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Understanding inequalities in SARS-CoV-2 transmission associated with the social determinants of health could help the development of effective mitigation strategies that are responsive to local transmission dynamics. This study aims to quantify social determinants of geographic concentration of SARS-CoV-2 cases across 16 census metropolitan areas (hereafter, cities) in 4 Canadian provinces, British Columbia, Manitoba, Ontario and Quebec.We used surveillance data on confirmed SARS-CoV-2 cases and census data for social determinants at the level of the dissemination area (DA). We calculated Gini coefficients to determine the overall geographic heterogeneity of confirmed cases of SARS-CoV-2 in each city, and calculated Gini covariance coefficients to determine each city's heterogeneity by each social determinant (income, education, housing density and proportions of visible minorities, recent immigrants and essential workers). We visualized heterogeneity using Lorenz (concentration) curves.We observed geographic concentration of SARS-CoV-2 cases in cities, as half of the cumulative cases were concentrated in DAs containing 21%-35% of their population, with the greatest geographic heterogeneity in Ontario cities (Gini coefficients 0.32-0.47), followed by British Columbia (0.23-0.36), Manitoba (0.32) and Quebec (0.28-0.37). Cases were disproportionately concentrated in areas with lower income and educational attainment, and in areas with a higher proportion of visible minorities, recent immigrants, high-density housing and essential workers. Although a consistent feature across cities was concentration by the proportion of visible minorities, the magnitude of concentration by social determinant varied across cities.Geographic concentration of SARS-CoV-2 cases was observed in all of the included cities, but the pattern by social determinants varied. Geographically prioritized allocation of resources and services should be tailored to the local drivers of inequalities in transmission in response to the resurgence of SARS-CoV-2.

Background Trainees aiming to specialize in Neonatal Perinatal Medicine (NPM), must be competent in a wide range of procedural skills as per the Royal College of Canada. While common neonatal procedures are frequent in daily clinical practice with opportunity to acquire competence, there are substantial gaps in the acquisition of advanced neonatal procedural skills. With the advent of competency by design into NPM training, simulation offers a unique opportunity to acquire, practice and teach potentially life-saving procedural skills. Little is known on the effect of simulation training on different areas of competence, and on skill decay. Methods We designed a unique simulation-based 4-h workshop covering 6 advanced procedures chosen because of their rarity yet life-saving effect: chest tube insertion, defibrillation, exchange transfusion, intra-osseus (IO) access, ultrasound-guided paracentesis and pericardiocentesis. Direct observation of procedural skills (DOPS), self-perceived competence, comfort level and cognitive knowledge were measured before (1), directly after (2), for the same participants after 9–12 months (skill decay, 3), and directly after a second workshop (4) in a group of NPM and senior general pediatric volunteers. Results The DOPS for all six procedures combined for 23 participants increased from 3.83 to 4.59. Steepest DOPS increase pre versus post first workshop were seen for Defibrillation and chest tube insertion. Skill decay was evident for all procedures with largest decrease for Exchange Transfusion, followed by Pericardiocentesis, Defibrillation and Chest Tube. Self-perceived competence, comfort and cognitive knowledge increased for all six procedures over the four time points. Exchange Transfusion stood out without DOPS increase, largest skill decay and minimal impact on self-assessed competence and comfort. All skills were judged as better by the preceptor, compared to self-assessments. Conclusions The simulation-based intervention advanced procedural skills day increased preceptor-assessed directly observed procedural skills for all skills examined, except exchange transfusion. Skill decay affected these skills after 9–12 months. Chest tube insertions and Defibrillations may benefit from reminder sessions, Pericardiocentesis may suffice by teaching once. Trainees’ observed skills were better than their own assessment. The effect of a booster session was less than the first intervention, but the final scores were higher than pre-intervention. Trial Registration Not applicable, not a health care intervention.

