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Background: Health care workers (HCWs) are particularly exposed to COVID-19 and therefore it is important to study preventive measures in this population., Aim: To investigate socio-demographic factors and professional practice associated with the risk of COVID-19 among HCWs in health establishments in Normandy, France., Methods: A cross-sectional and 3 case-control studies using bootstrap methods were conducted in order to explore the possible risk factors that lead to SARS-CoV2 transmission within HCWs. Case-control studies focused on risk factors associated with (a) care of COVID-19 patients, (b) care of non COVID-19 patients and (c) contacts between colleagues., Participants: 2,058 respondents, respectively 1,363 (66.2%) and 695 (33.8%) in medical and medico-social establishments, including HCW with and without contact with patients., Results: 301 participants (14.6%) reported having been infected by SARS-CoV2. When caring for COVID-19 patients, HCWs who declared wearing respirators, either for all patient care (ORa 0.39; 95% CI: 0.29-0.51) or only when exposed to aerosol-generating procedures (ORa 0.56; 95% CI: 0.43-0.70), had a lower risk of infection compared with HCWs who declared wearing mainly surgical masks. During care of non COVID-19 patients, wearing mainly a respirator was associated with a higher risk of infection (ORa 1.84; 95% CI: 1.06-3.37). An increased risk was also found for HCWs who changed uniform in workplace changing rooms (ORa 1.93; 95% CI: 1.63-2.29)., Conclusion: Correct use of PPE adapted to the situation and risk level is essential in protecting HCWs against infection., Competing Interests: The authors have declared that no competing interests exist.

Background: Needle stick and sharp injuries (NSSIs) are a common problem among healthcare workers (HCWs). Although the factors related to NSSIs for HCWs are well documented by several studies in Ethiopia, no evidence has been reported about the magnitude of and factors related to NSSIs in hospitals in northwestern Ethiopia., Methods: An institution-based cross-sectional study was carried out from January to March 2019 among 318 HCWs in three randomly-selected hospitals of the eight hospitals found in South Gondar Zone. Sample sizes were proportionally allocated to professional categories. Study participants were selected by systematic random sampling methods using the monthly salary payroll for each profession as the sampling frame. Data were collected using a self-administered questionnaire. The outcome of this study was the presence (injured) or absence of NSSIs during the 12 months prior to data collection. A binary logistic regression model with 95% confidence interval (CI) was used for data analysis. Variables from the bi-variable analysis with a p-value ≤ 0.25 were retained into the multivariable analysis. From the multivariable analysis, variables with a p-value less than 0.05 was declared as factors significantly associated with NSSIs., Main Findings: The prevalence of NSSIs was 29.5% (95% CI: 24.2-35.5%) during the 12 months prior to the survey. Of these, 46.0% reported that their injuries were moderate, superficial (33.3%) or severe (20.7%). About 41.4% of the injuries were caused by a suture needle. Factors significantly associated with NSSIs were occupation as a nurse (adjusted odds ratio [AOR] = 2.65, 95% CI: 1.18-4.26), disposal of sharp materials in places other than in safety boxes (AOR = 3.93, 95% CI: 2.10-5.35), recapping of needles (AOR = 2.27, 95% CI: 1.13-4.56), and feeling sleepy at work (AOR = 2.24, 95% CI: 1.14-4.41)., Conclusion: This study showed that almost one-third of HCWs had sustained NSSIs, a proportion that is high. Factors significantly associated with NSSIs were occupation as a nurse, habit of needle recapping, disposal of sharp materials in places other than in safety boxes and feeling sleepy at work. Observing proper and regular universal precautions for nurses during daily clinical activities and providing safety boxes for the disposal of sharp materials, practicing mechanical needle recapping and preventing sleepiness by reducing work overload among HCWs may reduce the incidence of NSSIs., Competing Interests: The authors have declared that no competing interests exist.

Objective: To assess prescribing and refilling trends of narcotics in postoperative urology patients at our institution. Although the opioid epidemic remains a public health threat, no series has assessed prescribing patterns across urologic surgery disciplines following discharge., Methods: All urologic surgeries were retrospectively reviewed from May 2017-April 2018. Demographics, comorbidities, and postoperative pain management strategies were analyzed. Narcotics usage following surgery were reported in total morphine equivalents (TME). Opioid refill rate was characterized by medical specialty and stratified by urologic discipline., Results: 817 cases were reviewed. Mean age and TME at discharge was 57±15.6 years and 35.43±19.5 mg, respectively. 13.6% (mean age 55±15.9) received a narcotic refill following discharge (mean TME/refill 37.7±28.9 mg). A higher proportion of patients with a pre-operative opioid prescription received a refill compared to opioid naïve patients (38.2% vs 21.6%, P < .01). Refill rate did not differ between urologic subspecialties (P = .3). Urologists were only responsible for 20.4% of all refills filled, despite all patients continuing follow-up with their surgeon. Procedures with the highest rates of post-operative refills were in oncology, male reconstruction/trauma and endourology. Patients with a history of chronic pain (OR 1.9, CI 1.1-3.3) preoperative narcotic prescription (OR 1.6, CI 1.0-2.6), and higher ASA score (OR 1.8, CI 1.6-2.8) were more likely to obtain a postoperative opioid prescription refill., Conclusion: Approximately 1 in 7 postoperative urology patients receive a postoperative narcotics refill; however, nearly two-thirds receive refills exclusively from non-urologic providers. Attempts to avoid overprescribing of postoperative narcotics need to account for both surgeon and nonsurgeon sources of opioid refills., (Copyright © 2021 Elsevier Inc. All rights reserved.)

Background: With the novel coronavirus-induced disease (COVID-19), there is the fear of nosocomial infections and severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) transmissions to healthcare workers (HCW). We report the case of a 64-year-old male patient who underwent explantation of a shoulder prosthesis due to a periprosthetic infection. He was tested SARS-CoV-2 positive 7 days after admission to the orthopaedic department following strict infection control measures, routinely including screening all patients for multi-drug-resistant organism (MDRO) colonization upon admission. Aim of our study is to report on the spreading potential of SARS-CoV-2 in a healthcare setting if standard contact precautions and infection control measures have been established., Methods: All HCW with exposure to the patient from day of admission until confirmed diagnosis of COVID-19 were identified and underwent oropharyngeal swab testing for SARS-CoV-2 by real-time RT-PCR., Results: Sixty-six HCW were identified: nine orthopaedic surgeons, four anaesthesiologists, 25 orthopaedic nurses, five nurse anesthetists, eight scrub nurses, five nursing students, two medical assistants and seven service employees. Fourteen HCW (21%) showed clinical symptoms compatible with a SARS-CoV-2 infection: cough (n = 4), sore throat (n = 3), nasal congestion (n = 3), dyspnea (n = 2), fever (n = 1), headache and myalgia (n = 1). SARS-CoV-2 was not detected in any of the 66 HCW., Conclusion: Hygienic measures and contact precautions, aimed at preventing the spread of MRDO, may have helped to prevent a SARS-CoV-2 transmission to HCW-despite high-risk exposure during intubation, surgical treatment and general care., Level of Evidence: IV, case series.

Objective: This study aimed to estimate the risk of SARS-Cov2 infection and severe COVID-19 among healthcare workers from a major social security system., Methods: This study actively followed a cohort of social security workers from March to December 2020 to determine the number of laboratory-confirmed symptomatic cases, asymptomatic associated contacts and COVID-19-associated hospitalizations and deaths. Workers were classified into those providing direct care to infected patients (COVID teams), other active healthcare workers (OAHCW), and workers under home protection (HPW). The number of cases and rates were also estimated by job category., Results: Among a total of 542 381 workers, 41 461 were granted stay-at-home protection due to advanced age or comorbidities. Among the 500 920 total active workers, 85 477 and 283 884 were classified into COVID teams and OAHCW, respectively. Infection rates for COVID teams, OAHCW, and HPW were 20.1% [95% confidence interval (CI) 19.8-20.4], 13.7% (95% CI 15.0-15.3), and 12.2% (95% CI 11.8-12.5), respectively. The risk of hospitalization was higher among HPW. COVID teams had lower mortality rate per 10 000 workers compared to HPW (5.0, 95% CI 4.0-7.0 versus 18.1, 95% CI 14.0-23.0). Compared to administrative workers, ambulance personnel (RR 1.20; 95% CI 1.09-1.32), social workers (RR 1.16; 95% CI 1.08-1.24), patient transporters (RR 1.15; 95% CI 1.09-1.22) and nurses (RR 1.13; 95% CI 1.10-1.15) had a higher risk of infection after adjusting for age and gender. Crude differences in mortality rates were observed according to job category, which could be explained by differences in age, sex, and comorbidity distribution. Diabetes, obesity, hypertension, hemolytic anemia, and HIV were associated with increased fatality rates., Conclusions: COVID team workers had higher infection rates compared to the total population of active workers and HPW. Doctors had lower risk of infection than respiratory therapists, nurses, and patient transporters, among whom interventions should be reconsidered to reduce risks. The presence of comorbidities, such as diabetes, obesity, arterial hypertension, hemolytic anemia, and HIV, increased the likelihood of complications caused by COVID-19, culminating in a poor prognosis.

