A Retrospective Study of Adult and Pediatric D‐Dimer Tests to Identify Opportunities for Improved Utilization

ABSTRACT Introduction D‐dimers are produced by lysis of cross‐linked fibrin. In children, D‐dimer testing is used to evaluate disseminated intravascular coagulation (DIC) and some inflammatory states, but its use is not validated for screening or ruling out suspected venous thromboembolic events (VTE). In adults, D‐dimers are used to evaluate DIC, and a low D‐dimer level is used to exclude VTE in patients when combined with a low or moderate probability of VTE. Methods To assess D‐dimer utilization and opportunities for improvement, we conducted a retrospective, consecutive‐case cohort study (with ethics approval) of patients who had D‐dimer tests at Hamilton hospitals, from 06/2022 to 05/2023. Results D‐dimer levels were evaluated for 175 children and 200 adults (respective results, children/adults: median ages: 12/63, ranges 0–17/18–94 years), and an overlapping cohort of 99 consecutive persons with ≥ 5 D‐dimer determinations. Most patients had D‐dimer tests in emergency departments (60%/62%) and elevated D‐dimer levels (55%/61%). Reasons for D‐dimer assessment included: suspected VTE (50%/70%), DIC (17%/3.5%), childhood inflammatory conditions (23%/0%), and “off‐label” uses (e.g., arterial thrombosis assessment; 5%/22%). VTE likelihood and DIC scores were rarely documented. Patients with multiple tests accounted for 15% of D‐dimer workload. Among patients with multiple tests for DIC, most had overt DIC on initial assessment, with declining D‐dimer levels over 10–14 days, including patients who died. Conclusion VTE and DIC assessment was the most common reason for D‐dimer assessments for children and adults. Quality improvement initiatives are needed to improve relevant clinical VTE and DIC score documentation and D‐dimer test utilization.

Vascular Access Specialist Teams Across Australia and New Zealand: A Survey of Workforce Models and Clinical Practice

ABSTRACT Aim The study's aim is to describe workforce models and practices related to vascular access device (VAD) insertion, maintenance and monitoring across Australia and New Zealand. Background VAD failure is associated with device selection and insertion, factors typically determined by the inserting clinician. However, clinician training and skill in vascular assessment and insertion are often inconsistent and undervalued. Design A prospective, cross‐sectional, internet‐based survey of workforce models and vascular access specialist teams (VASTs). Results Among 237 participants (November 2023 to February 2024), most worked in metropolitan ( n  = 127; 54.0%) or regional hospitals ( n  = 54; 23%), caring for adult ( n  = 227; 95.8%) and/or paediatric ( n  = 170; 71.7%) patients. One‐third ( n  = 78; 33.0%) had a VAST, primarily comprising clinical nurse specialist/consultants ( n  = 73; 93.6%), generalist nurses ( n  = 39; 50%) and anaesthetists ( n  = 15; 32%). VAD selection was most often performed by medical staff ( n  = 211; 89.0%), though 29.1% ( n  = 69) reported VAST‐led selection. Escalation pathways for difficult vascular access (DIVA) were more common in facilities with a VAST ( n  = 65; 83.3%) than without ( n  = 55; 41.0%). Midline catheter use was higher where VAST were present (76.9% vs. 48.5%). Conclusion VAST presence was associated with greater use of escalation pathways and varied device type/technique such as ultrasound guided‐PIVCs and midlines. However, limited staffing restricts the broader implementation of these benefits.

First 1000 Days Strategies to Prevent Childhood Obesity: A Narrative Review and Recommendations From the EndObesity Consortium

ABSTRACT Childhood obesity remains a major global public health challenge, leading to significant short‐ and long‐term adverse health outcomes and imposing substantial societal costs. Recognising the critical importance of early intervention, the Horizon2020 EU‐funded JPI Consortium EndObesity has prioritised the first 1000 days of life, from preconception to 2 years of age, as a key window for obesity prevention strategies. This narrative review synthesises findings from the EndObesity Consortium, summarising evidence from large multi‐cohort studies on the influence of family‐based health behaviours in the first 1000 days on offspring obesity risk, the potential of childhood obesity prediction models in the first 1000 days, and strategies to enhance prenatal and postnatal interventions to prevent childhood obesity development. Finally, we present recommendations for research, practice, and policy to address the complex, multifaceted challenges of childhood obesity prevention in the first 1000 days.

