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Whilst policymaking will always remain a highly political process, especially amidst crises, evidence-based pandemic management can benefit from adopting a socioecological perspective that integrates multi- and trans-disciplinary insights: from biology, biomedicine, mathematics, statistics, social and behavioural sciences, as well as the perspectives and experiences of non-scientific stakeholders. We make a case for an “integrated inter- and transdisciplinarity” that overcomes the typical additive nature of current interdisciplinary work and better captures the inherent complexity of public health and other public policy problems. We propose systems science and systems thinking approaches as a useful meta-theoretical, self-reflecting approach for such integration to take place. Enabled by systems thinking, the praxis of “integrated inter- and transdisciplinarity” allows for an understanding of public health crises in a human-centred socio-ecological perspective. This grounds more holistic policy responses, which by mobilising the whole of government and whole of society, put individuals, groups, governments and society at large in critical dialogue to co-produce and co-design interventions that address crises in all their physical, social, psychological, economic and political dimensions.

BackgroundTimely diagnosis and treatment for ST-elevation myocardial infarction (STEMI) requires a coordinated response from multiple providers. Rapid intervention is key to reducing mortality and morbidity. Activation of the cardiac catheterization laboratory may occur through verbal communication and may also involve the secure sharing of electrocardiographic images between frontline health care providers and interventional cardiologists. To improve this response, we developed a quick, easy-to-use, privacy-compliant smartphone app, that is SMART AMI-ACS (Strategic Management of Acute Reperfusion and Therapies in Acute Myocardial Infarction Acute Coronary Syndromes), for real-time verbal communication and sharing of electrocardiographic images among health care providers in Ontario, Canada. The app further provides information about diagnosis, management, and risk calculators for patients presenting with acute coronary syndrome. ObjectiveThis study aims to integrate the app into workflow processes to improve communication for STEMI activation, resulting in decreased treatment times, improved patient outcomes, and reduced unnecessary catheterization laboratory activation and transfer. MethodsImplementation of the app will be guided by the Reach, Effectiveness, Acceptability, Implementation, and Maintenance (RE-AIM) framework to measure impact. The study will use quantitative registry data already being collected through the SMART AMI project (STEMI registry), the use of the SMART AMI app, and quantitative and qualitative survey data from physicians. Survey questions will be based on the Consolidated Framework for Implementation Research. Descriptive quantitative analysis and thematic qualitative analysis of survey results will be conducted. Continuous variables will be described using either mean and SD or median and IQR values at pre- and postintervention periods by the study sites. Categorical variables, such as false activation, will be described as frequencies (percentages). For each outcome, an interrupted time series regression model will be fitted to evaluate the impact of the app. ResultsThe primary outcomes of this study include the usability, acceptability, and functionality of the app for physicians. This will be measured using electronic surveys to identify barriers and facilitators to app use. Other key outcomes will measure the implementation of the app by reviewing the timing-of-care intervals, false “avoidable” catheterization laboratory activation rates, and uptake and use of the app by physicians. Prospective evaluation will be conducted between April 1, 2022, and March 31, 2023. However, for the timing- and accuracy-of-care outcomes, registry data will be compared from January 1, 2019, to March 31, 2023. Data analysis is expected to be completed in Fall 2024, with the completion of a paper for publication anticipated by the end of 2024. ConclusionsSmartphone technology is well integrated into clinical practice and widely accessible. The proposed solution being tested is secure and leverages the accessibility of smartphones. Emergency medicine physicians can use this app to quickly, securely, and accurately transmit information ensuring faster and more appropriate decision-making for STEMI activation. Trial RegistrationClinicalTrials.gov NCT05290389; https://clinicaltrials.gov/study/NCT05290389 International Registered Report Identifier (IRRID)DERR1-10.2196/55506

