What supports and services post COVID-19 do children with disabilities and their parents need and want, now and into the future?

Introduction

Children and youth with disabilities and special healthcare needs, and their families, have been uniquely affected by the COVID-19 pandemic. However, the voices of children themselves are still not well represented in the existing literature.

Methods

This qualitative descriptive study used a combination of visual methods and interviews to learn about the experiences of Canadian children with disabilities (n=18) and their parents (n=14) during the COVID pandemic and into the post-pandemic period. Data collection was carried out between January and July 2023. The aim was to identify the supports and services children and families need at present and moving forward.

Results

Families' pandemic experiences were complex and nuanced. For many, the pandemic complicated and disrupted everyday activities and supports. These disruptions were largely buffered by parents. However, some families also identified unexpected benefits. Key themes pertaining to present and future needs included the need for services that are flexible; consistent; conducive to relationship-building; comprehensive; coordinated across sectors; and designed to support the needs of the whole family.

Discussion

Implications for policy and practice are outlined.

Paediatric acute hepatitis of unknown aetiology: a national investigation and adenoviraemia case-control study in the UK

BACKGROUND

An increase in acute severe hepatitis of unknown aetiology in previously healthy children in the UK in March, 2022, triggered global case-finding. We aimed to describe UK epidemiological investigations of cases and their possible causes.

METHODS

We actively surveilled unexplained paediatric acute hepatitis (transaminase >500 international units per litre) in children younger than 16 years presenting since Jan 1, 2022, through notifications from paediatricians, microbiologists, and paediatric liver units; we collected demographic, clinical, and exposure information. Then, we did a case-control study to investigate the association between adenoviraemia and other viruses and case-status using multivariable Firth penalised logistic regression. Cases aged 1-10 years and tested for adenovirus were included and compared with controls (ie, children admitted to hospital with an acute non-hepatitis illness who had residual blood samples collected between Jan 1 and May 28, 2022, and without known laboratory-confirmed diagnosis or previous adenovirus testing). Controls were frequency-matched on sex, age band, sample months, and nation or supra-region with randomised selection. We explored temporal associations between frequency of circulating viruses identified through routine laboratory pathogen surveillance and occurrence of cases by linear regression. SARS-CoV-2 seropositivity of cases was examined against residual serum from age-matched clinical comparison groups.

FINDINGS

Between Jan 1 and July 4, 2022, 274 cases were identified (median age 3 years [IQR 2-5]). 131 (48%) participants were male, 142 (52%) were female, and one (<1%) participant had sex data unknown. Jaundice (195 [83%] of 235) and gastrointestinal symptoms (202 [91%] of 222) were common. 15 (5%) children required liver transplantation and none died. Adenovirus was detected in 172 (68%) of 252 participants tested, regardless of sample type; 137 (63%) of 218 samples were positive for adenovirus in the blood. For cases that were successfully genotyped, 58 (81%) of 72 had Ad41F, and 57 were identified as positive via blood samples (six of these were among participants who had undergone a transplant). In the case-control analysis, adenoviraemia was associated with hepatitis case-status (adjusted OR 37·4 [95% CI 15·5-90·3]). Increases in the detection of adenovirus from faecal samples, but not other infectious agents, in routine laboratory pathogen surveillance correlated with hepatitis cases 4 weeks later, which independently suggested an association (β 0·06 [95% CI 0·02-0·11]). No association was identified for SARS-CoV-2 antibody seropositivity.

INTERPRETATION

We observed an association between adenovirus 41F viraemia and paediatric acute hepatitis. These results can inform diagnostic testing recommendations, clinical management, and exploratory in vitro or clinical studies of paediatric acute hepatitis of unknown aetiology. The role of potential co-factors, including other viruses and host susceptibility, requires further investigation.

FUNDING

None.

Pilot of asymptomatic swabbing of humans following exposures to confirmed avian influenza A(H5) in avian species in England, 2021/2022

A programme of asymptomatic swabbing was piloted in 2021/2022 in England to further understand the risk of human infection with avian influenza in exposed individuals and to evaluate this surveillance approach as a public health measure. There were challenges in deploying this pilot that will need to be addressed for future seasons. However, there was one detection of avian influenza A(H5N1) in a human despite low uptake in eligible exposed persons. Future use of asymptomatic swabbing could help provide an evidence base to quantify asymptomatic infection, quickly identify signals of increased animal to human transmission and improve public health preparedness.

