Search

ObjectivesTo examine coroners’ Prevention of Future Deaths reports (PFDs) to identify deaths involving SARS-CoV-2 that coroners deemed preventable.DesignConsecutive case series.SettingEngland and Wales.ParticipantsPatients reported in 510 PFDs dated between 01 January 2020 and 28 June 2021, collected from the UK’s Courts and Tribunals Judiciary website using web scraping to create an openly available database,https://preventabledeathstracker.net/.Main outcome measuresConcerns reported by coroners.Public and Patient InvolvementPatients and members of the public were not involved in this study.ResultsSARS-CoV-2 was involved in 23 deaths reported by coroners in PFDs. Twelve deaths were indirectly related to the COVID-19 pandemic, defined as those that were not medically caused by SARS-CoV-2, but were associated with mitigation measures. In 11 cases the coroner explicitly reported that COVID-19 had directly caused death. There was geographical variation in the reporting of PFDs; most (39%) were written by coroners in the North-West of England. The coroners raised 56 concerns, problems in communication being the most common (30%), followed by failure to follow protocols (23%). Organizations in the National Health Service (NHS) were sent the most PFDs (51%), followed by the Government (26%), but responses to PFDs by these organizations were poor.ConclusionsPFDs contain a rich source of information on preventable deaths that has previously been difficult to examine systematically. Our openly available tool (https://preventabledeathstracker.net/) streamlines this process and has identified many concerns raised by coroners that should be addressed during the Government’s inquiry into the handling of the COVID-19 pandemic, so that mistakes made are less likely to be repeated.Study protocol pre-registrationhttps://osf.io/bfypc/Summary boxWhat is already known about this subject?The UK Government has stated that there will be a public inquiry into the handling of the COVID-19 pandemic, to learn lessons for future pandemics.Coroners in England and Wales have a duty to report and communicate information about the deaths they investigate when the coroner believes that action should be taken to prevent future deaths.These reports, called Prevention of Future Death reports (PFDs), had not yet been systematically analysed to identify deaths that occurred during the COVID-19 pandemic.What are the new findings?We created the Preventable Deaths Database (https://preventabledeathstracker.net/) using web scraping to systematically assess PFDs published on the Courts and Tribunal Judiciary website.Between 01 January 2020 and 28 June 2021, one in 20 (4.5%, n=23) PFDs that were published by coroners involved SARS-CoV-2.Coroners raised many concerns about the care of patients in hospitals, care homes, and people in the community during the COVID-19 pandemic, which require action to prevent future deaths.How might it affect clinical practice in the foreseeable future?Preventable deaths that occurred during the COVID-19 pandemic should be referred to the coroner so that an inquest can be performed and a PFD issued, highlightng actions that could be avoided in improving the handling of future pandemics in both the UK and elsewhere.Our tool,https://preventabledeathstracker.net/, can be used by others to examine preventable deaths in England and Wales, and to identify signals for quality improvement to reduce avoidable harms in clinical practice.

While COVID-19 vaccines provide light at the end of thetunnel in a difficult time, they also bring forth the complexethical issue of global vaccine distribution. The currentunequal global distribution of vaccines is unjust towardsthe vulnerable living in low-income countries. A vaccine taxshould be introduced to remedy this. Under such a scheme,a small fraction of the money spent by a country on vaccinesfor its own population would go into a fund, such asCOVAX, dedicated to buying vaccines and distributing themto the world’s poorest. A vaccine tax would provide a muchneeded injection of funds to remedy the unequal distributionof vaccines. The tax allows for a distribution that, to alesser degree, reflects the ability to pay and is superior to adonation-based model because it minimises the opportunityfor free-riding.

The COVID-19 pandemic has caused widespread disruptions to tuberculosis (TB) care and service delivery in 2020, setting back progress in the fight against TB by several years. As newer COVID-19 variants continue to devastate many low and middle-income countries in 2021, the extent of this setback is likely to increase. Despite these challenges, the TB community can draw on the comprehensive approaches used to manage COVID-19 to help restore progress and mitigate the impact of COVID-19 on TB. Our team developed the ‘Swiss Cheese Model for Ending TB’ to illustrate that it is only through multisectoral collaborations that address the personal, societal and health system layers of care that we will end TB. In this paper, we examine how COVID-19 has impacted the different layers of TB care presented in the model and explore how we can leverage some of the lessons and outcomes of the COVID-19 pandemic to strengthen the global TB response.

ObjectivesTwitter is the most frequently used social media platform by healthcare practitioners, at medical conferences. This study aimed to analyze Twitter conversations during the virtual International Gynecological Cancer Society 2020 conference to understand the interactions between Twitter users related to the conference.MethodsTweets using the hashtag ‘#IGCS2020’ were searched using the Twitter Search Application Programming Interface (API) during the period 10–13 September 2020. NodeXL Pro was used to retrieve data. The Clauset-Newman-Moore cluster algorithm clustered users into different groups or ‘clusters’ based on how users interacted.ResultsThere were 2009 registrants for the virtual IGCS 2020 conference. The total number of users within the network was 168, and there were 880 edges connecting users. Five types of edges were identified as follows: ‘replies to’ (n=18), ‘mentions’ (n=221), ‘mentions in retweets’ (n=375), retweets (n=198), and tweets (n=68). The most influential account was that of the IGCS account itself (@IGCSociety). The overall network shape resembled a community where distinct groups formed within the network. Our current analyses demonstrated that less than 10% of the total members interacted on Twitter.ConclusionThis study identified the most influential Twitter users within the ‘#IGCS2020’ community. he results also confirmed the community network shape of the #IGCS2020 hashtag and found that the most frequent co-related words were ‘ovarian’ and ‘cancer’ (n=39).

