RESUMO
OBJECTIVE: Identify organizational factors associated with high clinical litigation rates among acute National Health Service (NHS) trusts in England. DESIGN: Cross-sectional analysis using routine data. SETTING: NHS trusts in England. PARTICIPANTS: A total of 235 NHS trusts used the NHS Clinical Negligence Scheme in 2016-17. Ninety-seven trusts (41.3%) with no maternity services, 2 (0.9%) providing specialized services and 3 (1.2%) without clinical negligence claims were excluded. Hence, the remaining 133 trusts (56.6%) were included. INTERVENTION(S): None. MAIN OUTCOME MEASURES: Rate of clinical litigation by trust per 100 000 occupied bed days. RESULTS: The mean rate of clinical litigation was 25.4 per 100 000 occupied bed days. In univariable analyses, higher values of summary hospital-level mortality indictor, staff sickness, written complaints, patient safety incidents and being in the North of England led to increased clinical litigation rates. Conversely, higher patient admissions, NHS Staff Survey overall engagement score and occupied bed days led to decreased clinical litigation rates. In the multivariable model, factors associated with increased clinical litigation rates were as follows: summary mortality hospital-level indicator (SHMI) (0.9 increase in litigation rate per 0.05 increase in SHMI; P = 0.012); new written complaints (0.62 increase per 50 complaints higher; P < 0.001); located in the North of England compared to London (5.22 higher; P < 0.001). Conversely, a higher number of occupied bed days (-0.64 change per 50 000 days higher; P = 0.007) was associated with lower clinical litigation rates. CONCLUSIONS: This study identified organizational factors associated with clinical litigation, which will be of interest to clinicians and the NHS. This research also highlights areas for further investigation.
Assuntos
Hospitais , Medicina Estatal , Estudos Transversais , Inglaterra , Humanos , LondresRESUMO
Shigella are globally important diarrhoeal pathogens that are endemic in low-to-middle income nations and also occur in high income nations, typically in travellers or community-based risk-groups. Shigella phylogenetics reveals population structures that are more reliable than those built with traditional typing methods, and has identified sublineages associated with specific geographical regions or patient groups. Genomic analyses reveal temporal increases in Shigella antimicrobial resistance (AMR) gene content, which is frequently encoded on mobile genetic elements. Here, we whole genome sequenced representative subsamples of S. flexneri 2a and S. sonnei (n = 366) from the United Kingdom from 2008 to 2014, and analysed these alongside publicly available data to make qualitative insights on the genomic epidemiology of shigellosis and its AMR within the broader global context. Combined phylogenetic, epidemiological and genomic anlayses revealed the presence of domestically-circulating sublineages in patient risk-groups and the importation of travel-related sublineages from both Africa and Asia, including ciprofloxacin-resistant sublineages of both species from Asia. Genomic analyses revealed common AMR determinants among travel-related and domestically-acquired isolates, and the evolution of mutations associated with reduced quinolone susceptibility in domestically-circulating sublineages. Collectively, this study provides unprecedented insights on the contribution and mobility of endemic and travel-imported sublineages and AMR determinants responsible for disease in a high-income nation.
Assuntos
Farmacorresistência Bacteriana , Disenteria Bacilar/genética , Shigella/isolamento & purificação , Ciprofloxacina/uso terapêutico , Diarreia/epidemiologia , Diarreia/genética , Disenteria Bacilar/tratamento farmacológico , Disenteria Bacilar/epidemiologia , Humanos , Filogenia , Shigella/genética , Reino Unido/epidemiologia , Sequenciamento Completo do GenomaRESUMO
Horizontal gene transfer has played a role in developing the global public health crisis of antimicrobial resistance (AMR). However, the dynamics of AMR transfer through bacterial populations and its direct impact on human disease is poorly elucidated. Here, we study parallel epidemic emergences of multiple Shigella species, a priority AMR organism, in men who have sex with men to gain insight into AMR emergence and spread. Using genomic epidemiology, we show that repeated horizontal transfer of a single AMR plasmid among Shigella enhanced existing and facilitated new epidemics. These epidemic patterns contrasted with slighter, slower increases in disease caused by organisms with vertically inherited (chromosomally encoded) AMR. This demonstrates that horizontal transfer of AMR directly affects epidemiological outcomes of globally important AMR pathogens and highlights the need for integration of genomic analyses into all areas of AMR research, surveillance and management.
