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In June of 2024, Becton Dickinson experienced a blood culture bottle shortage for their BACTEC system, forcing health systems to reduce usage or risk exhausting their supply. Virginia Commonwealth University Health System (VCUHS) in Richmond, VA decided that it was necessary to implement austerity measures to preserve the blood culture bottle supply.
Setting:
VCUHS includes a main campus in Richmond, VA as well as two affiliate hospitals in South Hill, VA (Community Memorial Hospital (CMH)) and Tappahannock Hospital in Tappahannock, VA. It also includes a free-standing Emergency Department in New Kent, VA.
Patients:
Blood cultures from both pediatric and adult patients were included in this study.
Interventions:
VCUHS intervened to decrease blood culture utilization across the entire health system. Interventions included communication of blood culture guidance as well as an electronic health record order designed to guide providers and discourage wasteful ordering.
Results:
Post-implementation analyses showed that interventions reduced overall usage by 35.6% (P < .0001) and by greater than 40% in the Emergency Departments. The impact of these changes in utilization on positivity were analyzed, and it was found that the overall positivity rate increased post-intervention from 8.8% to 12.1% (P = .0115) and in the ED specifically from 10.2% to 19.5% (P < .0001).
Conclusions:
These findings strongly suggest that some basic stewardship interventions can significantly change blood culture practice in a manner that minimizes the impact on patient care.
Most of the Ross Sea has been designated a marine protected area (MPA), proposed ‘to protect ecosystem structure and function’. To assess effectiveness, the Commission for the Conservation of Antarctic Marine Living Resources (CCAMLR) selected Adélie (Pygoscelis adeliae) and emperor (Aptenodytes forsteri) penguins, Weddell seals (Leptonychotes weddellii) and Antarctic toothfish (Dissostichus mawsoni) as ecosystem change ‘indicator species’. Stable for decades, penguin and seal populations increased during 1998–2018 to surpass historical levels, indicating that change in ecosystem structure and function is underway. We review historical impacts to population trends, decadal datasets of ocean climate and fishing pressure on toothfish. Statistical modelling for Adélie penguins and Weddell seals indicates that variability in climate factors and cumulative extraction of adult toothfish may explain these trends. These mesopredators, and adult toothfish, all prey heavily on Antarctic silverfish (Pleuragramma antarcticum). Toothfish removal may be altering intraguild predation dynamics, leading to competitive release of silverfish and contributing to penguin and seal population changes. Despite decades of ocean/weather change, increases in indicator species numbers around Ross Island only began once the toothfish fishery commenced. The rational-use, ecosystem-based viewpoint promoted by CCAMLR regarding toothfish management needs re-evaluation, including in the context of the Ross Sea Region MPA.
Structured processes to improve the quality and impact of clinical and translational research are a required element of the Clinical and Translational Sciences Awards (CTSA) program and are central to awardees’ strategic management efforts. Quality improvement is often assumed to be an ordinary consequence of evaluation programs, in which standardized metrics are tabulated and reported externally. Yet evaluation programs may not actually be very effective at driving quality improvement: required metrics may lack direct relevance; they lack incentive to improve on areas of relative strength; and the validity of inter-site comparability may be limited. In this article, we describe how we convened leaders at our CTSA hub in an iterative planning process to improve the quality of our CTSA program by intentionally focusing on how data collection activities can primarily advance continuous quality improvement (CQI) rather than strictly serve as evaluative tools. We describe our CQI process, which consists of three key components: (1) Logic models outlining goals and associated mechanisms; (2) relevant metrics to evaluate performance improvement opportunities; and (3) an interconnected and collaborative CQI framework that defines actions and timelines to enhance performance.
A series of natural clays, including 1:1 layer silicates (serpentines, kaolin minerals), smectites, vermiculite, micas, talc, pyrophyllite, sepiolite, and palygorskite, were studied by 19F magic-angle spinning (MAS) nuclear magnetic resonance (NMR) spectroscopy. The 19F chemical shift in these layer silicates is characteristic of the structure, in particular, to the local octahedral cation occupancy. Fluoride ions bonded to three Mg octahedral cations have a chemical shift of about −177 ppm and those bonded to two Al cations and a vacancy have a chemical shift of about −134 parts per million (ppm). The shift at −182.8 ppm in hectorite is apparently associated with fluoride bonded to two Al cations and a Li cation. Surprisingly, the difference in chemical shift of the interlayer and inner fluoride in 1:1 layer silicates is insufficient to distinguish these sites. Based on trends in chemical shift, it appears that fluoride substitution for inner hydroxyls in clays with octahedral substitution is not random. Fluoride is apparently preferentially associated with Mg rather than Al in the octahedral sheet as no resonance due to a fluoride bonded to two Al cations and a vacancy is observed in clays such as SAz-1.
