Modeling mammal response to fire based on species' traits.

Fire has shaped ecological communities worldwide for millennia, but impacts of fire on individual species are often poorly understood. We performed a meta-analysis to predict which traits, habitat, or study variables and fire characteristics affect how mammal species respond to fire. We modeled effect sizes of measures of population abundance or occupancy as a function of various combinations of these traits and variables with phylogenetic least squares regression. Nine of 115 modeled species (7.83%) returned statistically significant effect sizes, suggesting most mammals are resilient to fire. The top-ranked model predicted a negative impact of fire on species with lower reproductive rates, regardless of fire type (estimate = -0.68), a positive impact of burrowing in prescribed fires (estimate = 1.46) but not wildfires, and a positive impact of average fire return interval for wildfires (estimate = 0.93) but not prescribed fires. If a species' International Union for Conservation of Nature Red List assessment includes fire as a known or possible threat, the species was predicted to respond negatively to wildfire relative to prescribed fire (estimate = -2.84). These findings provide evidence of experts' abilities to predict whether fire is a threat to a mammal species and the ability of managers to meet the needs of fire-threatened species through prescribed fire. Where empirical data are lacking, our methods provide a basis for predicting mammal responses to fire and thus can guide conservation actions or interventions in species or communities.

Modelos de las respuestas de los mamíferos a los incendios basados en las características de la especie Resumen Durante milenios, los incendios han moldeado a las comunidades ecológicas en todo el mundo y aun así conocemos muy poco sobre el impacto que tienen sobre cada especie. Realizamos un metaanálisis para predecir cuáles características, hábitat o variable de estudio en conjunto con las características del incendio afectan la respuesta de los mamíferos ante este fenómeno. Usamos para modelar los tamaños del efecto de las medidas de la abundancia poblacional o la ocupación como función de varias combinaciones de estas características y variables mediante una regresión filogenética por mínimos cuadrados. Nueve de las 115 especies modeladas (7.83%) devolvieron tamaños del efecto con importancia estadística, lo que sugiere que la mayoría de los mamíferos son resilientes a los incendios. El modelo mejor clasificado pronosticó un impacto negativo de los incendios sobre las especies con tasas reproductivas más bajas, sin importar el tipo de incendio (estimado = -0.68); un impacto positivo de las madrigueras durante las quemas prescritas (estimado = 1.46) pero no durante los incendios forestales; y un impacto positivo del intervalo promedio de rendimiento del incendio para los incendios forestales (estimado = 0.93) pero no para las quemas prescritas. Si la valoración de una especie en la Lista Roja de la Unión Internacional para la Conservación de la Naturaleza incluye a los incendios como una amenaza conocida o posible, pronosticamos que la especie respondería negativamente a los incendios forestales con relación a la quema prescrita (estimado = -2.84). Estos hallazgos proporcionan evidencia de la habilidad que tienen los expertos para predecir si los incendios son una amenaza para los mamíferos y la habilidad de los gestores para cumplir con las necesidades de las especies amenazadas por incendios por medio de las quemas prescritas. En caso de que falte información empírica, nuestros métodos proporcionan una base para predecir las respuestas de los mamíferos a los incendios y así orientar a las acciones o intervenciones de conservación para una especie o comunidad.

Experiences of health professionals towards using mobile electrocardiogram (ECG) technology: A qualitative systematic review.

