LOVE in the time of Covid-19: a brief mental health intervention to overcome loneliness.

OBJECTIVE: The coronavirus disease 2019 outbreak and its containment through public health strategies has resulted in a parallel pandemic of psychological distress. Increased loneliness and social isolation are associated with adverse health outcomes, yet there is a gap in brief interventions that specifically target loneliness. This article introduces a brief intervention to strengthen connectedness, LOVE. In a systematic way, this solution-focused approach encourages openness and sharing of current struggles with the existing circle of support. There are four steps in LOVE: List people in one's life, Organise them on the helpfulness-availability matrix, Verify what they know to map them onto circles of trust and Engage them through self-disclosure. CONCLUSION: The article details each concept, its importance, the pragmatics involved and top tips to guide practice. The memorable acronym provides logical sequence and structure. It is time efficient in training and delivery, with no former mental health knowledge required so there is potential for wide application. It facilitates collaboration between health professionals and people in distress and promotes empowerment and self-resilience. Adapted from the safety planning component of PROTECT, a pre-existing suicide prevention framework, LOVE has to be fine-tuned as a brief intervention in the wider context of the pandemic.

Detection of OXA-48-like-producing Enterobacterales in Irish recreational water.

The rapid dissemination of carbapenemase-producing Enterobacterales (CPE) is a major public health concern. The role that the aquatic environment plays in this dissemination is underexplored. This study aimed to examine seawater as a reservoir for CPE. Seawater sampling took place at a bathing site throughout the 2017 bathing season. Each 30 L sample (n = 6) was filtered using the CapE filtration system. Wastewater samples (200 mL) (pre-treatment (n = 3) and post-treatment (n = 3)) were obtained from a nearby secondary wastewater treatment plant, during the same time period. All samples were examined for CPE. Whole genome sequencing of confirmed CPE was carried out using Illumina sequencing. Isolate genomes were hosted in corresponding BIGSdb databases and analyses were performed using multiple web-based tools. CPE was detected in 2/6 seawater samples. It was not detected in any wastewater samples. OXA-48-like-producing ST131 Escherichia coli (Ec_BM707) was isolated from a seawater sample collected in May 2017 and OXA-48-like-producing ST101 Klebsiella pneumoniae (Kp_BM758) was isolated from a seawater sample collected in August 2017. The genomes of the environmental isolates were compared to a collection of previously described Irish clinical OXA-48-like-producing Enterobacterales (n = 105). Ec_BM707 and Kp_BM758 harboured blaOXA-48 on similar mobile genetic elements to those identified in the clinical collection (pOXA-48 fragment in Ec_BM707 and IncL(pOXA-48) plasmid in Kp_BM758). Genetic similarities were observed between Ec_BM707 and several of the clinical ST131 E. coli, with allele matches at up to 98.2% of 2513 core genome multilocus sequence type (cgMLST) loci. In contrast, Kp_BM758 and the 34 clinical K. pneumoniae were genetically distant. The source of the CPE at this site was not identified. The detection of OXA-48-like-producing ST131 E. coli and OXA-48-like-producing ST101 K. pneumoniae in Irish recreational water is a concern. The potential for contamination of the aquatic environment to contribute to dissemination of CPE in Europe warrants further study.

The Anesthesia Perioperative "Call for Help"-Experience at a Quaternary Pediatric Medical Center: Analysis of 67,564 Anesthesia Encounters.

BACKGROUND: During the past several decades, anesthesia has become increasingly safe. Truly major adverse events are rare, and anesthesia quality researchers have instituted programs to evaluate "near miss" or less critical adverse events to evaluate the safety of anesthesia delivery. In this study, we aimed to evaluate calls for emergency help in our institution as a surrogate for pending critical events. We hypothesized that calls would be more common in patients with high American Society of Anesthesiologists (ASA) physical status, history of prematurity, and children with recent respiratory illness compared to those without these characteristics. METHODS: We analyzed emergent calls for help initiated by perioperative personnel ("STAT" calls) between August 2011 and September 2015 at Boston Children's Hospital. Our analysis had 2 phases: (1) All 193 STAT calls that occurred during this time period were analyzed for demographic variables (age, ASA physical status, gender) and specific features of the STAT calls (provider who initiated the call, anesthetic phase, presence of recent respiratory illness, location). We further categorized the STAT calls as "complicated" or "uncomplicated" based on an unexpected change in patient disposition, and analyzed how demographic factors and specific features related to the likelihood of a STAT call being complicated. (2) A subset of the total calls (108), captured after introduction of electronic intraoperative medical record in July 2012, were analyzed for the incidence of STAT calls by comparing the number and nature of the STAT calls to the number of surgical/diagnostic procedures performed. RESULTS: Univariable and multivariable analysis of the entire cohort of STAT calls (193 cases) identified several characteristics that were more likely to be associated with a complicated STAT call: higher ASA physical status; history of respiratory illness; cardiac inciting event; occurrence during induction phase of general anesthesia; postanesthesia care unit location; and calls initiated by an attending physician or a pediatric anesthesia fellow. Multivariable analysis of the subset of 108 indicated that age <1 year and a history of prematurity were independent predictors of a higher incidence of STAT calls. Offsite anesthesia services were associated with a lower frequency of STAT calls independent of the other variables. CONCLUSIONS: Our study offers the most comprehensive analysis of emergent perioperative calls for help in pediatric anesthesia to date. We identified several characteristics, independently associated with more complicated and frequent perioperative STAT calls. Further research is required to evaluate the utility of this information in preventing and treating adverse events in children undergoing surgery and anesthesia.

