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The co-occurrence of stroke and psychosis is a serious neuropsychiatric condition but little is known about the course of this comorbidity. We aimed to estimate longitudinal associations between stroke and psychosis over 10 years.
A 10-year population-based study using data from the English Longitudinal Study of Ageing. A structured health assessment recorded (i) first-occurrence stroke and (ii) psychosis, at each wave. Each were considered exposures and outcomes in separate analyses. Logistic and Cox proportional hazards regression and Kaplan–Meier methods were used. Models were adjusted for demographic and health behaviour covariates, with missing covariates imputed using random forest multiple imputation.
Of 19 808 participants, 24 reported both stroke and psychosis (median Wave 1 age 63, 71% female, 50% lowest quintile of net financial wealth) at any point during follow-up. By 10 years, the probability of an incident first stroke in participants with psychosis was 21.4% [95% confidence interval (CI) 12.1–29.6] compared to 8.3% (95% CI 7.8–8.8) in those without psychosis (absolute difference: 13.1%; 95% CI 20.8–4.3, log rank p < 0.001; fully-adjusted hazard ratio (HR): 3.57; 95% CI 2.18–5.84). The probability of reporting incident psychosis in participants with stroke was 2.3% (95% CI 1.4–3.2) compared to 0.9% (95% CI 0.7–1.1) in those without (absolute difference: 1.4%; 95% CI 0.7–2.1, log rank p < 0.001; fully-adjusted HR: 4.98; 95% CI 2.55–9.72).
Stroke is an independent predictor of psychosis (and vice versa), after adjustment for potential confounders.
To minimise infection during COVID-19, the clozapine haematological monitoring interval was extended from 4-weekly to 12-weekly intervals in South London and Maudsley NHS Foundation Trust.
To investigate the impact of this temporary policy change on clinical and safety outcomes.
All patients who received clozapine treatment with extended (12-weekly) monitoring in a large London National Health Service trust were included in a 1-year mirror-image study. A comparison group was selected with standard monitoring. The proportion of participants with mild to severe neutropenia and the proportion of participants attending the emergency department for clozapine-induced severe neutropenia treatment during the follow-up period were compared. Psychiatric hospital admission rates, clozapine dose and concomitant psychotropic medication in the 1 year before and the 1 year after extended monitoring were compared. All-cause clozapine discontinuation at 1-year follow-up was examined.
Of 569 participants, 459 received clozapine with extended monitoring and 110 controls continued as normal. The total person-years were 458 in the intervention group and 109 in the control group, with a median follow-up time of 1 year in both groups. During follow-up, two participants (0.4%) recorded mild to moderate neutropenia in the intervention group and one (0.9%) in the control group. There was no difference in the incidence of haematological events between the two groups (IRR = 0.48, 95% CI 0.02–28.15, P = 0.29). All neutropenia cases in the intervention group were mild, co-occurring during COVID-19 infection. The median number of admissions per patient during the pre-mirror period remained unchanged (0, IQR = 0) during the post-mirror period. There was one death in the control group, secondary to COVID-19 infection.
There was no evidence that the incidence of severe neutropenia was increased in those receiving extended monitoring.
Individuals with physical comorbidities and polypharmacy may be at higher risk of depression relapse, however, they are not included in the ‘high risk of relapse’ group for whom longer antidepressant treatment durations are recommended.
In individuals with comorbid depression and type 2 diabetes (T2DM), we aimed to investigate the association and interaction between depression relapse and (a) polypharmacy, (b) previous duration of antidepressant treatment.
This was a cohort study using primary care data from the UK Clinical Practice Research Datalink (CPRD) from years 2000 to 2018. We used Cox regression models with penalised B-splines to describe the association between restarting antidepressants and our two exposures.
