Personnel (CLASS-SM)

Service members face unique barriers to sufficient and high quality sleep. In the present study, a circadian, light, and sleep skills program for shipboard military personnel (CLASS-SM) was designed to encourage and inform strategies that support optimal sleep and circadian health in the context of those barriers. Phase 1 included program development and refinement via an iterative formative evaluation, including structured interviews with service members and feedback from veterans and experts, resulting in further tailoring to the population. In Phase 2, the highly tailored program was administered to shipboard personnel (n = 55), and acceptability indicators were measured. Sleep- and circadian-related knowledge (pre- and post-program) and the perceived relevance of, and satisfaction with, program content (post-program) were assessed. Before the intervention, most individuals were unaware that 7−9 h of sleep is recommended (72%) and had little understanding of the physiological effects of light; however, knowledge scores increased significantly post-program, from 51% to 88% correct (p < 0.0001). Reception was positive, with high reported satisfaction and relevance. Most individuals reported that they learned something new (89%), planned to use one or more learned strategies (100%), and intended to share learned information with others (85%); the physiological effects of light and circadian rhythms were the content areas most frequently reported as new and useful. The results demonstrate the need for, and feasibility of, the delivery of this program in operational environments.

Assessment of the Operational Characteristics of Research Ethics Committees in Ghana

There were eighteen Research Ethics Committees (RECs) operating in Ghana as of December 2019 but no empirical assessment of their operational characteristics had been conducted. We assessed the characteristics of Ghanaian RECs using an existing Self-Assessment Tool for RECs in Developing Countries. We present results from nine RECs that participated in this nation-wide assessment. Our results indicate that the RECs are generally adherent to the recommendations in the Tool including being composed of members with diverse expertise. They also reviewed and approved research protocols as well as had access to some limited funding for their activities. There is no national policy on research human protections or an ethics authority to regulate the activities of the RECs. We recommend the establishment of this authority in Ghana while encouraging institutions to sustain efforts aimed at making their RECs operate independently.

Surviving the surge: Evaluation of early impact of COVID-19 on inpatient pharmacy services at a community teaching hospital

Purpose

The coronavirus disease 2019 (COVID-19) pandemic has presented novel challenges to healthcare systems; however, an analysis of the impact of the pandemic on inpatient pharmacy services has not yet been conducted.

Methods

Results of an observational assessment of operational and clinical pharmacy services at a community teaching hospital during the first weeks of the COVID-19 pandemic are presented. Service outcomes of the inpatient pharmacy were evaluated from February 1 to April 8, 2020. Outcomes during the weeks preceding the first COVID-19 admission (February 1 to March 11, 2020) and during the pandemic period (March 12 to April 8, 2020) were compared. Evaluated outcomes included daily order verifications, clinical interventions, and usage of relevant medications. An exploratory statistical analysis was conducted using Student’s t test.

Results

During the pandemic period, the number of new order verifications decreased from approximately 5,000 orders per day to 3,300 orders per day (P < 0.01), a reduction of 30% during the first 4 weeks of the pandemic compared to the weeks prior. Average daily pharmacokinetic dosing consults were reduced in the pandemic period (from 82 to 67; P < 0.01) compared to the prepandemic period; however, total daily pharmacist interventions did not differ significantly (473 vs 456; P = 0.68). Dispensing of hydroxychloroquine, azithromycin, enoxaparin, and sedative medications increased substantially during the pandemic period (P < 0.01 for all comparisons).

Conclusion

The operational and clinical requirements of an inpatient pharmacy department shifted considerably during the first weeks of the COVID-19 pandemic. Pharmacy departments must be adaptable in order to continue to provide effective pharmaceutical care during the pandemic.

Victoria (Australia) radiotherapy response to working through the first and second wave of COVID-19: Strategies and staffing

Introduction

The COVID‐19 pandemic demanded a rapid response within Radiation Oncology services to minimise the risk of infection to patients and workforce. This study aimed to assess whether the operational changes put in place to reduce infection risks were effective in engaging and supporting staff.

Methods

Our service’s response saw staff and patients split into morning or afternoon shifts without overlap. Changes included extended clinic hours, modified treatment regimens, expanded online/electronic communication and remote working. Staff were invited to respond to an electronic questionnaire in September 2020, just after the peak of the second COVID‐19 wave in Victoria. Responses captured demographic data, parental status, profession, happiness levels, fear of COVID‐19 and e‐communication efficacy.

