Culture

The UK government made key failings in their strategic preparations and emergency response to coronavirus and this, in turn, undermined the NHS's ability to cope with the crisis.

These are the findings recently published in a research paper for the Journal of Risk Research by academics from Cass Business School, Glasgow Caledonian University, Vlerick Business School, and Nottingham University Business School.

The researchers conducted an extensive review of the literature focusing on key organisational resilience research, allowing them to identify the 'good, the bad and the ugly' of preparedness in readiness and response to the current pandemic.

The academics found that the NHS's resilience to the pandemic was compromised by an over-reliance on 'lean production' and 'just in time' continuity planning. This left NHS stockpiles short of vital supplies and capacity for personal protective equipment (PPE), ventilators and testing.

They argue that 'strategic redundancy' and 'slack in the system' could have left the NHS much better prepared to avoid the late 'ramping up' of capacity by government health officials in the face of the immense stresses and demands placed on global supply chains by a pandemic.

However, the researchers suggest this flawed strategy was not simply due to a lack of foresight. Instead they suggest that the UK government failed adequately to take account of known threats and clear signals of systemic weaknesses in the event of a pandemic uncovered by emergency exercises such as Operation Cygnus, the three-day simulation in 2016 which focused on the response and planning to a flu pandemic involving government and public health bodies.

The researchers suggest that, as the UK undergoes a period of adjustment in response to Covid-19, a new independent body should be set up to take responsibility for future national emergency preparedness free from political interference.

Lead researcher Dr Cormac Bryce, Cass Business School, said the paper has implications for future inquiries into the UK government's handling of the pandemic. He said it also highlights the need for new institutional arrangements to strengthen independence and transparency at the science-policy interface between expert advice, government decision-making, and provision for future pandemic threats.

"Benjamin Franklin suggested that by failing to prepare we should prepare to fail. We are witnessing the tragic consequences of such governmental failures - an overreliance on 'just in time' delivery amongst other factors has led to inadequate stockpiling of PPE and ventilators. Even though the warnings to prepare were there for those willing to look and act for years," he said.

"This inability to develop resilience in the face of Covid-19 has hampered the adaptation to the pandemic due to the slow upscaling of testing for key workers and the vulnerable in care homes - those most at risk."

While attention remains focused on the number of COVID-19 deaths and new cases, a separate statistic - the number of recovered patients - may be equally important to the goal of minimizing the pandemic's infection rate as shelter-in-place orders are lifted.

The presumed immunity of those who have recovered from the infection could allow them to safely substitute for susceptible people in certain high-contact occupations such as healthcare. Dubbed "shield immunity," the anticipated protection against short-term reinfection could allow recovered patients to expand their interactions with infected and susceptible people, potentially reducing overall transmission rates when interactions are permitted to expand.

New modeling of the virus' behavior suggests that an intervention strategy based on shield immunity could reduce the risk of allowing the higher levels of human interaction needed to support expanded economic activity. The number of Americans infected by the novel coronavirus is likely much higher than what has been officially reported, and that could be good news for efforts to utilize their presumed immunity to protect the larger community.

However, there are two important caveats to the strategy. The first is that the duration of immunity to reinfection by SARS-CoV-2 remains unknown; however, individuals who survived infections by related viral infections, like SARS, had persistent antibodies for approximately two years - and those who survived infection to MERS had evidence of immunity for approximately three years. The second issue is that determining on a broad scale who has antibodies that may protect them from the coronavirus will require a level of reliable serological testing not yet available in the United States.

"Our model describes ways in which serological tests used to identify individuals who have been infected by and recovered from COVID-19 could help both reduce future transmission and foster increased economic engagement," said Joshua Weitz, professor in the School of Biological Sciences and founding director of the Interdisciplinary Ph.D. in Quantitative Biosciences at the Georgia Institute of Technology. "The idea is to think in advance about how identifying recovered individuals could help serve the collective good, using information collected on neutralizing antibodies in new ways."

A paper describing the modeling behind the concept of shield immunity was published May 7 in the journal Nature Medicine by a team of researchers from Georgia Tech, Princeton University and McMaster University. The researchers studied the potential impacts of presumed immunity among recovered persons using a computational model of COVID-19 epidemiological dynamics, building upon a SEIR (susceptible-exposed-infectious-recovered) framework.

In a population of 10 million citizens, for example, the model predicts that in a worst-case transmission scenario, implementation of an intermediate shielding strategy could help reduce deaths from 71,000 to 58,000, while an enhanced shielding plan could cut deaths from 71,000 to 20,000. The model also suggests that shielding could enhance the effects of social distancing strategies that may remain in place once higher levels of economic activity resume.

Identification of individuals who have protective antibodies against the novel coronavirus has begun only recently. Antibody tests are not 100% specific, implying that tests can lead to false positives. However, targeted use of antibody testing in groups with elevated exposure will lead to increases in positive predictive value, even with imperfect tests. The serological antibody test differs from widespread polymerase chain reaction (PCR) testing being done to determine whether people are actively infected with the virus.

Among healthcare professionals, serological testing could identify recovered individuals who might then be able to interact with patients with reduced concern for infection. Other recovered individuals could be used to help reduce transmission risk in nursing homes, the food service industry, emergency medical services, grocery stores, retailing and other essential operations. Across society, the relatively small number of individuals with immunity could substitute for people whose immunity status isn't known; reducing transmission risk both for recovered individuals and those who remain immunologically naive.

"We want to think about serology as an intervention," Weitz said. "Finding out who is immune to the coronavirus could make a big difference in trying to reduce the risk to people who would be vulnerable by interacting with someone who could pass on the disease."

Serological testing to identify those with immunity might begin with healthcare workers, who may be more likely to have been infected by the coronavirus because of their exposure to infected persons, Weitz said. Because so many infections do not produce the distinctive COVID-19 symptoms, it's likely that many people have recovered from the illness without knowing they've had had it, potentially expanding the pool of recovered persons.

"There may be a deeper pool of individuals who can help within their own fields and other fields of specialization to reduce transmission," Weitz said. "The reality is that people within high-contact jobs probably are likely to have a higher incidence of infection than other groups."

But using antibody information about individuals would create potential privacy issues, and require that those individuals make informed decisions about accepting additional risks for the greater good of the community.