OBJECTIVES: To identify and explore the experiences of health professionals towards using mobile electrocardiogram (ECG) technology. INTRODUCTION: Mobile technology is increasingly being incorporated into healthcare systems, and when implemented well, has the potential to revolutionise the way in which care is delivered. The uptake of mobile ECG technology enables health professionals to record and transmit ECGs electronically, at the point of care. It is important to explore both the impact of this technology and staff experiences to help understand how readily it is accepted and how effectively it is used in practice. There is a paucity of knowledge and understanding from primary healthcare providers and a lack of qualitative evidence offering insight into the monitoring and use of mobile ECG technology. Therefore, this review adds to the available body of knowledge by giving insight from the perspectives of health professionals on its use. METHODS: TRIP, CINAHL, MEDLINE, Scopus and sources of grey literature were searched for eligible studies. Databases were searched from their inception dates, with a restriction on studies written in English. The results of the search are presented in a PRISMA flow diagram. Two reviewers independently screened studies and assessed methodological quality in accordance with JBI methodology for systematic reviews of qualitative evidence. Data were extracted from the included studies and meta-aggregation methodology adopted to identify categories and create synthesised findings related to the healthcare professionals' experiences. RESULTS: A total of six studies were included, which resulted in 18 findings and five categories. Three synthesised findings were generated: Quick, easy and feasible in both urban and remote settings; Increased accessibility of AF screening opportunities for all; Enhanced support in staff resources, time and technology are required. The level of confidence of synthesised findings varied from low to moderate according to ConQual. CONCLUSIONS: This systematic review synthesised the experiences of healthcare professionals using mobile ECG technology. The methodological quality of the included studies was high, and findings indicated healthcare professionals (HCPs) generally found mobile ECG technology simple, quick, easy to use and non-invasive. Enablers regarding mobile ECG technology were time, workload, and remuneration for improved interoperability with current systems and sustainability for screening long term. Data on the experiences of HCPs came from studies capturing mainly proactive, lower-risk patients; therefore, this review was unable to demonstrate if there are any differences between the experiences of HCPs working in primary care settings, such as GP practices/pharmacies, and those working remotely in the community. This highlights a gap in provision for those patients requiring HCPs to record an ECG in their own home. RELEVANCE TO CLINICAL PRACTICE: The experiences of HCPs towards using Mobile ECG technology in practice is quick, easy and feasible in both urban and remote settings. HCPs and organisations should consider identifying key staff as "change champions" and use change/leadership models to support the integration (with current workflows), transformation, and evaluation of mobile ECG technology in their practice setting. HCPs and providers using mobile ECG technology should ensure it prioritises at-risk individuals and includes the "housebound" population.

Workplace well-being in pediatric anesthesia: How to design and implement a bespoke evidence-based framework in your department.

BACKGROUND: All anesthetists are at risk of mental ill health and pediatric anesthetists face additional stressors that may impact upon well-being, particularly after an adverse outcome. The SARS COV-2 pandemic has resulted in a plethora of resources to support the well-being of frontline workers. Developing a well-being system for an anesthesia department using these resources may be complex to implement. AIMS: In this article we outline how an anesthesia department can design and implement a framework for wellbeing, regardless of resources and financial constraints. We use the example of a free online toolkit developed in Australia for anesthetists. METHODS: The "Long lives, Healthy Workplaces toolkit" is a framework which has been specifically developed by mental health experts for anesthetists, and does not require departments to pay for external experts.1 Departments can design a long-term model of evidence-based mental health strategies to meet their unique needs using five steps outlined in the toolkit and detailed in this article. The framework uses cycles of assessment and review to create an adaptable approach to incorporate emerging evidence. We explain how culture can impact the implementation of a well-being framework and we outline how departments can set goals and priorities. CONCLUSION: Departments have different constraints which will alter how they approach supporting anaesthetists' wellbeing. Regardless of location or funding all departments should explicitly address anesthetists well-being. Long term sustainable well-being programs require a strategic and coordinated approach.

Enteroviral and herpes simplex virus central nervous system infections in infants < 90 days old: a Paediatric Investigators' Collaborative Network on Infections in Canada (PICNIC) study.