Results

A 57% response rate was achieved. 69% of respondents were female; 40% were aged 45+ and 35% had school‐aged children. Staff aged 45+ showed a significantly greater fear of COVID‐19 than younger staff. 36% of respondents reported feeling nervous or anxious watching news reports about COVID‐19. 92% of staff were happy with their work arrangements; staff with children were happier than staff without children with their shifts. Online chat/channels were reported as the preferred e‐communication method between colleagues.

Conclusion

Staff provided predominantly positive feedback to the changes made in response to the pandemic, reporting high levels of happiness and willingness to continue with the changes implemented during COVID‐19. The strategies adopted worked well and the overall high levels of staff satisfaction will allow our service to quickly pivot should further surges, or another pandemic, arise.

Variation in referral rates to emergency departments and inpatient services from a GP out of hours service and the potential impact of alternative staffing models

Introduction

Out of hours (OOHs) primary care is a critical component of the acute care system overnight and at weekends. Referrals from OOH services to hospital will add to the burden on hospital assessment in the ED and on-call specialties.

Methods

We studied the variation in referral rates (to the ED and direct specialty admission) of individual clinicians working in the Oxfordshire, UK OOH service covering a population of 600 000 people. We calculated the referral probability for each clinician over a 13-month period of practice (1 December 2014 to 31 December 2015), stratifying by clinician factors and location and timing of assessment. We used Simul8 software to determine the range of hospital referrals potentially due to variation in clinician referral propensity.

Results

Among the 119 835 contacts with the service, 5261 (4.4%) were sent directly to the ED and 3474 (3.7%) were admitted directly to specialties. More referrals were made to ED by primary care physicians if they did not work in the local practices (5.5% vs 3.5%, p=0.011). For clinicians with >1000 consultations, percentage of patients referred varied from 1% to 21% of consultations. Simulations where propensity to refer was made less extreme showed a difference in maximum referrals of 50 patients each week.

Conclusions

There is substantial variation in clinician referral rates from OOHs primary care to the acute hospital setting. The number of patients referred could be influenced by this variation in clinician behaviour. Referral propensity should be studied including casemix adjustment to determine if interventions targeting such behaviour are effective.

Planning for success: overcoming challenges to recruitment and conduct of an open-label emergency department-led paediatric trial

BACKGROUND

Key challenges to the successful conduct of The Emergency treatment with Levetiracetam or Phenytoin in Status Epilepticus in children (EcLiPSE) trial were identified at the pre-trial stage. These included practitioner anxieties about conducting research without prior consent (RWPC), inexperience in conducting an ED-led trial and use of a medication that was not usual ED practice. As part of an embedded study, we explored parent and practitioner experiences of recruitment, RWPC and conduct of the trial to inform the design and conduct of future ED-led trials.

METHODS

A mixed-methods study within a trial involving (1) questionnaires and interviews with parents of randomised children, (2) interviews and focus groups with EcLiPSE practitioners and (3) audio-recorded trial discussions. We analysed data using thematic analysis and descriptive statistics as appropriate.

RESULTS

A total of 143 parents (93 mothers, 39 fathers, 11 missing information) of randomised children completed a questionnaire and 30 (25 mothers, 5 fathers) were interviewed. We analysed 76 recorded trial recruitment discussions. Ten practitioners (4 medical, 6 nursing) were interviewed, 36 (16 medical, 20 nursing) participated in one of six focus groups. Challenges to the success of the trial were addressed by having a clinically relevant research question, pragmatic trial design, parent and practitioner support for EcLiPSE recruitment and research without prior consent processes, and practitioner motivation and strong leadership. Lack of leadership negatively affected practitioner engagement and recruitment. EcLiPSE completed on time, achieving its required sample size target.

CONCLUSIONS

Successful trial recruitment and conduct in a challenging ED-led trial was driven by trial design, recruitment experience, teamwork and leadership. Our study provides valuable insight from parents and practitioners to inform the design and conduct of future trials in this setting.

