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The B.1.167.2 (Delta) variant quickly became the predominant circulating SARS-CoV-2 strain in the USA during summer 2021. Missouri identified a high number of outbreaks in long-term care facilities (LTCFs) across the state with low vaccination rates among LTCF staff members and poor adherence to mitigation measures within local communities. To describe COVID-19 outbreaks that occurred in Missouri LTCFs impacting staff and residents during the surge of the Delta variant. Outbreaks of COVID-19 in 178 LTCFs were identified by the Missouri Department of Health and Senior Services. Case data from LTCFs with the highest burden of disease were analysed to assess disease transmission, vaccination status, and outcomes among residents and staff. Additional investigational measures included onsite visits to facilities with recent COVID-19 outbreaks in communities with substantial transmission to assess mitigation measures. During April 22nd to July 29th, 2021, 159 COVID-19 cases among 72 staff members and 87 residents were identified in 10 LTCFs. More than 74.7% of resident cases were vaccinated compared to 23.6% of staff cases. Vaccinated residents had a lower proportion of hospitalizations and deaths reported compared to unvaccinated residents. Data analysis and contact-tracing efforts from a sample of the facilities suggest that staff members were likely a major factor in introducing SARS-CoV-2 virus into the facilities. Adherence to COVID-19 mitigation measures varied at the visited facilities. Data showed that vaccination rates varied between staff cases and resident cases in facilities with high-burden outbreaks. Differences were identified in mitigation practices in at least two facilities. [ABSTRACT FROM AUTHOR]

Objective: The prediction of preeclampsia in pregnancy has resulted in a plethora of prognostic models. Yet, very few make it past the development stage and most fail to influence clinical practice. The timely identification of high-risk pregnant women could deliver a tailored antenatal care regimen, particularly in low-resource settings. This study externally validated and calibrated previously published models that predicted the risk of preeclampsia, based on blood pressure (BP) at multiple time points in pregnancy, in a geographically diverse population.Methods: The prospective INTERBIO-21st Fetal Study included 3,391 singleton pregnancies from Brazil, Kenya, Pakistan, South Africa, Thailand and the UK, 2012-2018. Preeclampsia prediction was based on baseline characteristics, BP and deviation from the expected BP trajectory at multiple time points in pregnancy. The prediction rules from the Avon Longitudinal Study of Parents and Children (ALSPAC) were implemented in the INTERBIO-21st cohort.Results: Model discrimination was similar to the development cohort. Performance was best with baseline characteristics and a BP measurement at 34 weeks' gestation (AUC 0.85, 95 % CI 0.80-0.90). The ALSPAC models largely overestimated the true risk of preeclampsia incidence in the INTERBIO-21st cohort.Conclusions: After recalibration, these prediction models could potentially serve as a risk stratifying tool to help identify women who might benefit from increased surveillance during pregnancy. [ABSTRACT FROM AUTHOR]

Chronic subdural hematoma is a common pathology that typically affects the elderly. The Middle Meningeal Artery (MMA) provides blood supply to the dura matter and feeds the membrane capillaries covering the subdural hematoma. MMA embolization is a minimally invasive procedure combining angiography, microcatheters, and polyvinyl alcohol particles. The procedure blocks blood flow to the system and can promote hematoma resolution. Patients undergoing MMA embolization routinely progress from INR→ICU→Neurosurgery intermediate care→home. ICU care of these patients adds additional days in hospital and multiple care team handoffs. • Establish inclusion criteria to identify MMA embolization patients who are appropriate to bypass ICU and receive ICU level care in the PACU • Improve patient safety by reducing number of transfers of care from 3 teams to 2 teams • Improve patient experience by decreasing length of stay (LOS) • Improve utilization of ICU resources by increasing ICU bed availability • Multidisciplinary collaboration including Neurosurgery, INR, Nursing leadership, ICU, PACU, and Neurosurgery inpatient Nursing teams • Patients who are eligible are identified pre-procedure • Communication regarding patient enrollment in MMA→ PACU pathway is provided to PACU, INR, ICU, and Neurosurgery inpatient teams • Staff education regarding care of this new population through in-services, Perianesthesia SharePoint site, newsletter communication, and at the elbow support • Improve patient experience and decreased LOS • Multidisciplinary team collaboration enhances communication and patient safety • Improve ICU utilization and decrease in care team hand-offs • Improve PACU staff confidence and competency in caring for the MMA embolization population • Potential for utilizing this model for future Interventional Neuroradiology procedures • Improve hospital throughput [ABSTRACT FROM AUTHOR]

