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We characterized antibiotic prescribing patterns and management practices among recurrent urinary tract infection (rUTI) patients, and we identified factors associated with lack of guideline adherence to antibiotic choice, duration of treatment, and urine cultures obtained. We hypothesized that prior resistance to nitrofurantoin or trimethoprim–sulfamethoxazole (TMP-SMX), shorter intervals between rUTIs, and more frequent rUTIs would be associated with fluoroquinolone or β-lactam prescribing, or longer duration of therapy.
This study was a retrospective database study of adult women with International Classification of Diseases, Tenth Revision (ICD-10) cystitis codes meeting American Urological Association rUTI criteria at outpatient clinics within our academic medical center between 2016 and 2018. We excluded patients with ICD-10 codes indicative of complicated UTI or pyelonephritis. Generalized estimating equations were used for risk-factor analysis.
Among 214 patients with 566 visits, 61.5% of prescriptions comprised first-line agents of nitrofurantoin (39.7%) and TMP-SMX (21.5%), followed by second-line choices of fluoroquinolones (27.2%) and β-lactams (11%). Most fluoroquinolone prescriptions (86.7%), TMP-SMX prescriptions (72.2%), and nitrofurantoin prescriptions (60.2%) exceeded the guideline-recommended duration. Approximately half of visits lacked a urine culture. Receiving care through urology via telephone was associated with receiving a β-lactam (adjusted odds ratio [aOR], 6.34; 95% confidence interval [CI], 2.58–15.56) or fluoroquinolone (OR, 2.28; 95% CI, 1.07–4.86). Having >2 rUTIs during the study period and seeking care from a urology practice (RR, 1.28, 95% CI, 1.15–1.44) were associated with longer antibiotic duration.
We found low guideline concordance for antibiotic choice, duration of therapy and cultures obtained among rUTI patients. These factors represent new targets for outpatient antibiotic stewardship interventions.
Health and social care workers (HSCWs) are at risk of experiencing adverse mental health outcomes (e.g. higher levels of anxiety and depression) because of the COVID-19 pandemic. This can have a detrimental effect on quality of care, the national response to the pandemic and its aftermath.
A longitudinal design provided follow-up evidence on the mental health (changes in prevalence of disease over time) of NHS staff working at a remote health board in Scotland during the COVID-19 pandemic, and investigated the determinants of mental health outcomes over time.
A two-wave longitudinal study was conducted from July to September 2020. Participants self-reported levels of depression (Patient Health Questionnaire-9), anxiety (Generalised Anxiety Disorder-7) and mental well-being (Warwick-Edinburgh Mental Well-being Scale) at baseline and 1.5 months later.
The analytic sample of 169 participants, working in community (43%) and hospital (44%) settings, reported substantial levels of depression and anxiety, and low mental well-being at baseline (depression, 30.8%; anxiety, 20.1%; well-being, 31.9%). Although mental health remained mostly constant over time, the proportion of participants meeting the threshold for anxiety increased to 27.2% at follow-up. Multivariable modelling indicated that working with, and disruption because of, COVID-19 were associated with adverse mental health changes over time.
HSCWs working in a remote area with low COVID-19 prevalence reported substantial levels of anxiety and depression, similar to those working in areas with high COVID-19 prevalence. Efforts to support HSCW mental health must remain a priority, and should minimise the adverse effects of working with, and disruption caused by, the COVID-19 pandemic.
Conservation scientists are increasingly recognizing the need to evaluate the effectiveness of interventions to improve human–wildlife coexistence across different contexts. Here we assessed the long-term efficacy of the Long Shields Community Guardians programme in Zimbabwe. This community-based programme seeks to protect livestock and prevent depredation by lions Panthera leo through non-lethal means, with the ultimate aim of promoting human–lion coexistence. Using a quasi-experimental approach, we measured temporal trends in livestock depredation by lions and the prevalence of retaliatory killing of lions by farmers and wildlife managers. Farmers that were part of the Long Shields programme experienced a significant reduction in livestock loss to lions, and the annual number of lions subject to retaliatory killing by farmers dropped by 41% since the start of the programme in 2013, compared to 2008–2012, before the programme was initiated. Our findings demonstrate the Long Shields programme can be a potential model for limiting livestock depredation by lions. More broadly, our study demonstrates the effectiveness of community-based interventions to engage community members, improve livestock protection and ameliorate levels of retaliatory killing, thereby reducing human–lion conflict.