We identified 48 001 individuals with comorbid depression and T2DM, who started and discontinued antidepressant treatment during follow-up. Within 1 year of antidepressant discontinuation, 35% of participants restarted treatment indicating depression relapse. As polypharmacy increased, the rate of restarting antidepressants increased until a maximum of 18 concurrent medications, where individuals were more than twice as likely to restart antidepressants (hazard ratio (HR) = 2.15, 95% CI 1.32–3.51). As the duration of previous antidepressant treatment increased, the rate of restarting antidepressants increased – individuals with a previous duration of ≥25 months were more than twice as likely to restart antidepressants than those who previously discontinued in <7 months (HR = 2.36, 95% CI 2.25–2.48). We found no interaction between polypharmacy and previous antidepressant duration.
Polypharmacy and longer durations of previous antidepressant treatment may be associated with depression relapse following the discontinuation of antidepressant treatment.
Alcohol use is a risk factor for suicidal behaviour, yet the nature of the relationship is unclear. Most research on the topic is conducted in clinical populations, with few studies exploring this association across the general population.
We investigated the association between specific domains of alcohol use and suicide attempt, suicidal thoughts and non-suicidal self-harm in a general population sample.
A total of 14 949 adults who completed the 2007 or 2014 Adult Psychiatric Morbidity Survey were included. We measured alcohol use with the Alcohol Use Disorders Identification Test (AUDIT). Domains of alcohol use relating to risk categories, weekly consumption, binge drinking, dependence symptoms, harmful effects and concern from others were derived from relevant AUDIT items. Self-reported past year suicide attempt, suicidal thoughts and non-suicidal self-harm were measured with the Clinical Interview Schedule, Revised.
We found a linear association between total AUDIT score and outcomes. Three of six specific domains of alcohol use (dependence symptoms, harmful effects of drinking and binge drinking) were associated with increased odds of all three outcomes. There was no association of outcomes with the other domains of alcohol use.
We found evidence of a linear association between total AUDIT score and suicide attempt, suicidal thoughts and non-suicidal self-harm in a representative English general population sample. Our analyses suggest that where alcohol use significantly disrupts day-to-day functioning, this may underpin the relationship between alcohol use and suicide-related outcomes to a greater extent than higher alcohol consumption. Longitudinal research is needed to further understand these relationships.
People with severe mental illness (SMI) have more physical health conditions than the general population, resulting in higher rates of hospitalisations and mortality. In this study, we aimed to determine the rate of emergency and planned physical health hospitalisations in those with SMI, compared to matched comparators, and to investigate how these rates differ by SMI diagnosis.
We used Clinical Practice Research DataLink Gold and Aurum databases to identify 20,668 patients in England diagnosed with SMI between January 2000 and March 2016, with linked hospital records in Hospital Episode Statistics. Patients were matched with up to four patients without SMI. Primary outcomes were emergency and planned physical health admissions. Avoidable (ambulatory care sensitive) admissions and emergency admissions for accidents, injuries and substance misuse were secondary outcomes. We performed negative binomial regression, adjusted for clinical and demographic variables, stratified by SMI diagnosis.
Emergency physical health (aIRR:2.33; 95% CI 2.22–2.46) and avoidable (aIRR:2.88; 95% CI 2.60–3.19) admissions were higher in patients with SMI than comparators. Emergency admission rates did not differ by SMI diagnosis. Planned physical health admissions were lower in schizophrenia (aIRR:0.80; 95% CI 0.72–0.90) and higher in bipolar disorder (aIRR:1.33; 95% CI 1.24–1.43). Accident, injury and substance misuse emergency admissions were particularly high in the year after SMI diagnosis (aIRR: 6.18; 95% CI 5.46–6.98).
We found twice the incidence of emergency physical health admissions in patients with SMI compared to those without SMI. Avoidable admissions were particularly elevated, suggesting interventions in community settings could reduce hospitalisations. Importantly, we found underutilisation of planned inpatient care in patients with schizophrenia. Interventions are required to ensure appropriate healthcare use, and optimal diagnosis and treatment of physical health conditions in people with SMI, to reduce the mortality gap due to physical illness.
