Inconsistencies in authoritative national paediatric workforce data sources.

Objective National health workforce data are used in workforce projections, policy and planning. If data to measure the current effective clinical medical workforce are not consistent, accurate and reliable, policy options pursued may not be aligned with Australia's actual needs. The aim of the present study was to identify any inconsistencies and contradictions in the numerical count of paediatric specialists in Australia, and discuss issues related to the accuracy of collection and analysis of medical workforce data. Methods This study compared respected national data sources regarding the number of medical practitioners in eight fields of paediatric speciality medical (non-surgical) practice. It also counted the number of doctors listed on the websites of speciality paediatric hospitals and clinics as practicing in these eight fields. Results Counts of medical practitioners varied markedly for all specialties across the data sources examined. In some fields examined, the range of variability across data sources exceeded 450%. Conclusions The national datasets currently available from federal and speciality sources do not provide consistent or reliable counts of the number of medical practitioners. The lack of an adequate baseline for the workforce prevents accurate predictions of future needs to provide the best possible care of children in Australia. What is known about the topic? Various national data sources contain counts of the number of medical practitioners in Australia. These data are used in health workforce projections, policy and planning. What does this paper add? The present study found that the current data sources do not provide consistent or reliable counts of the number of practitioners in eight selected fields of paediatric speciality practice. There are several potential issues in the way workforce data are collected or analysed that cause the variation between sources to occur. What are the implications for practitioners? Without accurate data on which to base decision making, policy options may not be aligned with the actual needs of children with various medical needs, in various geographic areas or the nation as a whole.

Streptococcus pneumoniae sepsis in the newborn.

BACKGROUND: Streptococcus pneumoniae (SP) is an uncommon cause of neonatal sepsis. AIMS: To report on the spectrum of morbidity associated with SP infections in the neonatal period. METHODS: A case series of SP infection in the neonatal period was studied. Maternal and neonatal outcomes were noted. RESULTS: Four cases of neonatal SP infection are reported, one of which was due to a strain with reduced susceptibility to penicillin. All four cases had very early onset of severe clinical disease with bacteremia and pneumonia. In one case a retrospective diagnosis of meningitis was made as well. Maternal illness was a feature in one of these infants. CONCLUSIONS: Although less common now than in the pre-antibiotic era, Streptococcus pneumoniae remains a rare but important cause of neonatal sepsis and can mimic early onset Group B streptococcal sepsis. It is unclear whether current infant or adult pneumococcal immunisation programs might influence its incidence in the neonatal period. The potential for strains with reduced susceptibility to ß-lactam antibiotics to cause neonatal infection needs to be considered in relevant settings.

Curtobacterium flaccumfaciens septic arthritis following puncture with a Coxspur Hawthorn thorn.

Curtobacterium species are recognized plant pathogens. We report the first well-documented case of Curtobacterium human infection, a child with septic arthritis following puncture with a Coxspur Hawthorn plant thorn. The organism isolated from synovial tissue and the plant thorn was identified as Curtobacterium flaccumfaciens by 16S rRNA gene sequence analysis.

Interpreting positive cultures of endotracheal aspirates: factors associated with treatment decisions in ventilated neonates.

AIMS: Diagnosis of ventilator-associated pneumonia in newborns is challenging because of ease of colonisation, non-specific chest radiograph changes and lack of a consensus definition. The aims of this study were to review treatment decisions in neonates with culture-positive endotracheal aspirate and to assess impact on respiratory outcomes using blinded review of radiological studies. METHODS: Charts from all very low birthweight neonates ventilated for >48 h and with positive culture were assessed. Chest radiographs were reviewed by a radiologist masked to the grouping of the episode (treated/not treated). Clinical, investigational and radiological features used in practice were assessed on impact on treatment decisions. Association between treatment and outcomes was assessed. RESULTS: Seventy-four episodes of culture-positive endotracheal aspirate were analysed in 38 babies. Fifty-eight episodes were treated with antibiotics. Gestational age at birth and birthweight in both groups (treated vs. non-treated) were statistically comparable (25.5 ± 3.1 vs. 27.2 ± 2.3 weeks and 809 ± 302 vs. 870 ± 262 g). Comparative chest radiographs were available in 51 of 58 treated episodes; deterioration was noted in 42 (82.3%). Ventilatory parameters were significantly higher in the treatment group and showed a significant improvement after antibiotics. Twenty-three babies developed chronic lung disease. Odds ratio (of having chronic lung disease when treatment is initiated) was 4.5 (95% confidence interval = 0.97-20.8, P= 0.06). CONCLUSIONS: Treated culture-positive aspirate episodes were accompanied by higher ventilatory requirements, increased symptoms and elevated septic markers. Need for treatment was associated with greater likelihood of developing chronic lung disease.