This study aimed to characterize the association between paranoid ideation without psychosis (PIP) and suicide attempts in a general population. A total of 12,532 adults were randomly selected as the study sample through one-person-per-household method. Subjects completed a face-to-face interview. Among 12,532 subjects, 471 (3.76%) met criteria for the PIP group. The PIP group was younger with more divorced/widowed/separated and lower income than the non-PIP group. The PIP group showed more than fivefold higher lifetime suicide attempt (LSA) rates and ninefold multiple attempt rates than the non-PIP group. Among PIP symptoms, “spouse was being unfaithful” showed the strongest association with LSA (adjusted odds ratio [AOR], 4.49; 95% confidence interval, 2.95-6.85). Major depressive disorder (MDD) in combination with PIP was associated with a higher risk of LSA (AOR, 15.39; 95% confidence interval, 9.63-24.59) compared with subjects without MDD or PIP. In conclusion, PIP, especially “doubting spouse,” was significantly associated with LSA. PIP in combination with comorbid MDD showed higher risk of LSA than subjects without PIP or MDD.
Changes in lifestyle factors are known to affect mood. However, there is insufficient evidence supporting the association between smoking, alcohol consumption, physical activity and depression in middle-aged women who are likely to experience rapid hormonal changes.
Methods:
We used a nationwide database of medical records in South Korea. 901,721 premenopausal and 943,710 postmenopausal women aged 40 years or older included in this study. Information on smoking, alcohol consumption, physical activity was identified from health examination data and followed up for the occurrence of depression using claims data.
Results:
Compared with never-smokers, ex-smokers and current smokers among premenopausal and postmenopausal women showed an increased risk of depression in a dose-dependent manner (aHR 1.13 for ex-smokers; aHR 1.23 for current smokers). Compared with non-drinkers, mild drinkers showed a decreased risk of depression (aHR 0.98 for premenopausal women; aHR 0.95 for postmenopausal women), and heavy drinkers showed an increased risk of depression both among premenopausal (aHR 1.20) and postmenopausal women (aHR 1.05). The risk of depression due to smoking and heavy alcohol consumption was higher in premenopausal women than in postmenopausal women. Compared with those who had not engaged in regular physical activity, those who had engaged showed a decreased risk of depression both among premenopausal (aHR 0.96) and postmenopausal women (aHR 0.95).
Conclusions:
Smoking and heavy alcohol consumption increased the risk of depression, and the increased risk was prominent in premenopausal than in postmenopausal women. Regular physical activity decreased the risk of depression both in premenopausal and postmenopausal women.
Vascular abnormalities have been frequently reported in elderly adults as a potential risk factor of late-life depression. However, it is still unclear whether stenosis of cerebral arteries may increase risk of depression in the elderly.
Methods:
Study participants were 365 patients 65 years or older with depressive disorder who had undergone brain MRI and angiography (MRA) which were assessed by trained radiologists, and the 15-item Geriatric Depression Scale (GDS-15) and the Mini Mental State Examination (MMSE), and blood glucose and lipid profiles.
Results:
Of the 365 subjects, 108 had at least one location of cerebral artery stenosis (29.59%). Stenosis was associated with age, marital status, infarction, and atherosclerosis. In multivariable linear regression analysis of different locations of stenosis among the whole sample, only bilateral middle cerebral artery (MCA) stenosis was found to have a significant association with higher GDS-15 score (p= 0.0138), and more than 8 scores in the GDS-15 (p= 0.0045), but no significant associations with ACA (anterior cerebral artery), PCA (posterior cerebral artery) or ICA (internal carotid artery). In multivariable linear logistic analysis of different locations among patients with at least one cerebral artery stenosis, left MCA was found to be significantly related to higher GDS-15 scores but not with right MCA (p = 0.0202).
