Preventing disease and saving resources:the potential contribution of increasing breastfeeding rates in the UK

Two challenges stand out as we contemplate the future of health services in the United Kingdom. The first is the state of the public finances and therefore the pressure in real terms on health services funding. The second is the recurring and vexing problem of health inequalities. The state of health inequalities in Britain has been commented on by many, but we have seen precious little real change in the disproportionate burden of early death and illness among the most disadvantaged and indeed across the whole health gradient in recent years.This work was funded by UNICEF UK

Rituximab in autoimmune connective tissue disease–associated interstitial lung disease

Objective. CTD-associated interstitial lung disease (ILD) often fails to respond to conventional immunomodulatory agents. There is now considerable interest in the use of rituximab in systemic autoimmune CTD in patients refractory to standard treatments. The aim of this study was to review the experience of North Bristol NHS Trust managing patients with CTD-associated ILD with rituximab and explore possible associations with treatment response. Methods. We conducted a retrospective analysis of all patients who received rituximab under the Bristol CTD-ILD service, having failed to respond to other immunomodulatory treatments. Results were collated for pulmonary function and radiological outcomes before and after treatment. Results. Twenty-four patients were treated with rituximab. Their physiological parameters had failed to improve despite other immunomodulatory agents, with a mean change in forced vital capacity (FVC) prior to therapy of − 3.3% (95% CI − 5.6, −1.1) and mean change in diffusing capacity of carbon monoxide of − 4.3% (95% CI − 7.7, −0.9). After rituximab, radiology remained stable or improved for 11 patients, while worsening was observed in 9 patients. The decline in FVC was halted following treatment, with a mean change of + 4.1% (95% CI 0.9, 7.2), while diffusing capacity of carbon monoxide was stable [mean change +2.1% (95% CI − 1.0, 5.2)]. Patients with myositis overlap or antisynthetase syndrome appeared to respond well to treatment, with four patients showing clinically significant improvement in FVC >10%. Conclusion. Rituximab is a therapeutic option in treatment-refractory CTD-associated ILD. Some disease subgroups may respond better than others, however, more work is needed to define its role in managing these patients

Great Britain's Energy Vectors and Transmission Level Energy Storage

As an example of the challenges facing many developed countries, the scale of daily energy flows through Great Britain's electrical, gas and transport systems are presented. When this data is expressed graphically it illustrates important differences in the demand characteristics of these different vectors; these include the scale of energy delivered through the networks on a daily basis, and the scale of variability in the different demands over multiple timescales (seasonal, weekly and daily). The paper discusses energy storage in general; the scale of within day stores of energy available to the gas and electrical transmission networks, and suggests Synthetic Natural Gas as an interesting energy carrier that could use existing natural gas infrastructure

Developing a sustainable route to environmentally relevant metal-organic frameworks: ultra-rapid synthesis of MFM-300(Al) using microwave heating

NO2, SO2 and CO2 are major air pollutants causing significant environmental and health problems. Metal-organic frameworks (MOFs), in particular [Al2(OH)2(C16O8H6)](H2O)6 (trivial names: NOTT-300/MFM-300(Al)), have shown great promise for capturing these gases. However MOF syntheses often involve toxic solvents and long durations which are inherently energy intensive, an environmental burden, and have serious safety risks. There is a pressing need to develop environmentally-friendly routes to MOFs that require less energy and implement safer solvents particularly when considering scale-up beyond the laboratory for industrial application. We report the rapid synthesis of MFM-300(Al) in aqueous conditions and 10 minutes using microwave heating. This is the fastest reported synthesis of MFM-300(Al) to date with a 99.77 % reduction in reaction time compared to the current reported 3-day conventional heated route. The microwave synthesized sub-micron crystalline material exhibits gas uptake capacities of 8.8 mmol g-1 at 273 K and 1.0 bar for CO2, 8.5 mmol g-1 at 298 K and 0.17 bar for SO2, and 1.9 mmol g-1 at 298 K and 0.01 bar for NO2. These are 26 %, 70 %, and 90 % greater for CO2, SO2, and NO2, respectively, when compared to previously reported MFM-300(Al) materials produced via a 3-day conventionally heated route demonstrating the production of high quality materials at a fraction of the time with enhanced gas properties. Crucially, this offers an opportunity to move from batch to continuous processing owing to reduced reaction times underpinned by targeted heating

