Explore the vast range of titles available.

Before the coronavirus 2019 (COVID-19) pandemic began, antimicrobial resistance (AMR) was among the top priorities for global public health. Already a complex challenge, AMR now needs to be addressed in a changing healthcare landscape. Here, we analyse how changes due to COVID-19 in terms of antimicrobial usage, infection prevention, and health systems affect the emergence, transmission, and burden of AMR. Increased hand hygiene, decreased international travel, and decreased elective hospital procedures may reduce AMR pathogen selection and spread in the short term. However, the opposite effects may be seen if antibiotics are more widely used as standard healthcare pathways break down. Over 6 months into the COVID-19 pandemic, the dynamics of AMR remain uncertain. We call for the AMR community to keep a global perspective while designing finely tuned surveillance and research to continue to improve our preparedness and response to these intersecting public health challenges.

About the Authors: Monisha Sharma * E-mail: msharma1@uw.edu Affiliation: Department of Epidemiology, University of Washington, Seattle, Washington, United States of America ORCID http://orcid.org/0000-0002-7599-1561 Ruanne V. Barnabas Affiliations Department of Epidemiology, University of Washington, Seattle, Washington, United States of America, Department of Global Health, University of Washington, Seattle, Washington, United States of America, School of Medicine, University of Washington, Seattle, Washington, United States of America, Vaccine and Infectious Diseases Division, Fred Hutchinson Cancer Research Center, Seattle, Washington, United States of America Connie Celum Affiliations Department of Epidemiology, University of Washington, Seattle, Washington, United States of America, Department of Global Health, University of Washington, Seattle, Washington, United States of America, School of Medicine, University of Washington, Seattle, Washington, United States of AmericaCitation: Sharma M, Barnabas RV, Celum C (2017) Community-based strategies to strengthen men’s engagement in the HIV care cascade in sub-Saharan Africa. Abbreviations: ANC, antenatal care; APS, active partner notification service; ART, antiretroviral therapy; CD4, cluster of differentiation 4; DHS, Demographic and Health Survey(s); DO ART, Delivery Optimization for Antiretroviral Therapy; HOPE, Home-Based Partner Education and Testing; HTC, HIV testing and counseling; MSM, men who have sex with men; PrEP, pre-exposure prophylaxis; RCT, randomized controlled tria; SEARCH, Sustainable East Africa Research on Community Health; SHIMS, Swaziland HIV Incidence Measurement Survey; SMS, short message service; SSA, sub-Saharan Africa; VMMC, voluntary medical male circumcision Provenance: Not commissioned, externally peer reviewed Summary points * Men in sub-Saharan Africa are less likely than women to engage in HIV services across the care cascade, resulting in...

Background Dementia is caused by a variety of neurodegenerative diseases and is associated with a decline in memory and other cognitive abilities, while inflicting an enormous socioeconomic burden. The complexity of dementia and its associated comorbidities presents immense challenges for dementia research and care, particularly in clinical decision-making. Main body Despite the lack of disease-modifying therapies, there is an increasing and urgent need to make timely and accurate clinical decisions in dementia diagnosis and prognosis to allow appropriate care and treatment. However, the dementia care pathway is currently suboptimal. We propose that through computational approaches, understanding of dementia aetiology could be improved, and dementia assessments could be more standardised, objective and efficient. In particular, we suggest that these will involve appropriate data infrastructure, the use of data-driven computational neurology approaches and the development of practical clinical decision support systems. We also discuss the technical, structural, economic, political and policy-making challenges that accompany such implementations. Conclusion The data-driven era for dementia research has arrived with the potential to transform the healthcare system, creating a more efficient, transparent and personalised service for dementia.

The COVID-19 outbreak is putting tremendous strain on the US healthcare system, with a direct impact on medical professionals, hospital systems, and physical resources. While comprehensive public health and regulatory efforts are essential to overcome this crisis, it is important to recognize this moment as an opportunity to provide more intelligent and more efficient care in spite of increasing patient volumes and fewer resources. Specifically, we must limit unnecessary and wasteful medical practices and improve the delivery of those services which enhance the quality of patient care. In doing so, we will increase availability of the critical resources required for the provision of high-quality care to those in greatest need both now and in the future.