Co-enzyme Q10 (CoQ10), transported in the blood by lipoproteins, is an essential component of the inner mitochondrial membrane and is responsible for electron transport in the mitochondrial respiratory chain for oxidative phosphorylation to generate the energy substrate adenosine triphosphate (ATP), and acts as an anti-oxidant within the oocyte. Observational studies suggest that the follicular fluid concentration of CoQ10 diminishes with age (1), and low CoQ10 antioxidant status may indeed correlate with oocyte aneuploidy (2). Consequently it would appear there is a sound rationale for the use of CoQ10 during infertility treatment, perhaps for women with perceived ‘poor oocyte quality’. Furthermore the scientific rationale is supported by several animal studies which demonstrate a beneficial effect of CoQ10 supplementation on embryonic development. However, before all clinicians are encouraged to prescribe Coq10 as the eternal elixir of reproductive youth, evidence for a benefit of supplementation in the IVF clinical setting is required.
Evidence for risk of dying by suicide and other causes following discharge from in-patient psychiatric care throughout adulthood is sparse.
To estimate risks of all-cause mortality, natural and external-cause deaths, suicide and accidental, alcohol-specific and drug-related deaths in working-age and older adults within a year post-discharge.
Using interlinked general practice, hospital, and mortality records in the Clinical Practice Research Datalink we delineated a cohort of discharged adults in England, 2001–2018. Each patient was matched to up to 20 general population comparator patients. Cumulative incidence (absolute risks) and hazard ratios (relative risks) were estimated separately for ages 18–64 and ≥65 years with additional stratification by gender and practice-level deprivation.
The 1-year cumulative incidence of dying post-discharge was 2.1% among working-age adults (95% CI 2.0–2.3) and 14.1% (95% CI 13.6–14.5) among older adults. Suicide risk was particularly elevated in the first 3 months, with hazard ratios of 191.1 (95% CI 125.0–292.0) among working-age adults and 125.4 (95% CI 52.6–298.9) in older adults. Older patients were vulnerable to dying by natural causes within 3 months post-discharge. Risk of dying by external causes was greater among discharged working-age adults in the least deprived areas. Relative risk of suicide in discharged working-age women relative to their general population peers was double the equivalent male risk elevation.
Recently discharged adults at any age are at increased risk of dying from external and natural causes, indicating the importance of close monitoring and provision of optimal support to all such patients, particularly during the first 3 months post-discharge.
We performed viral culture of nasopharyngeal specimens in individuals aged 79 and older, infected with severe acute respiratory coronavirus virus 2 (SARS-CoV-2), 10 days after symptom onset. A positive viral culture was obtained in 10 (45%) of 22 participants, including 4 (33%) of 12 individuals with improving symptoms. The results of this small study suggest that infectivity may be prolonged among older individuals.
Antimicrobial resistance (AMR) is one of the defining global health threats of our time, but no international legal instrument currently offers the framework and mechanisms needed to address it. Fortunately, the actions needed to address AMR have considerable overlap with the actions needed to confront other pandemic threats.
This study describes the development of a pilot sentinel school absence syndromic surveillance system. Using data from a sample of schools in England the capability of this system to monitor the impact of disease on school absences in school-aged children is shown, using the coronavirus disease 2019 (COVID-19) pandemic period as an example. Data were obtained from an online app service used by schools and parents to report their children absent, including reasons/symptoms relating to absence. For 2019 and 2020, data were aggregated into daily counts of ‘total’ and ‘cough’ absence reports. There was a large increase in the number of absence reports in March 2020 compared to March 2019, corresponding to the first wave of the COVID-19 pandemic in England. Absence numbers then fell rapidly and remained low from late March 2020 until August 2020, while lockdown was in place in England. Compared to 2019, there was a large increase in the number of absence reports in September 2020 when schools re-opened in England, although the peak number of absences was smaller than in March 2020. This information can help provide context around the absence levels in schools associated with COVID-19. Also, the system has the potential for further development to monitor the impact of other conditions on school absence, e.g. gastrointestinal infections.
