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In this piece I characterise global expressivism, as I understand it, by contrasting it with five other views: the so-called Canberra Plan; Moorean non-naturalism and platonism; ‘relaxed realism’ and quietism; local expressivism; and response-dependent realism. Some other familiar positions, including fictionalism, error theories, and idealism, are also mentioned, but as sub-cases to one of these five.
Shakespeare wrote in the shadow of war. His plays deal with the historical conflicts of medieval England and ancient Rome but they were written during the French Wars of Religion, the Anglo-Spanish War, the Nine Years’ War in Ireland, and other significant pan-European conflicts.
To evaluate the clinical impact of an antimicrobial stewardship program (ASP) on high-risk pediatric patients.
Retrospective cohort study.
Free-standing pediatric hospital.
This study included patients who received an ASP review between March 3, 2008, and March 2, 2017, and were considered high-risk, including patients receiving care by the neonatal intensive care (NICU), hematology/oncology (H/O), or pediatric intensive care (PICU) medical teams.
The ASP recommendations included stopping antibiotics; modifying antibiotic type, dose, or duration; or obtaining an infectious diseases consultation. The outcomes evaluated in all high-risk patients with ASP recommendations were (1) hospital-acquired Clostridium difficile infection, (2) mortality, and (3) 30-day readmission. Subanalyses were conducted to evaluate hospital length of stay (LOS) and tracheitis treatment failure. Multivariable generalized linear models were performed to examine the relationship between ASP recommendations and each outcome after adjusting for clinical service and indication for treatment.
The ASP made 2,088 recommendations, and 50% of these recommendations were to stop antibiotics. Recommendation agreement occurred in 70% of these cases. Agreement with an ASP recommendation was not associated with higher odds of mortality or hospital readmission. Patients with a single ASP review and agreed upon recommendation had a shorter median LOS (10.2 days vs 13.2 days; P < .05). The ASP recommendations were not associated with high rates of tracheitis treatment failure.
ASP recommendations do not result in worse clinical outcomes among high-risk pediatric patients. Most ASP recommendations are to stop or to narrow antimicrobial therapy. Further work is needed to enhance stewardship efforts in high-risk pediatric patients.
Schools provide a unique opportunity to influence healthy eating decisions in children. Field experiments provide a practical tool for evaluating the types of interventions that can have the largest impact on these decisions in the short and long run. This article provides some insights on conducting field experiments in schools; the issues it covers are related to data collection, randomization, heterogeneous treatment effects, and statistical inference.
Within the third wave of digital service innovation, framing is becoming increasingly complex. Accordingly, design practice finds itself in a transition from designing single service solutions that are shared, to designing systemic solutions that are shareable. We report a case study in which we use Cultural Historical Activity Theory (CHAT) to analyze the framing process that a designer went through when designing a digital service for a Connected Care startup. Results show the importance of the designer's activity awareness and the challenge of dealing with relational complexity when framing the digital service innovation. With this work, we hope to inspire researchers and practitioners with the potential that CHAT has to offer for the reflective practice in digital service innovations.
Impaired capacity towards the end of life is common (Kolva, 2014). Physical frailty, uncontrolled physical symptoms or complications of chronic illness lead to hospital admissions, which are a vulnerable time for those with diminished capacity.
To identify the prevalence and demographic characteristics of food insecurity in a presurgical bariatric population. To date there has been no research on food insecurity in a presurgical bariatric population.
Participants completed the ten-item adult food security survey module created by the US Department of Agriculture (USDA), with additional questions related to food shopping behaviours and perceived affordability of post-bariatric supplements. USDA scoring guidelines were used to classify participants as food secure, marginally food secure and food insecure.
Academic medical centre bariatric surgery clinic in Central Pennsylvania, USA.
Adult bariatric surgery candidates (n 174).
There was a prevalence of 17·8 % for food insecurity and 27·6 % for marginal food security. Food insecurity was associated with younger age, higher BMI, non-White race/ethnicity, having less than a college education, living in an urban area, receiving Medicaid/Medicare and participating in nutrition assistance programmes. Food-insecure participants endorsed food shopping behaviours that could interfere with postsurgical dietary adherence and perceived post-bariatric supplies as unaffordable or inaccessible.
These results highlight the importance of screening bariatric surgical patients for food insecurity. Further study of this important problem within the bariatric population should address effects of food insecurity and related shopping behaviours on postsurgical outcomes and inform the development of programmes to better assist these high-risk patients.