Lessons learnt from an outbreak of COVID-19 in a workplace providing an essential service, Thames Valley, England 2020: Implications for investigation and control

Objectives

Human behavioural factors are an important consideration in the response to COVID-19 outbreaks. Prior to the emergence of highly infectious variants of SARS-CoV-2 and implementation of vaccination programmes, we conducted a study to explore the role of behavioural factors influencing transmission at an essential services workplace during an outbreak of COVID-19.

Study design

Observational cohort study.

Methods

In response to a COVID-19 outbreak in November 2020 at an office-based call centre workplace providing an essential service in Thames Valley, we designed and conducted an anonymous staff questionnaire to explore potential behavioural factors of staff behaviour that influence transmission.

Results

A total of 45 staff (27%) tested positive for SARS-CoV-2 over a six-week period between 26 October and 14 December 2020. The online questionnaire was cascaded to 168 staff members; the response rate was 41%. Self-reported use of hand sanitiser, face masks and cleaning of equipment in line with workplace guidance was 86%, 66% and 63% respectively. On the same behaviours, respondents reported that 33%, 31% and 14% of their colleagues followed the recommendations. Almost two thirds of respondents (63%) reported that they were unable to maintain social distancing at the workplace, primarily due to operational constraints.

Conclusions

Prevention and control of COVID-19 outbreaks at workplaces providing an essential service is challenging. Operational requirements, often compounded by reduced staff availability, impede implementation of more robust control measures. Ongoing assessment of human behavioural factors in the control of COVID-19 outbreaks at workplaces in the post-vaccine era is essential.

Life expectancy inequalities in Wales before COVID-19: an exploration of current contributions by age and cause of death and changes between 2002 and 2018

OBJECTIVES

The COVID-19 pandemic in Wales and the UK has highlighted significant and historic inequalities in health between social groups. To better understand the composition of these inequalities and inform planning after the pandemic, we undertook a decomposition of life expectancy inequalities between the most and least deprived quintiles for men and women by age and cause of death and explored trends between 2002 and 2018.

STUDY DESIGN

Statistical decomposition of life expectancy inequalities by age and cause of death using routine population mortality datasets.

METHODS

We used routine statistics from the Office for National Statistics for the period 2002-2018 on population and deaths in Wales stratified by age, gender, Welsh Index of Multiple Deprivation (WIMD) 2019 quintile and cause of death, categorised by International Classification of Disease, version 10, code into 15 categories of public health relevance. We aggregated data to 3-year rolling figures to account for low numbers of events in some groups annually. Next, we estimated life expectancy at birth by quintile, gender and period using life table methods. Lastly, we performed a decomposition analysis using the Arriaga method to identify the specific disease categories and ages at which excess deaths occur in more disadvantaged areas to highlight potential areas for action.

RESULTS

Life expectancy inequalities between the most and least WIMD quintiles rose for both genders between 2002 and 2018: from 4.69 to 6.02 years for women (an increase of 1.33 years) and from 6.34 to 7.42 years for men (an increase of 1.08 years). Exploratory analysis of these trends suggested that the following were most influential for women: respiratory disease (1.50 years), cancers (1.36 years), circulatory disease (1.35 years) and digestive disease (0.51 years). For men, the gap was driven by circulatory disease (2.01 years), cancers (1.39 years), respiratory disease (1.25 years), digestive disease (0.79 years), drug- and alcohol-related conditions (0.54 years) and external causes (0.54 years). Contributions for women from respiratory disease, cancers, dementia and drug- and alcohol-related conditions appeared to be increasing, while among men, there were rising contributions from respiratory, digestive and circulatory disease.

CONCLUSIONS

Life expectancy inequalities in Wales remain wide and have been increasing, particularly among women, with indications of worsening trends since 2010 following the introduction of fiscal austerity. As agencies recover from the pandemic, these findings should be considered alongside any resumption of services in Wales or future health and public policy.

A phase II study of tivozanib in patients with metastatic and nonresectable soft-tissue sarcomas

Background

Soft tissue sarcomas (STSs) overexpress vascular endothelial growth factors (VEGF) and VEGF-receptors (VEGFR) activation have been associated with tumor aggressiveness. Tivozanib is a potent small molecule tyrosine kinase inhibitor against VEGFR1-3, with activity against PDGFRα/β and cKIT. The primary endpoint of this study was progression free survival (PFS) rate at 16 weeks. Secondary end points were overall survival (OS), response rate, safety and correlative studies.

