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Ambulatory healthcare-associated infections (HAIs) occur frequently in children and are associated with morbidity. Less is known about ambulatory HAI costs. This study estimated additional costs associated with pediatric ambulatory central-line–associated bloodstream infections (CLABSIs), catheter-associated urinary tract infections (CAUTI), and surgical site infections (SSIs) following ambulatory surgery.
Retrospective case-control study.
Four academic medical centers.
Children aged 0–22 years seen between 2010 and 2015 and at risk for HAI as identified by electronic queries.
Chart review adjudicated HAIs. Charges were obtained for patients with HAIs and matched controls 30 days before HAI, on the day of, and 30 days after HAI. Charges were converted to costs and 2015 USD. Mixed-effects linear regression was used to estimate the difference-in-differences of HAI case versus control costs in 2 models: unrecorded charge values considered missing and a sensitivity analysis with unrecorded charge considered $0.
Our search identified 177 patients with ambulatory CLABSIs, 53 with ambulatory CAUTIs, and 26 with SSIs following ambulatory surgery who were matched with 382, 110, and 75 controls, respectively. Additional cost associated with an ambulatory CLABSI was $5,684 (95% confidence interval [CI], $1,005–$10,362) and $6,502 (95% CI, $2,261–$10,744) in the 2 models; cost associated with a CAUTI was $6,660 (95% CI, $1,055, $12,145) and $2,661 (95% CI, −$431 to $5,753); cost associated with an SSI following ambulatory surgery at 1 institution only was $6,370 (95% CI, $4,022–$8,719).
Ambulatory HAI in pediatric patients are associated with significant additional costs. Further work is needed to reduce ambulatory HAIs.
Resident education in emergency medicine (EM) relies upon a variety of teaching platforms and mediums, including real-life clinical scenarios, simulation, academic day (lectures, small group sessions), journal clubs, and teaching learners. However, the coronavirus disease 2019 (COVID-19) pandemic has disrupted teaching and learning, forcing programs to adapt to ensure residents can progress in their training.1 Suddenly, academic days cannot be held in person, emergency department (ED) volumes are dynamically changing, and the role of residents in ED procedures has been questioned. Furthermore, medical student rotations through the ED have been cancelled, decreasing resident exposure to undergraduate teaching. These changes to resident education threaten resident wellness and will have downstream effects on training and personal professional development. In response, programs must develop strategies to ensure that residents continue receiving high-quality training in a safe learning environment. In this review, we will cover recommended strategies put forth by two large EM programs in Ontario (Table 1).
Catheter-associated urinary tract infections (CAUTIs) occur frequently in pediatric inpatients, and they are associated with increased morbidity and cost. Few studies have investigated ambulatory CAUTIs, despite at-risk children utilizing home urinary catheterization. This retrospective cohort and case-control study determined incidence, risk factors, and outcomes of pediatric patients with ambulatory CAUTI.
Broad electronic queries identified potential patients with ambulatory urinary catheters, and direct chart review confirmed catheters and adjudicated whether ambulatory CAUTI occurred. CAUTI definitions included clean intermittent catheterization (CIC). Our matched case-control analysis assessed risk factors.
Five urban, academic medical centers, part of the New York City Clinical Data Research Network.
Potential patients were age <22 years who were seen between October 2010 and September 2015.
In total, 3,598 eligible patients were identified; 359 of these used ambulatory catheterization (representing186,616 ambulatory catheter days). Of these, 63 patients (18%) experienced 95 ambulatory CAUTIs. The overall ambulatory CAUTI incidence was 0.51 infections per 1,000 catheter days (1.35 for indwelling catheters and 0.47 for CIC; incidence rate ratio, 2.88). Patients with nonprivate medical insurance (odds ratio, 2.5; 95% confidence interval, 1.1–6.3) were significantly more likely to have ambulatory CAUTIs in bivariate models but not multivariable models. Also, 45% of ambulatory CAUTI resulted in hospitalization (median duration, 3 days); 5% resulted in intensive care admission; 47% underwent imaging; and 88% were treated with antibiotics.
Pediatric ambulatory CAUTIs occur in 18% of patients with catheters; they are associated with morbidity and healthcare utilization. Ambulatory indwelling catheter CAUTI incidence exceeded national inpatient incidence. Future quality improvement research to reduce these harmful infections is warranted.
A 53-year-old male presents with cough, fever, and myalgias for 7 days. Vitals include temperature, 38.0°C; heart rate, 110; blood pressure, 118/70 mm Hg; respiration rate, 28; and oxygen saturation 83% on room air. His only past medical history is hypertension. Your community is in the midst of the coronavirus disease 2019 (COVID-19) pandemic. The patient is hypoxic but responds to oxygen supplementation with nasal cannula and a face mask. His chest x-ray demonstrates multifocal infiltrates. Are there any therapeutic agents currently available for COVID-19?
