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What The Study Did: Personal protection is often cited as a reason for owning a firearm. Researchers in this study looked at 647 firearm deaths that occurred in homes in King County, Washington, from 2011 to 2018 and whether they were indicated as suicide, criminal homicide, self-defense homicide, unintentional or undetermined.

Authors: Elissa K. Butler, M.D., of the University of Washington in Seattle, is the corresponding author.

To access the embargoed study: Visit our For The Media website at this link https://media.jamanetwork.com/

(doi:10.1001/jamainternmed.2020.0806)

Editor's Note: The article includes conflict of interest disclosures. Please see the article for additional information, including other authors, author contributions and affiliations, conflicts of interest and financial disclosures, and funding and support.

What The Study Did: This observational study pooled data from five study groups to examine whether  cumulative blood pressure levels might explain racial differences in risk for cognitive decline later in life.

Authors: Deborah A. Levine, M.D., M.P.H., of the University of Michigan in Ann Arbor, is the corresponding author.

To access the embargoed study: Visit our For The Media website at this link https://media.jamanetwork.com/

(doi:10.1001/jamaneurol.2020.0568)

Editor's Note: The article includes conflict of interest and funding/support disclosures. Please see the article for additional information, including other authors, author contributions and affiliations, conflicts of interest and financial disclosures, and funding and support.

Current medical guidelines for diagnosing cow's milk allergy in babies and young children may be linked to overdiagnosis of the condition.

This is the finding of a new analysis from Imperial College London and Sechenov University in Moscow.

In the paper, a review published in the journal JAMA Pediatrics, the team found that around 1 per cent of children have cow's milk allergy, but up to 14 per cent of families believe their child to have the condition.

The team point to official guidelines for detecting cow's milk allergy as a possible cause for the overdiagnosis.

The researchers analysed nine official guidelines for cow's milk allergy published between 2012 and 2019.

These guidelines were from a range of medical organisations in a number of countries, predominantly in Europe. The team found that many of the guidelines named symptoms such as excessive crying, regurgitating milk and loose stools as indications of cow's milk allergy - but the authors argue that these symptoms are very common in normal, healthy babies.

The team found that in a recent European birth cohort study following over 12,000 infants in nine countries, less than 1 per cent of infants had cow's milk allergy. However, they also found that in some studies up to 14 per cent of families believe their infant has a cow's milk allergy.

In addition to this, the analysis suggests the prescription of specialist formulas for babies with cow's milk allergy had increased significantly between 2000 and 2018 in countries such as Australia and England, without any evidence for an increase in cow's milk allergy.

The team analysed the number of authors of the guidelines who had declared a conflict of interest with formula manufacturers, and found eight out of ten of all guideline authors reported a conflict of interest.

The team also found seven of the nine guidelines advised breast-feeding women to cut out all dairy from their diet if their child has a suspected cow's milk allergy. However, their analysis of 13 studies of breastmilk composition suggests less than one millionth of the protein from cow's milk travels through to breast milk, and this would be too small to trigger a reaction in most allergic children.

Dr Robert Boyle, Consultant Allergy Specialist and lead author of the research from Imperial's National Heart and Lung Institute, explained: "Many infants who are labelled as having milk allergy don't have the condition. Having a child with suspected milk allergy can be a stressful time for any family. Misdiagnosing milk allergy could lead to another condition with similar symptoms being missed, or breast-feeding mothers needlessly following restricted diets - or even stopping breast-feeding altogether. It can also lead to families and the NHS unnecessarily paying for expensive specialist formula."

Milk allergy is most common in children under two, and is categorised into two different types - IgE mediated, and non-IgE mediated. In IgE mediated, a reaction involves a component of the immune system, called IgE, and symptoms including vomiting, hives and in very rare cases, a severe reaction that causes difficulty breathing, called anaphylaxis.

The symptoms of non-IgE mediated reactions may include vomiting, diarrhoea or excessive crying. However, the team point out that the nature of these symptoms means they are often confused with normal symptoms in young babies.

Dr Daniel Munblit, Associate Professor of Paediatrics from Sechenov University and first author of the paper, explained: "In the nine guidelines we studied, seven of them suggested including milder symptoms as indication of non-IgE cow's milk allergy, such as regurgitating milk, crying and rashes - but many of these symptoms are present normally in babies, and will get better with time. Non-IgE cow's milk allergy affects less than 1 per cent of infants whereas troublesome vomiting, crying or eczema each affect 15-20 per cent of babies."

The team analysed data on the amount of a type of cow's milk protein known to trigger allergic reactions, called betalactoglobulin. Their analysis revealed that the amount of this protein in breast milk was just micrograms (millionths of a gram) per litre. The team also calculated that this amount is too low to trigger a reaction through breastfeeding for over 99 per cent of children with cow's milk allergy.

The team also found that three guidelines were directly supported by formula manufacturers or marketing consultants, and 81 per cent of all guideline authors reported a conflict of interest with formula manufacturers. A conflict of interest means receiving funding from a company that could make a profit from the advice included in the guideline.

