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Antibiotics are essential to combating infections; however, misuse and overuse has contributed to antimicrobial resistance (AMR). Antimicrobial stewardship programs (ASPs) are a strategy to combat AMR and are mandatory in Canadian hospitals for accreditation. The Canadian Nosocomial Infection Surveillance Program (CNISP) sought to capture a snapshot of ASP practices within the network of Canadian acute care hospitals. Objectives of the survey were to describe the status, practices, and process indicators of ASPs across acute care hospitals participating in CNISP.
Design:
The survey explored the following items related to ASP programs: 1) program structure and leadership, 2) human, technical and financial resources allocated, 3) inventory of interventions carried and implemented, 4) tracking antimicrobial use; and 5) educational and promotional components.
Methods:
CNISP developed a 34-item survey in both English and French. The survey was administered to 109 participating CNISP hospitals from June to August 2024, responses were analyzed descriptively.
Results:
Ninety-seven percent (106/109) of CNISP hospitals responded to the survey. Eighty-four percent (89/106) reported having a formal ASP in place at the time of the study. Ninety percent (80/89) of acute care hospitals with an ASP performed prospective audit and feedback for antibiotic agents and 85% (76/89) had formal surveillance of quantitative antimicrobial use. Additionally, just over 80% (74/89) provided education to their prescribers and other healthcare staff.
Conclusions:
CNISP acute care hospitals employ multiple key aspects of ASP including implementing interventions and monitoring/tracking antimicrobial use. There were acute care hospitals without an ASP, highlighting areas for investigation and improvement.
Economic variables such as socioeconomic status and debt are linked with an increased risk of a range of mental health problems and appear to increase the risk of developing of post-traumatic stress disorder (PTSD). Previous research has shown that people living in more deprived areas have more severe symptoms of depression and anxiety after treatment in England’s NHS Talking Therapies services. However, no research has examined if there is a relationship between neighbourhood deprivation and outcomes for PTSD specifically. This study was an audit of existing data from a single NHS Talking Therapies service. The postcodes of 138 service users who had received psychological therapy for PTSD were used to link data from the English Indices of Deprivation. This was analysed with the PCL-5 measure of PTSD symptoms pre- and post-treatment. There was no significant association between neighbourhood deprivation measures on risk of drop-out from therapy for PTSD, number of sessions received or PTSD symptom severity at the start of treatment. However, post-treatment PCL-5 scores were significantly more severe for those living in highly deprived neighbourhoods, with lower estimated income and greater health and disability. There was also a non-significant trend for the same pattern based on employment and crime rates. There was no impact of access to housing and services or living environment. Those living in more deprived neighbourhoods experienced less of a reduction in PTSD symptoms after treatment from NHS Talking Therapies services. Given the small sample size in a single city, this finding needs to be replicated with a larger sample.
Key learning aims
(1) Previous literature has shown that socioeconomic deprivation increases the risk of a range of mental health problems.
(2) Existing research suggests that economic variables such as income and employment are associated with greater incidence of PTSD.
(3) In the current study, those living in more deprived areas experienced less of a reduction in PTSD symptoms following psychological therapy through NHS Talking Therapies.
(4) The relatively poorer treatment outcomes in the current study are not explained by differences in baseline PTSD severity or drop-out rates, which were not significantly different comparing patients from different socioeconomic strata.
Pragmatic trials aim to speed translation to practice by integrating study procedures in routine care settings. This study evaluated implementation outcomes related to clinician and patient recruitment and participation in a trial of community paramedicine (CP) and presents successes and challenges of maintaining pragmatic study features.
Methods:
Adults in the pre-hospital setting, emergency department (ED), or hospital being considered for referral to the ED/hospital or continued hospitalization for intermediate-level care were randomized 1:1 to CP care or usual care. Referral and enrollment data were tracked administratively, and patient characteristics were abstracted from the electronic health record (EHR). Enrolled patients completed baseline surveys, and a subset of intervention patients were interviewed. All CPs and a sample of clinicians and administrators were invited to complete a survey and interview.