BACKGROUND: The relative contribution of viruses to central nervous system (CNS) infections in young infants is not clear. For viral CNS infections, there are limited data on features that suggest HSV etiology or on predictors of unfavorable outcome. METHODS: In this cross-sectional retrospective study, seven centers from the Pediatric Investigators Collaborative Network on Infections in Canada identified infants < 90 days of age with CNS infection proven to be due to enterovirus (EV) or herpes simplex virus (HSV) January 1, 2013 through December 31, 2014. RESULTS: Of 174 CNS infections with a proven etiology, EV accounted for 103 (59%) and HSV for 7 (4%). All HSV cases and 41 (40%) EV cases presented before 21 days of age. Four HSV cases (57%) and 5 EV cases (5%) had seizures. Three (43%) HSV and 23 (23%) EV cases lacked cerebrospinal fluid (CSF) pleocytosis. HSV cases were more likely to require ICU admission (p = 0.010), present with seizures (p = 0.031) and have extra-CNS disease (p < 0.001). Unfavorable outcome occurred in 12 cases (11% of all EV and HSV infections) but was more likely following HSV than EV infection (4 (57%) versus 8 (8%); p = 0.002). CONCLUSIONS: Viruses accounted for approximately two-thirds of proven CNS infections in the first 90 days of life. Empiric therapy for HSV should be considered in suspected CNS infections in the first 21 days even in the absence of CSF pleocytosis unless CSF parameters are suggestive of bacterial meningitis. Neurodevelopmental follow-up should be considered in infants whose course of illness is complicated by seizures.

Update on congenital cytomegalovirus infection: Prenatal prevention, newborn diagnosis, and management.

Cytomegalovirus (CMV) is the leading cause of congenital infection and the most common cause of non-genetic sensorineural hearing loss (SNHL) in childhood. Although most infected infants are asymptomatic at birth, the risk for SNHL and other neurodevelopmental morbidity makes congenital CMV (cCMV) a disease of significance. Adherence to hygienic measures in pregnancy can reduce risk for maternal CMV infection. The prompt identification of infected infants allows early initiation of surveillance and management. A multidisciplinary approach to management is critical to optimize outcomes in affected infants.

Using ideal distributions of the time since habitat was disturbed to build metrics for evaluating landscape condition.

Developing a standardized approach to measuring the state of biodiversity in landscapes undergoing disturbance is crucial for evaluating and comparing change across different systems, assessing ecosystem vulnerability and the impacts of destructive activities, and helping direct species recovery actions. Existing ecosystem metrics of condition fail to acknowledge that a particular community could be in multiple states, and the distribution of states could worsen or improve when impacted by a disturbance process, depending on how far the current landscape distribution of states diverges from pre-anthropogenic impact baseline conditions. We propose a way of rapidly assessing regional-scale condition in ecosystems where the distribution of age classes representing increasing time since last disturbance is suspected to have diverged from an ideal benchmark reference distribution. We develop two metrics that (1) compare the observed mean time since last disturbance with an expected mean and (2) quantify the summed shortfall of vegetation age-class frequencies relative to a reference age-class distribution of time since last disturbance. We demonstrate the condition metrics using two case studies: (1) fire in threatened southwestern Australian proteaceaous mallee-heath and (2) impacts of disturbance (fire and logging) in the critically endangered southeastern Australian mountain ash Eucalyptus regnans forest on the yellow-bellied glider Petaurus australis. We explore the effects of uncertainty in benchmark time since last disturbance, and evaluate metric sensitivity using simulated age-class distributions representing alternative ecosystems. By accounting for and penalizing too-frequent and too-rare disturbances, the summed shortfall metric is more sensitive to change than mean time since last disturbance. We find that mountain ash forest is in much poorer condition (summed shortfall 38.5 out of 100 for a 120-yr benchmark disturbance interval) than indicated merely by loss of extent (84% of vegetation remaining). Proteaceaous mallee-heath is in worse condition than indicated by loss of extent for an upper benchmark interval of 80 yr, but condition almost doubles for the minimum tolerable time since last disturbance interval of 20 yr. To fully describe ecosystem degradation, we recommend that our summed shortfall metric, focused on habitat quality and informed by biologically meaningful baselines, be added to existing condition measures focused on vegetation extent. This will improve evaluation of change in ecosystem states and enhance management of ecosystems in poor condition.

The benefits of influenza vaccine in pregnancy for the fetus and the infant younger than six months of age.

