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To assess the overall burden and outcomes of acute respiratory infections in paediatric inpatients with congenital heart disease (CHD).
This is a retrospective cross-sectional study of non-neonates <1 year with CHD in the Kid’s Inpatient Database from 2012. We compared demographics, clinical characteristics, cost, length of stay, and mortality rate for those with and without respiratory infections. We also compared those with respiratory infections who had critical CHD versus non-critical CHD. Multi-variable regression analyses were done to look for associations between respiratory infections and mortality, length of stay, and cost.
Of the 28,696 infants with CHD in our sample, 26% had respiratory infections. Respiratory infection-associated hospitalisations accounted for $440 million in costs (32%) for all CHD patients. After adjusting for confounders including severity, mortality was higher for those with respiratory infections (OR 1.5, p = 0.003), estimated mean length of stay was longer (14.7 versus 12.2 days, p < 0.001), and estimated mean costs were higher ($53,760 versus $46,526, p < 0.001). Compared to infants with respiratory infections and non-critical CHD, infants with respiratory infections and critical CHD had higher mortality (4.5 versus 2.3%, p < 0.001), longer mean length of stay (20.1 versus 15.5 days, p < 0.001), and higher mean costs ($94,284 versus $52,585, p < 0.001).
Acute respiratory infections are a significant burden on infant inpatients with CHD and are associated with higher mortality, costs, and longer length of stay; particularly in those with critical CHD. Future interventions should focus on reducing the burden of respiratory infections in this population.
Outbreaks of cyclosporiasis, a food-borne illness caused by the coccidian parasite Cyclospora cayetanensis have increased in the USA in recent years, with approximately 2300 laboratory-confirmed cases reported in 2018. Genotyping tools are needed to inform epidemiological investigations, yet genotyping Cyclospora has proven challenging due to its sexual reproductive cycle which produces complex infections characterized by high genetic heterogeneity. We used targeted amplicon deep sequencing and a recently described ensemble-based distance statistic that accommodates heterogeneous (mixed) genotypes and specimens with partial genotyping data, to genotype and cluster 648 C. cayetanensis samples submitted to CDC in 2018. The performance of the ensemble was assessed by comparing ensemble-identified genetic clusters to analogous clusters identified independently based on common food exposures. Using these epidemiologic clusters as a gold standard, the ensemble facilitated genetic clustering with 93.8% sensitivity and 99.7% specificity. Hence, we anticipate that this procedure will greatly complement epidemiologic investigations of cyclosporiasis.
Catatonia is a psychomotor dysregulation syndrome of diverse aetiology, increasingly recognised as a prominent feature of N-methyl-d-aspartate receptor antibody encephalitis (NMDARE) in adults. No study to date has systematically assessed the prevalence and symptomatology of catatonia in children with NMDARE. We analysed 57 paediatric patients with NMDARE from the literature using the Bush-Francis Catatonia Rating Scale. Catatonia was common (occurring in 86% of patients), manifesting as complex clusters of positive and negative features within individual patients. It was both underrecognised and undertreated. Immunotherapy was the only effective intervention, highlighting the importance of prompt recognition and treatment of the underlying cause of catatonia.
Refractory depression is a major contributor to the economic burden of depression. Radically open dialectical behaviour therapy (RO DBT) is an unevaluated new treatment targeting overcontrolled personality, common in refractory depression, but it is not yet known whether the additional expense of RO DBT is good value for money.
To estimate the cost-effectiveness of RO DBT plus treatment as usual (TAU) compared with TAU alone in people with refractory depression (trial registration: ISRCTN85784627).
We undertook a cost-effectiveness analysis alongside a randomised trial evaluating RO DBT plus TAU versus TAU alone for refractory depression in three UK secondary care centres. Our economic evaluation, 12 months after randomisation, adopted the perspective of the UK National Health Service (NHS) and personal social services. It evaluated cost-effectiveness by comparing the net cost of RO DBT with the net gain in quality-adjusted life-years (QALYs), estimated using the EQ-5D-3L measure of health-related quality of life.
The additional cost of RO DBT plus TAU compared with TAU alone was £7048 and was associated with a difference of 0.032 QALYs, yielding an incremental cost-effectiveness ratio (ICER) of £220 250 per QALY. This ICER was well above the National Institute for Health and Care Excellence (NICE) upper threshold of £30 000 per QALY. A cost-effectiveness acceptability curve indicated that RO DBT had a zero probability of being cost-effective compared with TAU at the NICE £30 000 threshold.
In its current resource-intensive form, RO DBT is not a cost-effective use of resources in the UK NHS.
