In acute ischemic stroke, a longer time from onset to endovascular treatment (EVT) is associated with worse clinical outcome. We investigated the association of clinical outcome with time from last known well to arrival at the EVT hospital and time from hospital arrival to arterial access for anterior circulation large vessel occlusion patients treated > 6 hours from last known well.

Retrospective analysis of the prospective, multicenter cohort study ESCAPE-LATE. Patients presenting > 6 hours after last known well with anterior circulation large vessel occlusion undergoing EVT were included. The primary outcome was the modified Rankin Scale (mRS) score at 90 days. Secondary outcomes were good (mRS 0–2) and poor clinical outcomes (mRS 5–6) at 90 days, as well as the National Institutes of Health Stroke Scale at 24 hours. Associations of time intervals with outcomes were assessed with univariable and multivariable logistic regression.

Two hundred patients were included in the analysis, of whom 85 (43%) were female. 90-day mRS was available for 141 patients. Of the 150 patients, 135 (90%) had moderate-to-good collaterals, and the median Alberta Stroke Program Early CT Score (ASPECTS) was 8 (IQR = 7–10). No association between ordinal mRS and time from last known well to arrival at the EVT hospital (odds ratio [OR] = 1.01, 95% CI = 1.00–1.02) or time from hospital arrival to arterial access (OR = -0.01, 95% CI = -0.02–0.00) was seen in adjusted regression models.

No relationship was observed between pre-hospital or in-hospital workflow times and clinical outcomes. Baseline ASPECTS and collateral status were favorable in the majority of patients, suggesting that physicians may have chosen to predominantly treat slow progressors in the late time window, in whom prolonged workflow times have less impact on outcomes.

Central line-associated bloodstream infection (CLABSI) is one of the most prevalent pediatric healthcare-associated infections and is used to benchmark hospital performance. Pediatric patients have increased in acuity and complexity over time. Existing approaches to risk adjustment do not control for individual patient characteristics, which are strong predictors of CLABSI risk and vary over time. Our objective was to develop a risk adjustment model for CLABSI in hospitalized children and compare observed to expected rates over time.

We conducted a prospective cohort study using electronic health record data at a quaternary Children’s Hospital.

We included hospitalized children with central catheters.

Risk factors identified from published literature were considered for inclusion in multivariable modeling based on association with CLABSI risk in bivariable analysis and expert input. We calculated observed and expected (risk model-adjusted) annual CLABSI rates.

Among 16,411 patients with 520,209 line days, 633 patients experienced 796 CLABSIs. The final model included age, behavioral health condition, non-English speaking, oncology service, port catheter type, catheter dwell time, lymphatic condition, total parenteral nutrition, and number of organ systems requiring ICU level care. For every organ system receiving ICU level care the odds ratio for CLABSI was 1.24 (95% CI 1.12–1.37). Although not statistically different, observed rates were lower than expected rates for later years.

Failure to adjust for patient factors, particularly acuity and complexity of disease, may miss clinically significant differences in CLABSI rates, and may lead to inaccurate interpretation of the impact of quality improvement efforts.

To assess cost-effectiveness of late time-window endovascular treatment (EVT) in a clinical trial setting and a “real-world” setting.

Data are from the randomized ESCAPE trial and a prospective cohort study (ESCAPE-LATE). Anterior circulation large vessel occlusion patients presenting > 6 hours from last-known-well were included, whereby collateral status was an inclusion criterion for ESCAPE but not ESCAPE-LATE. A Markov state transition model was built to estimate lifetime costs and quality-adjusted life-years (QALYs) for EVT in addition to best medical care vs. best medical care only in a clinical trial setting (comparing ESCAPE-EVT to ESCAPE control arm patients) and a “real-world” setting (comparing ESCAPE-LATE to ESCAPE control arm patients). We performed an unadjusted analysis, using 90-day modified Rankin Scale(mRS) scores as model input and analysis adjusted for baseline factors. Acceptability of EVT was calculated using upper/lower willingness-to-pay thresholds of 100,000 USD/50,000 USD/QALY.