Conclusion:
MCA stenosis is significantly associated with severity of depression in elderly adults with cerebral artery stenosis, especially in those with left MCA stenosis.
Key points
Patients with cerebral artery stenosis found with brain magnetic resonance angiography (MRA) were associated with higher depression severity.
Stenosis of both left and right middle cerebral artery (MCA) was associated with greater depression severity, with left MCA stenosis having a greater influence on depression severity than right MCA stenosis.
Higher depression severity in patients with MCA stenosis suggests that depression in elderly patients is mediated at least in part by vascular pathology of MCA supplied regions and careful investigation and management of cerebral artery stenosis and their risk factors may help reduce the severity of depression in elderly patients who visit psychiatrists.
INDUCT (Interdisciplinary Network for Dementia Using Current Technology), and DISTINCT (Dementia Inter-sectorial strategy for training and innovation network for current technology) are two Marie Sklodowska-Curie funded International Training Networks that aimed to develop a multi-disciplinary, inter-sectorial educational research framework for Europe to improve technology and care for people with dementia, and to provide the evidence to show how technology can improve the lives of people with dementia.
Methods:
In INDUCT (2016-2020) 15 Early Stage Researchers worked on projects in the areas of Technology to support everyday life; technology to promote meaningful activities; and healthcare technology. In DISTINCT (2019-2023) 15 Early Stage Researchers worked on technology to promote Social health in three domains: fulfilling ones potential and obligations in society, managing one’s own life, and participation in social and other meaningful activities.
Both networks adopted three transversal objectives: 1) To determine practical, cognitive and social factors needed to make technology more useable for people with dementia; 2) To evaluate the effectiveness of specific contemporary technology; 3) To trace facilitators and barriers for implementation of technology in dementia care.
Results:
The main recommendations resulting from all research projects are integrated in a web-based digital Best Practice Guidance on Human Interaction with Technology in Dementia which was recently updated (Dec 2022 and June 2023) and will be presented at the congress. The recommendations are meant for different target groups, i.e. people in different stages of dementia, their (in)formal carers, policy makers, designers and researchers, who can easily find the recommendations relevant to them in the Best Practice Guidance by means of a digital selection tool.
Conclusions:
The INDUCT/DISTINCT Best Practice Guidance informs on how to improve the development, usage, impact and implementation of technology for people with dementia in various technology areas. This Best Practice Guidance is the result of intensive collaborative partnership of INDUCT and DISTINCT with academic and non-academic partners as well as the involvement of representatives of the different target groups throughout the projects.
Although people who attempted suicide tend to repeat suicide attempts, there is a lack of evidence on the association between psychiatric service factors and suicide reattempt among them.
Methods:
We used a nationwide, population-based medical record database of South Korea to investigate the use of psychiatric services before and after the index suicide attempt and the association between psychiatric service factors after the index suicide attempt with the risk of suicide reattempt.
Results:
Among 5,874 people who had attempted suicide, the all-cause mortality within 3 months after the suicide attempt was 11.6%. Among all subjects who attempted suicide, 30.6% of them had used psychiatric services within 6 months before the suicide attempt; 43.7% of them had used psychiatric services within 3 months after the suicide attempt. Among individuals who had visited clinics following attempted suicide, the cumulative incidence of suicide reattempt over a mean follow-up period of 5.1 years was 3.4%. About half of suicide reattempts occurred within 1 year after the index suicide attempt. Referral to psychiatric services within 7 days was associated with a decreased risk of suicide reattempt (adjusted hazard ratio, 0.51; 95% confidence intervals, 0.29-0.89).
Conclusion:
An early psychiatric referral within 1 week after a suicide attempt was associated with a decreased risk of suicide reattempt.
The COVID-19 pandemic significantly disrupted schools and learning formats. Children with epilepsy are at-risk for generalized academic difficulties. We investigated the potential impact of COVID-19 on learning in those with epilepsy by comparing achievement on well-established academic measures among school-age children with epilepsy referred prior to the COVID-19 pandemic and those referred during the COVID-19 pandemic.