Declaration of interest
R.H. is co-owner and director of Radically Open Ltd, the RO DBT training and dissemination company. D.K. reports grants outside the submitted work from the National Institute for Health Research (NIHR). T.L. receives royalties from New Harbinger Publishing for sales of RO DBT treatment manuals, speaking fees from Radically Open Ltd, and a grant outside the submitted work from the Medical Research Council. He was co-director of Radically Open Ltd between November 2014 and May 2015 and is married to Erica Smith-Lynch, the principal shareholder and one of two directors of Radically Open Ltd. H.O'M. reports personal fees outside the submitted work from the Charlie Waller Institute and Improving Access to Psychological Therapy. S.R. provides RO DBT supervision through her company S C Rushbrook Ltd. I.R. reports grants outside the submitted work from NIHR and Health & Care Research Wales. M. Stanton reports personal fees outside the submitted work from British Isles DBT Training, Stanton Psychological Services Ltd and Taylor & Francis. M. Swales reports personal fees outside the submitted work from British Isles DBT Training, Guilford Press, Oxford University Press and Taylor & Francis. B.W. was co-director of Radically Open Ltd between November 2014 and February 2015.
Individuals with depression often do not respond to medication or psychotherapy. Radically open dialectical behaviour therapy (RO DBT) is a new treatment targeting overcontrolled personality, common in refractory depression.
To compare RO DBT plus treatment as usual (TAU) for refractory depression with TAU alone (trial registration: ISRCTN 85784627).
RO DBT comprised 29 therapy sessions and 27 skills classes over 6 months. Our completed randomised trial evaluated RO DBT for refractory depression over 18 months in three British secondary care centres. Of 250 adult participants, we randomised 162 (65%) to RO DBT. The primary outcome was the Hamilton Rating Scale for Depression (HRSD), assessed masked and analysed by treatment allocated.
After 7 months, immediately following therapy, RO DBT had significantly reduced depressive symptoms by 5.40 points on the HRSD relative to TAU (95% CI 0.94–9.85). After 12 months (primary end-point), the difference of 2.15 points on the HRSD in favour of RO DBT was not significant (95% CI –2.28 to 6.59); nor was that of 1.69 points on the HRSD at 18 months (95% CI –2.84 to 6.22). Throughout RO DBT participants reported significantly better psychological flexibility and emotional coping than controls. However, they reported eight possible serious adverse reactions compared with none in the control group.
The RO DBT group reported significantly lower HRSD scores than the control group after 7 months, but not thereafter. The imbalance in serious adverse reactions was probably because of the controls' limited opportunities to report these.
Land storms did not become a significant subject in the history of Italian art until the mid-seventeenth century when they appear as a well-developed sub-genre of landscape painting, notably in the works of two artists, Gaspard Dughet (1615–75) and Herman van Swanevelt (c.1603–55). However, it is unclear from existing literature with which artist the theme originated. This essay will elucidate the problem of assigning credit for the storm scene's invention. Close examination will clarify Dughet’s and Swanevelt's roles in the development of the new genre, especially the treatment of phenomenological aspects of stormy weather. The storm scene's origins in artistic precedent and theory, the literature of classical antiquity and the climatic conditions of seventeenth-century Europe will also be addressed.
Keywords: Swanevelt, Dughet, Cassiano dal Pozzo, storm scenes, climatic change
In 1651 Nicolas Poussin (1596–1664) wrote to his friend in Paris, the painter, Jacques Stella (1596–1657), on the fundamental role of the storm in his composition Landscape with Pyramus and Thisbe (1651, Städlisches Kunstinstitut, Frankfurt am Main), describing at length the exact meteorological effects he aimed at creating in his tale of Ovid’s star-crossed lovers (Met. IV). In the painting the distraught Thisbe rushes towards the supine Pyramus while lightning flashes in a dark, threatening sky and a raging storm tosses the leaves and limbs of trees, the whole conveying both nature's fury and Thisbe's emotional turmoil. It has been called an ‘ekphrastic masterpiece’, in which Poussin aimed to equal the mimetic abilities of two famous forerunners, the ancient Greek painter, Apelles, and the Renaissance master, Leonardo da Vinci (1452–1519), whose recommendations for how to represent a land storm in his Trattato della pittura Poussin appears to have followed carefully. Poussin showed trees that Leonardo recommended should ‘bend to earth almost as though they wished to follow the course of the winds’, as well as meteorological effects such as ‘smoky clouds, which, struck by the sun's rays […] descend to earth, lighting it up with their beams’ and ‘infuriated bolts of lightning’ that illuminate ‘the shadowed countryside in various places’. Clearly Leonardo's text motivated Poussin to explore the possibilities of the land storm – a subject far less common than the storm at sea in mid-seventeenth-century Roman art – and inspired him to create one of his most memorable landscapes.