This article argues that the well-known debate about the obligatory nature of the evening prayer, attributed to tannaitic authorities in both the Palestinian and Babylonian Talmuds, is in fact a Babylonian invention. The article documents the significant evidence that the evening prayer was assumed to be obligatory in tannaitic and early amoraic texts and then argues that the literary context of the debate in both Talmuds strongly suggests Babylonian origins for the debate. Dating the debate is more complex, but it seems relatively unlikely that this represents a pre-amoraic Babylonian tradition. Finally, the article considers the motivation for such a development in amoraic Babylonia and suggests that antiquarian interest in the temple may be the likeliest avenue to pursue.
This study examined the association and directionality of effect between mental wellbeing and depressive symptoms in Australian adolescents. Data were collected on two occasions 21 months apart. At Time 1, 1,762 10- to 14-year-old adolescents from a range of socio-economic status areas participated. At Time 2 (T2), 1,575 participated again. On both occasions, the Short Warwick-Edinburgh Mental Wellbeing Scale (SWEMWBS) and the Children's Depression Inventory 2 (CDI 2) were administered via online survey. Cross-lagged, longitudinal path analyses demonstrated a negative association between earlier symptoms of depression and later positive mental wellbeing, and that the reverse was also true, though weaker. The model accounted for 20% of the variance in males’ T2 CDI 2 depressive symptom scores (26% for females) and 21% of the variance in males’ T2 SWEMWBS mental wellbeing scores (23% for females). Depressive symptomatology and mental wellbeing were highly correlated, but symptoms of depression were more strongly associated with later mental wellbeing than vice versa. This has implications for educational psychologists, teachers, health professionals, and policy makers seeking to reduce depressive symptoms or promote mental wellbeing. Focusing solely on the promotion of mental wellbeing, without intervening to reduce symptoms of depression, may limit the potential outcomes that might be achieved.
Needle thoracostomy is the prehospital treatment for tension pneumothorax. Sufficient catheter length is necessary for procedural success. The authors of this study determined minimum catheter length needed for procedural success on a percentile basis.
A meta-analysis of existing studies was conducted. A Medline search was performed using the search terms: needle decompression, needle thoracentesis, chest decompression, pneumothorax decompression, needle thoracostomy, and tension pneumothorax. Studies were included if they published a sample size, mean chest wall thickness, and a standard deviation or confidence interval. A PubMed search was performed in a similar fashion. Sample size, mean chest wall thickness, and standard deviation were found or calculated for each study. Data were combined to create a pooled dataset. Normal distribution of data was assumed. Procedural success was defined as catheter length being equal to or greater than the chest wall thickness.
The Medline and PubMed searches yielded 773 unique studies; all study abstracts were reviewed for possible inclusion. Eighteen papers were identified for full manuscript review. Thirteen studies met all inclusion criteria and were included in the analysis. Pooled sample statistics were: n=2,558; mean=4.19 cm; and SD=1.37 cm. Minimum catheter length needed for success at the 95th percentile for chest wall size was found to be 6.44 cm.
A catheter of at least 6.44 cm in length would be required to ensure that 95% of the patients in this pooled sample would have penetration of the pleural space at the site of needle decompression, and therefore, a successful procedure. These findings represent Level III evidence.
ClemencyBM, TanskiCT, RosenbergM, MayPR, ConsiglioJD, LindstromHA. Sufficient Catheter Length for Pneumothorax Needle Decompression: A Meta-Analysis. Prehosp Disaster Med. 2015;30(3):15
Across 366 California hospitals, we identified hospital-level characteristics predicting increased hospital-associated Clostridium difficile infection (HA-CDI) rates including more licensed beds, teaching and long-term acute care (LTAC) hospitals, and polymerase chain reaction testing. Adjustment for these characteristics impacted rankings in 24% of teaching hospitals, 13% of community hospitals, and 11% of LTAC hospitals.
In recent years, there has been a surge in the study of ritual impurity and its relationship to immorality (or, perhaps more accurately, prohibited activity) in biblical literature and early Judaism. Yet relatively scant attention has been paid to one of the most important topics pertaining to impurity—the menstrual laws of Leviticus (the laws of [niddah]) and their development in early Jewish texts. The niddah laws are uniquely important because they appear both in the context of ritual-impurity legislation (Leviticus 12 and Leviticus 15) and in the context of legislation concerning prohibited acts (Lev 18:19 and Lev 20:18). Or, to put it another way: biblical menstrual laws comprise both impurity and prohibition elements.
Treatment of Staphylococcus aureus colonization before surgery reduces risk of surgical site infection (SSI). The regimen of nasal mupirocin ointment and topical chlorhexidine gluconate is effective, but cost and patient compliance may be a barrier. Nasal povidone-iodine solution may provide an alternative to mupirocin.
We conducted an investigator-initiated, open-label, randomized trial comparing SSI after arthroplasty or spine fusion in patients receiving topical chlorhexidine wipes in combination with either twice daily application of nasal mupirocin ointment during the 5 days before surgery or 2 applications of povidone-iodine solution into each nostril within 2 hours of surgical incision. The primary study end point was deep SSI within the 3 months after surgery.