Breastfeeding and Risk of Late-Onset Group B Streptococcal Disease.

BACKGROUND: Group B Streptococcus (GBS) is a major contributor to neonatal sepsis worldwide. Late-onset group B Streptococcus disease (LOGBS) and its risk factors remain poorly understood. The isolation of GBS from breast milk has been described in cases of LOGBS. This potential association has raised concerns for mothers and clinicians regarding the safety of ongoing breastfeeding. In this study, we aimed to investigate whether exposure to breast milk is associated with increased risk of LOGBS. METHODS: A case-control study of LOGBS was conducted across 4 hospital networks in Victoria, Australia, including the 2 major tertiary pediatric centers in the state, to evaluate 11 years of data (2007-2017). Cases were captured initially from microbiology databases and recaptured with International Classification of Diseases discharge coding. Each case patient was matched with 4 controls to assess feeding status. Patients were matched for chronological age, gestation, discharge status, recruitment site, and calendar year. RESULTS: We identified 92 cases of LOGBS: 73 cases on initial capture and 76 cases on the recapture analysis. Case patients were matched with 368 controls: 4 controls to each patient. Seventy-two patients were exposed to breast milk at the time of LOGBS (78.3%), compared with 274 controls (74.5%; odds ratio 1.2 [95% confidence interval 0.7-2.3]). CONCLUSIONS: Breastfeeding was not associated with increased risk of LOGBS. Breast milk should not be tested for GBS during a first episode of LOGBS.

Hepatitis B Testing: Old Tricks for Newborn Players.

We describe 2 preterm neonates with transient hepatitis B surface (HBs) antigenemia detected after Hepatitis B vaccination. Repeat serology in both cases tested negative for hepatitis B surface antigen, confirming transient HBs antigenemia. The duration of transient HBs antigenemia affirms current literature in the pediatric population.

Outbreak of vanB vancomycin-resistant Enterococcus faecium colonization in a neonatal service.

OBJECTIVE: To describe successful termination of an outbreak of vancomycin-resistant Enterococcus faecium (VREfm) colonization within a neonatal service. SETTING: Multisite neonatal intensive care unit and special care nurseries within a single health care service. PARTICIPANTS: Forty-four cases of VREfm-colonized neonatal inpatients-including 2 clinical isolates (eye swab and catheter-urine specimen) and 42 screening isolates. INTERVENTIONS: Active surveillance cultures, patient isolation, contact precautions, enhanced environment cleaning, and staff and parent education. Whole genome sequencing and multilocus sequence typing were used to characterize the outbreak and refine infection control procedures. RESULTS: Peak prevalence of VREfm colonization across all sites was 31% upon discovery of the outbreak. Subsequent to the intervention, transmission was halted within 8 weeks and no further isolates of the outbreak strain have been detected as of 12 months following outbreak cessation. Environmental swabs revealed VREfm colonization of baby-weighing scales, a baby bath, and a pharmacy refrigerator within the neonatal intensive care unit. All isolates were of a single multilocus sequence type (sequence type 796) and highly clonal at the core genome level. CONCLUSIONS: Bundled infection control interventions were effective in rapidly terminating a clonal outbreak of sequence type 796 VREfm colonization within a neonatal inpatient service. Strain-typing and active surveillance cultures were critical in guiding the management of this outbreak. The closed environment of a neonatal unit likely facilitated eradication of the patient and environment reservoirs of VREfm colonization.

Novel mutations in the thymidine kinase and DNA polymerase genes of acyclovir and foscarnet resistant herpes simplex viruses infecting an immunocompromised patient.

BACKGROUND: Mutations in the thymidine kinase (TK) and DNA polymerase (pol) genes of herpes simplex virus (HSV) may confer resistance to antiviral drugs, particularly in the context of immunosuppression induced by infection with the human immunodeficiency virus (HIV). OBJECTIVES: To characterise the HSV type 2 (HSV-2) TK and DNA pol genes in an immunocompromised patient with clinical resistance to both acyclovir and foscarnet. STUDY DESIGN: The TK and DNA pol genes of isolates obtained over a 2-year period from an AIDS patient with severe genital herpes infection were characterised both phenotypically and genotypically. RESULTS: HSV strains that were acyclovir resistant/foscarnet sensitive, acyclovir sensitive/foscarnet sensitive and acyclovir resistant/foscarnet resistant were isolated during this time. The TK gene of all the acyclovir resistant isolates contained a large 969 bp deletion which extended into a downstream untranslated region. The foscarnet resistance was associated with an S725G mutation in a conserved region (region II) of the herpesvirus DNA pol gene. CONCLUSIONS: Clinical and virological suppression of the infection was not always associated with subsequent reactivation with wild-type virus. Mutations of the nature we describe have not previously been reported occurring simultaneously in HSV strains isolated from patients treated with acyclovir and foscarnet.

