https://www.thelancet.com/pdfs/journals/lancet/PIIS0140-6736(07)61690-0.pdf

Maternal and child undernutrition: global and regional exposures and health consequences

admission. This proportion could already be greater in some parts of the country and may increase if referrals of cases of self-poisoning increase faster than the facilities for their assessment and management. The provision of social work and psychiatric expertise in casualty departments may be one means of preventing unnecessary medical admissions without risk to the patients. Dr Blake's and Dr Bramble's figures do not demonstrate, however, that any advantage would attach to medical teams taking over assessment from psychiatrists except that, by implication, assessments would be completed sooner by staff working on the ward full time. What the figures actually suggest is that if assessment of overdoses were left to house doctors there would be an increase in admissions to psychiatric units (by 19°U), outpatients (by 5O°'), and referrals to social services (by 140o). So for house doctors to assess overdoses would provide no economy for the psychiatric or social services. The study does not tell us what the consequences would have been for the six patients who the psychiatrists would have admitted but to whom the house doctors would have offered outpatient appointments. E J SALTER

Vitamin D deficiency.

Summary Background Since December, 2019, Wuhan, China, has experienced an outbreak of coronavirus disease 2019 (COVID-19), caused by the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). Epidemiological and clinical characteristics of patients with COVID-19 have been reported but risk factors for mortality and a detailed clinical course of illness, including viral shedding, have not been well described. Methods In this retrospective, multicentre cohort study, we included all adult inpatients (≥18 years old) with laboratory-confirmed COVID-19 from Jinyintan Hospital and Wuhan Pulmonary Hospital (Wuhan, China) who had been discharged or had died by Jan 31, 2020. Demographic, clinical, treatment, and laboratory data, including serial samples for viral RNA detection, were extracted from electronic medical records and compared between survivors and non-survivors. We used univariable and multivariable logistic regression methods to explore the risk factors associated with in-hospital death. Findings 191 patients (135 from Jinyintan Hospital and 56 from Wuhan Pulmonary Hospital) were included in this study, of whom 137 were discharged and 54 died in hospital. 91 (48%) patients had a comorbidity, with hypertension being the most common (58 [30%] patients), followed by diabetes (36 [19%] patients) and coronary heart disease (15 [8%] patients). Multivariable regression showed increasing odds of in-hospital death associated with older age (odds ratio 1·10, 95% CI 1·03–1·17, per year increase; p=0·0043), higher Sequential Organ Failure Assessment (SOFA) score (5·65, 2·61–12·23; p Interpretation The potential risk factors of older age, high SOFA score, and d-dimer greater than 1 μg/mL could help clinicians to identify patients with poor prognosis at an early stage. Prolonged viral shedding provides the rationale for a strategy of isolation of infected patients and optimal antiviral interventions in the future. Funding Chinese Academy of Medical Sciences Innovation Fund for Medical Sciences; National Science Grant for Distinguished Young Scholars; National Key Research and Development Program of China; The Beijing Science and Technology Project; and Major Projects of National Science and Technology on New Drug Creation and Development.

Clinical course and risk factors for mortality of adult inpatients with COVID-19 in Wuhan, China: a retrospective cohort study

Severe or therapy-resistant asthma is increasingly recognised as a major unmet need. A Task Force, supported by the European Respiratory Society and American Thoracic Society, reviewed the definition and provided recommendations and guidelines on the evaluation and treatment of severe asthma in children and adults. A literature review was performed, followed by discussion by an expert committee according to the GRADE (Grading of Recommendations, Assessment, Development and Evaluation) approach for development of specific clinical recommendations. When the diagnosis of asthma is confirmed and comorbidities addressed, severe asthma is defined as asthma that requires treatment with high dose inhaled corticosteroids plus a second controller and/or systemic corticosteroids to prevent it from becoming “uncontrolled” or that remains “uncontrolled” despite this therapy. Severe asthma is a heterogeneous condition consisting of phenotypes such as eosinophilic asthma. Specific recommendations on the use of sputum eosinophil count and exhaled nitric oxide to guide therapy, as well as treatment with anti-IgE antibody, methotrexate, macrolide antibiotics, antifungal agents and bronchial thermoplasty are provided. Coordinated research efforts for improved phenotyping will provide safe and effective biomarker-driven approaches to severe asthma therapy.