Occupational exposures and programmatic response to COVID-19 pandemic: an emergency medical services experience

Rigorous assessment of occupational COVID-19 risk and personal protective equipment (PPE) use is not well-described. We evaluated 9-1-1 emergency medical services (EMS) encounters for patients with COVID-19 to assess occupational exposure, programmatic strategies to reduce exposure and PPE use. We conducted a retrospective cohort investigation of laboratory-confirmed patients with COVID-19 in King County, Washington, USA, who received 9-1-1 EMS responses from 14 February 2020 to 26 March 2020. We reviewed dispatch, EMS and public health surveillance records to evaluate the temporal relationship between exposure and programmatic changes to EMS operations designed to identify high-risk patients, protect the workforce and conserve PPE. There were 274 EMS encounters for 220 unique COVID-19 patients involving 700 unique EMS providers with 988 EMS person-encounters. Use of 'full' PPE including mask (surgical or N95), eye protection, gown and gloves (MEGG) was 67%. There were 151 person-exposures among 129 individuals, who required 981 quarantine days. Of the 700 EMS providers, 3 (0.4%) tested positive within 14 days of encounter, though these positive tests were not attributed to occupational exposure from inadequate PPE. Programmatic changes were associated with a temporal reduction in exposures. When stratified at the study encounters midpoint, 94% (142/151) of exposures occurred during the first 137 EMS encounters compared with 6% (9/151) during the second 137 EMS encounters (p<0.01). By the investigation's final week, EMS deployed MEGG PPE in 34% (3579/10 468) of all EMS person-encounters. Less than 0.5% of EMS providers experienced COVID-19 illness within 14 days of occupational encounter. Programmatic strategies were associated with a reduction in exposures, while achieving a measured use of PPE.

Waiting times in emergency departments: exploring the factors associated with longer patient waits for emergency care in England using routinely collected daily data

Background

Long lengths of stay (also called waiting times) in emergency departments (EDs) are associated with higher patient mortality and worse outcomes.

Objective

To add to the literature using high-frequency data from a large number of hospitals to analyse factors associated with long waiting times, including exploring non-linearities for 'tipping points'.

Methods

Multivariate ordinary least squares regressions with fixed effects were used to analyse factors associated with the proportion of patients in EDs in England waiting more than 4 hours to be seen, treated and admitted or discharged. Daily situation reports (Sitrep), hospital episode statistics and electronic staffing records data over 90 days between December 2016 and February 2017 were used for all 138 English NHS healthcare providers with a major ED.

Results

Higher inpatient bed occupancy was correlated with longer ED waiting times, with a non-linear association. In a full hospital, with 100% bed occupancy, the proportion of patients who remained in the ED for more than 4 hours was 9 percentage points higher (95% CI 7.5% to 11.1%) than with an 85% occupancy level. For each percentage point change in the following factors, the proportion of ED stays over 4 hours also increased: more inpatients with hospital length of stay over 21 days (0.07%, 95% CI 0.008% to 0.13%); higher emergency admissions (0.08%, 95% CI 0.06% to 0.10%); and lower discharges relative to admissions on the same day (0.04%, 95% CI 0.02% to 0.06%), the following day (0.05%, 95% CI 0.03% to 0.06%) and at 2 days (0.05%, 95% CI 0.04% to 0.07%).

Conclusions

These results suggest that tackling patient flow and capacity in the wider hospital, particularly very high bed occupancy levels and patient discharge, is important to reduce ED waiting times and improve patient outcomes.

Going to war on COVID-19: Mobilizing an academic nephrology group practice

Aim

The COVID‐19 pandemic poses unprecedented operational challenges to nephrology divisions in every country as they cope with COVID‐19‐related kidney disease in addition to regular patient care. Although general approaches have been proposed, there is a lack of practical guidance for nephrology division response in a hospital facing a surge of cases. Here, we describe the specific measures that our division has taken in the hope that our experience in Singapore may be helpful to others.

Methods

Descriptive narrative.

Results

A compilation of operational responses to the COVID‐19 pandemic taken by a nephrology division at a Singapore university hospital.

Conclusion

Nephrology operational readiness for COVID‐19 requires a clinical mindset shift from usual standard of care to a crisis exigency model that targets best outcomes for available resources. Rapid multi‐disciplinary efforts that evolve flexibly with the local dynamics of the outbreak are required.

A valuable experience and operational response to COVID‐19 pandemic threat by a nephrology division at a Singapore university hospital. This article gives good example of shift of clinical mindset from usual standard of care to a crisis exigency model that targets best outcomes for available resources.