Missed breast carcinoma: pitfalls and pearls.

Mammography is the standard of reference for the detection of breast carcinoma, yet 10%-30% of breast cancers may be missed at mammography. Possible causes for missed breast cancers include dense parenchyma obscuring a lesion, poor positioning or technique, perception error, incorrect interpretation of a suspect finding, subtle features of malignancy, and slow growth of a lesion. Recent studies have emphasized the use of alternative imaging modalities to detect and diagnose breast carcinoma, including ultrasonography (US), magnetic resonance imaging, and nuclear medicine studies. However, the radiologist can take a number of steps that will significantly enhance the accuracy of image interpretation at mammography and decrease the false-negative rate. These steps include performing diagnostic as well as screening mammography, reviewing clinical data and using US to help assess a palpable or mammographically detected mass, strictly adhering to positioning and technical requirements, being alert to subtle features of breast cancers, comparing recent images with earlier mammograms to look for subtle increases in lesion size, looking for additional lesions when one abnormality is seen, and judging a lesion by its most malignant features.

The cognitive fusion questionnaire: a preliminary study of psychometric properties and prediction of functioning in chronic pain.

BACKGROUND: Acceptance and Commitment Therapy and the psychological flexibility model on which it is based are growing interests for those researching and treating chronic pain. One part of this model is a therapeutic process called cognitive defusion. Cognitive defusion is a process of experiencing a distinction between thoughts and the events or people they describe. This process is intended to reduce the dominating psychological influence of thoughts without necessarily changing the content or frequency of the thoughts. There are recently developed measures of this process but little study of it in people with chronic pain. METHODS: This study explored the reliability and validity of the Cognitive Fusion Questionnaire (CFQ) within a chronic pain population. A total of 326 adults with chronic pain completed this measure and a set of other standard clinical measures at the start of treatment in a specialty chronic pain service in the United Kingdom. RESULTS: An exploratory factor analysis revealed an interpretable 2-factor structure within the items of the CFQ. Internal consistency reliability was good (α=0.87). In the analyses of validity the CFQ significantly correlated with general psychological acceptance and pain-related acceptance as expected. In multiple regression analyses, which included relevant patient background variables, pain, and acceptance of pain, cognitive fusion contributed significantly to the explained variance in the prediction of 5 of 6 dependent variables tested. DISCUSSION: The CFQ may be a useful measure for further research and treatment development.

Rotavirus cerebellitis: new aspects to an old foe?

Rotavirus infection is a significant cause of childhood morbidity and mortality worldwide. Although infection primarily causes gastroenteritis and dehydration, systemic signs and neurologic manifestations in rotavirus infection are widely recognized. The pathophysiologic origins of neurologic signs in rotavirus infection remain incompletely understood. We present a 4-year-old girl with clinical features of severe cerebellitis in association with abnormalities detected on magnetic resonance imaging. Rotavirus nucleic acid was demonstrated in both serum and cerebrospinal fluid. Severe neurologic sequelae remain after 2 years of follow-up. This report adds further evidence supporting a direct role for rotavirus in neurologic illness.

An outbreak of necrotizing enterocolitis associated with norovirus genotype GII.3.

BACKGROUND: Necrotizing enterocolitis (NEC) is an acute abdominal emergency of unknown etiology predominantly affecting preterm infants. We describe a cluster of NEC in a level III NICU involving 15 infants over a6-month period. Cohorting and stringent infection control measures were associated with termination of the cluster. A case-control study was used to investigate potential risk factors associated with development of NEC. METHODS: Stool samples were collected from 55 infants (10 of 15 NEC and 45 non-NEC controls). Enteric pathogens were identified by culture and/or molecular diagnostic techniques. For the case-control study, controls were selected from admitted neonates during the same time and in the preceding 6-month period, matched for gestation and birthweight. RESULTS: Forty percent (4/10) of NEC infants had norovirus RNA detected compared with 9% (4/45) of non-NEC infants (OR: 6.83, 95% CI: 1.3-34.9,P = 0.021). A lower rate of prolonged rupture of membranes and a higher rate of maternal smoking was also observed in NEC infants than in controls. No significant differences in incidences of chorioamnionitis, intrapartum antibiotics,volume of feedings, time of first formula feeding, and rates of patent ductus arteriosus or intrauterine growth retardation were detected. CONCLUSIONS: Infants who developed NEC had an increased incidence of norovirus detection in their stool following diagnosis. This further strengthens the case for an etiologic role of norovirus in the pathogenesis of NEC.

