Forecasting Model to Predict the Spreading of the COVID-19 Outbreak in Turkey

This study aimed to forecast the future of the COVID-19 outbreak parameters such as spreading, case fatality, and case recovery values based on the publicly available epidemiological data for Turkey. We first performed different forecasting methods including Facebook's Prophet, ARIMA and Decision Tree. Based on the metrics of MAPE and MAE, Facebook's Prophet has the most effective forecasting model. Then, using Facebook's Prophet, we generated a forecast model for the evolution of the outbreak in Turkey fifteen-days-ahead. Based on the reported confirmed cases, the simulations suggest that the total number of infected people could reach 4328083 (with lower and upper bounds of 3854261 and 4888611, respectively) by April 23, 2021. Simulation forecast shows that death toll could reach 35656 with lower and upper bounds of 34806 and 36246, respectively. Besides, our findings suggest that although more than 86.38% growth in recovered cases might be possible, the future active cases will also significantly increase compared to the current active cases. This time series analysis indicates an increase trend of the COVID-19 outbreak in Turkey in the near future. Altogether, the present study highlights the importance of an efficient data-driven forecast model analysis for the simulation of the pandemic transmission and hence for further implementation of essential interventions for COVID-19 outbreak.

Fibrodysplasia Ossificans Progressiva: A Challenging Diagnosis

Fibrodysplasia ossificans progressiva (FOP) is an ultrarare genetic condition characterized by extraskeletal bone formation. Most of the musculoskeletal characteristics of FOP are related to dysregulated chondrogenesis, with heterotopic ossification being the most typical feature. Activating mutations of activin receptor A type I (ACVR1), a bone morphogenetic protein (BMP) type I receptor, are responsible for the skeletal and nonskeletal features. The clinical phenotype is always consistent, with congenital bilateral hallux valgus malformation and early-onset heterotopic ossification occurring spontaneously or, more frequently, precipitated by trauma. Painful, recurrent soft-tissue swellings (flare-ups) precede localized heterotopic ossification that can occur at any location, typically affecting regions near the axial skeleton and later progressing to the appendicular bones. A diagnosis of FOP is suspected in a proband presenting with hallux valgus malformation, heterotopic ossification, and confirmed by the identification of a heterozygous pathogenic variant in the ACVR1/ALK2 gene. Avoiding unnecessary surgical procedures, prescribing prophylactic corticosteroids, preventing falls, and using protective headgear represent essential interventions for care management. Different classes of medications to contain acute inflammation flare-ups have been proposed, with high dose corticosteroids and nonsteroidal anti-inflammatory drugs usually utilized. Here, we report on two FOP patients, with typical clinical features summarizing the principal aspects of FOP, and we aim to provide comprehensive information outlining some unusual findings, possibly contributing to FOP’s definition and management.

Bridging the gap: aligning economic research with disease burden

IntroductionCost-effectiveness analysis (CEA) is critical for identifying high-value interventions that address significant unmet need. This study examines whether CEA study volume is proportionate to the burden associated with 21 major disease categories.MethodsWe searched the Tufts Medical Center CEA and Global Health CEA Registries for studies published between 2010 and 2019 that measured cost per quality-adjusted life-year or cost per disability-adjusted life-year (DALY). Stratified by geographical region and country income level, the relationship between literature volume and disease burden (as measured by 2019 Global Burden of Disease estimates of population DALYs) was analysed using ordinary least squares linear regression. Additionally, the number of CEAs per intervention deemed ‘essential’ for universal health coverage by the Disease Control Priorities Network was assessed to evaluate how many interventions are supported by cost-effectiveness evidence.ResultsThe results located below the regression line but with relatively high burden suggested disease areas that were ‘understudied’ compared with expected study volume. Understudied disease areas varied by region. Higher-income and upper-middle-income country (HUMIC) CEA volume for non-communicable diseases (eg, mental/behavioural disorders) was 100-fold higher than that in low-income and lower-middle-income countries (LLMICs). LLMIC study volume remained concentrated in HIV/AIDS as well as other communicable and neglected tropical diseases. Across 60 essential interventions, only 33 had any supporting CEA evidence, and only 21 had a decision context involving a low-income or middle-income country. With the exception of one intervention, available CEA evidence revealed the 21 interventions to be cost-effective, with base-case findings less than three times the GDP per capita.ConclusionOur analysis highlights disease areas that require significant policy attention. Research gaps for highly prevalent, lethal or disabling diseases, as well as essential interventions may be stifling potential efficiency gains. Large research disparities between HUMICs and LLMICs suggest funding opportunities for improving allocative efficiency in LLMIC health systems.

