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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.
Background: Tracheal aspirate bacterial cultures are routinely collected in mechanically ventilated children for the evaluation of ventilator-associated infections (VAIs). However, frequent bacterial colonization of endotracheal and tracheostomy tubes contribute to the marginal performance characteristics of the test for diagnosing VAI. Published literature characterizing drivers of culture collection and the predictive value of positive cultures are limited. Methods: This single-center, retrospective cohort study included children admitted to the pediatric intensive care unit who were receiving mechanical ventilation for at least 48 hours and had 1 or more semiquantitative tracheal aspirate cultures collected between September 1, 2019, and August 31, 2020. Indications for culture collection were determined through medical record review and included fever, hypothermia, tracheal secretion changes, radiographic pneumonia, increased oxygen requirement, and/or increased positive end-expiratory pressure (PEEP). A positive culture was defined as moderate or heavy growth of a noncommensal bacterial organism. A purulent Gram stain was defined as detection of moderate or many white blood cells. Diagnosis of VAI was based on treating-clinician documentation and was ascertained through medical record review. Logistic regression accounting for clustering by patient was performed to estimate the association between indications for culture collection and (1) culture positivity, (2) purulent Gram stain, and (3) diagnosis of VAI. Results: In total, 625 tracheal aspirate cultures were performed in 261 unique patients. Common indications for culture collection included isolated fever or hypothermia (n = 124, 20%), fever with an increase in oxygen requirement or PEEP (n = 71, 11%), isolated increase in oxygen requirement or PEEP (n = 67, 11%), or isolated secretion change (n = 54, 9%) (Figure 1). Overall, 230 cultures (37%) were positive and 218 (35%) Gram stains were purulent. There were no associations between culture indications and a positive culture. Presence of isolated fever was negatively associated with a purulent Gram stain (odds ratio [OR], 0.49; 95% CI, 0.30–0.81; P = .005); otherwise, there were no associations between indication and purulent Gram stain. Finally, in a multivariable model, odds of VAI diagnosis increased with both the number of indications for culture collection and purulent Gram stain, but not with positive culture (Figure 2). Conclusions: Number and type of clinical signs were not associated with tracheal aspirate culture positivity or purulence on Gram stain, but they were associated with a clinical diagnosis of VAI. These findings suggest that positive tracheal aspirate cultures may not aid clinicians in the diagnosis of VAI, and they highlight the opportunity for improved diagnostic stewardship.
Registry-based trials have emerged as a potentially cost-saving study methodology. Early estimates of cost savings, however, conflated the benefits associated with registry utilisation and those associated with other aspects of pragmatic trial designs, which might not all be as broadly applicable. In this study, we sought to build a practical tool that investigators could use across disciplines to estimate the ranges of potential cost differences associated with implementing registry-based trials versus standard clinical trials.
We built simulation Markov models to compare unique costs associated with data acquisition, cleaning, and linkage under a registry-based trial design versus a standard clinical trial. We conducted one-way, two-way, and probabilistic sensitivity analyses, varying study characteristics over broad ranges, to determine thresholds at which investigators might optimally select each trial design.
Registry-based trials were more cost effective than standard clinical trials 98.6% of the time. Data-related cost savings ranged from $4300 to $600,000 with variation in study characteristics. Cost differences were most reactive to the number of patients in a study, the number of data elements per patient available in a registry, and the speed with which research coordinators could manually abstract data. Registry incorporation resulted in cost savings when as few as 3768 independent data elements were available and when manual data abstraction took as little as 3.4 seconds per data field.
Registries offer important resources for investigators. When available, their broad incorporation may help the scientific community reduce the costs of clinical investigation. We offer here a practical tool for investigators to assess potential costs savings.
The Single Ventricle Reconstruction Trial randomised neonates with hypoplastic left heart syndrome to a shunt strategy but otherwise retained standard of care. We aimed to describe centre-level practice variation at Fontan completion.
Centre-level data are reported as median or median frequency across all centres and range of medians or frequencies across centres. Classification and regression tree analysis assessed the association of centre-level factors with length of stay and percentage of patients with prolonged pleural effusion (>7 days).
The median Fontan age (14 centres, 320 patients) was 3.1 years (range from 1.7 to 3.9), and the weight-for-age z-score was −0.56 (−1.35 + 0.44). Extra-cardiac Fontans were performed in 79% (4–100%) of patients at the 13 centres performing this procedure; lateral tunnels were performed in 32% (3–100%) at the 11 centres performing it. Deep hypothermic circulatory arrest (nine centres) ranged from 6 to 100%. Major complications occurred in 17% (7–33%). The length of stay was 9.5 days (9–12); 15% (6–33%) had prolonged pleural effusion. Centres with fewer patients (<6%) with prolonged pleural effusion and fewer (<41%) complications had a shorter length of stay (<10 days; sensitivity 1.0; specificity 0.71; area under the curve 0.96). Avoiding deep hypothermic circulatory arrest and higher weight-for-age z-score were associated with a lower percentage of patients with prolonged effusions (<9.5%; sensitivity 1.0; specificity = 0.86; area under the curve 0.98).