Cardioneuroablation (CNA) has emerged as promising therapy for patients with refractory vasovagal syncope (VVS).The purpose of this study was to provide a freedom from syncope estimate for CNA, including subgroup analysis by method and target of ablation.A systematic search was performed in MEDLINE and EMBASE according to the PRISMA guidelines until February 14, 2022. Observational studies and clinical trials reporting freedom from syncope were included. Meta-analysis was performed with a random-effects model.A total of 465 patients were included across 14 studies (mean age 39.8 ± 4.0 year; 53.5% female). Different techniques were used to guide CNA: 50 patients (10.8%) by mapping fractionated electrograms, 73 (15.7%) with the spectral method, 210 (45.2%) with high-frequency stimulation, 73 (15.7%) with a purely anatomically guided method, and 59 (12.6%) with a combination. The target was biatrial in 168 patients (36.1%), left atrium only in 259 (55.7%), and right atrium only in 38 (8.2%). The freedom from syncope was 91.9% (95% confidence interval [CI] 88.1%-94.6%; IThis meta-analysis suggests a high freedom from syncope after CNA in VVS. Well-designed, double-blind, multicenter, sham-controlled randomized clinical trials are needed to provide evidence for future guidelines.

BackgroundThere is a growing recognition that strategies to reduce SARS-CoV-2 transmission should be responsive to local transmission dynamics. Studies have revealed inequalities along social determinants of health, but little investigation was conducted surrounding geographic concentration within cities. We quantified social determinants of geographic concentration of COVID-19 cases across sixteen census metropolitan areas (CMA) in four Canadian provinces.MethodsWe used surveillance data on confirmed COVID-19 cases at the level of dissemination area. Gini (co-Gini) coefficients were calculated by CMA based on the proportion of the population in ranks of diagnosed cases and each social determinant using census data (income, education, visible minority, recent immigration, suitable housing, and essential workers) and the corresponding share of cases. Heterogeneity was visualized using Lorenz (concentration) curves.ResultsGeographic concentration was observed in all CMAs (half of the cumulative cases were concentrated among 21-35% of each city’s population): with the greatest geographic heterogeneity in Ontario CMAs (Gini coefficients, 0.32-0.47), followed by British Columbia (0.23-0.36), Manitoba (0.32), and Québec (0.28-0.37). Cases were disproportionately concentrated in areas with lower income, education attainment, and suitable housing; and higher proportion of visible minorities, recent immigrants, and essential workers. Although a consistent feature across CMAs was concentration by proportion visible minorities, the magnitude of concentration by social determinants varied across CMAs.InterpretationThe feature of geographical concentration of COVID-19 cases was consistent across CMAs, but the pattern by social determinants varied. Geographically-prioritized allocation of resources and services should be tailored to the local drivers of inequalities in transmission in response to SARS-CoV-2’s resurgence.

ObjectivesNo randomised controlled trials have been conducted for breakthrough pain in paediatric palliative care and there are currently no standardised outcome measures. The DIPPER study aims to establish the feasibility of conducting a prospective randomised controlled trial comparing oral and transmucosal administration of opioids for breakthrough pain. The aim of the current study was to achieve consensus on design aspects for a small-scale prospective study to inform a future randomised controlled trial of oral morphine, the current first-line treatment, versus transmucosal diamorphine.MethodsThe nominal group technique was used to achieve consensus on best practice for mode of administration, dose regimen and a range of suitable pain intensity outcome measures for transmucosal diamorphine in children and young people with breakthrough pain. An expert panel of ten clinicians in paediatric palliative care and three parent representatives participated. Consensus was achieved when agreement was reached and no further comments from participants were forthcoming.ResultsThe panel favoured the buccal route of administration, with dosing according to the recommendations in the Association for Paediatric Palliative Medicine formulary (fifth Edition, 2020). The verbal Numerical Rating Scale was selected to measure pain in children 8 years old and older, the Faces Pain Scale-Revised for children between 4 and 8 years old, and Face, Legs, Activity, Cry and Consolability (FLACC)/FLACC-Revised as the observational tools.ConclusionsThe nominal group technique allowed consensus to be reached for a small-scale, prospective, cohort study and provided information to inform the design of a randomised controlled trial.