/pdf/international-ers-ats-guidelines-on-definition-evaluation-sedelwbk4v.pdf

International ERS/ATS guidelines on definition, evaluation and treatment of severe asthma

https://www.thelancet.com/pdfs/journals/lancet/PIIS0140-6736(10)61388-8.pdf

Worldwide burden of disease from exposure to second-hand smoke: a retrospective analysis of data from 192 countries.

Privatization has been shown to improve the efficiency and growth of public firms. However, the effects for consumers are understudied. We study potential trade-offs in the case of US hospitals, where public control of capacity declined by 42% over 1983–2019. Across 257 transitions, privatized hospitals downsize capacity and patient care, with Medicaid patients experiencing the greatest decline. While other patients are reallocated across facilities, Medicaid patients experience an aggregate decline in utilization at the market-level, which we interpret as a decline in access. Private control substantially decreases labor intensity and related spending, consistent with a trade-off between maintaining access and lowering costs. *We would like to thank Reigne Dadey, Emma Hou, and Megan Olomu for outstanding research assistance. We received helpful comments and suggestions from Diane Alexander, David Card, Janet Currie, Jetson Leder-Luis, Boris Vabson, and participants at Harvard-MIT-BU health economics, Berkeley, Wharton, National Tax Association, APPAM, ASHEcon, and the Midwest Health Economics annual conferences. All remaining errors are our own. †Corresponding author: Atul Gupta. Email: atulgup@wharton.upenn.edu Public hospital decline 1

The Impact of Privatization: Evidence from the Hospital Sector

Background Serum vitamin D levels have been related to asthma control and medication use in children with mild to moderate disease, but little is known about the relationship between serum vitamin D levels and airway remodelling and mucosal inflammation in asthma. We hypothesised that lower serum vitamin D levels would be associated with increased airway inflammation and remodelling and lower lung function in children with severe therapy resistant asthma (STRA). Methods Nineteen children aged between 6 and 16 years with STRA underwent spirometry, fiberoptic bronchoscopy, endobronchial biopsy, and measurement of serum vitamin D (25(OH)D 3 nmol/l). Endobronchial biopsies stained with H&E were used to quantify airway remodelling (reticular basement membrane thickness, smooth muscle mass and epithelial shedding). Immunohistochemistry was used to quantify smooth muscle cell proliferation using proliferating cell nuclear antigen, and inflammatory cells (eosinophils, neutrophils and mast cells). Results Seventeen of 19 children with STRA were vitamin D insufficient ( 3 29 (21–39) nmol/l. There was no relationship between serum 25(OH)D 3 and submucosal eosinophils, neutrophils or mast cells. Airway smooth muscle mass was inversely related to serum 25(OH)D 3 (r=−0.6, p=0.007) (Abstract S33 figure 1), but there was no relationship between vitamin D levels and reticular basement membrane thickness or epithelial shedding. Lung function was not related to serum vitamin D levels, however bronchodilator reversibility was inversely related to serum 25(OH)D 3 levels (r=−0.53, p=0.02). Conclusions Vitamin D insufficiency is common in children with STRA. Lower vitamin D levels in children with STRA were associated with increased airway smooth muscle and increased bronchodilator reversibility. Randomised controlled trials of vitamin D supplementation are warranted in paediatric STRA.

https://thorax.bmj.com/content/thoraxjnl/66/Suppl_4/A18.1.full.pdf

S33 Vitamin D and airway remodelling in paediatric severe therapy resistant asthma