Influenza is a serious problem for infants <6 months of age, whose hospitalization rates for influenza and associated illness are comparable with rates in the elderly. Because influenza vaccines are not effective in this age group, the optimal evidence-based strategy is to administer trivalent inactivated influenza vaccines during pregnancy. Immunizing with trivalent inactivated influenza vaccines in the second and third trimester is well studied and safe, not only providing protection for the pregnant woman and her infant <6 months of age, but also for the fetus by decreasing the risk for low birth weight.

La grippe est un grave problème pour les nourrissons de moins de six mois. Chez ces nourrissons, le taux d'hospitalisation attribuable à cette maladie et à des maladies connexes est comparable à celui des personnes âgées. Puisque les vaccins antigrippaux ne sont pas efficaces dans ce groupe d'âge, la stratégie optimale, fondée sur des données probantes, consiste à administrer les vaccins trivalents inactivés pendant la grossesse. L'administration de ces vaccins au cours des deuxième et troisième trimestres a fait l'objet d'études approfondies et est sécuritaire. Non seulement protège-t-elle la femme enceinte et son nourrisson de moins de six mois, mais elle est également bénéfique pour le fœtus. En effet, ce vaccin contribue à réduire le risque de faible poids à la naissance.

The benefits of influenza vaccine in pregnancy for the fetus and the infant younger than six months of age.

Influenza is a serious problem for infants <6 months of age, whose hospitalization rates for influenza and associated illness are comparable with rates in the elderly. Because influenza vaccines are not effective in this age group, the optimal evidence-based strategy is to administer trivalent inactivated influenza vaccines during pregnancy. Immunizing with trivalent inactivated influenza vaccines in the second and third trimester is well studied and safe, not only providing protection for the pregnant woman and her infant <6 months of age, but also for the fetus by decreasing the risk for low birth weight.

La grippe est un grave problème pour les nourrissons de moins de six mois. Chez ces nourrissons, le taux d'hospitalisation attribuable à cette maladie et à des maladies connexes est comparable à celui des personnes âgées. Puisque les vaccins antigrippaux ne sont pas efficaces dans ce groupe d'âge, la stratégie optimale, fondée sur des données probantes, consiste à administrer les vaccins trivalents inactivés pendant la grossesse. L'administration de ces vaccins au cours des deuxième et troisième trimestres a fait l'objet d'études approfondies et est sécuritaire. Non seulement protège-t-elle la femme enceinte et son nourrisson de moins de six mois, mais elle est également bénéfique pour le fœtus. En effet, ce vaccin contribue à réduire le risque de faible poids à la naissance.

A Pediatric Investigators Collaborative Network on Infections in Children (PICNIC) multi-centre Canadian descriptive analysis of Haemophilus influenzae bacteremia in children: Emerging serotypes.

Background: There has been dramatic reduction in Haemophilus influenzae serotype b (Hib) since introduction of Hib vaccines, but children still experience serious invasive Haemophilus influenzae (Hi) disease caused by various serotype and non-typeable bacteria. The object of this study was to describe the serotype distribution and clinical spectrum of Hi bacteremia in children admitted to Canadian hospitals. Methods: All children with Hi bacteremia admitted 2013 through 2017 to 10 centres across Canada were included. Demographic, clinical, treatment and outcome data were collected. Results: Haemophilus influenzae bacteremia occurred in 118 children of median age 12 months (inter-quartile range: 7-48 months). Forty-three (36%) isolates were non-typeable (NTHi) and 8 were not typed. Of the 67 typeable (THi), Hia (H. influenzae serotype a) (n=36, 54%), Hif (serotype f) (n=19, 26%) and Hib (serotype b) (n=9, 13%) dominated. The THi was more likely than NTHi bacteremia to present as meningitis (p<0.001), particularly serotype a (p=0.04) and less likely to present as pneumonia (p<0.001). Complicated disease (defined as intensive care unit admission, need for surgery, long-term sequelae or death) occurred in 31 (26%) cases and were more likely to have meningitis (p<0.001) than were those with uncomplicated disease. Conclusion: In the era of efficacious conjugate Hib vaccines, NTHi, Hia and Hif have emerged as the leading causes of invasive Hi in Canadian children, with Hia being most likely to result in meningitis and complicated disease. A vaccine for all NTHi and THi would be ideal, but knowledge of the current disease burden from circulating strains will inform prioritization of vaccine targets.

