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BackgroundChanges over the last 5 years (2013–18) in the serotypes implicated in adult pneumococcal pneumonia and the patient groups associated with vaccine-type disease are largely unknown.MethodsWe conducted a population-based prospective cohort study of adults admitted to two large university hospitals with community-acquired pneumonia (CAP) between September 2013 and August 2018. Pneumococcal serotypes were identified using a novel 24-valent urinary monoclonal antibody assay and from blood cultures. Trends in incidence rates were compared against national invasive pneumococcal disease (IPD) data. Persons at risk of vaccine-type pneumonia (pneumococcal conjugate vaccine (PCV)13 and pneumococcal polysaccharide vaccine (PPV)23) were determined from multivariate analyses.FindingsOf 2934 adults hospitalised with CAP, 1075 (36.6%) had pneumococcal pneumonia. The annual incidence of pneumococcal pneumonia increased from 32.2 to 48.2 per 100 000 population (2013–18), predominantly due to increases in PCV13non7-serotype and non-vaccine type (NVT)-serotype pneumonia (annual incidence rate ratio 1.12, 95% CI 1.04 to 1.21 and 1.19, 95% CI 1.10 to 1.28, respectively). Incidence trends were broadly similar to IPD data. PCV13non7 (56.9% serotype 3) and PPV23non13 (44.1% serotype 8) serotypes were identified in 349 (32.5%) and 431 (40.1%) patients with pneumococcal pneumonia, respectively. PCV13-serotype pneumonia (dominated by serotype 3) was more likely in patients in the UK pneumococcal vaccination clinical risk group (adjusted OR (aOR) 1.73, 95% CI 1.31 to 2.28) while PPV23-serotype pneumonia was more likely in patients outside the clinical risk group (aOR 1.54, 95% CI 1.13 to 2.10).InterpretationThe incidence of pneumococcal CAP is increasing, predominantly due to NVT serotypes and serotype 3. PPV23-serotype pneumonia is more likely in adults outside currently identified clinical risk groups.

Vaccination with the 23-valent pneumococcal polysaccharide vaccine (PPV23) is available in the United Kingdom to adults aged 65 years or older and those in defined clinical risk groups. We evaluated the vaccine effectiveness (VE) of PPV23 against vaccine-type pneumococcal pneumonia in a cohort of adults hospitalised with community-acquired pneumonia (CAP). Using a case-control test-negative design, a secondary analysis of data was conducted from a prospective cohort study of adults (aged ≥16 years) with CAP hospitalised at 2 university teaching hospitals in Nottingham, England, from September 2013 to August 2018. The exposure of interest was PPV23 vaccination at any time point prior to the index admission. A case was defined as PPV23 serotype-specific pneumococcal pneumonia and a control as non-PPV23 serotype pneumococcal pneumonia or nonpneumococcal pneumonia. Pneumococcal serotypes were identified from urine samples using a multiplex immunoassay or from positive blood cultures. Multivariable logistic regression was used to derive adjusted odds of case status between vaccinated and unvaccinated individuals; VE estimates were calculated as (1 - odds ratio) × 100%. Of 2,357 patients, there were 717 PPV23 cases (48% vaccinated) and 1,640 controls (54.5% vaccinated). The adjusted VE (aVE) estimate against PPV23 serotype disease was 24% (95% CI 5%-40%, p = 0.02). Estimates were similar in analyses restricted to vaccine-eligible patients (n = 1,768, aVE 23%, 95% CI 1%-40%) and patients aged ≥65 years (n = 1,407, aVE 20%, 95% CI -5% to 40%), but not in patients aged ≥75 years (n = 905, aVE 5%, 95% CI -37% to 35%). The aVE estimate in relation to PPV23/non-13-valent pneumococcal conjugate vaccine (PCV13) serotype pneumonia (n = 417 cases, 43.7% vaccinated) was 29% (95% CI 6%-46%). Key limitations of this study are that, due to high vaccination rates, there was a lack of power to reject the null hypothesis of no vaccine effect, and that the study was not large enough to allow robust subgroup analysis in the older age groups. In the setting of an established national childhood PCV13 vaccination programme, PPV23 vaccination of clinical at-risk patient groups and adults aged ≥65 years provided moderate long-term protection against hospitalisation with PPV23 serotype pneumonia. These findings suggest that PPV23 vaccination may continue to have an important role in adult pneumococcal vaccine policy, including the possibility of revaccination of older adults.

