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To evaluate broad-spectrum intravenous antibiotic use before and after the implementation of a revised febrile neutropenia management algorithm in a population of adults with hematologic malignancies.
Setting and population:
Patients admitted between 2014 and 2018 to the Adult Malignant Hematology service of an acute-care hospital in the United States.
Aggregate data for adult malignant hematology service were obtained for population-level antibiotic use: days of therapy (DOT), C. difficile infections, bacterial bloodstream infections, intensive care unit (ICU) length of stay, and in-hospital mortality. All rates are reported per 1,000 patient days before the implementation of an febrile neutropenia management algorithm (July 2014–May 2016) and after the intervention (June 2016–December 2018). These data were compared using interrupted time series analysis.
In total, 2,014 patients comprised 6,788 encounters and 89,612 patient days during the study period. Broad-spectrum intravenous (IV) antibiotic use decreased by 5.7% with immediate reductions in meropenem and vancomycin use by 22 (P = .02) and 15 (P = .001) DOT per 1,000 patient days, respectively. Bacterial bloodstream infection rates significantly increased following algorithm implementation. No differences were observed in the use of other antibiotics or safety outcomes including C. difficile infection, ICU length of stay, and in-hospital mortality.
Reductions in vancomycin and meropenem were observed following the implementation of a more stringent febrile neutropenia management algorithm, without evidence of adverse outcomes. Successful implementation occurred through a collaborative effort and continues to be a core reinforcement strategy at our institution. Future studies evaluating patient-level data may identify further stewardship opportunities in this population.
Few studies provide clear rationale for and the reception of adaptations of evidence-based interventions. To address this gap, we describe the context-dependent adaptations in critical time intervention-task shifting (CTI-TS), a manualized recovery program for individuals with psychosis in Rio de Janeiro, Brazil and Santiago, Chile. Implications of the adaptations – incorporating a task-shifting approach and modifying the mode of community-based service delivery – are examined from users' perspectives.
A secondary analysis of in-depth interviews with CTI-TS users (n = 9 in Brazil; n = 15 in Chile) was conducted. Using the framework method, we thematically compared how participants from each site perceived the main adapted components of CTI-TS.
Users of both sites appreciated the task-shifting worker pair to provide personalized, flexible, and relatable support. They wanted CTI-TS to be longer and experienced difficulty maintaining intervention benefits in the long-term. In Chile, stigma and a perceived professional hierarchy toward the task-shifting providers were more profound than in Brazil. Engagement with community-based services delivery in homes and neighborhoods (Chile), and at community mental health centers (Brazil) were influenced by various personal, familial, financial, and social factors. Uniquely, community violence was a significant barrier to engagement in Brazil.
CTI-TS’ major adaptations were informed by the distinct mental health systems and social context of Santiago and Rio. Evaluation of user experiences with these adaptations provides insights into implementing and scaling-up task-shifting and community-oriented interventions in the region through the creation of specialized roles for the worker pair, targeting sustained intervention effects, and addressing socio-cultural barriers.
Few studies have derived data-driven dietary patterns in youth in the USA. This study examined data-driven dietary patterns and their associations with BMI measures in predominantly low-income, racial/ethnic minority US youth. Data were from baseline assessments of the four Childhood Obesity Prevention and Treatment Research (COPTR) Consortium trials: NET-Works (534 2–4-year-olds), GROW (610 3–5-year-olds), GOALS (241 7–11-year-olds) and IMPACT (360 10–13-year-olds). Weight and height were measured. Children/adult proxies completed three 24-h dietary recalls. Dietary patterns were derived for each site from twenty-four food/beverage groups using k-means cluster analysis. Multivariable linear regression models examined associations of dietary patterns with BMI and percentage of the 95th BMI percentile. Healthy (produce and whole grains) and Unhealthy (fried food, savoury snacks and desserts) patterns were found in NET-Works and GROW. GROW additionally had a dairy- and sugar-sweetened beverage-based pattern. GOALS had a similar Healthy pattern and a pattern resembling a traditional Mexican diet. Associations between dietary patterns and BMI were only observed in IMPACT. In IMPACT, youth in the Sandwich (cold cuts, refined grains, cheese and miscellaneous) compared with Mixed (whole grains and desserts) cluster had significantly higher BMI (β = 0·99 (95 % CI 0·01, 1·97)) and percentage of the 95th BMI percentile (β = 4·17 (95 % CI 0·11, 8·24)). Healthy and Unhealthy patterns were the most common dietary patterns in COPTR youth, but diets may differ according to age, race/ethnicity or geographic location. Public health messages focused on healthy dietary substitutions may help youth mimic a dietary pattern associated with lower BMI.
