Objective
To characterise the obstetrical management and outcomes in a series of women with a history of Kawasaki disease (KD) in childhood.
Design
Retrospective case series.
Setting
Tertiary ...healthcare setting in the USA.
Population
Women with a history of KD in childhood.
Methods
Women completed a detailed health questionnaire and participated in research imaging studies as part of the San Diego Adult KD Collaborative Study.
Main outcome measures
Obstetrical management, complications during pregnancy and delivery, and infant outcomes.
Results
Ten women with a history of KD in childhood carried a total of 21 pregnancies to term. There were no cardiovascular complications during labour and delivery despite important cardiovascular abnormalities in four of the ten subjects. Pregnancy was complicated by pre‐eclampsia and the post‐partum course was complicated by haemorrhage in one subject each. Two of the 21 progeny subsequently developed KD.
Conclusions
Women with important cardiovascular sequelae from KD in childhood should be managed by a team that includes both a maternal–fetal medicine specialist and a cardiologist. Pre‐pregnancy counselling should include delineation of the woman's current functional and structural cardiovascular status and appropriate adjustment of medications, but excellent outcomes are possible with appropriate care. Review of the English and Japanese literature on KD and pregnancy revealed the occurrence of myocardial infarction during pregnancy in women with missed KD and aneurysms that were not diagnosed until their acute event. Our study highlights the need for counselling with regard to the increased genetic risk of KD in offspring born to these mothers.
Antimicrobial treatment of multidrug-resistant Acinetobacter baumannii (MDRAB) remains an important therapeutic challenge. With isolates resistant to all conventional agents now reported, clinicians ...are increasingly forced to turn to unorthodox combination treatments in the hope that these may be efficacious. Although a potent interaction between vancomycin and colistin has been demonstrated, there are concerns regarding the inherent toxicity of combining these agents in clinical practice. As teicoplanin has less nephrotoxic potential than vancomycin, we assessed whether a colistin/teicoplanin combination would have similar antimicrobial activities in vitro.
The antimicrobial activity of colistin alone and in combination with teicoplanin was assessed versus a collection of MDRAB belonging to a number of epidemic lineages present in the UK. Synergy studies were undertaken using microtitre plate chequerboard assays, an Etest agar dilution method and standard time-kill methodology.
The combination of teicoplanin and colistin was bactericidal versus all of the strains tested. In chequerboard assays, fractional inhibitory concentration indices of <0.5 were obtained, consistent with significant in vitro synergy. Using the Etest method the MIC of teicoplanin fell from >256 mg/L to ≤2 mg/L in the presence of subinhibitory concentrations of colistin.
Significant synergy was observed when colistin was combined with teicoplanin versus MDRAB in vitro. This may represent a useful therapeutic combination for the treatment of A. baumannii infections, especially when renal toxicity is a significant concern.
Performance-based financing (PBF) has been implemented in a number of countries with the aim of transforming health systems and improving maternal and child health. This paper examines the effect of ...PBF on health workers' job satisfaction, motivation, and attrition in Zambia. It uses a randomized intervention/control design to evaluate before-after changes for three groups: intervention (PBF) group, control 1 (C1; enhanced financing) group, and control 2 (C2; pure control) group.
Mixed methods are employed. The quantitative portion comprises of a baseline and an endline survey. The survey and sampling scheme were designed to allow for a rigorous impact evaluation of PBF or C1 on several key performance indicators. The qualitative portion seeks to explain the pathways underlying the observed differences through interviews conducted at the beginning and at the three-year mark of the PBF program.
Econometric analysis shows that PBF led to increased job satisfaction and decreased attrition on a subset of measures, with little effect on motivation. The C1 group also experienced some positive effects on job satisfaction. The null results of the quantitative assessment of motivation cohere with those of the qualitative assessment, which revealed that workers remain motivated by their dedication to the profession and to provide health care to the community rather than by financial incentives. The qualitative evidence also provides two explanations for higher overall job satisfaction in the C1 than in the PBF group: better working conditions and more effective supervision from the District Medical Office. The PBF group had higher satisfaction with compensation than both control groups because they have higher compensation and financial autonomy, which was intended to be part of the PBF intervention. While PBF could not address all the reasons for attrition, it did lower turnover because those health centers were staffed with qualified personnel and the personnel had role clarity.
In Zambia, the implementation of PBF schemes brought about a significant increase in job satisfaction and a decrease in attrition, but had no significant effect on motivation. Enhanced health financing also increased stated job satisfaction.
There is growing evidence that the interplay of genetic susceptibility and environmental factors leads to primary biliary cirrhosis (PBC). In particular, family members of an infected individual have ...up to a 100-fold higher risk of developing PBC. Although concordant rates for identical twins in other autoimmune diseases range between 25% and 50%, there are no such data on PBC. Accordingly, we evaluated the concordance of PBC in a genetically defined population of twin sets and evaluated the clinical characteristics between concordant subjects.
We identified 16 pairs of twins within a 1400-family cohort followed up by several centers worldwide, evaluated the diagnosis of PBC in all individuals, and determined the zygosity of sets reported as identical by the analysis of 2 highly variable HLA class II regions and 5 short tandem repeats.
Eight of 16 sets of twins were monozygotic. In 5 of 8 monozygotic twin sets, both individuals had PBC (pairwise concordance rate, 0.63). Among the dizygotic twins (n = 8), no set was found to be concordant for PBC. Interestingly, the age at onset of disease was similar in 4 of 5 concordant sets of monozygotic pairs; however, there were differences in natural history and disease severity.
