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Bloodstream infections (BSIs) are a frequent cause of morbidity in patients with acute myeloid leukemia (AML), due in part to the presence of central venous access devices (CVADs) required to deliver therapy.
Objective:
To determine the differential risk of bacterial BSI during neutropenia by CVAD type in pediatric patients with AML.
Methods:
We performed a secondary analysis in a cohort of 560 pediatric patients (1,828 chemotherapy courses) receiving frontline AML chemotherapy at 17 US centers. The exposure was CVAD type at course start: tunneled externalized catheter (TEC), peripherally inserted central catheter (PICC), or totally implanted catheter (TIC). The primary outcome was course-specific incident bacterial BSI; secondary outcomes included mucosal barrier injury (MBI)-BSI and non-MBI BSI. Poisson regression was used to compute adjusted rate ratios comparing BSI occurrence during neutropenia by line type, controlling for demographic, clinical, and hospital-level characteristics.
Results:
The rate of BSI did not differ by CVAD type: 11 BSIs per 1,000 neutropenic days for TECs, 13.7 for PICCs, and 10.7 for TICs. After adjustment, there was no statistically significant association between CVAD type and BSI: PICC incident rate ratio [IRR] = 1.00 (95% confidence interval [CI], 0.75–1.32) and TIC IRR = 0.83 (95% CI, 0.49–1.41) compared to TEC. When MBI and non-MBI were examined separately, results were similar.
Conclusions:
In this large, multicenter cohort of pediatric AML patients, we found no difference in the rate of BSI during neutropenia by CVAD type. This may be due to a risk-profile for BSI that is unique to AML patients.
To describe the cumulative seroprevalence of severe acute respiratory coronavirus virus 2 (SARS-CoV-2) antibodies during the coronavirus disease 2019 (COVID-19) pandemic among employees of a large pediatric healthcare system.
Design, setting, and participants:
Prospective observational cohort study open to adult employees at the Children’s Hospital of Philadelphia, conducted April 20–December 17, 2020.
Methods:
Employees were recruited starting with high-risk exposure groups, utilizing e-mails, flyers, and announcements at virtual town hall meetings. At baseline, 1 month, 2 months, and 6 months, participants reported occupational and community exposures and gave a blood sample for SARS-CoV-2 antibody measurement by enzyme-linked immunosorbent assays (ELISAs). A post hoc Cox proportional hazards regression model was performed to identify factors associated with increased risk for seropositivity.
Results:
In total, 1,740 employees were enrolled. At 6 months, the cumulative seroprevalence was 5.3%, which was below estimated community point seroprevalence. Seroprevalence was 5.8% among employees who provided direct care and was 3.4% among employees who did not perform direct patient care. Most participants who were seropositive at baseline remained positive at follow-up assessments. In a post hoc analysis, direct patient care (hazard ratio [HR], 1.95; 95% confidence interval [CI], 1.03–3.68), Black race (HR, 2.70; 95% CI, 1.24–5.87), and exposure to a confirmed case in a nonhealthcare setting (HR, 4.32; 95% CI, 2.71–6.88) were associated with statistically significant increased risk for seropositivity.
Conclusions:
Employee SARS-CoV-2 seroprevalence rates remained below the point-prevalence rates of the surrounding community. Provision of direct patient care, Black race, and exposure to a confirmed case in a nonhealthcare setting conferred increased risk. These data can inform occupational protection measures to maximize protection of employees within the workplace during future COVID-19 waves or other epidemics.
Although the involvement of citizen scientists in research can contribute to scientific benefits, much remains unknown about participants’ lived experiences in research. Thus, the purpose of this study was to explore how citizen scientists describe their role in, motivation for, and communication with researchers.
Methods:
In-depth interviews (N = 9) were conducted with citizen scientists at a translational health research center.
Results:
Key results include that citizen scientists were invested in learning researchers’ discipline-specific language and viewed small group sizes as conducive to their active participation.
Conclusions:
Programs can apply these findings in an effort to improve citizen scientists’ long-term engagement in research.