Dr Boyle explained: "Formula manufacturers may gain from promoting increased cow's milk allergy diagnosis - by influencing practitioners and parents to use a specialised formula in place of a cheaper formula, and by potentially undermining women's confidence in breastfeeding, so that specialised formula is used in place of breastmilk. "

He added: "We must not only critically appraise our current guidelines, and dissociate the development of guidelines from those who may profit from them, but also ensure we are giving each family the best possible care by avoiding overdiagnosis of cow's milk allergy."

What The Study Did: Researchers examined changes in the use of mental health and human services among children in Allegheny County, Pennsylvania, following the unexpected death of a parent because of an opioid-related overdose between 2002 and 2017.

Authors: Eric G. Hulsey, Dr.P.H., M.A., of the Allegheny County Department of Human Services, Pittsburgh, is the corresponding author.

To access the embargoed study: Visit our For The Media website at this link https://media.jamanetwork.com/

(doi:10.1001/jamapediatrics.2020.0613)

Editor's Note: Please see the article for additional information, including other authors, author contributions and affiliations, conflicts of interest and financial disclosures, and funding and support.

A nightly jaunt on the exercise wheel enhances muscle-repair capabilities in old mice, according to a new study by researchers at Stanford School of Medicine.

Only older mice saw this benefit, which the researchers found is due to the rejuvenation of the animals' muscle stem cells.

"The effect in old animals is very significant," said Thomas Rando, MD, PhD, professor of neurology and neurological sciences and director of Stanford's Glenn Center for the Biology of Aging. "We found that regular exercise restores youthfulness to tissue repair. Their muscle stem cells start to look and behave like those of much younger animals."

The researchers also identified a molecular pathway involved in turning back the clock on the cells. Drugs that manipulate the pathway might be an effective substitute for exercise, they suggest.

Rando is the senior author of the study, which will be published April 13 in Nature Metabolism. Medical student Jamie Brett, PhD, postdoctoral scholar Marina Arjona, PhD, and visiting scholar Mika Ikeda, PhD, are the lead authors.

Unlike embryonic or induced pluripotent stem cells, which can give rise to any tissue in the body, tissue-specific stem cells are restricted in their potential. Muscle stem cells wait in the wings along the muscle fibers in a resting state known as quiescence until called upon to repair damage.

"Studies conducted by us and others have shown that tissue regeneration decreases with age, and that this is due to declining function in adult stem cells," Rando said. "Many researchers are looking for a way to restore youthfulness."

Benefits of lifestyle adjustments

While no researchers have discovered a reliable fountain of youth, it's well known that certain lifestyle adjustments can be beneficial.

"Exercise is known to reduce the risk of a wide variety of age-related problems, including cardiovascular disease, cancer and perhaps even Alzheimer's disease," Rando said. "There's a lot of interest in understanding how exercise confers these health benefits."

In particular, the researchers wanted to know whether and how voluntary exercise affects the function of muscle stem cells in mice. They gave mice that were about 20 months old, the equivalent of being 60-70 years old in humans, and mice that were 3 to 4 months old, the equivalent of 20- to 30-year-old humans, access to an exercise wheel and allowed them to run at will. Young mice averaged about 10 kilometers each night, and the older mice covered about 5 kilometers. Two other groups of young and old mice were given wheels that didn't rotate to serve as controls.

"The animals were exercising at the intensity levels at which they were comfortable," Rando said, "much like what people do for their own health. This is a less stressful situation than resistance training or intense endurance exercise, which may themselves affect muscle stem cell function." Subsequent analysis showed that the muscle stem cells of the exercising animals remained quiescent, and that the animals did not develop significant numbers of new muscle fibers in response to the exercise.

After three weeks of nightly aerobics for the active groups, the researchers compared the ability of the animals to repair muscle damage. They found that, as expected, the aged, sedentary mice were significantly less able to repair muscle damage than younger sedentary mice. However, the older animals that had exercised regularly were significantly better at repairing muscle damage than were their counterparts that did not exercise. This exercise benefit was not observed in the younger animals.

Similar results were obtained when muscle stem cells from older mice that had exercised were transplanted into younger mice. The stem cells from the exercising animals contributed more to the repair process than did those from their sedentary peers.

Benefit of young blood

The researchers also showed that injecting blood from an old mouse that had exercised into an old mouse that hadn't conferred a similar benefit in stem cell function, suggesting that exercise simulates the production of some factors that then circulate in the blood and enhance the function of older stem cells.

"That's really fascinating," Rando said, noting that the result mirrors those from earlier studies jointly conducted by him and Tony Wyss-Coray, PhD, a professor of neurology and neurological sciences at the School of Medicine, indicating that blood from a young mouse appears to somehow enhance the tissue-specific stem cells in an older animal.

Further studies indicated that the exercise-induced rejuvenation observed by the researchers could be mimicked by increasing the expression of a signaling molecule called cyclin D1, which is involved in rousing resting muscle stem cells in response to damage. The discovery suggests that it may one day be possible to artificially activate this pathway to keep aging muscle stem cells functioning at their youthful best.

"If we could develop a drug that mimics this effect, we may be able to experience the benefit without having to do months of exercise," Rando said.