Evaluation and pilot implementation of essential interventions for the management of hypertension and prevention of cardiovascular diseases in primary health care in the Republic of Tajikistan

Background The aim of this study was to determine the feasibility of implementing and evaluating essential interventions for the management of hypertension and prevention of cardiovascular disease in primary healthcare in Tajikistan. Methods The study protocol was published a priori. A pragmatic, sequential, mixed methods explanatory design was piloted. The quantitative strand is reported here. All primary health care facilities that met inclusion criteria in Shahrinav district were included and computer randomized to either usual care or intervention. The intervention consisted of: adaptation of WHO PEN/HEARTS clinical algorithms for hypertension and diabetes, a two-day training of doctors and nurses, supportive supervision visits, clinical decision support tools, and quality improvement support. Data were collected from paper-based clinical records at baseline and 12 months follow-up. The primary outcome was blood pressure control among patients with hypertension, in addition to several secondary process indicators along the care pathway. Age and sex adjusted logistic regression models were used for intervention and control clinics to determine changes between baseline and follow-up and to assess interactions between allocation group and time. For continuous variables, multivariate linear regression models were used. Results 19 primary health care centres were included of which ten were randomized to intervention and nine to control. 120 clinicians received training. The records of all registered hypertensive patients were reviewed at baseline and follow-up for a total of 1,085 patient records. Blood pressure control significantly improved in the intervention clinics (OR 3.556, 95 % CI 2.219, 5.696) but not the control clinics (OR 0.644, 95 % CI 0.370, 1.121) (p < 0.001 for interaction). Smoking assessment, statin prescribing, triple therapy prescribing, and blood pressure measurement significantly improved in intervention clinics relative to control, whereas cholesterol and glucose testing, and aspirin prescribing did not. Conclusions It is feasible to use routine, paper-based, clinical records to evaluate essential CVD interventions in primary health care in Tajikistan. Adapted WHO PEN/HEARTS guidelines in the context of a complex intervention significantly improved blood pressure control after 12 months.

A Proof-of-Principle Study of the Design and Optimization of a Novel Fluid-Driven Automated Retracting Needle System

The cannulation of blood vessels is one of the most basic and essential interventions in medical practice. A common adverse event of this procedure is miscannulation with infiltration of the second part of the vessel wall, often resulting in a perivascular hematoma. In hemodialysis patients, surgically created arteriovenous conduits are cannulated 3–4 times per week to provide sufficient blood supply to the hemodialysis machine. However, the high blood flow and pressure in these vascular access sites increase the risk of complications upon miscannulation. A novel needle system that allows for rapid automatic retraction of the needle in response to contact with blood after positioning the cannula in the blood vessel was developed to reduce the risk of miscannulation. The device can easily be incorporated into existing needle designs. The mechanical functionality of the device was validated by testing prototypes in an ex vivo system. Optimization of the needle system was performed to enhance response time and piston shape. A final prototype design was manufactured and validated. The optimal membrane composition and piston shape were determined, which resulted in a needle response time of 40 ms upon contact with fluid at a pressure of 100 mmHg (arterial pressure). Here, we have successfully designed, mechanically validated, and tested a novel automated rapid needle retraction system that allows incorporation into existing needle systems. This device could notably decrease the difficulty of vessel cannulation and the prevalence of hematoma formation.

Traumatic Brain Injury Update

Traumatic brain injury is a devastating, life-changing event in most cases. After the primary brain insult, it is helpful to use evidence-based monitoring techniques to guide implementation of essential interventions to minimize secondary injury and thereby improve patient outcomes. An update on multimodal neuromonitoring is provided in this narrative review, with discussion of tools and techniques currently used in the treatment of patients with brain injury. Neuroprotective treatments, from the well-studied targeted temperature management to new potential therapeutics under investigation, such as glyburide, also are presented.

Oxygen administration for patients with ARDS

Acute respiratory distress syndrome (ARDS) is a fatal condition with insufficiently clarified etiology. Supportive care for severe hypoxemia remains the mainstay of essential interventions for ARDS. In recent years, adequate ventilation to prevent ventilator-induced lung injury (VILI) and patient self-inflicted lung injury (P-SILI) as well as lung-protective mechanical ventilation has an increasing attention in ARDS.Ventilation-perfusion mismatch may augment severe hypoxemia and inspiratory drive and consequently induce P-SILI. Respiratory drive and effort must also be carefully monitored to prevent P-SILI. Airway occlusion pressure (P0.1) and airway pressure deflection during an end-expiratory airway occlusion (Pocc) could be easy indicators to evaluate the respiratory drive and effort. Patient-ventilator dyssynchrony is a time mismatching between patient’s effort and ventilator drive. Although it is frequently unrecognized, dyssynchrony can be associated with poor clinical outcomes. Dyssynchrony includes trigger asynchrony, cycling asynchrony, and flow delivery mismatch. Ventilator-induced diaphragm dysfunction (VIDD) is a form of iatrogenic injury from inadequate use of mechanical ventilation. Excessive spontaneous breathing can lead to P-SILI, while excessive rest can lead to VIDD. Optimal balance between these two manifestations is probably associated with the etiology and severity of the underlying pulmonary disease.High-flow nasal cannula (HFNC) and non-invasive positive pressure ventilation (NPPV) are non-invasive techniques for supporting hypoxemia. While they are beneficial as respiratory supports in mild ARDS, there can be a risk of delaying needed intubation. Mechanical ventilation and ECMO are applied for more severe ARDS. However, as with HFNC/NPPV, inappropriate assessment of breathing workload potentially has a risk of delaying the timing of shifting from ventilator to ECMO. Various methods of oxygen administration in ARDS are important. However, it is also important to evaluate whether they adequately reduce the breathing workload and help to improve ARDS.