In the UK, gout management is suboptimum, with only 40% of patients receiving urate-lowering therapy, usually without titration to achieve a target serum urate concentration. Nurses successfully manage many diseases in primary care. We compared nurse-led gout care to usual care led by general practitioners (GPs) for people in the community. Research nurses were trained in best practice management of gout, including providing individualised information and engaging patients in shared decision making. Adults who had experienced a gout flare in the previous 12 months were randomly assigned 1:1 to receive nurse-led care or continue with GP-led usual care. We assessed patients at baseline and after 1 and 2 years. The primary outcome was the percentage of participants who achieved serum urate concentrations less than 360 μmol/L (6 mg/dL) at 2 years. Secondary outcomes were flare frequency in year 2, presence of tophi, quality of life, and cost per quality-adjusted life-year (QALY) gained. Risk ratios (RRs) and 95% CIs were calculated based on intention to treat with multiple imputation. This study is registered with www.ClinicalTrials.gov, number NCT01477346. 517 patients were enrolled, of whom 255 were assigned nurse-led care and 262 usual care. Nurse-led care was associated with high uptake of and adherence to urate-lowering therapy. More patients receiving nurse-led care had serum urate concentrations less than 360 μmol/L at 2 years than those receiving usual care (95% vs 30%, RR 3·18, 95% CI 2·42–4·18, p<0·0001). At 2 years all secondary outcomes favoured the nurse-led group. The cost per QALY gained for the nurse-led intervention was £5066 at 2 years. Nurse-led gout care is efficacious and cost-effective compared with usual care. Our findings illustrate the benefits of educating and engaging patients in gout management and reaffirm the importance of a treat-to-target urate-lowering treatment strategy to improve patient-centred outcomes. Arthritis Research UK.

Introduction In 2007, the United States Food and Drug Admini- stration (FDA) reported an increased rate of adverse events, including non-fatal heart attacks, strokes, heart fail- ure, blood clots, and death, in patients with CKD when ESAs were adjusted to achieve and maintain a hemoglo- bin (Hgb) level greater than 12 g/dL. The risks of blood transfusions are numerous, including iron overload, transfusion reactions, transmis- sion of infectious agents, acute lung injury, and the development of alloantibodies, which can affect a patient's ability to receive organ transplants (Lawler et al., 2010; University of California - San Diego [UCSD] Medical Center, 2007).

BackgroundWith higher valency pneumococcal vaccines on the horizon and new adult immunisation strategies under discussion, we aimed to evaluate the contribution of individual pneumococcal serotypes to the burden of pneumococcal community-acquired pneumonia (CAP). Over 10 years, trends in pneumococcal pneumonia epidemiology in adults hospitalised with CAP were assessed. The risk factors and severity associated with serotype 3 were examined.MethodsWe conducted a prospective cohort study of adults hospitalised with CAP between September 2013 and May 2023. Pneumococcal serotypes were identified using a serotype-specific 24-valent urinary-antigen assay. Trends in the proportion of CAP due to pneumococcus and causative serotypes were compared prepandemic and postpandemic. Risk factors and severity of serotype 3 pneumonia were compared with other serotypes using logistic regression.ResultsOf 5186 patients with CAP, 2193 (42.2%) had pneumococcal pneumonia. The proportion of CAP due to pneumococcus increased across all ages between 2013 and 2023 (36.4%–66.9%, p<0.001). The proportion due to serotype 3 increased significantly from 13.4% (2013) to 48.8% (2023). Serotype 3 pneumonia in adults was associated with older age (p<0.001), male sex (adjusted OR (aOR) 2.22, 95% CI 1.64 to 3.01) and chronic renal disease (aOR 1.81, 95% CI 1.09 to 3.02). Serotype 3 pneumonia was not observed to be associated with severity, critical care requirement, mortality or readmission.InterpretationSerotype 3 is the predominant serotype in adult pneumococcal CAP and has been increasing despite a mature infant pneumococcal immunisation programme, consistent with a lack of herd protection for this serotype.

