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Overprescribing of antibiotics in paediatrics accounts for a significant proportion of inappropriate antibiotic use in human healthcare, thereby contributing to the global health emergency of antimicrobial resistance. Antimicrobial stewardship efforts are complicated by the unique social dynamics in paediatric healthcare, with a specific challenge being the prominent role of parents and carers who act as intermediaries between prescribers and paediatric patients. In this Perspective article concentrating on healthcare of the United Kingdom, we describe this complicated interplay of different decision stakeholders (patients, parents and prescribers), outline four dimensions of decision challenges (social, psychological, systemic and specific diagnostic and treatment challenges) and provide a number of theory-based strategies for supporting different stakeholders during the decision process, ultimately with the aim of improving antimicrobial stewardship. Key decision challenges for patients and carers include limited knowledge and experience of managing infections, which were exacerbated during the COVID-19 pandemic and frequently result in health anxiety and inappropriate health-seeking behaviours. Challenges for medical prescribers span societal pressures from prominent patient litigation cases, cognitive biases, and system pressures to specific diagnostic problems (e.g., age limitations of current clinical scoring systems). Strategies for mitigating decision challenges in paediatric infection management will need to include a range of context- and stakeholder-specific actions, including improvements of integrated care and public health education as well as better clinical decision tools and access to evidence-based guidelines. [ABSTRACT FROM AUTHOR]

The study examined the relation between older adults' trust beliefs in nursing home carers (NHCs) and adjustment to residential care. Seventy-six older adults (mean age = 83 years, standard deviation = 7 years from UK nursing homes completed standardised scales of trust beliefs in NHCs and adjustment to residential care (satisfaction with care-giving, social engagement in the nursing home, loneliness and a latent measure). As expected, trust beliefs in NHCs were linearly associated with adjustment to residential care on all measures. There were quadratic relations between trust beliefs in NHCs and on given measures of adjustment to residential care (latent measure, satisfaction with care-giving and loneliness). Adults with very high and those with very low trust beliefs in NHCs showed depressed levels on those measures of adjustment to residential care relative to older adults with the middle range of trust beliefs. The research highlights the importance of older adults' trust beliefs in NHCs for adjustment to nursing homes. The findings show though, that older adults who hold very high, as well those who hold very low, trust beliefs in NHCs are at risk for lower levels of adjustment. [ABSTRACT FROM AUTHOR]

Background: Reporting of outpatient parenteral antimicrobial therapy (OPAT) outcomes with national benchmarking is key to informing service development and supporting quality improvement.Objectives: To analyse and report on data collected by the BSAC OPAT National Outcomes Registry from 2015 to 2019.Methods: Quarterly data to 2020 was extracted from the BSAC National Outcomes Registry and analysed.Results: 57 organizations submitted data on 27 841 patient episodes and 442 280 OPAT treatment days. A diverse range of infections and antimicrobials were reported with a mean OPAT treatment duration of 16.7 days (adults) and 7.7 days (paediatrics). In adults, the top five conditions treated were skin and soft tissue (27.6%), bronchiectasis (11.4%), urinary tract infections (7.6%), and diabetic foot infections (5.5%). Ceftriaxone followed by teicoplanin, ertapenem and piperacillin/tazobactam were the most-used antimicrobials. A median of 1.4 vascular-device-related complications were observed per 1000 OPAT treatment days (range 0.11 to 10.4) with device infections in 0.3 per 1000 OPAT days (range 0.1 to 1.7). Other adverse events (rash, blood dyscrasias, antibiotic-associated diarrhoea) were observed in a median of 1.9 per 1000 OPAT days. OPAT infection outcome (cured/improved) was 92.4% and OPAT outcome (success/partial success) was 90.7%.Conclusions: This report demonstrates the safety, breadth, and complexity of modern UK OPAT practice. Future analyses of OPAT data should focus on infection- and service-specific quality indicators. OPAT registries remain central to planning and assessing safe, effective, and efficient delivery of patient-centred care and should be an important focus for UK and global OPAT practice. [ABSTRACT FROM AUTHOR]