ObjectivesSeveral physiological abnormalities that develop during COVID-19 are associated with increased mortality. In the present study, we aimed to develop a clinical risk score to predict the in-hospital mortality in COVID-19 patients, based on a set of variables available soon after the hospitalisation triage.SettingRetrospective cohort study of 516 patients consecutively admitted for COVID-19 to two Italian tertiary hospitals located in Northern and Central Italy were collected from 22 February 2020 (date of first admission) to 10 April 2020.ParticipantsConsecutive patients≥18 years admitted for COVID-19.Main outcome measuresSimple clinical and laboratory findings readily available after triage were compared by patients’ survival status (‘dead’ vs ‘alive’), with the objective of identifying baseline variables associated with mortality. These were used to build a COVID-19 in-hospital mortality risk score (COVID-19MRS).ResultsMean age was 67±13 years (mean±SD), and 66.9% were male. Using Cox regression analysis, tertiles of increasing age (≥75, upper vs <62 years, lower: HR 7.92; p<0.001) and number of chronic diseases (≥4 vs 0–1: HR 2.09; p=0.007), respiratory rate (HR 1.04 per unit increase; p=0.001), PaO2/FiO2 (HR 0.995 per unit increase; p<0.001), serum creatinine (HR 1.34 per unit increase; p<0.001) and platelet count (HR 0.995 per unit increase; p=0.001) were predictors of mortality. All six predictors were used to build the COVID-19MRS (Area Under the Curve 0.90, 95% CI 0.87 to 0.93), which proved to be highly accurate in stratifying patients at low, intermediate and high risk of in-hospital death (p<0.001).ConclusionsThe COVID-19MRS is a rapid, operator-independent and inexpensive clinical tool that objectively predicts mortality in patients with COVID-19. The score could be helpful from triage to guide earlier assignment of COVID-19 patients to the most appropriate level of care.

Background Clinical pathways are tools used to guide evidence-based healthcare that have been implemented internationally since the 1980s. However, there is widespread lack of agreement on the impact of clinical pathways on hospital resources and patient outcomes. This can be partially attributed to the confusion for both researchers and healthcare workers regarding what constitutes a clinical pathway. This paper describes efforts made by a team of Cochrane Review authors to develop criteria to assist in the objective identification of clinical pathway studies from the literature. Methods We undertook a four-stage process aiming to develop criteria to define a clinical pathway: (1) identify publications exploring the definition of a clinical pathway; (2) derive draft criteria; (3) pilot test the criteria; and (4) modify criteria to maximise agreement between review authors. Results Previous literature and liaison with the European Pathways Association resulted in five criteria being used to define a clinical pathway: (1) the intervention was a structured multidisciplinary plan of care; (2) the intervention was used to translate guidelines or evidence into local structures; (3) the intervention detailed the steps in a course of treatment or care in a plan, pathway, algorithm, guideline, protocol or other 'inventory of actions'; (4) the intervention had timeframes or criteria-based progression; and (5) the intervention aimed to standardise care for a specific clinical problem, procedure or episode of healthcare in a specific population. After pilot testing it was decided that if an intervention met the first criteria (a structured multidisciplinary plan of care) plus three out of the other four criteria then it was included as a clinical pathway for the purposes of this review. In all, 27 studies were included in the final review. The authors of the included studies referred to these interventions as 'clinical pathways', 'protocols', 'care model', 'care map', 'multidisciplinary care', evidence-based care' and 'guideline'. Conclusions The criteria used for the identification of relevant studies for this Cochrane Review can be used as a foundation for the development of a standardised, internationally accepted definition of a clinical pathway.

Background Improving the quality and safety of perioperative care is a global priority. The Enhanced Peri-Operative Care for High-risk patients (EPOCH) trial was a stepped-wedge cluster randomised trial of a quality improvement (QI) programme to improve 90-day survival for patients undergoing emergency abdominal surgery in 93 hospitals in the UK National Health Service. Methods The aim of this process evaluation is to describe how the EPOCH intervention was planned, delivered and received, at both cluster and local hospital levels. The QI programme comprised of two interventions: a care pathway and a QI intervention to aid pathway implementation, focussed on stakeholder engagement, QI teamwork, data analysis and feedback and applying the model for improvement. Face-to-face training and online resources were provided to support senior clinicians in each hospital (QI leads) to lead improvement. For this evaluation, we collated programme activity data, administered an exit questionnaire to QI leads and collected ethnographic data in six hospitals. Qualitative data were analysed with thematic or comparative analysis; quantitative data were analysed using descriptive statistics. Results The EPOCH trial did not demonstrate any improvement in survival or length of hospital stay. Whilst the QI programme was delivered as planned at the cluster level, self-assessed intervention fidelity at the hospital level was variable. Seventy-seven of 93 hospitals responded to the exit questionnaire (60 from a single QI lead response on behalf of the team); 33 respondents described following the QI intervention closely (35%) and there were only 11 of 37 care pathway processes that > 50% of respondents reported attempting to improve. Analysis of qualitative data suggests QI leads were often attempting to deliver the intervention in challenging contexts: the social aspects of change such as engaging colleagues were identified as important but often difficult and clinicians frequently attempted to lead change with limited time or organisational resources. Conclusions Significant organisational challenges faced by QI leads shaped their choice of pathway components to focus on and implementation approaches taken. Adaptation causing loss of intervention fidelity was therefore due to rational choices made by those implementing change within constrained contexts. Future large-scale QI programmes will need to focus on dedicating local time and resources to improvement as well as on training to develop QI capabilities. EPOCH trial registration ISRCTN80682973 https://doi.org/10.1186/ISRCTN80682973 Registered 27 February 2014 and Lancet protocol 13PRT/7655.

