Ventilator-associated pneumonia in PICU - how are we doing?

Background: Ventilator-associated pneumonia (VAP) is a common hospital-acquired infection in children, leading to an increase in morbidity and mortality. A previous study in 2013 showed that VAP rates decreased dramatically after implementation of a VAP bundle and appointing a VAP coordinator. As part of a 'Plan, Do, Study, Act' cycle, it was necessary to evaluate the efficacy of these interventions. Objectives: To evaluate the VAP rate in the paediatric intensive care unit (PICU) over 2 years (2017 - 2018), and to describe the causative organisms and antibiotic sensitivity/resistance patterns during this period. Methods: This was a retrospective, descriptive study using the existing PICU VAP database as well as clinical folders. Results: Over the 2 years, 31 VAP cases were identified. The VAP rate for 2017 was 4.0/1 000 ventilator days and 5.4/1 000 ventilator days for 2018. Compliance with the VAP bundle was 68% in 2017 and 70% in 2018. The median (interquartile range (IQR)) duration of ventilation in 2017 was 9 (6 -12) days and 15 (11 - 28) days in 2018. The median (IQR) length of PICU stay in 2017 was 11 (8 - 22) days and 25 (17 - 37) days in 2018. The most common cultured organism was an extended-spectrum beta-lactamase (ESBL) Klebsiella pneumoniae sensitive to amikacin and carbapenems. Conclusion: Our VAP rate has not decreased since 2013. It is imperative that we improve compliance with the VAP bundle, in order to reduce VAP rates. K. pneumoniae and Pseudomonas aeruginosa were the most common organisms causing VAPs and empiric use of piptazobactam and amikacin is still appropriate. Contributions of the study: This study highlights the need for ongoing evaluation of quality improvement initiatives in PICU, considering that VAP rates remained largely unchanged from 2013 to 2018.

The urban wage premium is disappearing in U.S. micropolitan areas.

A key driver of urbanization is the pursuit of economic opportunities in cities. One such opportunity is the promise of higher wages in larger cities, a phenomenon known as the urban wage premium. While an urban wage premium has been well-documented among U.S. metropolitan areas, little is known about its existence in micropolitan areas, which represent an important link between rural and dense urban areas. Here we measure the power law scaling coefficient of annual wages versus employment for both U.S. metropolitan and micropolitan areas over a 37-year period. We take this coefficient to be a quantification of the urban wage premium for each type of urban area and find the relationship is superlinear in all years for both area types. Though both area types once had wage premiums of similar magnitude, the wage premium in micropolitan areas has steadily declined since the late 1980s while in metropolitan areas it has generally increased. This growing gap between micropolitan and metropolitan wage premiums is ongoing in parallel to other diverging characteristics, such as inequality and voting behavior, suggesting that our result is part of a broader social, cultural, and political divergence between small and large cities. Finally, we speculate that if urban residents respond to the COVID-19 crisis by migrating, the trends we describe may change significantly.

Job Mobility and Wealth Inequality.

The extent to which employees change jobs, known as the job mobility rate, has been steadily declining in the US for decades. This decline is understood to have a negative impact on both productivity and wages, and econometric studies fail to support any single cause brought forward. This decline coincides with decreases in household savings, increases in household debt and wage stagnation. We propose that the decline could be the consequence of a complex interaction between mobility, savings, wages and debt, such that if changing jobs incurs costs which are paid out of savings, or incurs debt in the absence of sufficient savings, a negative feedback loop is generated. People are further restricted in making moves by their debt obligations and inability to save, which in turn depresses wages further. To explore this hypothesis, we developed a stylized model in which agents chose their employment situation based on their opportunities and preferences for work and where there are costs to changing jobs and the possibility of borrowing to meet those costs. We indeed found evidence of a negative feedback loop involving changes, wages, savings and debt, as well as evidence that this dynamic results in a level of wealth inequality on the same scale as we see today in the US.

Effect of community-based newborn care on cause-specific neonatal mortality in Sylhet district, Bangladesh: findings of a cluster-randomized controlled trial.