Researchers from The Royal Women's Hospital, Melbourne, Monash University and the Alfred Hospital, Melbourne, have achieved a world-first breakthrough in ventilator splitting.

For the first time, researchers tested, in a simulated environment, the potential to ventilate two lungs of different compliances from a single ventilator using only commonly available hospital equipment.

The authors do not condone the practice of ventilator splitting and say the findings must be applied with caution.

The COVID-19 pandemic has led to a worldwide shortage of ventilators.

A world-first breakthrough by Australian researchers in ventilator splitting could help hospitals under severe stress as the number of critical COVID-19 cases continues to rise.

For the first time, researchers have successfully tested, in a simulated environment, the potential to ventilate two lungs of different compliances from a single ventilator.

While the authors do not condone the practice of ventilator splitting and say the findings must be interpreted and applied with caution, the experiments demonstrate the hope of simultaneously ventilating two test lungs of different compliances - using only standard hospital equipment - and modify the pressure, flow and volume of air in each lung, in case of extreme emergencies.

The COVID-19 pandemic has led to a worldwide shortage of ventilators. The worst affected parts of the globe are already experiencing serious shortages of ventilators, which are needed desperately to treat the failing lungs of seriously ill COVID-19 patients.

The study, published in the international journal Anaesthesia, is led by Dr Alexander Clarke from the Department of Anaesthesia at The Royal Women's Hospital in Melbourne, and Dr Shaun Gregory from the Department of Mechanical and Aerospace Engineering at Monash University.

Dr Andrew Stephens and Dr Sam Liao (Faculty of Engineering, Monash University) and Dr Timothy Byrne (Department of Intensive Care and Hyperbaric Medicine, Alfred Hospital, Melbourne) supported this investigation.

"Patients with COVID-19 may develop progressive viral pneumonitis leading to severe respiratory failure. The combination of unprecedented disease burden and global supply chain disruption has resulted in worldwide shortages of medical equipment," Dr Clarke said.

"Despite our advances in the practical application of ventilator splitting, the practice is unregulated and under tested. But as the COVID-19 pandemic continues to grow, some countries, like the USA, may consider ventilator splitting on compassionate grounds. The United States of America Food and Drug Administration has passed emergency use authorisation for the splitting of ventilators.

"While ventilator splitting has, at face value, validity in addressing ventilator shortages, we agree that on sober reflection, it is a solution that needs to be weighed up carefully as it may cause more harm than good."

The basic principle of ventilator splitting is simple - two or more patients are connected to one ventilator and both are exposed to the same circuit dynamics.

This presents many challenges including ventilator and patient synchronicity - ventilation requirements are different for a 100kg male and a 50kg female, cross-infection from inter-patient gas exchange, oxygen concentration, and the lack of monitoring for individual tidal volume, flow and pressure. Irregularly pressurised air supply can kill patients.

To counter this, researchers connected a flow restrictor apparatus, which consisted of a Hoffman clamp and tracheal tube, to the inspiratory limb of the ventilator to the high compliance test lungs.

The breathing circuit ran from the humidifier to a hospital-commodity Y-connector splitter. From the splitter, two identical limbs were created, simulating the ventilation of two pairs of patient lungs. The resistance was modified to achieve end-tidal volumes of 500ml ± 20mL.

The addition of the flow restrictor was critical to the way this setup works - without the restrictor, the researchers weren't able to control air flow to each simulated patient, Dr Gregory said.

While the research findings are exciting for crisis and trauma medicine, Dr Gregory says they need to be interpreted and applied with caution.

"Our experiment has demonstrated that in order to deliver a safe tidal volume and airway pressure, a resistance mechanism is required on at least one inspiratory limb of the circuit. One way of achieving this is through the use of a tracheal tube and Hoffman clamp - common, practical items found in hospitals," Dr Gregory said.

"While the discovery is promising, the use of this method in the clinical context has not been validated and we don't recommend its wider use without further trials. We are hopeful of one day being able to get great surety with this approach to ventilator splitting so we can help save lives in dire cases of emergency."

Skoltech scientists and their colleagues proposed a way to simplify the search for traces of medicines, narcotic substances and sports doping drugs in human biological samples by performing two additional tests with the search domain reduced tenfold.

Scientists determine the chemical composition of a substance using mass spectrometry: as neutral molecules and atoms turn into charged ions, the mass spectrum, i.e. the components' relative masses in the mixture, is determined based on the ions' trajectories in the electromagnetic field. Mass spectrometry helps detect anabolics, diuretics and even artificial testosterone.

The mass spectrum is only half the battle, though. Open-access databases of chemical compounds, such as PubChem, contain upwards of 120 million entries. As for mass spectrum databases, they are limited to half a million compounds only. PubChem may deliver several thousand compounds that match the molecular formula reconstructed using the mass spectrum.

Yury Kostyukevich, an associate professor at the Skoltech Center for Computational and Data-Intensive Science and Engineering (CDISE), and his colleagues put forward a method that helps reduce the search space, i.e. the multitude of options to choose from, by a factor of 10, which makes the formidable search task much easier by offering more information on the molecule structure.