Several studies have reported evidence of interference between respiratory viruses: respiratory viruses rarely reach their epidemic peak concurrently and there appears to be a negative association between infection with one respiratory virus and co-infection with another. We used results spanning 16 years (2002–2017) of a routine diagnostic multiplex panel that tests for nine respiratory viruses to further investigate these interactions in Victoria, Australia. Time series analyses were used to plot the proportion positive for each virus. The seasonality of all viruses included was compared with respiratory syncytial virus (RSV) and influenza A virus using cross-correlations. Logistic regression was used to explore the likelihood of co-infection with one virus given infection with another. Seasonal peaks were observed each year for influenza A and RSV and less frequently for influenza B, coronavirus and parainfluenza virus. RSV circulated an average of 6 weeks before influenza A. Co-infection with another respiratory virus was less common with picornavirus, RSV or influenza A infection. Our findings provide further evidence of a temporal relationship in the circulation of respiratory viruses. A greater understanding of the interaction between respiratory viruses may enable better prediction of the timing and magnitude of respiratory virus epidemics.
Optimal transition from child to adult services involves continuity, joint care, planning meetings and information transfer; commissioners and service providers therefore need data on how many people require that service. Although attention-deficit hyperactivity disorder (ADHD) frequently persists into adulthood, evidence is limited on these transitions.
To estimate the national incidence of young people taking medication for ADHD that require and complete transition, and to describe the proportion that experienced optimal transition.
Surveillance over 12 months using the British Paediatric Surveillance Unit and Child and Adolescent Psychiatry Surveillance System, including baseline notification and follow-up questionnaires.
Questionnaire response was 79% at baseline and 82% at follow-up. For those aged 17–19, incident rate (range adjusted for non-response) of transition need was 202–511 per 100 000 people aged 17–19 per year, with successful transition of 38–96 per 100 000 people aged 17–19 per year. Eligible young people with ADHD were mostly male (77%) with a comorbid condition (62%). Half were referred to specialist adult ADHD and 25% to general adult mental health services; 64% had referral accepted but only 22% attended a first appointment. Only 6% met optimal transition criteria.
As inclusion criteria required participants to be on medication, these estimates represent the lower limit of the transition need. Two critical points were apparent: referral acceptance and first appointment attendance. The low rate of successful transition and limited guideline adherence indicates significant need for commissioners and service providers to improve service transition experiences.
To determine the best nursing home facility characteristics for aggregating antibiotic susceptibility testing results across nursing homes to produce a useful annual antibiogram that nursing homes can use in their antimicrobial stewardship programs.
Derivation cohort study.
Center for Medicare and Medicaid Services (CMS) certified skilled nursing facilities in Georgia (N = 231).
All residents of eligible facilities submitting urine culture specimens for microbiologic testing at a regional referral laboratory.
Crude and adjusted metrics of antibiotic resistance prevalence (percent of isolates testing susceptible) for 5 bacterial species commonly recovered from urine specimens were calculated using mixed linear models to determine which facility characteristics were predictive of testing antibiotic susceptibility.
In a single year, most facilities had an insufficient number of isolates tested to create facility-specific antibiograms: 49% of facilities had sufficient Escherichia coli isolates tested, but only about 1 in 10 had sufficient isolates of Klebsiella pneumoniae, Proteus mirabilis, Enterococcus faecalis, or Pseudomonas aeruginosa. After accounting for antibiotic tested and age of the patient, facility characteristics predictive of susceptibility were: E. coli, region, year, average length of stay; K. pneumoniae, region, bed size; P. mirabilis, region; and for E. faecalis or P. aerginosa no facility parameter remained in the model.
Nursing homes often have insufficient data to create facility-specific antibiograms; aggregating data across nursing homes in a region is a statistically sound approach to overcoming data shortages in nursing home stewardship programs.
The archaeological site of Saruq al-Hadid, Dubai, United Arab Emirates, presents a long sequence of persistent temporary human occupation on the northern edge of the Rub’ al-Khali desert. The site is located in active dune fields, and evidence for human activity is stratified within a deep sequence of natural dune deposits that reflect complex taphonomic processes of deposition, erosion and reworking. This study presents the results of a program of radiocarbon (14C) and thermoluminescence dating on deposits from Saruq al-Hadid, allied with studies of material remains, which are amalgamated with the results of earlier absolute dating studies provide a robust chronology for the use of the site from the Bronze Age to the Islamic period. The results of the dating program allow the various expressions of human activity at the site—ranging from subsistence activities such as hunting and herding, to multi-community ritual activities and large scale metallurgical extraction—to be better situated chronologically, and thus in relation to current debates regarding the development of late prehistoric and early historic societies in southeastern Arabia.
Describe the epidemiological and molecular characteristics of an outbreak of Klebsiella pneumoniae carbapenemase (KPC)–producing organisms and the novel use of a cohorting unit for its control.
A 566-room academic teaching facility in Milwaukee, Wisconsin.
Solid-organ transplant recipients.
Infection control bundles were used throughout the time of observation. All KPC cases were intermittently housed in a cohorting unit with dedicated nurses and nursing aids. The rooms used in the cohorting unit had anterooms where clean supplies and linens were placed. Spread of KPC-producing organisms was determined using rectal surveillance cultures on admission and weekly thereafter among all consecutive patients admitted to the involved units. KPC-positive strains underwent pulsed-field gel electrophoresis and whole-genome sequencing.