Participants and Methods:
This study included 466 children [52% male, predominately White (76%), MAge=10.75 years] enrolled in the Pediatric Epilepsy Research Consortium Epilepsy (PERC) Surgery database project who were referred for surgery and seen for neuropsychological testing. Patients were divided into two groups based on a proxy measure of pandemic timing completed by PERC research staff at each site (i.e., “were there any changes to typical in-person administration [of the evaluation] due to COVID?”). 31% of the sample (N = 144) were identified as having testing during the pandemic (i.e., “yes” response), while 69% were identified as having testing done pre-pandemic (i.e., “no” response). Of the 31% who answered yes, 99% of administration changes pertained to in-person testing or other changes, with 1% indicating remote testing. Academic achievement was assessed by performance measures (i.e., word reading, reading comprehension, spelling, math calculations, and math word problems) across several different tests. T-tests compared the two groups on each academic domain. Subsequent analyses examined potential differences in academic achievement among age cohorts that approximately matched grade level [i.e., grade school (ages 5-10), middle school (ages 11-14), and high school (ages 15-18)].
Results:
No significant differences were found between children who underwent an evaluation before the pandemic compared to those assessed during the pandemic based on age norms across academic achievement subtests (all p’s > .34). Similarly, there were no significant differences among age cohorts. The average performance for each age cohort generally fell in the low average range across academic skills. Performance inconsistently varied between age cohorts. The youngest cohort (ages 5-10) scored lower than the other cohorts for sight-word reading, whereas this cohort scored higher than the middle cohort (ages 11-14) for math word problems and reading comprehension. There were no significant differences between the two pandemic groups on demographic variables, intellectual functioning, or epilepsy variables (i.e., age of onset, number of seizure medications, seizure frequency).
Conclusions:
Academic functioning was generally equivalent between children with epilepsy who underwent academic testing as part of a pre-surgical evaluation prior to the pandemic compared to those who received testing during the pandemic. Additionally, academic functioning did not significantly differ between age cohorts. Children with epilepsy may have entered the pandemic with effective academic supports and/or were accustomed to school disruptions given their seizure history. Replication is needed as findings are based on a proxy measure of pandemic timing and the extent to which children experienced in-person, remote, and hybrid learning is unknown. Children tested a year into the pandemic, after receiving instruction through varying educational methods, may score differently than those tested earlier. Future research can address these gaps. Although it is encouraging that academic functioning was not disproportionately impacted during the pandemic in this sample, children with epilepsy are at-risk for generalized academic difficulties and continued monitoring of academic functioning is necessary.
Neurocognitive decline is prevalent in patients with metastatic cancers, attributed to various disease, treatment, and individual factors. Whether the presence of brain metastases (BrMets) contributes to neurocognitive decline is unclear. Aims of this study are to examine neurocognitive performance in BrMets patients and compare findings to patients with advanced metastatic cancer without BrMets. Here, we present baseline findings from an ongoing, prospective longitudinal study.
Participants and Methods:
English-speaking adults with advanced metastatic cancers were recruited from the brain metastases and lung clinics at the Princess Margaret Cancer Centre. Participants completed standardized tests (WTAR, HVLT-R, BVMT-R, COWAT, Trailmaking test, WAIS-IV Digit Span) and questionnaires (FACT-Cog v3, EORTC-QLQ C30 and BN20, PROMIS Depression(8a) and Anxiety(6a)) prior to cranial radiotherapy for those who required it. Test scores were converted to z-scores based on published normative data and averaged to create a composite neurocognitive performance score and domain scores for memory, attention/working memory, processing speed and executive function. Neurocognitive impairment was defined according to International Cancer and Cognition Task Force criteria. Univariate and multivariate regressions were used to identify individual, disease and treatment variables that predict cognitive performance.