Adipose Depot Changes and Associated Metabolic Risk in the Longitudinal Health Influences of Puberty Study

ABSTRACT Objective To assess longitudinal changes in abdominal subcutaneous and visceral adipose tissue (SAT and VAT), hepatic fat fraction (HFF) and pancreatic fat fraction (PFF) across puberty in youth with/without obesity and examine associations with cardiometabolic risk markers. Methods Within the Health Influences of Puberty (HIP) cohort, we included 19 participants (53% female, 37% obesity) who completed magnetic resonance imaging (MRI) at early (Tanner 2/3) and late (Tanner 4/5) puberty to assess abdominal SAT and VAT areas (cm 2 ), HFF (%) and PFF (%). Cardiometabolic markers included glucose/insulin measures assessed by intravenous glucose tolerance test, fasting lipid panel and adipokines. Results From early to late puberty, among youth with obesity, median (interquartile range) abdominal SAT increased 83.1cm 2 (43.4) and, among youth without obesity, VAT/SAT ratio decreased −0.08 (0.08) and HFF increased 0.6% (0.5). In linear mixed models of adipose depots in early puberty and metabolic markers measured twice during puberty, adjusted for BMI group, abdominal SAT was positively associated with leptin β (95% confidence interval): 1.05 (0.35, 1.74), and VAT was positively associated with triglycerides 0.32 (0.02, 0.61) and high‐sensitivity c‐reactive protein (hsCRP) 1.40 (0.31, 2.49), while HFF was inversely associated with insulin sensitivity 0.32 (−0.58, −0.07) and PFF was inversely associated with adiponectin 0.23 (−0.42, −0.04) (all p  < 0.05). Conclusion In this small sample, abdominal and ectopic fat depots in early puberty were uniquely associated with alterations in cardiometabolic risk markers during puberty. Trial Registration: ClinicalTrials.gov identifier: NCT01775813

Humoral epitope dominance and immune imprinting by SARS ‐ CoV ‐1 and SARS ‐ CoV ‐2 vaccines

Abstract Long‐lasting protective immunity against sarbecoviruses is hampered by the dominance of elicited antibodies to variable parts of the Spike protein, allowing ongoing viral escape and evolution. We investigated Modified Vaccinia Ankara (MVA) vaccine candidates expressing the SARS‐CoV‐1 or SARS‐CoV‐2 Spike for their ability to induce antibodies targeting different epitopes on the SARS‐CoV‐2 Receptor Binding Domain (RBD), including those with wide variant conservation. We also explored the capacity of these different Spike proteins to induce broad cross‐reactive or cross‐neutralizing B cells against multiple variants. This revealed that the SARS‐CoV‐1 Spike induced distinct patterns of epitope dominance compared to the traditional SARS‐CoV‐2 Spike antigens. Following immune imprinting by previous exposure to ancestral SARS‐CoV‐2 Spike, the epitope dominance patterns induced by SARS‐CoV‐1 and SARS‐CoV‐2 vaccines still differed, with most of the germinal center response consisting of de novo recruited B cells. In addition to the de novo response, B cells with germline cross‐reactivity to both antigens further increased their binding toward the most recently immunized antigen. Interestingly, we found that, while SARS‐CoV‐2 vaccinated animals were extremely capable of mounting an antigen‐specific germinal center and plasmablast response to a booster immunization with SARS‐CoV‐1, SARS‐CoV‐2 boosters were less capable of inducing SARS‐CoV‐2 specific B cells following prior SARS‐CoV‐1 vaccination. These findings have broad implications for the implementation of vaccine strategies against emerging coronavirus variants and potential future coronavirus spillover events. The implications stemming from a fundamental directionality of immune imprinting and epitope dominance may have wider implications for noncoronavirus antigens.