Addressing global health crises requires a receptive and expedient policy environment to minimise delays in making available potentially life-saving technologies. Over time, the policy environment has adapted to ensure that communities have expedited access to promising technologies, such as vaccines, that can mitigate morbidity and mortality. Emergency authorisations are one such policy mechanism. While these have been employed successfully for several diseases, such as influenza, Ebola and COVID-19, the policy mechanism is tied to contexts where key bodies have designated the disease an ‘emergency’, whereas no equivalent mechanism exists for those failing to acquire the designation (eg, malaria and tuberculosis). In this paper, we examine ethical issues associated with emergency authorisations. We argue that there is no moral difference between those diseases considered emergencies and many that fail to be designated as such with respect to impact on affected communities. Thus, tying access to an expedient policy mechanism for approval to an emergency designation is ethically unjustified—it should be based on considerations of risks and benefits, the disease burden and the values of the communities that carry those risks and not contingent on if the disease is designated an emergency. We suggest the need to further enhance the policy environment to ensure access to similar expedited approval programmes irrespective of if a disease is an emergency. Levelling the field for access to expedited approval programmes across diseases can help in moving towards achieving global health equity but is not a panacea.

Abstract Background A variety of evidence-based algorithms and decision rules using D-Dimer testing have been proposed as instruments to allow physicians to safely rule out a pulmonary embolism (PE) in low-risk patients. Objective To describe the prevalence of D-Dimer utilization among emergency department (ED) physicians and its impact on positive yields and utilization rates of Computed Tomography Pulmonary Angiography (CTPA). Methods Data was collected on all CTPA studies ordered by ED physicians at three sites during a 2-year period. Using a chi-square test, we compared the diagnostic yield for those patients who had a D-Dimer prior to their CTPA and those who did not. Secondary analysis was done to examine the impact of D-Dimer testing prior to CTPA on individual physician diagnostic yield or utilization rate. Results A total of 2811 CTPAs were included in the analysis. Of these, 964 CTPAs (34.3%) were ordered without a D-Dimer, and 343 (18.7%) underwent a CTPA despite a negative D-Dimer. Those CTPAs preceded by a D-Dimer showed no significant difference in positive yields when compared to those ordered without a D-Dimer (9.9% versus 11.3%, p = 0.26). At the individual physician level, no statistically significant relationship was found between D-Dimer utilization and CTPA utilization rate or diagnostic yield. Conclusion This study provides evidence of suboptimal adherence to guidelines in terms of D-Dimer screening prior to CTPA, and forgoing CTPAs in patients with negative D-Dimers. However, the lack of a positive impact of D-Dimer testing on either CTPA diagnostic yield or utilization rate is indicative of issues relating to the high false-positive rates associated with D-Dimer screening.

Background: As with most ailments common to adult and paediatric age groups, studies that describe and characterize paediatric traumatic brain injuries (TBIs) lag those of their adult counterparts. This is more so in the developing countries where national data are not well developed. The development of local clinical guidelines has been shown to positively impact outcomes of paediatric TBI. Data on the characteristics and outcomes of TBI among paediatric age groups will provide a framework for the development of an all-encompassing management guideline. Methods: In this study, a retrospective review of demography, mechanism of injury, pattern of presentation, nature of treatment, duration of hospital admission, and outcome of children aged 0–17 years managed for traumatic TBI at the University of Nigeria Teaching Hospital, Enugu-Nigeria was performed. Data were analyzed using SPSS version 21. Relevant test statistics were used to test for associations. A P = 0.05 was considered statistically significant. Results: A total of 163 patients' medical records were retrieved and analyzed. Of these, 117 (71.8%) were males and 46 (28.2%) were females. Their ages ranged from 6 weeks to 17 years with a mean age of 7.66 ± 5.1 years and peaked at 3–5 years. No difference in mean age between gender (P = 0.427). Pedestrian motor vehicular accident was the most common cause of injury. Fall from fruit trees and assault were peculiar to children from suburban/rural areas. TBI severity on admission was mild (44.2%), moderate (38.7%), and severe (17.2%). Other systemic injuries were present in 33.7%, of which long bone fractures were the most common (23/55). Abnormal brain computed tomography findings were seen in 83.2% with skull fracture being the most common finding. Operative procedures were carried out on 19.6% of patients. Conservative measures were the mainstay of management. The mean duration of hospital admission was 14.01 ± 11.8 days was significantly associated with admission Glasgow Coma Scale (GCS) Score (P < 0.0001) and Glasgow Outcome Score (GOS) at discharge (P = 0.03). The overall outcome was good (GOS 4 and 5) in 92.0% and has a significant association with GCS on admission (P < 0.0001). Long-term (Extended GOS) was 8 in 98.2% of those followed up. Conclusion: Paediatric TBI is mainly mild to moderate in severity with a male predilection. The main cause is road traffic accidents with most victims being pedestrians. Management is mainly non-operative and the outcome at discharge is good even in a middle-income country and significantly determined by GCS on admission.