Results:
Between January 2022 and February 2023, 240 enrolled patients (42% rural) completed surveys, and 22 completed an interview; 63 staff completed surveys and 20 completed an interview. Ninety-three clinicians in 27 departments made at least one referral. Factors related to referrals included program awareness and understanding the CP practice scope. Most patients were enrolled in the hospital, but characteristics were similar to the primary care population and included older and medically complex patients. Challenges to achieving representativeness included limited EHR infrastructure, constraints related to patient consenting, and clinician concerns about patient randomization disrupting preferred care.
Conclusion:
Future pragmatic trials in busy clinical settings may benefit from regulatory policies and EHR capabilities that allow for real-world study conduct and representative participation. Trial registration: NCT05232799.
The UK Soft Drinks Industry Levy (SDIL) (announced in March 2016; implemented in April 2018) aims to incentivise reformulation of soft drinks to reduce added sugar levels. The SDIL has been applauded as a policy success, and it has survived calls from parliamentarians for it to be repealed. We aimed to explore parliamentary reaction to the SDIL following its announcement until two years post-implementation in order to understand how health policy can become established and resilient to opposition.
Design:
Searches of Hansard for parliamentary debate transcripts that discussed the SDIL retrieved 186 transcripts, with 160 included after screening. Five stages of Applied Thematic Analysis were conducted: familiarisation and creation of initial codebooks; independent second coding; codebook finalisation through team consensus; final coding of the dataset to the complete codebook; and theme finalisation through team consensus.
Setting:
The United Kingdom Parliament
Participants:
N/A
Results:
Between the announcement (16/03/2016) – royal assent (26/04/2017), two themes were identified 1: SDIL welcomed cross-party 2: SDIL a good start but not enough. Between royal assent – implementation (5/04/2018), one theme was identified 3: The SDIL worked – what next? The final theme identified from implementation until 16/03/2020 was 4: Moving on from the SDIL.
Conclusions:
After the announcement, the SDIL had cross-party support and was recognised to have encouraged reformulation prior to implementation. Lessons for governments indicate that the combination of cross-party support and a policy’s documented success in achieving its aim can help cement the resilience of it to opposition and threats of repeal.
To investigate the symptoms of SARS-CoV-2 infection, their dynamics and their discriminatory power for the disease using longitudinally, prospectively collected information reported at the time of their occurrence. We have analysed data from a large phase 3 clinical UK COVID-19 vaccine trial. The alpha variant was the predominant strain. Participants were assessed for SARS-CoV-2 infection via nasal/throat PCR at recruitment, vaccination appointments, and when symptomatic. Statistical techniques were implemented to infer estimates representative of the UK population, accounting for multiple symptomatic episodes associated with one individual. An optimal diagnostic model for SARS-CoV-2 infection was derived. The 4-month prevalence of SARS-CoV-2 was 2.1%; increasing to 19.4% (16.0%–22.7%) in participants reporting loss of appetite and 31.9% (27.1%–36.8%) in those with anosmia/ageusia. The model identified anosmia and/or ageusia, fever, congestion, and cough to be significantly associated with SARS-CoV-2 infection. Symptoms’ dynamics were vastly different in the two groups; after a slow start peaking later and lasting longer in PCR+ participants, whilst exhibiting a consistent decline in PCR- participants, with, on average, fewer than 3 days of symptoms reported. Anosmia/ageusia peaked late in confirmed SARS-CoV-2 infection (day 12), indicating a low discrimination power for early disease diagnosis.
Background: Hand-hygiene technology (HHT) intends to monitor and promote hand washing by healthcare workers, a critical measure of infection control. Healthcare worker noncompliance with HHT is a major limitation to its implementation and utility in clinical settings. We assessed perspectives on HHT in an academic hospital system. Methods: Hand-hygiene team members created an anonymous, 37-question, Likert-scale survey to assess healthcare worker attitudes toward HHT. Surveys targeted nursing staff, advanced practice providers, care partners, and internal medicine physicians. Clinical coordinators from 5 distinct nursing units and 1 physician department emailed surveys to eligible employees. Research coordinators and clinical coordinators also posted a QR code for survey fliers at nursing stations. Results: Overall, 120 surveys were completed. Most surveys were completed by nurses and physicians (66.4% and 14.0%). Most respondents (67.5%) do not find HHT useful. Additionally, 78.3% of respondents believe that HHT does not accurately record hand-washing events. Most (78.3%) do not like using HHT, and 75.8% find it annoying. Only 10.8% believe that patient care suffers because of HHT. Conclusions: Most healthcare workers dislike the HHT badges, primarily due to perceived inaccuracies, lack of utility, burden of use, and pressure to comply. Distrust and effect on patient care do not appear to be substantial factors contributing to negative perceptions of HHT. Weaknesses of the study include overrepresentation of nursing staff and potential bias because respondents may have provided exceptionally negative responses believing it could lead to the removal of HHT.
