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To determine which nursing home (NH) resident-level admission characteristics are associated with potentially preventable emergency department (PPED) transfers.We conducted a population-level retrospective cohort study on NH resident data collected using the Resident Assessment Instrument-Minimum Data Set Version 2.0 and linked to the National Ambulatory Care Reporting System for ED transfers.We used all NH resident admission assessments from January 1, 2017, to December 31, 2018, in Ontario.The cohort included the admission assessment of 56,433 NH residents.PPED transfers were defined based on the International Classification of Disease, Version 10 (Canadian) We used logistic regression with 10-fold cross-validation and computed average marginal effects to identify the association between resident characteristics at NH admission and PPED transfers within 92 days after admission.Overall, 6.2% of residents had at least 1 PPED transfer within 92 days of NH admission. After adjustment, variables that had a prevalence of 10% or more that were associated with a 1% or more absolute increase in the risk of a PPED transfer included polypharmacy [of cohort (OC) 84.4%, risk difference (RD) 2.0%], congestive heart failure (OC 29.0%, RD 3.0%), and renal failure (OC 11.6%, RD 1.2%). Female sex (OC 63.2%, RD -1.3%), a do not hospitalize directive (OC 24.4%, RD -2.6%), change in mood (OC 66.9%, RD -1.2%), and Alzheimer's or dementia (OC 62.1%, RD -1.2%) were more than 10% prevalent and associated with a 1% or more absolute decrease in the risk of a PPED.Though many routinely collected resident characteristics were associated with a PPED transfer, the absence of sufficiently discriminating characteristics suggests that emergency department visits by NH residents are multifactorial and difficult to predict. Future studies should assess the clinical utility of risk factor identification to prevent transfers.

IntroductionRedirecting suitable patients from the emergency department (ED) to alternative subacute settings may assist in reducing ED overcrowding while delivering equivalent care. The Emergency Department Avoidance Classification (EDAC) was constructed to retrospectively classify ED visits that may have been suitable for safe management in a subacute or virtual clinical setting. The EDAC has established face and content validity but has not been tested against a reference standard as a criterion.ObjectivesOur primary objective is to examine the agreement between the EDAC and ED physician judgements in retrospectively identifying ED visits suitable for subacute care management. Our secondary objective is to assess the validity of ED physicians’ judgement as a criterion standard. Our tertiary objective is to examine how the ED physician’s perception of a virtual ED care alternative correlates with the EDAC.Methods and analysisA randomised single-centre, single-blinded agreement study. We will randomly select ED charts between 1 January and 31 December 2019 from an academic hospital in Hamilton, Canada. ED charts will be randomly assigned to participating ED physicians who will evaluate if this ED visit could have been managed appropriately and safely in a subacute and/or virtual model of care. Each chart will be reviewed by two physicians independently. We compute our needed sample size to be 79 charts. We will use kappa statistics to measure inter-rater agreement. A repeated measures regression model of physician ratings will provide variance estimates that we will use to assess the intraclass correlation of ED physician ratings and the EDAC.Ethics and disseminationThis study has been approved by the Hamilton Integrated Research Ethics Board (2022-14625). If validated, the EDAC may provide an ED-based classification to identify potentially avoidable ED visits, monitor ED visit trends, and proactively delineate those best suited for subacute or virtual care models.

Tropical cyclones are among the costliest disasters in the world, with reported losses amounting to billions of US dollars on an annual basis. To reduce the impact of disasters including cyclones, Zimbabwe signed the Sendai Framework whose Target C is aimed at reducing the direct economic losses of disasters. Under the direction of the United Nations Office for Disaster Risk Reduction (UNDRR), an open-ended intergovernmental expert working group (OIEWG) developed a simple methodology for estimating direct disaster-economic loss. Therefore, this study tested the applicability of the OIEWG methodology in assessing the direct economic losses induced by Tropical Cyclone Idai (TCI) in Zimbabwe. The results revealed that TCI inflicted huge losses in most sectors of the economy, notably the housing, agriculture and the critical infrastructure. The sectoral analysis approach of the OIEWG methodology worked well in distinguishing direct and indirect loses as well as in underlining the need to adopt and effectively implement adequate risk reduction strategies in the built environment. Strengthening such strategies such as the ‘build back better’ principle, cyclone forecasting and warning systems and constructing cyclone-resilient infrastructure is critical in order to minimise direct losses attributed to cyclones.