COVID-19 Pandemic: Perspective From Italian Pediatric Emergency Physicians

ABSTRACTObjectives:To document the lived experience of Italian pediatric emergency physicians during the coronavirus disease 2019 (COVID-19) pandemic.Methods:We developed a structured interview to collect the lived experience of the staff of the pediatric emergency department (PED) of a tertiary referral university hospital in Northern Italy. The open-ended questions were draft according to the suggestions of Canadian colleagues and administered by 1 interviewer, who was part of the PED staff, at the end of March 2020. All the PED staff was interviewed, on a voluntary basis, using purposive sampling.Results:Most respondents declared to be afraid of becoming infected and of infecting their families. The number of patients seen in the PED has decreased, and the cases tend to be more severe. A shift in the clinical approach to the ill child has occurred, the physical examination is problem-oriented, aiming to avoid un-necessary maneuvers and to minimize the number of practitioners involved. The most challenging aspects reported are: (1) performing a physical examination in personal protective equipment (PPE), (2) being updated with rapidly evolving guidelines, and (3) staying focused on the possible COVID-19 clinical presentation without failing in differential diagnosis.Conclusions:During the COVID-19 pandemic, it seems that pediatric emergency physicians are radically changing their clinical practice, aiming at prioritizing essential interventions and maneuvers and self-protection.

Grain Legumes Production in Ethiopia: A Review of Adoption, Opportunities, Constraints and Emphases for Future Interventions

Accelerating agricultural growth remains one of the most urgent goal of Ethiopia as the agricultural sector is the backbone of the Ethiopian economy. The adoption of new agricultural technologies and improved practices are particularly important in increasing agricultural production. This comprises strengthening legumes adoption and production as it contributes to better food security and more sustainable farming systems. Grain legumes are necessary elements of crop production in Ethiopia. The adoption and use of legume crops have been advocated for enhanced nutrition and preserving soil resources. Different improved varieties and legume production technologies have been made available to farmers through various sectors and projects in the country. Various policy measures and initiatives have also been made in improving the adoption, technology generation and contribution of legumes to the various system. Despite their contribution and considerable initiatives, over-all level of adoption and use of legume production is still low. A wide array of technical, economic, social, and institutional factors has been found to encounter the adoption, use and production of legumes along with their value-chain. However, there are still various opportunities that different grain legumes are to be adopted and promoted to increase production and productivity. Essential interventions, innovative approaches, increased production packages and improved technologies and market access should be emphasized and integrated to strengthen grain legumes adoption and production.

Abstract WP443: Brain Matters Competition

Our goal was to improve patient metrics of stroke care by implementing competition among caregivers in the emergency department (ED). Patient metrics of stroke care are being tracked very closely for all stroke center organizations across the nation. Every year brings on challenges of meeting new evidenced based clinical practices metrics. This can be an ongoing challenge in healthcare. We recognized the need to improve our stroke care process numbers. Half of stroke survivors are left with some neurological deficit. Avoiding complications by providing time sensitive and systematic process is crucial to promote best outcomes for stroke patients. The timed targets for essential interventions during a stroke patients arrival to any ED include door to provider in < 10 min, door to stroke activation in < 15 min door to CT in < 20 min (new 2019), door to drug < 60 min (85% of cases), door to drug < 45 min (75% cases) and door to drug in 30 min (50% of cases – new 2019). Although our hospital was near the 20 min for door to CT we saw room for improvement. Refining the process from pre-arrival has a direct impact on treatment and intervention times later in the ED. Our door to drug posed more of a challenge from the previous year so we knew we had work to do. Using a competitive atmosphere in achieving outcomes is becoming more recognized as a powerful tool to promote engagement and motivation of caregivers in the healthcare system. We started with our EMS providers and established best door to CT time recognition. The RN’s with the best door to drug (< 45 min) were also acknowledged. 2018 year end data door to CT =21 min door to drug < 60 min (95%) < 45 min (33.3%) 2019 thru May door to CT =16 min, door to drug <60 min (100%), < 45 min (78%), < 30 min (33%). Overall metrics got better. Staff were engaged in the process of stroke care. Overall tPA times decreased from 47 min (2018) to 39 min (2019).