Many studies have examined the effectiveness of non-pharmaceutical interventions (NPIs) on SARS-CoV-2 transmission worldwide. However, less attention has been devoted to understanding the limits of NPIs across the course of the pandemic and along a continuum of their stringency. In this study, we explore the relationship between the growth of SARS-CoV-2 cases and an NPI stringency index across Canada before the accelerated vaccine roll-out.We conducted an ecological time-series study of daily SARS-CoV-2 case growth in Canada from February 2020 to February 2021. Our outcome was a back-projected version of the daily growth ratio in a stringency period (i.e., a 10-point range of the stringency index) relative to the last day of the previous period. We examined the trends in case growth using a linear mixed-effects model accounting for stringency period, province, and mobility in public domains.Case growth declined rapidly by 20-60% and plateaued within the first month of the first wave, irrespective of the starting values of the stringency index. When stringency periods increased, changes in case growth were not immediate and were faster in the first wave than in the second. In the first wave, the largest decreasing trends from our mixed effects model occurred in both early and late stringency periods, depending on the province, at a geometric mean index value of 30⋅1 out of 100. When compared with the first wave, the stringency periods in the second wave possessed little association with case growth.The minimal association in the first wave, and the lack thereof in the second, is compatible with the hypothesis that NPIs do not, per se, lead to a decline in case growth. Instead, the correlations we observed might be better explained by a combination of underlying behaviors of the populations in each province and the natural dynamics of SARS-CoV-2. Although there exist alternative explanations for the equivocal relationship between NPIs and case growth, the onus of providing evidence shifts to demonstrating how NPIs can consistently have flat association, despite incrementally high stringency.

The aim of this chapter will be to continue to develop the themes in Chap. 1 above. The ‘Engine Room’ was the name given to a group of middle managers at one production site who were given the task of managing redundancies and production line closures. The chapter will explore the practices used and the delays and subterfuge of everyday managerial practices to subvert and reconfigure the organisation’s strategic ‘choice’. Again ethnography in an insider account will demonstrate how practices are constructed and deployed as well as how a SasP perspective can be applied by researchers in other organisational settings. In addition, the theme of nonhuman actors will be developed drawing upon Actor-Network Theory themes (Callon, Some elements of a sociology of translation: Domestication of the scallops and the fishermen of Saint Brieuc bay. In J. Law (Ed.), Power, action and belief (pp. 196–233). London: Routledge and Kegan Paul, 1986).

The aim of this chapter will be to employ a Strategy as Practice (SasP) perspective to consider the organisation’s ‘Asset Optimisation Process’ (AOP). The AOP process was a rationalisation of products and production capacity that was conducted within the organisation. The rationalisation outcome was delayed, subverted and reconfigured by networks of middle managers, trade unions and other actors. The chapter will draw upon and inform SasP literature (e.g., Nicolini, Organization Studies, 30(12), 1391–1418, 2009, Practice theory, work, and organization: An introduction, Oxford University Press; Whittington, Long Range Planning, 29(5), 731–735, 1996, Organization Studies, 27(5), 613–634, 2006) and combine Actor-Network Theory perspectives with SasP (see Nicolini 2012). By using ethnography in an insider account the chapter will demonstrate how practices are constructed and deployed as well as how a SasP perspective can be applied by researchers in other organisational settings.

This chapter outlines the ontological and epistemological positioning of this book and then explores the at-home ethnographic methods employed in this book and the underpinning literature (e.g., Alvesson, Methodology for close up studies—struggling with closeness and closure. Higher Education, 46 (2), 167–193, 2003; At-home ethnography: Struggling with closeness and closure. In S. Ybema, D. Yanow, H. Wels, & F. Kamsteeg (Eds.), Organizational ethnography: Studying the complexity of everyday life (pp. 156–174). London: Sage, 2009; Punch, The politics and ethics of fieldwork. Beverly Hills: Sage, 1986; Van Maanen, Ethnography as work: Some rules of engagement. Journal of Management Studies, 48(1), 218–234, 2011; Vickers, At-home ethnography: a method for practitioners. Qualitative Research in Organizations and Management: An International Journal, 14 (1), 10–26, 2019). The book then gives an overview of Actor-Network Theory (ANT) (e.g., Latour, Reassembling the social. Oxford: Oxford University Press, 2005) and Strategy-as-Practice (SasP) (e.g., Whittington, Strategy as practice. Long Range Planning, 29 (5), 731–735, 1996) and explores the wider theoretical contributions of the book.

