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Retrospectively apply criteria from Center to Advance Palliative Care to a cohort of children treated in a cardiac ICU and compare children who received a palliative care consultation to those who were eligible for but did not receive one.
Medical records of children admitted to a cardiac ICU between January 2014 and June 2017 were reviewed. Selected criteria include cardiac ICU length of stay >14 days and/or ≥ 3 hospitalisations within a 6-month period.
Measurements and Results:
A consultation occurred in 17% (n = 48) of 288 eligible children. Children who received a consult had longer cardiac ICU (27 days versus 17 days; p < 0.001) and hospital (91 days versus 35 days; p < 0.001) lengths of stay, more complex chronic conditions at the end of first hospitalisation (3 versus1; p < 0.001) and the end of the study (4 vs.2; p < 0.001), and higher mortality (42% versus 7%; p < 0.001) when compared with the non-consulted group. Of the 142 pre-natally diagnosed children, only one received a pre-natal consult and 23 received it post-natally. Children who received a consultation (n = 48) were almost 2 months of age at the time of the consult.
Less than a quarter of eligible children received a consultation. The consultation usually occurred in the context of medical complexity, high risk of mortality, and at an older age, suggesting potential opportunities for more and earlier paediatric palliative care involvement in the cardiac ICU. Screening criteria to identify patients for a consultation may increase the use of palliative care services in the cardiac ICU.
To assess the extent to which evidence-based practices are regularly used in acute care hospitals in different countries.
Cross-sectional survey study. Participants and setting: Infection preventionists in acute care hospitals in the United States (US), the Netherlands, Switzerland, and Japan.
Data collected from hospital surveys distributed between 2015 and 2017 were evaluated to determine the use of practices to prevent catheter-associated urinary tract infection (CAUTI), central-line–associated bloodstream infection (CLABSI), ventilator-associated pneumonia (VAP), and Clostridioides difficile infection (CDI). Descriptive statistics were used to examine hospital characteristics and the percentage of hospitals reporting regular use of each infection prevention practice.
Survey response rates were 59% in the United States, 65% in the Netherlands, 77% in Switzerland, and 65% in Japan. Several recommended practices were used in the majority of hospitals: aseptic catheter insertion and maintenance (CAUTI), maximum sterile barrier precautions (CLABSI), semirecumbent patient positioning (VAP), and contact precautions and routine daily cleaning (CDI). Other prevention practices for CAUTI and VAP were used less frequently, particularly in Swiss and Japanese hospitals. Established surveillance systems were also lacking in Dutch, Swiss and Japanese hospitals.
Most hospitals in the United States, the Netherlands, Switzerland, and Japan have adopted certain infection prevention practices. Clear opportunities for reducing HAI risk in hospitals exist across all 4 countries surveyed.
This two-part article examines the global public health (GPH) information system deficits emerging in the coronavirus disease 2019 (COVID-19) pandemic. It surveys past, missed opportunities for public health (PH) information system and operational improvements, examines current megatrend changes to information management, and describes a new multi-disciplinary model for population-based management (PBM) supported by a GPH Database applicable to pandemics and GPH crises.
Background: Urinary catheters, vascular catheters, and wounds, such as pressure injuries are often hidden from view under gowns and sheets (ie, out of sight, out of mind), contributing to prolonged catheter use, infections, delayed interventions, and diagnostic errors for symptoms (eg, fever or delirium) related to catheters and wounds. We developed and pilot tested a digital bedside Patient Safety Display of catheter and wound information to improve awareness by rounding providers (ie, physicians and advanced practice providers, APPs). Methods: The display development was informed by clinical observations of provider rounds and nurse handoffs, interviews, and iterative prototype testing with clinicians in simulated cases using catheterized mannequins with wounds. The display reports the presence and duration of urinary and vascular catheter use, urinary catheter indication, and wound presence and severity, from real-time mandatory nurse documentation in the electronic medical record (Fig. 1). We conducted a pilot study in a tertiary-care medical-surgical step-down unit with 20 private rooms, including a preintervention period and a postintervention period including 10 rooms without the display (control rooms) and 10 rooms with the display (intervention rooms). We surveyed individual providers directly after rounds to assess their awareness of their patients’ catheters and wounds compared to medical record documentation. We also assessed display utility and usability from postintervention clinician interviews and we identified major themes using an adapted grounded theory approach. Results: In total, 787 surveys were completed: 681 medicine service with 89% response rate, 106 surgery service with 47% response rate; 363 preintervention surveys, and 424 postintervention surveys. The surveys involved 176 unique patients and 47 unique providers. Among all 787 patient encounters, 156 (19.8%) had a transurethral indwelling urinary catheter (Foley), 314 (39.9%) had a central venous catheter (including PICCs), and 247 (31.4%) had at least 1 pressure injury. Figure 2 summarizes provider awareness of catheters and pressure injuries when present as assessed for patients in the preintervention and postintervention periods. Moreover, 13 clinician postintervention interviews yielded preliminary themes regarding the display’s benefits and limitations (Fig. 3). Conclusions: In this pilot study of a novel Patient Safety Display, although provider awareness of Foley catheters, CVCs, and pressure injuries appeared higher for patients in the intervention rooms compared to awareness as measured in the preintervention rooms and/or postintervention control rooms, most of these comparisons did not meet statistical significance. Clinicians varied widely in their personal assessments of the display as a useful tool for improving awareness and prompting discussion about catheters and wounds.