Pre-exposure Prophylaxis: The Delivery Challenge

HIV pre-exposure prophylaxis (PrEP), despite its efficacy, has been slow in uptake throughout the world. This article discusses the operational and service delivery complexity, based on early real-world experience, with some recommendations on how this promising intervention could be made more available. Currently, access to PrEP is made complex by restricting delivery to dedicated health facilities, as well as requirements around HIV testing and toxicity monitoring. Expanding to verticalized services that focus on well-defined populations where HIV testing and treatment programmes already exist, has proven relatively simple. Providing PrEP outside of this environment has yet to be demonstrated at any scale, and will likely require innovative thinking addressing the regulatory and clinical environment, so as to ensure easier access to this promising HIV prevention tool.

Modelling attending physician productivity in the emergency department: a multicentre study

Objectives

Emergency physician productivity, often defined as new patients evaluated per hour, is essential to planning clinical operations. Prior research in this area considered this a static quantity; however, our group’s study of resident physicians demonstrated significant decreases in hourly productivity throughout shifts. We now examine attending physicians’ productivity to determine if it is also dynamic.

Methods

This is a retrospective cohort study, conducted from 2014 to 2016 across three community hospitals in the north-eastern USA, with different schedules and coverage. Timestamps of all patient encounters were automatically logged by the sites’ electronic health record. Generalised estimating equations were constructed to predict productivity in terms of new patients per shift hour.

Results

207 169 patients were seen by 64 physicians over 2 years, comprising 9822 physician shifts. Physicians saw an average of 15.0 (SD 4.7), 20.9 (SD 6.4) and 13.2 (SD 3.8) patients per shift at the three sites, with 2.97 (SD 0.22), 2.95 (SD 0.24) and 2.17 (SD 0.09) in the first hour. Across all sites, physicians saw significantly fewer new patients after the first hour, with more gradual decreases subsequently. Additional patient arrivals were associated with greater productivity; however, this attenuates substantially late in the shift. The presence of other physicians was also associated with slightly decreased productivity.

Conclusions

Physician productivity over a single shift follows a predictable pattern that decreases significantly on an hourly basis, even if there are new patients to be seen. Estimating productivity as a simple average substantially underestimates physicians’ capacity early in a shift and overestimates it later. This pattern of productivity should be factored into hospitals’ staffing plans, with shifts aligned to start with the greatest volumes of patient arrivals.

Impact of Physician Navigators on productivity indicators in the ED

OBJECTIVES

We created Physician Navigators in our ED to help improve emergency physician (EP) productivity. We aimed to quantify the effect of Physician Navigators on measures of EP productivity: patient seen per hour (Pt/hr), and turn-around time (TAT) to discharge. Secondary objectives included examining their impact on measures of ED throughput for non-resuscitative patients: ED length of stay (LOS), door-to-physician time and left-without-being-seen rates (LWBS).

METHODS

In this retrospective study, 6845 clinical shifts worked by 20 EPs at a community ED in Newmarket, Canada from 1 January 2012 to 31 March 2015 were evaluated. Using a clustered design, we compared productivity measures between shifts with and without Physician Navigators, by physician. We used a linear mixed model to examine mean changes in Pt/hr and TAT to discharge for EPs who employed Physician Navigators. For secondary objectives, autoregressive modelling was performed to compare ED throughput metrics before and after the implementation of Physician Navigators for non-resuscitative patients.

RESULTS

Patient volumes increased by 20 patients per day (p<0.001). Mean Pt/hr increased by 1.07 patients per hour (0.98 to 1.16, p<0.001). The mean TAT to discharge decreased by 10.6 min (-13.2 to -8.0, p<0.001). After implementation of the Physician Navigator programme, overall mean LOS for non-resuscitative patients decreased by 2.6 min (p=0.007), and mean door-to-physician time decreased by 7.4 min (p<0.001). LBWS rates decreased from 1.13% to 0.63% of daily patient volume (p<0.001).

CONCLUSION

Despite an ED volume increase, the use of a Physician Navigator was associated with significant improvements in EP productivity, and significant reductions in ED throughput times.