Results:
76 patients (mean (SD) age: 63.2 (11.7) years; 53% male) with BrMets were included. 61% experienced neurocognitive impairment overall; impairment rates varied across domains (38% memory, 39% executive functioning, 13% attention/working memory, 8% processing speed). BrMets quantity, volume, and location were not associated with neurocognitive performance. Better performance status (ECOG; ß[95%CI];-0.38[-0.70,-0.05], p=0.021), higher premorbid IQ (0.34[0.10,0.58], p=0.005) and greater cognitive concerns (0.02[-3.9e-04,0.04], p=0.051) were associated with better neurocognitive performance in univariate analyses. Only premorbid IQ (0.37[0.14,0.60], p=0.003) and cognitive concerns (0.02[0.0004, 0.03], p=0.05) remained significant in multivariate analysis. We also recruited 31 patients with metastatic non-small cell lung cancer (mNSCLC) with no known BrMets (age: 67.5 (8.3); 32% male) and compared them to the subgroup of BrMets patients in our sample with mNSCLC (N=32; age: 67.8 (11.7); 53% male). We found no differences in impairment rates (BrMets/non-BrMets: Cognitive Composite, 59%/55%; Memory, 31%/32%; Executive Functioning, 35%/29%; Attention/working memory, 16%/13%; Processing speed, 7%/6%; Wilcoxon rank-sum test, all p-value’s > 0.5). The presence or absence of BrMets did not predict neurocognitive performance. Among patients with mNSCLC, higher education (0.11[0.03,0.18], p=0.004) and premorbid IQ (0.36[0.12,0.61], p=0.003), fewer days since primary diagnosis (0.00290[-0.0052,-0.0005], p=0.015) fewer pack-years smoking history (0.01[0.02,-0.001], p=0.027) and greater cognitive concerns (0.02[7e-5,0.04], p=0.045) were associated with better neurocognitive performance in univariate analyses; only premorbid IQ (0.26[0.02,0.51], p=0.04) and cognitive concerns (0.02[0.01,0.04], p=0.02) remained significant in multivariate analysis.
Conclusions:
Cognitive impairment is prevalent in patients with advanced metastatic cancers, particularly affecting memory and executive functioning. However, 39% of patients in our sample were not impaired in any domain. We found no associations between the presence of BrMets and neurocognitive function in patients with advanced cancers prior to cranial radiation. Premorbid IQ, a proxy for cognitive reserve, was associated with cognitive outcomes in our sample. Our longitudinal study will allow us to identify risk and resilience factors associated with neurocognitive changes in patients with metastatic cancers to better inform therapeutic interventions in this population.
The Pediatric Epilepsy Research Consortium (PERC) Epilepsy Surgery Database Project is a multisite collaborative that includes neuropsychological evaluations of children presenting for epilepsy surgery. There is some evidence for specific neuropsychological phenotypes within epilepsy (Hermann et al, 2016); however, this is less clear in pediatric patients. As a first step, we applied an empirically-based subtyping approach to determine if there were specific profiles using indices from the Wechsler scales [Verbal IQ (VIQ), Nonverbal IQ (NVIQ), Processing Speed Index (PSI), Working Memory Index (WMI)]. We hypothesized that there would be at least four profiles that are distinguished by slow processing speed and poor working memory as well as profiles with significant differences between verbal and nonverbal reasoning abilities.
Participants and Methods:
Our study included 372 children (M=12.1 years SD=4.1; 77.4% White; 48% male) who completed an age-appropriate Wechsler measure, enough to render at least two index scores. Epilepsy characteristics included 84.4% with focal epilepsy (evenly distributed between left and right focus) and 13.5% with generalized or mixed seizure types; mean age of onset = 6.7 years, SD = 4.5; seizure frequency ranged from daily to less than monthly; 53% had structural etiology; 71% had an abnormal MRI; and mean number of antiseizure medications was two. Latent profile analysis was used to identify discrete underlying cognitive profiles based on intellectual functioning. Demographic and epilepsy characteristics were compared among profiles.
Results:
Based on class enumeration procedures, a 3-cluster solution provided the best fit for the data, with profiles characterized by generally Average, Low Average, or Below Average functioning. 32.8% were in the Average profile with mean index scores ranging from 91.7-103.2; 47.6% were in the Low Average profile with mean index ranging from 80.7 to 84.5; and 19.6% were in the Below Average profile with mean index scores ranging from 55.0-63.1. Across all profiles, the lowest mean score was the PSI, followed by WMI. VIQ and NVIQ represented relatively higher scores for all three profiles. Mean discrepancy between indices within a profile was as large as 11.5 IQ points. No demographics or epilepsy characteristics were significantly different across cognitive phenotypes.
Conclusions:
Latent cognitive phenotypes in a pediatric presurgical cohort were differentiated by general level of functioning; however, across profiles, processing speed was consistently the lowest index followed by working memory. These findings across phenotypes suggest a common relative weakness which may result from a global effect of antiseizure medications and/or the widespread impact of seizures on neural networks even in a largely focal epilepsy cohort; similar to adult studies with temporal lobe epilepsy (Hermann et al, 2007). Future work will use latent profile analysis to examine phenotypes across other domains relevant to pediatric epilepsy including attention, naming, motor, and memory functioning. These findings are in line with collaborative efforts towards cognitive phenotyping which is the aim of our PERC Epilepsy Surgery Database Project that has already established one of the largest pediatric epilepsy surgery cohorts.