Climate variability and change (CVC) affect many economic sectors including agriculture. In order to alleviate the negative impact of CVC on food production, farmers must adopt a range of strategies. However, the strategies will be less effective if farmers’ perceptions on CVC are not considered. This study therefore, examined the perceptions of commercial farmers on CVC and their adaptation strategies to the perceived impacts. It used a cross-sectional survey involving 365 farmers in the intensive farming region of Zimbabwe. Results showed that farmers’ perceptions on increasing temperatures and decreasing rainfall amounts were cognate with climate data from the meteorological office. The findings also demonstrated that farmers were well aware of the CVC impacts on their livelihoods. These include increases in the frequency and severity of drought, and a shortening of the length of the rainy season. However, the most significant changes were observed among the natural and economic capitals including soil salinization, reduction in grazing pastures, fodder and crop yields in addition to increases in food prices. In response to the perceived impacts of local CVC, the farmers were adopting crop and land use management strategies that include planting rotation, cultivating short-season varieties and drought tolerant crops, crop and farm diversification, intensified irrigation, agroforestry, soil moisture conservation and mixed farming. The study concludes that farmers are active observers of local CVC. Therefore, they should modify their agricultural calendar and diversify their farming systems so as to better meet current and future risks from CVC.

To determine if nursing home (NH) resident characteristics associated with potentially preventable emergency department transfers (PPEDs) are similarly associated with non-potentially preventable emergency department transfers (non-PPEDs).We conducted a population-level retrospective cohort study using linked administrative data reported using the Resident Assessment Instrument-Minimum Data Set Version 2.0 and the National Ambulatory Care Reporting System for emergency department transfers.We assessed all NH residents transferred to the emergency department within 92 days after admission. The cohort included 56,433 NH resident admissions assessment of which 3498 NH residents experienced PPEDs, and 9331 residents experienced non-PPEDs.We assessed Ontario NH residents admission assessments collected between January 1, 2017, and December 31, 2018. We used cumulative incidence functions and Cox regression to compare resident characteristics between residents experiencing PPEDs and non-PPEDs. PPEDs were defined based on the International Classification of Diseases, 10th Revision.Approximately 23% of residents experienced an emergency department transfer within 92 days of NH admission. The cumulative incidence of PPEDs was 6.3% and non-PPEDs was 16.8%. After adjusting for clinically relevant features, 14 of 18 resident admission characteristics were associated with both types of transfers. Resident admission characteristics associated with a greater risk of PPEDs solely were pneumonia [hazard ratio (HR) 1.48; CI 1.25-1.70] and oxygen therapy (HR 1.88; CI 1.69-2.10). Resident admission characteristics associated with a greater risk of non-PPEDs solely are experiencing a change in mood (HR 1.09; CI 1.01-1.18) and delirium (HR 1.08; CI 1.04-1.13).PPEDs were associated with a similar cluster of NH resident characteristics as those transferred for non-ambulatory reasons, suggesting that the clinical distinction between PPEDs vs non-PPEDs within the NH might be unclear. These findings highlight that the PPED indicator could be revised to improve specificity.