Summary box #### What are the new findings? ### Summary box #### How might it impact on healthcare in the future? There have been exponential increases in telemedicine, 1 2 mobile health platforms(mhealth)3–5 and virtual clinics during the COVID-19 pandemic. 6 Up to 87% of doctors routinely use their smartphones for work-related …

Older age is one of the greatest risk factors for severe outcomes from COVID-19. If we believe it is important to use limited supplies of COVID-19 vaccines to protect the most vulnerable and prevent deaths, then available doses should be allocated with significant priority to older adults. Yet, we should resist the conclusion that age should be the sole criterion for COVID-19 vaccine prioritisation or that no younger populations (eg, those under the age of 60) should be prioritised until all older adults have been vaccinated. This article examines arguments that are commonly presented to abandon ‘complex’ vaccine prioritisation schemes in favour of ‘just using age’ (eg, prioritising those 80 years of age and older and then decreasing in a 5-year age bands until the entire population has had the opportunity to be vaccinated), and articulates the ethical reasons why these arguments are not persuasive.

Lockdowns and quarantines have been implemented widely in response to the COVID-19 pandemic. This has been accompanied by a rise in interest in the ethics of ‘passport’ systems that allow low-risk individuals greater freedoms during lockdowns and exemptions to quarantines. Immunity and vaccination passports have been suggested to facilitate the greater movement of those with acquired immunity and who have been vaccinated. Another group of individuals who pose a low risk to others during pandemics are those with genetically mediated resistances to pathogens. In this paper, we introduce the concept of genomic passports, which so far have not been explored in the bioethics literature. Using COVID-19 as an illustrative example, we explore the ethical issues raised by genomic passports and highlight differences and similarities to immunity passports. We conclude that, although there remain significant practical and ethical challenges to the implementation of genomic passports, there will be ways to ethically use them in the future.

COVID-19 changed the way we delivered care to our patients at our Hospital. Prior to the pandemic, no patient facing video clinics and only a small number of telephone clinics were held. In this paper, we share our experience of rapidly implementing virtual clinics (VCs) due to COVID-19. This commentary is based on focused discussions between hospital leaders and provides a reflective account and commentary on leadership lessons learnt from our experience of deploying VCs. We outline success factors (being able to capitalise on existing strategy, having time and space to establish VCs, using an agreed improvement framework, empowering a diverse and expert implementation team with a flat hierarchy, using efficient decision pathways, communication and staff willingness to change), technical challenges (patient capability and skills to use technology, patient connectivity and platform capacity) and considerations for the future (sustaining new ways of working, platform selection, integration, business continuity and commissioning considerations, barriers regarding capability and communication, effectiveness and clinical outcomes). Finally, we provide an overview of the leadership lessons from this project and identify key areas of focus for delivering successful change projects in future (the vision, allocation of resources, methodology selection and managing the skills gap).

BackgroundPeople with specific health profiles and diseases (such as diabetes, lung and heart conditions) have been classified as ‘clinically vulnerable’ (CV) to COVID-19, that is, at higher risk of severe illness and mortality from COVID-19, and were targeted for shielding. However, there is as yet little evidence on how the pandemic and shielding impacted the health and social well-being of CV older people.MethodsWe used data from wave 9 (2018/2019) and the first COVID-19 substudy (June/July 2020) of the English Longitudinal Study of Ageing. Using logistic and linear regression models, we investigated associations between being CV and health and social well-being during the pandemic, while controlling for prepandemic levels of the outcome variables. We also explored the interactions between CV and age group (50s, 60s, 70s, 80+), and between CV and shielding.ResultsCV people were more likely to report worse health and social well-being outcomes during the pandemic, even taking into account prepandemic differences. However, changes in health were not uniform across different age groups, and CV respondents were generally at greater risks of deterioration in health and social well-being compared with those not CV in the same age group. CV respondents who were shielding reported worse outcomes compared with those not CV and not shielding.ConclusionsWhile policies focusing on shielding CV older people reduce rates of hospitalisation and death from COVID-19, policymakers should also pay attention to understanding and addressing the wider needs of this group if their long-term health and social well-being are not to be compromised.

The COVID-19 pandemic is shifting the digital transformation era into high gear. Artificial intelligence (AI) and, in particular, machine learning (ML) and deep learning (DL) are being applied on multiple fronts to overcome the pandemic. However, many obstacles prevent greater implementation of these innovative technologies in the clinical arena. The goal of this narrative review is to provide clinicians and other readers with an introduction to some of the concepts of AI and to describe how ML and DL algorithms are being used to respond to the COVID-19 pandemic. First, we describe the concept of AI and some of the requisites of ML and DL, including performance metrics of commonly used ML models. Next, we review some of the literature relevant to outbreak detection, contact tracing, forecasting an outbreak, detecting COVID-19 disease on medical imaging, prognostication and drug and vaccine development. Finally, we discuss major limitations and challenges pertaining to the implementation of AI to solve the real-world problem of the COVID-19 pandemic. Equipped with a greater understanding of this technology and AI's limitations, clinicians may overcome challenges preventing more widespread applications in the clinical management of COVID-19 and future pandemics. © Author(s) (or their employer(s)) 2021. No commercial re-use. See rights and permissions. Published by BMJ.

