What do we really know about infants who attend Accident and Emergency departments?

Aims: Accident and Emergency attendances continue to rise. Infants are disproportionately represented. This study examines the clinical reasons infants attend UK Accident and Emergency departments. Methods: A retrospective review of 6,667 infants aged less than one year attending Accident and Emergency at two district general hospitals in London from 1st April 2009 to 30th March 2010. All infants had been assigned to a diagnostic category by the medical coding department according to National Health Service (NHS) data guidelines, based on the clinical diagnoses stated in the medical records. The Accident and Emergency case notes of a random subsample of 10% of infants in each of the top five recorded diagnostic categories (n = 535) were reviewed in detail and audited against the standard national NHS data set. Results: The top 5 clinical diagnoses were ‘infectious diseases’, ‘gastrointestinal’, ‘respiratory’, ‘unclassifiable’ and ‘no abnormality detected’ (NAD). A third of infants were originally given a diagnosis of unclassifiable (21.5%) or NAD (11.5%). After detailed case-note review, we were able to reduce this to 9.7% (95% confidence interval (CI): 9.0, 10.4) and 8.8% (95% CI: 8.1, 9.5), respectively. Conclusion: This study demonstrates the importance of providing a clear clinical diagnosis and coding system for Accident and Emergency attendances and understanding that system fully. This would allow for better informed health service evaluation, planning and research as each of these relies on the interpretation of routine health-care data. Furthermore, the relatively high proportion (10%) of infants attending with no discernible underlying medical abnormality suggests the health needs of a significant proportion of infants attending Accident and Emergency departments may be better addressed by alternative service provision and/or improved education and support to parents

Evaluation of 'TRY': an algorithm for neonatal continuous positive airways pressure in low-income settings

BACKGROUND: Non-invasive respiratory support using bubble continuous positive airway pressure (bCPAP) is useful in treating babies with respiratory distress syndrome. Despite its proven clinical and cost-effectiveness, implementation is hampered by the inappropriate administration of bCPAP in low-resource settings. A clinical algorithm-'TRY' (based on Tone: good; Respiratory distress; Yes, heart rate above 100 beats/min)-has been developed to correctly identify which newborns would benefit most from bCPAP in a teaching hospital in Malawi. OBJECTIVE: To evaluate the reliability, sensitivity and specificity of TRY when employed by nurses in a Malawian district hospital. METHODS: Nursing staff in a Malawian district hospital baby unit were asked, over a 2-month period, to complete TRY assessments for every newly admitted baby with the following inclusion criteria: clinical evidence of respiratory distress and/or birth weight less than 1.3 kg. A visiting paediatrician, blinded to nurses' assessments, concurrently assessed each baby, providing both a TRY assessment and a clinical decision regarding the need for CPAP administration. Inter-rater reliability was calculated comparing nursing and paediatrician TRY assessment outcomes. Sensitivity and specificity were estimated comparing nurse TRY assessments against the paediatrician's clinical decision. RESULTS: Two hundred and eighty-seven infants were admitted during the study period; 145 (51%) of these met the inclusion criteria, and of these 57 (39%) received joint assessments. The inter-rater reliability was high (kappa 0.822). Sensitivity and specificity were 92% and 96%, respectively. CONCLUSIONS: District hospital nurses, using the TRY-CPAP algorithm, reliably identified babies that might benefit from bCPAP and thus improved its effective implementation

Health outcomes in international migrant children: protocol for a systematic review

