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Introduction: We implemented a pharmacist-led antimicrobial stewardship (AMS) service for patients discharged from the pediatric emergency department (PED). This service, supported by a collaborative practice agreement, allows pharmacists to follow up with patients and independently stop, start, or adjust antimicrobial agents based on culture results. The primary objective of our study was to evaluate the impact of this service on the rate of return visits to the PED within 96 hours. The secondary objective was to evaluate the appropriateness of the prescribed antimicrobial agent at follow up. Methods: This study was completed as a retrospective chart review 6 months pre-implementation (January 1st, 2016 to June 31st, 2016) and 6 months post-implementation (February 1st, 2017 to July 31st, 2017) of a pharmacist-led AMS service. A research assistant extracted data from electronic medical records using a standardized data collection form. All patients discharged from the PED with a suspected infection whose cultures fell within the parameters of the collaborative practice agreement were included in this study. Data were reported descriptively and compared using a two-sided chi-square test. Results: This study included 1070 patient encounters pre-implementation and 1040 patient encounters post-implementation of the AMS service. The most commonly reviewed culture was urine (38% pre-implementation and 41% post-implementation). The rate of return visits to the PED within 96 hours was 12.0% (129/1070) pre-implementation vs 10.0% (100/1049) post-implementation phase (p = 0.07). A significantly higher percentage of inappropriate antimicrobial therapy was identified at the time of follow up in the pre-implementation phase (7.0%, 68/975) compared to the post-implementation phase (5.0%, 46/952), p = 0.047. Conclusion: Although this pharmacist-led AMS service did not affect the rate of return visits within 96 hours, it may have led to more judicious use of antimicrobial agents.
Introduction: Telephone Triage Services (TTS) manage phone calls from the public regarding general medical problems and provide telephone advice. This telephone based care can overlap with care provided by Poison Centres. Our objective was to examine the impact of a provincial 811 TTS on the IWK Regional Poison Centre (RPC). Methods: This is a retrospective descriptive study using interrupted time series methodology. We compared monthly IWK RPC call volume in the pre-811 era (January 2007-July 2009) and the post-811 era (September 2009-December 2017). We summarized the characteristics of callers who accessed the IWK RPC in terms of client age, sex, intentionality, time of day, call disposition and outcome. Caller characteristics were compared between the pre- and post-811 eras using chi-square test for categorical variables. We used segmented regression analysis to evaluate changes in slope of call volume in the pre- and post 811 eras. The Durbin-Watson statistic was performed to test for serial correlation and the Dickey-Fuller test to investigate seasonality. Results: The dataset included 82683 calls to the IWK RPC – 27028 pre-811 and 55655 post-811. Overall, 55% of calls were for female clients and the largest age group was children aged 0-5 years (37%). Most calls originated from home (47%), followed by a health care facility (23%). Most calls were managed at home (65%). Less than 3% of calls resulted in major effect or death. The Durbin Watson statistic was not statistically significant (p = 0.94). The Dickey-Fuller test indicated series stationarity (p = 0.001). There was no statistically significant change in call volume to the IWK RPC due to the introduction of 811 (p = 0.39). There was no significant variation by time of day, day of week or month, with most calls occurring in the evening. There were significantly more calls regarding intentional ingestions in the post-811 era (23% vs. 19% pre-811, p < .001). Outcomes in the pre and post 811 eras were as follows: minor/no effect/non-toxic/minimal 80% vs. 78%; moderate 7% vs. 10%; and, major/death 1.7% vs. 2.0%. Conclusion: The introduction of a TTS did not change call volumes at our RPC. The increase in the percentage of calls about intentional ingestions may reflect an increase in call acuity as the 811-TTS likely manages calls about minor/non-toxic ingestions without consulting with the RPC. Our future research will examine the nature of poison related calls to the 811-TTS.
The Indian residential school (IRS) system in Canada ran for over a century until the last school closed in 1996. Conditions in the IRSs resulted in generations of Indigenous children being exposed to chronic childhood adversity. The current investigation used data from the 2008–2010 First Nations Regional Health Survey to explore whether parental IRS attendance was associated with suicidal thoughts and attempts in childhood, adolescence and in adulthood among a representative sample of First Nations peoples living on-reserve across Canada. Analyses of the adult sample in Study 1 (unweighted n=7716; weighted n=186,830) revealed that having a parent who attended IRS was linked with increased risk for suicidal thoughts and attempts in adolescence and adulthood. Although females were negatively affected by having a parent who attended IRS, the link with suicidal ideation in adulthood was greater for males. Analyses of the youth sample in Study 2 (unweighted n=2883; weighted n=30,190) confirmed that parental IRS attendance was associated with an increased risk for suicidal ideation and attempts. In contrast to the adult sample, parental IRS attendance had a significantly greater relation with suicidal ideation among female youth. A significant interaction also emerged between parental IRS attendance and age in the youth sample, with the influence of parental attendance being particularly strong among youth ages 12–14, compared with those 15–17 years. These results underscore the need for culturally relevant early interventions for the large proportions of Indigenous children and youth intergenerationally affected by IRSs and other collective traumas.