Background: Use of health services is increasing in many countries. Most health service research exploring determinants of use has focused on adults and on secondary care. Less is known about factors associated with the use of the emergency department (ED) and general practice (GP) among young children.Objective: To explore factors associated with GP consultations and ED attendances among children under 5 in a single UK city.Methods: Cross-sectional exploratory study using anonymized individual-level health service use data for children aged 0-4 from 21 GPs in Southampton, UK, linked to ED data, over a 1-year period. Univariate and multivariable logistic regression were used to explore the association of socio-demographic factors [using the 2015 Index of Multiple Deprivation (IMD) to define socio-economic status] with high service use (defined as more than eight GP consultations and/or two ED attendances respectively).Results: Among 11 062 children, there were 76 092 GP consultations and 6107 ED attendances. Three thousand two hundred thirty-three (29%) children were high users of GP and 564 (5%) of ED services. Greater socio-economic deprivation was independently associated with high use of GP and ED services separately [odds ratios (OR) for most versus least deprived IMD quintile 1.45 (95% confidence interval, CI 1.20-1.75) and 2.21 (95% CI 1.41-3.46), respectively], and together [OR 2.62 (95% CI 1.48-4.65)].Conclusion: Young children are frequent users of health services, particularly GP. Socio-economic deprivation is an important factor. Parents, carers and health services may benefit from interventions that support families in their management of children's health. [ABSTRACT FROM AUTHOR]

Congenital syphilis is a prevalent infection in much of the world but rare in contexts where antenatal screening and treatment are available. In the UK in 2016, three cases of congenital syphilis were reported in babies born to women who were seronegative at the time of booking and hence a high degree of clinical vigilance is required in the unwell infant. We present the case of a seven-week-old baby girl with congenital syphilis with the unusual finding of discrete liver lesions. This baby was successfully treated with intravenous ceftriaxone. [ABSTRACT FROM AUTHOR]

Outpatient parenteral antimicrobial therapy (OPAT) offers safe, effective and patient-centred care for adults and children. The OPAT UK good practice recommendations for adults and children have recently been updated through a process of literature review, expert consensus and extensive stakeholder consultation. Here we discuss the key changes in the updated recommendations in the context of recent developments, including novel antimicrobial agents and delivery devices, the place of oral antimicrobials as an alternative to intravenous therapy, new OPAT service models and the broader antimicrobial stewardship agenda. [ABSTRACT FROM AUTHOR]

The article examines whether the British courts would reconcile their interests in Parliamentary sovereignty and executive accountability. It mentions that individuals are allowed to find legitimate expectations on treaty provisions as the courts are being examined. It states that the treaties being bound on the international legal aspect would be of limited relevance to a legitimate expectation if the courts would allow individuals to rely on treaty provisions in legitimate expectation cases. It concludes that the individuals are allowed to set up legitimate expectations on treaties.

There is some evidence of a cross-sectional, and possibly causal, relationship of lipid levels with leukocyte counts in mice and humans. This study investigates the cross-sectional and longitudinal relationship of blood lipid and lipoprotein levels with leukocyte counts in the UK Biobank cohort. The primary cross-sectional analysis included 417,132 participants with valid data on lipid measures and leukocyte counts. A subgroup analysis was performed in 333,668 participants with valid data on lipoprotein(a). The longitudinal analysis included 9058 participants with valid baseline and follow-up data on lipid and lipoprotein levels and leukocyte counts. The association of lipid and lipoprotein levels with leukocyte counts was analysed by multivariable linear regression. Several relationships were significant in both cross-sectional and longitudinal analysis. After adjustment for demographic, socioeconomic and other confounding factors, a higher eosinophil count was associated with lower HDL cholesterol and apolipoprotein A-I concentration (p < 0.001). Higher triglycerides levels were associated with higher total leukocyte, basophil, eosinophil, monocyte and neutrophil counts (all p < 0.01). A higher lymphocyte count was associated with a higher apolipoprotein B level (p < 0.001). In the longitudinal analysis, lipoprotein(a) was inversely associated with basophil count in men but not women (p < 0.001). Triglyceride levels demonstrate a robust positive association with total and differential leukocyte counts suggesting they may be directly involved in leukogenesis. However, unlike in murine models, the remainder of these relationships is modest, which suggests that cholesterol and lipoproteins are minimally involved in leukogenesis in humans. Image 1 • Triglycerides are a robust predictor of total and differential leukocyte counts. • HDL cholesterol and apolipoprotein A-I are inversely associated with eosinophil count. • Apolipoprotein B is positively associated with lymphocyte count. • Total and LDL cholesterol predicts lymphocyte count in longitudinal analysis. • Lipoprotein(a) shows no longitudinal relationship with leukocyte counts. [ABSTRACT FROM AUTHOR]

