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To characterize the current state of antifungal stewardship practices and perceptions of antifungal use among pediatric antimicrobial stewardship programs (ASPs).
We developed and distributed an electronic survey, which included 17 closed-ended questions about institutional antifungal stewardship practices and perceptions, among pediatric ASPs.
ASP physicians and pharmacists of 74 hospitals participating in the multicenter Sharing Antimicrobial Reports for Pediatric Stewardship (SHARPS) Collaborative.
We sent surveys to 74 hospitals and received 68 unique responses, for a response rate of 92%. Overall, 63 of 68 the respondent ASPs (93%) reported that they conduct 1 or more antifungal stewardship activities. Of these 68 hospital ASPs, 43 (63%) perform prospective audit and feedback (PAF) of antifungals. The most common reasons reported for not performing PAF of antifungals were not enough time or resources (19 of 25, 76%) and minimal institutional antifungal use (6 of 25, 24%). Also, 52 hospitals (76%) require preauthorization for 1 or more antifungal agents. The most commonly restricted antifungals were isavuconazole (42 of 52 hospitals, 80%) and posaconazole (39 of 52 hospitals, 75%). Furthermore, 33 ASPs (48%) agreed or strongly agreed that antifungals are inappropriately used at their institution, and only 25 of 68 (37%) of ASPs felt very confident making recommendations about antifungals.
Most pediatric ASPs steward antifungals, but the strategies employed are highly variable across surveyed institutions. Although nearly half of respondents identified inappropriate antifungal use as a problem at their institution, most ASPs do not feel confident making recommendations about antifungals. Future studies are needed to determine the rate of inappropriate antifungal use and the best antifungal stewardship strategies.
To evaluate the effect of definitive radiotherapy dose on survival in patients with human papillomavirus positive oropharyngeal carcinoma.
Human papillomavirus positive oropharyngeal carcinoma patients staged T1–3 and N0–2c, who received definitive radiotherapy (fraction sizes of 180 cGy to less than 220 cGy), were identified from the National Cancer Database 2010–2014 and stratified by radiation dose (50 Gy to less than 66 Gy, or 66 Gy or more).
A total of 2173 patients were included, of whom 124 (6 per cent) received a radiation dose of 50 Gy to less than 66 Gy. With a median follow up of 33.8 months, patients had a 3-year overall survival rate of 88.6 per cent (95 per cent confidence interval = 87.1–90.1 per cent). On multivariate Cox analysis, a radiotherapy dose of 50 Gy to less than 66 Gy (hazard ratio = 0.95, 95 per cent confidence interval = 0.52–1.74, p = 0.86) was not a predictor of increased mortality risk.
Human papillomavirus positive oropharyngeal carcinoma patients had excellent outcomes with definitive radiotherapy doses of 50 Gy to less than 66 Gy. These results further support patients enrolling into clinical trials for radiation dose de-escalation.
There is growing concern about the influence of the pharmaceutical industry on psychiatric teaching and psychiatric professionalism as a whole. As a consequence, several national and international medical and psychiatric associations have issued guidelines to regulate the interactions between physicians and industry.
The EFPT-PRIRS study aims to provide the lacking data on the extent and nature of these interactions among psychiatric trainees across Europe.
Study objectives were determined by the EFPT research group (EFPT-RG), after discussion with national and international experts. A survey was then devised compiling previously published questionnaires extending them by questions with specific relevance to psychiatric trainees. The resulting questionnaire was piloted amongst members of the EFPT-RG, modified accordingly and subsequently distributed to the national study coordinators. All 24 EFPT member countries were invited to participate in the study and data collection is currently ongoing.
Preliminary analysis reveals the vast differences in industry - trainee relationships across European countries as well as major differences in personal attitudes towards these interactions.
EFPT-PRIRS will potentially have an impact on the regulation of the interactions between the pharmaceutical industry and psychiatric trainees.
There are some doubts as to whether psychotherapy will remain in the armamentarium of future psychiatrists. Few studies have explored early career psychiatrists’ views and their experience with psychotherapy training. The Early Career Psychiatrists’ Council of the WPA carried out an online survey on training and practice in psychotherapy in 13 European countries in order to assess:
1) main characteristics of psychotherapy training in the partecipating countries;
2) organizational and clinical differences of psychotherapy training;
3) trainees’ satisfaction and confidence in the use of psychotherapy.