Abstract Objectives The aim of this study was to report burnout time trends and describe the psychological effects of working as a Canadian emergency physician during the first weeks of the coronavirus disease 2019 (COVID‐19) pandemic. Methods This was a mixed‐methods study. Emergency physicians completed a weekly online survey. The primary outcome was physician burnout as measured by the emotional exhaustion and depersonalization items, from the Maslach Burnout Inventory. We captured data on work patterns, aerosolizing procedures, testing and diagnosis of COVID‐19. Each week participants entered free text explaining their experiences and well‐being. Results There were 468 participants who worked in 143 Canadian hospitals. Burnout levels did not significantly change over time (emotional exhaustion P = 0.632, depersonalization P = 0.155). Three participants were diagnosed with COVID‐19. Being tested for COVID‐19 (odds ratio [OR] 11.5, 95% confidence interval [CI] 3.1–42.5) and the number of shifts worked (OR 1.3, 95% CI 1.1–1.5 per additional shift) were associated with high emotional exhaustion. Having been tested for COVID‐19 (OR 4.3, 95% CI 1.1–17.8) was also associated with high depersonalization. Personal safety, academic and educational work, personal protective equipment, the workforce, patient volumes, work patterns, and work environment had an impact on physician well‐being. A new financial reality and contrasting negative and positive experiences affected participants’ psychological health. Conclusion Emergency physician burnout levels remained stable during the initial 10 weeks of this pandemic. The impact of COVID‐19 on the work environment and personal perceptions and fears about the impact on lifestyle have affected physician well‐being.

The purpose of this study was to explore the status of Paralympic hopefuls' athletic identity and how this identity was impacted by the training and competition cessation resulting from the COVID-19 pandemic. Researchers conducted in-depth semi-structured interviews that explored the experiences of 29 Paralympic hopefuls who compete in thirteen different Paralympic sports. A thematic analysis yielded two superordinate themes: a) Prominent athletic identity, multiplicity over exclusivity; b) Various Impact on AI: Mental adaptation helps overcome the lack of sport participation. Participants in this study possessed prominent strong athletic identities from the benefits of sport participation. Their prioritized athletic role still remains despite setbacks due to the pandemic. However, athletes identified with multiple roles rather than an exclusive athletic identity during COVID-19. As for the impacts on identity, the severity of challenges are determined by the mindset of the athletes. All of the athletes experienced a decreased amount of time and physical participation in their sport. Paralympians whose sole focus was on the loss of physical participation were impacted the most. Athletes who felt unchallenged did so because of their mental adaptation. Through a positive outlook and mentality, athletes were able to effectively cope and not dwell on the negative aspects brought on by the pandemic. In conclusion, having a strong AI did not necessarily coincide with a negative impact on identity from COVID-19, and those who do not possess a strong AI felt their AI was unchallenged by the pandemic. More importantly, Paralympians' mindset of how they view and interpret their AI is crucial to how the individual's AI is affected by the sport disruption of COVID-19.