The scientists suggested supplementing the standard mass spectrometry routines with two tests exploiting the exchange reactions that involve light and heavy hydrogen and oxygen isotopes (16O and 18O). The test results shed light on the molecule structure and serve as a filter in selecting suitable compounds.

The scientists tested their method on methylenedioxypyrovalerone (MDPV), a stimulant listed among controlled narcotic drugs, psychotropic substances and their precursors according to Russian law. MDPV is perfectly suitable for the purpose, since its formula, C16H21NO3, delivers 19,337 matches, of which only seven compounds have ready mass spectra. The two fairly simple tests proposed by the authors reduce the search domain by 13 times, limiting it to 1,515 molecules. According to Kostyukevich, only a small fraction of them are of biological origin, which makes things much easier.

The idea behind the new method will work even for previously unknown types of doping. "Our tests help detect a substance that other athletes do not have in their samples and see what the compound looks like. Then it will be up to sports physicians to figure out if the athlete took an illegal drug or had some exotic food the previous day," Kostyukevish explained.

In 2000, the measles virus was declared eliminated from the United States. Despite cases coming in from outside the country, there were few outbreaks because most people were vaccinated against measles. And then 2019 happened.

The U.S. saw 1,282 confirmed cases in 31 states - the greatest number reported since 1992, with nearly three-fourths linked to recent outbreaks in New York, according to the Centers for Disease Control and Prevention. Most cases were among people who were not vaccinated against measles.

After events like this, many people express confusion about others' hesitancy or unwillingness to get vaccinated or to vaccinate their children, a concept called vaccine skepticism. As vaccine skepticism has become increasingly widespread, two researchers in the Texas Tech University Department of Psychological Sciences have suggested a possible explanation.

In an article published recently in the journal Vaccine, Mark LaCour and Tyler Davis suggest some people find vaccines risky because they overestimate the likelihood of negative events, particularly those that are rare.

The fact that these overestimations carry over through all kinds of negative events - not just those related to vaccines - suggests that people higher in vaccine skepticism actually may process information differently than people lower in vaccine skepticism, said Davis, an associate professor of experimental psychology and director of the Caprock FMRI Laboratory.

"We might have assumed that people who are high in vaccine skepticism would have overestimated the likelihood of negative vaccine-related events, but it is more surprising that this is true for negative, mortality-related events as a broader category," Davis said. "Here we saw an overestimation of rare events for things that don't have anything to do with vaccination. This suggests that there are basic cognitive or affective variables that influence vaccine skepticism."

In their first experiment, LaCour and Davis surveyed 158 participants to determine the level of vaccine skepticism underlying their perceived dangers, feelings of powerlessness, disillusionment and trust in authorities regarding vaccines. Participants then estimated the frequency of death associated with 40 different causes, ranging from cancers, animal bites and childbirth to fireworks, flooding and car accidents. LaCour and Davis found that people higher in vaccine skepticism were less accurate in their estimations of how frequently these causes of death occur. Specifically, they found that higher vaccine skepticism was associated with an overestimation of rare events.

The second experiment followed the same procedures as the first, but participants additionally estimated the frequency of neutral or positive events - such as papal visits to the United States, triplet births or Willie Nelson concerts - to test whether the negative tone of mortality statistics may play a role. LaCour and Davis found that people higher in vaccine skepticism were less accurate in their estimations of mortality-related events and overestimated the negative events more than the neutral/positive events.

"My takeaway is that vaccine skeptics probably don't have the best understanding of how likely or probable different events are," said LaCour, a doctoral student in psychological sciences. "They might be more easily swayed by anecdotal horror stories. For example, your child can have a seizure from getting vaccinated. It's extremely rare, but it is within the realm of possibility. If you were so inclined, you could follow Facebook groups that publicize extremely rare events. These cognitive distortions of anecdotes into trends are probably exacerbated by decisions to subscribe to statistically non-representative information sources."

While the researchers didn't find an association between a person's education level and their vaccine skepticism, LaCour and Davis believe there is a difference in the information being consumed and used by people higher in vaccine skepticism.

"It may be the case that they are specifically seeking out biased information, for example, to confirm their skeptical beliefs," Davis said. "It could be that they have more of an attentional bias to negative, mortality-related events, which makes them remember this information better. Strategies to get the right information to people through public service announcements or formal education may work, but it doesn't seem to be an issue that people with higher vaccine skepticism are less educated in any fundamental way in terms of basic science or math education. Thus, simple increases in these alone - without targeted informational interventions - would seem unlikely to help."

As LaCour noted, these results leave open many new avenues for further research.

"Do some people encode scary stories - for instance, hearing about a child that has a seizure after getting vaccinated - more strongly than others and then consequently remember these anecdotes more easily?" he asked. "Do they instead have certain attitudes and search their memory harder for evidence to support this belief? Is it a bit of both? How can you counteract these processes?

"I'm excited that we're finding basic, cognitive factors that are linked with vaccine skepticism: It could end up being a way of reaching this diverse group."

New Rochelle, NY, April 9, 2020--In a new commentary, Alison Stuebe, MD, President of the Academy of Breastfeeding Medicine, addresses the risks and benefits of separating infants from COVID-19-positive mothers following birth. Although multiple public health organizations recommended keeping mothers and infants together, the United States' Centers for Disease Control and Prevention advises facilities to consider separating mothers and babies temporarily until the mother is no longer contagious, and recommends that the risks and benefits of temporary separation should be discussed with the mother by the healthcare team.