Patient refusal for care or transport is a common request to medical control physicians, and it is an especially challenging decision in the case of minors. Parents or guardians are able to refuse medical care for a minor if there is not an imminent threat of harm to the minor. However, if a minor patient is presumed to be in need of emergent medical care to prevent harm, medical personnel have the right to treat the minor, even if the parent or guardian objects. If the minor patient is a fetus or a neonate, it is not always clear when they are considered to be a separate patient. Apparently, there is no over-riding general rule or law and, consequently, Emergency Medical Services (EMS) protocols vary greatly from state to state. This case report describes one patient case that involved some of these unclear legal areas and how it fit with local EMS protocols. The legal question arose when a pregnant patient delivered her baby, but the umbilical cord was not cut. Are the mother’s rights violated by cutting the umbilical cord if she objects to the procedure? How is the medical control physician to decide when to go beyond established EMS protocols to ensure that the safest and most ethical care is provided to a patient in the field? Does the care of the infant or the mother take precedence? Continued analyses of cases are required to ensure that protocols and guidelines are protecting both patients and providers.
Venegas A, Ann Maggiore W, Wells R, Baker R, Watts S. Medical control decisions: when does a neonate become a separate patient? Prehosp Disaster Med. 2019;34(2):224–225
To describe the epidemiology of surgical site infections (SSIs) after pediatric ambulatory surgery.
Observational cohort study with 60 days follow-up after surgery.
The study took place in 3 ambulatory surgical facilities (ASFs) and 1 hospital-based facility in a single pediatric healthcare network.
Children <18 years undergoing ambulatory surgery were included in the study. Of 19,777 eligible surgical encounters, 8,502 patients were enrolled.
Data were collected through parental interviews and from chart reviews. We assessed 2 outcomes: (1) National Healthcare Safety Network (NHSN)–defined SSI and (2) evidence of possible infection using a definition developed for this study.
We identified 21 NSHN SSIs for a rate of 2.5 SSIs per 1,000 surgical encounters: 2.9 per 1,000 at the hospital-based facility and 1.6 per 1,000 at the ASFs. After restricting the search to procedures completed at both facilities and adjustment for patient demographics, there was no difference in the risk of NHSN SSI between the 2 types of facilities (odds ratio, 0.7; 95% confidence interval, 0.2–2.3). Within 60 days after surgery, 404 surgical patients had some or strong evidence of possible infection obtained from parental interview and/or chart review (rate, 48 SSIs per 1,000 surgical encounters). Of 306 cases identified through parental interviews, 176 cases (57%) did not have chart documentation. In our multivariable analysis, older age and black race were associated with a reduced risk of possible infection.
The rate of NHSN-defined SSI after pediatric ambulatory surgery was low, although a substantial additional burden of infectious morbidity related to surgery might not have been captured by standard surveillance strategies and definitions.
Following large declines in tuberculosis transmission the United States, large-scale screening programs targeting low-risk healthcare workers are increasingly a source of false-positive results. We report a large cluster of presumed false-positive tuberculin skin test results in healthcare workers following a change to 50-dose vials of Tubersol tuberculin.
The increased proportion of UK children diagnosed with autism spectrum disorder (ASD) has been attributed to improved identification, rather than true increase in incidence.
To explore whether the proportion of children with diagnosis of ASD and/or the proportion with associated behavioural traits had increased over a 10-year period.
A cross-cohort comparison using regression to compare prevalence of diagnosis and behavioural traits over time. Participants were children aged 7 years assessed in 1998/1999 (n=8139) and 2007/2008 (n=13831).
During 1998/1999, 1.09% (95% CI 0.86–1.37) of children were reported as having ASD diagnosis compared with 1.68% (95% CI 1.42–2.00) in 2007/2008: risk ratio (RR)=1.55 (95% CI 1.17–2.06), P=0.003. The proportion of children in the population with behavioural traits associated with ASD was also larger in the later cohort: RR=1.61 (95% CI 1.35–1.92), P<0.001. Increased odds of diagnosis at the later time point was partially accounted for by adjusting for the increased proportion of children with ASD-type traits.
Increased ASD diagnosis may partially reflect increase in rates of behaviour associated with ASD and/or greater parent/teacher recognition of associated behaviours.
We have previously shown that the minor alleles of vascular endothelial growth factor A (VEGFA) single-nucleotide polymorphism rs833069 and superoxide dismutase 2 (SOD2) single-nucleotide polymorphism rs2758331 are both associated with improved transplant-free survival after surgery for CHD in infants, but the underlying mechanisms are unknown. We hypothesised that one or both of these minor alleles are associated with better systemic ventricular function, resulting in improved survival.
This study is a follow-up analysis of 422 non-syndromic CHD patients who underwent neonatal cardiac surgery with cardiopulmonary bypass. Echocardiographic reports were reviewed. Systemic ventricular function was subjectively categorised as normal, or as mildly, moderately, or severely depressed. The change in function was calculated as the change from the preoperative study to the last available study. Stepwise linear regression, adjusting for covariates, was performed for the outcome of change in ventricular function. Model comparison was performed using Akaike’s information criterion. Only variables that improved the model prediction of change in systemic ventricular function were retained in the final model.