Children with epilepsy are at greater risk of lower academic achievement than their typically developing peers (Reilly and Neville, 2015). Demographic, social, and neuropsychological factors, such as executive functioning (EF), mediate this relation. While research emphasizes the importance of EF skills for academic achievement among typically developing children (e.g., Best et al., 2011; Spiegel et al., 2021) less is known among children with epilepsy (Ng et al., 2020). The purpose of this study is to examine the influence of EF skills on academic achievement in a nationwide sample of children with epilepsy.
Participants and Methods:
Participants included 427 children with epilepsy (52% male; MAge= 10.71), enrolled in the Pediatric Epilepsy Research Consortium (PERC) Epilepsy Surgery Database who had been referred for surgery and underwent neuropsychological testing. Academic achievement was assessed by performance measures (word reading, reading comprehension, spelling, and calculation and word-based mathematics) and parent-rating measures (Adaptive Behavior Assessment System (ABAS) Functional Academics and Child Behavior Checklist (CBCL) School Performance). EF was assessed by verbal fluency measures, sequencing, and planning measures from the Delis Kaplan Executive Function System (DKEFS), NEPSY, and Tower of London test. Rating-based measures of EF included the 'Attention Problems’ subscale from the CBCL and 'Cognitive Regulation’ index from the Behavior Rating Inventory of Executive Function (BRIEF-2). Partial correlations assessed associations between EF predictors and academic achievement, controlling for fullscale IQ (FSIQ; A composite across intelligence tests). Significant predictors of each academic skill or rating were entered into a two-step regression that included FSIQ, demographics, and seizure variables (age of onset, current medications) in the first step with EF predictors in the second step.
Results:
Although zero-order correlations were significant between EF predictors and academic achievement (.29 < r’s < .63 for performance; -.63 < r’s < -.50 for rating measures), partial correlations controlling for FSIQ showed fewer significant relations. For performance-based EF, only letter fluency (DKEFS Letter Fluency) and cognitive flexibility (DKEFS Trails Condition 4) demonstrated significant associations with performance-based academic achievement (r’s > .29). Regression models for performance-based academic achievement indicated that letter fluency (ß = .22, p = .017) and CBCL attention problems (ß = -.21, p =.002) were significant predictors of sight-word reading. Only letter fluency (ß = .23, p =.006) was significant for math calculation. CBCL Attention Problems were a significant predictor of spelling performance (ß = -.21, p = .009) and reading comprehension (ß = -.18, p =.039). CBCL Attention Problems (ß = -.38, p <.001 for ABAS; ß = -.34, p =.002 for CBCL School) and BRIEF-2 Cognitive Regulation difficulties (ß = -.46, p < .001 for ABAS; ß = -.46, p =.013 for CBCL School) were significant predictors of parent-rated ABAS Functional Academics and CBCL School Performance.
Conclusions:
Among a national pediatric epilepsy dataset, performance-based and ratings-based measures of EF predicted performance academic achievement, whereas only ratings-based EF predicted parent-rated academic achievement, due at least in part to shared method variance. These findings suggest that interventions that increase cognitive regulation, reduce symptoms of attention dysfunction, and promote self-generative, flexible thinking, may promote academic achievement among children with epilepsy.
The cost effectiveness of treating Bell’s palsy with prednisolone in children is unknown. This study aimed to assess the cost effectiveness of prednisolone, compared with placebo, in treating Bell’s Palsy in children from a healthcare sector perspective.
Methods
This economic evaluation was a prospectively planned secondary analysis of a triple-blind randomized superiority trial conducted from 2015 to 2020 that compared prednisolone with placebo. The time horizon was six months after randomization. The 180 participants were aged from six months to 17 years and presented within 72 hours of onset of clinician diagnosed Bell’s palsy. Interventions were oral prednisolone (1 mg per kg daily) or taste-matched placebo administered for ten days. Incremental cost-effectiveness ratios comparing prednisolone with placebo were estimated. Costs included medication costs, doctor visits, and medical tests over the six-month study period. Effectiveness was measured using quality-adjusted life-years (QALYs) derived from the Child Health Utility 9D instrument. Nonparametric bootstrapping was performed to capture uncertainties. Prespecified subgroup analyses by age (12 to 17 years versus <12 years) were performed.