"What this model says is that if we could identify individuals who are immune, there is a chance that some individuals would not have to reduce their level of interaction with others because that interaction would be less risky," he added. "Rather than trying to keep reducing interactions, which is helpful for reducing transmission but bad for what it does for the economy, we might be able to maintain interactions while reducing the risk, combined with other mitigation approaches."

Ultimately, addressing the pandemic will require development and mass production of a vaccine that could boost immunity levels beyond 60 percent in the general population. Until that is available, Weitz believes that shield immunity could become part of the approach to the challenge.

"We don't have a silver bullet," he said. "Until we have a vaccine, we will have to use a combination of strategies to control COVID-19, and shield immunity is potentially one of them."

To keep patients and health-care providers safe from COVID-19, while providing urgent treatment to stroke patients, extra precautions must be taken, according to new guidelines published in the journal Stroke.

The guidelines were established by the Society of Vascular & Interventional Neurology (SVIN).

UCLA professor of neurology Dr. David Liebeskind, who is president of SVIN and director of the UCLA Stroke Center, expressed concern that fear of COVID-19 may make patients hesitate to seek treatment in the event of a possible stroke.

"People are passing away or having severe strokes out of the hospital," he said. "There are a lot of people who are not coming in."

Delaying treatment by just 15 minutes can make a world of difference in terms of the patient's recovery. Yet stroke centers around the country report that they are treating fewer patients than usual. To minimize the possibility of transmitting infections among patients in the hospital, the SVIN team developed guidelines based on review of the published research, consensus among practicing neurologists and shared best practices.

"Some of these things are intuitive or straightforward in terms of minimizing exposure and maximizing the use of personal protective equipment," said Dr. Liebeskind. Because stroke patients may be unable to communicate and describe their history or symptoms, he said, every patient should be initially considered to be positive for COVID-19.

According to the guidelines, a definitive diagnosis of COVID-19 should be made as soon as possible, as patients who test negative can decrease the use of protective equipment. Patients who test positive should be placed in isolation in a negative pressure room, when available.

Any tests that do not change the treatment strategy should be delayed or deferred until COVID-19 status is established, the guidelines recommend.

The doctors say that telemedicine can play a monumental role in minimizing the number of people who come in direct exposure to the patient. For an acute stroke or thrombectomy code, one person in protective equipment can be with the patient, while another coordinates care via computer or phone.

Remote tele-stroke technology can also be used to obtain history, perform neurological exams and monitor the patient after the stroke has been treated.

"Telemedicine in neurology has evolved over the last 10 years to meet the needs of a consultation," said Dr. Liebeskind. "In stroke, imaging becomes incredibly important, and that becomes integrated as well. We can do the examination very easily via telemedicine, using a video link at the patient bedside. And, through that same link we can access the imaging information as well. At UCLA, we also have dedicated robots that can travel through the hospital that can do all of this."

A head CT or computerized tomography scan is typically the first test performed in the event of a stroke. A chest CT can be performed at the same time, to check the lungs for COVID-19, if this does not unduly delay stroke treatment. Angiography is another imaging technique that allows doctors to look at the blood vessels.

"The use of specific imaging approaches in planning endovascular therapy, and the decision-making regarding the use of intubation and general anesthesia, is always a case specific medical decision in any clinical environment," Dr. Liebeskind said.

Where possible, conscious sedation can be an alternative to general anesthesia and intubation. This could protect patients from unnecessary intubation and conserves mechanical ventilators, he said.

Finally, after thrombectomy or surgery to remove the blood clot, doctors should consider relocating patients back to primary stroke centers to recover, especially for hospitals overwhelmed with critical care or intensive care unit bed shortages. This can help maintain thrombectomy access, Dr. Liebeskind said.

"Our ability to deliver comprehensive stroke care, including endovascular therapy for acute ischemic stroke, remains an intact valuable resource for patients everywhere," he added.

MAYWOOD, IL-Broad modifications to current standards for treating acute stroke patients during the COVID-19 pandemic may be needed to preserve health care resources, limit disease spread and ensure optimal care, according to a Loyola Medicine neurologist.

"Doctors are seeing a rise in COVID-19 patients of all ages suffering from stroke and other vascular complications, as the COVID-19 virus overwhelms the health care system," said Jose Biller, MD, chairperson of neurology at Loyola University Medical Center, and professor, Loyola University Chicago Stritch School of Medicine, and co-author of a new editorial, "Acute Stroke Care in the Coronavirus 2019 Pandemic."

"COVID-19 may increase the risk of stroke as a result of several mechanisms, including enhanced inflammatory response, increased blood clotting tendencies, and damage of the inner layers of the blood vessels (endothelial damage)," said Dr. Biller. In general, the majority of stroke patients are older and have underlying medical conditions associated not only with risk for acute ischemic stroke (AIS), but also poor outcomes associated with COVID-19.

Dr. Biller says new guidelines are needed to safely manage stroke patients, both with and without COVID-19, within the limitations of strained health systems during this "ferocious novel pandemic."

"We believe that it is crucial for the stroke community to relax guidelines and stroke pathways while continuously providing high quality of care, including treatment algorithms, post intravenous thrombolysis monitoring, diagnostic work up, disposition planning, prevention measures, in order to optimally care for stroke patients while minimizing the chances of contributing to the rapid spread of COVID-19," according to the editorial, co-authored by Rima M. Dafer, MD, MPH, and Nicholas D. Osteraas, MD, MS, both of Rush University Medical Center, and appearing in the Journal of Stroke and Cerebrovascular Diseases.

The recommendations pertain to all aspects and stages of care, and include the following highlights:

Prehospitalization. Patients or loved ones should continue to call 911 to report a stroke. In addition to standard triage, emergency medical system (EMS) personnel should screen patients over the phone for COVID-19 symptoms. Telemedicine should be considered for patients with low suspicion of stroke, or mild symptoms with no potential indication for intervention. All patients with acute stroke symptoms should be treated as suspected or possible COVID-19 patients.

Emergency Room Evaluation. In the emergency room, patients should be screened for COVID-19 prior to evaluation by the stroke team. All patients should wear a mask.

Hospitalization. Hospitals should designate isolated units for stroke care. Patients receiving intravenous chemical thrombolysis (a common stroke treatment involving an intravenous injection of drugs directly to the blood clot) may be monitored virtually with two-way video conferencing to minimize staff infection.