Globally, mortality of Indigenous persons is greater than that of their non-Indigenous counterparts, which has been shown to be disproportionately attributable to non-communicable diseases. The historically subordinate position that Indigenous Knowledge (IK) held in comparison to Western science has shifted over the last several decades, with the credibility and importance of IK now being internationally recognized. Herein, we examine how Marsahall’s (2014) Two-Eyed Seeing can foster collaborative and culturally relevant Developmental Origins of Health and Disease (DOHaD) studies for health and well-being by using ‘..the best in Indigenous ways of knowing…[and] the best in Western (or mainstream) ways of knowing…and learn to use both these eyes for the benefit of all.’ At its core, Two-Eyed Seeing also includes the principles of ownership, control, access and possession, and Community-Based Participatory Research, which further reinforces the critical role of Indigenous peoples taking active roles in DOHaD research. Additionally, we also present a partnership model for working with Indigenous communities that includes the principles of respect, equity and empowerment. As researchers begin to fill the gap in Indigenous health, we outline how Two-Eyed Seeing should form the basis of DOHaD studies involving Indigenous communities. This model can be used to develop and guide projects that result in robust and meaningful participatory partnerships that have impactful uptake of research findings.
Several previous studies have identified a continuity between childhood anxiety/withdrawal and anxiety disorder (AD) in later life. However, not all children with anxiety/withdrawal problems will experience an AD in later life. Previous studies have shown that the severity of childhood anxiety/withdrawal accounts for some of the variability in AD outcomes. However, no studies to date have investigated how variation in features of anxiety/withdrawal may relate to continuity prognoses. The present research addresses this gap.
Data were gathered as part of the Christchurch Health and Development Study, a 40-year population birth cohort of 1265 children born in Christchurch, New Zealand. Fifteen childhood anxiety/withdrawal items were measured at 7–9 years and AD outcomes were measured at various interviews from 15 to 40 years. Six network models were estimated. Two models estimated the network structure of childhood anxiety/withdrawal items independently for males and females. Four models estimated childhood anxiety/withdrawal items predicting adolescent AD (14–21 years) and adult AD (21–40 years) in both males and females.
Approximately 40% of participants met the diagnostic criteria for an AD during both the adolescent (14–21 years) and adult (21–40 years) outcome periods. Outcome networks showed that items measuring social and emotional anxious/withdrawn behaviours most frequently predicted AD outcomes. Items measuring situation-based fears and authority figure-specific anxious/withdrawn behaviour did not consistently predict AD outcomes. This applied across both the male and female subsamples.
Social and emotional anxious/withdrawn behaviours in middle childhood appear to carry increased risk for AD outcomes in both adolescence and adulthood.
The Promoting Activity, Independence and Stability in Early Dementia (PrAISED) is delivering an exercise programme for people with dementia. The Lincolnshire partnership NHS foundation Trust successfully delivered PrAISED through a video-calling platform during the COVID-19 pandemic.
This qualitative case-study identified participants that video delivery worked for, and highlighted its benefits and challenges.
Interviews were conducted with participants with dementia, caregivers and therapists, and analysed through thematic analysis.
Video delivery worked best when participants had a supporting carer, when therapists showed enthusiasm and had an established rapport with the client. Benefits included time-efficiency of sessions, enhancing participants’ motivation, caregivers’ dementia awareness and therapists’ creativity. Limitations included users’ poor IT skills and resources.
The COVID-19 pandemic required innovative ways of delivering rehabilitation. This study supports that people with dementia can use tele rehab, but success is reliant on having a caregiver and an enthusiastic and known therapist.