Fontan perioperative practices varied widely among study centres. Strategies to decrease the duration of pleural effusion and minimise complications may decrease the length of stay. Further research regarding deep hypothermic circulatory arrest is needed to understand its association with prolonged pleural effusion.
Optimal rheumatoid arthritis (RA) management requires coordinated management and consistent communication by health practitioners with patients. Suboptimal methotrexate use is a factor leading to increased use of biological disease modifying antirheumatic drugs (bDMARDs), which account for significant government drug expenditure. A multidisciplinary co-design approach was used to develop and implement a program aiming to improve early management and quality use of medicines (QUM) for people with RA in Australia.
Literature review and key informant interviews identified broad potential QUM issues in RA management. An initial exploratory multidisciplinary meeting prioritized QUM issues, identified audiences and perspectives, and scoped focus areas to address with education. Iteratively through co-design meetings and activities, program objectives were agreed, barriers and enablers for change explored, characteristics of intervention activities considered and rated, and program products developed and reviewed. Program evaluation included participation and distribution data, surveys and interviews, and analyses of general practice and Pharmaceutical Benefits Scheme (PBS) data.
QUM issues addressed include: (i) timely initiation of conventional synthetic (cs) DMARDs; (ii) appropriate use and persistence with csDMARD therapy, especially methotrexate; and (iii) clarity around professional roles and best practice for prescribing, dispensing, and monitoring DMARDs, and managing lifestyle factors and other risks associated with RA. The educational program (October 2017 to June 2018) included: an article promoting key messages (email to ~115,000 health practitioners), prescriber feedback report based on PBS data (to all Australian rheumatologists), an RA action plan (completed by health practitioners for consumers), an interactive case study (553 participants), visits to 1200 pharmacies promoting key messages, a multidisciplinary webinar (431 live and 366 on-demand), fact sheets for consumers available through MedicineWise app (medicine management app for consumers), and social media activity.
A multidisciplinary co-design process has provided a model for developing a multifaceted QUM program incorporating and addressing multiple perspectives.
Involved fatherhood is crucial for the development of healthy, well-functioning families. In this chapter, we review empirical research from around the world on (a) the effects of involved fatherhood on the well-being of children, women, and families, (b) the predictors of and barriers to paternal involvement, and (c) how family-supportive public and employer-based policy can better support fathers so they can succeed both at the workplace and in their families. We conclude with suggestions for further research, public policy, and business practice.
Pepper & Nettle's theory of the behavioral constellation of deprivation (BCD) would benefit from teasing apart the conceptually distinct – although related – constructs of predictability and control. Our commentary draws from prior research conducted in the learning domain to demonstrate that predictability moderates the effects of control and independently exerts a powerful influence on outcomes relevant to the BCD.
Previous studies have identified risk factors for femoral arterial thrombosis after paediatric cardiac catheterisation, but none of them have evaluated the clinical and economic significance of this complication at the population level. Therefore, we examined the national prevalence and economic impact of femoral arterial thrombosis after cardiac catheterisation in children.
Patients⩽18 years of age who underwent cardiac catheterisation were identified in the 2003–2009 Kids’ Inpatient Database. Patients were stratified by age as follows: <1 year of age or 1–18 years of age. The primary outcome was arterial thrombosis of the lower extremity during the same hospitalisation as cardiac catheterisation. Propensity score matching was used to determine the impact of femoral arterial thrombosis on hospital length of stay, cost, and mortality.
Among the 11,497 paediatric cardiac catheterisations identified, 4558 catheterisations (39.6%) were performed in children <1 year of age. This age group experienced a higher prevalence of reported femoral arterial thrombosis, compared with children aged 1–18 years (1.3 versus 0.3%, p<0.001). After matching, femoral arterial thrombosis in children <1 year of age was associated with similar mortality (5.4 versus 1.8%, p=0.28), length of stay (8 versus 5 days, p=0.11), and total hospital cost ($27,135 versus $28,311, p=0.61), compared with absence of thrombosis.
Femoral arterial thrombosis is especially prevalent in children <1 year of age undergoing cardiac catheterisation. Clinicians should be vigilant in monitoring femoral arterial patency in neonates and infants after cardiac catheterisation.