Welfare of Anaesthesia Trainees Survey 2019.

This survey was designed to investigate levels of stress, anxiety and depression, and to identify factors exacerbating or relieving stress in anaesthesia trainees within the Australian and New Zealand College of Anaesthetists training scheme. In addition, the survey investigated levels of personal healthcare, some working conditions, and reports of bullying and reported discrimination along with stigmatisation of mental health issues in this cohort. Psychological distress was assessed using the Kessler psychological distress scale (K10). An electronic survey was sent to 1310 randomly selected registrars, and 417 (32%) responses were received. The majority of respondents (67%) reported being satisfied or very satisfied with their job and training. However, 31% had K10 scores indicating high or very high levels of distress. Eleven percent reported being currently on treatment for anxiety and/or depression. Major stressors were examinations, job prospects, critical incidents and fear of making errors. Forty-five percent of respondents reported having experienced bullying during anaesthesia training, 25% discrimination and 7% sexual harassment. Twenty-six percent reported an excessive workload and 21% reported that they felt their workload compromised patient safety. Forty-two percent reported that they would avoid seeking help for anxiety or depression and 50% reported that they thought revealing mental health problems would jeopardise their careers. The results of this survey demonstrate a high incidence of psychological distress, and high levels of bullying and discrimination, as well as stigmatisation of mental ill health among respondents. Appropriate education, a review of assessment tools, effective management of bullying and discrimination, a review of working conditions, and destigmatisation of mental illness appear to be indicated.

Perceived barriers and facilitators to accessing and utilising sexual and reproductive healthcare for people who experience homelessness: a systematic review.

INTRODUCTION: People who experience homelessness face disproportionately poor reproductive health and adverse pregnancy outcomes, including but not limited to unintended pregnancy, abortion, low birth weight and preterm birth, as well as a higher risk of sexually transmitted infections (STIs). Precarious living conditions are known to contribute to poor uptake and engagement with sexual and reproductive healthcare (SRH) for this population. AIM: To identify and understand the perceived barriers and facilitators for accessing and utilising SRH for people who experience homelessness from their perspective, and the perspective of support staff/volunteers and healthcare professionals. METHODS: Electronic databases and online sources were searched. Two reviewers independently carried out the screening, data extraction, critical appraisal, data synthesis and thematic analysis of findings. RESULTS: Following deduplication and screening, 23 papers/reports were considered eligible for the review. Barriers for people experiencing homelessness to accessing and utilising SRH were identified within the themes of complexity, feelings and knowledge (ie, individual-level factors), as well as patient/provider interaction and healthcare system (ie, organisational factors). Facilitators were identified within all of the above themes except for complexity. CONCLUSIONS: Both population characteristics and attributes of the healthcare system influence access and utilisation of SRH by people experiencing homelessness. Given the complexity of living conditions associated with homelessness, greater efforts to improve access should be placed on healthcare systems and aspects of care delivery. This systematic review highlights current gaps in the literature and provides recommendations for enhancing future research and practice to meet the needs of this vulnerable group more effectively.

Analysis and critique of 'Transforming children and young people's mental health provision: A green paper': Some implications for refugee children and young people.