The aim of this chapter will be to consider how human resource procedures, policies, systems and documentation are deployed to control others and achieve conformity to organisational goals. As an insider ethnographic account it is also possible to demonstrate how the interpretation of these policies, practices, systems and documents are contested. This will involve the exploration of counter networks and the idea of hegemonic and ante-narrative (see Vickers, Beyond the hegemonic narrative – A study of managers. Journal of Organizational Change Management, 21, 560–573, 2008) This chapter will draw upon and inform Actor-Network Theory (Latour, The pasteurization of France. Cambridge, MA: Harvard, 1988; Latour, Reassembling the social – An introduction to actor-network-theory. Oxford: Oxford University Press, 2005; Callon, Some elements of a sociology of translation: Domestication of the scallops and the fishermen of Saint Brieuc Bay. In Law, J. (Ed.) Power, action and belief (pp. 196–233). London: Routledge and Kegan Paul, 1986; Law, On the methods of long‐distance control: Vessels, navigation and the Portuguese route to India. In Law, J. (Ed.) Power, action and belief (pp. 234–263). London: Routledge and Kegan Paul, 1984) in relation to HR and critical HR literature (Watson, HRM and critical social science analysis. Journal of Management Studies, 41 (3), 447–467, 2004; Delbridge and Keenoy, Beyond managerialism? International Journal of Human Resource Management, 21 (6), 799–817, 2010; Vickers and Fox, Towards practice-based studies of HRM: An actor network and communities of practice informed approach. International Journal of Human Resource Management, 21 (6), 899–914, 2010).

The aim of this chapter will be to consider how safety practices are learned and carried out in situ. The employees at the production site having been newly acquired are required to learn new ways of practising safety. The chapter explores the espoused safety narrative and culture of the organisation and the reality of the everyday practice of safety and how managers, in particular, re-learn to practise safety and reconcile the difference between espoused safety and practice. The chapter will draw upon Communities of Practice theory, especially the ideas of noncanonical communities (Brown and Duguid, Organizational learning and communities of practice: Toward a unified view of working, learning and innovation. In E. L. Lesser, M. A. Fontaine, & J. A. Slusher (Eds.), Knowledge and communities (pp. 99–121). Oxford: Butterworth Heinemann, 1991) and newcomers as legitimate peripheral participants (Lave and Wenger, Situated learning: Legitimate peripheral participation. Cambridge: Cambridge University Press, 1991) and how this might inform SasP.

Introduction: Candidemia carries significant morbidity and mortality for hospitalized patients. Local epidemiology is needed to develop strategies to reduce infections. This article describes the epidemiology of candidemia at a tertiary-care hospital in Edmonton, Canada. Methods: Between 2004 and 2013, 250 episodes of candidemia were identified using an infection control database. Binary logistic regression analysis was used to identify risk factors for non-albicans isolates and for mortality. Results: The candidemia rate increased significantly, from 0.387/10,000 patient days (PD) in 2004 to 1.45/10,000 PD in 2013 (p=0.0061). The 30-day and overall in-hospital mortality rates were 38% and 47%, respectively. Candida albicans and C. glabrata represented 80% of isolates. Overall, 48% of episodes were attributable to central venous catheter (CVC) infections. The ratio of C. albicans to non-albicans isolates and the rate of CVC infections did not change significantly over the study period (p=0.98 and 0.14, respectively). Preceding azole therapy within 30 days of candidemia conferred an increased risk of a non-albicans isolate (odds ratio [OR] 2.59, 95% CI 1.24 to 5.43). Mortality was increased with immunosuppression (OR 3.30, 95% CI 1.74 to 6.24) and age, with an OR of 2.78 (95% CI 1.21 to 6.38) for the 61- to 68-year-old age group and an OR of 4.30 (95% CI 1.84 to 10.04) for the >69-year-old age group. Mortality was similar among C. albicans and non-albicans infections (OR 0.85, 95% CI 0.49 to 1.45). Conclusion: Candidemia at the authors' institution increased during the study period without a significant change in the ratio of C. albicans to other Candida spp. The risk of non-albicans candidemia was affected by previous azole therapy, and the risk of mortality was higher with increased age and immunosuppression. The etiology of the increased candidemia rate is likely complex, and strategies to address this, as well as the high mortality rate seen with candidemia, are needed.

SUMMARYPatients with methicillin-resistant Staphylococcus aureus (MRSA) clones, which were traditionally seen in the community setting (USA400/CMRSA7 and USA300/CMRSA10), are often identified as hospital-acquired (HA) infections using Infection Prevention and Control (IPC) surveillance definitions. This study examined the demographics and healthcare risk factors of patients with HA-MRSA to help understand if community MRSA clones are from a source internal or external to the hospital setting. Despite USA300/CMRSA10 being the predominant clone in Alberta, hospital clones (USA100/CMRSA2) still dominated in the acute care setting. In the Alberta hospitalized population, patients with USA400/CMRSA7 and USA300/CMRSA10 clones were significantly younger, had fewer comorbidities, and a greater proportion had none or ambulatory care-only healthcare exposure. These findings suggest that there are two distinct populations of HA-MRSA patients, and the patients with USA400/CMRSA7 and USA300/CMRSA10 clones identified in hospital more greatly resemble patients affected by those clones in the community. It is possible that epidemiological assessment overidentifies HA acquisition of MRSA in patients unscreened for MRSA on admission to acute care.