Objective: Examine the effect of a universal facemask policy for healthcare workers (HCW) and incidence of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) positivity., Methods: Daily number of symptomatic HCW tested, SARS-CoV-2 positivity rates, and HCW job-descriptions were collected pre and post Universal HCW facemask policy (March 26, 2020). Multiple change point regression was used to model positive-test-rate data. SARS-CoV-2 testing and positivity rates were compared for pre-intervention, transition, post-intervention, and follow-up periods., Results: Between March 12 and August 10, 2020, 19.2% of HCW were symptomatic for COVID-19 and underwent SARS-CoV-2 testing. A single change point was identified ∼March 28-30 (95% probability). Before the change point, the odds of a tested HCW having a positive result doubled every 4.5 to 7.5 days. Post-change-point, the odds of a tested HCW having a positive result halved every 10.5 to 13.5 days., Conclusions: Universal facemasks were associated with reducing HCW's risk of acquiring COVID-19., Competing Interests: Wang, O’Neill, Zervos, McKinnon, Allard, Alangaden, Schultz, Poisson, Chu, Kalkanis, and Suleyman have no relationships/conditions/circumstances that present potential conflict of interest., (Copyright © 2021 American College of Occupational and Environmental Medicine.)

Objective: Determine the industries with the highest proportion of accepted COVID-19 related workers' compensation (WC) claims., Methods: Study included 21,336 WC claims (1898 COVID-19 and 19,438 other claims) that were filed between January 1, 2020 and August 31, 2020 from 11 states in the Midwest United States., Result: The overwhelming proportion of all COVID-19 related WC claims submitted and accepted were from healthcare workers (83.77%). Healthcare was the only industrial classification that was at significantly higher COVID-19 WC claim submission risk (odds ratio [OR]: 4.00; 95% confidence intervals [CI]: 2.77 to 5.79) controlling for type of employment, sex, age, and presumption of COVID-19 work-relatedness. Within healthcare employment, WC claims submitted by workers in medical laboratories had the highest risk (crude rate ratio of 8.78)., Conclusion: Healthcare employment is associated with an increased risk of developing COVID-19 infections and submitting a workers' compensation claim., Competing Interests: Bernacki, Hunt, Yuspeh, Lavin, Kalia, Leung, Tsourmas, Williams, and Tao have no relationships/conditions/circumstances that present potential conflict of interest., (Copyright © 2021 American College of Occupational and Environmental Medicine.)

Abstract: Health care employees are the front liners whom are directly involved in the management of COVID-19 at high risk of developing psychological distress and other mental health illness. We aim to assess the burden of depression during this pandemic on health care employees treating COVID-19 in Saudi Arabia. We also will shed the light on the best solutions of how to encounter depression.A cross-sectional, hospital-based survey conducted via a region-stratified, 2-stage cluster sample was conducted for 554 participants in >15 hospitals from April 29, 2020, to June 30, 2020. Depression is measured using the established PHQ9 score system. We grade PHQ9 depression scores as: normal, 0 to 4, mild, 5 to 9, significant (moderate or severe), 10 to 27. χ2/Fisher exact test was used; significant association between level of depression and survey characteristics were made. P value <0.05 was considered statistically significant.A total of 554 participants completed the survey. A total of 18.9% (n = 105) were aged <29 years, 51.2% (n = 284) were between 30 to 39 years and female represent 70% of all participants. Of all participants, 53.7% (n = 298) were nurses, and 38.6% (n = 214) were physicians; 68.5% (n = 380) worked in central area hospitals in Saudi Arabia. No significant (P = .432, 95% confidence interval [CI]) association was observed between sex and depression classifications. However, female had high proportion of significant depression 75.0% (n = 76) was observed as compared to male 24.8% (n = 25). Depression was significant in Saudis 61.4% (n = 62) (P < .001, 95% CI) and medical staff who encountered corona patients 51.5% (n = 52) (P < .002, 95% CI). Hospital preparedness associated with more freedom of depression symptoms 69.1% (n = 199/288) (P < .001, 95% CI).Frontline young health care workers especially physician in Saudi Arabia reported a high rate of depression symptoms. Countermeasures for health care workers represent a key component for the mental and physical well-being as part of public health measures during this pandemic. Attention to hospital preparedness and adequacy of personal protective equipment contributed to milder depression symptoms. Further studies need to be conducted on crisis management and depression., Competing Interests: The authors report no conflicts of interest., (Copyright © 2021 the Author(s). Published by Wolters Kluwer Health, Inc.)

Objectives: We compared COVID-19 risk management, fear of infection and fear of transmission of infection among frontline employees working within eldercare, hospital/rehabilitation, psychiatry, childcare and ambulance service and explored if group differences in fear of infection and transmission could be explained by differences in risk management. We also investigated the association of risk management with fear of infection and fear of transmission of infection among eldercare personnel., Methods: We used cross-sectional questionnaire data collected by the Danish labour union, FOA . Data were collected 5½ weeks after the first case of COVID-19 was registered in Denmark. Data for the first aim included 2623 participants. Data for the second aim included 1680 participants. All independent variables were mutually adjusted and also adjusted for sex, age, job title and region., Results: Fear of infection (49%) and fear of transmitting infection from work to the private sphere (68%) was most frequent in ambulance service. Fear of transmitting infection during work was most frequent in the eldercare (55%). Not all differences in fear of infection and transmission between the five areas of work were explained by differences in risk management. Among eldercare personnel, self-reported exposure to infection and lack of access to test was most consistently associated with fear of infection and fear of transmission, whereas lack of access to personal protective equipment was solely associated with fear of transmission., Conclusion: We have illustrated differences and similarities in COVID-19 risk management within five areas of work and provide new insights into factors associated with eldercare workers' fear of infection and fear of transmission of infection., Competing Interests: Competing interests: MJ-M, CB and LOPH are employed by the labor union, FOA, which works for the promotion of its members’ salary level and working conditions., (© Author(s) (or their employer(s)) 2021. No commercial re-use. See rights and permissions. Published by BMJ.)

Objective: To describe the characteristics of healthcare workers (HCWs) infected with COVID-19 and to examine their sources of exposure., Methods: A descriptive cross-sectional study using data extracted from the centralized disease notification system comprising individuals confirmed with COVID-19 in Singapore between 23 January and 17 April 2020. Occupation of HCWs was categorized into six categories. Their job nature was classified into "frontline" or "back-end" based on the frequency of direct patient contact, and source of exposure was classified as family/household, social interaction or workplace. Chi-square and median tests were used to identify differences between categorical groups and sample medians, respectively., Results: A total of 88 (1.7%) HCWs were identified from 5,050 cases. Their median age was 35 years. Chinese and Indians constituted 42.0% and 31.8%, respectively, and 43.2% were foreigners. The majority (63.6%) was serving at frontlines handling patient-facing duties, 15.9% were doctors, 11.4% were nurses and 44.3% were ancillary staff. About 81.8% acquired the infection locally, of which 40.3% did not have a clearly identifiable source of exposure. Exposure from the family/household was most common (27.8%), followed by workplace (16.7%) and social interaction (15.3%). All HCWs were discharged well with no mortality; three (3.4%) were ever admitted to intensive care unit and required increased care., Conclusion: Healthcare workers accounted for a small proportion of COVID-19 cases in Singapore with favourable outcomes. The possibility of transmission resulting from family/household exposure and social interactions highlights the need to maintain strict vigilance and precautionary measures at all times beyond the workplace., (© 2020 The Authors. Influenza and Other Respiratory Viruses published by John Wiley & Sons Ltd.)