• Insomnia in older adults is under recognized and undertreated, and not a result of normal aging. • Insomnia has significant negative effects on quality of life and daily functioning, and leads to increased stress and social isolation. • Qualitative methods reveal negative outcomes from insomnia not captured in traditional sleep assessments. Insomnia in older adults has been linked to increased incidence of falls, depression and anxiety, cognitive impairment, institutionalization, and mortality, but traditional sleep assessment instruments, designed for the general adult population, fail to capture many of the experiences and causes that are unique to older adults. This mixed methods study elicited open narratives from 18 older adults (6 men,12 women, mean age 84, SD= 7.62, range 67–96) who reported chronic insomnia or disrupted sleep to learn how poor sleep affected their quality of life and daily functioning. The interviews were supplemented with three widely used self-report sleep instruments to provide baseline sleep quality and hygiene scores. Content analysis of the participants' narratives revealed the overriding theme of Insomnia Is Exhausting , which exemplifies the physical and emotional strain this chronic condition creates, and four categories : A Bad Night, Self-Management, Stoicism and Consequences. The narratives revealed severe, negative effects on quality of life, including reduced functional capacity and increased stress, anxiety, and social isolation. The results of this study can be used as a foundation for interventions to enhance sleep quality for this population. [ABSTRACT FROM AUTHOR]

• On-demand recycling startups have proliferated in urban India over the past decade. • A host of seemingly disparate policies have together enabled this rise. • Startups rely primarily on aggregation of materials to make a profit in this sector. • Traditional informal actors (kabadiwalas) are likely to be displaced as a result. • To protect livelihoods, collective organizing and state intervention are needed. Over the past decade, urban India has seen the emergence and proliferation of startups that are offering on-demand recycling services using web- and mobile-based platforms. These firms replicate the services of informal workers known as kabadiwalas who have historically made their livelihoods through trade in recyclable materials. Existing analyses of platformization in developed world contexts fail to explain the rise of platformization in India because of the particularity of the relationship between platform firms and the informal economy. This paper contextualizes the rise of platform recycling startups within a generally conducive policy environment focused on improving sanitation, encouraging entrepreneurship, and expanding the use of information technology in India. An examination of business models deployed by these firms reveals how and why the structure of recycling markets does not allow for a 'lean' model typically adopted by platform firms in other sectors. Rather than merely connecting service providers to consumers, these startups rely on aggregating recyclable materials and dispossessing intermediaries such as kabadiwalas in order to generate surplus value in an otherwise saturated market. Relying on an analysis of online content about these new firms, this paper examines the strategies that firms use to legitimize themselves and delegitimize kabadiwalas in an attempt to displace and dispossess them from the market space. [ABSTRACT FROM AUTHOR]

Objective To determine the sub-national seasonal prevalence and trends in wasting from 2007 to 2010 among children aged 6–59 months in Somalia using remote sensing and household survey data from nutritional surveys. Methods Bayesian hierarchical space–time model was implemented using a stochastic partial differential equation (SPDE) approach in integrated nested Laplace approximations (INLA) to produce risk maps of wasting at 1 × 1 km 2 spatial resolution and predict to seasons in each year of study from 2007 to 2010. Results The prevalence of wasting was generally at critical levels throughout the country, with most of the areas remaining in the upper classes of critical and very critical levels. There was minimal variation in wasting from year-to-year, but a well-defined seasonal variation was observed. The mean difference of the prevalence of wasting between the dry and wet season ranges from 0% to 5%. The risks of wasting in the South Central zone were highest in the Gedo (37%) and Bay (32%) regions. In North East zone the risk was highest in Nugaal (25%) and in the North West zone the risk was high in Awdal and Woqooyi Galbeed regions with 23%. Conclusion There was a clear seasonal variation in wasting with minimal year-to-year variability from 2007 to 2010 in Somalia. The prevalence was high during the long dry season, which affects the prevalence in the preceding long rainy season. Understanding the seasonal fluctuations of wasting in different locations and at different times is important to inform timely interventions. [ABSTRACT FROM AUTHOR]

• Patients undergoing supratentorial craniotomy routinely progress from OR → ICU → Intermediate care → home • Eighty percent of patients are stable and ready for discharge to home the next day • ICU care adds one extra day and multiple care team hand-offs • Delayed throughput for outside hospital transfers and ED admissions secondary to ICU census • Increased OR holds • Establish inclusion criteria to identify patients who can safely bypass the ICU and receive ICU level care in PACU prior to discharge to floor • Improve patient safety by reducing number of transfers of care from 3 teams to 2 teams • Improve patient experience by reducing overall hospital stay (goal 24 hours) • Decrease length of stay (LOS) • Improve utilization of ICU resources • Decrease OR hold time and delayed hospital throughput due to ICU bed availability • Lower cost of neurosurgical care delivery and optimize health care value for neurosurgical patients • Multidisciplinary collaboration including: Neurosurgery, Nursing Leadership, ICU, PACU, and Neurosurgical Floor Nursing • Patients potentially eligible for the POC-PACU Pathway are identified prior to surgery • Information regarding patient enrollment in the pathway is communicated to relevant parties including flow managers, PACU charge nurse, and admitting via shared calendar • Development of PACU protocol care standards including escalation criteria • Staff education through multiple in-services, newsletter communication, and at the elbow support • All enrolled pilot patients (n=11) successfully discharged from PACU to floor • All enrolled pilot patients successfully discharged from floor to home the next day • Improved patient experience and decreased LOS • Improved ICU utilization and decrease in care team hand-offs • Pilot was successful and program expanded to include multiple neurosurgeons • Improved PACU staff confidence and competency in caring for the postoperative craniotomy population • Improve hospital throughput [ABSTRACT FROM AUTHOR]