Patients with bipolar disorder (BPD) are prone to engage in risk-taking behaviours and self-harm, contributing to higher risk of traumatic injuries requiring medical attention at the emergency room (ER).We hypothesize that pharmacological treatment of BPD could reduce the risk of traumatic injuries by alleviating symptoms but evidence remains unclear. This study aimed to examine the association between pharmacological treatment and the risk of ER admissions due to traumatic injuries.
Individuals with BPD who received mood stabilizers and/or antipsychotics were identified using a population-based electronic healthcare records database in Hong Kong (2001–2019). A self-controlled case series design was applied to control for time-invariant confounders.
A total of 5040 out of 14 021 adults with BPD who received pharmacological treatment and had incident ER admissions due to traumatic injuries from 2001 to 2019 were included. An increased risk of traumatic injuries was found 30 days before treatment [incidence rate ratio (IRR) 4.44 (3.71–5.31), p < 0.0001]. After treatment initiation, the risk remained increased with a smaller magnitude, before returning to baseline [IRR 0.97 (0.88–1.06), p = 0.50] during maintenance treatment. The direct comparison of the risk during treatment to that before and after treatment showed a significant decrease. After treatment cessation, the risk was increased [IRR 1.34 (1.09–1.66), p = 0.006].
This study supports the hypothesis that pharmacological treatment of BPD was associated with a lower risk of ER admissions due to traumatic injuries but an increased risk after treatment cessation. Close monitoring of symptoms relapse is recommended to clinicians and patients if treatment cessation is warranted.
Antipsychotic polypharmacy (APP) occurs commonly but it is unclear whether it is associated with an increased risk of adverse drug reactions (ADRs). Electronic health records (EHRs) offer an opportunity to examine APP using real-world data. In this study, we use EHR data to identify periods when patients were prescribed 2 + antipsychotics and compare these with periods of antipsychotic monotherapy. To determine the relationship between APP and subsequent instances of ADRs: QT interval prolongation, hyperprolactinaemia, and increased body weight [body mass index (BMI) ⩾ 25].
We extracted anonymised EHR data. Patients aged 16 + receiving antipsychotic medication at Camden & Islington NHS Foundation Trust between 1 January 2008 and 31 December 2018 were included. Multilevel mixed-effects logistic regression models were used to elucidate the relationship between APP and the subsequent presence of QT interval prolongation, hyperprolactinaemia, and/or increased BMI following a period of APP within 7, 30, or 180 days respectively.
We identified 35 409 observations of antipsychotic prescribing among 13 391 patients. Compared with antipsychotic monotherapy, APP was associated with a subsequent increased risk of hyperprolactinaemia (adjusted odds ratio 2.46; 95% CI 1.87–3.24) and of registering a BMI > 25 (adjusted odds ratio 1.75; 95% CI 1.33–2.31) in the period following the APP prescribing.
Our observations suggest that APP should be carefully managed with attention to hyperprolactinaemia and obesity.
Background: A team of infectious diseases physicians, infectious diseases pharmacists, clinical laboratorians, and researchers collaborated to assess the management of lower respiratory tract infections (LRTIs). In 1 sample from our institution, 96.1% of pneumonia cases were prescribed antibiotics, compared to 85.0% in a comparison group. A collaborative effort led to the development of a protocol for procalcitonin (PCT)-guided antibiotic prescribing that was approved by several hospital committees, including the Antimicrobial Stewardship Committee and the Healthcare Pharmacy & Therapeutics Committee in December 2020. The aim of this analysis was to develop baseline information on PCT ordering and antibiotic prescribing patterns in LRTIs. Methods: We evaluated all adult inpatients (March–September 2019 and 2020) with a primary diagnosis of LRTI who received at least 1 antibiotic. Two cohorts were established to observe any potential differences in the 2 most recent years prior to adoption of the PCT protocol. Data (eg, demographics, specific diagnosis, length of stay, antimicrobial therapy and duration, PCT labs, etc) were obtained from the UK Center for Clinical and Translational Science, and the study was approved by the local IRB. The primary outcome of interest was antibiotic duration; secondary outcomes of interest were PCT orders, discharge antibiotic prescription, and inpatient length of stay. Results: In total, 432 patients (277 in 2019 and 155 in 2020) were included in this analysis. The average patient age was 61.2 years (SD, ±13.7); 47.7% were female; and 86.1% were white. Most patients were primarily diagnosed with pneumonia (58.8%), followed by COPD with complication (40.5%). In-hospital mortality was 3.5%. The minority of patients had any orders for PCT (29.2%); among them, most had only 1 PCT level measured (84.1%). The median length of hospital stay was 4 days (IQR, 2–6), and the median duration of antibiotic therapy was 4 days (IQR, 3–6). Conclusions: The utilization of PCT in LRTIs occurs in the minority of patient cases at our institution and mostly as a single measurement. The development and implementation of a PCT-guided therapy could help optimize antibiotic usage in patients with LRTIs.