Background: The World Health Organization has declared that infection with SARS-CoV-2 is a pandemic. Experiences with SARS in 2003 and SARS-CoV-2 have shown that health professionals are at higher risk of contracting COVID-19. Hence, it has been recommended that aperiodic wide-scale assessment of the knowledge and preparedness of health professionals regarding the current COVID-19 pandemic is critical., Objectives: This study aimed to assess the knowledge and preparedness of health professionals regarding COVID-19 among selected hospitals in Addis Ababa, Ethiopia., Methods: A facility-based cross-sectional study was conducted from the last week of March to early April, 2020. Government (n = 6) and private hospitals (n = 4) were included. The front-line participants with high exposure were proportionally recruited from their departments. The collected data from a self-administered questionnaire were entered using EpiData and analyzed in SPSS software. Both descriptive statistics and inferential statistics (chi-square tests) are presented., Results: A total of 1334 health professionals participated in the study. The majority (675, 50.7%) of the participants were female. Of the total, 532 (39.9%) subjects were nurses/midwives, followed by doctors (397, 29.8%) and pharmacists (193, 14.5%). Of these, one-third had received formal training on COVID-19. The mean knowledge score of participants was 16.45 (±4.4). Regarding knowledge about COVID-19, 783 (58.7%), 354 (26.5%), and 196 (14.7%) participants had moderate, good, and poor knowledge, respectively. Lower scores were seen in younger age groups, females, and non-physicians. Two-thirds (63.2%) of the subjects responded that they had been updated by their hospital on COVID-19. Of the total, 1020 (76.5%) participants responded that television, radio, and newspapers were their primary sources of information. Established hospital preparedness measures were confirmed by 43-57% of participants., Conclusion: The current study revealed that health professionals in Addis Ababa, Ethiopia, already know important facts but had moderate overall knowledge about the COVID-19 pandemic. There were unmet needs in younger age groups, non-physicians, and females. Half of the respondents mentioning inadequate preparedness of their hospitals point to the need for more global solidarity, especially concerning the shortage of consumables and lack of equipment., Competing Interests: The authors have declared that no competing interests exist.

Physical effort of workload of female employees in the healthcare system is perceived to rise. Research focused mainly on physical activity levels of registered nurses (RN). Therefore, we investigated physical strain during daily routine of other hospital workers next to RN. O 2 uptake, heart rate, breathing frequency and ventilation were measured in 33 female medical (associate) professionals (MAP) and Cleaners&Helpers (Cl&H) using Oxycon Mobile. Physical work load was compared to standardized CPET. Wilcoxon-test and ANOVA were calculated using SPSS 20.0. Cl&H performed heavy-lifting and had the lowest power during CPET. The O 2 -uptake for heavy-lifting as strong effort, differed significantly from office work ( p  < 0.001) and bedside-patient-care ( p  = 0.001). Compared with metabolic equivalent (MET) cleaning, heavy-lifting, and office work are underestimated. Bedside-patient-care, walking, pushing performed by MAP are overestimated. While Cl&H had the lowest maximal power in CPET, their work required the highest O 2 -uptake. The tasks are underestimated in the MET-tables.

Background: Health-care workers are thought to be highly exposed to severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection. We aimed to investigate the prevalence of antibodies against SARS-CoV-2 in health-care workers and the proportion of seroconverted health-care workers with previous symptoms of COVID-19., Methods: In this observational cohort study, screening was offered to health-care workers in the Capital Region of Denmark, including medical, nursing, and other students who were associated with hospitals in the region. Screening included point-of-care tests for IgM and IgG antibodies against SARS-CoV-2. Test results and participant characteristics were recorded. Results were compared with findings in blood donors in the Capital Region in the study period., Findings: Between April 15 and April 23, 2020, we screened 29 295 health-care workers, of whom 28 792 (98·28%) provided their test results. We identified 1163 (4·04% [95% CI 3·82-4·27]) seropositive health-care workers. Seroprevalence was higher in health-care workers than in blood donors (142 [3·04%] of 4672; risk ratio [RR] 1·33 [95% CI 1·12-1·58]; p<0·001). Seroprevalence was higher in male health-care workers (331 [5·45%] of 6077) than in female health-care workers (832 [3·66%] of 22 715; RR 1·49 [1·31-1·68]; p<0·001). Frontline health-care workers working in hospitals had a significantly higher seroprevalence (779 [4·55%] of 16 356) than health-care workers in other settings (384 [3·29%] of 11 657; RR 1·38 [1·22-1·56]; p<0·001). Health-care workers working on dedicated COVID-19 wards (95 [7·19%] of 1321) had a significantly higher seroprevalence than other frontline health-care workers working in hospitals (696 [4·35%] of 15 983; RR 1·65 [1·34-2·03]; p<0·001). 622 [53·5%] of 1163 seropositive participants reported symptoms attributable to SARS-CoV-2. Loss of taste or smell was the symptom that was most strongly associated with seropositivity (377 [32·39%] of 1164 participants with this symptom were seropositive vs 786 [2·84%] of 27 628 without this symptom; RR 11·38 [10·22-12·68]). The study is registered at ClinicalTrials.gov, NCT04346186., Interpretation: The prevalence of health-care workers with antibodies against SARS-CoV-2 was low but higher than in blood donors. The risk of SARS-CoV-2 infection in health-care workers was related to exposure to infected patients. More than half of seropositive health-care workers reported symptoms attributable to COVID-19., Funding: Lundbeck Foundation., (Copyright © 2020 Elsevier Ltd. All rights reserved.)

Background: Antimicrobial resistance is a significant public health concern with the establishment of antimicrobial stewardship in hospitals being increasingly obligatory. Perspectives and insights of health managers on antimicrobial stewardship (AMS), complementary health services and building blocks are imperative towards implementation of robust AMS programs. This study aimed to understand perspectives of hospital managers on AMS and identify areas of management engagement while addressing potential blockades to change., Methods: A cross-sectional, qualitative, multicenter study was conducted in three hospitals in Kenya. Key-informant interviews on perspectives on AMS were administered to hospital managers. Qualitative data was captured using audio tapes and field notes, transcribed and managed using NVivo 12 software. An iterative process was used to develop the thematic framework and updated in two rounds of iteration analysis. Analysis charts for each emergent theme were developed and categorized across all participants., Results: Perspectives on AMS are described in five thematic categories; Importance of antimicrobial stewardship and the role of medicines and therapeutics committee, availability of antimicrobial formulary and usage surveillance systems, laboratory competency and recommendations for infection prevention and management, educational resources and communications channels available, building blocks and low-lying fruits for Antimicrobial Stewardship Committees. The role of stewardship collaboration in diagnosis and antimicrobial prescription was alluded to with managers indicating a growing rise in occurrence of antimicrobial resistance. There lacked contextualized, hospital specific antimicrobial formulary and adequate laboratory competency. Staff training and communication channels were available in varying capacity across the three hospitals. Building blocks identified include medicines and therapeutics committee, education, and training platforms (Continuous Medical Education and Continuous Professional Development activities) and hospital leadership commitment., Conclusions: The practice of antimicrobial stewardship is not implemented and well developed as demonstrated by lack of core AMS complementary health services. However, the health managers are aware of the fundamental importance of antimicrobial stewardship programs and the vast benefits of implementation and institutionalization of AMS to hospitals and their clients. The findings underpin the importance of understanding and incorporating perspectives of health managers on existing contextual mechanisms that can be leveraged on to establish robust AMS programs in the fight against antimicrobial resistance.

Background: Healthcare workers are at increased risk of contracting influenza. However, existing studies do not differentiate professional categories or domains of the healthcare system that are most at risk., Methods: This case-control study compared proportions of patients with professional activity in the healthcare system between cases consulting their primary care physician for an influenza-like illness (ILI) and controls from the general patient population of the same practices of the Swiss sentinel network. Influenza was confirmed by rRT-PCR in a subset of practices. Analysis used a mixed logistic regression model, including age and sex as potential confounders., Results: During the 2018/2019 influenza surveillance season, out of 4287 ILI cases and 28 561 controls reported in 168 practices, 235 (5.5%), respectively 872 (3.1%), were active in the healthcare system. After adjustment, being active in health care increased the odds of consulting for an ILI (OR 1.66, 95% CI 1.40-1.97). The association was strongest for physicians and nursing aides. In terms of work setting, odds of consulting for ILI were increased for professionals of almost all healthcare settings except home-based care., Conclusion: Individuals active in the healthcare system were more likely to consult their primary care physician for an influenza-like illness than for another reason, compared with individuals not active in the healthcare system. These results warrant further efforts to understand influenza transmission in the healthcare system at large., (© 2020 The Authors. Influenza and Other Respiratory Viruses Published by John Wiley & Sons Ltd.)