Introduction: Idiopathic facial nerve palsy (FNP) is an uncommon but important presentation in children, with Lyme disease known to be a common cause. The UK county of Hampshire is a high incidence area of Lyme disease. We conducted a retrospective review of the investigation and management of paediatric FNP at a large University hospital, including serologic testing and treatment of Lyme disease. Methods: We conducted a retrospective chart review of children under 18 presenting between January 1st, 2010 and December 31st, 2017 with a diagnosis of FNP. Patients with clear non-Lyme aetiology at presentation were excluded. Data was collected on demographics, initial presentation, investigations including Lyme serology, and management. Results: A total of 93 children were identified, with an even proportion of male to female and median age 9.3 years (IQR 4.6–12 years). A history of rash was present in 5.4%, tick bite in 14% and recent travel to, or residence in the New Forest in 22.6%. Lyme serology was performed in 81.7% of patients, of which 29% were positive. Antibiotics were prescribed for 73.1% of patients, oral steroids for 44% and aciclovir for 17.2%. Conclusion: Lyme disease is a significant cause of FNP in this endemic area of the UK, and there was a large degree of variability in management prior to national guideline publication. Areas with endemic Lyme disease should consider introducing local guidelines supporting routine investigation and management for FNP, including empiric treatment for Lyme disease in accordance with NICE guidelines to improve care and reduce variability. [ABSTRACT FROM AUTHOR]

The negative impact of high antimicrobial use (AMU), antimicrobial resistance and healthcare-associated infections (HCAIs) on children is concerning. However, a lack of available paediatric data makes it challenging to design and implement interventions that would improve health outcomes in this population, and impedes efforts to secure additional resources. The upcoming 2023 national point-prevalence survey of HCAIs and AMU in hospitals, led by the UK Health Security Agency, is an opportunity to collect valuable information, which will enable healthcare providers and policy makers to optimize antimicrobial stewardship and infection prevention practices in all populations, including children. These data will facilitate benchmarking and sharing of best practice, internally, nationally and internationally. This is a joint call to action asking all healthcare professionals-particularly in paediatrics-to nominate a lead for their institution and participate in this survey, to ensure appropriate paediatric representation, and help protect children from these growing threats., (© The Author(s) 2023. Published by Oxford University Press on behalf of British Society for Antimicrobial Chemotherapy. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

Background: The aim of this study was to examine the COVID-19 pandemic and its associated impact on the provision of vascular services, and the pattern of presentation and practice in a tertiary referral vascular unit., Methods: This is a retrospective observational study from a prospectively maintained data-base comparing two time frames, Period 1(15th March-30th May 2019-P1) and Period 2(15th March-30th May 2020-P2)All the patients who presented for a vascular review in the 2 timeframes were included. Metrics of service and patient care episodes were collected and compared including, the number of emergency referrals, patient encounters, consultations, emergency admissions and interventions. Impact on key hospital resources such as critical care and imaging facilities during the two time periods were also examined., Results: There was an absolute reduction of 44% in the number of patients who required urgent or emergency treatment from P1 to P2 (141 vs 79). We noted a non-significant trend towards an increase in the proportion of patients presenting with Chronic Limb Threatening Ischaemia (CLTI) Rutherford 5&6 (P=0.09) as well as a reduction in the proportion of admissions related to Aortic Aneurysm (P=0.21). There was a significant absolute reduction of 77% in all vascular interventions from P1 to P2 with the greatest reductions noted in Carotid (P=0.02), Deep Venous (P=0.003) and Aortic interventions (P=0.016). The number of lower limb interventions also decreased though there was a significant increase as a relative proportion of all vascular interventions in P2 (P=0.001). There was an absolute reduction in the number of scans performed for vascular pathology; Duplex scans reduced by 86%(P<0.002), CT scans by 68%(P<0.003) and MRIs by 74%(P<0.009)., Conclusion: We report a decrease in urgent and emergency vascular presentations, admissions and interventions. The reduction in patients presenting with lower limb pathology was not as significant as other vascular conditions, resulting in a significant rise in interventions for CLTI and DFI as a proportion of all vascular interventions. These observations will help guide the provision of vascular services during future pandemics., (Copyright © 2021 Elsevier Inc. All rights reserved.)