Rehabilitation Planning. Rehabilitation for stroke patients can include physical, occupational, and speech therapy, along with other rehabilitation. All therapists and health care workers caring for COVID-19 patients should wear appropriate protective gear. Whenever appropriate, therapy services should emphasize patient exercises that can used at home.

Family Members. As many hospitals have restricted visitors during COVID-19, extra effort will need to be made to reach families by phone to discuss a patient's condition, treatment options and discharge planning. Exceptions to the visitor policy, such as discussions regarding end-of-life care, should be made when appropriate.

Transfers. Stroke care often involves networks of hospitals; commonly a comprehensive "hub" with multiple smaller hospitals or "spoke" sites which transfer stroke patients to the "hub" for emergency treatment or Intensive Care Unit (ICU) care. Tele-stroke should be encouraged to evaluate patients and to prevent unnecessary transfers. For AIS patients, neuroimaging and COVID-19 screening should be obtained at the smaller, spoke site hospital before a patient is transferred to a larger medical center.

Discharge Planning. Discharges to acute rehabilitation institutions and long-term facilities have been delayed due to concerns about the spread of COVID-19 infections in long-term care facilities and nursing homes. Hospitals may need to designate rehabilitation beds for patients who do not qualify for transfer to acute inpatient facilities, as well as discussing possible discharge to home when medically stable and appropriate until the pandemic is under control.

Finally, the article recommends establishing stroke networks within cities, as well as collaboration between institutions "as the surge of COVID-19 worsens." This should include "collaborations among stroke networks to establish a rotating weekly coverage for acute stroke care in a specified geographic area; thus, both freeing hospital resources and releasing stroke call responsibilities, and allowing these physicians to help in caring for patients on the COVID-19 units."

The COVID-19 pandemic has revealed major deficiencies and inequities in the U.S. healthcare system, shining a spotlight on improvements that must be made to steel the country for future disasters, argues Maia Dorsett in an Editorial. "US healthcare is incentivized to react to sickness rather than proactively focus on health maintenance," Dorsett writes. "As an emergency physician, I witness the impact of this approach daily." Dorsett further argues that - much like a school shooting or a terrorist attack - the COVID-19 pandemic should be defined as a mass casualty incident (MCI), which occur when casualties overwhelm local resources such as personnel and equipment. Public health systems designed to improve the health of the general population are underfunded and understaffed, with emergency departments operating near or beyond capacity on a given day while underlying issues such as housing, food security, and safety from violence remain inadequately addressed. These systemic weaknesses make it more difficult for society to cope with slow-moving MCIs such as COVID-19. As with all MCIs, understanding four phases of the emergency management cycle can help to analyze and guide the response to this pandemic: mitigation, preparation, response, and recovery. Dorsett contends that inadequate preparation for COVID-19, including stockpiling personal protective equipment, ventilators, and testing equipment, led to a sense of betrayal among healthcare professionals forced to contend with the pandemic using inadequate resources. "Emergency management is a cycle and we must now use the recovery phase to analyze the strengths and deficiencies of our response to begin the mitigation and planning phases for the next, unplanned hazard," Dorsett writes. "We can hope that our collective memory is long, not short."

Researchers using a technique known as "lucky imaging" with the Gemini North telescope on Hawaii's Maunakea have collected some of the highest resolution images of Jupiter ever obtained from the ground. These images are part of a multi-year joint observing program with the Hubble Space Telescope in support of NASA's Juno mission. The Gemini images, when combined with the Hubble and Juno observations, reveal that lightning strikes, and some of the largest storm systems that create them, are formed in and around large convective cells over deep clouds of water ice and liquid. The new observations also confirm that dark spots in the famous Great Red Spot are actually gaps in the cloud cover and not due to cloud color variations.

Three years of imaging observations using the international Gemini Observatory, a program of NSF's NOIRLab, have probed deep into Jupiter's cloud tops. The ultra-sharp Gemini infrared images complement optical and ultraviolet observations by Hubble and radio observations by the Juno spacecraft to reveal new secrets about the giant planet.

"The Gemini data were critical because they allowed us to probe deeply into Jupiter's clouds on a regular schedule," said Michael Wong of UC Berkeley. "We used a very powerful technique called lucky imaging," adds Wong. With lucky imaging, a large number of very short exposure images are obtained and only the sharpest images, when the Earth's atmosphere is briefly stable, are used. The result in this case is some of the sharpest infrared images of Jupiter ever obtained from the ground. According to Wong, "These images rival the view from space."

Gemini North's Near Infrared Imager (NIRI) allows astronomers to peer deep into Jupiter's mighty storms, since the longer wavelength infrared light can pass through the thin haze but is obscured by thicker clouds high in Jupiter's atmosphere. This creates a "jack-o-lantern"-like effect in the images where the warm, deep layers of Jupiter's atmosphere glow through gaps in the planet's thick cloud cover.

The detailed, multiwavelength imaging of Jupiter by Geminiand Hubble has, over the past three years, proven crucial to contextualizing the observations by the Juno orbiter, and to understanding Jupiter's wind patterns, atmospheric waves, and cyclones. The two telescopes, together with Juno, can observe Jupiter's atmosphere as a system of winds, gases, heat, and weather phenomena, providing coverage and insight not unlike the network of weather satellites meteorologists use to observe Earth.

Mapping giant lightning storms

On each of its close passes over Jupiter's clouds, Juno detected radio signals created by powerful lightning flashes called sferics (short for atmospherics) and whistlers (so-called because of the whistle-like tone they cause on radio receivers). Whenever possible, Gemini and Hubble focused on Jupiter and obtained high-resolution, wide-area maps of the giant planet.

Juno's instruments could determine the latitude and longitude coordinates of clusters of sferic and whistler signals. With Gemini and Hubble images at multiple wavelengths, researchers now can probe the cloud structure at these locations. By combining these three pieces of information the research team found that the lightning strikes, and some of the largest storm systems that create them, are formed in and around large convective cells over deep clouds of water ice and liquid.

"Scientists track lightning because it is a marker of convection, the turbulent mixing process that transports Jupiter's internal heat up to the visible cloud tops," explained Wong. The largest concentration of lightning seen by Juno came from a swirling storm called a "filamentary cyclone." Imaging from Gemini and Hubble shows details in the cyclone, revealing it to be a twisted collection of tall convective clouds with deep gaps offering glimpses to the water clouds far below.