OBJECTIVES: Community-based maternal and newborn intervention packages have been shown to reduce neonatal mortality in resource-constrained settings. This analysis uses data from a large community-based cluster-randomized trial to assess the impact of a community-based package on cause-specific neonatal mortality and draws programmatic and policy implications. In addition, the study shows that cause-specific mortality estimates vary substantially based on the hierarchy used in assigning cause of death, which also has important implications for program planning. Therefore, understanding the methods of assigning causes of deaths is important, as is the development of new methodologies that account for multiple causes of death. The objective of this study was to estimate the effect of two service delivery strategies (home care and community care) for a community-based package of maternal and neonatal health interventions on cause-specific neonatal mortality rates in a rural district of Bangladesh. STUDY DESIGN: Within the general community of the Sylhet district in rural northeast Bangladesh. Pregnancy histories were collected from a sample of women in the study area during the year preceding the study (2002) and from all women who reported a pregnancy outcome during the intervention in years 2004 to 2005. All families that reported a neonatal death during these time periods were asked to complete a verbal autopsy interview. Expert algorithms with two different hierarchies were used to assign causes of neonatal death, varying in placement of the preterm/low birth weight category within the hierarchy (either third or last). The main outcome measure was cause-specific neonatal mortality. RESULT: Deaths because of serious infections in the home-care arm declined from 13.6 deaths per 1000 live births during the baseline period to 7.2 during the intervention period according to the first hierarchy (preterm placed third) and from 23.6 to 10.6 according to the second hierarchy (preterm placed last). CONCLUSION: This study confirms the high burden of neonatal deaths because of infection in low resource rural settings like Bangladesh, where most births occur at home in the absence of skilled birth attendance and care seeking for newborn illnesses is low. The study demonstrates that a package of community-based neonatal health interventions, focusing primarily on infection prevention and management, can substantially reduce infection-related neonatal mortality.

Preterm birth and neonatal mortality in a rural Bangladeshi cohort: implications for health programs.

OBJECTIVE: To estimate the burden of prematurity, determine gestational age (GA)-specific neonatal mortality rates and provide recommendations for country programs. STUDY DESIGN: Prospective data on pregnancy, childbirth, GA and newborn mortality collected by trained community health workers from 10 585 mother-newborn pairs in a community-based study. RESULT: A total of 19.4% of newborn infants were preterm; 13.5% were late preterm (born between 34 and 36 weeks of gestation), 3.3% were moderate preterm (born at 32 to 33 weeks) and 2.6% were extremely preterm (born at 28 to 31 weeks of gestation). Preterm babies experienced 46% of all neonatal deaths; 40% of preterm deaths were in late preterm, 20% in moderate preterm and 40% in very preterm infants. The population attributable fraction of neonatal mortality in premature babies was 0.16 for very preterm, 0.07 for moderately preterm and 0.10 for late preterm. CONCLUSION: In settings where the majority of births and newborn deaths occur at home and successful referral is a challenge, moderate and late preterm babies may be an important target group for home-based or first-level facility-based management.

An evaluation of a psychosocial intervention for survivors of childhood cancer: paradoxical effects of response shift over time.

This study examined the impact of response shift on a psychosocial treatment evaluation of 22 young adult cancer survivors. An age-matched cohort of 54 healthy controls were included in the study to provide a comparison for normative levels and structure of quality-of-life (QOL). It was found that this evaluation of a psychosocial intervention for young adult cancer survivors was notably influenced by response shift phenomenon. Standard analyses suggested that the intervention had no impact on measured aspects of well-being. It did appear to yield an immediate gain in reported global QOL, but seemed to cause a significant decline over time. By considering response shift, it was highlighted that an apparently deleterious effect on QOL was largely a function of response shift. This response shift effect was reflected not only in changes in internal standards, but also in values and in conceptualization of QOL. The intervention seemed to have normalized survivors' conceptualization of QOL so that it was increasingly similar to their age-matched cohort. Future psychosocial intervention research should explicitly consider response shift in a randomized treatment evaluation.

Comparison of stress and stress management strategies between lesbian and heterosexual women.

Stress is said to be part of life, but stress may be uniquely experienced by different groups of women. We conducted this study to compare the experiences of stress and the methods of stress management used by lesbian and heterosexual women. A convenience sample of 215 (136 lesbian and 79 heterosexual) urban women was used. All women reported generally good mental health; however, more than 80% of the women reported moderate or severe stress. There were more similarities than differences between the groups, but lesbians reported more stress due to sexual identity, being female, and mental problems, and heterosexual women reported more stress due to parents and children. Both groups used a wide range of stress management strategies, although lesbians more frequently used meditation and therapy.