Two-hundred and forty-nine patients were included (ESCAPE-LATE:n = 200, ESCAPE EVT-arm:n = 29, ESCAPE control-arm:n = 20). Late EVT in addition to best medical care was cost effective in the unadjusted analysis both in the clinical trial and real-world setting, with acceptability 96.6%–99.0%. After adjusting for differences in baseline variables between the groups, late EVT was marginally cost effective in the clinical trial setting (acceptability:49.9%–61.6%), but not the “real-world” setting (acceptability:32.9%–42.6%).

EVT for LVO-patients presenting beyond 6 hours was cost effective in the clinical trial setting and “real-world” setting, although this was largely related to baseline patient differences favoring the “real-world” EVT group. After adjusting for these, EVT benefit was reduced in the trial setting, and absent in the real-world setting.

The emergence of eating problems during childhood increases the risk for eating disorders (EDs) during young adulthood. Previous studies highlight a relationship between poor self-regulation and onset of eating pathology. In this study, we investigated whether this association is mediated by decision-making difficulties.

To test this hypothesis, we used data from the Millennium Cohort Study. Decision-making performance was assessed with the Cambridge Gambling Task at age 11. Principal components analysis was used to derive an index of ED symptoms at age 14. The trajectories of scores of two subscales of the Child Social Behaviour Questionnaire, Independence and Self-Regulation (ISR) and Emotional Dysregulation (EmotDy), were modelled from ages 3 to 7 years in a latent growth curve analysis. The individual predicted values of the intercept (set at baseline, 3 years) and the slope (rate of annual change) were then used in the mediation analysis.

In our sample of 11 303 individuals, there was evidence for mediation by three measures of decision-making at age 11 (poor quality of decision-making, delay aversion and low risk-adjustment) in the association between EmotDy across ages 3–7 and ED symptoms at age 14 even after the adjustment for relevant covariates. We found no evidence of association between ISR and ED symptoms.

Our findings suggest that emotion regulation processes during childhood may be relevant for the future onset of ED symptoms via their association with decision-making skills. These findings, obtained from a large, representative, sample, shed light on the relationship between self-regulation, decision-making and symptoms of EDs.

Approximately 18% of adults with intellectual disabilities living in the community display behaviours that challenge. Intensive support teams (ISTs) have been recommended to provide high-quality responsive care aimed at avoiding unnecessary admissions and reducing lengthy in-patient stays.

To identify and describe the geographical distribution and characteristics of ISTs, and to develop a typology of IST service models in England.

We undertook a national cross-sectional survey of 73 ISTs. A hierarchical cluster analysis was performed based on six prespecified grouping factors (mode of referrals, size of case-load, use of outcome measures, staff composition, hours of operation and setting of service). A simplified form of thematic analysis was used to explore free-text responses.

Cluster analysis identified two models of IST provision: (a) independent and (b) enhanced provision based around a community intellectual disability service. ISTs aspire to adopt person-centred care, mostly use the framework of positive behaviour support for behaviour that challenges, and report concerns about organisational and wider context issues.

This is the first study to examine the delivery of intensive support to people with intellectual disability and behaviour that challenges. A two-cluster model of ISTs was found to have statistical validity and clinical utility. The clinical heterogeneity indicates that further evaluation of these service models is needed to establish their clinical and cost-effectiveness.

Recovery of multidrug-resistant (MDR) Pseudomonas aeruginosa and Klebsiella pneumoniae from a cluster of patients in the medical intensive care unit (MICU) prompted an epidemiologic investigation for a common exposure.

Clinical and microbiologic data from MICU patients were retrospectively reviewed, MICU bronchoscopes underwent culturing and borescopy, and bronchoscope reprocessing procedures were reviewed. Bronchoscope and clinical MDR isolates epidemiologically linked to the cluster underwent molecular typing using pulsed-field gel electrophoresis (PFGE) followed by whole-genome sequencing.

Of the 33 case patients, 23 (70%) were exposed to a common bronchoscope (B1). Both MDR P. aeruginosa and K. pneumonia were recovered from the bronchoscope’s lumen, and borescopy revealed a luminal defect. Molecular testing demonstrated genetic relatedness among case patient and B1 isolates, providing strong evidence for horizontal bacterial transmission. MDR organism (MDRO) recovery in 19 patients was ultimately linked to B1 exposure, and 10 of 19 patients were classified as belonging to an MDRO pseudo-outbreak.