Funding: This work was funded by the Agency for Healthcare Research and Quality (AHRQ) grant P30HS024385. Dr. Meddings’ effort was initially partially funded by concurrent support from AHRQ (K08 HS19767).
Disclosures: Dr. Meddings has reported receiving honoraria for lectures and teaching related to prevention and value-based purchasing policies involving catheter-associated urinary tract infection. The remaining authors report no conflicts of interest.
The Spoon-billed Sandpiper Calidris pygmaea is a ‘Critically Endangered’ migratory shorebird. The species faces an array of threats in its non-breeding range, making conservation intervention essential. However, conservation efforts are reliant on identifying the species’ key stopover and wintering sites. Using Maximum Entropy models, we predicted Spoon-billed Sandpiper distribution across the non-breeding range, using data from recent field surveys and satellite tracking. Model outputs suggest only a limited number of stopover sites are suitable for migrating birds, with sites in the Yellow Sea and on the Jiangsu coast in China highlighted as particularly important. All the previously known core wintering sites were identified by the model including the Ganges-Brahmaputra Delta, Nan Thar Island and the Gulf of Mottama. In addition, the model highlighted sites subsequently found to be occupied, and pinpointed potential new sites meriting investigation, notably on Borneo and Sulawesi, and in parts of India and the Philippines. A comparison between the areas identified as most likely to be occupied and protected areas showed that very few locations are covered by conservation designations. Known sites must be managed for conservation as a priority, and potential new sites should be surveyed as soon as is feasible to assess occupancy status. Site protection should take place in concert with conservation interventions including habitat management, discouraging hunting, and fostering alternative livelihoods.
The catastrophic declines of three species of ‘Critically Endangered’ Gyps vultures in South Asia were caused by unintentional poisoning by the non-steroidal anti-inflammatory drug (NSAID) diclofenac. Despite a ban on its veterinary use in 2006 (India, Nepal, Pakistan) and 2010 (Bangladesh), residues of diclofenac have continued to be found in cattle carcasses and in dead wild vultures. Another NSAID, meloxicam, has been shown to be safe to vultures. From 2012 to 2018, we undertook covert surveys of pharmacies in India, Nepal and Bangladesh to investigate the availability and prevalence of NSAIDs for the treatment of livestock. The purpose of the study was to establish whether diclofenac continued to be sold for veterinary use, whether the availability of meloxicam had increased and to determine which other veterinary NSAIDs were available. The availability of diclofenac declined in all three countries, virtually disappearing from pharmacies in Nepal and Bangladesh, highlighting the advances made in these two countries to reduce this threat to vultures. In India, diclofenac still accounted for 10–46% of all NSAIDs offered for sale for livestock treatment in 2017, suggesting weak enforcement of existing regulations and a continued high risk to vultures. Availability of meloxicam increased in all countries and was the most common veterinary NSAID in Nepal (89.9% in 2017). Although the most widely available NSAID in India in 2017, meloxicam accounted for only 32% of products offered for sale. In Bangladesh, meloxicam was less commonly available than the vulture-toxic NSAID ketoprofen (28% and 66%, respectively, in 2018), despite the partial government ban on ketoprofen in 2016. Eleven different NSAIDs were recorded, several of which are known or suspected to be toxic to vultures. Conservation priorities should include awareness raising, stricter implementation of current bans, bans on other vulture-toxic veterinary NSAIDs, especially aceclofenac and nimesulide, and safety-testing of other NSAIDs on Gyps vultures to identify safe and toxic drugs.