Patients and methods

A Simon two-stage phase II trial was performed using tivozanib given orally at 1.5 mg daily, 3 week on 1 week off on a 28 day cycle until disease progression or intolerable toxicity.

Results

Fifty-eight patients were enrolled and treated with tivozanib. Leiomyosarcoma was the most common STS histological type in our cohort (47%) and 27 patients (46%) had received at least 3 lines of therapy prior to study entry. Up to 24 patients (41%) had prior VEGF targeted therapies. Partial response and stable disease were observed in 2 (3.6%) and 30 (54.5%) patients. The 16 week PFS rate was 36.4% [95% confidence interval (CI) 23.7-49.1] and a median PFS of 3.5 months (95% CI 1.8-3). Median OS observed was 12.2 months (95% CI 8.1-16.8). The most frequent all grade toxicities were fatigue (48.3%), hypertension (43.1%), nausea (31%) and diarrhea (27.6%). The most common grade three toxicity was hypertension (22.4%). Correlative studies demonstrate no correlation between the expression of VEGFR 1, 2 or 3, PDGFRα/β or FGF, and activity of tivozanib.

Conclusion

Tivozanib was well tolerated and showed antitumor activity with a promising median PFS and PFS rate at 4 months in a heavily pretreated population of metastatic STSs. Our results support further studies to assess the clinical efficacy of tivozanib in STS.

Clinical Trial Number

NCT01782313.

Tuberculosis in South Asian communities in the UK: a systematic review of the literature

BACKGROUND

Rates of tuberculosis (TB) in UK South Asian communities are up to 17 times higher than in white British groups. Latent infection in new migrants provides only a partial explanation. We undertook a systematic review of the literature to establish existing knowledge about TB in South Asian communities.

METHODS

We undertook a search for literature relating to TB and its management in South Asian communities in the UK. Articles initially identified were screened for relevance. A narrative review of relevant articles was then conducted.

RESULTS

We found 18 relevant articles. Associated risk factors for TB included poverty, deprivation, return visits to the Indian subcontinent, history of close contact with a case, gender, religion, possible dietary factors such as Vitamin D deficiency, duration of stay in the UK and country of birth. However, the evidence for these factors was often conflicting or weak, and suggests that commonly proposed hypotheses may not provide robust explanations for the higher rates of diagnosis.

CONCLUSIONS

Migration patterns and the demographic profile of the South Asian communities are constantly changing. Further research into the determinants of TB infection in these communities in the UK is urgently needed to inform the commissioning of TB health services.

Development and testing of models of tuberculosis contact tracing in rural southern Africa

SETTING

A regional hospital in rural Swaziland.

OBJECTIVES

To evaluate a hospital-based contact screening programme and test approaches to improve its effectiveness.

DESIGN

An evaluation and quality improvement study of tuberculosis (TB) contact tracing services.

RESULTS

Hospital-based TB contact tracing led to screening of 157 (24%) of 658 contacts; of these, 4 (2.5%) were diagnosed with TB. Of 68 contacts eligible for human immunodeficiency virus (HIV) testing and counselling, 45 (66%) were tested and 7/45 (16%) were identified as HIV-positive. Twelve (50%) of 24 screened contacts aged <5 years were provided isoniazid prophylaxis. Three enhanced models of TB contact tracing were piloted to screen contacts in the community. Although some enhanced models screened large numbers of contacts, no contacts were diagnosed with TB.

CONCLUSION

Contact tracing of household members conducted in TB clinics within hospital settings is effective in high-burden, low-income settings, and can be provided using current resources. Enhanced household contact tracing models that followed up contacts in the community were not found to be effective. Additional resources would be required to provide household TB contact tracing in the community.

Infection control in a developing world

The global HIV and tuberculosis (TB) epidemics have placed enormous burdens upon already overstretched healthcare workers and poorly resourced healthcare facilities in sub-Saharan Africa. The rapid emergence of multi-drug resistant TB, and its association with hospital-based outbreaks, have highlighted the role that healthcare facilities inadvertently may play in maintaining TB transmission, and the vital importance of attaining good TB infection control. James Elston, a specialist physician in infectious diseases and general internal medicine, who recently returned from a second stint in Swaziland, says many of the region's healthcare facilities are outdated, poorly ventilated, and were not designed for their current purpose. Here he describes how U.K.-based architects and healthcare engineers responded to an urgent call for assistance and, via close collaboration, and using novel design software, empowered healthcare workers to dramatically and rapidly improve their TB inpatient facilities, and protect the health of patients and staff.