What we have learnt about the World Health Organization from the Ebola outbreak

The World Health Organization's (WHO) reputation became irrefutably damaged during the Ebola outbreak, with a general consensus in the global health community that it fell short of its leadership responsibilities. This commentary offers a brief synopsis of the WHO's role during the outbreak and suggests that the disease outbreak demonstrates the tension that exists between the organization's normative and operational roles in health crises. While the WHO did offer some normative leadership during the Ebola outbreak, as per its constitution, it did not provide an effective operational response, yet nor did it have a mandate to do so. This division between the normative and operational was further highlighted by the discrepancy between what the global community expects the WHO to do in a health emergency, and what it is able to do with its financial and organizational constraints. Finally, the commentary considers the introduction of the WHO Health Emergency Programme, but suggests that this too may suffer from the same structural concerns that need to be addressed if the WHO is to continue in the role the global health community expects it to play, as both a normative and operational leader in global disease control.This article is part of the themed issue 'The 2013-2016 West African Ebola epidemic: data, decision-making and disease control'.

Phosphorescent Pt(II) and Pd(II) Complexes for Efficient, High-Color-Quality, and Stable OLEDs

Phosphorescent organic light-emitting diodes (OLEDs) are leading candidates for next-generation displays and solid-state lighting technologies. Much of the academic and commercial pursuits in phosphorescent OLEDs have been dominated by Ir(III) complexes. Over the past decade recent developments have enabled square planar Pt(II) and Pd(II) complexes to meet or exceed the performance of Ir complexes in many aspects. In particular, the development of N-heterocyclic carbene-based emitters and tetradentate cyclometalated Pt and Pd complexes have significantly improved the emission efficiency and reduced their radiative lifetimes making them competitive with the best reported Ir complexes. Furthermore, their unique and diverse molecular design possibilities have enabled exciting photophysical attributes including narrower emission spectra, excimer -based white emission, and thermally activated delayed fluorescence. These developments have enabled the fabrication of efficient and "pure" blue OLEDs, single-doped white devices with EQEs of over 25% and high CRI, and device operational lifetimes which show early promise that square planar metal complexes can be stable enough for commercialization. These accomplishments have brought Pt complexes to the forefront of academic research. The molecular design strategies, photophysical characteristics, and device performance resulting from the major advancements in emissive Pt and Pd square planar complexes are discussed.

On the variability of near-surface screen temperature anomalies in the 20 March 2015 solar eclipse

Near-surface air temperature (NSAT) anomalies during the 20 March 2015 solar eclipse are investigated at 266 UK sites, using operational data. The high density of observing sites, together with the wide range of ambient meteorological conditions, provided an unprecedented opportunity for analysis of the spatial variability of NSAT anomalies under relatively uniform eclipse conditions. Anomalies ranged from -0.03°C to -4.23°C (median -1.02°C). The maximum (negative) anomaly lagged the maximum obscuration by 15 min on average. Cloud cover impacted strongly on NSAT anomalies, with larger anomalies in clear-sky situations (p<0.0001). Weaker, but statistically significant, correlations were found with wind speed (larger anomalies in weaker winds), proximity to coast (larger anomalies at inland sites), topography (larger anomalies in topographical low points) and land cover (larger anomalies over vegetated surfaces). In this mid-morning eclipse, the topographical influences on NSAT anomalies were apparently dominated by variations in residual nocturnal inversion strength, as suggested by significant correlations between post-sunrise temperature and NSAT anomaly at clear-sky sites (larger negative anomalies with lower post-sunrise temperatures). The largest NSAT anomaly occurred at a coastal site where flow transitioned from onshore to offshore during the eclipse, in a situation with large coastal temperature gradients associated with antecedent nocturnal cooling.This article is part of the themed issue 'Atmospheric effects of solar eclipses stimulated by the 2015 UK eclipse'.

Alignment of new tuberculosis drug regimens and drug susceptibility testing: a framework for action

New tuberculosis drug regimens are creating new priorities for drug susceptibility testing (DST) and surveillance. To minimise turnaround time, rapid DST will need to be prioritised, but developers of these assays will need better data about the molecular mechanisms of resistance. Efforts are underway to link mutations with drug resistance and to develop strain collections to enable assessment of new diagnostic assays. In resource-limited settings, DST might not be appropriate for all patients with tuberculosis. Surveillance data and modelling will help country stakeholders to design appropriate DST algorithms and to decide whether to change drug regimens. Finally, development of practical DST assays is needed so that, in countries where surveillance and modelling show that DST is advisable, these assays can be used to guide clinical decisions for individual patients. If combined judiciously during both development and implementation, new tuberculosis regimens and new DST assays have enormous potential to improve patient outcomes and reduce the burden of disease.