Despite considerable efforts to control tuberculosis (TB) among Ethiopian immigrants in Israel, an outbreak of TB among second-generation Ethiopian immigrants that involved native Israelis occurred between January 2011 and December 2019. The aim of this article is to report on this outbreak and discuss the patient and health system barriers that led to its propagation. Overall, 13 culture-positive TB patients were diagnosed in this outbreak. An additional 36 cases with identical mycobacterium tuberculosis genotypes were identified through cross-checking with the National TB Laboratory Registry. Among the 32 close contacts of the index case, 18 (56.3%) reported for screening and treatment of latent TB infection (LTBI) was recommended for 11 (61.1%) of them. However, none completed treatment and eight eventually developed TB. Of the 385 close contacts identified in this outbreak, 286 (74.3%) underwent contact investigation, 154 (53.8%) were recommended LTBI treatment, but only 26 (16.9%) completed the treatment. Routine contact investigation and treatment practice measures failed to contain the cascade of infection and disease, leading to the spread of the infecting strain of TB. This report highlights the challenges to identify the high-risk group and address barriers to care among such a vulnerable population.
The dendrite morphologies of the cast nickel-based superalloy CMSX-4® (CMSX-4® is registered trademarks of the Cannon-Muskegon Corporation) and the austenitic stainless steel HP microalloy have been obtained via an automated serial-sectioning process which allows three-dimensional (3D) microstructural characterization. The dendrite arm spacing, volume fraction of segregation, and fraction of porosity have been determined. This technique not only increases the depth, scope, and level of detailed microstructural characterization but also delivers microstructural data for modeling and simulation.
The Oxford English Dictionary defines psychopharmacology as ‘the scientific study of the effect of drugs on the mind and behaviour’ (Oxford English Dictionary Online, 2018). The earliest reference to the term was in 1548 when Reinhard Lorichius published the prayer book Psychopharmakon, hoc est Medicina Animae (Lehmann, 1993; Wolman, 1977). Lorichius coined the term ‘psychopharmakon’ to refer to spiritual medicine that could reduce human suffering. The word psychopharmacology was first used in a scientific paper in 1920 by a pharmacologist working at Johns Hopkins University who wrote a short paper entitled Contributions to psychopharmacology (Macht, 1920).
The design community can contribute significantly to the success of the United Nations Sustainable Development Goals in Africa. Currently, alignment of the design research community on sustainable development goals in Africa is not well understood. In this paper, we review relevant literature and identify trends in research topics studied and in patterns of collaboration between researchers. We find differences in topic representation and collaboration trends between African-based and non-African based researchers. Understanding these differences better will be important for future research.
Introduction: Paramedics commonly administer intravenous dextrose to severely hypoglycemic patients. Typically, the treatment provided is a 25g ampule of 50% dextrose (D50). This dose of D50 is meant to ensure a return to consciousness. However, this dose may be unnecessary and lead to harm or difficulties regulating blood glucose post treatment. We hypothesize that a lower dose such as dextrose 10% (D10) or titrating the D50 to desired level of consciousness may be optimal and avoid adverse events. Methods: We systematically searched Medline, Embase, CINAHL and Cochrane Central on June 5th 2019. PRISMA guidelines were followed. The GRADE methods and risk of bias assessments were applied to determine the certainty of the evidence. We included primary literature investigating the use of intravenous dextrose in hypoglycemic diabetic patients presenting to paramedics or the emergency department. Outcomes of interest were related to the safe and effective reversal of symptoms and blood glucose levels (BGL). Results: 660 abstracts were screened, 40 full text articles, with eight studies included. Data from three randomized controlled trials and five observational studies were analyzed. A single RCT comparing D10 to D50 was identified. The primary significant finding of the study was an increased post-treatment glycemic profile by 3.2 mmol/L in the D50 group; no other outcomes had significant differences between groups. When comparing pooled data from all the included studies we find higher symptom resolution in the D10 group compared to the D50 group; at 99.8% and 94.9% respectively. However, the mean time to resolution was approximately 4 minutes longer in the D10 group (4.1 minutes (D50) and 8 minutes (D10)). There was more need for subsequent doses in the D10 group at 23.0% versus 16.5% in the D50 group. The post treatment glycemic profile was lower in the D10 group at 5.9 mmol/L versus 8.5 mmol/L in the D50 group. Both treatments had nearly complete resolution of hypoglycemia; 98.7% (D50) and 99.2% (D10). No adverse events were observed in the D10 group (0/871) compared to 12/133 adverse events in the D50 group. Conclusion: D10 may be as effective as D50 at resolving symptoms and correcting hypoglycemia. Although the desired effect can take several minutes longer there appear to be fewer adverse events. The post treatment glycemic profile may facilitate less challenging ongoing glucose management by the patients.