Substance use disorders are highly prevalent, affecting millions of Americans directly (social, occupational, and health problems) and indirectly (billions of dollars in health care costs and lost revenues due to disability). This section briefly introduces the chemical classification and neurobehavioral properties of the most commonly misused substances.
The objectives of this study were to develop and refine EMPOWER (Enhancing and Mobilizing the POtential for Wellness and Resilience), a brief manualized cognitive-behavioral, acceptance-based intervention for surrogate decision-makers of critically ill patients and to evaluate its preliminary feasibility, acceptability, and promise in improving surrogates’ mental health and patient outcomes.
Part 1 involved obtaining qualitative stakeholder feedback from 5 bereaved surrogates and 10 critical care and mental health clinicians. Stakeholders were provided with the manual and prompted for feedback on its content, format, and language. Feedback was organized and incorporated into the manual, which was then re-circulated until consensus. In Part 2, surrogates of critically ill patients admitted to an intensive care unit (ICU) reporting moderate anxiety or close attachment were enrolled in an open trial of EMPOWER. Surrogates completed six, 15–20 min modules, totaling 1.5–2 h. Surrogates were administered measures of peritraumatic distress, experiential avoidance, prolonged grief, distress tolerance, anxiety, and depression at pre-intervention, post-intervention, and at 1-month and 3-month follow-up assessments.
Part 1 resulted in changes to the EMPOWER manual, including reducing jargon, improving navigability, making EMPOWER applicable for a range of illness scenarios, rearranging the modules, and adding further instructions and psychoeducation. Part 2 findings suggested that EMPOWER is feasible, with 100% of participants completing all modules. The acceptability of EMPOWER appeared strong, with high ratings of effectiveness and helpfulness (M = 8/10). Results showed immediate post-intervention improvements in anxiety (d = −0.41), peritraumatic distress (d = −0.24), and experiential avoidance (d = −0.23). At the 3-month follow-up assessments, surrogates exhibited improvements in prolonged grief symptoms (d = −0.94), depression (d = −0.23), anxiety (d = −0.29), and experiential avoidance (d = −0.30).
Significance of results
Preliminary data suggest that EMPOWER is feasible, acceptable, and associated with notable improvements in psychological symptoms among surrogates. Future research should examine EMPOWER with a larger sample in a randomized controlled trial.
Substantial progress has been made in the standardization of nomenclature for paediatric and congenital cardiac care. In 1936, Maude Abbott published her Atlas of Congenital Cardiac Disease, which was the first formal attempt to classify congenital heart disease. The International Paediatric and Congenital Cardiac Code (IPCCC) is now utilized worldwide and has most recently become the paediatric and congenital cardiac component of the Eleventh Revision of the International Classification of Diseases (ICD-11). The most recent publication of the IPCCC was in 2017. This manuscript provides an updated 2021 version of the IPCCC.
The International Society for Nomenclature of Paediatric and Congenital Heart Disease (ISNPCHD), in collaboration with the World Health Organization (WHO), developed the paediatric and congenital cardiac nomenclature that is now within the eleventh version of the International Classification of Diseases (ICD-11). This unification of IPCCC and ICD-11 is the IPCCC ICD-11 Nomenclature and is the first time that the clinical nomenclature for paediatric and congenital cardiac care and the administrative nomenclature for paediatric and congenital cardiac care are harmonized. The resultant congenital cardiac component of ICD-11 was increased from 29 congenital cardiac codes in ICD-9 and 73 congenital cardiac codes in ICD-10 to 318 codes submitted by ISNPCHD through 2018 for incorporation into ICD-11. After these 318 terms were incorporated into ICD-11 in 2018, the WHO ICD-11 team added an additional 49 terms, some of which are acceptable legacy terms from ICD-10, while others provide greater granularity than the ISNPCHD thought was originally acceptable. Thus, the total number of paediatric and congenital cardiac terms in ICD-11 is 367. In this manuscript, we describe and review the terminology, hierarchy, and definitions of the IPCCC ICD-11 Nomenclature. This article, therefore, presents a global system of nomenclature for paediatric and congenital cardiac care that unifies clinical and administrative nomenclature.