Indistinguishable NDM-producing Escherichia coli isolated from recreational waters, sewage, and a clinical specimen in Ireland, 2016 to 2017.

In this study, New Delhi metallo-beta-lactamase (NDM)-producing Enterobacteriaceae were identified in Irish recreational waters and sewage. Indistinguishable NDM-producing Escherichia coli by pulsed-field gel electrophoresis were isolated from sewage, a fresh water stream and a human source. NDM-producing Klebsiella pneumoniae isolated from sewage and seawater in the same area were closely related to each other and to a human isolate. This raises concerns regarding the potential for sewage discharges to contribute to the spread of carbapenemase-producing Enterobacteriaceae.

Anesthesiologist- and System-Related Risk Factors for Risk-Adjusted Pediatric Anesthesia-Related Cardiac Arrest.

BACKGROUND: Pediatric anesthesia-related cardiac arrest (ARCA) is an uncommon but potentially preventable adverse event. Infants and children with more severe underlying disease are at highest risk. We aimed to identify system- and anesthesiologist-related risk factors for ARCA. METHODS: We analyzed a prospectively collected patient cohort data set of anesthetics administered from 2000 to 2011 to children at a large tertiary pediatric hospital. Pre-procedure systemic disease level was characterized by ASA physical status (ASA-PS). Two reviewers independently reviewed cardiac arrests and categorized their anesthesia relatedness. Factors associated with ARCA in the univariate analyses were identified for reevaluation after adjustment for patient age and ASA-PS. RESULTS: Cardiac arrest occurred in 142 of 276,209 anesthetics (incidence 5.1/10,000 anesthetics); 72 (2.6/10,000 anesthetics) were classified as anesthesia-related. In the univariate analyses, risk of ARCA was much higher in cardiac patients and for anesthesiologists with lower annual caseload and/or fewer annual days delivering anesthetics (all P < 0.001). Anesthesiologists with the highest academic rank and years of experience also had higher odds of ARCA (P = 0.02). After risk adjustment for ASA-PS ≥ III and age ≤ 6 months, however, the association with lower annual days delivering anesthetics remained (P = 0.03), but the other factors were no longer significant. CONCLUSIONS: Case-mix explained most associations between higher risk of pediatric ARCA and anesthesiologist-related variables at our institution, but the association with fewer annual days delivering anesthetics remained. Our findings highlight the need for rigorous adjustment for patient risk factors in anesthesia patient safety studies.

Infantile postoperative encephalopathy: perioperative factors as a cause for concern.

We report on 6 infants who underwent elective surgery and developed postoperative encephalopathy, which had features most consistent with intraoperative cerebral hypoperfusion. All infants were <48 weeks' postmenstrual age and underwent procedures lasting 120 to 185 minutes. Intraoperative records revealed that most of the measured systolic blood pressure (SBP) values were <60 mm Hg (the threshold for hypotension in awake infants according to the Pediatric Advanced Life Support guidelines) but that only 11% of the measured SBP values were <1 SD of the mean definition of hypotension (<45 mm Hg) as reported in a survey of members of the Society for Pediatric Anesthesia in 2009. Four infants also exhibited prolonged periods of mild hypocapnia (<35 mm Hg). One infant did not receive intraoperative dextrose. All infants developed new-onset seizures within 25 hours of administration of the anesthetic, with a predominant cerebral pathology of supratentorial watershed infarction in the border zone between the anterior, middle, and posterior cerebral arteries. Follow-up of these infants found that 1 died, 1 had profound developmental delays, 1 had minor motor delays, 2 were normal, and 1 was lost to follow-up. Although the precise cause of encephalopathy cannot be determined, it is important to consider the role that SBP hypotension (as well as hypoglycemia, hyperthermia, hyperoxia, and hypocapnia) plays during general anesthesia in young infants in the development of infantile postoperative encephalopathy. Our observations highlight the lack of evidence-based recommendations for the lower limits of adequate SBP and end-tidal carbon dioxide in anesthetized infants.