The COVID-19 pandemic dramatically altered social determinants of health including work, education, social connections, movement, and perceived control; and loneliness was commonly experienced. This longitudinal study examined how social determinants at the personal (micro), community (meso), and societal (macro) levels predicted loneliness during the pandemic.
Methods
Participants were 2056 Australian adults surveyed up to three times over 18 months in 2020 and 2021. Multi-level mixed-effect regressions were conducted predicting loneliness from social determinants at baseline and two follow-ups.
Results
Loneliness was associated with numerous micro determinants: male gender, lifetime diagnosis of a mental health disorder, experience of recent stressful event(s), low income, living alone or couples with children, living in housing with low natural light, noise, and major building defects. Lower resilience and perceived control over health and life were also associated with greater loneliness. At the meso level, reduced engagement with social groups, living in inner regional areas, and living in neighbourhoods with low levels of belongingness and collective resilience was associated with increased loneliness. At the macro level, increased loneliness was associated with State/Territory of residence.
Conclusions
Therapeutic initiatives must go beyond psychological intervention, and must recognise the social determinants of loneliness at the meso and macro levels.
Pragmatic trials aim to generate timely evidence while ensuring feasibility, minimizing practice burden, and maintaining real-world conditions. We conducted rapid-cycle qualitative research in the preimplementation period of a trial evaluating a community paramedic program to shorten and prevent hospitalizations. Between December 2021 and March 2022, interviews (n = 30) and presentations/discussions (n = 17) were conducted with clinical and administrative stakeholders. Two investigators analyzed interview and presentation data to identify potential trial challenges, and team reflections were used to develop responsive strategies. Solutions were implemented prior to the commencement of trial enrollment and were aimed at bolstering feasibility and building ongoing practice feedback loops.
Cross-species evidence suggests that the ability to exert control over a stressor is a key dimension of stress exposure that may sensitize frontostriatal-amygdala circuitry to promote more adaptive responses to subsequent stressors. The present study examined neural correlates of stressor controllability in young adults. Participants (N = 56; Mage = 23.74, range = 18–30 years) completed either the controllable or uncontrollable stress condition of the first of two novel stressor controllability tasks during functional magnetic resonance imaging (fMRI) acquisition. Participants in the uncontrollable stress condition were yoked to age- and sex-matched participants in the controllable stress condition. All participants were subsequently exposed to uncontrollable stress in the second task, which is the focus of fMRI analyses reported here. A whole-brain searchlight classification analysis revealed that patterns of activity in the right dorsal anterior insula (dAI) during subsequent exposure to uncontrollable stress could be used to classify participants' initial exposure to either controllable or uncontrollable stress with a peak of 73% accuracy. Previous experience of exerting control over a stressor may change the computations performed within the right dAI during subsequent stress exposure, shedding further light on the neural underpinnings of stressor controllability.
To evaluate physical health monitoring standards in patients on Clozapine in the community.
Standards
NICE and BNF guidelines for patients on established clozapine treatment advise annual monitoring of weight, waist circumference, pulse, blood pressure, fasting blood glucose, HbA1c, blood lipids and overall physical health assessment. Full blood count is monitored 1-4 weekly.
Background
In the management of schizophrenia, antipsychotic medication remains the cornerstone of treatment. Patients affected carry a significant physical health burden with a reduced life expectancy of 10-25 years. Factors that contribute include sedentary lifestyles, consequent obesity and cardiovascular disease, disengagement from health services, a higher incidence of suicide and the physical side effects of antipsychotic medication. For these reasons, comprehensive routine physical assessment of patients on antipsychotic treatment is of central importance.
