Exploring the existence, strength, and independence of relative age and maturation selection biases: a case study in Gaelic football talent development programmes.

BACKGROUND: Biological maturity and relative age player selection biases are well documented in youth sports. However, there has been limited examination of the relationship between these biases. AIM: This study investigated the presence, strength, and independence of relative age and biological maturity selection biases in Gaelic football. SUBJECTS AND METHODS: A total of 247 male players from U14 to U16, from two talent academies were assessed for relative age (decimal age (DA)) and biological maturity (discrepancy between biological and chronological age (BA-CA)). RESULTS: Relative age effects (RAE) were observed in the U14 (DA = 0.62, d = 0.40) and U15 squads (DA = 0.57. d = 0.26) only. A bias towards advanced maturity status was present at U14 (BA-CA = 0.60, d = 0.83), U15 (BA-CA = 0.78, d = 0.89), and U16 (BA-CA, d = 1.01). There was a trivial (U14, r(83) = -0.210; U15, r(88) = 0.060) and low (U16, r(76) = 0.352) correlation between relative age and maturity status. CONCLUSION: Substantial maturity selection biases and, to a lesser degree, relative age biases are evident in youth Gaelic football. Critically, these biases are independent constructs. Coaches and policy makers should be educated on the distinct influences of relative age and maturation, and on strategies to address these biases.

Barriers and facilitators to infection prevention and control in a neonatal unit in Zimbabwe - a theory-driven qualitative study to inform design of a behaviour change intervention.

BACKGROUND: Hospital-acquired infection (HAI) is an increasing cause of neonatal morbidity/mortality in low-income settings. Hospital staff behaviours (e.g., hand hygiene) are key contributors to HAI. Understanding the drivers of these can inform interventions to improve infection prevention and control (IPC). AIM: To explore barriers/facilitators to IPC in a neonatal unit in Harare, Zimbabwe. METHODS: Interviews were conducted with 15 staff members of neonatal and maternity units alongside ethnographic observations. The interview guide and data analysis were informed by the COM-B (Capability, Opportunity, Motivation-Behaviour) model and explored individual, socio-cultural, and organizational barriers/facilitators to IPC. Potential interventions were identified using the Behaviour-Change Wheel. FINDINGS: Enablers within Capability included awareness of IPC, and within Motivation beliefs that IPC was crucial to one's role, and concerns about consequences of poor IPC. Staff were optimistic that IPC could improve, contingent upon resource availability (Opportunity). Barriers included: limited knowledge of guidelines, no formal feedback on performance (Capability), lack of resources (Opportunity), often leading to improvization and poor habit formation. Further barriers included the unit's hierarchy, e.g., low engagement of cleaners and mothers in IPC, and staff witnessing implementation of poor practices by other team members (Opportunity). Potential interventions could include role-modelling, engaging mothers and staff across cadres, audit and feedback and flexible protocols (adaptable to water/handrub availability). CONCLUSIONS: Most barriers to IPC fell within Opportunity, whilst most enablers fell under Capability and Motivation. Theory-based investigation provides the basis for systematically identifying and developing interventions to address barriers and enablers to IPC in low-income settings.

Auditing use of antibiotics in Zimbabwean neonates.

BACKGROUND: Neonatal sepsis is a major cause of morbidity and mortality in low-income settings. As signs of sepsis are non-specific and deterioration precipitous, antibiotics are often used profusely in these settings where diagnostics may not be readily available. Harare Central Hospital, Zimbabwe, delivers 12000 babies per annum admitting ∼4800 to the neonatal unit. Overcrowding, understaffing and rapid staff turnover are consistent problems. Suspected sepsis is highly prevalent, and antibiotics widely used. We audited the impact of training and benchmarking intervention on rationalizing antibiotic prescription using local, World Health Organization-derived, guidelines as the standard. METHODS: An initial audit of admission diagnosis and antibiotic use was performed between 8th May - 6th June 2018 as per the audit cycle. An intern training programme, focusing on antimicrobial stewardship and differentiating between babies 'at risk of' versus 'with' clinically-suspected sepsis was instituted post-primary audit. Re-audit was conducted after 5 months. RESULTS: Sepsis was the most common admitting diagnosis by interns at both time points but reduced at repeat audit (81% versus 59%, P<0.0001). Re-audit after 5 months demonstrated a decrease in antibiotic prescribing at admission and discharge. Babies prescribed antibiotics at admission decreased from 449 (98%) to 96 (51%), P<0.0001. Inpatient days of therapy (DOT) reduced from 1243 to 1110/1000 patient-days. Oral amoxicillin prescription at discharge reduced from 349/354 (99%) to 1% 1/161 (P<0.0001). CONCLUSION: A substantial decrease in antibiotic use was achieved by performance feedback, training and leadership, although ongoing performance review will be key to ensuring safety and sustainability.