Abstract The study of land use land cover has become increasingly significant with the availability of remote sensing data. The main objective of this study is to delineate geohazard-prone areas using semi-automatic classification technique and Sentinel-2 satellite imagery in Bhutan. An open-source, semi-automatic classification plugin tools in QGIS software enabled efficient and rapid conduct of land cover classification. Band sets 2-8, 8A, and 11-12 are utilized and the virtual colour composites have been used for the clustering and creation of training samples or regions of interest. An iterative self-organizing data analysis technique is used for clustering and the image is classified by a minimum distance algorithm in the unsupervised classification. The Random Forest (RF) classifier is used for the supervised classification. The unsupervised classification shows an overall accuracy of 85.47% (Kappa coefficient = 0.71) and the RF classifier resulted in an accuracy of 92.62% (Kappa coefficient = 0.86). A comparison of the classification shows a higher overall accuracy of the RF classifier with an improvement of 7.15%. The study highlights 35.59% (512,100 m2) of the study area under the geohazard-prone area. The study also overlaid the major landslide polygons to roughly validate the landslide hazards. Article highlights Semi-automatic classification technique was applied to delineate the geohazard-prone area in the heterogeneous region of Bhutan Himalaya. Unsupervised and supervised classification technique were used to perform land cover classification using the semi-automatic classification plugin (SCP). The Random Forest classifier predicted higher accuracy and the application is rapid and efficient compared to the unsupervised classification.

Objectives/Background and Objectives Prior epidemics of high-mortality human coronaviruses, such as the acute respiratory syndrome coronavirus (SARS-CoV or SARS-1) in 2003, have driven the characterization of compounds that could be possibly active against the currently emerging novel coronavirus SARS-CoV-2 (COVID-19). Presently, no approved treatment or prophylaxis is available for COVID-19. We comment on the existing COVID-19 research methodologies in general and the published reporting. Given the media attention and claims of effectiveness, we chose chloroquine and hydroxychloroquine, in combination with azithromycin, as an area of COVID-19 research to examine. Methods/Study Design and Setting MEDLINE and EMBASE electronic databases were searched from 2019 to present (April 3rd, 2020) using a mix of keywords such as COVID-19 and chloroquine and hydroxychloroquine. We also searched the largest clinical medicine preprint repository, medRxiv.org. Results We found 6 studies, 3 randomized control trials and 3 observational studies, focusing on chloroquine and hydroxychloroquine (with azithromycin). We critically appraised the evidence. Conclusion We found that the COVID-19 research methodology is very poor in the area of chloroquine/hydroxychloroquine research. In screening the literature, we observed the same across COVID-19 research in relation to potential treatments. The reporting is very poor and sparse, and patient-important outcomes needed to discern decision-making priorities are not reported. We do understand the barriers to perform rigorous research in health care settings overwhelmed by a novel deadly disease. However, this emergency pandemic situation does not transform flawed methods and data into credible results. The adequately powered, comparative, and robust clinical research that is needed for optimal evidence-informed decision-making remains absent in COVID-19.

Background Little is known about the prognostic differences between older emergency department (ED) patients who present with different formal support requirements in the community. We set out to describe and compare the patient profiles and patterns of health service use among three older ED cohorts: home care clients, nursing home residents and those receiving no formal support. Methods We conducted a secondary analysis of the Canadian cohort from the interRAI multinational ED study. Data were collected using interRAI ED contact assessment on patients 75 years of age and older (n = 2,274), in eight ED sites across Canada. A series of descriptive statistics were reported. Adjusted as­sociations were determined using logistic regression. Results Older adults receiving no formal support services were most stable. However, they were most likely to be hospitalized. Older home care clients were most likely to report depressive symptoms and distressed caregivers. They also had the great­est odds of frequent ED visitation post-discharge (OR=1.9; 95% CI=1.39–2.59). Older adults transferred from a nursing home were the frailest but had the lowest odds of hospital admission (OR=0.14; 95% CI=0.09–0.23). Conclusion We demonstrated the importance of inquiring about commu­nity-based formal support services and provide data to support decision-making in the ED.