In the UK, acute mental healthcare is provided by in-patient wards and crisis resolution teams. Readmission to acute care following discharge is common. Acute day units (ADUs) are also provided in some areas.
To assess predictors of readmission to acute mental healthcare following discharge in England, including availability of ADUs.
We enrolled a national cohort of adults discharged from acute mental healthcare in the English National Health Service (NHS) between 2013 and 2015, determined the risk of readmission to either in-patient or crisis teams, and used multivariable, multilevel logistic models to evaluate predictors of readmission.
Of a total of 231 998 eligible individuals discharged from acute mental healthcare, 49 547 (21.4%) were readmitted within 6 months, with a median time to readmission of 34 days (interquartile range 10–88 days). Most variation in readmission (98%) was attributable to individual patient-level rather than provider (trust)-level effects (2.0%). Risk of readmission was not associated with local availability of ADUs (adjusted odds ratio 0.96, 95% CI 0.80–1.15). Statistically significant elevated risks were identified for participants who were female, older, single, from Black or mixed ethnic groups, or from more deprived areas. Clinical predictors included shorter index admission, psychosis and being an in-patient at baseline.
Relapse and readmission to acute mental healthcare are common following discharge and occur early. Readmission was not influenced significantly by trust-level variables including availability of ADUs. More support for relapse prevention and symptom management may be required following discharge from acute mental healthcare.
To describe characteristics of adults with intellectual disability (ID) and/or autism spectrum disorder (ASD) accessing care in one mental health Trust.
To explore factors associated with in-patient admission/risk of re-admission within 12 months of discharge.
There is concern that adults with intellectual disability and those with autism spectrum disorder are frequently admitted to mental health hospitals. The evidence from NHS datasets suggests that this remains a significant issue and is associated with personal, social and economic costs.
Adults (≥ 18 years) with ICD-10 diagnosis of “mental retardation” and/or autism who had accessed care in the Camden and Islington Foundation Trust were identified using the Clinical Record Interactive Search (CRIS). The identification process was validated through cross checking of free text in the electronic clinical notes. We compared demographic and clinical characteristics and service use, including length of admission, of 315 individuals with ASD and 339 with ID (with or without ASD). Logistic regression was used to explore factors associated with in-patient admission and re-admission within 12 months of discharge.
A greater proportion of adults with ID (with or without ASD) had a diagnosis of psychosis, substance misuse, or dementia whereas diagnosis of anxiety disorder was greater in those with ASD. Antipsychotics and other psychotropics were twice as likely to be prescribed for the ID ± group. Admission to psychiatric in-patient care was greater in those with ID ± ASD (adjusted OR 4.00, 95% confidence interval (CI) 2.41-6.63), men (aOR 2.28, 95%CI 1.39-3.75), younger adults (aOR 0.98, 95%CI 0.97-1.00), and in those with a diagnosis of schizophrenia spectrum disorder (aOR 5.08, 95%CI 3.00-8.61), affective disorder (aOR 2.23, 95%CI 1.29-3.83), personality disorder (aOR 1.94, 95%CI 1.02-3.68), and record of previous inpatient admission (aOR 2.18, 95%CI 1.17-4.05). Having ASD alone was associated with a greater risk of re-admission within one year of discharge, although this difference was not statistically significant (aOR 0.70, 95% CI 0.32-1.52). Comorbid diagnoses of affective disorder or personality disorder were the only significant associations with re-admission (aOR 3.11, 95%CI 1.34-7.23 and aOR 8.28, 95%CI 2.85-24.04, respectively).