Introduction Falling on level ground is now the most common cause of traumatic intracranial bleeding worldwide. Older adults frequently present to the emergency department (ED) after falling. It can be challenging for clinicians to determine who requires brain imaging to rule out traumatic intracranial bleeding, and often head injury decision rules do not apply to older adults who fall. The goal of our study is to derive a clinical decision rule, which will identify older adults who present to the ED after a fall who do not have clinically important intracranial bleeding.Methods and analysis This is a prospective cohort study enrolling patients aged 65 years or older, who present to the ED of 11 hospitals in Canada and the USA within 48 hours of having a fall. Patients are included if they fall on level ground, off a chair, toilet seat or out of bed. The primary outcome is the diagnosis of clinically important intracranial bleeding within 42 days of the index ED visit. An independent adjudication committee will determine the primary outcome, blinded to all other data. We are collecting data on 17 potential predictor variables. The treating physician completes a study data form at the time of initial assessment, prior to brain imaging. Data extraction is supplemented by an independent, structured electronic medical record review. We will perform binary recursive partitioning using Classification and Regression Trees to derive a clinical decision rule.Ethics and dissemination The study was initially approved by the Hamilton Integrated Research Ethics Committee and subsequently approved by the research ethics boards governing all participating sites. We will disseminate our results by journal publication, presentation at international meetings and social media.Trial registration number NCT03745755.

Kinetics and selected variables (temperature, particle size and time) for extraction of Terminalia Catappa L Kernel Oil (TCKO) were investigated using solvent extraction. Kinetic models studied were: parabolic diffusion, power law, hyperbolic, Elovich and pseudo-second-order. In ascending order, the best-fitted models at the optimum temperature and oil yield were Elovich’s model, hyperbolic model, and Pseudo second-order model. Due to the highest value of linear correlation coefficient (R2) and lowest average values of Root Mean Square (RMS), absolute relative deviation (AARD %) and Standard Error of Estimation (SEE) recorded for Pseudo second order, it was selected as the best fit model. Parabolic and power-law models failed to give a good fit. The average maximum oil yield of 60.45 ± 0.05 % was obtained at a temperature of 55 °C, time of 150 min and an average particle size of 0.5 mm. The physicochemical properties of the TCKO showed its potential for industrial applications.

Accumulating evidence from diverse fields of inquiry suggests the existence of method hierarchies, where criteria employed by the same epistemic agent constitute a certain preference hierarchy. In this paper, we illustrate the phenomenon of method hierarchy by discussing several prominent studies in clinical epidemiology of coronary artery disease. The current “gold standard” in clinical epidemiology is the randomized controlled trial (RCT) method. Yet, in the absence of studies that satisfy the strict requirement of the RCT method, clinical epidemiologists often relax the requirements of double-blinding, complete follow-up, no treatment switching, and/or randomization. Instead, they sometimes employ less stringent requirements, such as the requirement to account for the potential imbalances between groups through statistical models. This suggests the existence of a certain method hierarchy. However, it is unclear how method hierarchies are to be conceptualized and documented. Specifically, it remains to be seen whether a method hierarchy is best understood as being composed of individual employed methods or as a single composite method with a complex system of if-s and else-s. Suggested Modifications [Sciento-2019-0013]: Accept the existence of method hierarchies. Accept the following definition of method hierarchy: • Method Hierarchy ≡ a set of methods is said to constitute a hierarchy iff theories that satisfy the requirements of methods that are higher in the hierarchy are preferred to theories that satisfy the requirements of methods that are lower in the hierarchy. Accept the following question as a legitimate topic of scientonomic inquiry: • Conceptualizing Method Hierarchies: should we conceive of a method hierarchy as being composed of individual employed methods/requirements, or should we think of it as constituting one composite method with a system of if-s and else-s, and-s and or-s?

