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To examine rural–urban differences in temporal trends and risk of inappropriate antibiotic use by agent and duration among women with uncomplicated urinary tract infection (UTI).
Observational cohort study.
Using the IBM MarketScan Commercial Database (2010–2015), we identified US commercially insured women aged 18–44 years coded for uncomplicated UTI and prescribed an oral antibiotic agent. We classified antibiotic agents and durations as appropriate versus inappropriate based on clinical guidelines. Rural–urban status was defined by residence in a metropolitan statistical area. We used modified Poisson regression to determine the association between rural–urban status and inappropriate antibiotic receipt, accounting for patient- and provider-level characteristics. We used multivariable logistic regression to estimate trends in antibiotic use by rural–urban status.
Of 670,450 women with uncomplicated UTI, a large proportion received antibiotic prescriptions for inappropriate agents (46.7%) or durations (76.1%). Compared to urban women, rural women were more likely to receive prescriptions with inappropriately long durations (adjusted risk ratio 1.10, 95% CI, 1.10–1.10), which was consistent across subgroups. From 2011 to 2015, there was slight decline in the quarterly proportion of patients who received inappropriate agents (48.5% to 43.7%) and durations (78.3% to 73.4%). Rural–urban differences varied over time by agent (duration outcome only), geographic region, and provider specialty.
Inappropriate antibiotic prescribing is quite common for the treatment of uncomplicated UTI. Rural women are more likely to receive inappropriately long antibiotic durations. Antimicrobial stewardship interventions are needed to improve outpatient UTI antibiotic prescribing and to reduce unnecessary exposure to antibiotics, particularly in rural settings.
An early economic evaluation to inform the translation into clinical practice of a spectroscopic liquid biopsy for the detection of brain cancer. Two specific aims are (1) to update an existing economic model with results from a prospective study of diagnostic accuracy and (2) to explore the potential of brain tumor-type predictions to affect patient outcomes and healthcare costs.
A cost-effectiveness analysis from a UK NHS perspective of the use of spectroscopic liquid biopsy in primary and secondary care settings, as well as a cost–consequence analysis of the addition of tumor-type predictions was conducted. Decision tree models were constructed to represent simplified diagnostic pathways. Test diagnostic accuracy parameters were based on a prospective validation study. Four price points (GBP 50-200, EUR 57-228) for the test were considered.
In both settings, the use of liquid biopsy produced QALY gains. In primary care, at test costs below GBP 100 (EUR 114), testing was cost saving. At GBP 100 (EUR 114) per test, the ICER was GBP 13,279 (EUR 15,145), whereas at GBP 200 (EUR 228), the ICER was GBP 78,300 (EUR 89,301). In secondary care, the ICER ranged from GBP 11,360 (EUR 12,956) to GBP 43,870 (EUR 50,034) across the range of test costs.
The results demonstrate the potential for the technology to be cost-effective in both primary and secondary care settings. Additional studies of test use in routine primary care practice are needed to resolve the remaining issues of uncertainty—prevalence in this patient population and referral behavior.
The separation dynamics of a sphere released from the surface of a ramp into a hypersonic flow is investigated, focusing on the influence of the ramp boundary layer on the sphere behaviour. First, numerical simulations are conducted of a sphere interacting with an isolated high-speed boundary layer to determine the influence on the sphere force coefficients as the sphere diameter and wall-normal location are varied. It is found that the lift coefficient is strongly affected by the near-wall interactions, becoming increasingly negative as the ratio of the sphere radius to boundary-layer thickness,
, is decreased. These results are combined with force coefficients derived from simulations of the sphere interacting with the ramp-generated oblique shock to enable numerical predictions of the sphere trajectories for a
ramp at Mach 6 (using a similar decoupled approach to Part 1 of this work). It is found that the three trajectory types of the inviscid situation – shock surfing, ejection followed by re-entrainment within the shock layer and direct entrainment – also characterize the sphere behaviour here. Their relative prevalence, however, is influenced by the sphere size: for smaller values of
, direct entrainment dominates because of the wall suction, while shock surfing and then ejection/re-entrainment become increasingly likely at larger values of
. Increasing the ramp angle and/or the free-stream Mach number reduces the relative influence of the boundary-layer interactions. Finally, experiments are conducted using free-flying spheres released from a ramp surface in a hypersonic shock tunnel, confirming the major trends predicted numerically.