Initial Characterization of Micafungin Pulmonary Delivery via Two Different Nebulizers and Multivariate Data Analysis of Aerosol Mass Distribution Profiles

Pharmaceutical aerosols have been targeted to the lungs for the treatment of asthma and pulmonary infectious diseases successfully. Micafungin (Astellas Pharma US, Deerfield, IL, USA) has been shown to be an effective antifungal agent when administrated intravenously. Pulmonary delivery of micafungin has not previously been reported. In the present pilot study, we characterize the performance of two nebulizers and their potential for delivering micafungin to the lungs as well as the use of multivariate data analysis for mass distribution profile comparison. The concentration of micafungin sodium increased by 21% when delivered by the Acorn II nebulizer and by 20% when delivered by the LC Plus nebulizer, respectively, from the first to the second sampling period. The Acorn II nebulizer delivered a fine particle fraction FPF(5.8) (%<5.8 microm) of 92.5 +/- 0.8 and FPF(3.3) (%<3.3 microm) of 82.3 +/- 2.1 during the first sampling period. For the LC Plus nebulizer, FPF(5.8) was 92.3 +/- 0.1 and FPF(3.3) was 67.0 +/- 0.7 during the first sampling period. The mass median aerodynamic diameter (MMAD) increased from 1.67 +/- 0.05 to 1.77 +/- 0.04 mum (Acorn II nebulizer) and from 2.09 +/- 0.01 to 2.20 +/- 0.01 microm (Pari LC Plus nebulizer) from the first to the second sampling periods. These changes in MMAD were statistically significant by paired t test. Multivariate data analysis showed that this could be explained systematically by greater drug deposition on stages with larger cutoff sizes and reduced drug deposition on stages with smaller cutoff sizes rather than multimodal deposition or other anomalies in size distribution

Threats to North American Forests from Southern Pine Beetle with Warming Winters

In coming decades, warmer winters are likely to lift range constraints on many cold-limited forest insects. Recent unprecedented expansion of the southern pine beetle (SPB, Dendroctonus frontalis) into New Jersey, New York, Connecticut, and Massachusetts in concert with warming annual temperature minima highlights the risk that this insect pest poses to the pine forests of the northern United States and Canada under continued climate change. Here we present the first projections of northward expansion in SPB-suitable climates using a statistical bioclimatic range modeling approach and current-generation general circulation model (GCM) output under the RCP 4.5 and 8.5 emissions scenarios. Our results show that by the middle of the 21st century, the climate is likely to be suitable for SPB expansion into vast areas of previously unaffected forests throughout the northeastern United States and into southeastern Canada. This scenario would pose a significant economic and ecological risk to the affected regions, including disruption oflocal ecosystem services, dramatic shifts in forest structure, and threats to native biodiversity

Significant regional differences in antibiotic use across 576 US hospitals and 11 701 326 adult admissions, 2016-2017