Mycobacterium thermoresistibile infection leading to wound dehiscence in an immunocompetent host

Current clinical practice trends in giant cell arteritis diagnosis and management: a national survey of Australian rheumatologists and rheumatology trainees

Abstract Introduction Giant cell arteritis (GCA) is the most common vasculitis of the elderly. Delayed diagnosis or inadequate treatment can lead to severe and irreversible consequences. There are limited data on diagnosis and management practices of rheumatologists and rheumatology trainees in Australia. This study aimed to determine practices and views of Australian rheumatologists/rheumatology trainees in the diagnosis and management of GCA. Methods An online survey was completed by Australian rheumatologists/trainees. The survey gathered data on the respondent demographics and a range of topics related to the diagnosis and management of GCA, including the use of temporal artery biopsy (TAB) and imaging, confidence in ultrasound, use of steroid‐sparing medication, and approaches to aortic aneurysm screening and referral back to primary care. Results There were 58 respondents (52 rheumatologists, six trainees). On average, respondents used TAB alone (56% of respondents), imaging alone (19%), both (15%) or neither (10%). The majority of respondents (79%) rarely or never made a diagnosis of GCA without TAB. Only 40% expressed confidence in GCA diagnosis by temporal artery ultrasound from their preferred radiology provider. Management approaches following the end of government‐funded tocilizumab varied. Only 12% of respondents reported that >50% of their GCA patients were able to cease prednisolone by 12 months. Conclusions Australian rheumatologists and trainees have low confidence in ultrasound and rarely make a diagnosis of GCA without a TAB. Variable practice would support the need to develop Australian clinical care standards for GCA.

Resistant Insistent Persistent: A Global Call by Mental Health Nursing Leaders

A Decade‐Long Follow‐Up of Supernumerary Tooth Leading Up to Cemental Tear: A Pediatric Case Report

ABSTRACT Background Cemental tear (CeT), a detachment of the root cementum, is rarely reported in pediatric populations and often misdiagnosed as root fractures or endodontic‐periodontal lesions. Case Report This is the first documented instance of CeT in a healthy 12‐year‐old female, likely a result of the extraction of a supernumerary tooth (mesiodens). The patient had a supernumerary tooth diagnosed at age 2 that was extracted at age 10. Radiograph after 1 year of supernumerary tooth extraction revealed a linear radiopacity adjacent to the left maxillary central incisor, diagnosed as CeT by specialists. Despite the radiographic signs, the tooth remained asymptomatic and vital, with no surgical intervention required. This case underscores the importance of including CeT in the differential diagnosis for pediatric patients with unexplained periodontal changes following surgical or traumatic events. Conservative monitoring was successful, likely due to children's enhanced regenerative capacity. The case also highlights the diagnostic value of angled periapical radiographs in detecting CeT. Conclusion Pediatric dentists should be aware of CeT as a potential diagnosis in young patients and consider less invasive management approaches. A revised decision‐making algorithm for managing supernumerary teeth is proposed to reflect these findings.

Offshoring and Labor Market Power: Comparing Belgian and Dutch Firms

ABSTRACT We study the relationship between offshoring and labor market imperfections at the firm level in Belgium and the Netherlands. In both countries, wage‐markup pricing stemming from workers' monopoly power is more prevalent than wage‐markdown pricing originating from firms' monopsony power. Offshoring is associated with a higher prevalence and intensity of wage markdowns, driven by an increase in productivity that is only imperfectly passed through into an increase in wages. The lower firm‐level productivity‐wage pass‐through in Belgium, attributed to its more centralized bargaining structure, makes wage markdowns more responsive to offshoring.