Childhood maltreatment and a family history of a schizophrenia spectrum disorder (SSD) are each associated with social-emotional dysfunction in childhood. Both are also strong risk factors for adult SSDs, and social-emotional dysfunction in childhood may be an antecedent of these disorders. We used data from a large Australian population cohort to determine the independent and moderating effects of maltreatment and parental SSDs on early childhood social-emotional functioning.
The New South Wales Child Development Study combines intergenerational multi-agency data using record linkage methods. Multiple measures of social-emotional functioning (social competency, prosocial/helping behaviour, anxious/fearful behaviour; aggressive behaviour, and hyperactivity/inattention) on 69 116 kindergarten children (age ~5 years) were linked with government records of child maltreatment and parental presentations to health services for SSD. Multivariable analyses investigated the association between maltreatment and social-emotional functioning, adjusting for demographic variables and parental SSD history, in the population sample and in sub-cohorts exposed and not exposed to parental SSD history. We also examined the association of parental SSD history and social-emotional functioning, adjusting for demographic variables and maltreatment.
Medium-sized associations were identified between maltreatment and poor social competency, aggressive behaviour and hyperactivity/inattention; small associations were revealed between maltreatment and poor prosocial/helping and anxious/fearful behaviours. These associations did not differ greatly when adjusted for parental SSD, and were greater in magnitude among children with no history of parental SSD. Small associations between parental SSD and poor social-emotional functioning remained after adjusting for demographic variables and maltreatment.
Childhood maltreatment and history of parental SSD are associated independently with poor early childhood social-emotional functioning, with the impact of exposure to maltreatment on social-emotional functioning in early childhood of greater magnitude than that observed for parental SSDs. The impact of maltreatment was reduced in the context of parental SSDs. The influence of parental SSDs on later outcomes of maltreated children may become more apparent during adolescence and young adulthood when overt symptoms of SSD are likely to emerge. Early intervention to strengthen childhood social-emotional functioning might mitigate the impact of maltreatment, and potentially also avert future psychopathology.
Childhood adversity is a putative risk factor for schizophrenia, although evidence supporting this suggestion is inconsistent and controversial. The aim of this review was to pool and quality assess the current evidence pertaining to childhood adversity in people with schizophrenia compared to other psychiatric disorders and to non-psychiatric controls.
Included were case-control, cohort and cross-sectional studies. Medline, EMBASE and PsycINFO databases were searched. Study reporting was assessed using the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) checklist and pooled evidence quality was assessed by the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach.
Twenty-five studies met inclusion criteria. Moderate to high quality evidence suggests increased rates of childhood adversity in schizophrenia compared to controls [odds ratio (OR) 3.60, p < 0.00001]. Increased childhood adversity was also reported in schizophrenia compared to anxiety disorders (OR 2.54, p = 0.007), although the effect was not significant in the subgroup analysis of five studies assessing only sexual abuse. No differences in rates of childhood adversity were found between schizophrenia and affective psychosis, depression and personality disorders whereas decreased rates of childhood adversity were found in schizophrenia relative to dissociative disorders and post-traumatic stress disorder (OR 0.03, p < 0.0001).
This is the first meta-analysis to report a medium to large effect of childhood adversity in people with schizophrenia and to assess specificity for schizophrenia. Further research is required that incorporates longitudinal design and other potentially causal variables to assess additive and/or interactive effects.
Modern time-domain surveys have demonstrated that finding variable objects is relatively straightforward. The problem now is one of selecting and following up discoveries. With even larger-scale surveys on the horizon, the magnitude of the problem will inevitably increase. One way to prepare for the coming deluge is to have realistic estimates of the numbers of potential detections so that resources can be developed to meet that need. To that end, astronomers at the National Optical Astronomy Observatory (NOAO) have begun a project to characterize the variable sky in terms of type of objects, distribution on the sky and range of variation.