The COVID-19 pandemic has stretched hospitals to capacity with highly contagious patients. Acute care hospitals around the world have needed to develop ways to conserve dwindling supplies of personal protective equipment (PPE) while front-line clinicians struggle to reduce risk of exposure. By placing intravenous smart pumps (IVSP) outside patient rooms, nurses can more quickly attend to alarms, rate adjustments and bag changes with reduced personal risk and without the delay of donning necessary PPE to enter the room. The lengthy tubing required to place IVSP outside of patient rooms comes with important clinical implications which increase the risk to patient safety for the already error-prone intravenous medication administration process. This article focuses on the implications of increasing medication dead volume as intravenous tubing lengths increase. The use of extended intravenous tubing will lead to higher medication volumes held in the tubing which comes with significant safety implications related to unintended alterations in drug delivery. Safe intravenous medication administration is a collaborative responsibility across the team of nurses, pharmacists and ordering providers. This article discusses the importance and safety implications for each role when dead volume is increased due to IVSP placement outside of patient rooms during the COVID-19 pandemic.

Summary box #### What are the new findings? ### Summary box #### How might it impact on healthcare in the future? ### History and evolution of the WISH Innovators Programme Launched in 2012, the World Innovation Summit for Health (WISH) is a global health initiative of the Qatar Foundation, under the patronage of Her Highness Sheikha Moza bint Nasser that aims to promote and facilitate innovation in healthcare …

ObjectiveRapid implementation of home sleep studies during the first UK COVID-19 ‘lockdown’—completion rates, family feedback and factors that predict success.DesignWe included all patients who had a sleep study conducted at home instead of as inpatient from 30 March 2020 to 30 June 2020. Studies with less than 4 hours of data for analysis were defined ‘unsuccessful’.Results137 patients were included. 96 underwent home respiratory polygraphy (HRP), median age 5.5 years. 41 had oxycapnography (O2/CO2), median age 5 years. 56% HRP and 83% O2/CO2 were successful. A diagnosis of autism predicted a lower success rate (29%) as did age under 5 years.ConclusionSwitching studies rapidly from an inpatient to a home environment is possible, but there are several challenges that include a higher failure rate in younger children and those with neurodevelopmental disorders.

IntroductionDuring COVID-19, the management of outpatient inflammatory bowel disease (IBD) changed from face-to-face (F2F) to telephone and video consultations across the UK. We surveyed patients with IBD and IBD healthcare professionals (HCPs) to evaluate the impact of this abrupt transition on patient and HCP satisfaction outcomes, including the barriers and enablers of this service.MethodsPatient satisfaction surveys were sent to patients who had a telephone consultation from May to July 2020. A second survey was sent to IBD HCPs across the UK. Questions from both surveys consisted of a mixture of multiple-choice options, ranking answers as well as short-answer questions.Results210 patients and 114 HCPs completed the survey. During COVID-19, there was a significantly greater use of telephone, video or a mixture of consultation. F2F consultations were consistently preferred by patients, with 50% of patients indicating they did not want the option of for video consultations. Patients were more likely to prefer a telephone consultation if they were stable and needed routine review. Significantly fewer HCPs (5.3%) intend to use F2F consultations alone, preferring the use of telephone (20.2%) or combinations of telephone/F2F (22.8%), telephone/video (4.4%) or combination of all three consultation types (34.2%). 63% indicated they intend to incorporate video consultations in the future.ConclusionTelephone and video consultations need to be balanced proportionately with F2F clinics to achieve both patient and HCP satisfaction. Further research needs to be done to explore the use of video medicine in patients with IBD.

BackgroundAs the epidemic of COVID-19 is gradually controlled in China, a summary of epidemiological characteristics and interventions may help control its global spread.MethodsData for COVID-19 cases in Hubei Province (capital, Wuhan) was extracted until 7 March 2020. The spatiotemporal distribution of the epidemic in four periods (before 10 January, 10–22 January, 23 January–6 February and 7 February–7 March) was evaluated, and the impacts of interventions were observed.ResultsAmong 67 706 COVID-19 cases, 52 111 (76.97%) were aged 30–69 years old, and 34 680 (51.22%) were women. The average daily attack rates (95% CI) were 0.5 (0.3 to 0.7), 14.2 (13.2 to 15.1), 45.7 (44.0 to 47.5) and 8.6 (7.8 to 9.3) cases per 106 people in four periods, and the harmonic means (95% CI) of doubling times were 4.28 (4.01 to 4.55), 3.87 (3.78 to 3.98), 5.40 (4.83 to 6.05) and 45.56 (39.70 to 52.80) days. Compared with the first period, daily attack rates rose rapidly in the second period. In the third period, 14 days after 23 January, the daily average attack rate in and outside Wuhan declined by 33.8% and 48.0%; the doubling times increased by 95.0% and 133.2%. In the four periods, 14 days after 7 February, the daily average attack rate in and outside Wuhan decreased by 79.1% and 95.2%; the doubling times increased by 79.2% and 152.0%.ConclusionsThe public health interventions were associated with a reduction in COVID-19 cases in Hubei Province, especially in districts outside of Wuhan.

The COVID-19 pandemic will likely recede only through development and distribution of an effective vaccine. Although there are many unknowns surrounding COVID-19 vaccine development, vaccine demand will likely outstrip early supply, making prospective planning for vaccine allocation critical for ensuring the ethical distribution of COVID-19 vaccines. Here, we propose three central goals for COVID-19 vaccination campaigns: to reduce morbidity and mortality, to minimise additional economic and societal burdens related to the pandemic and to narrow unjust health inequalities. We evaluate five prioritisation approaches, assess their likely impact on advancing the three goals of vaccine allocation and identify open scientific questions that may alter their outcomes. We argue that no single prioritisation approach will advance all three goals. Instead, we propose a multipronged approach that considers the risk of serious COVID-19 illness, instrumental value and the risk of transmission, and is guided by future research on COVID-19-specific clinical and vaccine characteristics. While we focus this assessment on the USA, our analysis can inform allocation in other contexts.