"Ongoing studies of lightning sources will help us understand how convection on Jupiter is different from or similar to convection in the Earth's atmosphere," Wong commented.

Glowing features in the Great Red Spot

While scanning the gas giant for gaps in cloud cover, Gemini spotted a telltale glow in the Great Red Spot, indicating a clear view down to deep, warmer atmospheric layers.

"Similar features have been seen in the Great Red Spot before," said team member Glenn Orton of JPL, "but visible-light observation couldn't distinguish between darker cloud material, and thinner cloud cover over Jupiter's warm interior, so their nature remained a mystery."

Now with the data from Gemini, this mystery is solved. Where visible light images from Hubble show a dark semicircle in the Great Red Spot, images taken by Gemini using infrared light reveal a bright arc lighting up the region. This infrared glow, from Jupiter's internal heat, would have been blocked by thicker clouds, but can pass through Jupiter's hazy atmosphere unobscured. By seeing these features as bright infrared hotspots, Gemini confirms that they are gaps in the clouds. Even though earlier observations have seen dark features in the Great Red Spot, the rapidly swirling winds within it hid the true nature of these spots until the simultaneous Hubble and Gemini observations were conducted.

"NIRI at Gemini North is the most effective way for the US and the international Gemini partnership investigators to get detailed maps of Jupiter at this wavelength," explained Wong. Gemini achieved a 500-kilometer (300-mile) resolution on Jupiter. "At this resolution, the telescope could resolve the two headlights of a car in Miami, seen from New York City," said Andrew Stephens, the Gemini astronomer who led the observations.[1]

"These coordinated observations prove once again that ground-breaking astronomy is made possible by combining the capabilities of the Gemini telescopes with complimentary ground- and space-based facilities," said Martin Still, an astronomy program director at the National Science Foundation, which is Gemini's US funding agency. "The international Gemini Partnership provides open access to a powerful combination of large telescopes' collecting area, flexible scheduling, and a broad selection of interchangeable instruments."

Despite a national opioid-related overdose epidemic that continues to claim tens of thousands of lives annually, a new nationwide study shows that a scant proportion of hospitalized patients with opioid use disorder receive proven life-saving medications both during and after they're discharged.

The study published in the Journal of General Internal Medicine.

"It really paints a bleak picture of the current state of affairs about the treatment of people with opioid use disorder nationwide," said lead author Kelsey Priest, Ph.D., M.P.H., a health systems researcher and current M.D./Ph.D. student in the Oregon Health & Science University School of Medicine.

The study plumbed an extensive database of patients in the Department of Veterans Affairs health care system. Researchers identified more than 12,000 patients across 109 hospitals who were hospitalized for various reasons but also had underlying opioid use disorder during the fiscal year ending in 2017.

The researchers identified 10,969 patients who had opioid use disorder at the time they were hospitalized but weren't receiving treatment. Of those patients, only 203 - 2% - received a medication to treat opioid use disorder while they were in the hospital and were subsequently linked to care after their discharge. That's important because findings from an earlier study from OHSU showed that patients who received medication such as buprenorphine in the hospital are twice as likely to continue their therapy after discharge.

"This is a huge missed opportunity," said co-author Honora Englander, M.D., associate professor of medicine in the OHSU School of Medicine.

Englander is director of an in-hospital intervention program that OHSU started in 2015.

Project IMPACT, or Improving Addiction Care Team, brings together physicians, social workers, peer-recovery mentors and community addiction providers to address addiction when patients are admitted to the hospital. The program is a rare exception, although part of a small but growing cohort of hospitals nationwide implementing these services. The need for these interventions is clear based on the study published today.

"Hospitalization is a reachable moment to initiate and coordinate therapy to treat substance use disorder," Englander said. "This study shows that in the VA - which most likely out-performs other U.S. hospitals - life-saving, evidence-based treatment is rarely prescribed."

Opioid agonist therapies available in the hospital include methadone or buprenorphine. Both relieve withdrawal symptoms and pain, normalizing brain function by acting on the same targets in the brain as prescription opioids or heroin.

A University of Cincinnati researcher says a study of COVID-19 patients shows loss of the sense of smell is most likely to occur by the third day of infection with the novel virus. Most of these patients are also experiencing a loss of the sense of taste.

The prospective, cross sectional telephone study examined characteristics and symptoms of 103 patients who were diagnosed with COVID-19 over a six-week period at Kantonsspital Aarau in Aarau, Switzerland. Patients were asked how many days they had COVID-19 symptoms and also asked to describe the timing and severity of loss or reduced sense of smell along with other symptoms.

At least 61% of the patients reported reduced or lost sense of smell, says Ahmad Sedaghat, MD, PhD, an associate professor in the UC College of Medicine's Department of Otolaryngology-Head and Neck Surgery and an UC Health physician specializing in diseases of the nose and sinuses, who was the principal investigator of the study. The mean onset for reduction or loss in the sense of smell was 3.4 days.

The findings are available online in the scholarly journal Otolaryngology-Head and Neck Surgery. The first author of the research is Marlene Speth, MD, at the Switzerland hospital.

"We also found in this study that the severity of the loss of smell is correlated with how bad your other COVID-19 symptoms will be," says Sedaghat. "If the anosmia, also known as loss of smell, is worse, the patients reported worse shortness of breath and more severe fever and cough."

"Should that concern patients?" says Sedaghat. "The relationship between decreased sense of smell and the rest of the COVID-19 is something to be aware of. If someone has a decreased sense of smell with COVID-19 we know they are within the first week of the disease course and there is still another week or two to expect."

Sedaghat says an experimental antiviral drug, remdesivir, developed by Gilead Sciences to initially treat Ebola, is showing some promise in treating COVID-19 patients. It has been granted emergency approval by the U.S. Food and Drug Administration to treat severely ill COVID-19 patients, since a National Institutes of Health-sponsored clinical trial showed that patients experienced a shorter recovery time when taking remdesivir compared to a placebo.

Sedaghat says that having an available antiviral treatment for COVID-19 may mean it's much more important to have an indicator of prognosis and how far the disease has progressed in patients.