BackgroundThe adoption of the transradial (TR) approach over the traditional transfemoral (TF) approach has been hampered by concerns of increased radiation exposure—a subject of considerable debate within the field. We performed a patient‐level, multi‐center analysis to definitively address the impact of TR access on radiation exposure. Methods and ResultsOverall, 10 centers were included from 6 countries—Canada (2 centers), United Kingdom (2), Germany (2), Sweden (2), Hungary (1), and The Netherlands (1). We compared the radiation exposure of TR versus TF access using measured dose‐area product (DAP). To account for local variations in equipment and exposure, standardized TR:TF DAP ratios were constructed per center with procedures separated by coronary angiography (CA) and percutaneous coronary intervention (PCI). Among 57 326 procedures, we demonstrated increased radiation exposure with the TR versus TF approach, particularly in the CA cohort across all centers (weighted‐average ratios: CA, 1.15; PCI, 1.05). However, this was mitigated by increasing TR experience in the PCI cohort across all centers (r=−0.8; P=0.005). Over time, as a center transitioned to increasing TR experience (r=0.9; P=0.001), a concomitant decrease in radiation exposure occurred (r=−0.8; P=0.006). Ultimately, when a center's balance of TR to TF procedures approaches 50%, the resultant radiation exposure was equivalent. ConclusionsThe TR approach is associated with a modest increase in patient radiation exposure. However, this increase is eliminated when the TR and TF approaches are used with equal frequency—a guiding principle for centers adopting the TR approach.

Introduction: Private sector engagement is recognized as one of the most critical interventions to achieve the End TB goals in India. We conducted a systematic review and a meta-synthesis of qualitative studies to identify the barriers and facilitators for private sector engagement in TB care in India., Methods: A systematic search in electronic databases was done. We assessed the methodological limitations of individual studies, synthesized the evidence using thematic analysis, and assessed our confidence in each finding., Results: Of the 19 eligible articles included for the qualitative synthesis, 31.5% (6/19) were conducted in northern states of India. Included studies had details from 31 focus group discussions and 303 in-depth interviews conducted among various stakeholders. The synthesis revealed that barriers to engaging the private sector were lack of coordination mechanisms, lack of the National TB Elimination Program (NTEP) staff capacity to deal with the private sector, lack of private practitioners' knowledge on various programmatic aspects, and perceived complexity of the data exchange mechanism. The private sector felt that NTEP was not sensitive to the patient's confidentiality and demanded too much patient data. The private sector considered nonfinancial incentives like recognition, feedback, involving them in planning, and giving them equal status in partnership as powerful enablers for their engagement in TB care., Conclusion: Factors related to the context in which the engagement occurs, the architecture of the engagement, and interaction among the actors contribute to barriers to engaging the private sector for TB care in India. Strengthening policies to protect patient confidentiality, using behavior change communication to NTEP program managers, providing managerial and soft-skill training to NTEP staff, promoting nonfinancial incentives to private providers, establishing a coordination mechanism between the sectors, and simplifying the data exchange mechanisms need to be done to further strengthen the private-sector engagement., (© Rakesh PS et al.)

Community-based active TB case finding (ACF) has become an essential part of TB elimination efforts in high-burden settings. In settings such as the state of Kerala in India, which has reported an annual decline of 7.5% in the estimated TB incidence since 2015, if ACF is not well targeted, it may end up with a less-than-desired yield, the wastage of scarce resources, and the burdening of health systems. Program managers have recognized the need to optimize resources and workloads, while maximizing the yield, when implementing ACF. We developed and implemented the concept of 'individuals'-vulnerability-based active surveillance' as a substitute for the blanket approach for population/geography-based ACF for TB. Weighted scores, based on an estimate of relative risk, were assigned to reflect the TB vulnerabilities of individuals. Vulnerability data for 22,042,168 individuals were available to the primary healthcare team. Individuals with higher cumulative vulnerability scores were targeted for serial ACF from 2019 onwards. In 2018, when a population-based ACF was conducted, the number needed to screen to diagnose one microbiologically confirmed pulmonary TB case was 3772 and the number needed to test to obtain one microbiologically confirmed pulmonary TB case was 112. The corresponding figures in 2019 for individuals'-vulnerability-based ACF were 881 and 39, respectively. Individuals'-vulnerability-based active surveillance is proposed here as a practical solution to improve health system efficiency in settings where the population is relatively stationary, the TB disease burden is low, and the health system is strong.