When the legal historian William Novak states, “the United States is distinctly a ‘legal or jural state,’”1 what does this mean? One very simple understanding is that the Constitution and the legal concepts contained in it are the supreme law of the land. Richard Epstein’s argument for the “classic liberal constitution” that “prized the protection of liberty and private property under a system of limited government”2 is one example of this. Phillip Hamburger’s framing of American government through legal concepts such as adjudication and legislation is another.3
On February 29, 2017, President Trump issued Executive Order 13778, “Restoring the Rule of Law, Federalism, and Economic Growth by Reviewing the ‘Waters of the United States.’”1 The purpose of this simultaneously ambitious-sounding and dull-sounding Order was to demand the reconsideration of a 2015 regulation – the “Waters of the United States” rule, known as the “WOTUS” rule. The rule adopted a definition of the term “waters of the United States” that defined the jurisdiction of the Army Corps of Engineers (Corps) and the Environmental Protection Agency (EPA) under the Clean Water Act.2 On signing the Executive Order, Trump remarked “a few years ago the EPA decided that navigable waters can mean every puddle or every ditch … it was a massive power grab.”3
As the law of public administration, judicial review is fundamental. As Louis Jaffe stated in 1965, the “availability of judicial review is the necessary condition, psychologically if not logically, of a system of administrative power which purposes to be legitimate or legally valid.”1 As a forum for active and authoritative accountability, it ensures the worthiness of the administrative state to be recognized. But judicial review for the sake of judicial review is not prima facie meaningful. If it is to be a form of meaningful accountability,2 it must take both administrative authority and capacity into account. As we have said in Chapter 1, the legitimacy of the administrative state depends not only on the legal authority to act, but on the administrative capacity to implement statutory mandates.
For the anxious administrative lawyer, the problem is this – if expert administrative capacity is a complex set of knowledge and institutional practices, is it possible for administrative law to truly ensure that public administration stays within its authority and is properly held to account? Is the only solution to trust in the judgment of expert administrators? Does that not carry a whole range of threats? Is the only real answer to constrain that power and limit it to a set of specific tasks?
In 1975, a young administrative law scholar, Richard Stewart, published “The Reformation of American Administrative Law” in the Harvard Law Review.1 His 150-page narrative is a grand portrayal of a dramatic shift in the nature of administrative law. According to this narrative, the traditional understanding of administrative law, which Stewart called the “transmission belt model,”2 was “essentially a negative instrument for checking government power,”3 aimed at the management of “the problem of discretion.”4 Harkening back to the idea that the New Dealers saw expertise as a solution for this discretion, Stewart allowed that expertise “could plausibly by advocated as a solution to the problem of discretion,” but only if the “agency’s goal could be realized through the knowledge that comes from specialized experience,”5 which Stewart doubted was possible.6
The last chapter showed how ideas of administrative competence were entangled with debates over good government in the Founding and the Federalist period. Not only that, the first structures of administrative capacity were being developed at that time. At the end of the chapter, we pointed to how the construction of the Pensions Building in the 1880s reflected a series of commitments that can be traced back to the end of the eighteenth century. The building was a late nineteenth-century construction, but its shape and structure were the product of nearly a century of pensions administration, and more importantly, the democratic aspiration for such a scheme.
In the first half of the 2010s, the sociologist Arlie Russell Hochschild spent five years conducting field research in Southwest Louisiana on what she saw as the Great Paradox.1 As she explained, “I had imagined before I came [to Louisiana] that the more polluted the place in which people live, the more alarmed they would be by that pollution and the more in favor of cleaning it up. Instead I found Louisiana to be highly polluted and the people I talked with to be generally opposed to any more environmental regulation and indeed, regulation in general.”2 That opposition has led to support for political movements aimed at “deconstructing the administrative state.”3 Many of the people Hochschild interviews are Tea Party voters. Their views are not a world away from those who deny the legitimacy of the administrative state that we touched on in Chapter 1.
As Professor James Boyd White once observed, the “life of imagination work[s] with inherited materials and against inherited constraints.”1 “The greatest power of law,” he continued, “lies not in particular rules or decisions but in the way … it structures sensibility and vision.”2 The reader has seen this insight in operation in the preceding pages.
Administrative competence exists because government cannot be done through the articulation of rules alone. It requires expert administrative capacity – not only to execute a set of legislative mandates, but also to articulate what those mandates mean. This capacity transforms expectations such as those for clean water, clean air, and safe workplaces into realizable realities. Such capacity is not amorphous. It must be fit and proper. It must act in accordance with the rule of law. Judicial review of how an agency interprets its statutory framework is important. Done properly it contributes to meaningful accountability by fostering active administrative competence.
In 1974, Harold Leventhal, a judge of the District of Columbia (DC) Circuit of the Federal Court of Appeals, wrote that “[t]he law of the environment now seems suddenly ablaze, a development which has taken place essentially within the last five years.”1 As seen in Chapter 7, the subject of Leventhal’s comment was the legislation that had been passed in those five years because it required “administrative implementation through rules and orders rooted in technical expertise and inquiry.”2 It was not just that, however. As also seen in Chapter 7, there were calls for more responsive government – government that fulfilled the democratic wishes of the American people.3
Expertise is not a new concept for administrative lawyers. One of the major justifications for the administrative state is the expertise it brings to governing. Felix Frankfurter once opined that “expertise is the lifeblood of the administrative process”1 and few administrative lawyers would doubt him. It is a term that plays a pivotal role in administrative law reasoning.2