"Antiviral medications have historically worked best when given early during a viral infection. The same is hypothesized to be true for remdesivir," says Sedaghat. "Our study indicates that a decreased sense of smell may be an indicator of patients early in the disease course as well as those who may go on to develop more severe symptoms, like shortness of breath, later on. "Once remdesivir becomes more widely available, decreased sense of smell may therefore identify patients who would be excellent candidates for the medication," he says.

Sedaghat cautions that while the loss of smell is an indicator of COVID-19, it's not the only factor. "When you start to experience serious symptoms of COVID-19 which include shortness of breath and respiratory distress, that's when you should become alarmed," he adds.

The study also found that younger patients and women in the study were also more likely to experience a decreased loss of smell, says Sedaghat.

Also, about 50% of study patients experienced a stuffy nose and 35% experienced a runny nose. Sedaghat says this is important because previous studies indicated that these nasal symptoms were rare in COVID-19 and these symptoms were attributed to allergy and not the novel coronavirus.

"This just means that greater awareness is needed of COVID-19's nasal symptoms so people are not running around sneezing in public and thinking it is okay since this is just allergies," says Sedaghat. "It very well could be COVID-19 and wearing masks as protective gear for others you encounter is a good idea."

Sedaghat says understanding more about loss of smell and COVID-19 is important for a public health perspective.

"No one is going to die because of a loss of the sense of smell and it's not the symptom that will kill anyone," says Sedaghat. "However, it is important because it helps us to identify these COVID-19 patients as asymptomatic carriers so they don't spread the disease to others. Now we can potentially identify them early during the disease to start antiviral medications and ultimately maximize our ability to effectively treat these patients."

Washington State legalized cannabis sales to adults in 2012, the first U.S. state to do so. Yet little is known about how police, who are on the front lines of implementing the law, experience legalization. A new study evaluated the effects of legalizing cannabis on police officers' law enforcement efforts in Washington. The study found that officers in that state, although not supportive of recriminalization, had a variety of concerns, from worries about the effect on youth to increases in impaired driving. The study can inform other states' efforts to address legalization.

Conducted by researchers at Washington State University (WSU), the study appears in Justice Evaluation Journal, a publication of the Academy of Criminal Justice Sciences.

"The trend both nationally and internationally is toward greater decriminalization, medicalization, and legalization of cannabis," says Mary Stohr, professor of criminal justice and criminology at WSU, who led the study. "Because this represents a significant policy shift in the war on drugs, which focused on the volume of arrests and prosecutions of marijuana use and sales, it is imperative that we listen to the voices of police in a state like Washington for insight into areas of impact."

To determine how the change in law affected law enforcement, researchers held focus groups to speak with 48 police officers from nine police, sheriff, and tribal agencies around Washington in 2017 and 2018. Officers came from rural, suburban, urban, and college agencies, as well as agencies with statewide jurisdiction and a Native American tribe. While the officers represented a mix of ages, genders, races and ethnicities, years on the job, and types of experience, most were White males with more than five years of experience in police work.

Among the questions asked were ones that attempted to determine how marijuana possession was handled by the police prior to and after legalization, whether and how officers' jobs have changed since legalization, and whether legalization has made things easier or more challenging for police agencies.

The study found that while police officers were not necessarily opposed to the law, they expressed concerns about a variety of issues, including:

Youth access and use: With legalization, youth have easier access to marijuana and the use of the substance is therefore normalized, officers said.

Lack of appropriate educational programs: In the runup to legalization, the state did not develop adequate educational programs to inform youth about the dangers of marijuana, many officers said.

Increases in drugged driving: Officers expressed concern about the challenge of legalization for traffic law enforcement and safety, saying they struggled with how to manage potential cannabis DUI cases and were encountering more impaired drivers.

Prosecutors' reluctance to charge offenders: Cannabis remains illegal outside of regulatory confines, but officers noted the reluctance of some prosecutors to bring charges after legalization because of the risk of the charges being dismissed.

Lack of police preparation for legalization: While some officers said their agencies had prepared them, others said they had not received sufficient training on how to manage incidents involving cannabis since legalization within regulatory boundaries.

The impact on police workload: Despite claims that legalization would allow officers to reallocate resources from cannabis enforcement, most officers said legalization had not reduced their workload.

Asked to provide guidance for agencies in other states that would soon operate in a legalized environment for marijuana, the officers called for broad public educational programs (emphasizing juveniles and drivers and how the law affects them), more research on the effects of cannabis and impairment from the drug, and expanded officer training (especially on the regulatory rules governing growing cannabis). They also suggested that base pay for officers be increased, given the increasing role they play now that cannabis is legal.

"The purpose of our study was to add a key stakeholder's voice to the conversation--that of police officers," notes Craig Hemmens, professor of criminal justice and criminology at WSU, who coauthored the study. "Officers in other states may find their thoughts useful as they transition to legalization."

In terms of limitations, the authors say that while the group of officers they interviewed was robust, their findings are not necessarily generalizable to all law enforcement officers in Washington. In addition, the authors note the tendency of members of focus groups to censor their comments because they are with fellow officers.

Infants spend most of their first year of life asleep. Those hours are prime time for brain development, when neural connections form and sensory memories are encoded.

But when sleep is disrupted, as occurs more often among children with autism, brain development may be affected, too. New research led by the University of Washington finds that sleep problems in a baby's first 12 months may not only precede an autism diagnosis, but also may be associated with altered growth trajectory in a key part of the brain, the hippocampus.

In a study published May 7 in the American Journal of Psychiatry, researchers report that in a sample of more than 400 6- to 12-month-old infants, those who were later diagnosed with autism were more likely to have had difficulty falling asleep. This sleep difficulty was associated with altered growth trajectories in the hippocampus.

"The hippocampus is critical for learning and memory, and changes in the size of the hippocampus have been associated with poor sleep in adults and older children.

However, this is the first study we are aware of to find an association in infants as young as 6 months of age," said lead author Kate MacDuffie, a postdoctoral researcher at the UW Autism Center.

As many as 80% of children with autism spectrum disorder have sleep problems, said Annette Estes, director of the UW Autism Center and senior author on the study. But much of the existing research, on infants with siblings who have autism, as well as the interventions designed to improve outcomes for children with autism, focus on behavior and cognition. With sleep such a critical need for children -- and their parents -- the researchers involved in the multicenter Infant Brain Imaging Study Network, or IBIS Network, believed there was more to be examined.