Introduction: Symptoms of depression and anxiety are a common consequence of occupational injury regardless of its cause and type. Nevertheless, mental health care is rarely covered by workers' compensation systems. The aim of this study was to assess the use of mental health care post-injury., Methods: We used a subsample of patient-care workers from the Boston Hospital Workers Health Study (BHWHS). We matched one injured worker with three uninjured workers during the period of 2012-2014 based on age and job title (nurse or patient-care associate) and looked at their mental health care use pre- and post-injury using medical claims data from the employer sponsored health plan. We used logistic regression analysis to assess the likelihood of mental health care use three and six months post-injury controlling for any pre-injury visits. Analyses were repeated separately by job title., Results: There were 556 injured workers between 2012 and 2014 that were matched with three uninjured workers at the time of injury (n = 1,649). Injured workers had a higher likelihood of seeking mental health care services than their uninjured counterparts during the six months after injury (OR = 1.646, 95% CI: 1.23-2.20), but not three months post-injury (OR = 0.825, 95% CI: 0.57-1.19). Patient-care associates had a higher likelihood to seek mental health care post-injury, than nurses (OR: 2.133 vs OR: 1.556) during the six months period., Conclusions: Injured workers have a higher likelihood to experience symptoms of depression and anxiety based on their use of mental health care post-injury and use is more predominant among patient-care associates; however, our sample has a small number of patient-care associates. Practical Applications: Treating depression and anxiety as part of the workers' compensation system has the potential of preventing further physical ailment and improving the return to work process regardless of nature of injury., (Copyright © 2020. Published by Elsevier Ltd.)

Engagement of healthcare workers (HCWs) is critical to maintaining high levels of hand hygiene (HH). However, attitudes of HCWs to how compliance is monitored has been poorly described. This study explored the HCW perspective on direct observation (DO) as a gold standard for HH monitoring. It also sought their opinions on innovative technology. A survey was emailed to all staff in two NHS trusts: 1120 responses were analysed. Nursing staff and doctors accounted for the largest quantity of responses; 58% of HCWs did not strongly endorse DO assessment of HH compliance. Staff were open to considering alternative innovative technologies., (Copyright © 2020 The Healthcare Infection Society. Published by Elsevier Ltd. All rights reserved.)

In light of the evolving COVID-19 pandemic, the Association of American Medical Colleges (AAMC) and Liaison Committee on Medical Education (LCME) released a joint statement in March 2020 recommending an immediate suspension of medical student participation in direct patient contact. As graduating medical students who will soon begin residency, the authors fully support this recommendation. Though paid health care workers, like residents, nurses, and environmental services staff, are essential to the management of COVID-19 patients, medical students are not. Students' continued involvement in direct patient care will contribute to SARS-CoV-2 exposures and transmissions and will waste already limited personal protective equipment. By decreasing nonessential personnel in health care settings, including medical students, medical schools will contribute to national and global efforts to "flatten the curve."The authors also assert that medical schools are responsible for ensuring medical student safety. Without the protections provided to paid health care workers, students are uniquely disadvantaged within the medical hierarchy; these inequalities must be addressed before medical students are safely reintegrated into clinical roles. Although graduating medical students and institutional leadership may worry that suspending clinical rotations might prevent students from completing graduation requirements, the authors argue the ethical obligation to "flatten the curve" supersedes usual teaching responsibilities. Therefore, the authors request further guidance from the LCME and AAMC regarding curricular exemptions/alternatives and adjusted graduation timelines. The pool of graduating medical students affected by this pause in direct patient contact represents a powerful reserve, which may soon need to be used as the COVID-19 pandemic continues to challenge the U.S. health care infrastructure.

Background: Transitioning from pediatric care to adult-oriented care at age 18 (the age of transfer in most countries and jurisdictions) is a complex process for adolescents and young adults affected by chronic physical health and/or mental health conditions. The role of primary health care (PHC) providers for this population is poorly understood. Perspectives from these providers, such as family physicians and other members of the primary care team, have not been explored in depth., Methods: A total of 18 participants (e.g., family physicians, social workers, nurses) were recruited from 6 Primary Care Networks in Calgary, Alberta, Canada. Semi-structured individual interviews were conducted, and transcribed verbatim. A qualitative description approach was used to analyze the data, and included thematic analysis., Results: Five distinct, yet overlapping, roles of primary health care providers for adolescents and young adults transitioning to adult care resulted from our analysis: (1) being the "common thread" (continuous accessible care); (2) caring for the "whole patient" (comprehensive care); (3) "knowing families" (family-partnered care); (4) "empowering" adolescents and young adults to develop "personal responsibility" (developmentally-appropriate care); and (5) "quarterbacking" care (coordination of specialist and/or community-based care). Participants identified potential benefits of these roles for adolescents and young adults transitioning to adult care, and barriers in practice (e.g., lack of time, having minimal involvement in pediatric care)., Conclusions: Input from family physicians, who follow their patients across the lifespan and provide the majority of primary care in Canada, are critical for informing and refining recommended transition practices. Our findings provide insights, from PHC providers themselves, to bolster the rationale for primary care involvement during transitions from pediatric specialty and community-based care for AYAs. Solutions to overcome barriers for integrating primary care and specialty care for adolescents and young adults need to be identified, and tested, with input from key stakeholders.

Background: The Estudio Vacuna de Influenza Peru (VIP) cohort aims to describe the frequency of influenza virus infection, identify predictors of vaccine acceptance, examine the effects of repeated influenza vaccination on immunogenicity, and evaluate influenza vaccine effectiveness among HCP., Methods: The VIP cohort prospectively followed HCP in Lima, Peru, during the 2016-2018 influenza seasons; a fourth year is ongoing. Participants contribute blood samples before and after the influenza season and after influenza vaccination (for vaccinees). Weekly surveillance is conducted to identify acute respiratory or febrile illnesses (ARFI). When an ARFI is identified, participants self-collect nasal swabs that are tested for influenza viruses by real-time reverse transcriptase-polymerase chain reaction. Influenza vaccination status and 5-year vaccination history are ascertained. We analyzed recruitment and enrollment results for 2016-2018 and surveillance participation for 2016-2017., Results: In the first 3 years of the cohort, VIP successfully contacted 92% of potential participants, enrolled 76% of eligible HCP, and retained >90% of participants across years. About half of participants are medical assistants (54%), and most provide "hands-on" medical care (76%). Sixty-nine percent and 52% of participants completed surveillance for >70% of weeks in years 1 and 2, respectively. Fewer weeks of completed surveillance was associated with older age (≥50 years), being a medical assistant, self-rated health of fair or poor, and not receiving the influenza vaccine during the current season (P-values < .05)., Conclusions: The VIP cohort provides an opportunity to address knowledge gaps about influenza virus infection, vaccination uptake, effectiveness and immunogenicity among HCP., (© 2020 The Authors. Influenza and Other Respiratory Viruses Published by John Wiley & Sons Ltd.)

The present study investigated factors that influenced home care physiotherapy (HCP) services and profile of the practitioners in Nigeria. It also investigated if the service was registered with the Regulatory Agency. Three hundred and thirty conveniently sampled physiotherapists in Nigeria participated in the cross-sectional survey. A newly developed, nine-part, content-validated questionnaire was used to obtain information about the demographics, sources of referral, case types, frequency of treatment, costing, benefits, and challenges of the HCP, job satisfaction, and registration status. Data were analyzed using descriptive statistics. All the respondents (100%) were involved in HCP irrespective of their professional profile. The mean duration of practice experience was 9.09 ± 7.34 years. Stroke (41.8%) was the most prevalent case treated. Poor working environment ( M = 4.16, R = 1-5), transportation cost ( M = 4.16, R = 1-5) and intrusion by impostors ( M = 3.66, R = 1-5), were some of the factors that had impact on the HCP services. A preponderance of HCP services was not registered with the Regulatory Agency in Nigeria.