Background: Studies on COVID-19 infection in pregnancy thus far have largely focused on characterizing maternal and neonatal clinical characteristics. However, another evolving focus is assessing and mitigating the risk of vertical transmission amongst COVID-19-positive mothers. The objective of this review was to summarize the current evidence on the vertical transmission potential of COVID-19 infection in the third trimester and its effects on the neonate.Methods: OVID MEDLINE, EMBASE, and Cochrane Central Register of Controlled Trial (CENTRAL) were searched from January 2020 to May 2020, with continuous surveillance.Results: 18 studies met the inclusion criteria, consisting of 157 mothers and 160 neonates. The mean age of the pregnant patients was 30.8 years and the mean gestational period was 37 weeks and 1 d. Currently, there is currently no conclusive evidence to suggest that vertical transmission of SARS-CoV-2 occurs. Amongst 81 (69%) neonates who were tested for SARS-CoV-2, 5 (6%) had a positive result. However, amongst these 5 neonates, the earliest test was performed at 16 h after birth, and only 1 neonate was positive when they were later re-tested. However, this neonate initially tested negative at birth, suggesting that the SARS-CoV-2 infection was likely hospital-acquired rather than vertically transmitted. 13 (8%) neonates had complications or symptoms.Conclusions: The findings of this rapid descriptive review based on early clinical evidence suggest that vertical transmission of SARS-CoV-2 from mother to neonate/newborn did not occur. Future studies are needed to determine the optimal management of neonates born to COVID-19-positive mothers.

BackgroundCoronavirus disease 2019 (COVID-19), caused by the novel coronavirus SARS-CoV-2, has led to significant global mortality and morbidity. Until now, no treatment has proven to be effective in COVID-19. To explore whether the use of remdesivir, initially an experimental broad-spectrum antiviral, is effective in the treatment of hospitalized patients with COVID-19, we conducted a systematic review and meta-analysis of randomized, placebo-controlled trials investigating its use.MethodsA rapid search of the MEDLINE and EMBASE medical databases was conducted for randomized controlled trials. A systematic approach was used to screen, abstract, and critically appraise the studies. Grading of Recommendations Assessment, Development, and Evaluation (GRADE) method was applied to rate the certainty and quality of the evidence reported per study.ResultsTwo RCTs studies were identified (n=1,299). A fixed-effects meta-analysis revealed reductions in mortality (RR=0.69, 0.49 to 0.99), time to clinical improvement (3.95 less days, from 3.86 days less to 4.05 less days), serious adverse events (RR=0.77, 0.63 to 0.94) and all adverse events (RR=0.87, 0.79 to 0.96).ConclusionIn this rapid systematic review, we present pooled evidence from the 2 included RCT studies that reveal that remdesivir has a modest yet significant reduction in mortality and significantly improves the time to recovery, as well as significantly reduced risk in adverse events and serious adverse events. It is more than likely that as an antiviral, remdesivir is not sufficient on its own and may be suitable in combination with other antivirals or treatments such as convalescent plasma. Research is ongoing to clarify and contextual these promising findings.

Introduction Acute respiratory distress syndrome (ARDS) is a life-threatening disease characterized by respiratory failure with rapidly progressing inflammation. Currently, no effective pharmacological treatment for ARDS is available. Objectives We conducted this systematic review and meta‑ analysis to examine the use of interferon beta-1a in patients with ARDS. Methods Data sources included the following databases: MEDLINE, EMBASE, and the Cochrane Central Register of Controlled Trials. We retained trials from 1996 to February 25, 2020 that comparatively examined the use of interferon beta-1a in patients with ARDS. Two reviewers identified eligible studies, independently extracted study data, and assessed the risk of bias. The authors evaluated the certainty of evidence using the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) approach. Results We included 2 trials (n = 392 patients). No significant differences in 28-day hospital mortality (risk ratio [RR], 0.59; 95% CI, 0.13-2.67; P = 0.49; very low certainty) and the number of ventilator-free days (mean difference, 4.85 days; 95% CI, -3.25 to 12.93; P = 0.24, very low certainty) were observed in patients treated with interferon beta-1a compared with those not receiving this drug. Interferon beta-1a also had no significant impact on the risk of adverse events (RR, 0.98%; 95% CI, 0.94-1.03; P = 0.47; low certainty). Conclusions The use of interferon beta-1a does not appear to improve mortality or reduce the number of ventilator-free days and adverse events in patients with ARDS. This review is based on 2 small studies reporting a limited number of events, which raises questions regarding the true effects of interferon beta-1a. The analysis of 1 study revealed increased mortality with the concomitant use of corticosteroids and interferon beta-1a, suggesting a need for careful consideration of this drug-drug interaction.

