An epidemiological investigation of COVID-19 outbreaks in a group of care homes in Wales, UK: a retrospective cohort study.

BACKGROUND: This study describes the epidemiology of COVID-19 outbreaks in four care homes in terms of spread, severity, presentation and interventions. METHODS: Participants were 100 residents and 102 staff from four co-located care homes in Wales. Data were collected from the homes and Public Health Wales, including demographics, presentations, test status and results, hospital admissions and deaths. Genomic sequencing of confirmed case samples was completed, where possible. Epi-curves, crude attack rates, a Kaplan-Meier survival curve and adjusted hazard ratios were calculated using R. RESULTS: About 14 confirmed and 43 possible resident cases, 23 confirmed and 47 possible staff cases occurred. Crude attack rates of possible and confirmed cases were 57% (residents) and 69% (staff). Genomic sequencing for 10 confirmed case PCR samples identified at least 5 different UK lineages of COVID-19.42 (42%) residents died, 23 (55%) with COVID-19 or suspected COVID-19 recorded on the death certificate. The hazard ratio for death amongst resident possible and confirmed cases compared to null cases, adjusting for age and sex, was 13.26 (95% CI 5.61-31.34). CONCLUSIONS: There were extensive outbreaks of COVID-19 in these homes with high crude attack rates and deaths. Universal testing and early isolation of residents are recommended.

Hospital admissions in infants with Down syndrome: a record-linked population-based cohort study in Wales.

BACKGROUND: Despite recent advances, mortality in children with Down syndrome remains five times higher than in the general population. This study aims to describe the burden, patterns and causes of hospital admissions in infants with Down syndrome, and compare this with infants without Down syndrome in a population-based cohort. METHODS: This study used data from the Wales Electronic Cohort for Children, a cohort of all children born in Wales between 1990 and 2012. The cohort was generated from routine administrative data, linked to create an anonymised data set within the Secure Anonymised Information Linkage databank. This analysis is based on all infants born between January 2003 and January 2012 who were followed to their first birthday, a move out of Wales, death, or until 31 October 2012 (end of follow-up). Infants with Down syndrome were identified using the Congenital Anomaly Register and Information Service in Wales. Multivariable Cox regression was used to compare the time to first hospital admission. Admission codes were used to identify the commonest indications for hospitalisation and to determine the presence of other congenital anomalies. RESULTS: We included 324 060 children, 356 of whom had Down syndrome. Of infants with Down syndrome, 80.3% had at least one hospital inpatient admission during the first year of life, compared with 32.9% of infants without Down syndrome. These first admissions were earlier [median of 6 days interquartile range (IQR) (3, 72) compared with 45 days [IQR 6, 166)] and longer [median of 4 days (IQR 1, 15) compared with 1 day (IQR 0, 3)] than in infants without Down syndrome. The most common causes of admissions were congenital abnormalities, respiratory diseases, conditions originating in the perinatal period and infectious diseases. The presence of other congenital abnormalities increased hospitalisations in all infants, but more so in infants with Down syndrome who spent a median of 21 days in hospital (IQR 11, 47) during their first year of life. CONCLUSION: Infants with Down syndrome are at high risk for early, more frequent and longer hospital admissions. Congenital heart disease and respiratory infections remain a major burden in this population. More research is needed to understand how to better manage these conditions particularly in the first month of life when most admissions occur.

The causal web of foetal alcohol spectrum disorders: a review and causal diagram.

Foetal alcohol spectrum disorders (FASDs) are a leading cause of developmental disability. Prenatal alcohol use is the sole necessary cause of FASD, but it is not always sufficient. Multiple factors influence a child's susceptibility to FASD following prenatal alcohol exposure. Much of the FASD risk factor literature has been limited to discussions of association, rather than causation. While knowledge of predictor variables is important for identifying who is most at risk of FASD and for targeting interventions, causal knowledge is important for identifying effective mechanisms for prevention and intervention programmes. We conducted a systematic search and narrative synthesis of the evidence and used this to create a causal diagram (directed acyclic graph; DAG) to describe the causal pathways to FASD. Our results show that the aetiology of FASD is multifaceted and complex. FASD risk is determined by a range of lifestyle, sociodemographic, maternal, social, gestational, and genetic factors. The causal diagram that we present in this review provides a comprehensive summary of causal risk factors for FASD and can be used as a tool to inform data collection and statistical modelling strategies to minimise bias in future studies of FASD.

