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Interfacility patient movement plays an important role in the dissemination of antimicrobial-resistant organisms throughout healthcare systems. We evaluated how 3 alternative measures of interfacility patient sharing were associated with C. difficile infection incidence in Ontario acute-care facilities.
The cohort included adult acute-care facility stays of ≥3 days between April 2003 and March 2016. We measured 3 facility-level metrics of patient sharing: general patient importation, incidence-weighted patient importation, and C. difficile case importation. Each of the 3 patient-sharing metrics were examined against the incidence of C. difficile infection in the facility per 1,000 stays, using Poisson regression models.
The analyzed cohort included 6.70 million stays at risk of C. difficile infection across 120 facilities. Over the 13-year period, we included 62,189 new cases of healthcare-associated CDI (incidence, 9.3 per 1,000 stays). After adjustment for facility characteristics, general importation was not strongly associated with C. difficile infection incidence (risk ratio [RR] per doubling, 1.10; 95% confidence interval [CI], 0.97–1.24; proportional change in variance [PCV], −2.0%). Incidence-weighted (RR per doubling, 1.18; 95% CI, 1.06–1.30; PCV, −8.4%) and C. difficile case importation (RR per doubling, 1.43; 95% CI, 1.29–1.58; PCV, −30.1%) were strongly associated with C. difficile infection incidence.
In this 13-year study of acute-care facilities in Ontario, interfacility variation in C. difficile infection incidence was associated with importation of patients from other high-incidence acute-care facilities or specifically of patients with a recent history of C. difficile infection. Regional infection control strategies should consider the potential impact of importation of patients at high risk of C. difficile shedding from outside facilities.
Expressivists about normative thought and discourse traditionally deny that there are nondeflationary normative propositions. However, it has recently been suggested that expressivists might avoid a number of problems by providing a theory of normative propositions compatible with expressivism. This paper explores the prospects for developing an expressivist theory of propositions within the framework of cognitive act theories of propositions. First, I argue that the only extant expressivist theory of cognitive propositions—Michael Ridge's ‘ecumenical expressivist’ theory—fails to explain identity conditions for normative propositions. Second, I argue that this failure motivates a general constraint—the ‘unity requirement’—that any expressivist theory of propositions must provide a unified nonrepresentational explanation of that in virtue of which propositional attitudes have the content that they have. Third, I argue that conceptual role accounts of content provide a promising framework in which to develop an expressivist theory of cognitive propositions.
Disaster Medicine (DM) education for Emergency Medicine (EM) residents is highly variable due to time constraints, competing priorities, and program expertise. The investigators’ aim was to define and prioritize DM core competencies for EM residency programs through consensus opinion of experts and EM professional organization representatives.
Investigators utilized a modified Delphi methodology to generate a recommended, prioritized core curriculum of 40 DM educational topics for EM residencies.
The DM topics recommended and outlined for inclusion in EM residency training included: patient triage in disasters, surge capacity, introduction to disaster nomenclature, blast injuries, hospital disaster mitigation, preparedness, planning and response, hospital response to chemical mass-casualty incident (MCI), decontamination indications and issues, trauma MCI, disaster exercises and training, biological agents, personal protective equipment, and hospital response to radiation MCI.
This expert-consensus-driven, prioritized ranking of DM topics may serve as the core curriculum for US EM residency programs.
We have observed the G23 field of the Galaxy AndMass Assembly (GAMA) survey using the Australian Square Kilometre Array Pathfinder (ASKAP) in its commissioning phase to validate the performance of the telescope and to characterise the detected galaxy populations. This observation covers ~48 deg2 with synthesised beam of 32.7 arcsec by 17.8 arcsec at 936MHz, and ~39 deg2 with synthesised beam of 15.8 arcsec by 12.0 arcsec at 1320MHz. At both frequencies, the root-mean-square (r.m.s.) noise is ~0.1 mJy/beam. We combine these radio observations with the GAMA galaxy data, which includes spectroscopy of galaxies that are i-band selected with a magnitude limit of 19.2. Wide-field Infrared Survey Explorer (WISE) infrared (IR) photometry is used to determine which galaxies host an active galactic nucleus (AGN). In properties including source counts, mass distributions, and IR versus radio luminosity relation, the ASKAP-detected radio sources behave as expected. Radio galaxies have higher stellar mass and luminosity in IR, optical, and UV than other galaxies. We apply optical and IR AGN diagnostics and find that they disagree for ~30% of the galaxies in our sample. We suggest possible causes for the disagreement. Some cases can be explained by optical extinction of the AGN, but for more than half of the cases we do not find a clear explanation. Radio sources aremore likely (~6%) to have an AGN than radio quiet galaxies (~1%), but the majority of AGN are not detected in radio at this sensitivity.
To evaluate the association between novel pre- and post-operative biomarker levels and 30-day unplanned readmission or mortality after paediatric congenital heart surgery.
Children aged 18 years or younger undergoing congenital heart surgery (n = 162) at Johns Hopkins Hospital from 2010 to 2014 were enrolled in the prospective cohort. Collected novel pre- and post-operative biomarkers include soluble suppression of tumorgenicity 2, galectin-3, N-terminal prohormone of brain natriuretic peptide, and glial fibrillary acidic protein. A model based on clinical variables from the Society of Thoracic Surgery database was developed and evaluated against two augmented models.