BACKGROUND: Quantifying the amount and diversity of antibiotic use in United States hospitals assists antibiotic stewardship efforts but is hampered by limited national surveillance. Our study aimed to address this knowledge gap by examining adult antibiotic use across 576 hospitals and nearly 12 million encounters in 2016-2017. METHODS: We conducted a retrospective study of patients aged ≥ 18 years discharged from hospitals in the Premier Healthcare Database between 1 January 2016 and 31 December 2017. Using daily antibiotic charge data, we mapped antibiotics to mutually exclusive classes and to spectrum of activity categories. We evaluated relationships between facility and case-mix characteristics and antibiotic use in negative binomial regression models. RESULTS: The study included 11 701 326 admissions, totaling 64 064 632 patient-days, across 576 hospitals. Overall, patients received antibiotics in 65% of hospitalizations, at a crude rate of 870 days of therapy (DOT) per 1000 patient-days. By class, use was highest among β-lactam/β-lactamase inhibitor combinations, third- and fourth-generation cephalosporins, and glycopeptides. Teaching hospitals averaged lower rates of total antibiotic use than nonteaching hospitals (834 vs 957 DOT per 1000 patient-days; P \u3c .001). In adjusted models, teaching hospitals remained associated with lower use of third- and fourth-generation cephalosporins and antipseudomonal agents (adjusted incidence rate ratio [95% confidence interval], 0.92 [.86-.97] and 0.91 [.85-.98], respectively). Significant regional differences in total and class-specific antibiotic use also persisted in adjusted models. CONCLUSIONS: Adult inpatient antibiotic use remains high, driven predominantly by broad-spectrum agents. Better understanding reasons for interhospital usage differences, including by region and teaching status, may inform efforts to reduce inappropriate antibiotic prescribing

Electronically available patient claims data improve models for comparing antibiotic use across hospitals: Results from 576 US facilities

BACKGROUND: The Centers for Disease Control and Prevention (CDC) uses standardized antimicrobial administration ratios (SAARs)-that is, observed-to-predicted ratios-to compare antibiotic use across facilities. CDC models adjust for facility characteristics when predicting antibiotic use but do not include patient diagnoses and comorbidities that may also affect utilization. This study aimed to identify comorbidities causally related to appropriate antibiotic use and to compare models that include these comorbidities and other patient-level claims variables to a facility model for risk-adjusting inpatient antibiotic utilization. METHODS: The study included adults discharged from Premier Database hospitals in 2016-2017. For each admission, we extracted facility, claims, and antibiotic data. We evaluated 7 models to predict an admission\u27s antibiotic days of therapy (DOTs): a CDC facility model, models that added patient clinical constructs in varying layers of complexity, and an external validation of a published patient-variable model. We calculated hospital-specific SAARs to quantify effects on hospital rankings. Separately, we used Delphi Consensus methodology to identify Elixhauser comorbidities associated with appropriate antibiotic use. RESULTS: The study included 11 701 326 admissions across 576 hospitals. Compared to a CDC-facility model, a model that added Delphi-selected comorbidities and a bacterial infection indicator was more accurate for all antibiotic outcomes. For total antibiotic use, it was 24% more accurate (respective mean absolute errors: 3.11 vs 2.35 DOTs), resulting in 31-33% more hospitals moving into bottom or top usage quartiles postadjustment. CONCLUSIONS: Adding electronically available patient claims data to facility models consistently improved antibiotic utilization predictions and yielded substantial movement in hospitals\u27 utilization rankings

First evidence for zooplankton feeding sustaining key physiological processes in a scleractinian cold-water coral

Scleractinian cold-water corals (CWC) represent key taxa controlling deep-sea reef ecosystem functioning by providing structurally complex habitats to a high associated biodiversity, and by fuelling biogeochemical cycles via the release of organic matter. Nevertheless, our current knowledge on basic CWC properties, such as feeding ecology and key physiological processes (i.e. respiration, calcification and organic matter release), is still very limited. Here, we show evidence for the trophic significance of zooplankton, essentially sustaining levels of the investigated key physiological processes in the cosmopolitan CWC Desmophyllum dianthus (Esper 1794). Our results from laboratory studies reveal that withdrawal (for up to 3 weeks) of zooplankton food (i.e. Artemia salina) caused a significant decline in respiration (51%) and calcification (69%) rates compared with zooplankton-fed specimens. Likewise, organic matter release, in terms of total organic carbon (TOC), decreased significantly and eventually indicated TOC net uptake after prolonged zooplankton exclusion. In fed corals, zooplankton provided 1.6 times the daily metabolic C demand, while TOC release represented 7% of zooplankton-derived organic C. These findings highlight zooplankton as a nutritional source for D. dianthus, importantly sustaining respiratory metabolism, growth and organic matter release, with further implications for the role of CWC as deep-sea reef ecosystem engineersPublicado