INTRODUCTION Acute respiratory distress syndrome (ARDS) is a rapidly progressing, inflammatory lung disease with a high mortality rate and no specific pharmacological treatment available. OBJECTIVES We conducted a systematic review and meta‑analysis on corticosteroid use in ARDS. METHODS We searched 4 medical literature databases and retained randomized controlled trials on the use of corticosteroids in hospitalized adults with ARDS, which could be found there until February 2020. Two reviewers identified eligible studies, independently extracted data, and evaluated the risk of bias. The authors assessed the certainty of evidence using the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) approach. RESULTS We included 7 randomized controlled trials involving 851 patients. They showed that corticosteroids reduced all‑cause mortality (risk ratio [RR], 0.75; 95% CI, 0.59-0.95; P = 0.02; moderate certainty) and the duration of mechanical ventilation (mean difference [MD], -4.93 days; 95% CI; -7.81 to -2.06; P

Background Dietary recommendations and policies should be guided by rigorous systematic reviews. Reviews that are of poor methodological quality may be ineffective or misleading. Most of the evidence in nutrition comes from nonrandomized studies of nutritional exposures (usually referred to as nutritional epidemiology studies), but to date methodological evaluations of the quality of systematic reviews of such studies have been sparse and inconsistent. Objectives We aimed to investigate the quality of recently published systematic reviews and meta-analyses of nutritional epidemiology studies and to propose guidance addressing major limitations. Methods We searched MEDLINE (January 2018-August 2019), EMBASE (January 2018-August 2019), and the Cochrane Database of Systematic Reviews (January 2018-February 2019) for systematic reviews of nutritional epidemiology studies. We included a random sample of 150 reviews. Results Most reviews were published by authors from Asia (n = 49; 32.7%) or Europe (n = 43; 28.7%) and investigated foods or beverages (n = 60; 40.0%) and cancer morbidity and mortality (n = 54; 36%). Reviews often had important limitations: less than one-quarter (n = 30; 20.0%) reported preregistration of a protocol and almost one-third (n = 42; 28.0%) did not report a replicable search strategy. Suboptimal practices and errors in the synthesis of results were common: one-quarter of meta-analyses (n = 30; 26.1%) selected the meta-analytic model based on statistical indicators of heterogeneity and almost half of meta-analyses (n = 50; 43.5%) did not consider dose-response associations even when it was appropriate to do so. Only 16 (10.7%) reviews used an established system to evaluate the certainty of evidence. Conclusions Systematic reviews of nutritional epidemiology studies often have serious limitations. Authors can improve future reviews by involving statisticians, methodologists, and researchers with substantive knowledge in the specific area of nutrition being studied and using a rigorous and transparent system to evaluate the certainty of evidence.

BackgroundAn essential component of systematic reviews is the assessment of risk of bias. To date, there has been no investigation of how reviews of non-randomised studies of nutritional exposures (called ‘nutritional epidemiologic studies’) assess risk of bias.ObjectiveTo describe methods for the assessment of risk of bias in reviews of nutritional epidemiologic studies.MethodsWe searched MEDLINE, EMBASE and the Cochrane Database of Systematic Reviews (Jan 2018–Aug 2019) and sampled 150 systematic reviews of nutritional epidemiologic studies.ResultsMost reviews (n=131/150; 87.3%) attempted to assess risk of bias. Commonly used tools neglected to address all important sources of bias, such as selective reporting (n=25/28; 89.3%), and frequently included constructs unrelated to risk of bias, such as reporting (n=14/28; 50.0%). Most reviews (n=66/101; 65.3%) did not incorporate risk of bias in the synthesis. While more than half of reviews considered biases due to confounding and misclassification of the exposure in their interpretation of findings, other biases, such as selective reporting, were rarely considered (n=1/150; 0.7%).ConclusionReviews of nutritional epidemiologic studies have important limitations in their assessment of risk of bias.