An online survey was conducted through the use of a questionnaire specifically developed for the purposes of this study.Responders were required to collect their opinions on the basis of their own experience. Different aspects of psychotherapy training, such as compulsoriness, payment and supervision, as well as satisfaction with received training and confidence in the use of psychotherapy have been investigated. Results show that training in psychotherapy is mandatory in all countries, except Belgium and France, but most of early career psychiatrists have to pay for it. European trainees are satisfied (70%) with received training, and feel confident to treat patients in psychotherapy settings. Psychodynamic and cognitive-behavioural techniques are more common than systemic, interpersonal, supportive and psychoeducational ones.
In 3 countries out of 12 it is not compulsory to attend a psychotherapy training, and only psychodynamic and cognitive-behavioural approaches are widely spread in all countries.This survey is a starting point to improve training and practice of psychotherapy across Europe and to enhance early career psychiatrists’ psychotherapeutic skills and knowledge.
Multiple sclerosis (MS) is the commonest chronic autoimmune demyelinating and inflammatory disease of the CNS, afflicting both body and mind. Typical symptoms are fatigue, paraesthesia and depression, along with cognitive impairments. Whereas there is extant research on fatigue, depression, and cognitive impairment of patients with MS during the clinical course, no research focused on sleep, psychological functioning, and physical activity (PA) at the moment of the diagnose. The aims of the present study were therefore to assess possible state markers of mental toughness (MT) as a dimension of psychological functioning, sleep disturbances (SD), PA among patients at the moment of the diagnose, and to compare these data with those of healthy adolescents and healthy young adults.
A total of 23 patients with recently diagnosed MS (M = 32.31 years), 23 healthy adolescents (M = 17.43 years), and 25 healthy young adults (M = 20.72 years) took part in the study. They completed questionnaires covering socio-demographic data, MT, SD, and PA.
Patients with MS reported similar MT traits as adolescents, and an equal amount of moderate PA and SD as young adults. Further, patients reported a lower level of vigorous PA, compared to healthy adolescents and young adults.
Compared to healthy adolescents and young adults, patients at the moment of the diagnose of MS reported similar MT traits, SD and moderate PA. The pattern of results suggests that at the moment of the diagnose MS is not predictable by poor MT, poor sleep, and decreased level of moderate PA.
Disclosure of interest
The authors have not supplied their declaration of competing interest.
The hippocampus plays an important role in psychopathology and treatment outcome. While posterior hippocampus (PH) may be crucial for the learning process that exposure-based treatments require, affect-focused treatments might preferentially engage anterior hippocampus (AH). Previous studies have distinguished the different functions of these hippocampal sub-regions in memory, learning, and emotional processes, but not in treatment outcome. Examining two independent clinical trials, we hypothesized that anterior hippocampal volume would predict outcome of affect-focused treatment outcome [Interpersonal Psychotherapy (IPT); Panic-Focused Psychodynamic Psychotherapy (PFPP)], whereas posterior hippocampal volume would predict exposure-based treatment outcome [Prolonged Exposure (PE); Cognitive Behavioral Therapy (CBT); Applied Relaxation Training (ART)].
Thirty-five patients with posttraumatic stress disorder (PTSD) and 24 with panic disorder (PD) underwent structural magnetic resonance imaging (MRI) before randomization to affect-focused (IPT for PTSD; PFPP for PD) or exposure-based treatments (PE for PTSD; CBT or ART for PD). AH and PH volume were regressed with clinical outcome changes.
Baseline whole hippocampal volume did not predict post-treatment clinical severity scores in any treatment. For affect-focused treatments, but not exposure-based treatments, anterior hippocampal volume predicted clinical improvement. Smaller AH correlated with greater affect-focused treatment improvement. Posterior hippocampal volume did not predict treatment outcome.
This is the first study to explore associations between hippocampal volume sub-regions and treatment outcome in PTSD and PD. Convergent results suggest that affect-focused treatment may influence the clinical outcome through the ‘limbic’ AH, whereas exposure-based treatments do not. These preliminary, theory-congruent, therapeutic findings require replication in a larger clinical trial.
We observed pediatric S. aureus hospitalizations decreased 36% from 26.3 to 16.8 infections per 1,000 admissions from 2009 to 2016, with methicillin-resistant S. aureus (MRSA) decreasing by 52% and methicillin-susceptible S. aureus decreasing by 17%, among 39 pediatric hospitals. Similar decreases were observed for days of therapy of anti-MRSA antibiotics.