Risk in the "Red Zone": Outcomes for Children Admitted to Ebola Holding Units in Sierra Leone Without Ebola Virus Disease.

We collected data on 1054 children admitted to Ebola Holding Units in Sierra Leone and describe outcomes of 697/1054 children testing negative for Ebola virus disease (EVD) and accompanying caregivers. Case-fatality was 9%; 3/630 (0.5%) children discharged testing negative were readmitted EVD-positive. Nosocomial EVD transmission risk may be lower than feared.

Term and preterm labour are associated with distinct microbial community structures in placental membranes which are independent of mode of delivery.

Infection is considered a possible trigger for preterm labour, supported by evidence showing the presence of bacteria in the placenta and placental membranes from preterm births. In this study, 16S rDNA pyrosequencing was used to identify bacteria in placental membranes. Caesarean sections and vaginal deliveries at term were found to harbour common genera. Mycoplasma hominis, Aerococcus christensenii, Gardnerella vaginalis and Fusobacterium nucleatum were either only present in preterm membranes or in greater abundance than at term. These data support previous studies that used either targeted qPCR or broad-range 16S rDNA PCR and cloning but not a recent microbiome analysis of placental tissue using high-throughput sequencing.

Psychopharmacologic treatment of adolescent depression.

Child and adolescent depression is one of the greatest health concerns in our society today. This article critically reviews the literature on the psychopharmacologic treatment of adolescent depression. Although double-blind studies have failed to show the efficacy of tricyclic antidepressants, more recent evidence has emerged for the use of selective serotonin reuptake inhibitors in this population. However, placebo-controlled, double-blind studies are limited, and many of the other newer antidepressants have yet to be investigated in treating adolescent depression. Nonetheless, antidepressants are widely prescribed to these populations, and psychiatric nurses are actively involved in assessing and monitoring the need for these medications in adolescents.

Chest pain and the treatment of psychosocial/emotional distress in CAD patients.

Treatment of psychosocial/emotional distress as a strategy for diminishing chest pain in such patients remains entirely unutilized in standard care. Sixty-three patients with known or suspected CAD were entered in an aggressive lifestyle modification program. Patients completed the Symptom Checklist 90-Revised (SCL90R) at the diagnostic interview session, at 3 and at 12 months. Statistically significant drops were observed on multiple scales of the SCL90R at both 3 and 12 months. An item from the SCL90R was used as a proxy for angina. Multiple measures of emotional distress at baseline were found to correlate with chest pain at baseline, but not a number of traditional cardiovascular risk factors. The chest pain item displayed improvement at both 3 and 12 months. Improvement on all scales of the SCL90R correlated with improvement in chest pain. It may be possible to control chest pain in some CAD patients with psychosocial interventions.

Continuous positive airway pressure improves nocturnal baroreflex sensitivity of patients with heart failure and obstructive sleep apnea.

OBJECTIVES: To determine the acute effects of continuous positive airway pressure (CPAP) on baroreceptor reflex sensitivity (BRS) for heart rate during sleep in congestive heart failure (CHF) patients with obstructive sleep apnea (OSA). DESIGN AND METHODS: In eight CHF patients with OSA not previously treated with CPAP, spontaneous BRS was assessed during overnight polysomnography prior to the onset of sleep, and during stage 2 non-rapid eye movement sleep (NREM) before, during and after application of CPAP. RESULTS: CPAP alleviated OSA and acutely increased the slope of BRS (median, 25%,75%) [from 3.9 (3.5, 4.8) to 6.2 (4.6, 26.2) ms/mmHg, P<0.05]. Increases in the slope of BRS persisted following withdrawal of CPAP [4.9 (4.3, 6.9) ms/mmHg, P<0.05]. CPAP also lowered heart rate (from 81.3 +/- 4.9 to 76.0 +/- 5.7 bpm, P< 0.05), an effect which persisted after its withdrawal (76.7 +/- 5.7 bpm, P < 0.05). Systolic blood pressure at the midpoint of the pressure range of BRS sequences fell while on CPAP (from 139 +/- 8 to 120 +/- 7 mmHg, P < 0.05), and remained lower following CPAP withdrawal (124 +/- 9 mmHg, P < 0.05). CONCLUSIONS: In CHF patients with OSA, CPAP increases acutely BRS during sleep, lowers heart rate and resets the operating point for BRS to a lower blood pressure. These effects of CPAP persist after its withdrawal, suggesting that nocturnal CPAP therapy may cause sustained improvement in the neural control of heart rate.

Pathophysiological interactions of ventilation, arousals, and blood pressure oscillations during cheyne-stokes respiration in patients with heart failure.