Mental health promotion and socio-economic disadvantage: lessons from substance abuse, violence and crime prevention and child health

ISSUE ADDRESSED

Mental health promotion aimed at populations with low socio-economic status (SES) may benefit by investigating prevention strategies that effectively address related child and adolescent problems.

METHODS

Evidence from a number of literature reviews and program evaluations was synthesised. First, the impact of SES on development from childhood to adulthood is considered in light of research on substance abuse, violence, crime, and child development problems. Second, evaluations of interventions are reviewed to identify those that have shown outcomes in research studies (efficacy) or in real-world settings (effectiveness) in reducing developmental problems associated with low SES. Low SES is measured in different ways including low levels of education and/or income or definitions that combine several variables into a new indicator of low SES.

RESULTS

Factors associated with low SES are also associated to varying extent with the development of violence and crime, substance abuse and child health problems. Interventions that address underlying determinants of low SES show strong efficacy in decreasing adolescent crime and violence and effectiveness in improving child health outcomes. Although there is limited efficacy evidence that substance abuse prevention can be effectively addressed by targeting low SES, programs designed to improve educational pathways show some efficacy in reducing aspects of adolescent substance use.

CONCLUSION

Mental health promotion strategies can draw on the approaches outlined here that are associated with the prevention of child and adolescent problems within low SES communities. Alternatively, such interventions could be supported in mental health promotion policy as they may assist in preventing related problems that undermine mental health.

Molecular genetic characterisation of frontotemporal dementia on chromosome 3

We have previously localized a locus causing familial nonspecific dementia to the centromeric region of chromosome 3 in a pedigree from the Jutland area of Denmark. This pedigree shows anticipation. Here we present further analysis of these anticipation data which are suggestive of trinucleotide repeat expansion involvement. We also outline our strategies to clone the mutant gene via its putative associated trinucleotide repeat sequence.

Exploring new territory: police organizational responses to child sexual abuse

Police response to the escalating numbers of child sexual abuse cases has led to the development of a wide range of organizational models within both police departments and the interagency context. This paper compares the results of different models of police intervention in New South Wales, Australia. The data suggest that specialist police units in which police manage the full investigation provide a more comprehensive service than those where the police response is fragmented between units within the police force.

Whatever happened on the way to counselling? Hurdles in the interagency environment

A study of confirmed cases of child sexual abuse showed that only 56% of children received an appointment at a counselling agency in spite of explicit policy guidelines that children have an opportunity for counselling in the aftermath of the abuse. The study revealed that problems created at all levels within the interagency environment led to children becoming "lost" in the system and not receiving the services from which they could have benefited. Particular attention is given to changes in the broader policy and resource context which have ramifications at the local interagency level and in the services provided for sexually abused children.

Stomach cancer--is it a lost cause?

A retrospective study of 7 years of endoscopy at Trafford General Hospital from 1986-1993 identified 143 patients diagnosed as having gastric cancer, of whom 13 cases were identified as early gastric cancer. Epigastric pain was the main symptom (66%) of those presenting with resectable disease. Weight loss (70%) was the most common symptom of patients presenting with advanced disease. Forty-seven patients had no surgery and 25 had palliative non-resective surgery. These two groups account for 50% of cases. With such a small detection rate of early gastric cancer and consequent curative surgery rate one must debate whether treatment of stomach cancer in the Trust hospital of the future is a lost cause.

Theorizing about power: intersecting the ideas of Foucault with the "problem" of power in family therapy

How to theorize about power has been a controversial issue in systemic family therapy, which, in its understanding of power, has shown the legacy of Gregory Bateson's ideas in terms of its earlier censorship of the concept of power as well as in the way in which the more recent challenges continue to be framed in relation to Bateson's position. This essay examines the work of the French philosopher, Michel Foucault, and his ideas on power in relation to family therapy themes. The main aim in intersecting Foucault's ideas with the "problem" of power in family therapy is to shed a different light on the way in which family therapy has theorized about power. A strong point of connection is made between Foucault's commitment to a relational analysis of power and family therapy's commitment to recursive analysis. However, a number of major contrasts are also identified. These contrasts are used to underline the need for family therapy to abandon the restrictions of Bateson's ideas on power, and to tackle the task of developing and using a recursive understanding of power.

