Bacterial Causes of Empyema in Children, Australia, 2007–2009

Most infections were caused by non–7-valent pneumococcal conjugate vaccine serotypes

New genetic loci link adipose and insulin biology to body fat distribution.

Body fat distribution is a heritable trait and a well-established predictor of adverse metabolic outcomes, independent of overall adiposity. To increase our understanding of the genetic basis of body fat distribution and its molecular links to cardiometabolic traits, here we conduct genome-wide association meta-analyses of traits related to waist and hip circumferences in up to 224,459 individuals. We identify 49 loci (33 new) associated with waist-to-hip ratio adjusted for body mass index (BMI), and an additional 19 loci newly associated with related waist and hip circumference measures (P < 5 × 10(-8)). In total, 20 of the 49 waist-to-hip ratio adjusted for BMI loci show significant sexual dimorphism, 19 of which display a stronger effect in women. The identified loci were enriched for genes expressed in adipose tissue and for putative regulatory elements in adipocytes. Pathway analyses implicated adipogenesis, angiogenesis, transcriptional regulation and insulin resistance as processes affecting fat distribution, providing insight into potential pathophysiological mechanisms

Effect of angiotensin-converting enzyme inhibitor and angiotensin receptor blocker initiation on organ support-free days in patients hospitalized with COVID-19

IMPORTANCE Overactivation of the renin-angiotensin system (RAS) may contribute to poor clinical outcomes in patients with COVID-19. Objective To determine whether angiotensin-converting enzyme (ACE) inhibitor or angiotensin receptor blocker (ARB) initiation improves outcomes in patients hospitalized for COVID-19. DESIGN, SETTING, AND PARTICIPANTS In an ongoing, adaptive platform randomized clinical trial, 721 critically ill and 58 non–critically ill hospitalized adults were randomized to receive an RAS inhibitor or control between March 16, 2021, and February 25, 2022, at 69 sites in 7 countries (final follow-up on June 1, 2022). INTERVENTIONS Patients were randomized to receive open-label initiation of an ACE inhibitor (n = 257), ARB (n = 248), ARB in combination with DMX-200 (a chemokine receptor-2 inhibitor; n = 10), or no RAS inhibitor (control; n = 264) for up to 10 days. MAIN OUTCOMES AND MEASURES The primary outcome was organ support–free days, a composite of hospital survival and days alive without cardiovascular or respiratory organ support through 21 days. The primary analysis was a bayesian cumulative logistic model. Odds ratios (ORs) greater than 1 represent improved outcomes. RESULTS On February 25, 2022, enrollment was discontinued due to safety concerns. Among 679 critically ill patients with available primary outcome data, the median age was 56 years and 239 participants (35.2%) were women. Median (IQR) organ support–free days among critically ill patients was 10 (–1 to 16) in the ACE inhibitor group (n = 231), 8 (–1 to 17) in the ARB group (n = 217), and 12 (0 to 17) in the control group (n = 231) (median adjusted odds ratios of 0.77 [95% bayesian credible interval, 0.58-1.06] for improvement for ACE inhibitor and 0.76 [95% credible interval, 0.56-1.05] for ARB compared with control). The posterior probabilities that ACE inhibitors and ARBs worsened organ support–free days compared with control were 94.9% and 95.4%, respectively. Hospital survival occurred in 166 of 231 critically ill participants (71.9%) in the ACE inhibitor group, 152 of 217 (70.0%) in the ARB group, and 182 of 231 (78.8%) in the control group (posterior probabilities that ACE inhibitor and ARB worsened hospital survival compared with control were 95.3% and 98.1%, respectively). CONCLUSIONS AND RELEVANCE In this trial, among critically ill adults with COVID-19, initiation of an ACE inhibitor or ARB did not improve, and likely worsened, clinical outcomes. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT0273570

The experiences of midwives when caring for obese women in labour, a qualitative study

Backgroundmaternal obesity is a significant public health challenge for maternity services, especially those in developed countries. Obesity presents an increased risk of mortality and morbidity during the childbearing continuum.Caring for the obese woman in labour is challenging for midwives and there is a dearth of qualitative research which examines their experiences.Objectivesto explore the experiences of midwives caring for obese women in labour.Designa qualitative, phenomenological approach was used to enable in-depth exploration of midwives' experiences.Settingone maternity centre in the North of England.Participantsa purposive sampling approach was used.Eleven midwives who had experience of caring for obese women in labour were interviewed using in depth, digitally recorded semi-structured interviews for data collection.Methodsinterpretative Phenomenological Analysis was performed, and underlying themes emerged from the data resulting in an exhaustive description of midwives' experiences of caring for obese women in labour.Findingsthe heart sinking phenomena when caring for obese women in labour emerged from the data from these midwives. Midwives were faced with a constant challenge to promote normality during childbearing in a medicalised environment. Mobilisation of the obese woman was a significant factor for midwives who were striving for normality for the woman. A sense of loss of control and helplessness underlying their care provision was apparent. Perceptions of obesity differed, with confusion between embarrassment and empathy emerging. Difficulties of how and when is the best opportunity to address obesity with the women arose. Different provisions of care amongst midwives were discussed.Key conclusionsthe findings suggest that midwives have different levels of understanding of the complexities associated with the condition. There was a sense of frustration at the ‘loss’ of normality for this group of women. Different provisions of care emerged with the need for more explicit guidelines to guide and support midwives. Communication and education were identified as key concepts when addressing the increasing prevalence of obesity