In her commentary, Dr. Stuebe, Professor of Obstetrics and Gynecology at the University of North Carolina School of Medicine and distinguished professor in infant and young child feeding at the Carolina Global Breastfeeding Institute at the UNC Gillings School of Global Public Health, notes that there is no evidence to show that early separation of infants and mothers with suspected or confirmed COVID-19 improves outcomes. While separation may minimize the risk of transmission of the virus from mother to infant during the hospital stay, it has potential negative consequences for both mother and infant, according to the commentary published in Breastfeeding Medicine, the official journal of the Academy of Breastfeeding Medicine published by Mary Ann Liebert, Inc., publishers. Click here to read the protocol free on the Breastfeeding Medicine website.

Dr. Stuebe outlines several risks of separating mothers and infants in the hospital, which disrupts breastfeeding and skin-to-skin contact during the critical hours and days following birth. For example, infants who lack skin-to-skin contact with their mothers tend to have higher heart rates and respiratory rates and lower glucose levels. The separation also stresses the mother, which could make it more difficult for her to fight off the viral infection. In addition, separation interferes with the provision of maternal milk to the infant, which is important for the development of the infant's immune system. Separation also disrupts breastfeeding, which puts the infant at increased risk of severe respiratory infections, including pneumonia and COVID-19.

"As we navigate the COVID-19 pandemic," Stuebe writes, "I am hopeful that we can center mothers and babies and remember to first do no harm."

Arthur I. Eidelman, MD, Editor-in-Chief of Breastfeeding Medicine, concurs that "there is no need or indication to categorically separate infants from COVID-19 suspect or positive mothers other than in circumstances wherein the mother's medical condition precludes her caring for the infant. Feeding mothers' own breast milk, either by nursing or by feeding of expressed milk, is OK and desired!"

A new survey of people who inject illicit drugs in the state of Washington yields positive and important findings for policy makers as the world struggles to deal with the COVID-19 pandemic, said authors of the survey by the University of Washington and Public Health-Seattle & King County.

Most people - 82% ¬- who inject heroin and roughly half of methamphetamine users are interested in reducing or stopping their use and are open to a broad array of services to help them manage their substance use, according to the 2019 Syringe Exchange Health Survey led by UW's Alcohol & Drug Abuse Institute and Public Health-Seattle & King County.

The latest results of the survey, which has been conducted every two years since 2015, also show that possession of naloxone -- a drug that rapidly reverses opioid overdose -- has increased substantially. Researchers found that nearly 80% of respondents in King County and outside the county who use opioids possessed a naloxone kit in 2019, compared to 2015 when only 47% in King County and 24% outside the county possessed naloxone.

"These surveys provide important insights into the complex lives of people who use drugs in our state and can be used to inform our health care, public health, social service, public policy and criminal legal system responses, particularly during and after the COVID-19 pandemic," said study co-author Caleb Banta-Green, principal research scientist at the institute.

During the COVID-19 crisis, syringe exchanges continue to operate across Washington State, although programs have had to substantially modify how they deliver services, including distributing pre-packaged supplies, moving outdoors and providing mobile and delivery services.

Public Health-Seattle & King County is also offering screening and COVID-19 testing at the Robert Clewis Center, Downtown Public Health, Monday through Friday from 1 to 4 p.m. (one of the sites participating in the survey). At other syringe-services program locations, providers are asking COVID-19 screening questions and providing information about testing locations and other resources, public health officials said.

"People who inject drugs, and also smoke them, are at high risk for contracting and having serious consequences of COVID-19 and already use emergency health care resources at high rates," said Banta-Green.

Consequently, access to syringe services - which distribute clean syringes and help to reduce the risk of contracting or transmitting infectious diseases - during this crisis can help alleviate pressure for emergency medical care while also helping this at-risk population get treatment to reduce or stop their drug use.

"This report confirms that the majority of persons who inject drugs are interested in reducing or stopping their drug use and improving their health," said Dr. Jeff Duchin, Health Officer at Public Health-Seattle & King County. "The syringe exchange provides an important entry point and ongoing resources to help connect people to treatment when they are ready."

For instance, programs such as Public Health-Seattle & King County's Buprenorphine Pathways provides access to treatment co-located with needle exchange. The program lowers barriers to treatment safely and successfully.

Another important finding in the survey, Banta-Green pointed out, is that 68% of participants who have been diagnosed with hepatitis C remain untreated and were interested in treatment for that disease, which is good news since hepatitis C can be cured with a three-month course of medication.

"We are honored to work with our syringe-services partners across Washington state to better understand how we can best serve people who use drugs," said Banta-Green. "It's so important to understand that people are very interested in getting help, and that syringe exchanges provide an incredible array of life-saving services. They also provide ongoing personal relationships with members of our communities who are often in personal crisis and poor health."