These findings provide the first longitudinal investigation into the acute care pathway for adults with ID and/or ASD in the NHS. Replication in other trusts is now needed to inform “at risk of admission” registers and guide targeted interventions to prevent admission.
Physical activity is a modifiable risk factor for several physical and mental health conditions. It is well established that people with severe mental illness have increased risk of physical health complications, particularly cardiovascular disease. They are also more likely to be physically inactive, contributing to the elevated cardiovascular and metabolic risks, which are further compounded by antipsychotic medication use. Interventions involving physical activity are a relatively low risk and accessible way of reducing physical health problems and weight in people with severe mental illness. They also have wider benefits for mental health symptoms and quality of life. However, many barriers still exist to the widespread implementation of physical activity interventions in the treatment of severe mental illness. A more concerted effort is needed to facilitate their translation into routine practice and to increase adherence to activity interventions.
For people in mental health crisis, acute day units (ADUs) provide daily structured sessions and peer support in non-residential settings, often as an addition or alternative to crisis resolution teams (CRTs). There is little recent evidence about outcomes for those using ADUs, particularly compared with those receiving CRT care alone.
We aimed to investigate readmission rates, satisfaction and well-being outcomes for people using ADUs and CRTs.
We conducted a cohort study comparing readmission to acute mental healthcare during a 6-month period for ADU and CRT participants. Secondary outcomes included satisfaction (Client Satisfaction Questionnaire), well-being (Short Warwick–Edinburgh Mental Well-being Scale) and depression (Center for Epidemiologic Studies Depression Scale).
We recruited 744 participants (ADU: n = 431, 58%; CRT: n = 312, 42%) across four National Health Service trusts/health regions. There was no statistically significant overall difference in readmissions: 21% of ADU participants and 23% of CRT participants were readmitted over 6 months (adjusted hazard ratio 0.78, 95% CI 0.54–1.14). However, readmission results varied substantially by setting. At follow-up, ADU participants had significantly higher Client Satisfaction Questionnaire scores (2.5, 95% CI 1.4–3.5, P < 0.001) and well-being scores (1.3, 95% CI 0.4–2.1, P = 0.004), and lower depression scores (−1.7, 95% CI −2.7 to −0.8, P < 0.001), than CRT participants.
Patients who accessed ADUs demonstrated better outcomes for satisfaction, well-being and depression, and no significant differences in risk of readmission, compared with those who only used CRTs. Given the positive outcomes for patients, and the fact that ADUs are inconsistently provided in the National Health Service, their value and place in the acute care pathway needs further consideration and research.
Mental health policy makers require evidence-based information to optimise effective care provision based on local need, but tools are unavailable.
To develop and validate a population-level prediction model for need for early intervention in psychosis (EIP) care for first-episode psychosis (FEP) in England up to 2025, based on epidemiological evidence and demographic projections.
We used Bayesian Poisson regression to model small-area-level variation in FEP incidence for people aged 16–64 years. We compared six candidate models, validated against observed National Health Service FEP data in 2017. Our best-fitting model predicted annual incidence case-loads for EIP services in England up to 2025, for probable FEP, treatment in EIP services, initial assessment by EIP services and referral to EIP services for ‘suspected psychosis’. Forecasts were stratified by gender, age and ethnicity, at national and Clinical Commissioning Group levels.
A model with age, gender, ethnicity, small-area-level deprivation, social fragmentation and regional cannabis use provided best fit to observed new FEP cases at national and Clinical Commissioning Group levels in 2017 (predicted 8112, 95% CI 7623–8597; observed 8038, difference of 74 [0.92%]). By 2025, the model forecasted 11 067 new treated cases per annum (95% CI 10 383–11 740). For every 10 new treated cases, 21 and 23 people would be assessed by and referred to EIP services for suspected psychosis, respectively.