Integrative medicine in general practice in Australia : a mixed-methods study exploring education pathways and training needs

Background: Globally, a substantial proportion of general practitioners (GPs) incorporate integrative medicine (IM) into their clinical practice. Objective: This study aimed to map the IM education and training pathways and needs of a cohort of Australian GPs who are members of the Royal Australian College of General Practitioners’ IM Specific Interest Network, which is a group of GPs with interest in IM. Methods: We conducted a mixed-methods study comprising of an online, cross-sectional survey supplemented with in-depth semi-structured interviews. Data from the survey and interviews were initially analysed separately and then combined. Results: Eighty-three (83) of 505 eligible GPs/GPs in training (16.4%) participated in the survey, and 15 GPs were interviewed. Results from the two datasets either converged or were complementary. Almost half (47%) of survey respondents had undertaken formal undergraduate or postgraduate IM education, a short course (63%), informal education (71%) or self-education (54%), in at least one of 20 IM modalities listed. Interviewees affirmed there was no single education pathway in IM. Survey respondents who identified as practicing IM were significantly more likely to have IM education, positive attitudes towards IM, particularly natural products, and higher self-rated IM knowledge and competencies. However, knowledge gaps were identified in professional skills domains of population health and context, and organisational and legal dimensions of applied IM practice. Interviewees also highlighted a range of professional and systemic barriers to the practice of IM, education, and training. There was broad support for recognition of IM as a sub-specialty through formalised postgraduate training and accreditation. Most survey respondents (62%) expressed interest in post-fellowship recognition of GPs with advanced skills in IM. Conclusion: Our findings demonstrate that it is important to define best practice in IM for GPs in Australia and provide a standardised pathway towards recognition of advanced skills in IM

Mental illness in Australian immigration detention centres

[Extract] The Detention Health Advisory Group (DeHAG) applauds Patrick McGorry's statements about the risks associated with Australian immigration detention, outlined in your Feb 6 Editorial (p 434).1 The quoted study from the University of Wollongong2 examined the health of individuals within Australian detention centres; not surprisingly it showed that lengthy detention is associated with negative mental health consequences

Mental illness in Australian immigration detention centres

[Extract] The Detention Health Advisory Group (DeHAG) applauds Patrick McGorry's statements about the risks associated with Australian immigration detention, outlined in your Feb 6 Editorial (p 434).1 The quoted study from the University of Wollongong2 examined the health of individuals within Australian detention centres; not surprisingly it showed that lengthy detention is associated with negative mental health consequences

Comparison of Bolus Dosing of Methohexital and Propofol in Elective Direct Current Cardioversion

Background Methohexital and propofol can both be used as sedation for direct current cardioversion (DCCV). However, there are limited data comparing these medications in this setting. We hypothesized that patients receiving methohexital for elective DCCV would be sedated more quickly, recover from sedation faster, and experience less adverse effects. Methods and Results This was a prospective, blinded randomized controlled trial conducted at a single academic medical center. Eligible participants were randomly assigned to receive either methohexital (0.5 mg/kg) or propofol (0.8 mg/kg) as a bolus for elective DCCV. The times from bolus of the medication to achieving a Ramsay Sedation Scale score of 5 to 6, first shock, eyes opening on command, and when the patient could state their age and name were obtained. The need for additional medication dosing, airway intervention, vital signs, and medication side effects were also recorded. Seventy patients who were randomized to receive methohexital (n=37) or propofol (n=33) were included for analysis. The average doses of methohexital and propofol were 0.51 mg/kg and 0.84 mg/kg, respectively. There were no significant differences between methohexital and propofol in the time from end of injection to loss of conscious (1.4±1.8 versus 1.1±0.5 minutes; P=0.33) or the time to first shock (1.7±1.9 versus 1.4±0.5 minutes; P=0.31). Time intervals were significantly lower for methohexital compared with propofol in the time to eyes opening on command (5.1±2.5 versus 7.8±3.7 minutes; P=0.0005) as well as at the time to the ability to answer simple questions of age and name (6.0±2.6 versus 8.6±4.0 minutes; P=0.001). The methohexital group experienced less hypotension (8.1% versus 42.4%; P<0.001) and less hypoxemia (0.0% versus 15.2%; P=0.005), had lower need for jaw thrust/chin lift (16.2% versus 42.4%; P=0.015), and had less pain on injection compared with propofol using the visual analog scale (7.2±9.7 versus 22.4±28.1; P=0.003). Conclusions In this model of fixed bolus dosing, methohexital was associated with faster recovery, more stable hemodynamics, and less hypoxemia after elective DCCV compared with propofol. It can be considered as a preferred agent for sedation for DCCV. Registration URL: https://www.clinicaltrials.gov/ct; Unique identifier: NCT04187196