A total of 8 KPC cases (5 identified by surveillance) were identified from April 2016 to April 2017. After the index patient, 3 patients acquired KPC-producing organisms despite implementation of an infection control bundle. This prompted the use of a cohorting unit, which immediately halted transmission, and the single remaining KPC case was transferred out of the cohorting unit. However, additional KPC cases were identified within 2 months. Once the cohorting unit was reopened, no additional KPC cases occurred. The KPC-positive species identified during this outbreak included Klebsiella pneumoniae, Enterobacter cloacae complex, and Escherichia coli. blaKPC was identified on at least 2 plasmid backbones.
A complex KPC outbreak involving both clonal and plasmid-mediated dissemination was controlled using weekly surveillances and a cohorting unit.
Workforce shortages in psychiatry are common worldwide. The international literature provides insights into factors influencing decisions to train in psychiatry but is predominately survey based. This national cohort study aimed to identify the characteristics of doctors who were most likely to apply to psychiatry training programmes. The sample comprised doctors who entered UK medical schools in 2007/8 and who made first-time specialty training applications in 2015. The association between application to psychiatry and doctors' sociodemographic and educational characteristics was examined using multivariable logistic regression.
Those most likely to apply were White, privately educated older doctors with below average performance at medical school.
To reduce workforce shortages, psychiatry must make itself more attractive to all doctors, especially those from underrepresented groups such as state-educated Black and minority ethnic individuals. Otherwise, national policies to widen participation in the study of medicine by such groups may exacerbate the current recruitment crisis.
Introduction: Trauma and injury play a significant role in the population's burden of disease. Limited research exists evaluating the role of trauma bypass protocols. The objective of this study was to assess the impact and effectiveness of a newly introduced prehospital field trauma triage (FTT) standard, allowing paramedics to bypass a closer hospital and directly transport to a trauma centre (TC) provided transport times were within 30 minutes. Methods: We conducted a 12-month multi-centred health record review of paramedic call reports and emergency department health records following the implementation of the 4 step FTT standard (step 1: vital signs and level of consciousness, step 2: anatomical injury, step 3: mechanism and step 4: special considerations) in nine paramedic services across Eastern Ontario. We included adult trauma patients transported as an urgent transport to hospital, that met one of the 4 steps of the FTT standard and would allow for a bypass consideration. We developed and piloted a standardized data collection tool and obtained consensus on all data definitions. The primary outcome was the rate of appropriate triage to a TC, defined as any of the following: injury severity score ≥12, admitted to an intensive care unit, underwent non-orthopedic operation, or death. We report descriptive and univariate analysis where appropriate. Results: 570 adult patients were included with the following characteristics: mean age 48.8, male 68.9%, attended by Advanced Care Paramedic 71.8%, mechanisms of injury: MVC 20.2%, falls 29.6%, stab wounds 10.5%, median initial GCS 14, mean initial BP 132, prehospital fluid administered 26.8%, prehospital intubation 3.5%, transported to a TC 74.6%. Of those transported to a TC, 308 (72.5%) had bypassed a closer hospital prior to TC arrival. Of those that bypassed a closer hospital, 136 (44.2%) were determined to be “appropriate triage to TC”. Bypassed patients more often met the step 1 or step 2 of the standard (186, 66.9%) compared to the step 3 or step 4 (122, 39.6%). An appropriate triage to TC occurred in 104 (55.9%) patients who had met step 1 or 2 and 32 (26.2%) patients meeting step 3 or 4 of the FTT standard. Conclusion: The FTT standard can identify patients who should be bypassed and transported to a TC. However, this is at a cost of potentially burdening the system with poor sensitivity. More work is needed to develop a FTT standard that will assist paramedics in appropriately identifying patients who require a trauma centre.
