Inequalities in emergency care use across transition from paediatric to adult care: a retrospective cohort study of young people with chronic kidney disease in England.

Transition of young people with chronic kidney disease (CKD) from paediatric to adult healthcare has been associated with poor outcomes, but few population-level studies examine trends in subgroups. We aimed to assess sociodemographic inequalities in changes in unplanned secondary care utilisation occurring across transfer to adult care for people with CKD in England. A cohort was constructed from routine healthcare administrative data in England of young people with childhood-diagnosed CKD who transitioned to adult care. The primary outcome was the number of emergency inpatient admissions and accident and emergency department (A&E) attendances per person year, compared before and after transfer. Injury-related and maternity admissions were excluded. Outcomes were compared via sociodemographic data using negative binomial regression with random effects. The cohort included 4505 individuals. Controlling for age, birth year, age at transfer, region and sociodemographic factors, transfer was associated with a significant decrease in emergency admissions (IRR 0.75, 95% CI 0.64-0.88) and no significant change in A&E attendances (IRR 1.10, 95% CI 0.95-1.27). Female sex was associated with static admissions and increased A&E attendances with transfer, with higher admissions and A&E attendances compared to males pre-transfer. Non-white ethnicities and higher deprivation were associated with higher unplanned secondary care use. CONCLUSION:  Sociodemographic inequalities in emergency secondary care usage were evident in this cohort across the transition period, independent of age, with some variation between admissions and A&E use, and evidence of effect modification by transfer. Such inequalities likely have multifactorial origin, but importantly, could represent differential meetings of care needs. WHAT IS KNOWN: • In chronic kidney disease (CKD), transfer from paediatric to adult healthcare is associated with declining health outcomes. • Known differences in CKD outcomes by sociodemographic factors have limited prior exploration in the context of transfer. WHAT IS NEW: • Population-level data was used to examine the impacts of transfer and sociodemographic factors on unplanned secondary care utilisation in CKD. • Healthcare utilisation trends may not reflect known CKD pathophysiology and there may be unexplored sociodemographic inequalities in the experiences of young people across transfer.

Country of Origin of Medical Products and Risk of Labour Rights Abuse: A Cross-Sectional Analysis Using Four Procurement Datasets.

Background Case studies have highlighted labour rights abuse in the manufacture of several healthcare products, but little is known about the scale of the problem or the specific products involved. We aimed to quantify and compare the overall and product-specific risks of labour rights abuse in the manufacture of healthcare products supplied to high-income settings using multiple datasets on the product country of origin (COO). Methods Public procurement data from South-Eastern Norway (n=23,972 products) were compared to datasets from three other high-income settings: procurement data from Cambridge University Hospitals, trade data from UN Comtrade, and registry data from the US Food and Drug Administration (FDA). In each dataset, the product COO was matched to the International Trade Union Confederation risk rating for labour abuse and deemed high-risk when rated 4, 5, or 5+. Results In the Norway data, 55.4% of products by value had a COO declared, 49.1% of which mapped as high-risk of labour rights abuses. COO was identified for 70/100 products in the Cambridge data, with COO matching high-risk at 59.9% by value. The level of risk for specific medical product categories varied between the Norway, US FDA, and UN Comtrade datasets, but those with higher proportional risk included medical/surgical gloves and electrosurgical products. Conclusion Evidence of high-risk of labour rights abuse in the manufacture of healthcare products present in these data indicates a likely high level of risk across the sector. There is an urgent need for global legislative and political reform, with a particular focus on supply chain transparency as a key mechanism for tackling this issue.

Function, regulation, and transcriptional organization of the hemin utilization locus of Bartonella quintana.

Bartonella quintana is a gram-negative agent of trench fever, chronic bacteremia, endocarditis, and bacillary angiomatosis in humans. B. quintana has the highest known hemin requirement among bacteria, but the mechanisms of hemin acquisition are poorly defined. Genomic analyses revealed a potential locus dedicated to hemin utilization (hut) encoding a putative hemin receptor, HutA; a TonB-like energy transducer; an ABC transport system comprised of three proteins, HutB, HutC, and HmuV; and a hemin degradation/storage enzyme, HemS. Complementation analyses with Escherichia coli hemA show that HutA functions as a hemin receptor, and complementation analyses with E. coli hemA tonB indicate that HutA is TonB dependent. Quantitative reverse transcriptase PCR analyses show that hut locus transcription is subject to hemin-responsive regulation, which is mediated primarily by the iron response regulator (Irr). Irr functions as a transcriptional repressor of the hut locus at all hemin concentrations tested. Overexpression of the ferric uptake regulator (fur) represses transcription of tonB in the presence of excess hemin, whereas overexpression of the rhizobial iron regulator (rirA) has no effect on hut locus transcription. Reverse transcriptase PCR analyses show that hutA and tonB are divergently transcribed and that the remaining hut genes are expressed as a polycistronic mRNA. Examination of the promoter regions of hutA, tonB, and hemS reveals consensus sequence promoters that encompass an H-box element previously shown to interact with B. quintana Irr.