Objectives: We sought to identify patterns of knowledge, attitudes, and behaviors (KABs) about influenza and influenza vaccination among healthcare personnel (HCP) and define characteristics associated with these patterns. Methods: We used an Internet panel survey of HCP (N = 2265) during March 27-April 17, 2018; clustered HCP by their vaccination-related KABs. Results: Four clusters were identified: Immunization Champions (61.1% of the sample) received influenza vaccine to prevent disease; Unworried Vaccinators (15.4%) received the influenza vaccine but did not believe influenza is a serious threat to themselves; Fence Sitters (8.1%) believed the vaccine is safe and worth the time and expense but is not effective; Skeptics (15.4%) did not believe the vaccine is safe or effective. Influenza vaccination coverage was 78.4% overall and higher among Immunization Champions (90.2%) and Unworried Vaccinators (87.0%) than Fence Sitters (61.6%) or Skeptics (32.2%). Conclusions: Findings suggest that based on KABs, the 3 clusters comprising 85% of HCP might be vaccinated in the future. Using messages specific to each group may improve vaccination coverage among HCP.

Foetal surgery to repair open spina bifida before birth improves infant motor function and reduces ventriculoperitoneal shunt requirement. Alongside the development of the first UK foetal surgery service, we surveyed the knowledge and acceptability of this treatment to healthcare professionals in the UK and Ireland via an electronic questionnaire. Ninety-eight (98) responses were received: MFM clinicians (21), midwives (20), paediatric neurosurgeons (17), obstetricians (15), neonatologists (13), theatre nurses (11) and commissioners (1). Overall 70% of responders agreed with the concept that foetal surgery improved neonatal outcome in selected cases; although, only 41% of paediatric neurosurgeons agreed. A variety of concerns were expressed, the most common being the lack information regarding mid- to long-term effects on the child and mother.In offering this new service, it is important that we are cognisant of healthcare professional concerns and address them by applying internationally accepted criteria for foetal surgery, emphasising patient choice and collecting long-term data.Impact statement What is already known on this subject? Foetal surgery is a potentially controversial intervention, which is increasing in availability globally. Foetal surgery is now available in the UK on a charitable-funding basis. Prior to starting a UK foetal surgery service, we assessed the attitudes and knowledge of healthcare professionals in the UK towards this new surgery. What the results of this study add? Overall the majority of healthcare professionals agree with the concept that foetal surgery improves neonatal outcome in selected cases, but a variety of concerns exist, the most common being the lack of information regarding mid- to long-term effects on the child and mother. Other concerns included a lack of education, training and research; the specific risk of preterm birth following surgery; the evidence base for this procedure; effects on maternal choice and financial implications. What the implications are of these findings for clinical practice and/or further research? Those developing this new service should be mindful of the concerns expressed and address them by applying internationally accepted criteria for foetal surgery, emphasising patient choice and collecting long-term data.

In sub-Saharan Africa, accessibility to affordable quality care is often poor and health expenditures are mostly paid out of pocket. Health insurance, protecting individuals from out-of-pocket health expenses, has been put forward as a means of enhancing universal health coverage. We explored the utilization of different types of healthcare providers and the factors associated with provider choice by insurance status in rural Nigeria. We analysed year-long weekly health diaries on illnesses and injuries (health episodes) for a sample of 920 individuals with access to a private subsidized health insurance programme. The weekly diaries capture not only catastrophic events but also less severe events that are likely underreported in surveys with longer recall periods. Individuals had insurance coverage during 34% of the 1761 reported health episodes, and they consulted a healthcare provider in 90% of the episodes. Multivariable multinomial logistic regression analyses showed that insurance coverage was associated with significantly higher utilization of formal health care: individuals consulted upgraded insurance programme facilities in 20% of insured episodes compared with 3% of uninsured episodes. Nonetheless, regardless of insurance status, most consultations involved an informal provider visit, with informal providers encompassing 73 and 78% of all consultations among insured and uninsured episodes, respectively, and individuals spending 54% of total annual out-of-pocket health expenditures at such providers. Given the high frequency at which individuals consult informal providers, their position within both the primary healthcare system and health insurance schemes should be reconsidered to reach universal health coverage., (© The Author(s) 2020. Published by Oxford University Press in association with The London School of Hygiene and Tropical Medicine.)

This study aims to investigate a potential association between different categories of service providers in primary healthcare in Brazil and the quality of care provided, as measured by the Program for Improvement of Access and Quality of Basic Care (PMAQ). The study adopted a quantitative design with a descriptive and inferential approach via logistic regression. A total of 4,469 Brazilian municipalities (counties) were analyzed. The results showed that there was no association between type of service provider (public vs. private) and the score obtained in the certification process (p-value > 0.05). Larger and more socioeconomically dynamic municipalities concentrated the largest proportions of municipalities with primary care services managed by private providers (23.2%). They also received the highest certification scores. Finally, for both categories (public and private), most municipalities obtained intermediate scores (from 50 to 69.99). We thus found that the quality of care in basic healthcare in Brazil, as measured by the PMAQ, is not associated with the type of provider involved in management of the service when the data are analyzed at the municipal level. Private providers and the highest scores in the certification process are concentrated in larger municipalities and those with the best socioeconomic indicators.

Background: Efficient testing to identify poor quality artemisinin-based combination therapy (ACT) is important to optimize efforts to control and eliminate malaria. Healthcare professionals interact with both ACT and malaria patients they treat and hence could observe, first-hand, suspect poor quality artemisinin-based combinations linked to poor malaria treatment outcomes and the factors associated with inappropriate use or treatment failure., Methods: A cross-sectional study of 685 HCP perspectives about the efficacy of ACT between June and July 2018 at selected health facilities in Uganda. Medicine samples were obtained from the seven regions of Uganda and tested for quality using the Germany Pharma Health Fund™ minilabs., Results: The average age of the 685 respondents was 30 (SD = 7.4) years. There was an almost equal distribution between male and female respondents (51:49), respectively. Seventy percent (n = 480) were diploma holders and the nurses contributed to half (49%, n = 334) of the study population. Sixty-one percent of the HCPs reported having ever encountered ACT failures while treating uncomplicated malaria. Nineteen percent of HCPs thought that dihydroartemisinin/piperaquine gave the most satisfactory patient treatment outcomes, while 80% HCPs thought that artemether/lumefantrine gave the least satisfactory patient treatment outcomes, possibly due to dosing schedule and pill burden. Healthcare professionals from the Central region (OR = 3.0, CI 0.3-1.0; P = 0.0001), Eastern region (OR = 5.4, CI 2.9-9.8; P = 0.0001) and Northern region (OR = 5.3, CI 2.9-9.9; P = 0.0001) had a higher chance of encountering ACT failure in 4 weeks prior to the survey as compared to those from the western region. Healthcare professionals from private health facilities also had higher chances of encountering ACT failures in past 4 weeks as compared to those from public health facilities (OR = 2.7, CI 1.7-3.9; P = 0.0001). All 192 samples passed the quality screening tests. The random sample of 10% of all samples randomly obtained by the laboratory staff also passed the chemical content analysis and dissolution tests., Conclusion: ACT medicines are widely available over-the-counter to the public and it is very difficult to report and monitor a decrease in efficacy or treatment failure. The perspectives of HCPs on treatment failure or lack of efficacy may potentially guide optimization efforts of sampling methodologies for the quality survey of ACT medicines.

Background: Needle Stick Injuries (NSIs) are the most common occupational injuries among HCWs. The aim of this study was to explore the prevalence and distribution of determinants for such injuries in a university hospital in Tehran, Iran, in 2016., Methods: We conducted a descriptive cross-sectional study in Ziaeian Hospital, a teaching hospital of Tehran University. The medical records of 55 Health Care Workers (HCWs) who experienced NSIs in 2016, were extracted from the hospital registry and analyzed using SPSS version 22., Results: Available data of 55 HCWs with a history of NSIs were extracted from the hospital registry. The highest number of NSIs belonged to registered nurses (34.6%), licensed practical nurses (14.5%) and medical doctors (12.7%), respectively. The majority of the NSIs occurred in the morning shift (50.9%) followed by night shift (36.4%) and evening shift (12.7%). Most of the NSIs occurred in the emergency department (38.1%) and operating room (18.2%). The healthcare workers reported fatigue as the most common reason for being injured by needles (67.4%). All the HCWs were trained and familiarized with the safety and risk control measures after needle stick exposures in the hospital., Discussion: The present study described the determinants of NSIs among HCWs in a university hospital. The fatigue and working overload were the main reasons for NSIs. The results of this study could be used to address the shortcoming in the guidelines and protocols to ensure the sustainable safety measures that could reduce the occurrence of the NSIs in hospitals in Iran., (Copyright© Bentham Science Publishers; For any queries, please email at epub@benthamscience.net.)