Adopting a children's rights perspective, a critique and analysis underpinned by documentary research methodology was undertaken in order to assess the extent to which the government's Green Paper (Department of Health and Social Care and Department of Education, 2017. Transforming children and young people's mental health provision: a green paper. Available at: https://www.gov.uk/government/consultations/transforming-children-and-young-peoples-mental-health-provision-a-green-paper (accessed 7 December 2017)) addresses the mental health and well-being needs of refugee children and young people in England and Wales, identifying strengths, limitations and challenges for future policy and practice. Findings suggest that there is much of potential benefit to refugee children and young people's future mental health and well-being. However, a paradigm shift, explicit in implications, scale and time frame, will be required, if the Green Paper is to achieve those changes in attitudes, practice and service delivery which it anticipates. We argue that this Green Paper's overarching challenge is that it is premised on Western-centric models in its understanding of the experiences of refugee children and young people, and management of trauma and mental health. It fails to recognize the meanings and significance of culture, and of diversity and difference, and the need to invest in all communities in facilitating engagement and support for children and young people's mental health issues.

Predictive value of repeated cerebrospinal fluid parameters in the outcomes of bacterial meningitis in infants <90 days of age.

BACKGROUND: There are variations in recommendations from different guidelines regarding the indications for repeat lumbar puncture (LP) in young infants with the diagnosis of bacterial meningitis. OBJECTIVE: To evaluate the frequency of repeat LPs and the characteristics of cerebrospinal fluid (CSF) parameters in repeated sampling and their predictive values for adverse outcomes in a national cohort. METHODS: This cohort study included infants born January 1, 2013 through December 31, 2014, who had proven or suspected bacterial meningitis within the first 90 days of life at seven paediatric tertiary care hospitals across Canada, and who underwent a repeat LP at the discretion of the treating physicians. RESULTS: Forty-nine of 111 infants (44%) underwent repeat LP at a median of 5 (IQR: 3, 13) days after the LP that led to the diagnosis of bacterial meningitis. Those who had meningitis caused by gram negative bacilli were more likely to have repeat LP than those with gram positive bacteria (77% versus 57%; p = 0.012). White blood cell (WBC) count on the second spinal tap yielded an area under the curve of 0.88 for predicting sequelae of meningitis at discharge from the hospital, with a cut-off value of 366 × 106/L, providing a sensitivity of 91% and specificity of 88%. CONCLUSION: In this multi-centre retrospective cohort study, infants with gram negative meningitis were more likely to have repeated LP. A high WBC on the second CSF sample was predictive of adverse outcome at the time of discharge from the hospital.

Paediatric Investigators Collaborative Network on Infections in Canada (PICNIC) study of the current landscape of invasive meningococcal disease in children.

BACKGROUND: Immunizations have led to a decrease in the incidence of invasive meningococcal disease (IMD) in Canada, but this infection still leads to significant morbidity and mortality. OBJECTIVES: The purpose of this study was to determine the burden of illness and management of IMD in paediatric hospitals. METHODS: Data were collected on all cases of IMD in eight paediatric hospitals from 2013 to 2017. RESULTS: There were 17 cases of IMD. Three of eight hospitals had no cases. Just over half of the cases were serogroup B (n=9); a quarter (n=4) were serogroup W; less than a quarter (n=3) were serogroup Y; and one was unknown. Two infected children were not started on antibiotics until day one and day five after the initial blood culture was collected, but had uneventful recoveries. Six cases required admission to intensive care units; two died. Six cases had probable or proven meningitis. Thrombocytopenia was documented in seven cases. All cases had elevated C-reactive protein levels. Seven children received more than seven days of antibiotics; of these seven, only two had complications that justified prolonged therapy (subdural empyema and septic knee). Six cases had a central line placed. CONCLUSION: IMD is now rare in Canadian children, but about one-third of the cases in our study required treatment in the intensive care unit and two died. Clinicians appear to not always be aware that a five to seven-day course is adequate for uncomplicated cases of bacteremia or meningitis.

Anesthesia for children with hyperleukocytosis a retrospective review.