Background: A robust disaggregated understanding of the determinants of tuberculosis (TB) in each local setting is essential for effective health system and policy action to control TB., Objectives: The objective of the study was to identify population attributable risk (PAR) for TB disease based on the locally available evidences for Kerala, India., Methods: Systematic review was done for risk factors of TB in the state. The second set of searches was done to understand the prevalence of the identified risk factors in general population in Kerala. With all available studies and reports, an expert group consensus was made to finalize state-specific prevalence of risk factors. Population attributable fractions were calculated for identified risk factors., Results: PAR for TB disease in Kerala obtained was 24% for undernutrition, 15% for diabetes, 15% for tobacco use, and 1% for HIV., Conclusion: Kerala state's PAR for TB was comparatively lower for HIV but higher for diabetes mellitus. Similar exercises for summarizing population risk factors need to happen at all states for making plans to effectively combat TB., Competing Interests: There are no conflicts of interest., (Copyright: © 2020 Indian Journal of Community Medicine.)

Introduction: Factors associated with tuberculosis (TB) in Kerala, the southern Indian state that notifies approximately 33 microbiologically confirmed new cases per 100,000 population every year for the past two decades, are still unclear. We did a community-based case-control study in Kollam district, Kerala, to identify the individual-level risk factors for TB., Methods: Structured questionnaire was applied to 101 microbiologically confirmed new TB cases registered under Revised National Tuberculosis Control Program and 202 age- and gender-matched neighborhood controls without present or past TB. Information was sought on socioeconomic status (SES), smoking, consumption of alcohol, close contact with active TB during childhood or recent past, diabetes mellitus (DM), and other comorbid conditions., Results: Close contact with TB during childhood [odds ratio (OR) 15.88, 95% confidence interval (CI) 3.21-78.55], recent close contact with TB (OR 4.81, 95% CI 2.09-11.07), DM (OR 1.64, 95% CI 1.04-3.06), SES (OR 2.16, 95% CI 1.16-4.03), smoking more than 10 cigarettes/beedis per day (OR 3.32, 95% CI 1.27-8.96), consuming more than 10 standard drinks per week (OR 2.91, 95% CI 1.33-6.37), and the interaction term of having close contact with TB during childhood and DM at present (OR 7.37, 95% CI 1.18-50.29) were found to be associated with TB., Conclusion: Close contact with a case of TB, presence of DM, lower SES, smoking, and alcohol consumption were associated with active TB in Kollam. Having close contact with a case of TB during childhood and development of DM in later life together are significantly associated with active TB in the study population. The findings also direct further studies to confirm and explore mechanisms of interaction of diabetes with childhood exposure to TB., Competing Interests: There are no conflicts of interest.

Polymicrobial bacterial infection is an important factor contributing to wound chronicity. Consequently, clinicians frequently adopt a biofilm-based wound care approach, in which wounds are treated utilizing DNA sequencing information about microbial communities. While more successful than treatment not using community information, there is little information about temporal dynamics of wound communities and optimal approaches over the course of treatment. To characterize these dynamics, temporal analysis over three sampling points was conducted for 167 chronic wounds. Across sampling intervals, wound communities from the same patients changed in composition, and most commonly shared less than 50% of observed species. There was a significant relationship between community similarity and time between sampling. Classifying wounds into state types, we found that communities frequently transitioned from Pseudomonas or Staphylococcus dominated, into a highly variable state type. Although low abundance microbial species are typically disregarded due to uncertainty of biological importance, we found that 80% of wound microbiomes included common or dominant species at subsequent time points that were in low abundance in earlier samples. Moreover, these species were often those known to frequently infect wounds. Results document compositional shifts through the course of treatment and suggest that routine consideration of low abundance species may improve biofilm-based wound care. Moreover, findings indicate that integrating ecological modeling to understand wound microbiome succession may lead to more informed therapy., (© 2017 by the Wound Healing Society.)