Arousals from sleep can be associated with increases in blood pressure (BP). However, it is uncertain whether this is due to a direct effect of arousals on BP, or is secondary to respiratory stimuli present at the time of the arousal. Cheyne-Stokes respiration (CSR) in patients with congestive heart failure (CHF) provides unique conditions that may allow these two possibilities to be distinguished. In CSR, the apnea-hyperpnea cycle can be dissociated from arousals because when CSR occurs during wakefulness, it does so in the absence of arousals, and when it occurs during sleep, arousals occur either at the termination of apnea (early arousals) or several breaths after the onset of hyperpnea (late arousals). We therefore measured BP during wakefulness and non-rapid eye movement (NREM) sleep in eight patients with CHF and CSR. During wakefulness, CSR was associated with wide fluctuations in systolic BP (mean +/- SD, 11.3 +/- 6.0 mm Hg) synchronous with the apnea-hyperpnea cycle, in the absence of arousals. Similar fluctuations in BP were observed during CSR with early arousals (13. 7 +/- 7.0 mm Hg) in NREM sleep. However, late arousals during CSR were associated with a small, but significant additional effect on systolic BP (14.2 +/- 7.1 mm Hg, p < 0.05). Furthermore, the degree of BP increase following arousals was directly related to the associated increase in ventilation (r = 0.70, p < 0.05). We conclude that BP fluctuations during CSR in patients with CHF are primarily related to oscillations in ventilation during the CSR cycle and can occur in the absence of arousals. Arousals augment these BP oscillations, but only when they occur late in hyperpnea.

Effects of continuous positive airway pressure on cardiovascular outcomes in heart failure patients with and without Cheyne-Stokes respiration.

BACKGROUND: Continuous positive airway pressure (CPAP) improves cardiac function in patients with congestive heart failure (CHF) who also have Cheyne-Stokes respiration and central sleep apnea (CSR-CSA). However, the effects of CPAP in CHF patients without CSR-CSA have not been tested, and the long-term effects of this treatment on clinical cardiovascular outcomes are unknown. METHODS AND RESULTS: We conducted a randomized, controlled trial in which 66 patients with CHF (29 with and 37 without CSR-CSA) were randomized to either a group that received CPAP nightly or to a control group. Change in left ventricular ejection fraction (LVEF) from baseline to 3 months and the combined mortality-cardiac transplantation rate over the median 2.2-year follow-up period were compared between the CPAP-treated and control groups. For the entire group of patients, CPAP had no significant effect on LVEF, but it was associated with a 60% relative risk reduction (95% confidence interval, 2% to 64%) in mortality-cardiac transplantation rate in patients who complied with CPAP therapy. Stratified analysis of patients with and without CSR-CSA revealed that those with CSR-CSA experienced both a significant improvement in LVEF at 3 months and a relative risk reduction of 81% (95% confidence interval, 26% to 95%) in the mortality-cardiac transplantation rate of those who used CPAP. CPAP had no significant effect on either of these outcomes in patients without CSR-CSA. CONCLUSIONS: CPAP improves cardiac function in CHF patients with CSR-CSA but not in those without it. Although not definitive, our findings also suggest that CPAP can reduce the combined mortality-cardiac transplantation rate in those CHF patients with CSR-CSA who comply with therapy.

Variation in the use of alternative levels of hospital care for newborns in a managed care organization.

OBJECTIVE(S): To assess the extent to which variation in the use of neonatal intensive care resources in a managed care organization is a consequence of variation in neonatal health risks and/or variation in the organization and delivery of medical care to newborns. STUDY DESIGN: Data were collected on a cohort of all births from four sites in Kaiser Permanente by retrospective medical chart abstraction of the birth admission. Likelihood of admission into a neonatal intensive care unit (NICU) is estimated by logistic regression. Durations of NICU stays and of hospital stay following birth are estimated by Cox proportional hazards regression. RESULTS: The likelihood of admission into NICU and the duration of both NICU care and hospital stay are proportional to the degree of illness and complexity of diagnosis. Adjusting for variation in health risks across sites, however, does not fully account for observed variation in NICU admission rates or for length of hospital stay. One site has a distinct pattern of high rates of NICU admissions; another site has a distinct pattern of low rates of NICU admission but long durations of hospital stay for full-term newborns following NICU admission as well as for all newborns managed in normal care nurseries. CONCLUSIONS: Substantial variations exist among sites in the risk-adjusted likelihood of NICU admission and in durations of NICU stay and hospital stay. Hospital and NICU affiliation (Kaiser Permanente versus contract) or affiliation of the neonatologists (Kaiser Permanente versus contract) could not explain the variation in use of alternative levels of hospital care. The best explanation for these variations in neonatal resource use appears to be the extent to which neonatology and pediatric practices differ in their policies with respect to the management of newborns of minimal to moderate illness.