Systematic review of survival following liver or lung metastasectomy for metastatic anal squamous cell carcinoma.

INTRODUCTION: Metastatic anal squamous cell carcinoma (SCC) carries a poor prognosis and the evidence base for surgical resection of metastases remains limited. The aim of this study was to establish the survival outcomes for patients undergoing metastasectomy for anal SCC. METHODS: A systematic review was performed using the MEDLINE®, Embase®, Cochrane and PubMed® databases. Studies were considered for inclusion in the review if they involved patients aged >18 years with a diagnosis of stage IV anal SCC who underwent metastasectomy for liver and/or lung metastases. The primary outcome measure was overall survival. Secondary outcome measures were disease free survival, early morbidity according to the Clavien-Dindo classification and quality of life, measured using a validated scoring tool. Risk of bias was assessed with the ROBINS-I (Risk Of Bias In Non-randomised Studies - of Interventions) tool. RESULTS: There were 10 studies with a total of 98 patients. There was heterogeneity in results reporting, with recurrence free survival the most reported outcome. For all studies reporting on liver metastasectomy, the one-year overall survival rate was 87%. In studies with adequate follow-up reported, the three and five-year overall survival rates were 53% and 38% respectively. Only one study reported on lung metastasectomy patients; the overall median survival was 24 months. None of the studies reported on quality of life measures. The ROBINS-I tool identified a critical risk of bias in six studies, a serious risk in one study and a moderate risk in three studies. CONCLUSIONS: The evidence base for metastasectomy in metastatic anal SCC is limited. Further information is required to inform future treatment methods and use of a standardised outcomes reporting method is needed to support this.

Where have all the appendicectomies gone?

INTRODUCTION: The COVID-19 pandemic stimulated a national lockdown in the UK. The public were advised to avoid unnecessary hospital attendances and health professionals were advised to avoid aerosol-generating procedures wherever possible. The authors hypothesised that these measures would result in a reduction in the number of patients presenting to hospital with acute appendicitis and alter treatment choices. METHODS: A multicentred, prospective observational study was undertaken during April 2020 to identify adults treated for acute appendicitis. Searches of operative and radiological records were performed to identify patients treated during April 2018 and April 2019 for comparison. RESULTS: A total of 190 patients were treated for acute appendicitis pre-lockdown compared with 64 patients treated during lockdown. Patients treated during the pandemic were more likely to have a higher American Society of Anesthesiology (ASA) score (p = 0.049) and to have delayed their presentation to hospital (2 versus 3 days, p = 0.03). During the lockdown, the use of computed tomography (CT) increased from 36.3% to 85.9% (p < 0.001), the use of an antibiotic-only approach increased from 6.2% to 40.6% (p < 0.001) and the rate of laparoscopic appendicectomy reduced from 85.3% to 17.2% (p < 0.001). The negative appendicectomy rate decreased from 21.7% to 7.1% during lockdown (p < 0.001). CONCLUSIONS: The COVID-19 lockdown was associated with a decreased incidence of acute appendicitis and a significant shift in the management approach. The increased use of CT allows the identification of simple appendicitis for conservative treatment and decreases the negative appendicectomy rate.

Does the number of sons born affect long-term mortality of parents? A cohort study in rural Bangladesh.

It has been suggested that bearing sons increases long-term mortality in women, because sons may be more physiologically demanding to produce than daughters. In this historical cohort study in rural Bangladesh, no association between the number of sons born and mortality was seen in women in the unadjusted analyses. However, a significant reduction in mortality with the number of surviving sons was seen. In addition, after adjusting for the number of surviving sons, there was evidence of increasing mortality with the number of sons born, in women. In men, mortality also depended strongly on the number of surviving sons, but not on the number born. These data provide support for negative long-term costs of bearing sons in mothers in rural Bangladesh, and suggest that there are context-specific factors that mask the true effects of sons in some populations.

Effects of education and other socioeconomic factors on middle age mortality in rural Bangladesh.