Background While clinical pathways have the potential to improve patient outcomes and reduce healthcare costs, their true impact has been limited by variable implementation strategies and suboptimal research designs. This paper explores a comprehensive set of factors perceived by emergency department staff and administrative leads to influence clinical pathway implementation within the complex and dynamic environments of community emergency department settings. Methods This descriptive, qualitative study involved emergency health professionals and administrators of 15 community hospitals across Ontario, Canada. As part of our larger cluster randomized controlled trial, each site was in the preparation phase to implement one of two clinical pathways: pediatric asthma or pediatric vomiting and diarrhea. Data were collected from three sources: (i) a mediated group discussion with site champions during the project launch meeting; (ii) a semi-structured site visit of each emergency department; and (iii) key informant interviews with an administrative lead from each hospital. The Theoretical Domains Framework (TDF) was used to guide the interviews and thematically analyze the data. Domains within each major theme were then mapped onto the COM-B model—capability, opportunity, and motivation—of the Behaviour Change Wheel. Results Seven discrete themes and 58 subthemes were identified that comprised a set of barriers and enablers relevant to the planned clinical pathway implementation. Within two themes, three distinct levels of impact emerged, namely (i) the individual health professional, (ii) the emergency department team, and (iii) the broader hospital context. The TDF domains occurring most frequently were Memory, Attention and Decision Processes, Environmental Context and Resources, Behavioural Regulation, and Reinforcement. Mapping these barriers and enablers onto the COM-B model provided an organized perspective on how these issues may be interacting. Several factors were viewed as both negative and positive across different perspectives. Two of the seven themes were limited to one component, while four involved all three components of the COM-B model. Conclusions Using a theory-based approach ensured systematic and comprehensive identification of relevant barriers and enablers to clinical pathway implementation in ED settings. The COM-B system of the Behaviour Change Wheel provided a useful perspective on how these factors might interact to effect change. Trial registration ClinicalTrials.gov, NCT01815710 .

The COVID-19 pandemic has led to a surge of information being presented to clinicians regarding this novel and deadly disease. There is a clear urgency to collate, review, appraise and act on this information if we are to do the best for clinicians and patients. However, the speed of the pandemic is a threat to traditional models of knowledge translation and practice change. In this concepts paper, we argue that clinicians need to be agile in their thinking and practice in order to find the right time to change. Adoption of new methods should be based on clinical judgement, the weight of evidence and the balance of probabilities that any new technique, test or treatment might work. The pandemic requires all of us to reach a new level of evidence-based medicine characterised by scepticism, thoughtfulness, responsiveness and clinically agility in practice.

About the Authors: Matthew P. Fox * E-mail: mfox@bu.edu Affiliations Department of Global Health, Boston University School of Public Health, Boston, Massachusetts, United States of America, Department of Epidemiology, Boston University School of Public Health, Boston, Massachusetts, United States of America, Health Economics and Epidemiology Research Office, Department of Internal Medicine, School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa ORCID http://orcid.org/0000-0001-9887-0634 Sydney Rosen Affiliations Department of Global Health, Boston University School of Public Health, Boston, Massachusetts, United States of America, Health Economics and Epidemiology Research Office, Department of Internal Medicine, School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa ORCID http://orcid.org/0000-0002-6560-2964Citation: Fox MP, Rosen S (2017) A new cascade of HIV care for the era of “treat all”. Funding: MPF and SR received funding from the Bill & Melinda Gates Foundation through Funding Opportunity 1136158 to Boston University and by the generous support of the American people though Cooperative Agreement AID 674-A-12-00029 to the Wits Health Consortium from the United States Agency for International Development (USAID). Provenance: Not commissioned, externally peer reviewed Summary points * Now that the World Health Organization has recommended antiretroviral therapy for all people infected with HIV regardless of their CD4 count, millions more people will become eligible for HIV treatment. * We and others have previously described the cascade of care for HIV treatment for monitoring retention in care and targeting interventions to improve retention to areas of greatest need. * To...