Objective: We sought to provide evidence-based guidelines for utilization of Doppler studies for fetuses with intrauterine growth restriction (IUGR). Methods: Relevant documents were identified using PubMed (US National Library of Medicine, 1983 through 2011) publications, written in English, which describe the peripartum outcomes of IUGR according to Doppler assessment of umbilical arterial, middle cerebral artery, and ductus venosus. Additionally, the Cochrane Library, organizational guidelines, and studies identified through review of the above were utilized to identify relevant articles. Consistent with US Preventive Task Force suggestions, references were evaluated for quality based on the highest level of evidence, and recommendations were graded. Results and Recommendations: Summary of randomized and quasirandomized studies indicates that, among high-risk pregnancies with suspected IUGR, the use of umbilical arterial Doppler assessment significantly decreases the likelihood of labor induction, cesarean delivery, and perinatal deaths (1.2% vs 1.7%; relative risk, 0.71; 95% confidence interval, 0.52–0.98). Antepartum surveillance with Doppler of the umbilical artery should be started when the fetus is viable and IUGR is suspected. Although Doppler studies of the ductus venous, middle cerebral artery, and other vessels have some prognostic value for IUGR fetuses, currently there is a lack of randomized trials showing benefit. Thus, Doppler studies of vessels other than the umbilical artery, as part of assessment of fetal well-being in pregnancies complicated by IUGR, should be reserved for research protocols. [Copyright &y& Elsevier]

Background: Reference values for umbilical artery Doppler indices are used clinically to assess fetal well-being. However, many studies that have produced reference charts have important methodologic limitations, and these result in significant heterogeneity of reported reference ranges.Objectives: To produce international gestational age-specific centiles for umbilical artery Doppler indices based on longitudinal data and the same rigorous methodology used in the original Fetal Growth Longitudinal Study of the INTERGROWTH-21st Project.Study Design: In Phase II of the INTERGROWTH-21st Project (the INTERBIO-21st Study), we prospectively continued enrolling pregnant women according to the same protocol from 3 of the original populations in Pelotas (Brazil), Nairobi (Kenya), and Oxford (United Kingdom) that had participated in the Fetal Growth Longitudinal Study. Women with a singleton pregnancy were recruited at <14 weeks' gestation, confirmed by ultrasound measurement of crown-rump length, and then underwent standardized ultrasound every 5±1 weeks until delivery. From 22 weeks of gestation umbilical artery indices (pulsatility index, resistance index, and systolic/diastolic ratio) were measured in a blinded fashion, using identical equipment and a rigorously standardized protocol. Newborn size at birth was assessed using the international INTERGROWTH-21st Standards, and infants had detailed assessment of growth, nutrition, morbidity, and motor development at 1 and 2 years of age. The appropriateness of pooling data from the 3 study sites was assessed using variance component analysis and standardized site differences. Umbilical artery indices were modeled as functions of the gestational age using an exponential, normal distribution with second-degree fractional polynomial smoothing; goodness of fit for the overall models was assessed.Results: Of the women enrolled at the 3 sites, 1629 were eligible for this study; 431 (27%) met the entry criteria for the construction of normative centiles, similar to the proportion seen in the original fetal growth longitudinal study. They contributed a total of 1243 Doppler measures to the analysis; 74% had 3 measures or more. The healthy low-risk status of the population was confirmed by the low rates of preterm birth (4.9%) and preeclampsia (0.7%). There were no neonatal deaths and satisfactory growth, health, and motor development of the infants at 1 and 2 years of age were documented. Only a very small proportion (2.8%-6.5%) of the variance of Doppler indices was due to between-site differences; in addition, standardized site difference estimates were marginally outside this threshold in only 1 of 27 comparisons, and this supported the decision to pool data from the 3 study sites. All 3 Doppler indices decreased with advancing gestational age. The 3rd, 5th 10th, 50th, 90th, 95th, and 97th centiles according to gestational age for each of the 3 indices are provided, as well as equations to allow calculation of any value as a centile and z scores. The mean pulsatility index according to gestational age = 1.02944 + 77.7456*(gestational age)-2 - 0.000004455*gestational age3.Conclusion: We present here international gestational age-specific normative centiles for umbilical artery Doppler indices produced by studying healthy, low-risk pregnant women living in environments with minimal constraints on fetal growth. The centiles complement the existing INTERGROWTH-21st Standards for assessment of fetal well-being. [ABSTRACT FROM AUTHOR]

Severe anaemia often secondary to malaria is a major contributor to child mortality in sub-Saharan Africa. We have confirmed that use of simple clinical and laboratory criteria can identify those children likely to benefit most from treatment. We have also shown that the speed of response may be critical. The quality and capacity of blood transfusion services could therefore have a major, direct effect on inpatient child mortality. [Copyright &y& Elsevier]