INTRODUCTION: Migration status is a key determinant of health, but health outcomes among migrant children and young people (CYP), that is, those aged under 18 years, are poorly understood. A 'healthy migrant' effect has been demonstrated among adults, but evidence for the same effect in CYP is lacking. No large studies or reviews exist reporting comprehensive or holistic health outcomes among migrant CYP. We aim to identify and synthesise original quantitative research on health of migrant CYP to explore the relations between migration status and health outcomes. METHODS AND ANALYSIS: A search of PubMed/Medline, Embase, Cochrane and grey literature sites will be undertaken for any original quantitative research on health outcomes of migrant CYP from 01 January 2000 onwards. Outcomes addressed: mortality, communicable diseases, non-communicable diseases, nutritional status, mental health, disability, vaccine coverage, and accidental and non-accidental injuries (including assault and abuse). Search results will be screened and presented in a Preferred Reporting Items for Systematic Reviews and Meta-Analyses flow diagram.The Newcastle-Ottawa Scale assessment tool will be used to assess study quality. If feasible, depending on study availability data heterogeneity (explored using I2 statistic), results will be pooled for meta-analysis. If sufficient data are available, a priori defined subgroup analyses will be undertaken. A narrative quantitative synthesis will be presented, taking account of study quality and assessed risk of bias.The anticipated search completion date is 01 June 2021 with write-up completed by 01 April 2022. ETHICS AND DISSEMINATION: Formal ethical approval will not be sought as we will be accessing data already in the public domain. This review will be submitted for publication in a high-impact journal and presented at international conferences. The results of this work will be shared with groups of migrant children as part of an ongoing engagement project. PROSPERO REGISTRATION NUMBER: CRD42020166305

Distributed Time-Memory Tradeoff Attacks on Ciphers (with Application to Stream Ciphers and Counter Mode)

In this paper, we consider the implications of parallelizing time-memory tradeoff attacks using a large number of distributed processors. It is shown that Hellman’s original tradeoff method and the Biryukov-Shamir attack on stream ciphers, which incorporates data into the tradeoff, can be effectively distributed to reduce both time and memory, while other approaches are less advantaged in a distributed approach. Distributed tradeoff attacks are specifically discussed as applied to stream ciphers and the counter mode operation of block ciphers, where their feasibility is considered in relation to distributed exhaustive key search. In particular, for counter mode with an unpredictable initial count, we show that distributed tradeoff attacks are applicable, but can be made infeasible if the entropy of the initial count is at least as large as the key. In general, the analyses of this paper illustrate the effectiveness of a distributed tradeoff approach and show that, when enough processors are involved in the attack, it is possible some systems, such as lightweight cipher implementations, may be practically susceptible to attack

Insulin-induced gene expression changes in breast cancer cells and normal breast epithelial cells.

Obesity increases breast cancer incidence rates in postmenopausal women. Chronic high levels of insulin, present in the majority of obese and insulin resistant patients, may provide the growth promoting stimulus to explain this connection. In this work, the cancer progression and cancer initiating properties of high insulin levels were examined in breast cancer cells (MDA-MB-231) and breast epithelial cells (MCF-10a), respectively. High insulin levels (100 nM) induced differential changes in cell proliferation in the two cell lines used. Human Cancer PathwayFinder DNA Microarrays (SABiosciences) were used to examine gene expression changes after insulin treatment. High insulin levels increased expression of genes involved in cell cycle control (e.g. cyclin D1) and DNA damage repair (e.g. ATM) in MDA-MB 231 cells and in MCF-10a cells (e.g. cyclin E1, CDC25a). Expression of genes responsible for mediating apoptosis and cell senescence (e.g. APAF, BAD, bcl-X) was decreased after insulin treatment in MDA-MB 231 cells but the expression of the same group of genes did not change in MCF-10a cells. High insulin levels increased expression of genes encoding for signal transduction molecules (e.g. AKT1) and transcription factors (e.g. FOS, JUN, MYC), and of genes responsible for invasion and metastasis (e.g. MMP2) in MCF-10a cells whereas gene expression of the same groups of genes did not change or was decreased in MDA-MB 231 cells. These results suggest a role for insulin resistance in breast cancer initiation and progression, aggravating the potential of breast cancer to evade apoptosis, to metastasise and may promote carcinogenesis of healthy epithelial cells

Validity of self-reported versus actual age in Nepali children and young people

• Self-reported age is a potential source of misclassification bias in International Surveys. • We compare objectively recorded age with self-reported age at mean age 11.5 years in 3943 children in rural Nepal. • There was high agreement between actual and self-reported age with an error rate of 7%