PurposeThe purpose of this paper is to compare the competencies of managers in the UK and Taiwan.Design/methodology/approachA comparative analysis of managers using a behavioural event interviewing (BEI) technique.FindingsBoth cultures were highly achievement focussed. However, there were several marked differences in other behaviours which appear to be cultural in nature. UK managers demonstrated more interpersonal awareness, and concern for impact, whereas Taiwanese managers were more likely to demonstrate critical information seeking behaviour.Research limitations/implicationsInterviews in some instances failed to uncover data and this has implications for the use of generic behavioural event interviews internationally.Practical implicationsThe research suggests the idea of organisations' employing generic “international” competency models and behavioural event interview techniques is problematic.Originality/valueThe research is able to demonstrate the problems with international competency models through unique access to an organisation's competency model and to managers in two locations.

Background Knee and hip replacements are an effective intervention for improving quality of life. Rates of these surgeries in North America are growing, coinciding with increasing obesity and an aging population. Methods Alberta Health Services' infection prevention and control program collects data prospectively on surgical site infections (SSIs) after primary total hip and knee arthroplasty completed in Alberta, Canada. We reviewed all SSIs within 180 days of surgical procedures between March 1, 2012, and June 30, 2014. Results There were 312 SSI cases reviewed. Rates of SSI (per 100 procedures) were 1.77 and 1.26 for hip and knee arthroplasties, respectively. Seventy-nine percent of infections occurred within 30 days postoperatively. Stratified by time to infection, larger proportions of knee SSIs occurred after 30 days versus hip SSI. Colonization with methicillin-resistant Staphylococcus aureus (MRSA) was associated with subsequent infection (odds ratio, 40; 95% confidence interval, 10.2-154.2). We have identified important characteristics that may be helpful for determining optimal prevention strategies. Conclusions Intensive postoperative follow-up within 30 days of knee arthroplasty may help to identify SSI early, allowing for prompt treatment and avoiding the need for invasive therapy, such as surgery for hardware revision. Decolonization techniques may decrease subsequent MRSA SSI in colonized patients.

Background Infection Prevention and Control (IPC) surveillance for incident methicillin-resistant Staphylococcus aureus (MRSA) in hospitalized patients is performed in a complete provincial surveillance network of all acute care facilities in Alberta, Canada. IPC surveillance is centralized using a web-based data entry platform so that each patient is counted only once. All diagnostic laboratories submit the first clinical MRSA isolate associated with a patient without previous MRSA positive clinical cultures in the preceding year to the Provincial Laboratory for Public Health (ProvLab) for molecular typing. This study will investigate the relationship between the IPC epidemiological classification based on time of detection following admission to hospital (Hospital Acquired and Community Associated) and the matched laboratory MRSA surveillance data using a retrospective cohort study design. Methods Incident IPC MRSA cases were classified according to IPC epidemiologic definitions. DNA sequencing of the Staphylococcus protein A (spa) gene and pulsed-field gel electrophoresis (PFGE) typing was performed. IPC MRSA surveillance data were matched to the ProvLab molecular surveillance data. Univariate comparisons of proportions were performed for categorical variables and the Student’s t test for continuous variables. Results MRSA molecular typing data were available for matching for 46.7 % (2248/4818) of incident IPC cases. There was agreement in definitions for traditional nosocomial clones (USA100/CMRSA2) with Hospital Acquired (HA)-MRSA (65.1 % of all IPC HA-MRSA) and traditional community clones (USA400/CMRSA7 and USA300/CMRSA10) with Community Acquired (CA)-MRSA (62.4 % of CA-MRSA). However, we observed discordance for both traditional nosocomial/CA-MRSA (30.4 % of CA-MRSA) and for traditional community/HA-MRSA (26.9 % of HA-MRSA). Conclusions We note agreement between traditional nosocomial clones and HA-MRSA, and traditional community clones and CA-MRSA. However, approximately one-quarter of HA-MRSA are those of traditional community clones while approximately one-third of CA-MRSA are those of traditional nosocomial clones. Collaborative provincial MRSA surveillance is important as the distinction between IPC case attribution in acute care settings and the historical definitions of MRSA clones as community- or healthcare-associated have blurred.