BackgroundCybersecurity in healthcare has become increasingly important as the COVID-19 pandemic has increased the use of digital technologies in healthcare provision around the world, while simultaneously encouraged cybercriminals to target healthcare organisations in greater numbers. Despite the threat of cyberattack to patient safety and the provision of healthcare, cybersecurity in the health sector lags behind other industries. Additionally, no adequate cybersecurity framework exists which considers the unique needs of the health sector.MethodsAn online Delphi was carried out to develop a globally relevant and applicable readiness framework to guide cybersecurity planning in healthcare. Experts (n=42) in the areas of cybersecurity, information communications and technology and health informatics were invited to list the components they felt were essential to a framework and subsequently agree with consensus on a final framework based on the identified components.ResultsAfter two rounds, the Essentials of Cybersecurity in Healthcare Organizations (ECHO) framework with 51 components, grouped into six categories, was regarded by the experts as an acceptable planning tool to guide cybersecurity in healthcare at the global level.ConclusionsThe ECHO framework, designed based on components chosen by international experts to meet the challenges of cybersecurity scale-up in the health and care sector globally, can help guide policymakers and health and care organisations in strengthening their cybersecurity infrastructure and deliver safe and effective care.

Completing meaningful and high-fidelity Collective Training during the COVID-19 pandemic presents an entirely new set of challenges to both the Chain of Command and supporting medical assets. Under Project PHOENIX, the Field Army will gradually phase the return of Collective Training, starting with Deployed Operation Force Generation. This article describes the personal experiences and challenges faced by 1st Battalion Coldstream Guards Battle Group and the Mission Training and Mobilisation Centre to enable the Operation SHADER 11 Mission Rehearsal Exercise, the first Collective Training the Field Army completed during the national lockdown.

Systems models, which by design aim to capture multi-level complexity, are a natural choice of tool for bridging the divide between social epidemiology and causal inference. In this commentary, we discuss the potential uses of complex systems models for improving our understanding of quantitative causal effects in social epidemiology. To put systems models in context, we will describe how this approach could be used to optimise the distribution of COVID-19 response resources to minimise social inequalities during and after the pandemic.

BackgroundDuring the first wave of COVID-19 pandemic, hospitals were forced to cancel or postpone non-COVID-19 care. With new outbreaks emerging, hospitals are now figuring out how to balance preparedness for future COVID-19 waves with their elective and regular services. This report discusses how four hospital systems deal with these dual responsibilities in China, Norway and the UK.ReflectionsBased on the experiences and combined reflections of hospital executives, we have formulated five strategic and leadership lessons for hospitals as they manage these dual responsibilities. (1) Redesign organisation to separate COVID-19 and non-COVID-19 services both within and across hospitals. (2) Expand virtual care strategies to improve access. (3) Use data-driven models to allocate resources across COVID-19 and non-COVID-19 units. (4) Invest in programmes to promote frontline staff well-being. (5) Secure financial support to continue to deliver on the dual responsibilities.ConclusionThe COVID-19 pandemic gives rise to leadership challenges that have fuelled organisational change and new approaches to healthcare delivery. Leading hospitals during the pandemic is a balancing act—providing care for both patients with COVID-19 and non-COVID-19, while at the same time preparing for the next waves of the pandemic.

A pandemic has sent the world into chaos. It has not only upended our lives; hundreds of thousands of lives have already been tragically lost. The global crisis has been disruptive, even a threat, to healthcare simulation, affecting all aspects of operations from education to employment. While simulationists around the world have responded to this crisis, it has also provided a stimulus for the continued evolution of simulation. We have crafted a manifesto for action, incorporating a more comprehensive understanding of healthcare simulation, beyond tool, technique or experience, to understanding it now as a professional practice. Healthcare simulation as a practice forms the foundation for the three tenets comprising the manifesto: safety, advocacy and leadership. Using these three tenets, we can powerfully shape the resilience of healthcare simulation practice for now and for the future. Our call to action for all simulationists is to adopt a commitment to comprehensive safety, to advocate collaboratively and to lead ethically.

ObjectivesTo summarise the published evidence on the gastrointestinal manifestations of COVID-19 in children and to determine the prevalence of gastrointestinal symptoms.MethodsIn this systematic review and meta-analysis, we searched PubMed, Embase, CINAHL and the WHO’s database of publications on novel coronavirus. We included English language studies that had described original demographic and clinical characteristics of children diagnosed with COVID-19 and reported on the presence or absence of gastrointestinal symptoms. Meta-analysis was conducted using the random-effects model. The pooled prevalence of gastrointestinal symptoms was expressed as proportion and 95% CI.ResultsThe search identified 269 citations. Thirteen studies (nine case series and four case reports) comprising data for 284 patients were included. Overall, we rated four studies as having a low risk of bias, eight studies as moderate and one study as high risk of bias. In a meta-analysis of nine studies, comprising 280 patients, the pooled prevalence of all gastrointestinal symptoms was 22.8% (95% CI 13.1% to 35.2%; I2=54%). Diarrhoea was the most commonly reported gastrointestinal symptom followed by vomiting and abdominal pain.ConclusionsNearly a quarter of children with COVID-19 have gastrointestinal symptoms. It is important for clinicians to be aware of the gastrointestinal manifestation of COVID-19.PROSPERO registration numberCRD42020177569.