The Late Triassic fauna of the Lossiemouth Sandstone Formation (LSF) from the Elgin area, Scotland, has been pivotal in expanding our understanding of Triassic terrestrial tetrapods. Frustratingly, due to their odd preservation, interpretations of the Elgin Triassic specimens have relied on destructive moulding techniques, which only provide incomplete, and potentially distorted, information. Here, we show that micro-computed tomography (μCT) could revitalise the study of this important assemblage. We describe a long-neglected specimen that was originally identified as a pseudosuchian archosaur, Ornithosuchus woodwardi. μCT scans revealed dozens of bones belonging to at least two taxa: a small-bodied pseudosuchian and a specimen of the procolophonid Leptopleuron lacertinum. The pseudosuchian skeleton possesses a combination of characters that are unique to the clade Erpetosuchidae. As a basis for investigating the phylogenetic relationships of this new specimen, we reviewed the anatomy, taxonomy and systematics of other erpetosuchid specimens from the LSF (all previously referred to Erpetosuchus). Unfortunately, due to the differing representation of the skeleton in the available Erpetosuchus specimens, we cannot determine whether the erpetosuchid specimen we describe here belongs to Erpetosuchus granti (to which we show it is closely related) or if it represents a distinct new taxon. Nevertheless, our results shed light on rarely preserved details of erpetosuchid anatomy. Finally, the unanticipated new information extracted from both previously studied and neglected specimens suggests that fossil remains may be much more widely distributed in the Elgin quarries than previously recognised, and that the richness of the LSF might have been underestimated.
This article explores the spatial history and ‘afterlives’ of Galway jail, where an innocent man, Myles Joyce, was executed in 1882 following his conviction for the Maamtrasna murders; in 2018 he was formally pardoned by President Michael D. Higgins. The article traces how the political and cultural meanings of this incident were instrumentalised in the building of Ireland's last Catholic cathedral on the site of the former Galway jail. It analyses how the site was depicted – in different ways and at different moments – as one of justice, of injustice, of triumph, and of redemption. It investigates how these different legacies were instrumentalised – or at times ignored – by Irish nationalists and later by the Catholic bishop of Galway, Michael Browne. It uses Joyce's execution to explore the site's legacy, an incident that at times dominated its representations but at other moments faded from prominence. The article situates the former jail site within theoretical writings on memorialisation, ‘difficult’ heritage, and studies of architectural demolition, while also commenting on mid twentieth-century Irish Catholic politics and culture.
This article explores the intellectual culture of Catholic architectural production in 1950s Ireland through the study of a church-building project in rural West Cork. It analyses the phenomenon of the Irish ‘church-building priest’ in terms of their socio-economic background, fundraising abilities, and position within rural communities – in the context of significant rural emigration and economic stagnation. It also considers the role that the Irish countryside played in conditioning clerical understandings of architectural style and taste, and priests’ political readings of the rural landscape. Furthermore, it explores the phenomenon of Marianism in church design and ornamentation around the time of the international ‘Marian Year’ of 1954, and the political meanings of the rhetoric employed by clerics at church consecration ceremonies. The article concludes with reflections on social and economic aspects of Irish rural life and religious expression in a decade primarily understood as one of cultural insularity and conservative Catholicism.
The Kilmaluag Formation on the Isle of Skye, Scotland, provides one of the richest Mesozoic vertebrate fossil assemblages in the UK, and is among the richest globally for Middle Jurassic tetrapods. Since its discovery in 1971, this assemblage has predominantly yielded small-bodied tetrapods, including salamanders, choristoderes, lepidosaurs, turtles, crocodylomorphs, pterosaurs, dinosaurs, non-mammalian cynodonts and mammals, alongside abundant fish and invertebrates. It is protected as a Site of Special Scientific Interest and by Nature Conservancy Order. Unlike contemporaneous localities from England, this assemblage yields associated partial skeletons, providing unprecedented new data. We present a comprehensive updated overview of the Kilmaluag Formation, including its geology and the fossil collections made to date, with evidence of several species occurrences presented here for the first time. We place the vertebrate faunal assemblage in an international context through comparisons with relevant contemporaneous localities from the UK, Europe, Africa, Asia and the US. This wealth of material reveals the Kilmaluag Formation as a vertebrate fossil assemblage of global significance, both in terms of understanding Middle Jurassic faunal composition and the completeness of specimens, with implications for the early evolutionary histories of mammals, squamates and amphibians.