Results
The mean cost per patient was USD188 in the prednisolone group and USD121 in the placebo group over the six-month period (difference USD66, 95% confidence interval [CI]: 47, 179). The mean QALYs gained over six months were 0.45 in the prednisolone group and 0.44 in the placebo group (difference 0.01, 95%CI: -0.01, 0.03). Prednisolone was very likely cost effective given a conventional willingness-to-pay threshold of USD 50,000 per QALY gained (the cost per additional QALY gained was USD6,625 using prednisolone compared with placebo). Subgroup analysis suggested that this was primarily driven by the high probability of prednisolone being cost effective in children aged 12 to 17 years (98%), compared with those younger than 12 years (51%).
Conclusions
This study provides new evidence to stakeholders and policy makers who are considering whether to make prednisolone available for treating Bell’s palsy in children aged 12 to 17 years.
In Australia, 18F-fluorodeoxyglucose positron emission tomography with low-dose computed tomography (FDG-PET/CT) is currently only funded for cancer staging-related indications. A recent multicenter randomized trial demonstrated that FDG-PET/CT, compared with standard of care computed tomography (CT) imaging, improved antimicrobial management and the outcomes of patients with persistent and recurrent neutropenic fever. There is potential value in expanding the use of FDG-PET/CT as a diagnostic tool for this high-risk population. We conducted an economic evaluation from a healthcare perspective alongside the randomized trial and compared FDG-PET/CT with standard CT up to 6 months after the scans.
Methods
Case report forms were used to collect resource utilization data and length of hospitalization. Effectiveness was measured as the number of patients with antimicrobial rationalization and quality-adjusted life-years (QALYs) derived from patient-reported trial-based health-related quality of life. Generalized linear models (GLM) were used to analyze costs and outcomes. Incremental cost-effectiveness ratios (ICERs) for each of the outcomes were calculated and interpreted as the cost per patient with antimicrobial rationalization and cost per QALY gained. To account for sampling, we performed bootstrapping with 1,000 replications using the recycled predictions method.
Results
The adjusted healthcare costs were lower in the FDG-PET/CT group (mean AUD49,563, 95% confidence interval [CI]: 36,867, 65,133; equivalent to USD34,268, 95% CI: 25,490, 45,033) compared with the standard CT group (mean AUD57,574, 95% CI: 44,837, 73,347; equivalent to USD39,807, 95% CI: 31,000, 50,712). The magnitude of differences in QALYs between the two groups was small (0.001; 95% CI: -0.001, -0.001). When simulated 1,000 times, our analysis showed that across both outcomes FDG-PET/CT was the dominant strategy as it was cheaper and had better outcomes than standard CT in 74 percent of simulations.
Conclusions
FDG-PET/CT is cost effective when compared with standard CT for investigating persistent or recurrent neutropenic fever in high-risk patients. Aligning economic evaluations with clinical studies is key to an integrated evidence generation approach for supporting funding for FDG-PET/CT in this patient group.
To understand the relationship between social media and mental health we need research that examines what people are doing and how this relates to other, measurable, variables such as their personal characteristics and the outcome of their social media use. We also need research that explores how and why people use social media and their experiences of doing so. In this chapter we will look at research that explores how and why people use social media and their experiences of doing so. We will present an overview of qualitative approaches that focuses on methods of data collection and analysis. We will discuss the main approaches to data collection and offer some important pointers to bear in mind when evaluating the results of studies that use these methods.
Derive and externally validate a prediction model for pneumococcal urinary antigen test (pUAT) positivity.
Methods:
Retrospective cohort study of adults admitted with community-acquired pneumonia (CAP) to 177 U.S. hospitals in the Premier Database (derivation and internal validation samples) or 12 Cleveland Clinic hospitals (external validation sample). We utilized multivariable logistic regression to predict pUAT positivity in the derivation dataset, followed by model performance evaluation in both validation datasets. Potential predictors included demographics, comorbidities, clinical findings, and markers of disease severity.