Enterococcus faecium of the vanA genotype in rural drinking water, effluent, and the aqueous environment.

Total enterococci and vancomycin-resistant enterococci (VRE) were enumerated in samples of effluent (n = 50) and water (n = 167) from a number of sources. VRE were detected in the outflow of a wastewater treatment plant and in a single rural drinking water supply, suggesting potential for transmission to humans through environmental contamination.

Enumeration and characterization of antimicrobial-resistant Escherichia coli bacteria in effluent from municipal, hospital, and secondary treatment facility sources.

We describe a modification of the most probable number (MPN) method for rapid enumeration of antimicrobial-resistant Escherichia coli bacteria in aqueous environmental samples. E. coli (total and antimicrobial-resistant) bacteria were enumerated in effluent samples from a hospital (n = 17) and municipal sewers upstream (n = 5) and downstream (n = 5) from the hospital, effluent samples from throughout the treatment process (n = 4), and treated effluent samples (n = 13). Effluent downstream from the hospital contained a higher proportion of antimicrobial-resistant E. coli than that upstream from the hospital. Wastewater treatment reduced the numbers of E. coli bacteria (total and antimicrobial resistant); however, antimicrobial-resistant E. coli was not eliminated, and E. coli resistant to cefotaxime (including extended-spectrum beta-lactamase [ESBL] producers), ciprofloxacin, and cefoxitin was present in treated effluent samples.

High dose dexmedetomidine as the sole sedative for pediatric MRI.

OBJECTIVE: This large-scale retrospective review evaluates the sedation profile of dexmedetomidine. AIM: To determine the hemodynamic responses, efficacy and adverse events associated with the use of high dose dexmedetomidine as the sole sedative for magnetic resonance imaging (MRI) studies. BACKGROUND: Dexmedetomidine has been used at our institution since 2005 to provide sedation for pediatric radiological imaging studies. Over time, an effective protocol utilizing high dose dexmedetomidine as the sole sedative agent has evolved. METHODS/MATERIALS: As part of the ongoing Quality Assurance process, data on all sedations are reviewed monthly and protocols modified as needed. Data were analyzed from all 747 consecutive patients who received dexmedetomidine for MRI sedation from April 2005 to April 2007. RESULTS: Since 2005, the 10-min loading dose of our dexmedetomidine protocol increased from 2 to 3 microg.kg(-1), and the infusion rate increased from 1 to 1.5 to 2 microg.kg(-1).h(-1). The current sedation protocol progressively increased the rate of successful sedation (able to complete the imaging study) when using dexmedetomidine alone from 91.8% to 97.6% (P = 0.009), reducing the requirement for adjuvant pentobarbital in the event of sedation failure with dexmedetomidine alone and decreased the mean recovery time by 10 min (P < 0.001). Although dexmedetomidine sedation was associated with a 16% incidence of bradycardia, all concomitant mean arterial blood pressures were within 20% of age-adjusted normal range and oxygen saturations were 95% or higher. CONCLUSION: Dexmedetomidine in high doses provides adequate sedation for pediatric MRI studies. While use of high dose dexmedetomidine is associated with decreases in heart rate and blood pressure outside the established 'awake' norms, this deviation is generally within 20% of norms, and is not associated with adverse sequelae. Dexmedetomidine is useful as the sole sedative for pediatric MRI.

The frequency of anesthesia-related cardiac arrests in patients with congenital heart disease undergoing cardiac surgery.

BACKGROUND: The frequency of anesthesia-related cardiac arrests during pediatric anesthesia has been reported between 1.4 and 4.6 per 10,000 anesthetics. ASA physical status >III and younger age are risk factors. Patients with congenital cardiac disease may also be at increased risk. Therefore, in this study, we evaluated the frequency of cardiac arrest in patients with congenital heart disease undergoing cardiac surgery at a large pediatric tertiary referral center. METHODS: Using an established data registry, all cardiac arrests from January 2000 through December 2005 occurring in the cardiac operating rooms were reviewed. A cardiac arrest was defined as any event requiring external or internal chest compressions, with or without direct cardioversion. Events determined to be anesthesia-related were classified as likely related or possibly related. RESULTS: There were 41 cardiac arrests in 40 patients (median age, 2.9 mo; range, 2 days to 23 yr) during 5213 anesthetics over the time period, for an overall frequency of 0.79%; 78% were open procedures requiring cardiopulmonary bypass and 22% closed procedures not requiring cardiopulmonary bypass. Eleven cardiac arrests (26.8%) were classified as either likely (n = 6) or possibly related (n = 5) to anesthesia, (21.1 per 10,000 anesthetics) but with no mortality; 30 were categorized as procedure-related. The incidence of anesthesia-related and procedure-related cardiac arrests was highest in neonates (P < 0.001). There was no association with year of event or experience of the anesthesiologist. CONCLUSION: The frequency of anesthesia-related cardiac arrest in patients undergoing cardiac surgery is increased, but is not associated with an increase in mortality. Neonates and infants are at higher risk. Careful preparation and anticipation is important to ensure timely and effective resuscitation.