"In our clinical experience, parents have a lot of concerns about their children's sleep, and in our work on early autism intervention, we observed that sleep problems were holding children and families back," said Estes, who is also a UW professor of speech and hearing sciences.

Researchers launched the study, Estes said, because they had questions about how sleep and autism were related. Do sleep problems exacerbate the symptoms of autism? Or is it the other way around -- that autism symptoms lead to sleep problems? Or something different altogether?

"It could be that altered sleep is part-and-parcel of autism for some children. One clue is that behavioral interventions to improve sleep don't work for all children with autism, even when their parents are doing everything just right. This suggests that there may be a biological component to sleep problems for some children with autism," Estes said.

To consider links among sleep, brain development and autism, researchers at the IBIS Network looked at MRI scans of 432 infants, surveyed parents about sleep patterns, and measured cognitive functioning using a standardized assessment. Researchers at four institutions -- the UW, University of North Carolina at Chapel Hill, Washington University in St. Louis and the Children's Hospital of Philadelphia -- evaluated the children at 6, 12 and 24 months of age and surveyed parents about their child's sleep, all as part of a longer questionnaire covering infant behavior. Sleep-specific questions addressed how long it took for the child to fall asleep or to fall back asleep if awakened in the middle of the night, for example.

At the outset of the study, infants were classified according to their risk for developing autism: Those who were at higher risk of developing autism -- about two-thirds of the study sample -- had an older sibling who had already been diagnosed. Infant siblings of children with autism have a 20 percent chance of developing autism spectrum disorder -- a much higher risk than children in the general population.

A 2017 study by the IBIS Network found that infants who had an autistic older sibling and who also showed expanded cortical surface area at 6 and 12 months of age were more likely to be diagnosed with autism compared with infants without those indicators.

In the current study, 127 of the 432 infants were identified as "low risk" at the time the MRI scans were taken because they had no family history of autism. They later evaluated all the participants at 24 months of age to determine whether they had developed autism. Of the roughly 300 children originally considered "high familial risk," 71 were diagnosed with autism spectrum disorder at that age.

Those results allowed researchers to re-examine previously collected longitudinal brain scans and behavioral data and identify some patterns. Problems with sleep were more common among the infants later diagnosed with autism spectrum disorder, as were larger hippocampi. No other subcortical brain structures were affected, including the amygdala, which is responsible for certain emotions and aspects of memory, or the thalamus, a signal transmitter from the spinal cord to the cerebral cortex.

The UW-led sleep study is the first to show links between hippocampal growth and sleep problems in infants who are later diagnosed with autism.

Other studies have found that "overgrowth" in different brain structures among infants who go on to develop those larger structures has been associated, at different stages of development, with social, language and behavioral aspects of autism.

While the UW sleep study found a pattern of larger hippocampal volume, and more frequent sleep problems, among infants who went on to be diagnosed with autism, what isn't yet known is whether there is a causal relationship. Studying a broader range of sleep patterns in this population or of the hippocampus in particular may help determine why sleep difficulties are so prevalent and how they impact early development in children with autism spectrum disorder.

"Our findings are just the beginning -- they place a spotlight on a certain period of development and a particular brain structure but leave many open questions to be explored in future research," MacDuffie said.

A focus on early assessment and diagnosis prompted the UW Autism Center to establish an infant clinic in 2017. The clinic provides evaluations for infants and toddlers, along with psychologists and behavior analysts to create a treatment plan with clinic- and home-based activities -- just as would happen with older children.

The UW Autism Center has evaluated sleep issues as part of both long-term research studies and in the clinical setting, as part of behavioral intervention.

"If kids aren't sleeping, parents aren't sleeping, and that means sleep problems are an important focus for research and treatment," said MacDuffie.

The authors note that while parents reported more sleep difficulties among infants who developed autism compared to those who did not, the differences were very subtle and only observed when looking at group averages across hundreds of infants. Sleep patterns in the first years of life change rapidly as infants transition from sleeping around the clock to a more adult-like sleep/wake cycle. Until further research is completed, Estes said, it is not possible to interpret challenges with sleep as an early sign of increased risk for autism.

AUSTIN, Texas - A mother's use of antidepressants during pregnancy does not appear to increase her child's risk for autism, according to a new meta-analysis by Jeffrey Newport, M.D., published in The American Journal of Psychiatry.

Newport is director of the Women's Reproductive Mental Health program at UT Health Austin's Mulva Clinic for the Neurosciences and a professor of psychiatry at Dell Medical School at The University of Texas at Austin.

He examined 14 studies, many of which identified a connection between prenatal antidepressant use and autism. However, Newport says that research failed to account for ascertainment bias, which occurs when one group of patients or subjects is tested more frequently than others.

In the analysis, Newport found the root of bias is limited access to health care among ethnic minority and immigrant mothers.

"In these studies, immigrant and Latina mothers consistently had both lower rates of antidepressant treatment and lower rates of autism diagnosis in their children," Newport said. "This is not surprising, as these minority groups are known to have poorer access to health care, including treatment for depression and careful diagnostic assessment of concerning behaviors in a child."

Newport discovered that family-based studies eliminated the bias problem by comparing children with antidepressant exposure or autism diagnosis with their siblings who did not have antidepressant exposure or autism. With the ethnic bias eliminated, the family-based studies revealed no association between prenatal antidepressant use and autism.

"This should remind us that although insurance databases and national registries have the advantage of huge numbers of participants, their data is not collected to answer research questions, but to manage business and clinical concerns," Newport said. "Thankfully, the results of this meta-analysis show that with thoughtful study designs, researchers can overcome the biases often encountered when using such databases."

Researchers from University of California Irvine published a new paper in the Journal of Marketing that finds that marketing mix elements mitigate sacrifice, which serves to engage individuals in the donation task and thereby increase the likelihood that they will continue.

The study forthcoming in the Journal of Marketing is titled "Help Me Help You!: Employing the Marketing Mix to Alleviate Experiences of Donor Sacrifice" and is authored by Tonya Bradford and Naja Boyd.

Nonprofits contribute significant value to society with the support from the individuals who contribute to them. This study suggests that managers consider the composite of sacrifices required from individuals as they proceed through each phase of donation and employ the marketing mix to proactively and compassionately address the various types of sacrifice that emerge. The researchers use the topic of living organ donation, an extreme type of sacrifice, to explore this concept more fully.