Background: The transition from a whole-cell to a 5-component acellular pertussis vaccine provided a unique opportunity to compare the effect that each type of vaccine had on the incidence of pertussis, under routine conditions, among children less than 10 years of age. Methods: Analyses were based on passive surveillance data collected between 1995 and 2005. The incidence of pertussis by year and birth cohort was compiled according to age during the surveillance period. We determined the association between vaccine type (whole-cell, acellular or a combination of both) and the incidence of pertussis using Poisson regression analysis after controlling for age ( Results: During 7 of the 11 years surveyed, infants ( Interpretation: These results suggest that current immunization practices may not be adequate in protecting infants and children less than 5 years of age against pertussis. Altering available acellular formulations or adopting immunization practices used in some European countries may increase the clinical effectiveness of routine pertussis vaccination programs among infants and preschool children.

Child and family involvement is key to improving the quality of children’s hospice services. This article reports on a quality assurance initiative undertaken as one component of a clinical governance strategy. Service users participated in focus groups followed by lunch to discuss how staff communicated with them about their child’s care, their family support needs, and how staff liaised with other professionals and organizations. There was general commendation of hospice services (in-house and community), but parents wished for more quantity and consistency with all elements of the care model. There was tension between respite and end-of-life care needs. Parents considered that the myth of hospices being ‘just for death’ needed dispelling and wanted other professionals to be more aware of its role, and the choice of earlier referral. Transition, both age and prognosis related, caused concern, with anxiety about long-term future or loss of support when prognosis improved. Parents also wanted better information about practical help and psycho-social support as well as up-to-date information about their child’s treatment and management from all care providers.

This chapter addresses the question: Is there a virtuous circle between situated learning within communities of practice and the corporate pursuit of innovation in large companies? The authors trace a succession of ways in which it has been formulated, reframed, and addressed across a range and sequence of qualitative studies. Overall, they argue for more ethnographic studies of organizational learning and innovation and recommend further use of actor-network theory, which has potential to add considerably to communities of practice theory. The authors illustrate this argument in the chapter through a discussion of Carlile's (2002) important paper and cite a number of other studies that use actor-network theory in combination with communities of practice theory.

Objective Advisory committees in Canada and the United States have updated recommendations for quadrivalent meningococcal conjugate vaccines against serogroups A, C, W135, and Y. Our objective was to evaluate optimally effective meningococcal vaccination policies using a stochastic dynamic model. Canada was used as an example. Methods Our stochastic dynamic model of Neisseria meningitidis (Nm) transmission in an age-structured population assumed partial cross-immunity among two aggregated serogroup categories: ‘AWY’ containing A, W135, and Y; and ‘Other’ containing B, C, and ungroupable types. We compared the impact of monovalent C versus quadrivalent ACWY vaccination on Nm carriage and invasive meningococcal disease (IMD). Our model was parameterized with Canadian epidemiological and demographic data and employed probabilistic sensitivity analysis. Results Routine infant immunization at 12 months and boosting at 15 years with a quadrivalent vaccine is projected to have the largest impact on total IMD incidence: a 74% reduction over 40 years. Routine infant immunization with a monovalent vaccine at 12 months only has much less impact and also generates strain replacement appearing after approximately ten years of continuous use. Conclusions Immunizing infants at 12 months and boosting adolescents at 15 years with an ACWY vaccine is predicted to be most effective at reducing IMD incidence.

What you need to know Children and young people can have a wide range of life limiting conditions and may sometimes live with such conditions for many years. This guideline recommends that end of life care be managed as a long term process that begins at the time of diagnosis of a life limiting condition and entails planning for the future. Sometimes it may begin before the child’s birth. It is part of the overall care of the child or young person and runs in parallel with other active treatments for the underlying condition itself.1 Finally, it includes those aspects related to the care of the dying. This guideline was commissioned with the aim to standardise end of life care for infants, children, and young people living with a life limiting condition, and thus promote equity and consistency. Important themes are to involve children and young people and their parents or carers in decisions about their care, facilitate their care in their preferred location (most likely home), and plan for day and night care. This article summarises the most recent guidance from the recent National Institute for Health and Care Excellence (NICE) on the planning and management of end of life care in infants, children, and young people.2 For a visual summary, please …