The livestock sector is one of the fastest growing subsectors of the agricultural economy and, while it makes a major contribution to global food supply and economic development, it also consumes significant amounts of natural resources and alters the environment. In order to improve our understanding of the global environmental impact of livestock supply chains, the Food and Agriculture Organization of the United Nations has developed the Global Livestock Environmental Assessment Model (GLEAM). The purpose of this paper is to provide a review of GLEAM. Specifically, it explains the model architecture, methods and functionality, that is the types of analysis that the model can perform. The model focuses primarily on the quantification of greenhouse gases emissions arising from the production of the 11 main livestock commodities. The model inputs and outputs are managed and produced as raster data sets, with spatial resolution of 0.05 decimal degrees. The Global Livestock Environmental Assessment Model v1.0 consists of five distinct modules: (a) the Herd Module; (b) the Manure Module; (c) the Feed Module; (d) the System Module; (e) the Allocation Module. In terms of the modelling approach, GLEAM has several advantages. For example spatial information on livestock distributions and crops yields enables rations to be derived that reflect the local availability of feed resources in developing countries. The Global Livestock Environmental Assessment Model also contains a herd model that enables livestock statistics to be disaggregated and variation in livestock performance and management to be captured. Priorities for future development of GLEAM include: improving data quality and the methods used to perform emissions calculations; extending the scope of the model to include selected additional environmental impacts and to enable predictive modelling; and improving the utility of GLEAM output.
Standard metrics for antimicrobial use consider volume but not spectrum of antimicrobial prescribing. We developed an antibiotic spectrum index (ASI) to classify commonly used antibiotics based on activity against important pathogens. The application of this index to hospital antibiotic use reveals how this tool enhances current antimicrobial stewardship metrics.
We analyzed antifungal and antiviral prescribing among high-risk children across freestanding children’s hospitals. Antifungal and antiviral days of therapy varied across hospitals. Benchmarking antifungal and antiviral use and developing antimicrobial stewardship strategies to optimize use of these high cost agents is needed.
Missing outcome data plague many randomized experiments. Common solutions rely on ignorability assumptions that may not be credible in all applications. We propose a method for confronting missing outcome data that makes fairly weak assumptions but can still yield informative bounds on the average treatment effect. Our approach is based on a combination of the double sampling design and nonparametric worst-case bounds. We derive a worst-case bounds estimator under double sampling and provide analytic expressions for variance estimators and confidence intervals. We also propose a method for covariate adjustment using poststratification and a sensitivity analysis for nonignorable missingness. Finally, we illustrate the utility of our approach using Monte Carlo simulations and a placebo-controlled randomized field experiment on the effects of persuasion on social attitudes with survey-based outcome measures.
We conducted a prospective cohort study between 1 January 2010 and 31 December 2012 at five adult and paediatric academic medical centres to identify factors associated with persistent methicillin-resistant Staphylococcus aureus (MRSA) colonisation. Adults and children presenting to ambulatory settings with a MRSA skin and soft tissue infection (i.e. index cases), along with household members, performed self-sampling for MRSA colonisation every 2 weeks for 6 months. Clearance of colonisation was defined as two consecutive negative sampling periods. Subjects without clearance by the end of the study were considered persistently colonised and compared with those who cleared colonisation. Of 243 index cases, 48 (19·8%) had persistent colonisation and 110 (45·3%) cleared colonisation without recurrence. Persistent colonisation was associated with white race (odds ratio (OR), 4·90; 95% confidence interval (CI), 1·38–17·40), prior MRSA infection (OR 3·59; 95% CI 1·05–12·35), colonisation of multiple sites (OR 32·7; 95% CI 6·7–159·3). Conversely, subjects with persistent colonisation were less likely to have been treated with clindamycin (OR 0·28; 95% CI 0·08–0·99). Colonisation at multiple sites is a risk factor for persistent colonisation and may require more targeted decolonisation efforts. The specific effect of clindamycin on MRSA colonisation needs to be elucidated.
The attribution of factors influencing positive and negative phase durations of climate teleconnections is an important problem in climate research. In addition to inferring such an attribution directly from climate models or from the available data, distinguishing the true causality from simple correlations is often hampered by the multiscale nature of the geophysical system. Here we deploy a data-driven multiscale causality inference methodology to extract the statistically most significant Bayesian causality relations between the discretized historical, seasonal climate teleconnections time series in order to quantify the probabilistic causality impacts from the unresolved/weather scales (i.e. beyond and above the synoptic scales). Our results enable us to quantify the leading role of the annular modes (in particular the Southern Annular Mode) and the tropical Pacific on monthly scale causalities, revealing that the joint causality impacts from these modes lead to a Bayesian predictability that is approximately four times stronger than the joint predictability of the northern hemisphere teleconnections on the same monthly scales. We further show how the obtained causality networks can be validated and elucidate the possible physical mechanisms inducing these relations. This approach enables the prediction of characteristics like phase duration probabilities and provides a better plausible data-driven explanation for the observed higher frequencies of long phases of teleconnections such as the El Niño Southern Oscillation.