Assuntos
Antibacterianos/farmacologia , Farmacorresistência Bacteriana/genética , Disenteria Bacilar/microbiologia , Transferência Genética Horizontal , Shigella/genética , Adolescente , Adulto , Azitromicina/farmacologia , Estudo de Associação Genômica Ampla , Homossexualidade Masculina , Humanos , Masculino , Testes de Sensibilidade Microbiana , Pessoa de Meia-Idade , Fenótipo , Filogenia , Plasmídeos/metabolismo , Fatores de Tempo , Adulto JovemRESUMO
INTRODUCTION: Gastrointestinal infections (GII) can cause serious ill health and morbidity. Although primarily transmitted through faecal contamination of food or water, transmission through sexual activity is well described, especially among men who have sex with men (MSM). METHODS: We investigated the prevalence of GIIs among a convenience sample of MSM who were consecutively diagnosed with rectal Chlamydia trachomatis (CT) at 12 UK genitourinary medicine clinics during 10â weeks in 2012. Residual rectal swabs were coded, anonymised and tested for Shigella, Campylobacter, Salmonella, shiga toxin-producing Escherichia coli and enteroaggregative E. coli (EAEC) using a real-time PCR. Results were linked to respective coded and anonymised clinical and demographic data. Associations were investigated using Fisher's exact tests. RESULTS: Of 444 specimens tested, overall GII prevalence was 8.6% (95% CI 6.3% to 11.6%): 1.8% (0.9% to 3.6%) tested positive for Shigella, 1.8% (0.9% to 3.6%) for Campylobacter and 5.2% (3.5% to 7.7%) for EAEC. No specimens tested positive for Salmonella or other diarrhoeagenic E. coli pathotypes. Among those with any GII, 14/30 were asymptomatic (2/7 with Shigella, 3/6 with Campylobacter and 9/17 with EAEC). Shigella prevalence was higher in MSM who were HIV-positive (4.7% (2.1% to 10.2%) vs 0.5%(0.1% to 3.2%) in HIV-negative MSM; p=0.01). CONCLUSIONS: In this small feasibility study, MSM with rectal CT appeared to be at appreciable risk of GII. Asymptomatic carriage may play a role in sexual transmission of GII.
Assuntos
Infecções por Chlamydia/epidemiologia , Gastroenteropatias/epidemiologia , Homossexualidade Masculina , Doenças Retais/epidemiologia , Reto/microbiologia , Adulto , Infecções Assintomáticas/epidemiologia , Infecções por Chlamydia/diagnóstico , Infecções por Chlamydia/microbiologia , Infecções por Chlamydia/transmissão , Chlamydia trachomatis/genética , Chlamydia trachomatis/isolamento & purificação , Estudos Transversais , Escherichia coli/genética , Escherichia coli/isolamento & purificação , Infecções por Escherichia coli/epidemiologia , Estudos de Viabilidade , Gastroenteropatias/etiologia , Gastroenteropatias/microbiologia , Gonorreia/epidemiologia , Humanos , Masculino , Programas de Rastreamento , Neisseria gonorrhoeae/genética , Neisseria gonorrhoeae/isolamento & purificação , Reação em Cadeia da Polimerase , Prevalência , Doenças Retais/diagnóstico , Doenças Retais/microbiologia , Fatores de Risco , Comportamento Sexual , Doenças Bacterianas Sexualmente Transmissíveis/complicações , Doenças Bacterianas Sexualmente Transmissíveis/epidemiologia , Doenças Bacterianas Sexualmente Transmissíveis/microbiologia , Reino Unido/epidemiologiaRESUMO