Since December 2019, the novel COVID-19 outbreak has spread rapidly around the globe and infected millions of people. Although the major transmission route of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) is considered to be airborne droplets and close contact, the ocular transmission route has been reported with great concern. The current work summarises the characteristics of SARS-CoV-2, the ocular distribution of the major SARS-CoV-2 binding protein, and the experimental and clinical evidence of the ocular transmission route. Although it seems that the likelihood of the ocular surface being an infection gateway is low, SARS-CoV-2 infection or transmission via the ocular surface may cause conjunctivitis and other ocular discomfort. Therefore, good eye protection is an essential safeguard procedure, especially for medical staff.

Reducing access to lethal means can prevent suicides. However, substitution of a suicide method remains a concern. Until 1986, the Ellington Bridge was the site of one-half of all Washington, DC bridge suicides. An antisuicide fence was installed in 1986, creating a naturalistic case–control design for testing the substitution hypothesis with the adjacent and equally as lethal jump site, the Taft Bridge. We found that suicide deaths from the Ellington Bridge were reduced by 90% (p=0.001) following barrier construction, without changes in rates of jumps from either the Taft Bridge or any other bridge in the city. Suicides by all methods decreased significantly across the study period. While the decline in suicides from the Ellington Bridge may reflect a broader decline in suicide, the decline in bridge suicide without persistent shifts in deaths to other bridges provides evidence that restricting access to one highly lethal method is effective.

Life in pedants’ corner is (and was BC—before the COVID-19 pandemic) always more rewarding when clinical and scientific morsels from our recent reading can be shared over coffee (black and strong of course!). For the pedant, malapropisms, particularly those penned by eminent neurologists in certain highly regarded journals, are a particularly rich seam; the deeper one has to mine, the greater the pleasure. Recently, at least one of our number all but aspirated their coffee after reading a reference to ‘ Lhermitte’s sign ’ in an article on dorsal root ganglionopathy! Jean Lhermitte (figure 1) described only one clinical sign, or more correctly a collection of inseparable signs. Known as ‘Lhermitte’s syndrome’, it describes the clinical manifestations of a lesion to the medial longitudinal fasciculus, for which Lhermitte coined the term ‘internuclear ophthalmoplegia’.1 Internuclear ophthalmoplegia is not a recognised feature of dorsal root ganglionopathy and thus, whether malapropism or editorial error, the article should correctly have referred to ‘ Lhermitte’s symptom (or phenomenon) ’. Figure 1 Jean Lhermitte (1877–1959) as (A) an intern at La Salpetriere hospital in 1901, and photographic portraits from around 1920 (B) and the late 1950s (C). (D) Francois Lhermitte …

In response to an imminent surge in COVID-19 cases, the state of Massachusetts (MA) released its Crisis Standards of Care (CSC) guidelines in April 2020. A small group of Boston healthcare providers, community members, lawyers, ethicists and disability advocates brought to bear our collective strengths to forge a formidable coalition now known as the Massachusetts Coalition for Health Equity, to champion the rights of marginalised groups that would be adversely affected by the implementation of the original MA CSC guidelines. In this coalition, members of marginalised communities were adequately represented, led discussions on the implications of implementing inequitable elements of the CSC guidelines and actively involved in creating an alternative framework. In this article, we discuss the process of building a coalition whose concerted advocacy efforts led to the revision of the MA CSC guidelines.

People can clearly incubate and transmit SARS-CoV-2 in the absence of symptoms. Nonetheless, the value of mass testing (large scale asymptomatic screening to identify cases) has been contested. In principle, isolation of people with pre-symptomatic or asymptomatic SARS-CoV-2 infection will prevent further spread. In practice, it is less clear whether enough infectious people can be identified through screening to have a quantitatively important effect on transmission, and whether the direct benefits of enhanced case ascertainment are outweighed by direct or indirect costs. The debate is complicated by an absence of data from randomised controlled trials, and controversy about the suitability of lateral flow tests for this purpose.

ObjectivesTo assess the potential impacts of successive lockdown-easing measures in England, at a point in the COVID-19 pandemic when community transmission levels were relatively high.DesignWe developed a Bayesian model to infer incident cases and reproduction number (R) in England, from incident death data. We then used this to forecast excess cases and deaths in multiple plausible scenarios in which R increases at one or more time points.SettingEngland.ParticipantsPublicly available national incident death data for COVID-19 were examined.Primary outcomeExcess cumulative cases and deaths forecast at 90 days, in simulated scenarios of plausible increases in R after successive easing of lockdown in England, compared with a baseline scenario where R remained constant.ResultsOur model inferred an R of 0.75 on 13 May when England first started easing lockdown. In the most conservative scenario modelled where R increased to 0.80 as lockdown was eased further on 1 June and then remained constant, the model predicted an excess 257 (95% CI 108 to 492) deaths and 26 447 (95% CI 11 105 to 50 549) cumulative cases over 90 days. In the scenario with maximal increases in R (but staying ≤1), the model predicts 3174 (95% CI 1334 to 6060) excess cumulative deaths and 421 310 (95% CI 177 012 to 804 811) cases. Observed data from the forecasting period aligned most closely to the scenario in which R increased to 0.85 on 1 June, and 0.9 on 4 July.ConclusionsWhen levels of transmission are high, even small changes in R with easing of lockdown can have significant impacts on expected cases and deaths, even if R remains ≤1. This will have a major impact on population health, tracing systems and healthcare services in England. Following an elimination strategy rather than one of maintenance of R ≤1 would substantially mitigate the impact of the COVID-19 epidemic within England.