Background: Antibiotic-resistant organism (ARO) colonization rates in skilled nursing facilities (NFs) are high; hand hygiene is crucial to interrupt transmission. We aimed to determine factors associated with hand hygiene adherence in NFs and to assess rates of ARO acquisition among healthcare personnel (HCP)., Methods: HCP were observed during routine care at 6 NFs. We recorded hand hygiene adherence, glove use, activities, and time in room. HCP hands were cultured before and after patient care; patients and high-touch surfaces were cultured. HCP activities were categorized as high-versus low-risk for self-contamination. Multivariable regression was performed to identify predictors of hand hygiene adherence., Results: We recorded 385 HCP observations and paired them with cultures performed before and after patient care. Hand hygiene adherence occurred in 96 of 352 observations (27.3%) before patient care and 165 of 358 observations (46.1%) after patient care. Gloves were worn in 169 of 376 observations (44.9%). Higher adherence was associated with glove use before patient care (odds ratio [OR], 2.55; 95% confidence interval [CI], 1.44-4.54) and after patient care (OR, 3.11; 95% CI, 1.77-5.48). Compared with nurses, certified nurse assistants had lower hand hygiene adherence (OR, 0.31; 95% CI, 0.15-0.67) before patient care and physical/occupational therapists (OR, 0.22; 95% CI, 0.11-0.44) after patient care. Hand hygiene varied by activity performed and time in the room. HCP hands were contaminated with AROs in 35 of 385 cultures of hands before patient care (0.9%) and 22 of 350 cultures of hands after patient care (6.3%)., Conclusions: Hand hygiene adherence in NFs remain low; it is influenced by job title, type of care activity, and glove use. Hand hygiene programs should incorporate these unique care and staffing factors to reduce ARO transmission.

While many hospitals have transitioned from traditional maternity care to a single-room maternity model, little is known about how healthcare providers' practice differs between the models. This mixed-methods study compared healthcare providers' job satisfaction and team collaboration between traditional and single-room maternity care and explored how each model shaped providers' practice. Data were collected via questionnaires and interviews with healthcare providers from 2 hospitals. Independent t tests, Mann-Whitney U tests, and thematic analysis were used in analysis; findings were then triangulated. No difference was found in team collaboration and job satisfaction scores between single-room (n = 84) and traditional (n = 42) maternity care; however, providers described different means toward satisfaction and collaboration in the interviews (n = 18). Single-room maternity care providers valued interprofessional teamwork, patient/family involvement, and continuity of care. Traditional maternity care providers enjoyed specialization but described teamwork as uniprofessional and disconnected across professions; transfers between units weakened communication and fragmented care. While single-room maternity care providers described less tension and a more holistic patient-family journey, further research must be undertaken to examine whether and how interprofessional collaboration and communication impact patient and health system outcomes.

Objectives: To synthesize the literature describing compliance with World Health Organization hand hygiene guidelines in ICUs, to evaluate the quality of extant research, and to examine differences in compliance levels across geographical regions, ICU types, and healthcare worker groups, observation methods, and moments (indications) of hand hygiene., Data Sources: Electronic searches were conducted in August 2018 using Medline, CINAHL, PsycInfo, Embase, and Web of Science. Reference lists of included studies and related review articles were also screened., Study Selection: English-language, peer-reviewed studies measuring hand hygiene compliance by healthcare workers in an ICU setting using direct observation guided by the World Health Organization's "Five Moments for Hand Hygiene," published since 2009, were included., Data Extraction: Information was extracted on study location, research design, type of ICU, healthcare workers, measurement procedures, and compliance levels., Data Synthesis: Sixty-one studies were included. Most were conducted in high-income countries (60.7%) and in adult ICUs (85.2%). Mean hand hygiene compliance was 59.6%. Compliance levels appeared to differ by geographic region (high-income countries 64.5%, low-income countries 9.1%), type of ICU (neonatal 67.0%, pediatric 41.2%, adult 58.2%), and type of healthcare worker (nursing staff 43.4%, physicians 32.6%, other staff 53.8%)., Conclusions: Mean hand hygiene compliance appears notably lower than international targets. The data collated may offer useful indicators for those evaluating, and seeking to improve, hand hygiene compliance in ICUs internationally.

Objective: To investigate the relative importance of 10 attributes identified in prior studies as essential for effective disaster medical responders and leaders., Methods: Emergency and disaster medical response personnel (N=220) ranked 10 categories of disaster worker attributes in order of their importance in contributing to the effectiveness of disaster responders and leaders., Results: Attributes of disaster medical leaders and responders were rank ordered, and the rankings differed for leaders and responders. For leaders, problem-solving/decision-making and communication skills were the highest ranked, whereas teamwork/interpersonal skills and calm/cool were the highest ranked for responders., Conclusions: The 10 previously identified attributes of effective disaster medical responders and leaders include personal characteristics and general skills in addition to knowledge of incident command and disaster medicine. The differences in rank orders of attributes for leaders and responders suggest that when applying these attributes in personnel recruitment, selection, and training, the proper emphasis and priority given to each attribute may vary by role. (Disaster Med Public Health Preparedness. 2019;13:700-703).

Objective: Depression guidelines discourage benzodiazepine monotherapy and limit use to short-term adjunctive therapy with antidepressants; however, patients with depression continue to receive benzodiazepine monotherapy. The prevalence and predictors of this prescribing pattern have not been described previously and are warranted to assist clinicians in identifying patients at highest risk of receiving benzodiazepine monotherapy., Methods: A national, cross-sectional analysis of the National Ambulatory Medical Care Survey from 2012 to 2015 was performed for adults treated for depression. Depression was identified using a survey item specifically assessing the presence of depression. Office visits involving patients with bipolar disorder, schizoaffective disorder, or pregnancy were identified by ICD-9 code or specific survey item and were excluded. The primary endpoint was benzodiazepine monotherapy prescribing rate defined as initiation or continuation of a benzodiazepine in the absence of any antidepressant agent. A multivariate logistic regression model was created to identify variables associated with benzodiazepine monotherapy., Results: In total, 9,426 unweighted visits were eligible for inclusion. Benzodiazepine monotherapy was identified in 9.3% of patients treated for depression (95% CI, 8.2%-10.6%). Predictors of benzodiazepine monotherapy included age of 45-64 years (OR = 1.39; 95% CI, 1.01-1.91), epilepsy-related office visit (OR = 5.34; 95% CI, 1.39-20.44), anxiety-related office visit (OR = 1.67; 95% CI, 1.23-2.27), underlying pulmonary disease (OR = 1.43; 95% CI, 1.09-1.87), and concomitant opiate prescribing (OR = 2.86; 95% CI, 2.01-4.06). Psychiatrists were less likely to prescribe benzodiazepine monotherapy than were other providers (OR = 0.42; 95% CI, 0.29-0.61)., Conclusions: Benzodiazepine monotherapy is utilized in nearly 1 in 10 patients treated for depression. Adults aged 45 to 65 years, patients prescribed opioids, patients seen by primary care providers, and those with underlying anxiety, epilepsy, or pulmonary disorders are at highest risk., (© Copyright 2019 Physicians Postgraduate Press, Inc.)

Introduction: We identified the frequency and assessed the validity of marketing claims made by American chiropractors, naturopaths, homeopaths, acupuncturists, and integrative medicine practitioners relating to the diagnosis and treatment of celiac disease and nonceliac gluten sensitivity (NCGS), both of which have increased in prevalence in recent years., Methods: We performed a cross-sectional study analyzing websites of practitioners from 10 cities in the United States and analyzed the websites for any mention of celiac or NCGS as well as specific claims of ability to diagnose, ability to treat, and treatment efficacy. We classified treatments promoted as true, false, or unproven, as assessed independently by 2 authors., Results: Of 500 clinics identified, 178 (35.6%) made a claim regarding celiac disease, NCGS, or a gluten-free diet. Naturopath clinic websites have the highest rates of advertising at least one of diagnosis, treatment, or efficacy for celiac disease (40%), followed by integrative medicine clinics (36%), homeopaths (20%), acupuncturists (14%), and chiropractors (12%). Integrative medicine clinics have the highest rates of advertising at least one of diagnosis, treatment, or efficacy for NCGS (45%), followed by naturopaths (37%), homeopaths (14%), chiropractors (14%), and acupuncturists (10%). A geographic analysis yielded no significant variation in marketing rates among clinics from different cities. Of 232 marketing claims made by these complementary and alternative medicine (CAM) clinic websites, 138 (59.5%) were either false or unproven., Discussion: A significant number of CAM clinics advertise diagnostic techniques or treatments for celiac disease or NCGS. Many claims are either false or unproven, thus warranting a need for increased regulation of CAM advertising to protect the public.