CHICAGO (April 10, 2020): Major metropolitan areas such as New York, Seattle, and Detroit have dominated news of the COVID-19 outbreak, but rural hospitals and health care systems must also prepare for a surge of coronavirus patients. Surgeons at one rural health care system on both sides of the New York-Pennsylvania border have reported on their preparedness response plan for dealing with the COVID-19 surge in an "article in press" appearing on the website of the Journal of the American College of Surgeons ahead of print. This rural surgery plan takes into account challenges unique to a rural population and geography, and it includes greater utilization of telehealth and coordination of resources and communications at affiliated centers spread over a large geographic area.

"We have an older patient population, and they have more comorbid conditions than what you might find in an urban area," said Jean Miner, MD, MHA, MMEL, FACS, a general surgeon at Guthrie Clinic/Robert Packer Hospital in Sayre, Pa., and article coauthor. "Our population is also very spread out, with about 77 people per square mile, and some of the research shows that up to 35 percent of the people in rural areas don't have Internet access. Some of our staff doesn't even have Internet access." By comparison, New York City has about 27,500 people per square mile.
Robert Packer Hospital is a 267-bed tertiary care teaching hospital in Sayre, a town of about 5,400 people, 270 miles northwest of New York City. It is the primary institution of the Guthrie Clinic, a nonprofit system of five hospitals that serves an area of about 770,000 people in 12 counties in northern Pennsylvania and the southern tier of New York State.
"Our older patients are at risk of not only complications from COVID-19 and the higher mortality rates, but also have chronic diseases that we must also take care of to try to keep them out of the hospital at this time," Dr. Miner said.

Key components of the preparedness plan include:

Implementation of a screening process for visitors and employees (which began in early February) and tightening that process as more information about the coronavirus became available
Having nonessential staff work at home before such a mandate was in place from governors in either state
Conserving personal protective equipment (PPE)
Postponing elective procedures
Having a contingency plan to redeploy a pool of volunteer physicians and advanced practitioners to cover areas where they're needed during a surge of COVID-19 patients

A centerpiece of the response plan is a rapid expansion of telehealth. Like many health systems, Guthrie Clinic has limited the number of in-person clinic visits. With the recent approval for telehealth expansion by the Centers for Medicare and Medicaid Services, Guthrie Clinic saw its number of providers participating in telehealth soar from 12 before the COVID-19 outbreak to 252 providers performing remote office visits and 450 having access to the platform after the outbreak began.

The telehealth system works despite the limits of Internet access in rural areas, explained coauthor Burt Cagir, MD, FACS, a general surgeon. Most outpatient clinics within the system have telehealth kiosks, and the system is flexible to fit each patient's needs. "We allow all of our patients to communicate with any and every modality available to them, such as cellphones so they're able to do video conferencing," he said. Landline telephone calls are also handled and documented in patient records. The system now has the capability to do 1,000 video visits daily, he said.

Another important element of the response plan is what Dr. Cagir called "the patient safety huddle" first introduced in 2016. Senior leadership staff meets for a half hour each weekday morning to review patient safety issues. By 2018 a second huddle was added to identify trends from the previous day or week and to extrapolate forecasts for the next day or week. "We converted our forecasting and trend huddle to a COVID-19 huddle immediately in February, and the patient safety huddle system became the patient safety and personnel safety huddle," Dr. Cagir said. Huddles were added for Saturday and Sunday.

Dr. Miner explained the huddle works on four staffing levels: front-line, department, hospital, and systemwide.

Joseph Scopelliti, MD, a gastroenterologist and president of Guthrie Clinic, explained that for the huddles to work effectively, they must be blame-free zones. "It means that everybody has to expose their challenges, so the second series of huddles we have every day is the patient safety huddle," he said. "Think of it as the huddle where you have to answer the question, 'What is impeding you from doing your job today?'"

Dr. Cagir explained that the processes the Guthrie Clinic adopted were developed using the Lean Six Sigma and the PDCA cycle (for plan, do, check, act) principles that industry has used to improve efficiency and quality.

"Without a doubt this approach is scalable to every urban and rural center," Dr. Miner said. "Frequent communication has been key." She noted that staff gets a daily e-mail with that day's news, trends and expectations and that there are multiple ways staff can exchange ideas, including a Workplace from Facebook portal.

Researchers pushing the limits of magnets as a means to create faster electronics published their proof of concept findings today, April 10, in the journal Science.

The University of Central Florida is the lead university in the multidisciplinary university research initiative (MURI) project, which is funded by a $7.5 million grant from the Department of Defense. The team exploring methods for creating machines that operate at trillions of cycles per second includes the University of California, Santa Cruz and Riverside, Ohio State University, Oakland University (Michigan) and New York University, among others.

Today's computers rely on ferromagnets (the same kind that stick to your refrigerator) to align the binary 1s and 0s that process and store information. Anti-ferromagnets are much more powerful, but their natural state, displaying no net measurable magnetization, makes it difficult to harness their power.

The laboratory of Enrique del Barco, Ph.D., and collaborators at the University of California, the National High Magnetic Field Laboratory, the Norwegian University of Science and Technology and the Chinese Northeastern University are successfully overcoming that natural resistance using electrical currents passed through anti-ferromagnets on the nanoscale. The results are groundbreaking because they represent proof of concept showing that antiferromagnetic devices can operate on the terahertz level -- or calculations completed in a trillionth of a second. Not only does that hold potential for everything from guidance systems to communications, but it brings devices closer to mimicking the way the brain operates.