Understanding the causal relations between the respective teleconnections of the climate system is one of the central problems in ocean/atmosphere/climate science. If we denote the climate variable of interest as y and all other known and measurable variables as x1, …, xn, inference of causality means that in the context of some model (e.g. of the climate model or, alternatively, of some simplified data-driven probabilistic model) we would like to identify all of the xi that have a statistically significant impact on the “explanation”/ prediction of y while distinguishing them from all xj that are “insignificant” (for said y).
Regression discontinuity (RD) designs enable researchers to estimate causal effects using observational data. These causal effects are identified at the point of discontinuity that distinguishes those observations that do or do not receive the treatment. One challenge in applying RD in practice is that data may be sparse in the immediate vicinity of the discontinuity. Expanding the analysis to observations outside this immediate vicinity may improve the statistical precision with which treatment effects are estimated, but including more distant observations also increases the risk of bias. Model specification is another source of uncertainty; as the bandwidth around the cutoff point expands, linear approximations may break down, requiring more flexible functional forms. Using data from a large randomized experiment conducted by Gerber, Green, and Larimer (2008), this study attempts to recover an experimental benchmark using RD and assesses the uncertainty introduced by various aspects of model and bandwidth selection. More generally, we demonstrate how experimental benchmarks can be used to gauge and improve the reliability of RD analyses.
The debate about the cost-effectiveness of randomized field experimentation ignores one of the most important potential uses of experimental data. This article defines and illustrates “downstream” experimental analysis—that is, analysis of the indirect effects of experimental interventions. We argue that downstream analysis may be as valuable as conventional analysis, perhaps even more so in the case of laboratory experimentation.
Field experiments on voter mobilization enable researchers to test theoretical propositions while at the same time addressing practical questions that confront campaigns. This confluence of interests has led to increasing collaboration between researchers and campaign organizations, which in turn has produced a rapid accumulation of experiments on voting. This new evidence base makes possible translational works such as Get Out the Vote: How to Increase Voter Turnout that synthesize the burgeoning research literature and convey its conclusions to campaign practitioners. However, as political groups develop their own in-house capacity to conduct experiments whose results remain proprietary and may be reported selectively, the accumulation of an unbiased, public knowledge base is threatened. We discuss these challenges and the ways in which research that focuses on practical concerns may nonetheless speak to enduring theoretical questions.
To determine the impact of total household decolonization with intranasal mupirocin and chlorhexidine gluconate body wash on recurrent methicillin-resistant Staphylococcus aureus (MRSA) infection among subjects with MRSA skin and soft-tissue infection.
Three-arm nonmasked randomized controlled trial.
Five academic medical centers in Southeastern Pennsylvania.
Adults and children presenting to ambulatory care settings with community-onset MRSA skin and soft-tissue infection (ie, index cases) and their household members.
Enrolled households were randomized to 1 of 3 intervention groups: (1) education on routine hygiene measures, (2) education plus decolonization without reminders (intranasal mupirocin ointment twice daily for 7 days and chlorhexidine gluconate on the first and last day), or (3) education plus decolonization with reminders, where subjects received daily telephone call or text message reminders.
MAIN OUTCOME MEASURES
Owing to small numbers of recurrent infections, this analysis focused on time to clearance of colonization in the index case.
Of 223 households, 73 were randomized to education-only, 76 to decolonization without reminders, 74 to decolonization with reminders. There was no significant difference in time to clearance of colonization between the education-only and decolonization groups (log-rank P=.768). In secondary analyses, compliance with decolonization was associated with decreased time to clearance (P=.018).
Total household decolonization did not result in decreased time to clearance of MRSA colonization among adults and children with MRSA skin and soft-tissue infection. However, subjects who were compliant with the protocol had more rapid clearance
Following implementation of automatic end dates for antimicrobial orders to facilitate antimicrobial stewardship at a large, academic children’s hospital, no differences were observed in patient mortality, length of stay, or readmission rates, even among patients with documented bacteremia.