Lamb mortality remains a significant welfare and economic issue for sheep production. Lamb survival is to a degree dependent upon an easy delivery and the expression of appropriate behaviours from both mother and offspring, such as rapid standing, udder seeking and sucking by the lamb. Genetic solutions have the potential to improve birth assistance and lamb behaviour but large amounts of data are needed. Therefore, to achieve this objective, simple, proxy methods (scoring systems) were developed to quantify the level of birth difficulties and lamb vigour on farm. In the first study, detailed historical behavioural data from 1156 lambs (Scottish Blackface and Suffolk (S)) were analysed to develop criteria for 3 scores: birth assistance, lamb vigour and sucking assistance. The birth assistance score was developed by analysing the relationships between birth presentation and intervention levels, and intervention level and labour length. Lambs with abnormal birth positions required more assistance than normally presented lambs and lambs with long labours required more and greater assistance than those with short labours. Lamb vigour score was developed by analysing the latencies for the lamb to first perform specific behaviours; more vigorous lambs reach landmark behaviours faster than low vigour lambs. The sucking assistance score was developed from the relationship between the latency to suck successfully and assistance level, where lambs that were slow to suck required more assistance than lambs that were quick to suck. In the second study, the behaviour scoring systems (5-point categorical scales) were validated using a commercial flock of 80 twin-bearing crossbred ewes mated with either Texel (T) or S sires by simultaneously recording scores and the latency to perform specific landmark behaviours (i.e. to stand, seek the udder and suck). The vigour scores (recorded at 5 min of age) were compared with the latency from birth to standing and showed that lambs with lower (better) vigour scores were faster to stand after birth than those with higher scores. The sucking assistance scores were compared with the latency from birth to sucking, and showed that lambs with lower sucking assistance scores are quicker to suck than those with high scores. These results showed that the scoring systems could provide a practical and reliable assessment of birth assistance and lamb behaviour on farm and were sufficiently sensitive to discriminate vigour levels between lambs sired by either S or T rams.
This study evaluated the epidemiology of Pseudomonas aeruginosa keratitis in contact lens (CL) wearers; the relationships between CL storage case contamination and CL hygiene practice and between CL hygiene and the development of keratitis. Sixteen CL wearers with keratitis were compared with 44 asymptomatic controls. Lens hygiene practice was assessed and CL care materials, domestic water sites and endogenous sites were evaluated microbiologically. Poor CL hygiene was not associated with Ps. aeruginosa keratitis. There was an association between keratitis and bacterial contamination of the CL and storage case (P < 0·0005). Lens and storage case contamination were not significantly associated with poor hygiene. No domestic or endogenous source for Ps. aeruginosa was found. Causative organisms may be derived from other sources, but CLs and CL storage cases provide a favourable environment for Ps. aeruginosa colonization. Changing the CL care environment to one less favourable for Ps. aeruginosa may help to eliminate this problem.
The effect of the density and in-plane distribution of interfacial interactions on crack initiation in an epoxy-silicon joint was studied in nominally pure shear loading. Well-defined combinations of strong (specific) and weak (nonspecific) interactions were created using self-assembling monolayers. The in-plane distribution of strong and weak interactions was varied by employing two deposition methods: depositing mixtures of molecules with different terminal groups resulting in a nominally random distribution, and depositing methyl-terminated molecules in domains defined lithographically with the remaining area interacting through strong acid-base interactions. The two distributions lead to very different fracture behavior. For the case of the methyl-terminated domains (50 μm on a side) fabricated lithographically, the joint shear strength varies almost linearly with the area fraction of strongly interacting sites. From this we infer that cracks nucleate on or near the interface over nearly the entire range of bonded area fraction and do so at nearly the same value of local stress (load/bonded area). We postulate that the imposed heterogeneity in interfacial interactions results in heterogeneous stress and strain fields within the epoxy in close proximity to the interface. Simply, the bonded areas carry load while the methyl terminated domains carry negligible load. Stress is amplified adjacent to the well-bonded regions (and reduced adjacent to the poorly bonded regions), and this leads to crack initiation by plastic deformation and chain scission within the epoxy near the interface. For the case of mixed monolayers, the dependence is entirely different. At low areal density of strongly interacting sites, the joint shear strength is below the detection limit of our transducer for a significant range of mixed monolayer composition. With increasing density of strongly interacting sites, a sharp increase in joint shear strength occurs at a methyl terminated area fraction of roughly 0.90. We postulate that this coincides with the onset of yielding in the epoxy. For methyl-terminated area fractions less than 0.85, the joint shear strength becomes independent of the interfacial interactions. This indicates that fracture no longer initiates on the interface but away from the interface by a competing mechanism, likely plastic deformation and chain scission within the bulk epoxy. The data demonstrate that the in-plane distribution of interaction sites alone can affect the location of crack nucleation and the far-field stress required.