"What we're seeing now is that operating at this level is possible and doable," del Barco said.

The next steps will require close collaboration between the theory, experiment and materials groups within the MURI. Creating devices on the nanoscale (with lateral dimensions below half a micron) takes a fundamental understanding of the appropriate materials. Both theoretical and experimental study will follow this proof of concept with the intention of finding creative ways to scale down anti-ferromagnets.

CHICAGO (April 10, 2020): As the number of people infected with Coronavirus Disease 2019 (COVID-19) rises in the U.S. and around the world, hospitals are faced with difficult decisions for how to best provide care for a growing number of patients. The lessons learned by a small military surgical team who had to transition into a pandemic response team during the COVID-19 pandemic can offer insights for medical centers around the U.S. that are adapting in a rapidly changing environment. The medical team's recommendations are published as the "article in press" on the website of the Journal of the American College of Surgeons ahead of print.

The surgical team is based in a remote region of Africa. They provide care for the active duty military population stationed there, which the authors describe as young and healthy, but supported by civilian personnel of various ages.

"The team members were trained and equipped for damage control resuscitation and surgery. No one had hands on experience with pandemics at home, so rifling through information for truths to familiarize ourselves was time consuming," said lead author MAJ Andrew Hall, MD, FACS, Special Operations Command Africa, speaking for the team. "We cannot do many proposed cutting-edge therapies but have to rely on tried medical principles. We have many supply chain challenges that need to be factored in when planning a response."

Military medical teams are typically focused on treating traumatic injuries and performing damage control surgery. As the threat of the COVID-19 pandemic grew, the team--consisting of a surgeon, an emergency medicine physician, a certified nurse anesthetist, an intensive care nurse, a scrub technician, and a medical planner--transitioned into an infectious disease containment and treatment team.

"This transition to a new primary medical mission in the face of a pandemic is applicable to any small medical team tasked with taking care of isolated populations," the authors write.

The COVID-19 pandemic has created a situation where even in places where health care resources are typically abundant, hospitals are being forced to come up with creative solutions to provide care for the increasing number of critically ill patients with COVID-19 requiring medical treatment. Medical teams providing care around the world in regions that do not have abundant resources are used to adapting in innovative ways.

"It is essential to evaluate everyone's skillsets and experience. It is not just the doctors. Everyone can have valuable skills to rely on," Dr. Hall said.

Dr. Hall's team was working with an isolated population, which presents its own unique set of challenges. During times of crisis, he said it's important to learn to rely on non-medical labor to provide medical interventions. Specifically, he said things like refilling oxygen tanks can be done by non-medical providers. The tanks can be moved out of contaminated areas to be picked up and refilled, then brought back by non-medical personnel. He also said checks to ensure adequate lighting, temperature controls, and electrical outlets in the tents should be done. "Consider alternate sources for materials. For example, our metal fabricators made ICU beds out of spare materials," he said.

However, he did say, "Thankfully, odds are in a small population's favor in that not many people are going to get deathly ill. You must limit the spread, so those relatively rare events don't statistically become likely. There are definite limitations to our capabilities, and we had to come to grips with those limitations and try to mitigate them as best as possible."

"If possible, exercise plans and processes before they arrive," Dr. Hall said. "If other small teams are dealing with this, the best is all you can do."

Social distancing has Americans mostly out of the places they usually gather and in their homes as we try to reduce the spread of COVID-19. But some buildings, such as hospitals and grocery stores, have to remain open, and at some point, most of us will go back to the office or workplace. What is the role of building design in disease transmission, and can we change how we design the built environment to make it healthier? Those questions are addressed in a review just published in the journal mSystems by David Coil, project scientist, and Professor Jonathan Eisen at the UC Davis Genome Center and School of Medicine; and colleagues at the Biology and the Built Environment Center, University of Oregon.

Among the simplest suggestions for healthier buildings: opening windows to improve air circulation and opening blinds to admit natural daylight.

While more research needs to be done on the effect of sunlight on SARS-CoV-2 indoors, "Daylight exists as a free, widely available resource to building occupants with little downside to its use and many documented positive human health benefits," the authors write.

We spend almost all of our daily lives inside human-built environments whether homes, vehicles or workplaces. Built environments provide lots of opportunities for people to come into contact with viruses and bacteria -- through air flow, from surfaces and also from the way buildings make us interact with each other.

So far, the only documented route of transmission of SARS-CoV-2 is directly from person to person. But viruses also settle on surfaces, which can become heavily contaminated quite quickly. How long SARS-CoV-2 survives on surfaces is still up for debate. Estimates range from a couple of hours to a few days, depending on the material and conditions. Regularly cleaning surfaces and thorough handwashing are important.

Air flow and humidity

Viral particles are too small to be blocked by HEPA and MERV air filters, but ventilation strategies can still play a role in reducing disease transmission, the authors write. Increasing the amount of air flowing in from outside and the rate of air exchange can dilute virus particles indoors. This can include "perimeter ventilation" -- opening a window, when outdoor temperatures allow it. However, high air flow could also stir up settled particles and put them back in the air -- and it also uses more energy.