BACKGROUND: Evidence suggests that sexual transmission between men has replaced foreign travel as the predominant mode of Shigella transmission in England. However, sexuality and HIV status are not routinely recorded for laboratory-reported Shigella, and the role of HIV in the Shigella epidemic is not well understood. METHODS: The Modular Open Laboratory Information System containing all Shigella cases reported to Public Health England (PHE) and the PHE HIV and AIDS Reporting System holding all adults living with diagnosed HIV in England were matched using a combination of Soundex code, date of birth and gender. RESULTS: From 2004 to 2015, 88â 664 patients were living with HIV, and 10â 269 Shigella cases were reported in England; 9% (873/10â 269) of Shigella cases were diagnosed with HIV, of which 93% (815/873) were in men. Shigella cases without reported travel history were more likely to be living with HIV than those who had travelled (14% (751/5427) vs 3% (134/4854); p<0.01). From 2004 to 2015, the incidence of Shigella in men with HIV rose from 47/100â 000 to 226/100â 000 (p<0.01) peaking in 2014 at 265/100 000, but remained low in women throughout the study period (0-24/100â 000). Among Shigella cases without travel and with HIV, 91% (657/720) were men who have sex with men (MSM). HIV preceded Shigella diagnosis in 86% (610/720), and 65% (237/362) had an undetectable viral load (<50 copies/mL). DISCUSSION: We observed a sustained increase in the national rate of shigellosis in MSM with HIV, who may experience more serious clinical disease. Sexual history, HIV status and STI risk might require sensitive investigation in men presenting with gastroenteritis.
Assuntos
Disenteria Bacilar/epidemiologia , Disenteria Bacilar/transmissão , Epidemias , Infecções por HIV/epidemiologia , Infecções por HIV/transmissão , Minorias Sexuais e de Gênero , Adolescente , Adulto , Coinfecção/epidemiologia , Coinfecção/microbiologia , Coinfecção/virologia , Disenteria Bacilar/microbiologia , Disenteria Bacilar/virologia , Inglaterra/epidemiologia , Infecções por HIV/microbiologia , Infecções por HIV/virologia , Homossexualidade Masculina , Humanos , Incidência , Masculino , Pessoa de Meia-Idade , Fatores de Risco , Comportamento Sexual , Parceiros Sexuais , Shigella/isolamento & purificação , Shigella flexneri/isolamento & purificação , Shigella sonnei/isolamento & purificação , Viagem , Adulto JovemRESUMO
OBJECTIVE: Understanding the effects of antiretroviral treatment (ART) interruption on neurocognition and quality of life (QoL) are important for managing unplanned interruptions and planned interruptions in HIV cure research. DESIGN: Children previously randomized to continuous (continuous ART, nâ=â41) vs. planned treatment interruption (PTI, nâ=â47) in the Pediatric European Network for Treatment of AIDS (PENTA) 11 study were enrolled. At study end, PTI children resumed ART. At 1 and 2 years following study end, children were assessed by the coding, symbol search and digit span subtests of Wechsler Intelligence Scale for Children (6-16 years old) or Wechsler Adult Intelligence Scale (≥17 years old) and by Pediatrics QoL questionnaires for physical and psychological QoL. Transformed scaled scores for neurocognition and mean standardized scores for QoL were compared between arms by t-test and Mann-Whitney U test, respectively. Scores indicating clinical concern were compared (<7 for neurocognition and <70 for QoL tests). RESULTS: Characteristics were similar between arms with a median age of 12.6 years, CD4⺠of 830 cells/µl and HIV RNA of 1.7 log10copies/ml. The median cumulative ART exposure was 9.6 in continuous ART vs. 7.7 years in PTI (Pâ=â0.02). PTI children had a median of 12 months off ART and had resumed ART for 25.2 months at time of first assessment. Neurocognitive scores were similar between arms for all tests. Physical and psychological QoL scores were no different. About 40% had low neurocognitive and QoL scores indicating clinical concern. CONCLUSION: No differences in information processing speed, sustained attention, short-term memory and QoL functioning were observed between children previously randomized to continuous ART vs. PTI in the PENTA 11 trial.