The study identifies actions for managers to employ the marketing mix--product, place, price, promotion, people, and process--to address the types of sacrifices (psychic, pecuniary, physical) identified in the donation process. Also included are general considerations for organizations. Product is reflected most clearly in a nonprofit organization's mission statement and manifests in the offering the donation supports. Place focuses on how disparate entities are integrated to support an individual's escalation of commitment from interested to committed as well as the delivery of the offering. Price is the component that conveys the costs incurred by donors to provide the contributions. Promotion is most often found in messages educating and persuading potential donors about the importance of the offering. An organization's people are an important factor in the entirety of the process and guide donors throughout the process.

Donation is the manifestation of the process component that includes the steps required for individuals to transform from potential to actual donor. The process we define is comprised of three phases. In the deliberation phase, individuals considering the opportunity are more involved in moving the process forward with some input from the organization. Within the decision phase, there is a balance of influence between individuals and organizations. As individuals move to the donation phase, the balance of influence shifts toward the organization. Thus, an awareness of the process and perceptions of the organization to which individuals are contributing is also important. Bradford explains, "It is imperative that organizations understand what they are asking of donors and how donors may experience sacrifice. It is also important for donors to experience a degree of success, particularly when they are not able to readily observe the outcomes of their donations. Therefore, the processes through which donors contribute should provide them with satisfaction that is in some way commensurate with the sacrifices they make." Importantly, process and people influence each phase of the donation experience and should be audited regularly to ensure that the interfaces between them and each phase, as well as the other marketing mix components, are integrated.

The integration of each of the six marketing mix elements is more likely to result in an environment where individuals feel their donations are valued and respected. Each marketing mix element should be aligned to engender the desired response to the organization: that of converting an individual into a volunteer. The study notes that marketing mix elements mitigate sacrifice, which serves to engage individuals in the donation task and thereby increase the likelihood that they will continue. For organizations where donation may continue, the enactment of such sacrifices is likely to engender loyalty and continuity.

Organizations are not static as evident in alterations to their operations, offerings, and positioning. Similarly, nonprofit organizations may adjust their offerings to remain relevant to those they serve, thereby maintaining or growing their client base. Boyd adds, "It is important that nonprofit organizations assess how those changes may impact the degree of sacrifice required for existing and potential donors and operationalize the marketing mix to address those sacrifices. Deft employment of the marketing mix to extend the tenure of donors may lead to other organizational benefits such as confidence in operational projections, service stability, and reduction in delivery service cost."

Though these findings emerged from a particular type of donation, they are relevant to organizations that depend on contributions borne of sacrifice (e.g., hosts for foreign exchange students, families to adopt children, hospice care providers, or those offering compassionate care to individuals in crisis).

Researchers from University of Groningen, University of Mannheim, and SAP Germany published a new paper in the Journal of Marketing that explores the potential benefits of winning back lost customers and the best strategies for accomplishing that goal.

The study forthcoming in the Journal of Marketing is titled "Tolerating and Managing Failure: An Organizational Perspective on Customer Reacquisition Management" and is authored by Arnd Vomberg, Christian Homburg, and Olivia Gwinner.

Do attempts to regain lost customers pay off? Experts report that the costs of reaching out to lost customers are generally far lower than the costs of contacting new customers. In addition, the chance of winning back a lost customer is up to eight times greater than of acquiring a new customer. In recognition of these advantages, McDonald's announced plans to invest from $150,000 to $700,000 per location in the U.S. to win back lost customers.

However, experts also report that customers can defect strategically. Customers defect because they anticipate improved offers such as lower prices from competitors. In such a scenario, a firm's win-back activities could unnecessarily lower firm revenues. In addition, resources are misallocated if win-back offers to defected customers provoke negative attitudes in loyal customers (e.g., feelings of unfairness if loyal customers pay higher prices than defected customers).

Using a cross-industry data set, the research team reports that reacquisition increases firm profits. The positive outcomes of customer reacquisition such as increased revenues more than offset the costs of customer reacquisition management such as price concessions.

However, the study also demonstrates that managers need to understand the important role that a company's culture plays in effective customer win-back. While winning back lost customers can lead to increased profits, win-back processes are often unpleasant for employees. Vomberg explains that "Employees likely perceive customer defection as an undesirable occurrence. Usually, employees do not freely and deliberately discuss their mistakes. They may fear blame from colleagues or punishment by superiors. Thus, company cultures that reward success and punish failures can instill reluctance in employees to address customer defections."

The study demonstrates that successful customer reacquisition management requires a failure-tolerant organizational culture that encourages a constructive treatment of failures. In failure-tolerant cultures, employees feel free to voice ideas, discuss customer defections openly, and assume responsibility for the reacquisition process. Such feelings of responsibility spur employees to work harder, be more creative, and act unconventionally when reacquiring customers. As a result, employees address more defections and increase win-back success.

However, failure tolerance can also have a boomerang effect: High levels of failure tolerance reduce win-back success. Highly failure-tolerant cultures can induce laxness in employees. Once employees have internalized a tolerance for failure, they may make decisions with less due diligence and effort, provoking more and increasingly severe failures in customer relationships. More and increasingly severe failures can create irrecoverable damage to win-back success.

Win-back guidelines also increase win-back success. Such guidelines establish and enforce strict formal rules and procedures that employees must follow when reacquiring customers. These guidelines help employees detect customer defection, formulate expected actions, and outline monitoring activities to ensure learning for future reacquisition attempts. Homburg adds, "Importantly, formal reacquisition guidelines do not conflict with motivational effects that failure tolerance raises in employees. Instead, the guidelines help unfold the full potential of failure tolerant cultures. In other words, such guidelines help employees structure the otherwise unstructured context of customer reacquisition management."

These findings have managerial implications. First, even if customer acquisition and retention management are well-established in company practice, managers should stimulate reacquisition activities. Addressing failures, shortcomings, and defections is likely less appealing than acquiring new customers, so win-back endeavors must be encouraged. Second, to benefit from reacquisition activities, Gwinner suggests that "... managers organize for customer reacquisition management. Managers need to establish cultures that are open to failure. However, managers need to be aware that failure tolerance can create "too-much-of-a-good-thing" so that high levels of failure tolerance reduce reacquisition performance. Thus, managers also need to recognize that failure tolerance is not a substitute for management." Third, currently only few companies have comprehensive reacquisition guidelines in place. Because those guidelines steer employees towards successful win-back and also amplify the performance effects of failure-tolerance cultures, managers should establish reacquisition guidelines.