Virus particles like drier air, so maintaining a high relative humidity can help. Virus-bearing droplets get bigger in humid air, meaning they settle out more quickly and don't travel as far. Humidity also seems to interfere with the lipid envelope around viruses such as SARS-CoV-2. Too much humidity, however, can promote mold growth.

Modern buildings are generally designed to promote social mixing -- from open plan living areas in homes to open offices where many workers share space. By promoting interaction and chance encounters, these layouts are thought to generate more creativity and teamwork. At the same time, they are probably also really great for spreading viruses around.

It may not be practical in the short term to make big changes in office layout. But understanding how layout and the ways people use shared spaces affect disease transmission could help in developing effective social distancing measures and making decisions about when people can go back to work.

Scientists at the Icahn School of Medicine at Mount Sinai have discovered a new role for the brain chemical dopamine that is independent of classic neurotransmission. The new role appears to be critical to changes in gene expression related to chronic exposure to, or abuse of, cocaine, according to a study published Friday, April 10, in the journal Science.

"Our study provides the first evidence of how dopamine can directly impact drug-induced gene expression abnormalities and subsequent relapse behavior," says Ian Maze, PhD, Associate Professor of Neuroscience, and Pharmacological Sciences, at the Icahn School of Medicine at Mount Sinai, and lead author of the study. "Beyond transmission of signals between neurons in the brain, we have found that dopamine can be chemically attached to histone proteins, which causes cells to switch different genes on and off, affecting regions of the brain that are involved in motivation and reward behavior. This biochemical process significantly affects cocaine vulnerability and relapse when perturbed by drugs of abuse."

The study revolves around DNA and how it works to form each person's individual biological map. Each cell in the body contains two meters of DNA, the blueprint for all functions of all cells in the body. This DNA is wound around spools of histone proteins (proteins that package DNA in the nucleus of cells, and are heavily prone to chemical modifications that aid in the regulation of gene expression) into structures referred to as nucleosomes. When DNA encoding a specific gene is wound tightly within the spool, that gene is less likely to be expressed. When the gene is not wound as tightly, it is more likely to be expressed. This can affect many functions of a given cell.

Dopamine, known as the feel-good neurotransmitter, is a chemical that ferries information between neurons. The brain releases it when we eat food that we crave or while we have sex, contributing to feelings of pleasure and satisfaction as part of the natural reward system. This important neurochemical boosts mood, motivation, and attention, and helps regulate movement, learning, and emotional responses. Dopamine also enables us not only to see rewards but to take action to move toward them.

Vulnerability to relapse during periods of cocaine withdrawal is believed to result from functional rewiring of the brain's reward circuitry, particularly within mid-brain regions, such as the ventral tegmental area (VTA). The research team discovered that a protein called transglutaminase 2 can directly attach dopamine molecules to histone proteins (a process called histone dopaminylation or H3Q5dop) which, in turn, affects the histone-DNA spool to enable environmentally regulated alterations in gene expression. They found that histone dopaminylation plays a critical role in fueling heightened vulnerability to relapse over a prolonged period of time. Specifically, accumulation of H3Q5dop in the VTA can, in effect, hijack the reward circuitry, making it difficult to distinguish between good and maladaptive behavior. The study found, however, that reducing H3Q5dop in rats programmed to undergo withdrawal from cocaine significantly reversed cocaine-mediated gene expression changes and reduced cocaine-seeking behavior.

"The question that has always challenged neuroscientists is, what are the underlying molecular phenomena that drive increased vulnerability to drug relapse in people," says Ashley Lepack, PhD, a researcher in the Department of Neuroscience, The Friedman Brain Institute, in Dr. Maze's lab at Mount Sinai, and first author of the study. "Our research is shedding valuable light on this area by identifying histone dopaminylation as a new, neurotransmission-independent role for dopamine that hasn't been implicated before in brain pathology."

"We believe these findings represent a paradigm shift in how we think of dopamine, not just in the context of drug abuse, but also potentially in other reward-related behaviors and disorders, as well as in neurodegenerative diseases like Parkinson's, where dopamine neurons are dying," says Dr. Maze. "In this case, the question becomes, 'could this neuronal death be due, in part, to aberrant dopaminylation of histone proteins?' "

In a study published last year, Dr. Maze and his team found that another neurotransmitter, serotonin, a chemical involved in the regulation of mood, acts in a similar way as dopamine on gene expression inside brain cells.

"When we observed this unique signaling mechanism with serotonin, we decided to look at other neurotransmitters, particularly dopamine, and found that it could also undergo this type of chemical modification on the same histone protein," explains Dr. Maze.

Early-stage work with human post-mortem tissues has demonstrated to Dr. Maze that strong parallels may well exist, but that basic questions around biochemical function still remain before human trials can begin. "From a therapeutic standpoint, we've started to identify from rodent models the mechanisms that can actually reverse aberrant and addictive behaviors," says Dr. Maze, "and that knowledge could be vital to moving this novel research into the clinic."