Objective: The incidence of chronic limb-threatening ischemia in diabetic patients is increasing. The factors influencing outcome after infrapopliteal revascularization in these patients are largely unknown. Therefore, this study aims to identify the impact of perioperative glucose control on the long-term outcomes in this patient cohort, and furthermore to identify other factors independently associated with outcome., Methods: Consecutive diabetic patients undergoing infrapopliteal endovascular revascularization for chronic limb-threatening ischemia were identified. Patients' demographics, procedural details, daily capillary blood glucose, and hemoglobin A1C levels were collected and analyzed against the study end points using Kaplan-Meier and Cox regression analysis., Results: A total of 437 infrapopliteal target vessels were successfully crossed in 203 patients. Amputation-free survival by Kaplan-Meier (estimate (standard error)%) was 74 (3.3)% and 63 (3.7)%, primary patency was 61 (4.2)% and 50 (4.9)%, assisted primary patency was 69 (5.2)% and 55 (6.1)%, and secondary patency was 71 (3.8)% and 59 (4.1)% at 1 year and 2 years, respectively. Cox regression analysis showed high perioperative capillary blood glucose levels to be an independent predictor of binary restenosis (hazard ratio [HR], 1.49; 95% confidence interval [CI], 1.31-1.1.78; P = .015). Postprocedural dual-antiplatelet therapy was found to be an independent predictor of amputation-free survival (HR, 1.69; 95% CI, 1.04-2.75; P = .033), and freedom from major adverse limb events (HR: 1.96; 95% CI, 1.16-3.27; P = .023) and baseline estimated glomerular filtration rate was significantly associated with better amputation-free survival (HR, 0.52; 95% CI, 0.31-0.87; P = .014)., Conclusions: Poor perioperative glycemic control is associated with a higher incidence of restenosis after infrapopliteal revascularization in diabetic patients. Dual antiplatelet therapy is associated with better outcomes in this group., (Crown Copyright © 2021. Published by Elsevier Inc. All rights reserved.)

Background: Recent advances in outpatient parenteral antibiotic therapy (OPAT) have largely focused on adult practice, and there are few published data on the safety and effectiveness of pediatric OPAT (p-OPAT)., Methods: During a 3-year period (2012 to 2015), data were prospectively collected on patients managed within the p-OPAT service at Southampton Children's Hospital, a tertiary pediatric hospital in the South of England., Results: A total of 130 p-OPAT episodes were managed during this period. The most frequently managed pathologies were bone and joint infections (44.6%), followed by ear, nose and throat (10.7%), respiratory (10.0%) and central nervous system (10.0%) infections. The most frequently used antimicrobial agent was ceftriaxone (n = 103; 79.2%). For the majority of p-OPAT episodes, antimicrobials were delivered in prefilled syringes (n = 109; 83.8%); 24-hour infusions administered by elastomeric devices were used less commonly (n = 16; 12.3%). The median duration of p-OPAT treatment was 9.2 days (interquartile range: 7.6-19.0 days). With regard to patient outcomes, 113 (86.9%) p-OPAT episodes resulted in cure and 12 (9.2%) in improvement; treatment failure occurred in 5 (3.9%) episodes. Intravenous catheter-related complications were rare. A total of 1683 bed days were saved over the 3-year period., Conclusions: Our data suggest that p-OPAT is safe and effective, with the potential to offer considerable savings for the healthcare economy through reduced length of inpatient stay.

Rationale: To identify infected contacts of tuberculosis (TB) cases, the UK National Institute for Health and Care Excellence (NICE) recommended the addition of IFN-γ release assays (IGRA) to the tuberculin skin test (TST) in its 2006 TB guidelines. Treatment for TB infection was no longer recommended for children who screened TST-positive but IGRA-negative., Objectives: We performed a cohort study to evaluate the risk of TB disease in this group., Methods: Children exposed to an infectious case of TB in their household were recruited from 11 pediatric TB clinics. TST and IGRA were performed at baseline, with IGRA repeated at 8 weeks and TST repeated if initially negative. Children were treated according to 2006 NICE guidelines and followed for 24 months., Measurements and Main Results: Of 431 recruited children, 392 completed the study. We diagnosed 48 (12.2%) cases of prevalent TB disease, 105 (26.8%) with TB infection, and 239 (60.9%) without TB infection or disease. Eighteen children aged 2 years and above had a positive TST but persistently negative IGRA. None received TB infection treatment and none developed TB disease. Ninety (26.1%) children qualified for TB infection treatment according to 2006 NICE guidelines. In contrast, 147 (42.7%) children would have qualified under revised NICE guidance, issued in 2016., Conclusions: In this low-prevalence setting we saw no incident cases of TB disease in children who were TST-positive but IGRA-negative and did not receive treatment for TB infection. Following the latest NICE guidance, significantly more children will require medication.