Rationale Pulmonary complications are common after Orthotopic Liver Transplant (OLT). The aim of study was to establish the incidence of pulmonary complications and associated mortality in first year after liver transplants in children at King’s College Hospital, London, one of the largest Paediatric Liver transplant centres in Europe. Methods This was a retrospective study on children with OLT who developed pulmonary complications in the post transplant period. Medical records and radiology reports of children who had liver transplants from 2009–2011 were evaluated and incidence and outcome of acute pulmonary complications were determined. These complications were pleural effusion, atelectasis, consolidation, pulmonary oedema, pulmonary haemorrhage and diaphragmatic dysfunction. The association between these and mortality within one year was assessed. The incidence of chronic cough, new onset asthma and sleep related problems were also analysed during the one-year follow up. Results The study included 146 children who underwent a total of 151 liver transplantations. Medical records were available for 148 transplant episodes. Median age was 2.5 years with an Inter Quartile Range (IQR) of 1.0 – 8.9 years. Out of 148 transplants, 74 (50%) developed pleural effusion (95% CI of OR 1.3 –2.3), 44/148 had atelectasis while more than half (78/148) had evidence of infiltrates or lobar consolidation (95% CI of OR 0.8 –1.7). Thirty-two had pulmonary oedema while only 3 had pulmonary hypertension or pulmonary haemorrhage. Twelve children died at the end of 1 year with a 92% survival rate. Amongst different causes of liver transplant, acute liver failure was statistically significant to cause pleural effusion, and a major cause of mortality. Pulmonary complications were independent of the medical condition at the time of occurrence, and did not predict mortality. The number of children with documented new onset asthma, chronic cough or sleep disordered breathing during the first year of follow up period was 3/148 (1.3%). Conclusion Pulmonary complications are common after OLT. The mortality rate due to these pulmonary complications is lower than in previously reported studies. A study with a larger sample size and a long term follow up that primarily focuses on acute liver failure will confirm the association between the acute complications and mortality.

https://adc.bmj.com/content/archdischild/99/Suppl_1/A37.1.full.pdf

G87 Pulmonary complications in children with orthotopic liver transplant

Introduction Spirometry is often normal in children with STRA, and is thus a poor outcome measure (1). Lung Clearance Index is a sensitive, non-effort dependent measure of distal airway gas mixing, which has been shown to be more sensitive than spirometry in Cystic Fibrosis (2). We hypothesised that LCI would be a better marker of steroid response in STRA than spirometry. Patients and Methods 22 STRA children (Mean age 11.9 years, 15 male) had LCI and spirometry measured before and 4 weeks after intramuscular triamcinolone. Results LCI was elevated in 18/22 prior to triamcinolone and 12/22 at the follow-up; in contrast FEV 1 was only abnormal in 10/22 and 6/22 pretriamcinolone and posttriamcinolone respectively. Mean LCI fell from 7.86 to 7.25 (p 1 after triamcinolone. Conclusion LCI is a better discriminant of STRA then FEV 1 , and is more responsive to steroid treatment. LCI may thus be a better outcome measure in STRA.

https://thorax.bmj.com/content/thoraxjnl/66/Suppl_4/A99.2.full.pdf

P77 Lung clearance index (LCI) in children with severe, therapy resistant asthma (STRA)

A 4 year old boy with Down’s syndrome has a long history of sleep disturbance. He snores at night, his sleep is very restless, and he sleeps for long periods during the day while at nursery. He was admitted for an overnight sleep study, a six hour epoch of which is displayed below (fig 1)⇓. A treatment intervention improved sleep quality. 



Fig 1 Overnight sleep study showing transcutaneous carbon dioxide (CO2), oxygen saturation (SaO2), and heart recordings





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Fig 2 Overnight sleep study showing abnormalities in transcutaneous carbon dioxide (CO2), oxygen saturation (SaO2), and heart recordings

Atul Gupta

Papers

The Impact of Privatization: Evidence from the Hospital Sector

S33 Vitamin D and airway remodelling in paediatric severe therapy resistant asthma

G87 Pulmonary complications in children with orthotopic liver transplant

P77 Lung clearance index (LCI) in children with severe, therapy resistant asthma (STRA)

Sleep disordered breathing in a 4 year old child with Down's syndrome.