Neurocognitive impairments in depression have traditionally been regarded as epiphenomena of the illness. Increasing evidence for the stability of neurocognitive deficits outside of depressive episodes implicates their potential role as mechanisms for emotion dysregulation associated with depressive states. This study thus examined associations between neurocognition and emotion regulation in currently depressed patients.
Participants were thirty patients presenting with current DSM-IV major depression. Participants completed neurocognitive tasks assessing executive function, attention, working memory, and response control to emotional stimuli. The capacity to implement functional emotion regulation strategies was assessed using additive sub-scales from the ‘Cognitive Emotion Regulation Questionnaire’ (CERQ), while emotion regulation difficulties were assessed using the ‘Difficulties in Emotion Regulation Scale’ (DERS).
Neurocognitive performance was compared between sub-groups of patients identified via median split on combined CERQ and DERS items. Patients reporting greater difficulties in emotion regulation demonstrated impaired sustained attention and response control, and increased reaction time to negative stimuli, in comparison to those reporting fewer difficulties. In addition, patients with better access to functional strategies demonstrated better attentional performance and fewer errors of omission to positive stimuli on the response control task.
Neuropsychological impairments in attention and response inhibition may contribute to emotion dysregulation in depressive episodes. By implication, remediation of particular neurocognitive deficits may improve the capacity to implement context-appropriate emotion regulation strategies in affective disorders. Examination of associations between neurocognitive impairment and emotion dysregulation outside of acute illness episodes is necessary to determine the relevance of these associations for illness development.
We know from neurological diseases that there is not only one way to hallucinate. This might also be the case in the psychiatric field. During a trial on refractory verbal hallucinations, we rediscovered a subgroup described under several names in France (Délire chronique d’évolution systématique 1882, Psychose Hallucinatoire Chronique 1911-1953), England (Late Paraphrenia, 1954) and Germany (Affective Paraphrenia - AP, 1968). Roughly, AP can be viewed as the core of paranoid schizophrenia.
We compared 10 AP patients with refractory hallucinations to 35 healthy controls with structural and functional MRI (fMRI). We looked for regions that presented with both grey matter deficit relative to controls and with hallucination-related activity. The lateral orbito-frontal cortex (LOF) was bilaterally involved both anatomically and functionally.
Using fMRI, we studied whole brain functional connectivity, both as a trait factor, i.e. hallucinators vs controls, and as a state factor, i.e. ON vs OFF hallucinations in the same patient. As a trait, functional connectivity was significantly increased between left and right LOF in patients relative to controls; however as a state, functional connectivity dropped to zero between left LOF, left and right superior temporal sulcus (STS) when ON relative to OFF hallucination.
In a larger group of AP patients without ongoing hallucinations, the LOF was still disconnected from the cingulate and temporal regions, in comparison not only to controls, but also relative to non AP type schizophrenias, most of whom also hallucinate during episodes.
We will discuss the “LOF-story hypothesis” for AP patients and their hallucinations.
22q11.2 deletion syndrome (22q11.2DS) and Williams syndrome (WS) are common neurogenetic microdeletion syndromes. The aim of the present study was to compare the neuropsychiatric and neurocognitive phenotypes of 22q11.2DS and WS.
Forty-five individuals with 22q11.2DS, 24 with WS, 22 with idiopathic developmental disability (DD) and 22 typically developing (TD) controls were compared for the rates of psychiatric disorders as well as cognitive executive and visuospatial functions.
We found that while anxiety, mood and disruptive disorders had an equally high prevalence among individuals with 22q11.2DS, WS and DDs, the 22q11.2DS group had the highest rates of psychotic disorders and the WS group had the highest rates of specific phobia. We also found that the WS group demonstrated more severe impairments in both executive and visuospatial functions than the other groups. WS and 22q11.2DS subjects had worse Performance-IQ than Verbal-IQ, a feature typical of non-verbal learning disorders.
These findings offer a wide perspective on unique versus common phenotypes in 22q11.2DS and WS.
Buprenorphine, a partial μ-opioid agonist and κ-opioid antagonist, is frequently used in the treatment of heroin dependence, and to prevent complications arising from intravenous injection and social consequences of heroin use. Psychosis occurring after discontinuation of buprenorphine or other opioids has been described, but is uncommon.