Communications between two human or animal individuals conventionally depend on sensory systems for vision, audition, olfaction, or touch. Science fiction has popularized the potentials of directly transmitting information between brains for locomotor control. For example, in the 2009 film Avatar, humans use their minds to remotely control the brains of Na'vi-human hybrids to navigate in the real world. Several recent studies proposed the possibility of retrieving electrophysiological signals from one brain to influence the neuronal activity in another brain through electrical or transcranial magnetic stimulation, suggesting the exciting concept of direct information exchange between brains through the Brain-to-Brain interfaces (BtBIs). However, BtBIs have thus far required the use of demanding techniques for long-term, multi-channel recordings to decode the information from an encoder individual, and has been limited by low rates of information transmission to a target neural circuit. Multi-channel single-unit recordings are technically challenging and often lack cell-type specificity. EEG recording are inaccessible to subcortical areas to precisely decode specific intention. Moreover, EEG recordings of steady-state visually evoked potentials require external visual stimulation to generate the brain activity rather than the internal neural activity. Another challenge lies in the need of feeding the electrophysiological information, once decoded, into correct cell types and neural circuits in the target brain. Due to these technical limitations, the information transfer rates were often in the low range of 0.004-0.033 bits/s. Using a BtBI to control locomotion appears to be particularly difficult, since locomotion involves frequent starts, stops, and continuous changes in velocity at a sub-second scale.

Recently, Dr. Minmin Luo's lab published a research article entitled "An Optical Brain-to-brain Interface Supports Rapid Information Transmission for Precise Locomotion Control" in journal Science China Life Sciences. In this work, the authors established an optical BtBI that supports rapid information transmission for precise locomotion control, thus providing a proof-of-principle demonstration of fast BtBI for real-time behavioral control.

In this study, the authors demonstrated an optical BtBIs that used fiber photometry to record the population Ca2+ signals of NI neurons from the Master mouse, and then transformed the signals to blue laser pulses, and finally delivered the laser pulses into the NI of the Avatar mouse (Figure 1A, B). This optical BtBI directed the Avatar mice to closely mimic the locomotion of their Masters with information transfer rate about three two orders of magnitude higher than previous BtBIs (Figure 1C-E).

This study emphasize the importance of choosing appropriate neural circuits and of choosing suitable circuit-probing technologies when building a high-performance BtBI. First, the choice of brain structures is important for implementing task-relevant BtBIs. Here the authors collected neuronal signals that precisely report locomotor state and control locomotor speed from the genetically-identified NMB neurons in the NI of the pons. Second, the choice of fiber photometry of Ca2+ signals offers several advantages: 1) it stably records the population neuronal activity of specific cell-type that performs similar functions; 2) it has high signal-to-noise ratio (SNR); 3) it is easy to implement, since it bypasses the challenging task of multi-channel single-unit recording from behaving animals and obviates the need for the extensive decoding of information from large datasets. Finally, the authors used optogenetic stimulation, which also enjoys the advantage of fine-tuning the activity of a genetically defined set of neurons in a given brain area.

In summary, this study demonstrated an optical brain-to-brain interface that supports rapid information transmission for precise locomotion control, and represented a major step toward realizing the full potential of BtBIs.

Additive manufacturing is a technique in which the final three-dimensional object is produced by successively adding new layers of building material to those that have already been deposited. Recently, the commercially available 3D printers have been experiencing rapid development and so do the 3D-printers materials, including transparent media of high optical quality. These advancements open up new possibilities in many fields of science and technology including biology, medicine, metamaterials studies, robotics and micro-optics.

Researchers from the Faculty of Physics, University of Warsaw, Poland, have designed tiny lenses (with dimensions as small as a fraction of the human hair diameter) that can easily be manufactured by laser 3D printing technique on top of various materials, including fragile novel 2D graphene-like materials. The presented lenses increase the extraction of light emitted from semiconductor samples and reshape its outgoing part into an ultra-narrow beam. Thanks to this property, there is no longer a need for including a bulky microscope objective in the experimental setup when performing optical measurements of single nanometre-sized light emitters (like quantum dots), which up to now could not be avoided. A typical microscope objective used in such a study has roughly a handbreadth size, weights up to one pound (half a kilogram) and must be placed at a distance of about one-tenth of an inch (few millimetres) from the analysed sample. These impose significant limitations on many types of modern experiments, like measurements in pulsed high magnetic fields, at cryogenic temperatures or in microwave cavities, which on the other hand can easily be lifted by the presented lenses.

High speed of the 3D-printing technique makes it very easy to produce hundreds of microlenses on one sample. Arranging them into regular arrays provides a convenient coordinate system, which accurately specifies the location of a chosen nanoobject and allows for its multiple measurements in different laboratories all over the world. The invaluable opportunity of coming back to the same light emitter allows for much more time-efficient research and hypothesis testing. Specifically, one can entirely focus on designing and performing a new experiment on the nanoobject studied before, instead of carrying out a time-consuming investigation of thousands of other nanoobjects before eventually finding an analogue to the previous one.

The shape of the proposed microlenses can easily be adapted to the so-called 2.5D microfabrication technique. The objects satisfying its prerequisites can be produced over large-scale surfaces by pressing a patterned stamp against the layer of material they are supposed to be made of. The 2.5D fabrication protocol is especially attractive from the viewpoint of potential applications of the microlenses, as can be readily up-scaled which is an important factor in possible future industrial use.

Physics and Astronomy first appeared at the University of Warsaw in 1816, under the then Faculty of Philosophy. In 1825 the Astronomical Observatory was established. Currently, the Faculty of Physics' Institutes include Experimental Physics, Theoretical Physics, Geophysics, Department of Mathematical Methods and an Astronomical Observatory. The research covers almost all areas of modern physics, on scales from the quantum to the cosmological. The Faculty's research and teaching staff includes ca. 200 university teachers, of which 78 are employees with the title of professor. The Faculty of Physics, University of Warsaw, is attended by ca. 1000 students and more than 170 doctoral students.