Elective surgical suspension during the COVID-19 pandemic resulted in a sizeable surgical case backlog throughout the world. As we ramp back up, how do we decide which cases take priority? Potential future waves (or a future pandemic) may lead to additional surgical shutdown and subsequent reopening. Deciding which cases to prioritise in the face of limited health system capacity has emerged as a new challenge for healthcare leaders. Here we present an ethically grounded and operationally efficient surgical prioritisation framework for healthcare leaders and practitioners, drawing insights from decision analysis and organisational sciences.

Edited by Dr Gabrielle Prager on behalf of the RCEM COVID-19 CPD team Following from the successful ‘RCEM weekly top five’ series starting in April 2020, this is the third of a monthly format for EMJ readers. We have undertaken a focused search of the PubMed literature using a standardised COVID-19 search string. Our search between 1 December and 31 December 2020 returned 1183 papers limited to human subjects and English language. We also searched high impact journals for papers of interest. Our team have narrowed down the most interesting, relevant and important of the papers and provided a critical snapshot of five of those we felt most deserved EMJ reader attention. Importantly, we have highlighted not only the main findings from the papers but also key limitations and considerations for EM clinicians when interpreting the work. In doing so we have created an accessible window into pertinent research findings for our busy colleagues during this fast-paced and ever-changing COVID-19 landscape. The papers are ranked in one of three categories, allowing you to focus on those that are most vital to your practice: This month’s searches were undertaken by the Centre for Urgent and Emergency Care Research at the University of Sheffield. We look forward to next month’s instalment by our colleagues in Leicester. ### Topic: treatment #### Rating: game changer In March 2020, the WHO recommended randomised trials into potential treatments for COVID-19. Experts agreed on four antiviral drugs that could be repurposed to reduce mortality in this patient group. The four drugs were remdesivir, hydroxychloroquine, lopinavir and interferon beta-1a. Within a month a large international, open-label randomised trial was launched at 405 hospitals in 30 different countries. There was no placebo group; the control group consisted …

The risk of SARS-CoV-2 transmission in endoscopy is not only between patients and endoscopy staff but is also through inadequately reprocessed endoscopes. There are no studies that could confirm the efficacy of current ways of endoscope reprocessing on the elimination of SARS-CoV-2. The aim of this pilot study was to evaluate the efficacy of high disinfection of endoscopes with peracetic acid on eliminating SARS-CoV-2, but surprisingly we found that the virus cannot be detected on any part of endoscopes used in critically ill patients due to SARS-CoV-2 and this was the same for all types of endoscopies and procedures. If confirmed in larger studies, these findings will probably open a new scenario in the overall understanding of the real impact of the virus.

Understanding of personal leadership style has been shown to be a key part of effective leadership practice. It has been a topic of interest for many decades as we have tried to understand, and replicate, what makes those considered to be ‘great leaders’ so successful. This article gives a brief introduction to different leadership ‘theories’, leadership ‘styles’ and the effect they have on the ‘climate’ in organisations. Having an understanding of the different approaches can help leaders be more effective through comprehending how and why they do what they do, as well as helping them identify where and when they need to adapt their style. By considering how our understanding of leadership has evolved, it is possible to show how effective leadership is not linked to one approach. It is a combination of knowledge, attitudes and behaviours with a focus on both the task in hand and concern for those undertaking that task. Furthermore this understanding supports impactful personal development, which creates positive climates in organisations where compassionate and inclusive leadership behaviours can, and do result in better outcomes for staff and patients.

False negatives from nasopharyngeal swabs (NPS) using reverse transcriptase PCR (RT-PCR) in SARS-CoV-2 are high. Exhaled breath condensate (EBC) contains lower respiratory droplets that may improve detection. We performed EBC RT-PCR for SARS-CoV-2 genes (E, S, N, ORF1ab) on NPS-positive (n=16) and NPS-negative/clinically positive COVID-19 patients (n=15) using two commercial assays. EBC detected SARS-CoV-2 in 93.5% (29/31) using the four genes. Pre-SARS-CoV-2 era controls (n=14) were negative. EBC was positive in NPS negative/clinically positive patients in 66.6% (10/15) using the identical E and S (E/S) gene assay used for NPS, 73.3% (11/15) using the N/ORF1ab assay and 14/15 (93.3%) combined.

It is acknowledged that direct ophthalmoscopy is underutilised by non-ophthalmic specialists, a view which is frequently supported by research.1–4 Omission of ophthalmoscopy is, of course, perilous as it is may lead to delayed diagnosis and treatment. Clinicians will miss the opportunity to undertake a non-invasive in vivo assessment of retinal integrity, vasculature, and the optic nerve head; thus, potentially limiting the examination of patients with suspected conditions such as malignant hypertension; raised intracranial pressure; secondary metastases; and more common ocular conditions such as diabetic retinopathy or macula degeneration. The exact reasons for poor ophthalmoscopy uptake remain unclear, but there is indication that medics would be more inclined to embrace ophthalmoscopy if there were easier access to a working instrument.2 5 However, such rationale is somewhat at odds with more recent work where constant provision to an ophthalmoscope failed to stimulate a significant increase in usage.3 Other reasons for not undertaking ophthalmoscopy may include time constraints; an inability to see anything useful,2 which could particularly be the case with elderly patients who may have smaller pupils and hospital wards are generally well-illuminated environments; a belief that the procedure was low priority2 or a lack of confidence using the instrument, especially on undilated pupils.6 The consensus appears to be that more training is required.5 Indeed, adequate ophthalmoscopy training in UK medical students has often been a point of concern.7 8 Successful direct ophthalmoscopy …

Despite evidence that firearm access in the home is a strong risk factor for firearm injury, firearms are owned more often for self-protection than for any other reason. In this cross-sectional study, we describe the association between firearm ownership and perceived risk of personal firearm injury using logistic regressions applied to data from the 2018 California Safety and Well-being Survey. Most respondents (57.7%) reported being very/somewhat worried about gun violence happening to them. Compared with non-owners in households without firearms, firearm owners were 60% (adjusted OR (aOR) 0.40, 95% CI: 0.27 to 0.58) less likely to be worried about gun violence happening to them; non-owners living in homes with firearms were 46% (aOR 0.54, 95% CI: 0.33 to 0.88) less likely. This suggests an underestimation of actuarial risk that conflicts with the available evidence, with important implications for public health messaging.