Electoral violence is conceived of as violence that occurs contemporaneously with elections, and as violence that would not have occurred in the absence of an election. While measuring the temporal aspect of this phenomenon is straightforward, measuring whether occurrences of violence are truly related to elections is more difficult. Using machine learning, we measure electoral violence across three elections using disaggregated reporting in social media. We demonstrate that our methodology is more than 30 percent more accurate in measuring electoral violence than previously utilized models. Additionally, we show that our measures of electoral violence conform to theoretical expectations of this conflict more so than those that exist in event datasets commonly utilized to measure electoral violence including ACLED, ICEWS, and SCAD. Finally, we demonstrate the validity of our data by developing a qualitative coding ontology.
The aim of this study was to explore associations between internet/email use in a large sample of older English adults with their social isolation and loneliness. Data from the English Longitudinal Study of Ageing Wave 8 were used, with complete data available for 4,492 men and women aged ⩾ 50 years (mean age = 64.3, standard deviation = 13.3; 51.7% males). Binomial logistic regression was used to analyse cross-sectional associations between internet/email use and social isolation and loneliness. The majority of older adults reported using the internet/email every day (69.3%), fewer participants reported once a week (8.5%), once a month (2.6%), once every three months (0.7%), less than every three months (1.5%) and never (17.4%). No significant associations were found between internet/email use and loneliness, however, non-linear associations were found for social isolation. Older adults using the internet/email either once a week (odds ratio (OR) = 0.60, 95% confidence interval (CI) = 0.49–0.72) or once a month (OR = 0.60, 95% CI = 0.45–0.80) were significantly less likely to be socially isolated than every day users; those using internet/email less than once every three months were significantly more likely to be socially isolated than every day users (OR = 2.87, 95% CI = 1.28–6.40). Once every three months and never users showed no difference in social isolation compared with every day users. Weak associations were found between different online activities and loneliness, and strong associations were found with social isolation. The study updated knowledge of older adults’ internet/email habits, devices used and activities engaged in online. Findings may be important for the design of digital behaviour change interventions in older adults, particularly in groups at risk of or interventions targeting loneliness and/or social isolation.
I write this commentary as a part of a special issue published in this journal to celebrate Nick Martin’s contribution to the field of human genetics. In this commentary, I briefly describe the background of the Yang et al. (2010) study and show some of the unpublished details of this study, its contribution to tackling the missing heritability problem and Nick’s contribution to the work.
Current dietary recommendations encourage increased fibre and reduced sugar consumption. In the UK, specific targets and benchmarks have been established for the sugar content of some foods but not for fibre. National Food Consumption Surveys provide comprehensive information of all foods consumed by representative population samples. The Irish national food surveys as completed by the Irish Universities Nutrition Alliance (IUNA) capture dietary data at brand level with all details as gathered on pack entered into a discrete but inter-linked database, the Irish National Food Ingredient Database (INFID). The aim of this study was to profile the carbohydrate quality of a convenience sub-sample of packaged foods as eaten by Irish children during the National Children's Food Survey II (2017/2018) as entered into INFID.
Materials and Methods:
All on-pack details from 385 available foods in the categories ‘white breads and rolls’; ‘brown breads and rolls’; ‘other breads and scones’; ‘ready to eat breakfast cereals (RTEBC)’; ‘biscuits’; and ‘cakes, buns and pastries’ were entered in to INFID and quality control completed. The carbohydrate profile of the products was assessed with respect to fibre labelling criteria and UK sugar guidelines and targets. SPSS Version 25 was used for all analyses.