STUDY OBJECTIVE: To examine socioeconomic gradients in mortality in adult women and their husbands in Bangladesh, paying particular attention to the independent effects of the educational status of each spouse. DESIGN: Historical cohort study. SETTING: Matlab, a rural area 60 km south east of Dhaka, the capital of Bangladesh. PARTICIPANTS: 14803 married women aged 45 or over and their husbands who were resident in the Matlab Demographic Surveillance area between 30 June 1982 and 31 December 1998. MAIN RESULTS: Mortality was lower in women with formal or Koranic education compared with those with none (adjusted rate ratio for formal education = 0.68, 95% CI 0.53 to 0.86; adjusted rate ratio for Koranic schooling = 0.82, 95% CI 0.66 to 1.00). After adjusting for her own education, the husband's level of education or occupation did not have an independent effect on a woman's survival. Men who had attended formal education had lower mortality than those without any education (adjusted rate ratio = 0.84, 95% CI 0.75 to 0.93), but men whose wives had been educated had an additional survival advantage independent of their own education and occupation (adjusted rate ratio = 0.76, 95% CI 0.67 to 0.87). Mortality in both sexes was also significantly associated with marital status and the percentage of surviving children, and in men was associated with the man's occupation, religion, area of residence. CONCLUSIONS: The data suggest that socioeconomic status has a strong influence on mortality in adults in Bangladesh. They also illustrate how important the continued promotion of education, particularly for women, may be for the survival of both women and men in rural Bangladesh.

How do people evaluate social sexual conduct at work? A psycholegal model.

The authors tested a psycholegal model of how people evaluate social sexual conduct at work with videotaped reenactments of interviews with alleged complainants, perpetrators, and other workers. Participants (200 full-time male and female workers) were randomly assigned to evaluate the complaints with either the reasonable person or reasonable woman legal standard. Participants answered questions about sexual harassment law and completed the Ambivalent Sexism Inventory. Participants who took the reasonable woman perspective, as compared with those who took the reasonable person perspective, were more likely to find the conduct harassing; this was especially the case among participants high in hostile sexism. Medium-sized gender effects were found in the severe case but were absent in the weaker, more ambiguous case. The implications of these findings for hostile work environment law are discussed.

[Blood picture of calves from primiparae kept under large-scale production conditions in the early postnatal period]. / Krevní obraz telat od prvotelek v raném postnatálním období ve velkovýrobních podmínkách.

Twelve calves of the Red Spotted breed and its crossbreds born by first-calvers, kept in a large-capacity stable of a dairy farm, were subject to the study of the ontogenetic development of the values of the blood picture from birth up to the 10th day of age. The erythrocyte and leucocyte count, the packed cell volume and the relative and absolute number of neutrophils reached the significantly highest levels in calves before drinking the colostrum. The amount of haemoglobin, MCV and MCHC reached the highest values on the first day after birth. The values of the red blood picture decreased in the first week of life and reached the minimum on the tenth day. The leucocyte count decreased during the first to second day after birth, the decrease being due to a drop of the absolute number of neutrophils, and on the tenth day the leucocyte count returned to its initial value. Neutrophils prevailed in the peripheral blood of new-born calves whereas lymphocytes prevailed in the peripheral blood from the fourth day of life on. The amount of cosinophiles in the peripheral blood of the calves was about 0.5% up to the fourth day; on the seventh day it exceeded 1%. The relative number of monocytes was at its minimum level just after birth and showed a significant increase during the second to fourth day.

Clinical nurse specialist role development: quantifying actual practice over three years.

A task force of five clinical nurse specialists (CNSs) developed a data collection instrument to document CNS weekly work activities in 30-minute segments. This CNS group collected data for 2-week periods quarterly from June 1984 to May 1987. These data showed that: (1) greater than 50% of work time was allocated to clinical practice and consultation; (2) the proportion of time spent on activities in each role component varied with the number of years of experience in the CNS role; and (3) variations in amount of time spent in role categories were evident among practice specialties. The project demonstrated that it is possible to document CNS practice conveniently. The project has also enhanced the professional development of the CNS group and has set the stage for implementing peer review.

Care management: providing a connecting link.

Care management monitors the variances of the entire patient population in a given area versus specific cases as demonstrated in case management. It includes CQI principles, variance analysis and regulatory standards. Care management serves as a conduit for continuing education, involves a multidisciplinary team approach, which involves the family and assists managed care and utilization review.