Melting muscles: novel H1N1 influenza A associated rhabdomyolysis.

We report the first case of myositis and rhabdomyolysis after infection with novel influenza A (H1N1/09) virus. The case demonstrates the novel virus' capacity for causing significant disease. Myositis and the possibility of rhabdomyolysis should be considered in any individual presenting with influenza-like symptoms in which severe myalgia or muscle weakness is apparent. It is likely that we will see severe clinical manifestations of infection with this novel influenza virus in the coming respiratory virus season.

Congenital tuberculosis after in-vitro fertilisation.

A 6-week old infant who had been conceived through in-vitro fertilisation (IVF) presented with a skin lesion and enlarged lymph nodes, and developed severe respiratory distress. Mycobacterium tuberculosis was identified; his mother was the only potential source identified. To our knowledge, this is the first case of congenital tuberculosis after IVF reported in Australia and the second worldwide. It highlights the importance of adequate screening during investigation of infertility and the difficulties in diagnosing congenital tuberculosis.

Effectiveness of a bivalent Haemophilus influenzae type B-hepatitis B vaccine in preventing hepatitis B virus infection among children born to hepatitis B e antigen-positive carrier mothers.

BACKGROUND: This observational study evaluated a modified immunoprophylactic regimen (hepatitis B immune globulin [HBIG]) and a dose of thimerosal-free monovalent hepatitis B (HB) vaccine shortly after birth followed by doses of thimerosal-free bivalent Haemophilus influenzae type b (Hib)-HB vaccine at 2 and 4 months of age, and a booster at 12 months of age) in infants at high risk of hepatitis B virus (HBV) infection (mothers HBeAg+). METHODS: Children >or=6 months of age vaccinated in routine clinical practice were tested twice (>or=6 months apart) for HBV antigens surface antigen (HBsAg) and "e" antigen, and for antibody to HBsAg. Partial nucleotide sequence analysis was performed on HBV DNA isolated from infants identified with a breakthrough chronic HBV infection. A fully sequential statistical design was used to maximize patient safety and study efficiency. RESULTS: Four of 60 children developed chronic HBV infection despite vaccination, but at no point did the cumulative number of cases reach the boundary of statistical significance. Overall, the analysis adjusted for sequential testing yielded an estimated breakthrough rate of 6.7% (90% CI: 2.3%-14.6%). In a subset of uninfected children tested for antibody to HBsAg 1 to 4 months after the second dose of Hib-HB vaccine, 90% (9/10) had >or=10 milli-International Units per milliliter (mIU/mL). The third dose of Hib-HB vaccine induced a secondary increase in the level of antibody; 94.7% (18/19) of a second group developed >or=100 mIU/mL, with a geometric mean concentration of 771 mIU/mL (95% CI: 351.4-1692.1 mIU/mL). CONCLUSION: The tested regimen is comparably effective to historical experience with a standard one employing HBIG plus monovalent thimerosal-containing HB vaccine given at 0, 1, and 6 months of age.

Tradable permits without legislative targets: a review of the potential for a permit scheme for sterilized clinical waste in the UK.

Tradable-permit schemes are becoming an increasingly popular technique for encouraging materials recovery and the diversion of waste from landfill. Such schemes operate using various forms of market-based trading of waste permits between polluters but usually rely on mandatory recycling targets to provide an incentive for trading. Using the UK's Packaging Recovery Note (PRN) scheme as a template, this paper examines the potential for permit trading where mandatory targets are absent and schemes must be driven solely by the financial benefits of reduced landfill costs and permit/material sales. The case examined is sterilized clinical waste, which has considerable recycling potential but suffers from health concerns and a poor public image. Interviews with healthcare and waste-management representatives indicate that although elements of the PRN scheme might prove appropriate for encouraging materials recovery, the absence of government targets and uncertain end markets for sterilized clinical waste present major obstacles to trading. Alternative incentives would therefore be required to catalyse schemes and develop recycling infrastructure. In the final analysis, thermal processing may be a more practical alternative to landfill than materials recovery for this particular waste stream.