The members of ISNPCHD realize that the nomenclature published in this manuscript will continue to evolve. The version of the IPCCC that was published in 2017 has evolved and changed, and it is now replaced by this 2021 version. In the future, ISNPCHD will again publish updated versions of IPCCC, as IPCCC continues to evolve.
This work investigated the effects of repeated sweet taste exposure at breakfast on perceptions and intakes of other sweet foods, while also examining the effects due to duration of exposure (1/3 weeks), test context (breakfast/lunch) and associations between taste perceptions and intakes. Using a randomised controlled parallel-group design, participants (n 54, 18 male, mean age: 23·9 (sd 5·8) years, mean BMI: 23·6 (sd 3·5) kg/m2) were randomised to consume either a sweet breakfast (cereal with sucralose) (n 27) or an equienergetic non-sweet breakfast (plain cereal) (n 27) for 3 weeks. On days 0 (baseline), 7 and 21, pleasantness, desire to eat and sweetness were rated for other sweet and non-sweet foods and sweet food consumption was assessed in an ad libitum meal at breakfast and lunch. Using intention-to-treat analyses, no statistically significant effects of exposure were found at breakfast (largest F2,104 = 1·84, P = 0·17, ηp2 = 0·03) or lunch (largest F1,52 = 1·22, P = 0·27, ηp2 = 0·02), and using Bayesian analyses, the evidence for an absence of effect in all rating measures was strong to very strong (smallest BF01 = 297·97 (BF01error = 2·68 %)). Associations between ratings of pleasantness, desire to eat and intake were found (smallest r = 0·137, P < 0·01). Effects over time regardless of exposure were also found: sugars and percentage energy consumed from sweet foods increased throughout the study (smallest (F2,104 = 4·54, P = 0·01, ηp2 = 0·08). These findings demonstrate no effects of sweet taste exposure at breakfast for 1 or 3 weeks on pleasantness, desire for, sweetness or intakes of other sweet foods in either the same (breakfast) or in a different (lunch) meal context.
Only a few fourteenth-century recipes for gunpowder proper (for use in shooting projectiles from guns) are known. They can be difficult to interpret, partly because their rarity hinders comparisons between texts in order to clarify ambiguous directions. This article presents and discusses the earliest known recipe, from Friuli and dated 1336, in comparison to what was previously the earliest widely-known formulation: the Augsburg recipe of 1338–c. 1350. The German text (translated into English here for the first time) provides context for the Italian recipe, and the latter, in turn, in combination with laboratory testing, settles a disputed reading of the German formula.
In two articles in the previous volume of this journal, Clifford J. Rogers and Trevor Russell Smith offered new transcriptions and translations of several nearly unknown gunpowder recipes from the last hundred years of the Middle Ages. Rogers noted that there were very few complete recipes for gunpowder proper (that is, for mixtures specifically intended to propel projectiles from guns) that could be reliably dated to the first fifty years of the history of cannon in Europe (1326–1375). In fact, since the recipes in the Munich copy of the Büchsenmeisterbuch (MS. Cgm 600) probably date to around 1400 (rather than c. 1350, as once thought), and since the French “recipes” of c. 1338, 1345, and 1350 are actually purchase records rather than instructions for manufacture, and moreover do not specify the proportion of charcoal to be used,3 that left only one such recipe known to scholars of early artillery: one from Augsburg, composed not long after 1337. That one recipe, moreover, is sufficiently ambiguous that different scholars have read it in two different ways, leaving the earliest history of cannon-powder very unclear. It is now possible to expand the roster from one to two, adding an even earlier formulation: one written down in northern Italy in 1336. Comparison to this earlier recipe, in combination with laboratory testing, makes clear which reading of the German recipe is correct. The combination of the two recipes, correctly interpreted, gives us a good picture of the earliest cannon-powders, which were by modern standards low in saltpeter and high in sulfur.