Protohistoric Ancestral Apache Dismal River groups (A.D. 1600–1750)
participated in large exchange networks linking them to other peoples on the
Plains and U.S. Southwest. Ceramic vessels made from micaceous materials
appear at many Dismal River sites, and micaceous pottery recovered from the
Central High Plains is typically seen as evidence for interaction with
northern Rio Grande pueblos. However, few mineral or chemical
characterization analyses have been conducted on these ceramics, and the
term “micaceous” has been applied to a broad range of vessel types
regardless of the form, size, or amount of mica in their pastes. Our recent
analyses, including macroscopic evaluation combined with petrography and
neutron activation analyses (NAA), indicate that only a small subset of
Dismal River sherds are derived from New Mexico clays. The rest were likely
manufactured using materials from Colorado and Wyoming. Seasonal mobility
patterns may have given Dismal River potters the opportunity to collect mica
raw materials as they traveled between the Central Plains and Front Range,
and this has implications for the importance of internal Plains social
networks during the Protohistoric and Historic periods.
In the United States alone, ∼14,000 children are hospitalised annually with acute heart failure. The science and art of caring for these patients continues to evolve. The International Pediatric Heart Failure Summit of Johns Hopkins All Children’s Heart Institute was held on February 4 and 5, 2015. The 2015 International Pediatric Heart Failure Summit of Johns Hopkins All Children’s Heart Institute was funded through the Andrews/Daicoff Cardiovascular Program Endowment, a philanthropic collaboration between All Children’s Hospital and the Morsani College of Medicine at the University of South Florida (USF). Sponsored by All Children’s Hospital Andrews/Daicoff Cardiovascular Program, the International Pediatric Heart Failure Summit assembled leaders in clinical and scientific disciplines related to paediatric heart failure and created a multi-disciplinary “think-tank”. The purpose of this manuscript is to summarise the lessons from the 2015 International Pediatric Heart Failure Summit of Johns Hopkins All Children’s Heart Institute, to describe the “state of the art” of the treatment of paediatric cardiac failure, and to discuss future directions for research in the domain of paediatric cardiac failure.
Brain tumors have been loosely divided between primary (occurring from the cells native to the CNS) and secondary or metastatic (from spread by direct contiguous contact or hematologic spread). The incidence of primary brain tumors in the USA is roughly 6.4 for every 100,000 people, with the majority comprising the glioblastoma subtype. Metastatic brain tumors occur in 15–20% of all cancer patients with the primary etiology being lung, breast, melanoma, and renal tumors. With the development of new imaging techniques, innovative surgical techniques, and progressive adjunctive therapies, the treatment of brain tumors now involves earlier diagnosis, improved accuracy for surgery, and more medical and radiation options for patients with brain tumors. Despite improved imaging techniques that can better describe the characteristics of brain tumors without tissue evaluation, the role of craniotomy surgery is an important component of both diagnosis and treatment of patients with brain tumors. As opposed to formal craniotomy, stereotactic needle biopsy can be used for those patients with tumor in a deep, functionally important region of the brain and in patients with poor systemic health. Histologic examination of these core needle biopsies is then used to direct therapy. Craniotomy and surgical debulking/excision are especially beneficial in those patients with large lesions that are symptomatic due to size and edema that cause compression of surrounding brain tissue.
Preoperative imaging for brain tumors is technically specific to each individual patient. With expert interpretation, surgical planning can be made with a general understanding of the goal of the procedure. Imaging techniques have progressed to include digital subtraction angiography, MRI, MR spectroscopy and functional MRI, to name a few. These techniques provide valuable information, but are frequently unable to exclude all other non-tumorous lesions like infarction, infection, and multiple sclerosis. Thus a craniotomy or needle biopsy is required to obtain definitive diagnosis.
Sport is an integral part of British culture and an important aspect of modern life. Although its importance has been recognised by academic historians, sport has yet to be fully appreciated in the growing and related fields of heritage and museum studies. Sport and heritage have operated as seemingly separate spheres, yet together they can convey powerful messages; convergence between them is seen in the rise and popularity of sports museums, the collecting of sporting art and memorabilia, and popular concern over the demise of historic sports buildings and sport-related sites. These places, exhibitions and activities help to shape our understanding of sport, history and the past. The essays in this volume explore sports history as manifested in academic enquiry, museum exhibitions and heritage sites. They deal among other things with the public representation of sport and its significance; its impact on public spheres; the direction of sports heritage studies and their aims; the role of museums in public history; and place, memory and meaning in the historic sports landscape. Contributors: Jeffrey Hill, Jed Smith, Anthony Bateman, Ray Physick, Neil Skinner, Matthew Taylor, Tim O'Sullivan, Kevin Moore, Max Dunbar, Santiago De Pablo, John K. Walton, Wray Vamplew, Honor Godfrey, Jason Wood, Andrea Titterington, Stephen Done, Mike McGuinness, David Storey, Daphné Bolz, Jean Williams, Richard Holt. Jeffrey Hill is Emeritus Professor of Historical and Cultural Studies, De Montfort University, Leicester; Kevin Moore is Director, National Football Museum, Manchester; Jason Wood is Director, Heritage Consultancy Services.