Effects of continuous positive airway pressure on cardiac volumes in patients with ischemic and dilated cardiomyopathy.

The effects of continuous positive airway pressure (CPAP) on left (LV) and right ventricular (RV) volumes in patients with congestive heart failure (CHF) have not been studied. We hypothesized that CPAP would cause greater reductions in cardiac volumes in CHF patients with idiopathic dilated cardiomyopathy (IDC) than in those with ischemic cardiomyopathy (IsC), because their ventricles are more compliant. The effects of a 30-min CPAP application at 10 cm H(2)O on RV and LV end-diastolic (EDV) and end-systolic volumes (ESV), determined by radionuclide angiography, were therefore tested in 22 patients with CHF due to IsC (n = 13) or IDC (n = 9). CPAP-induced reductions in LVEDV, LVESV, RVEDV, and RVESV were significantly greater (p < 0.05) in the IDC than in the IsC group. Whereas in the IsC group CPAP caused no significant changes in LV or RV volumes, in the IDC group it induced significant reductions in RVEDV (527 +/- 77 ml to 354 +/- 50 ml, p = 0.03) and RVESV (400 +/- 78 ml to 272 +/- 54 ml, p = 0.04) that were greater than any reductions in LVEDV and LVESV. We conclude that CPAP causes greater short-term reductions in RV and LV volumes in CHF patients with IDC than in those with IsC, and that among patients with IDC, CPAP causes greater reductions in RV than in LV volumes.

Psychosocial and traditional risk factors in early ischaemic heart disease: cross-sectional correlates.

BACKGROUND: Psychosocial/emotional distress has been repeatedly found to be a correlate of the onset/aggravation of ischaemic heart disease. METHODS: Eighty-three patients (63 men and 20 women) with known coronary artery disease who entered an aggressive lifestyle modification programme were administered a clinical/demographic history and the Symptom Checklist 90--Revised at baseline. Several measures of social isolation/alienation (shyness/self-consciousness, feeling lonely, feeling abused and overall) were derived from the the Symptom Checklist 90--Revised. RESULTS: Univariate tests of the association of known cardiovascular risk factors and the Symptom Checklist 90--Revised scales with age at initial diagnosis yielded several significant results for history of hypercholesterolaemia (P = 0.018), history of hypertension (P = 0.030), somatization (P = 0.007), obsessive-compulsive (P = 0.009), depression (P = 0.006), anxiety (P = 0.021), hostility (P = 0.003), paranoia (P = 0.050), psychoticism (P = 0.029), the Global Severity Index (P = 0.007), the Positive Symptom Distress Index (P = 0.005), the Positive Symptom Total Score (P = 0.003) and feeling abused (P = 0.037). Only history of hypertension, history of hypercholesterolaemia and the hostility scale (overall F = 6.08 and P = 0.0009) emerged as unique correlates of age at initial diagnosis in a multiple regression using only the significant univariate predictors. CONCLUSIONS: Psychosocial factors are sufficiently confounded with one another that they lose their predictive value once one is entered in the equation. High scores on the hostility scale were associated with a 5.7 year differential in age at initial diagnosis. The younger a patient is at initial diagnosis, the more likely he/she is to have high levels of emotional distress.

Risk factors for central and obstructive sleep apnea in 450 men and women with congestive heart failure.

In previous analyses of the occurrence of central (CSA) and obstructive sleep apnea (OSA) in patients with congestive heart failure (CHF), only men were studied and risk factors for these disorders were not well characterized. We therefore analyzed risk factors for CSA and OSA in 450 consecutive patients with CHF (382 male, 68 female) referred to our sleep laboratory. Risk factors for CSA were male gender (odds ratio [OR] 3.50; 95% confidence interval [CI], 1.39 to 8.84), atrial fibrillation (OR 4.13; 95% CI 1.53 to 11. 14), age > 60 yr (OR 2.37; 95% CI 1.35 to 4.15), and hypocapnia (PCO(2 )< 38 mm Hg during wakefulness) (OR 4.33; 95% CI 2.50 to 7. 52). Risk factors for OSA differed by gender: in men, only body mass index (BMI) was significantly associated with OSA (OR for a BMI > 35 kg/m(2), 6.10; 95% CI 2.86 to 13.00); whereas, in women, age was the only important risk factor (OR for age > 60 yr, 6.04; 95% CI 1.75 to 20.0). We conclude that historical information, supplemented by a few simple laboratory tests may enable physicians to risk stratify CHF patients for the presence of CSA or OSA, and the need for diagnostic polysomnography for such patients. Sin DD, Fitzgerald F, Parker JD, Newton G, Floras JS, Bradley TD. Risk factors for central and obstructive sleep apnea in 450 men and women with congestive heart failure.