In the modified intent-to-treat analysis, a deep SSI developed after 14 of 855 surgical procedures in the mupirocin group and 6 of 842 surgical procedures in the povidone-iodine group (P = .1); S. aureus deep SSI developed after 5 surgical procedures in the mupirocin group and 1 surgical procedure in the povidone-iodine group (P = .2). In the per protocol analysis, S. aureus deep SSI developed in 5 of 763 surgical procedures in the mupirocin group and 0 of 776 surgical procedures in the povidone-iodine group (P = .03).
Nasal povidone-iodine may be considered as an alternative to mupirocin in a multifaceted approach to reduce SSI.
Due to rising rates of obesity globally, the present study aimed to examine differences in overweight and underweight prevalence in Western Australian schoolchildren in 2008 compared with 2003.
Cross-sectional study at two time points; using two-stage stratified sampling, primary and secondary schools in both metropolitan and non-metropolitan Western Australia; sample selected was representative of the State's population figures.
Seventeen primary and thirteen secondary (2008) and nineteen primary and seventeen secondary (2003) schools. Government and non-government funded schools in metropolitan and non-metropolitan (regional/rural) Western Australia were recruited.
Height and weight were measured for 1708 (961 primary and 747 secondary) students in 2008 and 1694 (876 primary and 817 secondary) students in 2003.
Overweight and obesity prevalence in primary students was similar in 2008 (22·9 %) to 2003 (23·2 %; P > 0·05). In secondary girls overweight and obesity prevalence dropped from 23·1 % (2003) to 15·9 % (2008; P = 0·002). Secondary boys showed a slight decrease in overweight and obesity prevalence; however, this was not statistically significant (P = 0·102). Higher proportions of underweight in primary girls were observed in 2008 (9·9 %) compared with 2003 (4·2 %; P < 0·001) and in secondary girls in 2008 (9·4 %) compared with 2003 (5·5 %; P < 0·001).
Prevalence of overweight and obesity in Western Australian primary students was stable; however, it declined in secondary students. Both primary and secondary girls showed an increase in underweight prevalence. Public health interventions are needed for the high percentage of youth still overweight, whereas the observed increase in underweight girls warrants attention and further investigation.
It is likely that there are substantial subconscious effects of organizations’ efforts to associate their products with sport via sponsorships, but most research methods are unable to capture these effects. The present study employed a novel projective technique to explore children's implicit associations between popular sports and a range of sports sponsors.
Children participated in an activity using magnets bearing the logos of numerous sports and sponsors. They were invited to arrange the magnets on a whiteboard without being advised that the activity related to sponsorship.
Perth, Western Australia.
Children (n 164) aged 5–12 years.
Three-quarters (76 %) of the children aligned at least one correct sponsor magnet with the relevant sport. Just over half the children (54 %) correctly matched the most popular sport (an Australian Football League team) with its relevant sponsor (a fast-food chain).
Given the unstructured nature of the projective task, the results provide some support for the argument that sports sponsorship can effectively reach child audiences. This is of concern given the current extent of sponsorship by alcohol and fast-food companies.
This chapter is an atlas of digital mammography intended to introduce the reader to the appearance of various benign and malignant entities as they may appear on digital imaging. Cases 1–17 were contributed by Robert D. Rosenberg, and cases 18–34 are from Michael N. Linver.
Dr. Rosenberg’s practice switched from film-screen mammography to computed radiographic technique using Fuji equipment with 50 mm pixel size, and approximately two years later switched again to Hologic direct digital radiographic technique with a 70 mm pixel size. Therefore, his digital images are a combination of these two image types. When it makes a difference which type of image is being shown, the Fuji computed radiographic images are designated as CR images, and the Hologic direct digital radiographic images as DR images.
Dr. Linver’s practice moved from film-screen mammography directly to Hologic direct digital mammography with a 70 mm pixel size, so all of his digital mammography images are obtained with that equipment.
Agents of opportunity (AO) in academic medical centers (AMC) are defined as unregulated or lightly regulated substances used for medical research or patient care that can be used as “dual purpose” substances by terrorists to inflict damage upon populations. Most of these agents are used routinely throughout AMC either during research or for general clinical practice. To date, the lack of careful regulations for AOs creates uncertain security conditions and increased malicious potential. Using a consensus-based approach, we collected information and opinions from staff working in an AMC and 4 AMC-affiliated hospitals concerning identification of AO, AO attributes, and AMC risk and preparedness, focusing on AO security and dissemination mechanisms and likely hospital response. The goal was to develop a risk profile and framework for AO in the institution. Agents of opportunity in 4 classes were identified and an AO profile was developed, comprising 16 attributes denoting information critical to preparedness for AO misuse. Agents of opportunity found in AMC present a unique and vital gap in public health preparedness. Findings of this project may provide a foundation for a discussion and consensus efforts to determine a nationally accepted risk profile framework for AO. This foundation may further lead to the implementation of appropriate regulatory policies to improve public health preparedness. Agents of opportunity modeling of dissemination properties should be developed to better predict AO risk.
(Disaster Med Public Health Preparedness. 2010;4:318-325)