BACKGROUND: Hyperleukocytosis (a white cell count in peripheral blood >100 x 10(9) l(-1)) is a well-recognized medical emergency. Rates of morbidity associated with anesthesia in hyperleukocytotic patients have not been previously described. This retrospective study describes the perioperative morbidity and mortality of children who present acutely with hyperleukocytosis. METHODS: All patients under 17 years of age with leukemia complicated by hyperleukocytosis and who received general anesthesia as part of their acute care at the Children's Hospital in Westmead from July 1999 to June 2008 were included. Data describing perioperative adverse events within 48 h of anesthesia were collected using a systematic chart review. RESULTS: Over the 8- year period, 60 children were admitted with hyperleukocytosis related to a new diagnosis of leukemia. Fifty-two children had general anesthesia within 48 h of their admission. Eleven children required two separate general anesthetics within this same time frame. Two deaths were recorded within 48 h of anesthesia; one child died from neurological complications of her disease, and the second died from multi-organ failure. Three children had serious respiratory adverse events requiring postanesthesia intensive care. Thirteen children had notable but less serious adverse events. These were typically respiratory in nature and required supplemental oxygen for more than 2 h after anesthesia. CONCLUSION: Children with leukemia-related hyperleukocytosis often require general anesthesia at the time of presentation and are at significant perioperative risk. Respiratory adverse events are very common and mandate close postanesthesia care.

Evaluation of a commercial direct fluorescent-antibody assay for human metapneumovirus in respiratory specimens.

The performance of a commercially manufactured direct fluorescent-antibody assay kit for human metapneumovirus was compared to that of reverse transcriptase PCR, the current "gold standard." The kit demonstrated a sensitivity of 95.2%, a specificity of 100%, and an accuracy of 98.9%.

Empyema associated with community-acquired pneumonia: a Pediatric Investigator's Collaborative Network on Infections in Canada (PICNIC) study.

BACKGROUND: Although the incidence of serious morbidity with childhood pneumonia has decreased over time, empyema as a complication of community-acquired pneumonia continues to be an important clinical problem. We reviewed the epidemiology and clinical management of empyema at 8 pediatric hospitals in a period before the widespread implementation of universal infant heptavalent pneumococcal vaccine programs in Canada. METHODS: Health records for children<18 years admitted from 1/1/00-31/12/03 were searched for ICD-9 code 510 or ICD-10 code J869 (Empyema). Empyema was defined as at least one of: thoracentesis with microbial growth from pleural fluid, or no pleural fluid growth but compatible chemistry or cell count, or radiologist diagnosis, or diagnosis at surgery. Patients with empyemas secondary to chest trauma, thoracic surgery or esophageal rupture were excluded. Data was retrieved using a standard form with a data dictionary. RESULTS: 251 children met inclusion criteria; 51.4% were male. Most children were previously healthy and those

Time to think outside the box? Prothrombin time, international normalised ratio, international sensitivity index, mean normal prothrombin time and measurement of uncertainty: a novel approach to standardisation.

BACKGROUND: The prothrombin time (PT) assay is the most clinically ordered coagulation test, and most often used for monitoring of vitamin K antagonist therapy (e.g., warfarin), where results are expressed as an international normalised ratio (INR). The INR is in essence the patient's PT 'mathematically adjusted' to a standardised value taking into account the peculiarities of the test system as defined by an ISI (international sensitivity index) and MNPT (mean normal prothrombin time). Although some manufacturers provide assigned ISI values for specific PT reagents and instrumentation, it is still recommended practice that laboratories check or validate these ISIs, as well as estimate the MNPT. Where an ISI is not provided by a manufacturer, the laboratory needs to estimate its own value. Current recommendations suggest the use of commercial reference-plasma calibration sets, but there is limited information on the performance of these in the field. RESULTS: We report a comparative study that assessed the utility of three such commercial calibration plasma sets, used as recommended, as well as alternate or supplementary procedures for estimation of ISI and MNPT. The latter included one novel approach using comparative data of 'existing' versus 'replacement' reagent, as well as assessment of external quality assurance data. Although MNPT value estimates were not grossly disparate, a wide variety of ISI values (e.g., 1.12-1.30 for our primary instrument) was obtained with the different plasma sets. CONCLUSION: Because of the above, further verification checks are required prior to acceptance of ISI and MNPT estimates generated from commercial plasma calibration sets. We also provide some recommendations regarding the process of standardisation of INR testing.