We report the case of a 37-year-old man, suffering from opiates dependence, presenting acute and intense psychotic symptoms beginning after an abrupt discontinuation of buprenorphine, which he was taking for two years as substitution therapy for heroin dependence. The initial medication by risperidone, up to a dose of 8 mg/day was inefficient to control psychotic symptoms. Four weeks later, buprenorphine was finally restarted at 8 mg/day, which allowed a complete remission of psychotic and anxiety-related symptoms. The antipsychotic medication was gradually discontinued two months later, allowing the patient to remain symptom-free eighteen months later.
We discuss the potential role of abrupt withdrawal syndrome in the apparition of the psychotic symptoms and the presence of a latent psychotic disorder. An interesting issue in our case report is that a correctly conducted antipsychotic treatment did not succeed in stopping symptoms of delusions, even after four weeks, while reintroducing buprenorphine did, showing in this context an antipsychotic effect. This case report highlights the importance of taking opiate dependence into account in patients with recent onset of psychotic symptoms, even several weeks after withdrawal.
We assessed infection prevention in Swiss hospitals via a national survey focusing on infection prevention practices prior to a large national infection prevention initiative. Of the 59 hospitals that responded (77%), 98% had infection prevention teams and 40% very good or excellent leadership support. However, a minority of hospitals used recommended infection prevention practices and surveillance systems regularly.
Cognitive impairment impacts on patient outcomes  but is under-recognised in acute hospitals . Data on rates and degree of impairment among hospital inpatients remain sparse. This information is vital for strategic planning of health services as the European population ages.
To examine the rates and degree of cognitive impairment among patients aged 65 and older who were admitted to an acute general hospital and to assess its impact on patient outcomes.
All patients aged over 65 who were admitted over a 2-week period were invited to participate. Those who met the inclusion criteria were screened for delirium then underwent a cognitive screening battery. Normative values for age and level of education were obtained from the TILDA study . Demographic and outcome data were obtained from medical records.
One hundred and forty-eight patients underwent cognitive screening. Thirty-nine over 148 (26%) met the DSM-IV criteria for dementia of whom only 16 (41%) had a previously-documented impairment. Thirty over 148 (20%) had evidence of cognitive impairment that did not meet criteria for dementia, only 3 (10%) of whom were previously documented. Seventy-three over 148 (49%) were normal. Six over 148 (4%) were not classifiable. The impact of cognitive status on length of hospital stay, number of readmissions in 6 months and discharge destination was investigated. Impact on length of stay was significant (P = 0.017) but significance was not achieved against number of readmissions or discharge destination.
Cognitive impairment is pervasive and under-recognised in the acute hospital and impacts on length of hospital stay. Longer interval analysis is necessary to investigate further implications.
References 1–3 available upon request.
Disclosure of interest
The authors have not supplied their declaration of competing interest.
Observational studies have shown a relationship between maternal mental health (MMH) and child development, but few studies have evaluated whether MMH interventions improve child-related outcomes, particularly in low- and middle-income countries. The objective of this review is to synthesise findings on the effectiveness of MMH interventions to improve child-related outcomes in low- and middle-income countries (LMICs).
We searched for randomised controlled trials conducted in LMICs evaluating interventions with a MMH component and reporting children's outcomes. Meta-analysis was performed on outcomes included in at least two trials.
We identified 21 trials with 28 284 mother–child dyads. Most trials were conducted in middle-income countries, evaluating home visiting interventions delivered by general health workers, starting in the third trimester of pregnancy. Only ten trials described acceptable methods for blinding outcome assessors. Four trials showed high risk of bias in at least two of the seven domains assessed in this review. Narrative synthesis showed promising but inconclusive findings for child-related outcomes. Meta-analysis identified a sizeable impact of interventions on exclusive breastfeeding (risk ratio = 1.39, 95% confidence interval (CI): 1.13–1.71, ten trials, N = 4749 mother–child dyads, I2 = 61%) and a small effect on child height-for-age at 6-months (std. mean difference = 0.13, 95% CI: 0.02–0.24, three trials, N = 1388, I2 = 0%). Meta-analyses did not identify intervention benefits for child cognitive and other growth outcomes; however, few trials measured these outcomes.
These findings support the importance of MMH to improve child-related outcomes in LMICs, particularly exclusive breastfeeding. Given, the small number of trials and methodological limitations, more rigorous trials should be conducted.