A major town planning dispute between church and state in Galway in the 1940s over the location for a new school provides a lens for rethinking Ireland's distinctive engagement with modernity. Using town planning and urban governance lenses, this article argues that existing scholarship on the postwar Irish Catholic Church overstates its hegemonic power. In analyzing the dispute, it critiques the undue focus within European town-planning studies on the state and on the supposedly “rational” agendas of mid-century planners, showing instead how religious entities forged parallel paths of urban modernity and urban governance. It thus adds an Irish and an urban-planning dimension to existing debates within religious history about urbanization and secularization, showing how adaptive the Irish Catholic Church was to high modernity. Finally, with its focus on a school building, it brings a built environment angle into studies of education policy in Ireland. In seeking to revisit major historiographical debates within town planning, religious history, and studies of urban modernity, the article makes extensive use of the recently opened papers of Bishop Michael Browne of Galway, a noted public intellectual within the Irish Catholic Church and a European expert on canon law.
Spinal muscular atrophy (SMA) is a devastating rare disease that affects individuals regardless of ethnicity, gender, and age. The first-approved disease-modifying therapy for SMA, nusinursen, was approved by Health Canada, as well as by American and European regulatory agencies following positive clinical trial outcomes. The trials were conducted in a narrow pediatric population defined by age, severity, and genotype. Broad approval of therapy necessitates close follow-up of potential rare adverse events and effectiveness in the larger real-world population.
The Canadian Neuromuscular Disease Registry (CNDR) undertook an iterative multi-stakeholder process to expand the existing SMA dataset to capture items relevant to patient outcomes in a post-marketing environment. The CNDR SMA expanded registry is a longitudinal, prospective, observational study of patients with SMA in Canada designed to evaluate the safety and effectiveness of novel therapies and provide practical information unattainable in trials.
The consensus expanded dataset includes items that address therapy effectiveness and safety and is collected in a multicenter, prospective, observational study, including SMA patients regardless of therapeutic status. The expanded dataset is aligned with global datasets to facilitate collaboration. Additionally, consensus dataset development aimed to standardize appropriate outcome measures across the network and broader Canadian community. Prospective outcome studies, data use, and analyses are independent of the funding partner.
Prospective outcome data collected will provide results on safety and effectiveness in a post-therapy approval era. These data are essential to inform improvements in care and access to therapy for all SMA patients.
Depression is the most common mental disease in patients hospitalized with physical illness. Disorders of anxiety and depression in general hospitals are frequently underdiagnosed and inappropriately treated. Our objective was to assess the prevalence of undiagnosed anxiety and depression in surgical inpatients and assess the referral rate and utilization of liaison psychiatry services.
A prospective multi-centre study of surgical admissions (n=96) to two surgical services at two separate institutions between 1/01/05 and 31/12/05. The surgical services included general surgery and cardiothoracic surgery. Data was collected prospectively utilizing the computerized hospital inpatient system (HIS) and supplemented with data from medical records. The Hospital Anxiety and Depression (HAD) scale was used to evaluate all patients in the study cohort. Patients with a documented psychiatric history and established psychiatric diagnosis were excluded.
We had 96 individuals in our patient cohort. The mean age was 59.6 years. There was a slight female predominance with a female: male ratio of 1.18:1. Surgical procedures were performed in 68.75% of our patient cohort. 12.5% of patients were discovered to suffer with significant depression. 18.75% of patients suffered with significant anxiety. 8.3% of patients had significant mixed anxiety and depression. 22.9% of patients warranted referral to liaison psychiatry services for further assessment and management.
Disorders of anxiety and depression are highly prevalent in surgical inpatients. There needs to be an increased awareness of the possibility of undiagnosed psychiatric disorders in such patients along with prompt and appropriate use of liaison psychiatry services.
Out of hours, there is only one on-site junior doctor. First year psychiatry trainees (CT1s) and GP trainees may have no prior experience in psychiatry. On-call shifts are therefore potentially daunting for new trainees.
Expand the resources available for trainees when on-call.
We issued questionnaires to CT1s asking if they would have appreciated more information about on-call scenarios and in what format.
Based on the questionnaire results we implemented some changes. These were:
– a printed “pocket-guide” summarising common on-call scenarios;
– a training video on common on-call scenarios.
The handout was given to new trainees in February 2016 and in August 2016. The video was shown to new trainees in August 2016. Trainees provided feedback on the resources.
Of 24 CT1s, 15 (63%) were “neutral” or “disagreed” that they had felt prepared for on-calls.
CT1s wanted additional resources, especially a paper handout or phone download.
Feedback on the “pocket-guide” from trainees in February 2016 (n = 8) was positive (62.5% reported increased confidence in on-call situations). Feedback is also being collected from trainees who received the guide in August 2016.