Childhood risks from the ferret.

The ferret is becoming an increasingly popular pet, yet the dangers of ferret ownership remain unrecognized by physicians and the general public. Reported are three incidents of ferret attacks in a 3-month period of time. The risk of attack is greatest in infants and small children. Wounds caused by ferret attacks must be evaluated for injury, infection, and rabies prophylaxis. Such attacks should be reported to animal control authorities. Physicians need to recognize the ferret as a risk to children.

Practice variations between family physicians and obstetricians in the management of low-risk pregnancies.

BACKGROUND: Studies suggest that family physicians and other generalist physicians practice differently than specialists. This study was performed to determine whether practice patterns and outcomes differ for women with low-risk pregnancies who obtain maternity care from family physicians as compared with those who are cared for by obstetricians. METHODS: A retrospective chart review was performed at five sites across the United States. Women who presented for elective repeat cesarean section or who had any one of 14 high-risk conditions were excluded from the analysis. The final sample analyzed included 4865 women. Family physicians managed the labor of 2000 of these women, and obstetricians managed 2865. RESULTS: During intrapartum care, women managed by family physicians were less likely to have their labor induced (8.6% vs 10.4%, P = .03), receive oxytocin augmentation (14.9% vs 17.8%, P = .006), or receive epidural anesthesia (5.4% vs 17.0%, P < .001) as compared with those managed by obstetricians. Delivery outcomes showed that patients of family physicians were less likely to have an episiotomy during vaginal delivery (53.7% vs 74.5%, P < .001) and a lower frequency of cesarean section deliveries (9.3% vs 16.0%, P < .001), especially for cephalopelvic disproportion. When adjusted for potential confounders, rates for cesarean section and episiotomy for obstetricians were still significantly higher than those of family physicians. For neonatal outcomes (low 1-minute Apgar score, neonatal intensive care unit admission, birth trauma, or neonatal infection), no significant differences were found between the care delivered by obstetricians and family physicians. CONCLUSIONS: Women obtaining maternity care from family physicians were less likely to receive epidural anesthesia during labor or an episiotomy after vaginal births, and had a lower rate of cesarean section delivery rates, primarily because of a decreased frequency in the diagnosis of cephalopelvic disproportion. Differences between outcomes persisted after adjustment for potential confounders such as parity, previous cesarean delivery, and use of epidural anesthesia during labor. No differences between the two physician groups with respect to neonatal outcomes were found.

Cesarean section rate: a comparison between family physicians and obstetricians.

This retrospective study compared the cesarean section rates of family physicians and obstetricians for low-risk pregnancies. The study populations (n = 492) were demographically similar. The overall cesarean section rate for the study was 7.5%. Chi-square analysis revealed a statistically significant higher rate of cesarean section for obstetricians compared to family physicians. Obstetricians were overall three times more likely to deliver by cesarean section than were family physicians (11.3% compared to 3.8%). This pattern persisted for normal-length Stage I and Stage II labors. Equal cesarean section rates were noted in prolonged labor patterns. The rate of fetal distress, meconium, or other complications was equal between family physicians and obstetricians; equivalent fetal outcomes and Apgar scores were noted. None of the studied patient factors explained the difference in cesarean section rates between family physicians and obstetricians.

Men as elder caregivers: a response to changing families.

Results are presented from a study that examined the relationship between gender orientation and the unique stresses and gratifications for men who are engaged in caregiving tasks traditionally performed by women. The men report having found emotional gratification an important motivating factor, and they tended to ascribe to themselves many affective traits usually associated with the female role.

Persistant corpus luteum cyst of pregnancy: sonographic evaluation of cause of third trimester bleeding.

Corpus luteum cysts are frequently observed in pregnant patients evaluated with diagnostic ultrasound. They are usually regarded as incidental findings because of their limited size and usual pattern of regression by ten weeks. The presence and persistence of larger corpus luteum cysts or other extrauterine masses may complicate pregnancy. A case of a large persistent corpus luteum cyst associated with third trimester bleeding is presented.