Building resilience to disasters has become a strategic goal of many risk reduction programs across the globe. This is because resilience ensures that communities develop capacities which prevent or minimise loses to disasters. In view of this, there is need to develop a baseline that tracks changes in resilience through time. This study responded to this gap in Zimbabwe by developing composite resilience indices (CRI) using 26 variables that reflected 5 subdomains of resilience: community capital, economic, infrastructure, social and health. The CRI were then used to map the spatial variation of resilience across 91 districts. The results show that the majority of the districts with below moderate resilience are mainly rural and marginalised, while the most resilient districts emerged in urban areas where service provision and infrastructure are better developed. These findings were further subjected to factor analyses which deconstructed the overall CRI and identified six latent factors behind resilience: infrastructure, health, household head, and income, access to maize and fortified food. These factors were mapped in a GIS environment to show their geographic variation in the country. Furthermore, Moran's Index and the Getis Ord Gi* statistical tests were applied to determine clusters of resilience across space. Results confirmed the spatial clustering of CRI. The results are therefore, useful in planning mitigation, response and preparedness measures across the country.

This article explores Nepal׳s vulnerability from a local perspective. Nepal currently has a disaster management policy and legislative framework yet it is perceived as not trickling down effectively to make significant progress in reducing the impact of disasters at the local level. The article uses the case study method to explore local disaster vulnerability in the Mountain, Hill and Terai regions of Nepal. It concludes that a lack of micro-disaster vulnerability analysis is a problem that remains for effective disaster risk management in Nepal. On the one hand, disaster management practitioners create and enforce disaster management programmes without location-specific knowledge. On the other hand, traditional, less scientific and less disaster risk reduction-centred administrative approaches dominate and push local people into situations where they are vulnerable to disasters.

This paper explores the circumstances in which communities may effectively reduce risks. It draws on the example of two 'Risk and Resilience Committees' (RRCs) that were established in Nepal as part of an action research project: one in Panchkhal in the central region, operating as a community-based organisation (CBO); and the other in Dhankuta in the eastern region, embedded in municipal government. In-depth interviews were conducted with RRC members. Wider community preferences for risk reduction were examined through a questionnaire survey. In Dhankuta, the RRC obtained further funding, developed strong upward and downward institutional links, and applied a 'disaster risk reduction lens' to existing local government responsibilities. In Panchkhal, RRC activities have been limited by funding and have focused on the strengthening of livelihoods. It may be concluded tentatively that community-based disaster risk reduction activities are more successful when they are institutionally embedded in local government structures.

In the neo-liberal climate of reduced responsibility for the state, alongside global platforms established to implement the Hyogo Framework for Action, a new arena opens for a multitude of stakeholders to engage in disaster risk reduction (DRR). The key role that the state can play in instituting effective DRR tends to receive little attention, yet in situations where the state apparatus is weak, such as in Nepal, it becomes evident that integrating DRR into development is a particularly challenging task. Due to the political situation in Nepal, progress has been stalled in providing a legislative context conducive to effective DRR. This paper traces the evolution of key DRR initiatives that have been developed in spite of the challenging governance context, such as the National Strategy for Disaster Risk Management and the Nepal Risk Reduction Consortium. Informed by in-depth interviews with key informants, the argument is made that the dedicated efforts of national and international non-governmental organisations, multilateral agencies and donors in mainstreaming DRR demonstrate that considerable progress can be made even where government departments are protective of their own interests and are slow to enact policies to support DRR. The paper suggests however, that without stronger engagement of key political actors the prospects for further progress in DRR may be limited. The findings have implications for other post-conflict countries or weak states engaging in DRR.

The people of Nepal today are exposed to perennial local disaster events and profound vulnerability to disaster. The combined efforts of government, donors, UN agencies, NGOs, and Nepalese communities are needed to avert the impacts of disaster events. Much more can be done immediately to reduce the impacts by reviewing the scope and distribution of past disaster events. This article provides an overview of Nepal’s disaster vulnerability through an analysis of the record of disaster events that occurred from 1900 to 2005. The data were generated from historical archives and divided into incidents at the district, subnational, and national levels. Statistical and Geographical Information System (GIS) analyses were carried out to generate district level disaster vulnerability maps. It is concluded that small-scale, local disasters have a greater cumulative impact in terms of casualties than large-scale, national disasters.