The concordance rate of PBC in identical twins is among the highest reported in autoimmunity. However, discordant pairs were identified. The data show not only the role of genetics but also emphasize that either epigenetic factors and/or environment play a critical role.
New Zealand lacks a formal abdominal aortic aneurysm screening programme and owing to its rural nature, many patients have limited access to vascular surgery. Patients with vascular emergencies often ...have limited treatment options locally, especially if they present perimortem. In our small hospital in Whanganui, with the nearest vascular centre more than 150km away, there are cases of aneurysms diagnosed incidentally on radiology reporting but lost to follow-up.
Clinical Portal (CP) is a widely used patient-centred dashboard for viewing health information that is managed by Orion Health. A search strategy utilising the CP common database was devised that aimed to find aneurysms which were not followed up. This search was performed retrospectively for all imaging within a 5-month period.
Some 294 scans were flagged and 53 patients with aneurysms were found. Of these patients, 36 had follow-up by the ordering provider and 17 (32%) were found to have been lost to follow-up.
Our pilot study demonstrated high rates of loss to follow-up and a lack of communication of important health information across multiple health disciplines in the region, and represents a potential method for identifying 'lost' aneurysms. For patients in rural communities, this may be critical to preventing future complications from aneurysmal disease.
Summary
Animal hoarding is one of the most complex, costly and difficult to manage animal welfare issues, but it is poorly understood and little researched. In addition to the considerable welfare ...issues and animal suffering, animal hoarding has a significant impact on the humans involved, as well as their communities and the environment. The hoarding of equines is not uncommon, but it is not specifically recognised or addressed in the published literature. There is also very little information published about any interventions that can be successful with those who are, or are at risk of, animal hoarding. One intervention that has been briefly mentioned is Motivational Interviewing, a well‐researched and evidenced intervention used across a range of difficult to change human health behaviours, including substance misuse and other addictions. This paper describes the evaluation of motivational interview training which was delivered after a preliminary exploration of equine welfare officers’ experiences of complex multi‐horse cases which confirmed that equine hoarding occurs. The training taught motivational interviewing skills and theory to equine welfare officers, in order for them to be able to use this approach during their general duties as well as more specifically in equine hoarding cases. The findings indicate that, for many equine welfare workers these skills can be beneficially applied to their caseload and can have good outcomes in the most difficult of areas, that of equine hoarding.
A series of self-paced reading time experiments was performed to assess how characteristics of noun phrases (NPs) contribute to the difference in processing difficulty between object- and ...subject-extracted relative clauses. Structural semantic characteristics of the NP in the embedded clause (definite vs. indefinite and definite vs. generic) did not influence the magnitude of the processing difficulty even though corpus analysis showed a strong association between these NP classes and type of relative clause. Richness of lexical semantic content in a descriptive NP also had no influence on processing difficulty. However, the difference in processing difficulty was significantly reduced when a quantified pronoun appeared as the NP in the embedded clause. Together with previous findings, these results support the conclusion that NPs with common nouns differ in representational similarity from NPs consisting of proper names and pronouns, and that similarity in the memory representation of NPs contributes to the difficulty of processing syntactically complex sentences.
Lack of expertise in home parenteral nutrition (HPN) management has been reported as a barrier to its initiation in patients with advanced cancer (AC), and there are limited data describing hospital ...readmissions and HPN-related complications. We aimed to assess a centralized approach for managing HPN in AC and evaluate associated outcomes, including hospital readmissions and HPN-related complications. This was a cohort study of adults with AC requiring palliative HPN between 2010–2018 at a tertiary intestinal failure (IF) center, primarily utilizing a centralized model of HPN oversight to discharge patients remotely from an oncology center to their homes over a wide geographic area. A total of 126 patients were included, with a median distance between the patient’s home and the IF center of 17.5 km (IQR 10.9–39.1; maximum 317.4 km). A total of 28 (22%) patients experienced at least one HPN-related complication, the most common being a central venous catheter (CVC) occlusion and electrolyte abnormalities. The catheter-related bloodstream infection (CRBSI) rate was 0.49/1000 catheter days. The CVC type, administration of concomitant chemotherapy via a distinct CVC lumen separate from PN, venting gastrostomy and distance between the patient’s home and the IF center were not associated with CRBSI or mechanical CVC complications. A total of 82 (65.1%) patients were readmitted while on HPN, but only 7 (8.5%) of these readmissions were HPN-related. A total of 44 (34.9%) patients died at home, 41 (32.5%) at a hospice and 41 (32.5%) in a hospital. In conclusion, this study demonstrates that a centralized approach to IF care can provide HPN to patients over a large geographical area while maintaining low HPN-related complications that are comparable to patients requiring HPN for benign conditions and low hospital readmission rates.
Human trophoblast cultures provide powerful tools to model key processes of placental development. In vitro trophoblast studies to date have relied on commercial media that contains nonphysiological ...levels of nutrients, and the impact of these conditions on trophoblast metabolism and function is unknown. Here, we show that the physiological medium (Plasmax) with nutrient and metabolite concentrations recapitulating human plasma improves human trophoblast stem cell (hTSC) proliferation and differentiation compared with standard medium (DMEM-F12). hTSCs cultured in Plasmax-based medium also show altered glycolytic and mitochondrial metabolism, as well as reduced S-adenosylmethionine/S-adenosyl-homocysteine ratio compared with DMEM-F12-based medium. These findings demonstrate the importance of the nutritional environment for phenotyping cultured human trophoblasts.
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