Method
This audit is a retrospective study of patients known to South Kensington & Chelsea Community Mental Health Team (CMHT). Patients (n = 48) were audited from the Clozapine clinic SystemOne database over a one year period (October 2018-2019) to assess annual monitoring of full blood count (FBC), urea and electrolytes (U&Es), lipid profile, liver function tests (LFTs), HbA1C, thyroid function tests (TFTs), clozapine levels, ECG, and general physical and mental health review.
Result
Of the 48 patients, one was transferred to a different service so was excluded (n = 47 total).
All (100.0%) of the patients had annual FBC tests. All but one (97.9%) of the patients had a physical health review including blood pressure, pulse, weight and BMI measurement. Three quarters (74.5%) received annual U&Es and LFTs. Almost two thirds of patients had annual lipid and HBA1c screening (63.8%) and over half the cohort had annual TFTs (61.7%). Regarding annual multidisciplinary mental health review, this was performed for the majority of the patients (70.2%).
Contrastingly, only a quarter of the patients received annual screening of glucose and Clozapine levels (27.7% for both). Only 12 patients had annual ECG (25.5%).
Conclusion
Following review it is clear that most parameters were monitored annually in a majority of patients. However, shortcomings were detected, specifically annual ECG and waist circumference monitoring.
In order to ensure comprehensive monitoring of mental and physical health of patients on Clozapine, flow charts of tests and reviews needed for each patient were written up clearly and will be included in the management pathway for every patient on Clozapine. This was agreed to minimise missing any step, particularly annual ECGs.
A subcommittee of the Hawaii Governor's Joint Task Force on Rat Lungworm Disease developed preliminary guidelines for the diagnosis and treatment of neuroangiostrongyliasis (NAS) in 2018 (Guidelines, 2018). This paper reviews the main points of those guidelines and provides updates in areas where our understanding of the disease has increased. The diagnosis of NAS is described, including confirmation of infection by real-time polymerase chain reaction (RTi-PCR) to detect parasite DNA in the central nervous system (CNS). The treatment literature is reviewed with recommendations for the use of corticosteroids and the anthelminthic drug albendazole. Long-term sequelae of NAS are discussed and recommendations for future research are proposed.
BACKGROUND: IGTS is a rare phenomenon of paradoxical germ cell tumor (GCT) growth during or following treatment despite normalization of tumor markers. We sought to evaluate the frequency, clinical characteristics and outcome of IGTS in patients in 21 North-American and Australian institutions. METHODS: Patients with IGTS diagnosed from 2000-2017 were retrospectively evaluated. RESULTS: Out of 739 GCT diagnoses, IGTS was identified in 33 patients (4.5%). IGTS occurred in 9/191 (4.7%) mixed-malignant GCTs, 4/22 (18.2%) immature teratomas (ITs), 3/472 (0.6%) germinomas/germinomas with mature teratoma, and in 17 secreting non-biopsied tumours. Median age at GCT diagnosis was 10.9 years (range 1.8-19.4). Male gender (84%) and pineal location (88%) predominated. Of 27 patients with elevated markers, median serum AFP and Beta-HCG were 70 ng/mL (range 9.2-932) and 44 IU/L (range 4.2-493), respectively. IGTS occurred at a median time of 2 months (range 0.5-32) from diagnosis, during chemotherapy in 85%, radiation in 3%, and after treatment completion in 12%. Surgical resection was attempted in all, leading to gross total resection in 76%. Most patients (79%) resumed GCT chemotherapy/radiation after surgery. At a median follow-up of 5.3 years (range 0.3-12), all but 2 patients are alive (1 succumbed to progressive disease, 1 to malignant transformation of GCT). CONCLUSION: IGTS occurred in less than 5% of patients with GCT and most commonly after initiation of chemotherapy. IGTS was more common in patients with IT-only on biopsy than with mixed-malignant GCT. Surgical resection is a principal treatment modality. Survival outcomes for patients who developed IGTS are favourable.