Background: Macrosomia (birthweight ≥4kg) and rapid weight gain in infancy are both strong independent risk factors for early child overweight. Whilst there are environmental and genetic factors that contribute to an infant's high birthweight, the continued exposure to an obesogenic environment that predisposes macrosomia may also have an effect on early infant growth patterns. Rapid weight gain is potentially modifiable if identified during early life. There is some evidence from randomised controlled trials that interventions delivered in infancy may reduce the risk of early child overweight. However parental beliefs on infant size have identified a preference for bigger babies and as such these beliefs may be barriers to engaging with interventions that could mitigate rapid weight gain. Aims: 1. To determine the prevalence of macrosomia in a representative sample of infants in Nottinghamshire. 2. To explore the relationship between social disadvantage and macrosomia. 3. To determine the prevalence of rapid weight gain in the first year of life. 4. To explore the relationship between social disadvantage and rapid weight gain in the first year of life 5. To explore the interaction between macrosomia and rapid weight gain in socially deprived areas. 6. To investigate whether infants who undergo rapid weight gain in the first year of life in deprived areas remain heavy at year two. 7. To explore the relationship between social disadvantage and rapid weight gain in the first year of life in low birth weight infants. For infants born big and/or growing rapidly the aim for the qualitative study was: To explore parental beliefs around caring for infants with risk factors for child obesity with a view to informing the development of a targeted behaviour change intervention. Results: The research cohort contained 8904 term infants, born to mothers registered with a Nottinghamshire General Practitioner. In an area with a high rate of child obesity, the overall prevalence of macrosomia in the 2008 Nottingham birth research cohort was 12.2%, the proportion of rapid weight gain (as an increase of >0.67in weight-for-age z score) infants was 29.7%. Male infants were found to have a 1.9 times increased risk of macrosomia and a 1.4 times increased risk of rapid weight gain compared to females. Asian ethnicity appeared to be protective for both macrosomia (54%) and rapid weight gain (30%) compared to White infants. Black ethnicity was associated with a three-fold increased risk of being overweight at aged two. There was a 30% increased risk of macrosomia for infants born in the moderately deprived area compared with the most deprived. Infants in the most deprived areas had only 1.2 times increased risk of rapid weight gain compared to the least deprived areas. In a small subsample n=36, infants born macrosomic in the most deprived areas, the risk of rapid weight gain increased more than two-fold compared to infants in the least deprived areas. Being classified as macrosomic at birth increased the infant's chances of being overweight at age two by 3.9 times. Infants who grew rapidly in their first year also had an increased chance of being overweight at aged two by 2.4 times. From this study there appears to be little evidence that deprivation is associated with either macrosomia or rapid infant weight gain. The strongest predictors of child overweight at aged two were being born macrosomic and growing rapidly in the first year. Twenty four parents of infants who were born big and/or grew rapidly were recruited to the qualitative study. Four key themes emerged from the thematic data analysis. Parents were unconcerned about their child's high weight and justified high weight status with a variety of explanations including familial traits and that weight gain was believed to be positive and indicative of health. Parents' understanding of feeding baby demonstrated a propensity for overfeeding and parents' weaning decisions were heavily influenced by infant size with parents believing that bigger infants required earlier weaning. Implications for practice There is emerging evidence that responsive feeding is effective in reducing early childhood overweight. However rather than targeting responsive feeding interventions in accordance to socioeconomic status for which this research found no justification, focusing on those infants who were born big or growing fast may be more effective. In order to recognise those infants with a growth pattern of concern it is recommended that all infants are weighed at 4 months. This would allow the Health Visiting teams the opportunity to assess early childhood overweight risk based on growth trajectory. The study also identifies that further research is needed to facilitate communication between Health Visitors and parents with regard to preventing rapid infant weight gain and a checklist grounded in the parental beliefs of caring for infants at risk of early childhood overweight needs to be developed. Conclusions: Macrosomia and rapid weight gain prevalence rates are high in this representative birth cohort. For infants who are born big, and/or grow rapidly their parents report behaviours that will maintain this situation. Whilst responsive feeding interventions have shown promise in mitigating rapid infant growth, there is a need to facilitate communication between Health Visitors and parents on preventing rapid infant weight gain, for these interventions to become effective.

Community-acquired pneumonia (CAP) is associated with prolonged symptom persistence during recovery. However, the effect of the residual symptom load on healthcare utilisation is unknown. The aim of this study was to quantify healthcare reconsultation within 28 days of hospital discharge for an index episode of CAP, and explore reasons for these reconsultations. Adults of working age admitted to any of four hospitals in the UK, with a primary diagnosis of CAP, were prospectively studied. Of 108 patients, 71 (65.7%) reconsulted healthcare services within 28 days of discharge; of these, 90.1% consulted their GP. Men were less likely to reconsult than women (adjusted odds ratio [aOR] 0.34, 95% confidence interval 0.13–0.91, p=0.032). Persistence of respiratory symptoms accounted for the majority of these reconsultations. Healthcare utilisation is high in working-age adults after an episode of hospitalised CAP and, in most cases, is due to failure to resolve index symptoms.

I am a former Valleyview resident, having lived there from 1969 to 1980. I attended all grades of school in Valleyview back when my name was Debbie Smith.

I was shocked and dismayed to read that the teachers union does not support athletics for students. Shame on you!

What do people around the world know about Melbourne? We sent reporters on to the streets of New York, London, Tokyo, Moscow and Beijing to find out.