For curable infectious diseases, public health strategies such as treatment can effectively shorten an individual's infectious period, and thus limit their role in transmission. However, because treatment effectively eliminates antigen impingement, these types of control strategies may also paradoxically impair the development of adaptive immune responses. For sexually transmitted Chlamydia trachomatis infections, this latter effect has been coined the arrested immunity hypothesis, and is discussed to carry significant epidemiological implications for those individuals who return to similar sexual networks with similar sexual behavior. Here, we examine the effect of antibiotic treatment on the spread of Chlamydia infection through a simple immunoepidemiological framework that characterizes the population as a collection of dynamically evolving individuals in small, paradigmatic networks. Within each individual there is an explicit representation of pathogen replication, accumulation and persistence of an immune response, followed by a gradual waning of that response once the infection is cleared. Individuals are then nested in networks, allowing the variability in the life history of their infection to be functions of both individual immune dynamics as well as their position in the network. Model results suggest that the timing and coverage of treatment are important contributors to the development of immunity and reinfection. In particular, the impact of treatment on the spread of infection between individuals can be beneficial, have no effect, or be deleterious depending on who is treated and when. Although we use sexually transmitted Chlamydia infection as an example, the observed results arise endogenously from a basic model structure, and thus warrant consideration to understanding the interaction of infection, treatment, and spread of other infectious diseases.

Katayama syndrome is an early clinical manifestation of schistosomiasis that occurs several weeks post-infection with Schistosoma spp (trematode) worms. Because of this temporal delay and its non-specific presentation, it is the form of schistosomiasis most likely to be misdiagnosed by travel medicine physicians and infectious disease specialists in non-endemic countries. Katayama syndrome appears between 14-84 days after non-immune individuals are exposed to first schistosome infection or heavy reinfection. Disease onset appears to be related to migrating schistosomula and egg deposition with individuals typically presenting with nocturnal fever, cough, myalgia, headache, and abdominal tenderness. Serum antibodies and schistosome egg excretion often substantiate infection if detected. Diffuse pulmonary infiltrates are found radiologically, and almost all cases have eosinophilia and a history of water contact 14-84 days before presentation of clinical symptoms; patients respond well to regimens of praziquantel with and without steroids. Artemisinin treatment given early after exposure may decrease the risk of the syndrome.

Continuous economic pressures have moved a large percent of integrated device manufacturing (IDM) operations either overseas or to foundry operations over the last 10 years. These pressures have left the IDM fabs in the U.S. with required COO improvements in order to maintain operations domestically. While the assets of many of these factories are at a very favorable point in the depreciation life cycle, the equipment and processes are constrained to the quality of the equipment in its original state and the degradation over its installed life. With the objective to enhance output and improve process performance, this factory and their primary lithography process tool supplier have been able to extend the usable life of the existing process tools, increase the output of the tool base, and improve the distribution of the CDs on the product produced. Texas Instruments Incorporated lead an investigation with the POLARIS ® Systems & Services business of FSI International to determine the sources of variance in the i-line processing of a wide array of IC device types. Data from the sources of variance were investigated such as PEB temp, PEB delay time, develop recipe, develop time, and develop programming. While PEB processes are a primary driver of acid catalyzed resists, the develop mode is shown in this work to have an overwhelming impact on the wafer to wafer and across wafer CD performance of these i-line processes. These changes have been able to improve the wafer to wafer CD distribution by more than 80 %, and the within wafer CD distribution by more than 50 % while enabling a greater than 50 % increase in lithography cluster throughput. The paper will discuss the contribution from each of the sources of variance and their importance in overall system performance.