[Graphic][1] ### Biography Tom is a consultant in prehospital care at Bart’s Health and consultant in intensive care medicine at King’s College Hospital. He trained predominantly in Greater Manchester before undertaking a secondment to London’s Air Ambulance in 2008. He is the medical director of London’s Air Ambulance. I think something that has served me well is the idea of positive regard, the assumption of positive intent. This particularly holds during a difficult period where people are under significant stress and strain and we don’t always know what’s going on for people in the other facet of their lives. This involves looking at behaviours or issues that are raised and asking yourself ‘what's the most positive possible explanation for this?’ and then assuming that’s the case. Then you can explore it with them if you need to, rather than thinking ‘They’re a problem and they need to do what they’re told.’ That is something that has been useful for me during this…because it’s all very easy to say ‘don’t overreact and keep calm,’ but actually, what’s the intellectual underpinning for that? One intellectual underpinning is you can’t possibly know all of the what’s going on in someone’s head. You can’t possibly know all the things that are relevant for that person. Everyone sees this as a major challenge we’re all trying to do what we think is the right thing. Let’s work with that as an assumption, that this makes sense for that person and that they think this is a helpful and positive contribution that they’re making. I started a new leadership role as the medical director for the air ambulance in January. I had a couple of months in the early phases of the role and I was busy doing the initial engaging and meeting people and building a team. Then … [1]: /embed/inline-graphic-1.gif

BackgroundThe COVID-19 pandemic has raised concern for healthcare workers getting infected via aerosol from non-invasive respiratory support of infants. Attaching filters that remove viral particles in air from the expiratory limb of continuous positive airway pressure (CPAP) devices should theoretically decrease the risk. However, adding filters to the expiratory limb could add to expiratory resistance and thereby increase the imposed work of breathing (WOB).ObjectiveTo evaluate the effects on imposed WOB when attaching filters to the expiratory limb of CPAP devices.MethodsTwo filters were tested on three CPAP systems at two levels of CPAP in a mechanical lung model. Main outcome was imposed WOB.ResultsThere was a minor increase in imposed WOB when attaching the filters. The differences between the two filters were small.ConclusionTo minimise contaminated aerosol generation during CPAP treatment, filters can be attached to expiratory tubing with only a minimal increase in imposed WOB in a non-humidified environment. Care has to be taken to avoid filter obstruction and replace filters as recommended.

The past week has seen an explosion of media commentary about whether children in the UK should go back to school. Since ‘lockdown’ (23 March 2020) began schools have been open to vulnerable children and young people, and to the children of ‘key workers’. Right from the start there have been differing opinions about the necessity or wisdom of closing schools. Viner et al 1 produced a rapid systematic review that concludes that school closures have less impact on infection rate and mortality than other social distancing measures. Many countries have closed their schools for less time than the UK and have already started to reopen with several protective measures in place.2 Concerns about the long-term economic, social and mental impact of lockdown led to the generation of plans to ‘get back to business’. This was conveyed to the population of the UK on 10 May by the UK prime minister, Boris Johnson. He announced a range of measures to gradually reduce the level of lockdown. This is in keeping with modelling undertaken by various groups, including a preprint (not peer-reviewed) modelling exercise by Zhang et al .3 Mr Johnson announced that there would be a phased return (in England) of some children to school from 1 June. There are no national guidelines as it is recognised that school have differences that require a flexible approach, but there are a broad set of principles relating to social distancing and hygiene. Government ministers and teachers’ unions have opposing views on the safety of reopening schools. In a joint statement nine unions representing teachers stated that they thought 1 June was too early to be safe.4 They recognise that the opening of schools is a vital part of restarting the UK economy, but they have concerns about the safety …

The COVID-19 pandemic continues to spread rapidly and overwhelm health systems around the world. To cope with this unprecedented usage of healthcare resources, increasingly novel solutions are being brought into the fray. Telemedicine has been thrust into the spotlight in the fight against COVID-19 and is being employed in many different ways to better tackle the challenges. Telemedicine will likely have a more permanent place in traditional healthcare delivery long after COVID-19 is over as users and providers recognise its utility.