Background: Approximately 60-70% of breast cancer survivors experience sexuality problems resulting from treatment. This study investigated information and communication preferences with professionals on the topic intimacy and sexuality of women diagnosed with breast cancer., Methods: Members of the Dutch Breast Cancer Patient Association were surveyed regarding their experiences and preferences about information on intimacy and sexuality. An online questionnaire was developed that included five close-ended and one open-ended question regarding: information received; type of professional preferred; method and timing of communication on the topics of intimacy and sexuality. Quantitative data were analysed using descriptive statistics. A deductive framework analysis was performed on the open-ended answers to enrich the data of the close-ended questions., Results: In total, 667 female breast cancer (ex-)patients participated. In 46% of the women, the information received matched their needs. Most women preferred to receive information about the impact on intimacy and sexuality from a nurse (66.4%) or primary doctor (27.9%). The preferred method of communication was a conversation with a professional together with their partner (51.6%) or a personal conversation with a professional. Respondents emphasized the importance of appropriate timing of information, preferably at least shortly after the treatment started (45.1%)., Conclusions: This study shows that intimacy and sexuality should be repeatedly included in consultations, at every stage of the disease but especially shortly after treatment started. Women with breast cancer expect that professionals (preferably nurse or primary doctor) initiate this subject via a personal conversation (alone or with their partner).

Introduction: Heart disease (HD) accounts for high morbidity and mortality in Brazil. Underserved populations often suffer long delays in diagnosis. We aimed to evaluate the feasibility of integrating screening echocardiography (echo) with remote interpretation in the established primary care system (PC) in Brazil and to assess HD prevalence., Methods: Over 11 months, 20 healthcare workers (four physicians, four nurses, and 12 technicians) at 16 PC centres were trained on simplified handheld echo protocols. Three screening (SC) groups, including all consented patients aged 17-20, 35-40 and 60-65 years, and patients referred (RF) for clinical indications underwent focused echo. Studies were remotely interpreted through telemedicine. Significant HD was defined as moderate/severe valve disease, ventricular dysfunction/hypertrophy, pericardial effusion, wall-motion abnormalities and congenital heart disease., Results: Total 1004 patients underwent echo; 299 (29.8%) in the SC group. Median age was 51±18 years, 63.9% females; 42.7% had cardiovascular symptoms. Significant HD was found in 354 (35.3%) patients (23.4% in SC vs 40.3% in RF group, p<0.001). Prevalence was higher in patients in the SC group aged >60 years (29.2%), compared with 35-40 (14.9%) and under 20 (16.5%), p=0.012. Comparing SC to RF groups, moderate/severe left ventricular dysfunction was observed in 4.1% vs 8.1%, p=0.03, mitral regurgitation in 8.9% vs 20.3%, p<0.001 and aortic stenosis in 5.4% vs 4.3%, p=0.51., Conclusions: Integration focused echo into PC is feasible in Brazil as a strategy to deliver cardiovascular care to low-resourced areas through task shifting. The burden of HD observed suggests this tool may improve early diagnosis and referral., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2019. No commercial re-use. See rights and permissions. Published by BMJ.)

Purpose: Opioid use disorder (OUD) is a substantial public health problem. Buprenorphine is an effective medication-assisted treatment (MAT) for OUD, but access is difficult for patients, especially in rural locations. To improve access, the Comprehensive Addiction and Recovery Act of 2016 extended the ability to get a Drug Enforcement Administration (DEA) waiver to prescribe buprenorphine to treat OUD to nurse practitioners (NPs) and physician assistants (PAs). This study summarizes the geographic distribution of waivered physicians, NPs, and PAs at the end of 2017 and compares it to the distribution of waivered physicians 5 years earlier., Methods: Using the DEA list of providers with a waiver to prescribe buprenorphine to treat OUD and the Area Health Resources File, we assigned waivered providers to counties in 1 of 4 geographic categories. We calculated the number of counties in each category that did not have a waivered provider and county provider to population ratios and then compared our results to the waivered workforce in 2012., Findings: The availability of a physician with a DEA waiver to provide office-based MAT has increased across all geographic categories since 2012. More than half of all rural counties (56.3%) still lack a provider, down from 67.1% in 2012. Almost one-third (29.8%) of rural Americans compared to 2.2% of urban Americans live in a county without a buprenorphine provider. NPs and PAs add otherwise lacking treatment availability in 56 counties (43 rural)., Conclusions: Overall, MAT access has improved, but rural communities still experience treatment disparities., (© 2018 National Rural Health Association.)

Objectives: To compare the performance of critical care providers with that of electroencephalography experts in identifying seizures using quantitative electroencephalography display tools., Design: Diagnostic accuracy comparison among healthcare provider groups., Setting: Multispecialty quaternary children's hospital in Canada., Subjects: ICU fellows, ICU nurses, neurophysiologists, and electroencephalography technologists., Intervention: Two-hour standardized one-on-one training, followed by a supervised individual review of 27 continuous electroencephalography recordings with the task of identifying individual seizures on eight-channel amplitude-integrated electroencephalography and color density spectral array displays., Measurements and Main Results: Each participant reviewed 27 continuous electroencephalograms comprising 487 hours of recording containing a total of 553 seizures. Performance for seizure identification was compared among groups using a nested model analysis with adjustment for interparticipant variability within groups and collinearity among recordings. Using amplitude-integrated electroencephalography, sensitivity for seizure identification was comparable among ICU fellows (83.8%), ICU nurses (73.1%), and neurophysiologists (81.5%) but lower among electroencephalographic technologists (66.7%) (p = 0.003). Using color density spectral array, sensitivity was comparable among ICU fellows (82.4%), ICU nurses (88.2%), neurophysiologists (83.3%), and electroencephalographic technologists (73.3%) (p = 0.09). Daily false-positive rates were also comparable among ICU fellows (2.8 for amplitude-integrated electroencephalography, 7.7 for color density spectral array), ICU nurses (4.2, 7.1), neurophysiologists (1.2, 1.5), and electroencephalographic technologists (0, 0) (p = 0.41 for amplitude-integrated electroencephalography; p = 0.13 for color density spectral array). However, performance varied greatly across individual electroencephalogram recordings. Professional background generally played a greater role in determining performance than individual skill or electroencephalogram recording characteristics., Conclusions: Following standardized training, critical care providers and electroencephalography experts displayed similar performance for identifying individual seizures using both amplitude-integrated electroencephalography and color density spectral array displays. Although these quantitative electroencephalographic trends show promise as a tool for bedside seizure screening by critical care providers, these findings require confirmation in a real-world ICU environment and in daily clinical use.

The article analyzes the application of four criteria for the (re)distribution of basic health teamwork at the local level. This was a descriptive, cross-sectional, case study conducted in Nueva Esparta, Venezuela, in 2016. An instrument was designed to consolidate in a single database the local data on basic health teamwork in 170 popular clinics serving 447 communities. The target criteria were: (1) basic health teamwork/population ratio, calculating the number of complete and incomplete basic health teamwork and the density of health professionals per 10,000 inhabitants; (2) distance between the popular clinics and the population; (3) characteristics of the health professionals comprising the basic health teamwork, by sex, age, and health profession; (4) analysis of the metrics for inequality as an innovative criterion, calculating two summary measures of gap and one health inequality gradient to assess the proposals for (re)distribution of the basic health teamwork. There were differences within states at the municipal and local community levels in the distribution of health professionals and a shortage of nurses and health promoters. Of the 317 required basic health teamwork, there were 52 complete basic health teamwork. The measures of inequality reflect an eco-social equidistribution of human resources, favoring the poorer populations. Combined application of the criteria allowed identifying geographic areas and populations with the greatest need and shortage of basic health teamwork and optimizing their equitable (re)distribution at the local level. The limitation of lack of disaggregated information was overcome by using a single data repository with consensual information among the state and local health teamwork. In conclusion, investments should be made in efficient information systems.