Results:
Of 198,130 Premier patients admitted with CAP, 27,970 (14.1%) underwent pUAT; 1962 (7.0%) tested positive. The strongest predictors of pUAT positivity were history of pneumococcal infection in the previous year (OR 6.99, 95% CI 4.27–11.46), severe CAP on admission (OR 1.76, 95% CI 1.56–1.98), substance abuse (OR 1.57, 95% CI 1.27–1.93), smoking (OR 1.23, 95% CI 1.09–1.39), and hyponatremia (OR 1.35, 95% CI 1.17–1.55). Negative predictors included IV antibiotic use in past year (OR 0.65, 95% CI 0.52–0.82), congestive heart failure (OR 0.72, 95% CI 0.63–0.83), obesity (OR 0.71, 95% CI 0.60–0.85), and admission from skilled nursing facility (OR 0.60, 95% CI 0.45–0.78). Model c-statistics were 0.60 and 0.67 in the internal and external validation cohorts, respectively. Compared to guideline-recommended testing of severe CAP patients, our model would have detected 23% more cases with 5% fewer tests.
Conclusion:
Readily available data can identify patients most likely to have a positive pUAT. Our model could be incorporated into automated clinical decision support to improve test efficiency and antimicrobial stewardship.
In Tanzania, there are high rates of suicidal thoughts and behavior among people living with HIV (PLWH), yet few instruments exist for effective screening and referral. To address this gap, we developed and validated Swahili translations of the Columbia Suicide Severity Rating Scale (C-SSRS) Screen Version and two accompanying scales assessing self-efficacy to avoid suicidal action and reasons for living. We administered a structured survey to 80 PLWH attending two HIV clinics in Moshi, Tanzania. Factor analysis of the items revealed four subscales: suicide intensity, self-efficacy to avoid suicide, fear and social concern about suicide, and family and spirituality deterrents to suicide. The area under the receiver operating curve showed only suicide intensity, and fear and social concern met the prespecified cutoff of ≥0.7 in accurately identifying patients with a plan and intent to act on suicidal thoughts. This study provides early evidence that brief screening of intensity of suicidality in the past month, assessed by the C-SSRS Screen Version, is a strong, resource-efficient strategy for identifying suicide risk in the Tanzanian setting. Patients who report little fear of dying and low concern about social perceptions of suicide may also be at increased risk.
This study explored programme recipients’ and deliverers’ experiences and perceived outcomes of accessing or facilitating a grocery gift card (GGC) programme from I Can for Kids (iCAN), a community-based programme that provides GGC to low-income families with children.
Design:
This qualitative descriptive study used Freedman et al’s framework of nutritious food access to guide data generation and analysis. Semi-structured interviews were conducted between August and November 2020. Data were analysed using directed content analysis with a deductive–inductive approach.
Participants:
Fifty-four participants were purposively recruited, including thirty-seven programme recipients who accessed iCAN’s GGC programme and seventeen programme deliverers who facilitated it.
Setting:
Calgary, Alberta, Canada.
Results:
Three themes were generated from the data. First, iCAN’s GGC programme promoted a sense of autonomy and dignity among programme recipients as they appreciated receiving financial support, the flexibility and convenience of using GGC, and the freedom to select foods they desired. Recipients perceived these benefits improved their social and emotional well-being. Second, recipients reported that the use of GGC improved their households’ dietary patterns and food skills. Third, both participant groups identified programmatic strengths and limitations.
Conclusion:
Programme recipients reported that iCAN’s GGC programme provided them with dignified access to nutritious food and improved their households’ finances, dietary patterns, and social and emotional well-being. Increasing the number of GGC provided to households on each occasion, establishing clear and consistent criteria for distributing GGC to recipients, and increasing potential donors’ awareness of iCAN’s GGC programme may augment the amount of support iCAN could provide to households.
Children need to be repeatedly and consistently exposed to a variety of vegetables from an early age to achieve an increase in vegetable intake. A focus on enjoyment and learning to like eating vegetables at an early age is critical to forming favourable lifelong eating habits. Coordinated work is needed to ensure vegetables are available and promoted in a range of settings, using evidence-based initiatives, to create an environment that will support children’s acceptance of vegetables. This will help to facilitate increased intake and ultimately realise the associated health benefits. The challenges and evidence base for a new approach are described.