The national service framework for children, young people, and maternity services is the culmination of a process started three years ago and has been heavily influenced by the Kennedy and Laming reports.1-3 That it responds to two of the most critical reports on child health service adds to its importance. It provides the NHS with measures to assess the quality of service provided for children and mothers. Children have been invisible in the NHS. Until now they have been regarded as an addendum to adult services. In the NHS Plan children were largely ignored.4 Recent reforms have focused on adult services, with targets set by government to achieve them. One can argue that, as patients, pregnant women and children benefited from these reforms in terms of quantitative measures such as waiting times. However, the care of children requires a clearer vision in the more difficult qualitative areas. The national service framework emphasises that the majority of service needs for children are in the community and can only be provided by the NHS in partnership with education and social services as envisaged in Every Child Matters and the Children's Bill.5 The national service framework provides the opportunity for service developments that allow the holistic needs of children and pregnant mothers to be met. Key to this is the recognition that children and young people are different and individuals in their own right, with specific requirements which can be met only by reorganisation of service delivery. This requires a change in how health professionals and managers view maternal and child health and a reassessment of how parents, children, and young people participate in and are consulted in planning services. The national service framework sets out a comprehensive, long term (10 year) agenda for change and a framework for healthcare provision in the broadest context. Its 11 standards for care, applying to children (defined as under 19 years) and their families, cover all aspects of NHS care including maternal health and primary care. It is encouraging that mental health is a constant strand, and that maternal health is seen as part of the continuum of health care. Key features include better consultation with children and families; changes towards care focused on children and women; and facilities designed for children with input from children and parents. A central concept is of services designed around the child's journey, to meet children's needs, with emphasis on holistic and integrated approaches including proper engagement with the voluntary sector. The earlier framework for hospital services implied that NHS trusts needed to critically examine services for children.6 It inferred that reallocation of resources was needed, along with reconfiguration of service provision and incorporation of the overriding principles in all new hospital design and development. Change in how children are currently seen within adult services is also required. Children must be seen as important users, and their needs given similar weight to those of adults. The impact of the national service framework on out of hospital services will be huge, especially with the emerging public health agenda.7 Primary care trusts have a central role in ensuring that the needs of mothers and children are addressed. Community based services must look at how they are organised and relate to other non-health services, including social care and education. Recent high profile cases around child abuse and child deaths highlight the needs of the most vulnerable in our society, and this is emphasised in the framework. Current concerns about the future of community child health should be noted.8 The national service framework suggests strengthening of out of hospital services, and commissioners must consider how they can use and develop current services. The challenge for general practice is also clear. Despite the absence of specifics in their new contract, the role of primary care in the development of better services for children is critical, and the national service framework sets out this agenda. Development of tool kits to help organisations assess their current status against the national service framework and to measure progress is a priority. The lack of set targets and a clear budget stream is a criticism that can be levied at the document. Like all documents it is a compromise, a balance between the desired and the possible. However, the message is clear—we need a radical shift in our mindset towards children and we must develop a society where maternal and child health is a priority and not a luxury. The vision of the national service framework is huge and implies considerable cultural change in the NHS, and beyond. The aim is child and family centred services, designed and delivered around their needs rather than those of organisations. The NHS must grasp this opportunity. The national service framework is government policy, strengthened by concurrent reports, and signals a higher priority for children and maternity services across all areas of government.9,10 If the service and all clinicians working with women and children do not respond, children will be the losers.

Christopher Francis Howard Vickers (“Chris”) was born in Congleton, Cheshire. After graduating he was intent on specialising in cardiology, but while holding a post as medical registrar at Sheffield Royal Infirmary he was persuaded by I B Sneddon to try dermatology, to which he devoted the rest of his clinical career. He later became a senior registrar at St John’s Hospital for Diseases of the Skin and also Great Ormond Street, spending a year as a …

Background: Chlamydia trachomatis is a common human pathogen that mediates disease processes capable of inflicting serious complications on reproduction. Aggressive inflammatory immune responses are thought to not only direct a person’s level of immunity but also the potential for immunopathology. With human immunobiology being debated as a cause of prevailing epidemiological trends, we examined some fundamental issues regarding susceptibility to multiple chlamydial infections that could have implications for infection spread. We argue that, compared to less-frequent exposure, frequent exposure to chlamydia may well produce unique immunobiological characteristics that likely to have important clinical and epidemiological implications. Methods and Results: As a novel tool for studying chlamydia, we applied principles of modeling within-host pathogen dynamics to enable an understanding of some fundamental characteristics of an individual’s immunobiology during multiple chlamydial infections. While the models were able to reproduce shorter-term infection kinetics of primary and secondary infections previously observed in animal models, it was also observed that longer periods between initial and second infection may increase an individual’s chlamydial load and lengthen their duration of infectiousness. The cessation of short-term repeated exposure did not allow for the formation of long-lasting immunity. However, frequent re-exposure non-intuitively linked the formation of protective immunity, persistent infection, and the potential for immunopathology. Conclusions: Overall, these results provide interesting insights that should be verified with continued study. Nevertheless, these results appear to raise challenges for current evidence of the development of long-lasting immunity against chlamydia, and suggest the existence of a previously unidentified mechanism for the formation of persistent infection. The obvious next goal is to investigate the qualitative impact of these results on the spread of chlamydia.