The effect of number of births on women's mortality: systematic review of the evidence for women who have completed their childbearing.

Mortality in women who have completed their childbearing may increase with the number of births experienced because of maternal depletion or a trade-off between reproduction and mortality. We report a systematic review of the evidence on this association. We searched Medline, Embase, Popline, and the Science Citation Index for published and unpublished studies up to September 2003, and the book catalogues of relevant London libraries. Where necessary we also contacted authors for additional information. Mortality declined with increasing numbers of births in twelve historical cohorts, but in eight contemporary cohorts the highest mortality was seen in the nulliparous and in women with more than four births. All effects seen were small and there were few statistically significant results. Studies examining the relationship in other ways (such as by linear trends or by mean number of births by age at death) found inconsistent associations. We discuss methodological, social, and biological factors that may have affected these associations.

Hormone replacement therapy and cataract: a population-based case-control study.

PURPOSE: Laboratory studies have suggested that hormone replacement therapy (HRT) may protect against the development of cataract, but epidemiological studies in humans have thus far been inconclusive. The aim of this study was to assess the association between hormone replacement therapy and cataract. METHODS: Population-based case-control study using data from the General Practice Research Database in the UK. Participants were 10 000 women aged 45 years and over with diagnosed cataract and 10 000 controls matched on age, general practice, and calendar period. RESULTS: The crude odds ratio for the association between cataract and ever-use of oestrogen-only hormone replacement therapy was 1.13 (95% CI 0.99-1.29). This reduced to 0.81 (95% CI 0.71-0.94) after adjustment for consultation rate. Similarly, the crude odds ratio for the association between cataract and ever-use of a formulation containing oestrogen and progestogen was 1.18 (95% CI 1.01-1.39), reducing to 0.86 (95% CI 0.72-1.02) after adjustment for consultation rate. CONCLUSIONS: Oestrogen-only and oestrogen-progestogen hormone replacement therapies are associated with a small reduced risk of cataract. This data adds to the growing body of evidence on the effects of HRT on health. All potential benefits and risks of this therapy should be taken into account when considering its use.

Perceptions of sexual harassment: the effects of gender, legal standard, and ambivalent sexism.

This research tests the possibility that the reasonable woman as compared to the reasonable person test of hostile work environment sexual harassment interacts with hostile and benevolent sexist beliefs and under some conditions triggers protectionist attitudes toward women who complain of sexual harassment. We administered to a sample of undergraduates the ambivalent sexism inventory along with the fact patterns in two harassment cases and asked them to make legally relevant decisions under either the reasonable woman or person standard. We found that those high in hostile sexism, and women, found more evidence of harassment. However, those high in benevolent sexism did not exhibit the hostile sexism effects. Although men were less sensitive to the reasonable woman standard than women, under some conditions the reasonable woman standard enabled both genders to find greater evidence of harassment. The results are discussed from the perspectives of law and psychology.

Gender differences in evaluating social-sexual conduct in the workplace.

Qualitative interviews exploring gender differences in perceptions of sexual harassment were conducted with 100 full-time St. Louis area employees. Women more than men reported that telling dirty/sexual jokes was a non-harassing behavior, qualified behaviors as harassing when they happened in the workplace, and considered behaviors as non-harassing when the man's intentions were not harmful. Men more than women reported that requesting a date was a non-harassing behavior, qualified behaviors as harassing when the woman did not welcome the behavior, and considered behaviors as non-harassing when they did not violate workplace norms. Logistic regression analysis predicted the respondent gender with 86% accuracy. Finally, concept mapping suggested that when women think about harassers they are concerned with power and social aptitude, while men seem to be more concerned about the responsibility and psychological adjustment of perpetrators of sexual harassment. When women think about victims of harassment they are concerned with a woman's assertiveness and work effectiveness, while men are more concerned with the psychological state of the woman and how provocative she is when they think about victims of sexual harassment.

The prevention of nitrosomethylurea-induced mammary tumors by d-limonene and orange oil.

The monocyclic monoterpenoid d-limonene and its source, orange oil, were found to prevent rat mammary carcinomas induced by the direct-acting carcinogen nitrosomethylurea. This chemopreventive effect was limited to the promotion/progression stage in this carcinogenesis model.