Our evidence-based methodology provides an accurate, validated tool to inform clinical provision of EIP services about future population need for care, based on local variation of major social determinants of psychosis.
Adults with intellectual disability or autism are at risk of psychiatric admission which carries personal, social and economic costs. We identified 654 adults with intellectual disability or autism in the electronic clinical records of one mental health trust. We investigated the demographic and clinical factors associated with admission and readmission after discharge. Young male patients with intellectual disability, schizophrenia and previous admissions are most at risk of the former, whereas affective and personality disorders predict the latter. Both community intellectual disability services and mental health crisis care must focus on providing effective support for those patients.
Policies addressing the physical health of people with mental disorders have historically focused on those with severe mental illness (SMI), giving less prominence to the more prevalent common mental disorders (CMDs). Little is known about the comparative physical health outcomes of these patient groups. We aimed to first compare the: (a) number of past-year chronic physical conditions and (b) recent physical health service utilization between CMDs vs. SMI, and secondly compare these outcomes between people with CMDs vs. people without mental disorders.
We analyzed cross-sectional data from the third Adult Psychiatric Morbidity Survey, a representative sample of the English population. We determined the presence of physical conditions and health service utilization by self-report and performed logistic regression models to examine associations of these outcomes between participant groups.
Past-year physical conditions were reported by the majority of participants (CMDs, n = 815, 62.1%; SMI = 27, 63.1%) with no variation in the adjusted odds of at least one physical condition between diagnoses (odds ratio [OR] = 0.96, 95% confidence intervals [CI] 0.42–1.98, p = 0.784). People with CMDs were significantly more likely to be recently hospitalized relative to with those with SMI (OR = 6.33, 95% CI 5.50–9.01, p < 0.05). Having a CMD was associated with significantly higher odds of past-year physical conditions and recent health service utilization (all p < 0.001) compared with the general population.
People with CMDs experience excess physical health morbidities in a similar pattern to those found among people with SMI, while their somatic hospitalization rates are even more elevated. Findings highlight the importance of recalibrating existing public health strategies to bring equity to the physical health needs of this patient group.
Prevention of Clostridioides difficile infection (CDI) is a national priority and may be facilitated by deployment of the Targeted Assessment for Prevention (TAP) Strategy, a quality improvement framework providing a focused approach to infection prevention. This article describes the process and outcomes of TAP Strategy implementation for CDI prevention in a healthcare system.
Hospital A was identified based on CDI surveillance data indicating an excess burden of infections above the national goal; hospitals B and C participated as part of systemwide deployment. TAP facility assessments were administered to staff to identify infection control gaps and inform CDI prevention interventions. Retrospective analysis was performed using negative-binomial, interrupted time series (ITS) regression to assess overall effect of targeted CDI prevention efforts. Analysis included hospital-onset, laboratory-identified C. difficile event data for 18 months before and after implementation of the TAP facility assessments.
The systemwide monthly CDI rate significantly decreased at the intervention (β2, −44%; P = .017), and the postintervention CDI rate trend showed a sustained decrease (β1 + β3; −12% per month; P = .008). At an individual hospital level, the CDI rate trend significantly decreased in the postintervention period at hospital A only (β1 + β3, −26% per month; P = .003).
This project demonstrates TAP Strategy implementation in a healthcare system, yielding significant decrease in the laboratory-identified C. difficile rate trend in the postintervention period at the system level and in hospital A. This project highlights the potential benefit of directing prevention efforts to facilities with the highest burden of excess infections to more efficiently reduce CDI rates.
In October 2017, the American Association of Blood Bankers (AABB; Bethesda, Maryland USA) approved a petition to allow low-titer group O whole blood as a standard product without the need for a waiver. Around that time, a few Texas, USA-based Emergency Medical Services (EMS) systems incorporated whole blood into their ground ambulances. The purpose of this project was to describe the epidemiology of ground ambulance patients that received a prehospital whole blood transfusion. The secondary aim of this project was to report an accounting analysis of these ground ambulance prehospital whole blood programs.