Although 56% (n210) of all products entered were eligible to make a ‘source of’ or ‘high’ fibre claim, only 20% (n78) made such a claim. Of this, 46% stated ‘high fibre’ and 32% ‘source’, predominately in the ‘brown breads and rolls’ and ‘RTEBC’ groups. When compared to UK Department of Health guidance for ‘low’, ‘medium’ and ‘high’ sugar, 65% of all products examined (n250) were either ‘low’ or ‘medium’ sugar. Comparison of median sugar contents with Public Health England sugar reformulation targets revealed different responses in each category, with all categories other than foods deemed as “morning goods” yet to meet the 2020 target of 20% reduction in sugar content.
This small pilot study of a convenience sample of foods suggests that for the limited number of foods examined, for some there remains challenges to reduce sugar and increase fibre contents. Strategies such as reformulation, change in portion size, flexibility in labelling and/or a shift in sales portfolios could be considered but only alongside technological and safety considerations. Further research to broaden this analysis and to link nutrient levels as listed on pack with actual consumption patterns could help ensure all recent initiatives including reformulation are recognised.
A major uncertainty in the determination of the mass profile of the Milky Way using stellar kinematics in the halo is the poorly determined anisotropy parameter, , where σr is the Galactocentric radial velocity dispersion, and σθ and σφ are the tangential components of the velocity dispersion. We have used a sample of over 24,000 Galactic halo K giant and blue horizontal branch stars from the LAMOST stellar spectroscopic survey and SDSS/SEGUE, combined with proper motions from Gaia Data Release 2, to measure β(rgc) over a wide range of Galactocentric distances rgc from 5 to 80 kpc. Kinematic substructures have been carefully removed to reveal the underlying diffuse stellar halo prior to measuring β. We find that orbits are generally radial (β > 0) and β is constant out to distances of about 40 kpc, with a dependence on metallicity of the stars, such that β declines with lower metallicity. Similar behavior is seen in both the K giant and BHB samples.
We report the utility of whole-genome sequencing (WGS) conducted in a clinically relevant time frame (ie, sufficient for guiding management decision), in managing a Streptococcus pyogenes outbreak, and present a comparison of its performance with emm typing.
A 2,000-bed tertiary-care psychiatric hospital.
Active surveillance was conducted to identify new cases of S. pyogenes. WGS guided targeted epidemiological investigations, and infection control measures were implemented. Single-nucleotide polymorphism (SNP)–based genome phylogeny, emm typing, and multilocus sequence typing (MLST) were performed. We compared the ability of WGS and emm typing to correctly identify person-to-person transmission and to guide the management of the outbreak.
The study included 204 patients and 152 staff. We identified 35 patients and 2 staff members with S. pyogenes. WGS revealed polyclonal S. pyogenes infections with 3 genetically distinct phylogenetic clusters (C1–C3). Cluster C1 isolates were all emm type 4, sequence type 915 and had pairwise SNP differences of 0–5, which suggested recent person-to-person transmissions. Epidemiological investigation revealed that cluster C1 was mediated by dermal colonization and transmission of S. pyogenes in a male residential ward. Clusters C2 and C3 were genomically diverse, with pairwise SNP differences of 21–45 and 26–58, and emm 11 and mostly emm120, respectively. Clusters C2 and C3, which may have been considered person-to-person transmissions by emm typing, were shown by WGS to be unlikely by integrating pairwise SNP differences with epidemiology.
WGS had higher resolution than emm typing in identifying clusters with recent and ongoing person-to-person transmissions, which allowed implementation of targeted intervention to control the outbreak.
Individuals with personality disorders often have extensive involvement with healthcare services including frequent utilisation of emergency departments.
The aim of this study was to identify factors associated with emergency department presentations by individuals with personality disorders.
A 12-month retrospective data analysis of all mental-health-related emergency department visits was performed. Age, gender, time and season of presentation, length of stay, mode of arrival and discharge arrangements for individuals with personality disorders were compared to individuals with other psychiatric diagnoses.
There were 336 visits by individuals with personality disorders and 5290 visits by individuals with other psychiatric diagnoses.
Individuals with personality disorders were significantly more likely to be female, young adults, brought in by police, arrive in the evening, discharged home and have a longer median length of stay.
Knowing what factors are associated with emergency department presentations by individuals with personality disorders can help ensure that appropriately trained support staff are available.