Intraoperative hyperglycemia during infant cardiac surgery is not associated with adverse neurodevelopmental outcomes at 1, 4, and 8 years.

BACKGROUND: It is unknown whether intraoperative hyperglycemia in infants is associated with worse neurodevelopmental outcomes after low-flow cardiopulmonary bypass (LF), deep hypothermic circulatory arrest (CA), or both. METHODS: In a database review of a prospective trial of 171 infants undergoing arterial switch for D-transposition of the great arteries who were randomly assigned to predominantly LF or CA, glucose was measured after induction (T1), 5 min after cardiopulmonary bypass onset (T2), at the onset of CA or LF (T3), 5 min after CPB resumption (T4), at rewarming to 32 degrees C (T5), 10 min after cardiopulmonary bypass weaning (T6), and 90 min after CA or LF (T7). Outcomes included seizures, electroencephalographic findings, and neurodevelopmental evaluation at 1, 4, and 8 yr. RESULTS: Glucose concentrations were affected by support strategy and age at surgery. Lower glucose in the entire group at T6-T7 tended to predict electroencephalographic seizures (P = 0.06 and P = 0.007) but was not related to clinical seizures. Within the predominantly CA group, higher glucose did not correlate with worse outcomes. Rather, it was associated with more rapid electroencephalographic normalization of "close burst" and "relative continuous" activity at all times except T2 (P < or = 0.03), a finding more pronounced in infants aged 7 days old or younger. Intraoperative serum glucose concentrations were unrelated to neurodevelopmental outcomes at ages 1, 4, and 8 yr. CONCLUSIONS: Low glucose after cardiopulmonary bypass tended to relate to electroencephalographic seizures and slower electroencephalogram recovery, independent of CA duration. High glucose concentrations were not associated with worse neurodevelopmental outcomes. Avoiding hypoglycemia may be preferable to restricting glucose in infants undergoing heart surgery.

Time course of early induction of intracellular adhesion molecule-1 messenger RNA during reperfusion, following cardiopulmonary bypass with hypothermic circulatory arrest in lambs.

OBJECTIVE: We investigated the time course of intracellular adhesion molecule-1 messenger RNA induction following cardiopulmonary bypass with hypothermic circulatory arrest. DESIGN: Animal case study. SETTING: An animal research laboratory and molecular biology laboratory at a university children's hospital. SUBJECTS: Neonatal lambs. INTERVENTIONS: Neonatal lambs were cooled on cardiopulmonary bypass for 30 mins, followed by hypothermic circulatory arrest at 15 degrees C for 120 mins and warming on cardiopulmonary bypass for 30 mins. Animals were killed after 0, 3, or 6 hrs of reperfusion. Control animals had sternotomy only. To generate a species-specific probe, ovine intracellular adhesion molecule-1 complementary DNA was cloned and sequenced. By using a ribonuclease protection assay, we measured intracellular adhesion molecule-1 messenger RNA in lung, cardiac ventricle, and brain, with nonmuscle actin as an internal control. Data were quantitated by Phosphorlmager. MEASUREMENTS AND MAIN RESULTS: In lung, intracellular adhesion molecule-1 messenger RNA was induced immediately following cardiopulmonary bypass/hypothermic circulatory arrest with no reperfusion (mean increase of 1.7-fold vs. control). The highest intracellular adhesion molecule-1 messenger RNA levels were found at 3 hrs reperfusion (mean increase of 2.8-fold vs. control), but the levels remained significantly elevated at 6 hrs reperfusion (mean increase of two-fold vs. control). Although not statistically significant, cardiac ventricle showed the highest intracellular adhesion molecule-1 messenger RNA levels at 6 hrs reperfusion. The brain had lower levels of intracellular adhesion molecule-1 messenger RNA than lung or ventricle and did not demonstrate induction. CONCLUSIONS: We found an earlier peak induction of intracellular adhesion molecule-1 messenger RNA in lung compared with ventricle. This may represent both local ischemic injury and filtering of bypass-related inflammatory mediators in the pulmonary capillary bed. Early intracellular adhesion molecule-1 messenger RNA induction may reflect its role in neutrophil-mediated, ischemia-reperfusion injury.