Surveillance of bronchoscope-derived clinical culture data was important for early detection of this outbreak, and whole-genome sequencing was important for the confirmation of findings. Visualization of bronchoscope lumens to confirm integrity should be a critical component of device reprocessing.

Effective communication regarding death and dying in pediatrics is a vital component of any quality palliative care service. The goal of the current study is to understand communication among health care professionals regarding death and dying in children. The three hypotheses tested were: (1) hospital staff (physicians of all disciplines, nurses, and psychosocial clinicians) that utilize consultation services are more comfortable communicating about death and dying than those who do not use such services, (2) different disciplines of health care providers demonstrate varying levels of comfort communicating about a range of areas pertaining to death and dying, and (3) health care staff that have had some type of formal training in death and dying are more comfortable communicating about these issues.

A primary analysis of a survey conducted in a tertiary care teaching children's hospital.

Health care professionals who felt comfortable discussing options for end of life care with colleagues also felt more comfortable: initiating a discussion regarding a child's impending death with his/her family (r = 0.42), discussing options for terminal care with a family (r = 0.58), discussing death with families from a variety of ethnic/cultural backgrounds (r = 0.51), guiding parents in developmentally age-appropriate discussions of death with their children (r = 0.43), identifying and seeking advice from a professional role model regarding management concerns (r = 0.40), or interacting with a family following the death of a child (r = 0.51). Among all three disciplines, physicians were more likely to initiate discussions with regards to a child's impending death (F = 13.07; p = 0.007). Health care professionals that received formal grief and bereavement training were more comfortable discussing death.

The results demonstrated that consultation practices are associated with a higher level of comfort in discussing death and dying in pediatrics.

To examine the differences in dietary intakes of children consuming school meals and packed lunches, the contribution of lunchtime intake to overall dietary intake, and how lunchtime intake relates to current food-based recommendations for school meals.

Cross-sectional analysis of overall intake of macronutrients and food choice from 4 d food diaries and school lunchtime intake from the two diary days completed while at school.

Norfolk, UK.

One thousand six hundred and twenty-six children (aged 9–10 years) attending ninety Norfolk primary schools.

At school, lunchtime school meal eaters consumed more vegetables, sweet snacks, chips, starchy foods and milk, and less squash/cordial, fruit, bread, confectionery and savoury snacks than packed lunch eaters. These differences were also reflected in the overall diet. On average school meal eaters met the School Food Trust (SFT) food-based standards, while food choices among packed lunch eaters were less healthy. The contribution of food consumed at school lunchtime to overall diet varied by food and lunch type, ranging from 0·8 % (milk intake in packed lunches) to 74·4 % (savoury snack intake in packed lunches).

There were significant differences in the foods consumed by school meal and packed lunch eaters, with food choices among school meal eaters generally in line with SFT standards. The food choices made at school lunchtime make a significant contribution to overall diet.

To examine whether parents offering a sticker reward to their child to taste a vegetable the child does not currently consume is associated with improvements in children's liking and consumption of the vegetable.

A randomized controlled trial evaluated the effectiveness of exposure only (EO) and exposure plus reward (E + R), relative to a control group, on children's liking and consumption of a target vegetable. Assessments were conducted at baseline and 2 weeks from baseline (post-intervention). Follow-up assessments were conducted at 4 weeks and 3 months from baseline.

The study took place in Adelaide, South Australia. Participants were self-selected in response to local media advertisements seeking to recruit parents finding it difficult to get their children to eat vegetables.

Participants were 185 children (110 boys, seventy-five girls) aged 4–6 years and their primary caregiver/parent (172 mothers, thirteen fathers).

The E + R group was able to achieve more days of taste exposure. Both EO and E + R increased liking at post-intervention compared with control and no further change occurred over the follow-up period. All groups increased their intake of the target vegetable at post-intervention. Target vegetable consumption continued to increase significantly over the follow-up period for E + R and control but not for EO.

The findings provide support for the effectiveness of using a sticker reward with a repeated exposure strategy. In particular, such rewards can facilitate the actual tastings necessary to change liking.