Introduction: Depending on the time and day of initial Emergency Department (ED) presentation, some patients may require a return to the ED the following day for ultrasound examination. Return visits for ultrasound may be time and resource intensive for both patients and the ED. Qualitative experience suggests that a percentage of return ultrasounds could be performed at a non-ED facility. Our objective was to undertake a retrospective audit of return for ultrasound usage, patterns and outcomes at 2 academic EDs. Methods: A retrospective review of all adult patients returning to the ED for ultrasound at both LHSC ED sites in 2016 was undertaken. Each chart was independently reviewed by two emergency medicine consultants. Charts were assessed for day and time of initial presentation and return, type of ultrasound ordered, and length of ED stay on initial presentation and return visit. Opinion based questions were considered by reviewers, including urgency of diagnosis clarification required, if symptoms were still present on return, and if any medical or surgical treatment or follow up was arranged based on ultrasound results. Agreement between reviewers was assessed. Results: After eliminating charts for which the return visit was not for a scheduled ultrasound examination, 328 patient charts were reviewed. 63% of patients were female and median [IQR] age was 40 years [27-56]. Abdomen/pelvis represented 50% of the ultrasounds; renal 24%; venous Doppler 15.9%. Symptoms were still present and documented in 79% of cases. 22% of cases required a medical intervention and 9% an immediate surgical intervention. 11% of patients were admitted to hospital on their return visit. Outpatient follow-up based on US results was initiated in 29% of cases. Median [IQR] combined LOS was 479.5 minutes [358.5-621.75]. Agreement between reviewers for opinion based questions was poor (63%-96%). Conclusion: Ideally, formal ultrasound should be available on a 24 hour basis for ED patients in order to avoid return visits. A percentage of return for ultrasound examinations do not result in any significant change in treatment. Emergency departments should consider the development of pathways to avoid return visits for follow up ultrasound when possible. The low incidence of surgical treatment in those returning for US suggests that this population could be served in a non-hospital setting. Further research is required to support this conclusion.
Age at sexual debut is known to have implications for future sexual behaviours and health outcomes, including HIV infection, early pregnancy and maternal mortality, but may also influence educational outcomes. Longitudinal data on schooling and sexual behaviour from a demographic surveillance site in Karonga district, northern Malawi, were analysed for 3153 respondents between the ages of 12 and 25 years to examine the association between sexual debut and primary school dropout, and the role of prior school performance. Time to dropout was modelled using the Fine and Gray survival model to account for the competing event of primary school completion. To deal with the time-varying nature of age at sexual debut and school performance, models were fitted using landmark analyses. Sexual debut was found to be associated with a five-fold increase in rate of subsequent dropout for girls and a two-fold increase in dropout rate for boys (adjusted hazard ratio [aHR] of 5.27, CI 4.22–6.57, and 2.19, CI 1.77–2.7, respectively). For girls who were sexually active by age 16, only 16% ultimately completed primary schooling, compared with 70% aged 18 or older at sexual debut. Prior to sexual debut, girls had primary completion levels similar to those of boys. The association between sexual debut and school dropout could not be explained by prior poor school performance: the effect of sexual debut on dropout was as strong among those who were not behind in school as among those who were overage for their school grade. Girls who were sexually active were more likely to repeat a grade, with no effect being seen for boys. Pathways to dropout are complex and may differ for boys and girls. Interventions are needed to improve school progression so children complete primary school before sexual debut, and to improve sex education and contraception provision.
The noun ‘affect’ derives from the Latin affectus, past participle of the verb afficere, meaning ‘to influence’. The Oxford English Dictionary (OED) compares it to the Old French affet, meaning ‘desire, passion’, and the Middle French affect meaning ‘state, disposition’. The connotations of affectus include physical, mental and emotional states and an ‘influence or impression’ (OED). Since the end of the eighteenth century, scholarly contemplations of ‘affect’ have been characterized by consideration of the relationship between mind and body, and between sensation, feeling, emotion, thought and action. For instance, in 1799, Kant distinguished between ‘affects’ and ‘passions’, commenting that ‘the former belong to feeling, so far as it, preceding reflection, renders it more difficult, or even impossible’ (OED). In 1891 J. M. Baldwin observed: ‘Affects […] are the feeling antecedents of involuntary movements; as motives, including affects, are the inner antecedents of acts of will’ (OED). Baldwin's comment draws out the idea of movement inherent in the etymology of ‘affect’: the term indicates both the impetus to movement and its effect, as one thing ‘influences’ or ‘impresses’ itself upon another.
Affect has remained a contested concept since the critical debates generated by the ‘affective turn’ (Clough 2007) that took place in the mid-1990s in the humanities and other disciplines. But studies of affect share a focus on the relationship between the body and feelings, elucidating ‘both our power to affect the world around us and our power to be affected by it’ (Hardt 2007, ix). This relationship is the subject of the two works published in 1995 which are widely agreed to have established the two main areas of enquiry about affect in the humanities: Eve Sedgwick and Adam Frank's essay, ‘Shame in the Cybernetic Fold’, which discusses Silvan Tomkins's ‘psychobiological’ Affect, Imagery, and Consciousness: The Positive Affects (1962); and Brian Massumi's ‘The Autonomy of Affect’, which draws on Gilles Deleuze's ‘Spinozist ethology of bodily capacities’ (Gregg and Seigworth 2010, 5). Theorists working in these areas frequently return to Darwin, Spinoza or Freud to explore the relationship between external, bodily and pre-cognitive energies and forces, and how they are both ‘captured’ in emotion and ‘escape’ into what Massumi (1995, 96) argues is ‘unassimilable to any particular, functionally anchored perspective’ (emphasis in the original).