The dataset came from the Harris County Emergency Service District 48 Fire Department (HCESD 48; Harris County, Texas USA) and San Antonio Fire Department (SAFD; San Antonio, Texas USA) whole blood Quality Assurance/Quality Improvement (QA/QI) databases from September 2017 through December 2018. The primary outcome of this study was the prehospital transfusion indication. The secondary outcome was the projected cost per life saved during the first 10 years of the prehospital whole blood initiative.
Of 58 consecutive prehospital whole blood administrations, the team included all 58 cases. Hemorrhagic shock from a non-traumatic etiology accounted for 46.5% (95% CI, 34.3%-59.2%) of prehospital whole blood recipients. In the non-traumatic hemorrhagic shock cohort, gastrointestinal hemorrhage was the underlying etiology of hemorrhagic shock in 66.7% (95% CI, 47.8%-81.4%) of prehospital whole blood transfusion recipients. The projected average cost to save a life in Year 10 was US$5,136.51 for the combined cohort, US$4,512.69 for HCESD 48, and US$5,243.72 for SAFD EMS.
This retrospective analysis of ground ambulance patients that receive prehospital whole blood transfusion found that non-traumatic etiology accounted for 46.5% (95% CI, 34.3%-59.2%) of prehospital whole blood recipients. Additionally, the accounting analysis suggests that by Year 10 of a ground ambulance whole blood transfusion program, the average cost to save a life will be approximately US$5,136.51.
Rheumatic fever, an immune sequela of untreated streptococcal infections, is an important contributor to global cardiovascular disease. The goal of this study was to describe trends, characteristics, and cost burden of children discharged from hospitals with a diagnosis of RF from 2000 to 2012 within the United States.
Using the Kids’ Inpatient Database, we examined characteristics of children discharged from hospitals with the diagnosis of rheumatic fever over time including: overall hospitalisation rates, age, gender, race/ethnicity, regional differences, payer type, length of stay, and charges.
The estimated national cumulative incidence of rheumatic fever in the United States between 2000 and 2012 was 0.61 cases per 100,000 children. The median age was 10 years, with hospitalisations significantly more common among children aged 6–11 years. Rheumatic fever hospitalisations among Asian/Pacific Islanders were significantly over-represented. The proportion of rheumatic fever hospitalisations was greater in the Northeast and less in the South, although the highest number of rheumatic fever admissions occurred in the South. Expected payer type was more likely to be private insurance, and the median total hospital charges (adjusted for inflation to 2012 dollars) were $16,000 (interquartile range: $8900–31,200). Median length of stay was 3 days, and the case fatality ratio for RF in the United States was 0.4%.
Rheumatic fever persists in the United States with an overall downwards trend between 2003 and 2012. Rheumatic fever admissions varied considerably based on age group, region, and origin.
We compared systematic and random survey techniques to estimate breeding population sizes of burrow-nesting petrel species on Marion Island. White-chinned (Procellaria aequinoctialis) and blue (Halobaena caerulea) petrel population sizes were estimated in systematic surveys (which attempt to count every colony) in 2009 and 2012, respectively. In 2015, we counted burrows of white-chinned, blue and great-winged (Pterodroma macroptera) petrels within 52 randomized strip transects (25 m wide, total 144 km). Burrow densities were extrapolated by Geographic Information System-derived habitat attributes (geology, vegetation, slope, elevation, aspect) to generate island-wide burrow estimates. Great-winged petrel burrows were found singly or in small groups at low densities (2 burrows ha−1); white-chinned petrel burrows were in loose clusters at moderate densities (3 burrows ha−1); and blue petrel burrows were in tight clusters at high densities (13 burrows ha−1). The random survey estimated 58% more white-chinned petrels but 42% fewer blue petrels than the systematic surveys. The results suggest that random transects are best suited for species that are widely distributed at low densities, but become increasingly poor for estimating population sizes of species with clustered distributions. Repeated fixed transects provide a robust way to monitor changes in colony density and area, but might fail to detect the formation/disappearance of new colonies.