Differences in treatment trajectory following brief paediatric inpatient admissions for children and young people with eating disorders.

OBJECTIVE: Little is known about factors associated with treatment trajectory following brief paediatric admissions for children and young people (CYP) admitted for medical complications of their eating disorder (ED). This project aimed to identify possible factors and ways to improve the usefulness of paediatric admissions. METHOD: Retrospective NHS data was analysed to explore differences between paediatric admissions followed by community-based care or inpatient psychiatric care. Twelve parents were interviewed to seek feedback about paediatric admissions. RESULTS: Patients who received subsequent inpatient psychiatric care were unwell for longer, had longer paediatric admissions and more crisis team input, were more likely to have had previous admissions, and had higher parent-reported anxiety and depression. However, the groups did not significantly differ in ED severity. The interviews identified recommendations for improving paediatric admissions, which included improving understanding of EDs, enhancing communication channels, and providing psychological support to parents. CONCLUSIONS: Factors linked with illness severity (but not illness severity itself) appear to be associated with the difference between CYP either returning to community-based care or requiring more intensive psychiatric input. These factors may help clinicians understand who requires subsequent inpatient care, allowing clinicians to target more intensive support earlier and facilitate smoother transitions between services.

Can CBT-E be delivered in an online group format? A pilot study of the Body Image module in a child and adolescent eating disorder service.

The increased prevalence of eating disorders during the COVID-19 pandemic has led to long waiting lists in child and adolescent services. A pilot study was conducted to evaluate the feasibility and acceptability of providing the Body Image module, from the enhanced cognitive behavioral therapy for eating disorders (CBT-E), in a virtual group setting. Primary outcomes were acceptance rates, completion rates, qualitative feedback and quantitative data from routine questionnaires. From 22 eligible referrals, 12 participants accepted and enrolled in therapy. Eight completed all six sessions. Qualitative feedback was positive, with both the content and group nature of the intervention being described as helpful. There was an reduction in scores in the Clinical Impairment Assessment and all subscales of the Eating Disorder Examination for Adolescents, suggesting this was a feasible method of providing psychological therapy within the service. A larger trial is recommended to robustly test the effectiveness of the intervention compared to one-to-one in-person CBT-E, and whether the full CBT-E protocol can be effectively delivered in the same format.

Do primary care quality improvement frameworks consider equity?

BACKGROUND: Quality improvement (QI) is used by healthcare organisations internationally to improve care. Unless QI explicitly addresses equity, projects that aim to improve care may exacerbate health and care inequalities for disadvantaged groups. There are several QI frameworks used in primary care, but we do not know the extent to which they consider equity. This work aimed to investigate whether primary care QI frameworks consider equity. METHODS: We conducted a search of MEDLINE, EMBASE and key websites to compile a list of the QI frameworks used in primary care. This list was refined by an expert panel. Guidance documents for each of the QI frameworks were identified from national websites or QI organisations. We undertook a document analysis of the guidance using NVivo. RESULTS: We analysed 15 guidance documents. We identified the following themes: (1) there was a limited discussion of equity or targeted QI for disadvantaged groups in the documents, (2) there were indirect considerations of inequalities via patient involvement or targeting QI to patient demographics and (3) there was a greater focus on efficiency than equity in the documents. CONCLUSION: There is limited consideration of equity in QI frameworks used in primary care. Where equity is discussed, it is implicit and open to interpretation. This research demonstrates a need for frameworks to be revised with an explicit equity focus to ensure the distribution of benefits from QI is equitable.

Bacterial nitric oxide detoxification prevents host cell S-nitrosothiol formation: a novel mechanism of bacterial pathogenesis.

S-nitrosylation is an important mediator of multiple nitric oxide-dependent biological processes, including eukaryotic cellular events such as macrophage apoptosis and proinflammatory signaling. Many pathogenic bacteria possess NO detoxification mechanisms, such as the nitric oxide reductase (NorB) of Neisseria meningitidis and the flavohemoglobins (Hmp) of Salmonella enterica and Escherichia coli, which serve to protect the microorganism from nitrosative stress within the intracellular environment. In this study, we demonstrate that expression of meningococcal NorB increases the rate at which low-molecular-weight S-nitrosothiol (SNO) decomposes in vitro. To determine whether this effect occurs in cells during infection by bacteria, we induced SNO formation in murine macrophages by activation with lipopolysaccharide and gamma-interferon and observed a reduced abundance of SNO during coincubation with N. meningitidis, S. enterica, or E. coli. In each case, this effect was shown to be dependent on bacterial NO detoxification genes, which act to prevent SNO formation through the removal of NO. This may represent a novel mechanism of host cell injury by bacteria.