Genetic and echocardiographic data were available for 335/422 subjects (79%). Of them, 33 (9.9%) developed worse systemic ventricular function during a mean follow-up period of 13.5 years. After covariate adjustment, the presence of the VEGFA minor allele was associated with preserved ventricular function (p=0.011).
These data support the hypothesis that the mechanism by which the VEGFA single-nucleotide polymorphism rs833069 minor allele improves survival may be the preservation of ventricular function. Further studies are needed to validate this genotype–phenotype association and to determine whether this mechanism is related to increased vascular endothelial growth factor production.
Taking four assumptions in turn, this review article considers some of the lenses through which researchers might look at later-life leisure travel and the implications of adopting each of them. First, we consider the ‘active ageing’ agenda and what this means for how leisure travel may be thought about in academia and beyond. Second, we turn to studies underpinned by worries about the appetite for significant consumption thought to typify the ‘baby-boomer’ generation and question whether these studies could inadvertently be promoting the very future they hope to avoid. Third, we explore how research on the benefits of everyday ‘mobility’ in later life may have morphed into a more general belief about the value of travel in older age. Finally, we reflect on how relevant studies of tourism are often underpinned by an argument about the financial rewards that now await those ready to target the older traveller. Our overall contention is that, though for different reasons, all four could be serving to encourage more later-life travel. Whilst for some this prospect is not at all troubling, the spectre of adverse energy demand consequences leads us to explore a more critical view.
Compared to chart review, a definition based on the International Classification of Disease, Ninth Revision, Clinical Modification (ICD-9-CM) diagnosis code for healthcare-associated influenza-like illness (HA-ILI) among young children in a large pediatric network demonstrated high positive and negative predictive values. This finding suggests that electronic health record–based definitions for surveillance can accurately identify medically attended outpatient HA-ILI cases for research and surveillance.
Studies have suggested that contact precautions (CP) for methicillin-resistant Staphylococcus aureus and vancomycin-resistant enterococcus may have risks that outweigh the benefits. These risks, coupled with more widespread use of horizontal interventions such as daily bathing with chlorhexidine gluconate, have brought into question the value of routine CP for these organisms.
To assess the state of utilization of CP as well as adjunctive measures to reduce the risk of transmission in US hospitals.
Total of 751 physician members of the Emerging Infections Network.
An 8-question electronic survey distributed by email.
A total of 426/751 (57%) responded to the survey; 337/364 (93%) of respondents use routine CP for methicillin-resistant S. aureus and 335/364 (92%) use routine CP for vancomycin-resistant enterococcus. The most widely used trigger for initiation of CP for both pathogens was positive clinical culture. Practices for discontinuation of isolation varied widely. We found that 325/354 (92%) perform routine chlorhexidine gluconate bathing and 236/353 (67%) perform S. aureus decolonization with mupirocin for 1 or more subsets of inpatients, and 82/356 (23%) reported using either hydrogen peroxide vapor or ultraviolet-C room disinfection at discharge. Free text responses noted frustration and variation in the application, practice, and process for initiation and discontinuation of CP.
Use of CP for methicillin-resistant S. aureus and vancomycin-resistant enterococcus remains commonplace, although horizontal interventions such as chlorhexidine gluconate bathing are increasingly used. The heterogeneity of practices and policies was striking. Evidence-based guidelines regarding CP and horizontal interventions are needed.
The Janiculum Hill in antiquity was a place of noble villas, military triumphs, ancient burials and Christian martyrdoms, all of which were recorded and interpreted in various ways in the antiquarian maps and literature of the sixteenth and seventeenth centuries. Many of its associations had significance to the Pamphilj family, who bought a modest vigna there in 1630, not long after Giovan Battista Pamphilj (1574–1655) became cardinal. In the fourteen years that separated the purchase of the vigna and the elevation of Cardinal Pamphilj to the papal throne as Innocent X (1644–55) more land was acquired in the area, and the Casino del Bel Respiro, the Pamphilj's palazzo di rappresentanza at the Villa Pamphilj, was eventually built some distance from the original farmhouse, its entrance directly facing the dome of Saint Peter's. The villa played an essential role in constructing a public image for the Pamphilj that was inseparable from their claims to descend from the very founders of Rome, claims that were delineated by Niccolò Angelo Cafferri in his genealogy of the Pamphilj, a work initiated by Cardinal Girolamo Pamphilj (1544–1610) and published in 1662. This paper discusses how Cafferri's genealogy and antiquarian scholarship in Rome contributed to the selection of the Casino's site, design, decoration and iconology.