Writing a winning business plan

Nurse executives are key contributors to business decisions in today's cost-conscious health care arena. To make sound decisions about initiating new services or expanding existing programs, nurse executives must know how to plan and produce sophisticated business plans that win support and speak successfully for nursing.

Be your own coroner: an audit of 500 consecutive deaths in a general practice

General practitioners' medical records of a geographically defined population of about 1600-1800 have been retained since 1964. Details of care by general practitioners and hospital correspondence were available for 500 deaths (277 men, 223 women) from 1964 to 1985, including deaths at home, at work, in the street, in short term and long term institutional care, and within six months of release from institutional care. The periods 1964-73 and 1974-85 were compared. The proportion of men aged greater than or equal to 80 who died increased from 20 (14%) in 1964-73 to 22 (16%) in 1974-85, but the proportion of women aged greater than or equal to 80 who died increased from 21 (23%) to 50 (39%). Of all deaths, 223 (45%) were thought to have had avoidable causal factors, of which 132 (59%) were attributed to patients, 45 (20%) to the general practitioner, 9 (4%) to hospitals, and 37 (17%) to others. The number of deaths related to smoking decreased from 31 (43%) in men aged less than 70 to 19 (30%) but in women aged less than 70 increased from 4 (10%) to 11 (26%). The proportion of deaths in women who were already dependent six months before death increased from 55 (58%) to 81 (63%) but in men remained constant at 64 (46%) in the first period and 62 (46%) in the second. Nearly two thirds of all deaths occurred at home in both periods--about twice the proportion for England and Wales--but the proportion of men dying at home decreased from 87 (62%) to 76 (56%). A critical analysis of deaths in whole populations by primary care teams can identify changes that are needed both in the work and organisation of the team and in the behaviour of the population itself.

Synthesis and biological activity of several amino nucleoside-platinum(II) complexes

Several platinum(II) complexes of 3',5'-diamino-3',5'-dideoxythymidine (compound 1), 5'-amino-5'-deoxythymidine (compound 2), and 3'-amino-3'-deoxythymidine (compound 3) and the respective 2'-deoxyuridine amino nucleoside complexes, 4-6, have been synthesized. Whereas compounds 1, 2, and 4-6 had no inhibitory effect on the replication of murine L1210 cells in cell culture, compound 3 [(3'-AdThd)2PtCl2] inhibited these cells with an ED50 of 0.8 microM. Incubation of L1210 cells with 10-20 microM compound 3 for 2 h produced less than 18% inhibition of RNA, DNA, or protein synthesis, which is of questionable significance. However a 16-h incubation resulted in an increased uptake of labeled thymidine into DNA (77%), labeled uridine into RNA (17%), and labeled amino acids into protein (100%). These unexpected results indicate that inhibition of macromolecules may not be involved in the inhibition of the replication of L1210 cells. The increased incorporation of labeled metabolites into macromolecules may be related to the increase in cell volume after a 2-h incubation of L1210 cells with compound 3 plus a marked increase after 2 h in the proportion of cells in their S phase. Compound 3 appears to delay the progression of cells through their cell cycle. A marked inhibitory effect on the transport of methionine or aminoisobutyric acid into L1210 cells was found with compound 3, which was slightly greater than that produced with cisplatin. Compound 3 had a dose-dependent effect on the survival of mice bearing the L1210 ascites neoplasm, with a T/C X 100 of 175 at a dose of 320 mg/kg. Investigation of the kinetics of decomposition in aqueous systems demonstrated that the primary UV-absorbing decomposition product is 3'-amino-3'-deoxythymidine and that only a limited amount of the compound is formed (less than 8%). Although 3'-amino-3'-deoxythymidine could account for a part of the inhibition of the replication of L1210 cells in culture, it cannot account for the inhibition of amino acid transport by compound 3, the platinum complex of 3'-amino-3'-deoxythymidine. Compound 3 has been shown to limit part of the amino acid uptake into L1210 cells in a similar manner to cisplatin.

Jejunoileal tuberculosis: a diagnostic pitfall in Crohn's disease

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