Prevalence of mechanisms decreasing quinolone-susceptibility among Salmonella spp. clinical isolates.

Fluoroquinolone treatment failure has been reported in patients with nalidixic acid-resistant Salmonella infections. Both chromosomal- and plasmid-mediated quinolone-resistance mechanisms have been described. The objective of this study was to identify the prevalence of these mechanisms in a collection of 41 Salmonella spp. clinical isolates causing acute gastroenteritis, obtained in the Hospital Clinic, Barcelona. The minimum inhibitory concentrations (MICs) of nalidixic acid and ciprofloxacin were determined by Etest. Mutations in the quinolone-resistance determining regions (QRDRs) of the gyrA, gyrB, and parC genes and the presence of the qnr, aac(6')-Ib-cr, and qepA genes were detected by PCR and DNA sequencing. All isolates showed constitutive expression of an efflux pump. None of the isolates were ciprofloxacin-resistant, whereas 41.5% showed nalidixic acid resistance associated with a mutation in gyrA and overexpression of an efflux pump. Although qnrS1, qnrB6, and qepA were found in four isolates, the expression of these genes was not associated with decreased quinolone susceptibility. Mutations in the gyrA gene and overexpression of an efflux pump were critical for nalidixic acid resistance and decreased susceptibility to ciprofloxacin in these isolates. However, plasmid-mediated quinolone resistance did not seem to play a major role. To our knowledge, this is the first description of qepA in Salmonella.

Reducing inappropriate antibiotic prescribing in upper respiratory tract infection in a primary care setting in Kolkata, India.

Inappropriate antibiotic use is a key factor in the emergence of antibiotic resistance. The majority of antibiotics are prescribed in primary care, where upper respiratory tract infection (URTI) is a common presentation. Inappropriate antibiotic prescribing in URTI is common globally and has increased markedly in developing and transitional countries. Antibiotic stewardship is crucial to prevent the emergence and spread of resistant microbes. This project aimed to reduce inappropriate antibiotic prescribing in URTI in a non-governmental organisation's primary care outreach clinics in Kolkata, India, from 62.6% to 30% over 4 months. A multifaceted intervention to reduce inappropriate antibiotic use in non-specific URTI was implemented. This consisted of a repeated process of audit and feedback, interactive training sessions, one-to-one case-based discussion, antibiotic guideline development and coding updates. The primary outcome measure was antibiotic prescribing rates. A baseline audit of all patients presenting with non-specific URTI over 8 weeks in November and December 2016 (n=222) found that 62.6% were prescribed antibiotics. Postintervention audit over 4 weeks in April 2017 (n=69) showed a marked reduction in antibiotic prescribing to 7.2%. An increase in documentation of examination findings was also observed, from 52.7% to 95.6%. This multifaceted intervention was successful at reducing inappropriate antibiotic prescribing, with sustained reductions demonstrated over the 4 months of the project. This suggests that approaches previously used in Europe can successfully be applied to different settings.

Prevalence of mechanisms decreasing quinolone-susceptibility among Salmonella spp. clinical isolates

Fluoroquinolone treatment failure has been reported in patients with nalidixic acid-resistant Salmonella infections. Both chromosomal- and plasmid-mediated quinolone-resistance mechanisms have been described. The objective of this study was to identify the prevalence of these mechanisms in a collection of 41 Salmonella spp. clinical isolates causing acute gastroenteritis, obtained in the Hospital Clinic, Barcelona. The minimum inhibitory concentrations (MICs) of nalidixic acid and ciprofloxacin were determined by Etest. Mutations in the quinolone-resistance determining regions (QRDRs) of the gyrA, gyrB, and parC genes and the presence of the qnr, aac(6’)-Ib-cr, and qepA genes were detected by PCR and DNA sequencing. All isolates showed constitutive expression of an efflux pump. None of the isolates were ciprofloxacin-resistant, whereas 41.5% showed nalidixic acid resistance associated with a mutation in gyrA and overexpression of an efflux pump. Although qnrS1, qnrB6, and qepA were found in four isolates, the expression of these genes was not associated with decreased quinolone susceptibility. Mutations in the gyrA gene and overexpression of an efflux pump were critical for nalidixic acid resistance and decreased susceptibility to ciprofloxacin in these isolates. However, plasmid-mediated quinolone resistance did not seem to play a major role. To our knowledge, this is the first description of qepA in Salmonella (AU)

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