Here we report on the material chemistry following crystallization in the presence of water vapor of chlorinated formamidinium lead-triiodide (NH2CH = NH2PbI3−xClx) perovskite films. We found in-situ exposure to water vapor reduces, or possibly eliminates, the retention of chlorine (Cl) inside NH2CH = NH2PbI3−xClx crystals. There is a strong tendency toward Cl volatility, which indicates the sensitivity of these materials for their integration into solar cells. The requisite for additional efforts focused on the mitigation of water vapor is reported. Based on the in situ results, hot casting (<100 °C) in dry conditions demonstrates improved film coverage and Cl retention with efficiencies reaching 12.07%.
We aimed to evaluate a pilot service to facilitate discharge of patients with stable long-term mental health needs from secondary to primary care.
Patients with stable long-term mental health conditions are often not discharged from secondary mental health services when no longer needed due to insufficient systems and processes to enable safe, effective, recovery-focussed treatment and support. The Primary Care Mental Health Specialist (PCMHS) Service was developed to address this gap; new PCMHS posts were introduced to act as a conduit for patients being discharged from secondary care and a single point of referral back into secondary care, should it be required. The two-year pilot, across six Clinical Commissioning Groups in South East England, began in March 2013.
Interviews were conducted with all PCMHS employed in the pilot service (n=13) and a sample of service users (n=12). The views of professionals working alongside the service, including GPs, Psychiatrists and Mental Health Nurses, were captured using a brief online questionnaire (n=50). Time and Activity Recording Sheets were used to capture data required for economic analysis.
Our findings indicate that the service is working well from the perspective of patients; staff employed within the service and professionals working alongside the service. Patients described the service as a ‘safety net’ they could fall back on in case of difficulties, whereas staff used the analogy of a ‘bridge’ to describe the way the service improved communication and collaboration between the various professionals and organisations involved in the patient’s care. Improvements in well-being were seen to result from increased support for those transitioning from secondary to primary care, a more pro-active approach to relapse prevention and increased engagement in daily activities. Each PCMHS covered 36 patients in a one-month period, with a unit cost of £73.01 per patient.
Approximately half of the variation in wellbeing measures overlaps with variation in personality traits. Studies of non-human primate pedigrees and human twins suggest that this is due to common genetic influences. We tested whether personality polygenic scores for the NEO Five-Factor Inventory (NEO-FFI) domains and for item response theory (IRT) derived extraversion and neuroticism scores predict variance in wellbeing measures. Polygenic scores were based on published genome-wide association (GWA) results in over 17,000 individuals for the NEO-FFI and in over 63,000 for the IRT extraversion and neuroticism traits. The NEO-FFI polygenic scores were used to predict life satisfaction in 7 cohorts, positive affect in 12 cohorts, and general wellbeing in 1 cohort (maximal N = 46,508). Meta-analysis of these results showed no significant association between NEO-FFI personality polygenic scores and the wellbeing measures. IRT extraversion and neuroticism polygenic scores were used to predict life satisfaction and positive affect in almost 37,000 individuals from UK Biobank. Significant positive associations (effect sizes <0.05%) were observed between the extraversion polygenic score and wellbeing measures, and a negative association was observed between the polygenic neuroticism score and life satisfaction. Furthermore, using GWA data, genetic correlations of -0.49 and -0.55 were estimated between neuroticism with life satisfaction and positive affect, respectively. The moderate genetic correlation between neuroticism and wellbeing is in line with twin research showing that genetic influences on wellbeing are also shared with other independent personality domains.
We analyzed birth order differences in means and variances of height and body mass index (BMI) in monozygotic (MZ) and dizygotic (DZ) twins from infancy to old age. The data were derived from the international CODATwins database. The total number of height and BMI measures from 0.5 to 79.5 years of age was 397,466. As expected, first-born twins had greater birth weight than second-born twins. With respect to height, first-born twins were slightly taller than second-born twins in childhood. After adjusting the results for birth weight, the birth order differences decreased and were no longer statistically significant. First-born twins had greater BMI than the second-born twins over childhood and adolescence. After adjusting the results for birth weight, birth order was still associated with BMI until 12 years of age. No interaction effect between birth order and zygosity was found. Only limited evidence was found that birth order influenced variances of height or BMI. The results were similar among boys and girls and also in MZ and DZ twins. Overall, the differences in height and BMI between first- and second-born twins were modest even in early childhood, while adjustment for birth weight reduced the birth order differences but did not remove them for BMI.