Objective: We aimed to describe the differences in workload between team leaders and CPR providers during a simulated pediatric cardiac arrest, to evaluate the impact of a CPR feedback device on provider workload, and to describe the association between provider workload and the quality of CPR., Methods: We conducted secondary analysis of data from a randomized trial comparing CPR quality in teams with and without use of a real-time visual CPR feedback device [1]. Healthcare providers (team leaders and CPR providers) completed the NASA Task Load Index survey after participating in a simulated cardiac arrest scenario. The effect of provider roles and real-time feedback on workload were compared with independent t-tests., Results: Team leaders reported higher levels of mental demand, temporal demand, performance-related workload and frustration, while CPR providers reported comparatively higher physical workload. CPR providers reported significantly higher average workload (control 58.5 vs. feedback 62.3; p = 0.035) with real-time feedback provided compared to the group without feedback. Providers with high workloads (average score >60) had an increased percentage of time with guideline-compliant CPR depth versus those with low workloads (average score <60) (p = 0.034)., Conclusions: Healthcare providers reported high workloads during a simulated pediatric cardiac arrest. Physical and mental workloads differed based on provider role. CPR providers using a CPR feedback device reported increased average workloads. The quality of CPR improved with higher reported physical workloads., (Copyright © 2018 Elsevier B.V. All rights reserved.)

ABSTRACTBackground:Acknowledging increasing demand of dementia care for patients in China, this paper aims to understand the training needs of dementia care from the perspectives of mental health providers by examining who should be the trainees, what should be the contents of training, and how to deliver the training in China., Methods: Using purposive sampling, data were gathered via four focus group discussions with 40 mental health providers in Beijing, China, in 2011. Data were transcribed by independent investigators and then translated into English. Researchers used content analysis to separately identify themes and codes. Discrepancies were discussed until final agreement achieved., Results: To improve the quality of dementia care, all participants agreed there is a significant need to train both formal or professional (physicians, nurses, hospital administrators, community workers) and informal caregivers (family, friends, or non-kin hired caregivers). For formal or professional caregivers, suggested training content included clinical knowledge of dementia (i.e. pathogenesis, approaches for preventing dementia deterioration) and clinical practice skills (i.e. diagnostic, treatment, caregiving, counseling, communicating skills). For informal caregivers, basic dementia knowledge and home-based caregiving skills such as safety, restorative, stress management, and communication were identified as key training contents. Multilevel support from the government and community centers were considered crucial factors to delivering the training and educating the public to enhance awareness of dementia., Conclusions: Culturally, sensitive education and specific trainings for formal and informal dementia caregivers are urgently needed in China. Policy and program implications are discussed.

Background: When profiling multiple health care providers, adjustment for case-mix is essential to accurately classify the quality of providers. Unfortunately, misclassification of provider performance is not uncommon and can have grave implications. Propensity score (PS) methods have been proposed as viable alternatives to conventional multivariable regression. The objective was to assess the outlier classification performance of risk adjustment methods when profiling multiple providers., Methods: In a simulation study based on empirical data, the classification performance of logistic regression (fixed and random effects), PS adjustment, and three PS weighting methods was evaluated when varying parameters such as the number of providers, the average incidence of the outcome, and the percentage of outliers. Traditional classification accuracy measures were considered, including sensitivity and specificity., Results: Fixed effects logistic regression consistently had the highest sensitivity and negative predictive value, yet a low specificity and positive predictive value. Of the random effects methods, PS adjustment and random effects logistic regression performed equally well or better than all the remaining PS methods for all classification accuracy measures across the studied scenarios., Conclusions: Of the evaluated PS methods, only PS adjustment can be considered a viable alternative to random effects logistic regression when profiling multiple providers in different scenarios.

Background: A high level of burnout has been described in health professionals. However, literature regarding other hospital employees is scarce., Aims: To assess the prevalence of burnout in different professional groups of hospital staff and how the professional category is associated with levels of burnout., Methods: Employees of a University Hospital in Portugal completed a self-administered online questionnaire in 2014-2015. We used the Portuguese version of the Maslach Burnout Inventory-Human Services Survey and scored three dimensions of burnout (emotional exhaustion, depersonalization, personal accomplishment) as low, average or high. We estimated odds ratios (OR) and 95% confidence intervals (95% CI) by logistic regression, adjusting for age, sex, use of anxiolytic/antidepressant drugs and job satisfaction., Results: There was a 10% response rate; 368 questionnaires were available for analysis. High levels of burnout due to emotional exhaustion were observed in all professional categories. Nurses, administrative staff and technicians more frequently scored higher levels of emotional exhaustion (59%, 50% and 50%, respectively) and lack of personal accomplishment (41%, 52% and 38%, respectively) than physicians and healthcare assistants. Not all professionals scored highly for depersonalization. Emotional exhaustion scores were significantly lower in healthcare assistants than nurses (adjusted OR 0.26, 95% CI 0.10-0.64)., Conclusions: Burnout affects all professional categories of hospital staff. Future studies should use larger, more representative samples of hospital staff, perform longitudinal analyses and analyse data on specifics of each professional category and other potential confounders.

In the United States, at least half of older adults living with dementia do not have a diagnosis. Their cognitive impairment may not have been detected, and some older adults whose physician recommends that they obtain a diagnostic evaluation do not follow through on the recommendation. Initiatives to increase detection of cognitive impairment and diagnosis of dementia have focused primarily on physician practices and public information programs to raise awareness about the importance of detection and diagnosis. Nonphysician care providers who work with older adults in community and residential care settings, such as aging network agencies, public health agencies, senior housing, assisted living, and nursing homes, interact frequently with older adults who have cognitive impairment but have not had a diagnostic evaluation. These care providers may be aware of signs of cognitive impairment and older adults' concerns about their cognition that have not been expressed to their physician. Within their scope of practice and training, nonphysician care providers can help to increase detection of cognitive impairment and encourage older adults with cognitive impairment to obtain a diagnostic evaluation to determine the cause of the condition. This article provides seven practice recommendations intended to increase involvement of nonphysician care providers in detecting cognitive impairment and encouraging older adults to obtain a diagnostic evaluation. The Kickstart-Assess-Evaluate-Refer (KAER) framework for physician practice in detection and diagnosis of dementia is used to identify ways to coordinate physician and nonphysician efforts and thereby increase the proportion of older adults living with dementia who have a diagnosis., (© The Author(s) 2018. Published by Oxford University Press on behalf of The Gerontological Society of America. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

Objective: To verify whether an intervention based on disseminating health evidence summaries by e-mail to health professionals increases access to health evidence databases, and whether health professionals intend to apply the evidence received by e-mail in their clinical practice., Methods: This quantitative study started with a survey to collect demographic data and patterns of access to health evidence databases. It was followed by a longitudinal intervention, over 48 weeks, that disseminated 143 health evidence summaries to 339 health professionals with higher education degree who work in the Brazilian Unified Health System. In the longitudinal intervention phase, health professionals voluntarily assessed the received health evidence summaries using the information assessment method. Finally, the study concluded with a survey to identify changes in accessing health evidence databases., Results: Of the 339 Brazilian health professionals participating in this research, 90 (26.5%) answered the initial and final surveys. After 48 weeks, there was an increase in the use of health evidence databases; 186 (54.9%) participants submitted 7,942 assessments of health evidence summaries, which were relevant for patient care in 5,409 (68%) assessments., Conclusions: The dissemination of health evidence summaries by e-mail to health professionals in Brazil increases the reported use of evidence in clinical practice.

The study aimed to compare the experiences with the organization of universal public healthcare systems in relation to health promotion in primary care units in Florianópolis, Santa Catarina State, Brazil, and Toronto, Ontario, Canada. This was a descriptive exploratory study with a qualitative approach in primary care units. Data were collected with semi-structured interviews containing questions on health promotion practices, with 25 health professionals in Florianópolis and 10 in Toronto. The data were discussed using thematic analysis, identifying the practices, difficulties, and facilities in health promotion. In the two cities, 60% of health professionals and health administrators had not received any specific knowledge on health promotion during their training. As for health promotion skills, health professionals in Toronto identified them with autonomy and social determinants, while in Florianópolis they were related to health education and community participation. In both cities, health promotion practices are targeted to individual and collective activities. The motivation to act comes from interdisciplinarity and the demands raised by the population. Health promotion is a relevant form of care and stimulus for individual and community autonomy, in light of social determinants. Such practices aim at comprehensive health for the community, but there are limits in the teams that still conduct disease-centered activities. Resources are limited, requiring inter-sector actions to improve quality of life. Healthcare centers on the hegemonic model, and progress is needed to achieve a positive approach to health and social determinants.