Trainees in August 2016 (n = 36) liked the video – no trainees “disagreed” with statements asking if the video had been useful.
The video improved the confidence of trainees about on-call situations by an average of 2.8 points.
We have expanded available resources relating to on-calls and improved confidence. Further improvements would include making resources more easily available in downloadable formats.
Disclosure of interest
The authors have not supplied their declaration of competing interest.
Acute respiratory tract infections (ARIs) are commonly diagnosed and major drivers of antibiotic prescribing. Clinician-focused interventions can reduce unnecessary antibiotic prescribing for ARIs. We elicited clinician feedback to design sustainable interventions to improve ARI management by understanding the mental framework of clinicians surrounding antibiotic prescribing within Veterans’ Health Administration clinics.
We conducted one-on-one interviews with clinicians (n = 20) from clinics targeted for intervention at 5 facilities. The theory of planned behavior guided interview questions. Interviews were audio recorded and transcribed for qualitative analysis. An iterative coding approach identified 6 themes.
Emergent themes: (1) barriers to appropriate prescribing are multifactorial and include challenges of behavior change; (2) antibiotic prescribing decisions are perceived as autonomous yet, diagnostic uncertainty and perceptions of patient demand can make prescribing decisions difficult; (3) clinicians perceive variation in peer prescribing practices and influences; (4) clinician-focused interventions are valuable if delivered with sensitivity; (5) communication strategies for educating patients are preferred to a shared decisions process; and (6) team standardization of practice and communication are key to facilitate appropriate prescribing. Clinicians perceived audit-and-feedback with peer comparison, academic detailing, and enhanced patient communication strategies as viable approaches to improving appropriate prescribing.
Implementation strategies that enable clinicians to overcome diagnostic uncertainty, perceived patient demand, and improve patient education are desired. Implementation strategies were welcomed, and some were more readily accepted (eg, audit feedback) than others (eg, shared decision making). Implementation strategies should address clinicians’ perceptions of antibiotic prescribing practices and should enhance their patient communication skills.
Breakfast cereals are known to provide a nutrient-dense meal and are a useful source of carbohydrate, fibre and micronutrients. However, in the UK cereal products are the primary contributor of free sugars in the diets of children aged 1.5 to 10 years; and are the second leading source of free sugars in children aged 11 to 18 years and adults aged 19 to 64 years. For this reason, breakfast cereals were included among food items recommended by the UK government for a 20% reduction in sugar by 2020 for childhood obesity prevention. Therefore, this study aimed to investigate the nutrient contents, including sugars, of breakfast cereals sold in the UK, in particular those marketed to children. Nutritional information and ingredients of cereal products available in five major online supermarkets in the UK, in 2018, were collected into a comprehensive database for analysis. A systematic process flow approach was utilised to separate products into nine distinct categories. Children's products were stratified both on being wholegrain rich (≥ 50%, WG) or not (NWG), and on total sugar content; with > 12.3g/100 g defined as ‘highly flavoured and sweetened’ (HFS) versus ‘plain’ containing ≤ 12.3g/100 g (the target set by the UK for industry sugar reduction). Of the 757 unique products surveyed, 97 cereals were categorised as children's. Cereals not explicitly marketed to children were categorised as either ‘family favourites’ (containing < 50% wholegrains), ‘free-from and organic’, ‘porridge and oats’, ‘healthier with dried fruits’, or ‘healthier without dried fruits’ (healthier defined as wholegrain rich, ≥ 50%). Children's HFS products (n = 78) contained by far the highest sugar contents of all cereals examined. While there was no difference in total sugar between NWG/HFS (n = 69, median [range]: 29.0g/100 g [12.4, 41.0]) and WG/HFS (n = 9, 22.0g/100 g [13.6, 26.0]) cereals; these were much higher (P < 0.01) than the median sugar contents (8.8–19.0g/100g) observed in the other seven product categories. Children's NWG cereals contained dramatically lower fibre (NWG/HFS: 3.5 [0, 8.7], NWG/Plain: 1.6g/100 g [1.3, 7.2]) than all other product categories (7.3–9.1g/100 g; P < 0.001). Similarly, NWG/HFS cereals were lower in protein content (7.4/100 g [3.6, 17.2]) than the non-children's cereals (8.8–11g/100 g; P < 0.05). In conclusion, children's categories of cereal contain significantly greater amounts of sugar and lower amounts of fibre and protein than other cereal categories. Despite their fortification with vitamins and minerals, reformulation of this food category should be a priority alongside additional sugar-reducing strategies.