Assuntos
Antirretrovirais/uso terapêutico , Terapia Antirretroviral de Alta Atividade/métodos , Cognição , Infecções por HIV/tratamento farmacológico , Infecções por HIV/patologia , Qualidade de Vida , Adolescente , Criança , Feminino , Infecções por HIV/psicologia , Humanos , Masculino , Resultado do TratamentoRESUMO
United Kingdom (UK) national data show a sharp increase in diagnoses of lymphogranuloma venereum (LGV) since 2012. Most cases are in men who have sex with men (MSM) living in London, with high rates of co-infection with HIV and other sexually transmitted infections. In light of these data, and the recent finding that one quarter of LGV infections may be asymptomatic, clinicians should be vigilant in testing for LGV, including in asymptomatic HIV-positive MSM.
Assuntos
Chlamydia trachomatis/isolamento & purificação , Coinfecção/epidemiologia , Homossexualidade Masculina , Linfogranuloma Venéreo/epidemiologia , Doenças Bacterianas Sexualmente Transmissíveis/epidemiologia , Adolescente , Adulto , Idoso , Infecções por HIV/diagnóstico , Infecções por HIV/epidemiologia , Humanos , Linfogranuloma Venéreo/diagnóstico , Linfogranuloma Venéreo/microbiologia , Masculino , Pessoa de Meia-Idade , Fatores de Risco , Vigilância de Evento Sentinela , Doenças Bacterianas Sexualmente Transmissíveis/diagnóstico , Doenças Bacterianas Sexualmente Transmissíveis/microbiologia , Reino Unido/epidemiologia , Adulto JovemRESUMO
BACKGROUND: About a third of children with HIV have virological failure within 2 years of beginning antiretroviral treatment (ART). We assessed the probability of switch to second-line ART or virological re-suppression without switch in children who had virological rebound on first-line ART in the UK and Ireland. METHODS: In this study, we used data reported to the Collaborative HIV Paediatric Study (CHIPS), a national multicentre observational cohort. We included children with virological rebound (confirmed viral load>400 copies per mL after suppression<400 copies per mL) on first-line ART. We did a competing-risk analysis to estimate the probability of switch to second-line treatment, confirmed resuppression (two consecutive viral load measurments<400 copies per mL) without switch, and continued viral load above 400 copies per mL without switch. We also assessed factors that predicted a faster time to switch. FINDINGS: Of the 900 children starting first-line ART who had a viral load below 400 copies per mL within a year of starting treatment, 170 (19%) had virological rebound by a median of 20·6 months (IQR 9·740·5). At rebound, median age was 10·6 years (5·613·4), median viral load was 3·6 log10 copies per mL (3·14·2), and median CD4% was 24% (1732). 89 patients (52%) switched to second-line ART at a median of 4·9 months (1·713·4) after virological rebound, 53 (31%) resuppressed without switch (19 [61%] of 31 patients on a first-line regimen that included a protease inhibitor and 31 [24%] of 127 patients on a first-line regimen that included a non-nucleoside reverse transcriptase inhibitor; NNRTI), and 28 (16%) neither resuppressed nor switched. At 12 months after rebound, the estimated probability of switch was 38% (95% CI 3045) and of resuppression was 27% (2134). Faster time to switch was associated with a higher viral load (p<0·0001), later calendar year at virological rebound (p=0·02), and being on an NNRTI-based or triple nucleoside reverse transcriptase inhibitor-based versus protease-inhibitor-based first-line regimen (p=0·001). INTERPRETATION: A third of children with virological rebound resuppressed without switch. Clinicians should consider the possibility of resuppression with adherence support before switching treatment in children with HIV. FUNDING: NHS England (London Specialised Commissioning Group).