Biography Raed A Dweik, MD, MBA, is the Chairman of the Respiratory Institute at Cleveland Clinic. He is board-certified in internal medicine, pulmonary disease and critical care medicine. Dr Dweik’s clinical interests are in pulmonary disease, pulmonary hypertension, asthma, chronic beryllium disease and critical care. He is Professor of Medicine in the Lerner College of Medicine and has a joint appointment in the Lerner Research Institute, with continuous funding from the National Institutes of Health (NIH) since 2002. He has published more than 250 peer-reviewed manuscripts and book chapters and serves on several journal editorial boards, NIH review panels, and American Thoracic Society, American Heart Association and Association of American Medical Colleges committees. Dr Dweik is a Fellow of the American College of Physicians, the Royal College of Physicians of Canada, the American College of Chest Physicians, the Society of Critical Care Medicine, the American Heart Association, the Pulmonary Vascular Research Institute and the American Thoracic Society. Dr Dweik earned his medical degree from the University of Jordan before moving to the USA for internal medicine training at Wright State University, followed by a fellowship in Pulmonary and Critical Medicine at Cleveland Clinic. He earned an MBA from Case Western Reserve University. ![Graphic][1] Communication, transparency, trust, time management and planning. Communication and transparency are key. Do it early, do it often. One important point to make is that communication is more about listening than talking! Many people think that they have communicated when they have told you something! The reality is that communication is not complete until you have listened. I have had hour-long meetings where I spoke for less than 5 minutes, and people felt I was a great communicator! And I have been at hour-long meetings where one person spoke most of the time and people felt they did not communicate … [1]: /embed/inline-graphic-1.gif

Covid-19 is a respiratory infection, although it can be associated with both acute and long term systemic complications. Breathlessness is among the most common symptoms reported in people followed up after hospital admission,1 following infection identified in the community,2 and in those reporting that they have long-covid.3 Consistent with this, Ayoubkhani and colleagues report rates of respiratory disease, …

Objective To estimate the direct and indirect effects of the covid-19 pandemic on mortality in 2020 in 29 high income countries with reliable and complete age and sex disaggregated mortality data. Design Time series study of high income countries. Setting Austria, Belgium, Czech Republic, Denmark, England and Wales, Estonia, Finland, France, Germany, Greece, Hungary, Israel, Italy, Latvia, Lithuania, the Netherlands, New Zealand, Northern Ireland, Norway, Poland, Portugal, Scotland, Slovakia, Slovenia, South Korea, Spain, Sweden, Switzerland, and United States. Participants Mortality data from the Short-term Mortality Fluctuations data series of the Human Mortality Database for 2016-20, harmonised and disaggregated by age and sex. Interventions Covid-19 pandemic and associated policy measures. Main outcome measures Weekly excess deaths (observed deaths versus expected deaths predicted by model) in 2020, by sex and age (0-14, 15-64, 65-74, 75-84, and ≥85 years), estimated using an over-dispersed Poisson regression model that accounts for temporal trends and seasonal variability in mortality. Results An estimated 979 000 (95% confidence interval 954 000 to 1 001 000) excess deaths occurred in 2020 in the 29 high income countries analysed. All countries had excess deaths in 2020, except New Zealand, Norway, and Denmark. The five countries with the highest absolute number of excess deaths were the US (458 000, 454 000 to 461 000), Italy (89 100, 87 500 to 90 700), England and Wales (85 400, 83 900 to 86 800), Spain (84 100, 82 800 to 85 300), and Poland (60 100, 58 800 to 61 300). New Zealand had lower overall mortality than expected (−2500, −2900 to −2100). In many countries, the estimated number of excess deaths substantially exceeded the number of reported deaths from covid-19. The highest excess death rates (per 100 000) in men were in Lithuania (285, 259 to 311), Poland (191, 184 to 197), Spain (179, 174 to 184), Hungary (174, 161 to 188), and Italy (168, 163 to 173); the highest rates in women were in Lithuania (210, 185 to 234), Spain (180, 175 to 185), Hungary (169, 156 to 182), Slovenia (158, 132 to 184), and Belgium (151, 141 to 162). Little evidence was found of subsequent compensatory reductions following excess mortality. Conclusion Approximately one million excess deaths occurred in 2020 in these 29 high income countries. Age standardised excess death rates were higher in men than women in almost all countries. Excess deaths substantially exceeded reported deaths from covid-19 in many countries, indicating that determining the full impact of the pandemic on mortality requires assessment of excess deaths. Many countries had lower deaths than expected in children

> ‘Of concern is the WHO Region of the Americas, where incidence is estimated to be slowly increasing after many years of decline, owing to an upward trend in Brazil during 2016–2019.’—2020 Global TB report. On the 24 March, we will commemorate the World TB Day. Despite important achievements on tuberculosis (TB) control summarised in the 2020 WHO Global TB report,1 the above quotation referring to the WHO Region of the Americas is concerning. In contrast with global decreases in TB incidence rates over the past decade, in 2019, the Region of the Americas has taken a step backwards and the TB incidence rate has shown an unexpected upturn in recent years (online supplemental efigure-1 in the supplemental file).### Supplementary data [bmjgh-2021-005639supp001.pdf] The Region of the Americas comprises 46 countries and territories and Brazil and Peru are among the WHO high-TB burden countries. To illustrate the recent increase in TB incidence in the region, we selected 12 countries from Latin America (Argentina, Brazil, Chile, Colombia, Ecuador, El Salvador, Mexico, Panama, Paraguay, Peru, Uruguay and Venezuela), which account for approximately 80% of the total estimated TB cases in the region. Using data from WHO TB databases (exported on 22 October 2020), we show that, between 2014 and 2019, the estimated TB incidence rate increased from 38.4 to 41.7 per 100 000 (8.6% relative increase) and the estimated number of incident cases increased from 202 290 to 230 100 (27 810 more cases, 13.8% relative increase) for these 12 countries (figure 1, for the same data in separated panels by each country, please see online supplemental eFigure-2 in the supplemental file). Figure 1 Estimated incidence rate, case notification rate and estimated incident cases of tuberculosis for 12 countries in Latin America between 2000 and 2019. Data generated …

Taking a principled approach is crucial to the successful use of AI in pandemic management, say Stephen Cave and colleagues