Unplanned readmission or mortality within 30 days of cardiac surgery occurred among 21 (13%) children. The clinical model augmented with pre-operative biomarkers demonstrated a statistically significant improvement over the clinical model alone with a receiver-operating characteristics curve of 0.754 (95% confidence interval: 0.65–0.86) compared to 0.617 (95% confidence interval: 0.47–0.76; p-value: 0.012). The clinical model augmented with pre- and post-operative biomarkers demonstrated a significant improvement over the clinical model alone, with a receiver-operating characteristics curve of 0.802 (95% confidence interval: 0.72–0.89; p-value: 0.003).
Novel biomarkers add significant predictive value when assessing the likelihood of unplanned readmission or mortality after paediatric congenital heart surgery. Further exploration of the utility of these novel biomarkers during the pre- or post-operative period to identify early risk of mortality or readmission will aid in determining the clinical utility and application of these biomarkers into routine risk assessment.
The initial classic Fontan utilising a direct right atrial appendage to pulmonary artery anastomosis led to numerous complications. Adults with such complications may benefit from conversion to a total cavo-pulmonary connection, the current standard palliation for children with univentricular hearts.
A single institution, retrospective chart review was conducted for all Fontan conversion procedures performed from July, 1999 through January, 2017. Variables analysed included age, sex, reason for Fontan conversion, age at Fontan conversion, and early mortality or heart transplant within 1 year after Fontan conversion.
A total of 41 Fontan conversion patients were identified. Average age at Fontan conversion was 24.5 ± 9.2 years. Dominant left ventricular physiology was present in 37/41 (90.2%) patients. Right-sided heart failure occurred in 39/41 (95.1%) patients and right atrial dilation was present in 33/41 (80.5%) patients. The most common causes for Fontan conversion included atrial arrhythmia in 37/41 (90.2%), NYHA class II HF or greater in 31/41 (75.6%), ventricular dysfunction in 23/41 (56.1%), and cirrhosis or fibrosis in 7/41 (17.1%) patients. Median post-surgical follow-up was 6.2 ± 4.9 years. Survival rates at 30 days, 1 year, and greater than 1-year post-Fontan conversion were 95.1, 92.7, and 87.8%, respectively. Two patients underwent heart transplant: the first within 1 year of Fontan conversion for heart failure and the second at 5.3 years for liver failure.
Fontan conversion should be considered early when atrial arrhythmias become common rather than waiting for severe heart failure to ensue, and Fontan conversion can be accomplished with an acceptable risk profile.
In 2013, the national surveillance case definition for West Nile virus (WNV) disease was revised to remove fever as a criterion for neuroinvasive disease and require at most subjective fever for non-neuroinvasive disease. The aims of this project were to determine how often afebrile WNV disease occurs and assess differences among patients with and without fever. We included cases with laboratory evidence of WNV disease reported from four states in 2014. We compared demographics, clinical symptoms and laboratory evidence for patients with and without fever and stratified the analysis by neuroinvasive and non-neuroinvasive presentations. Among 956 included patients, 39 (4%) had no fever; this proportion was similar among patients with and without neuroinvasive disease symptoms. For neuroinvasive and non-neuroinvasive patients, there were no differences in age, sex, or laboratory evidence between febrile and afebrile patients, but hospitalisations were more common among patients with fever (P < 0.01). The only significant difference in symptoms was for ataxia, which was more common in neuroinvasive patients without fever (P = 0.04). Only 5% of non-neuroinvasive patients did not meet the WNV case definition due to lack of fever. The evidence presented here supports the changes made to the national case definition in 2013.
Measurements of x-ray production as a function of depth in a sample (ϕ(ρz) curves) are fundamental to the determination of the quantitative equations for relating x-ray intensity to composition in electron probe microanalysis. These ϕ(ρz) curves have been measured for four different voltages and a number of different tracers in aluminum, copper, silver arid gold as matrix elements. From these ϕ(ρz) curves the absorption correction curves (f(x) curves) can be calculated. Such curves have been obtained and comparison is made with the absorption correction equations of Philibert. The effect of a tilted sample on the absorption correction is also discussed.
A method for measuring the atomic number effect is developed using a sandwich sample technique. The depth distributions of x-ray production, ϕ(ρz) curves, have been measured for a zinc tracer in aluminum, copper, silver and gold matrices at 30, 25, 20 and 15 keV. The ϕ(ρz) curves were measured using a Cambridge Microscan 5 in which the electron beam is normal to the sample surface and the x-ray take-off angle is 75°.
Samples of the low concentrations of copper (∼1 Weight %) in aluminum, nickel, silver and gold were prepared. For each alloy system (for example, Cu - Al), three different concentrations of copper were prepared. The intensity ratios from the sample to the pure element (standard) for each system have been plotted against concentration. At such low concentrations of copper the relation between this ratio and concentration is linear. The slopes of the curves have been compared to the equivalent factors obtained as ratios of the area under F(ρz) curves for aluminum, silver and gold to the area under F(ρz) curve for copper, respectively. The F(ρz) curves are obtained from ϕ(ρz) curves; F(ρz) = ϕ(ρz) exp(-μρz csc ψ) where μ is mass absorption coefficient.
Comparisons are made between these experimental data and the current methods of calculating the atomic number effect.
A method for calculation of the integral reflection coefficient of crystals of interrnediate perfection is introduced. This method can greatly reduce experimental effort for the selection and calibration of crystals, It also serves as a conceptual framework for studies of mosaic block structure and of crystal modification. Good agreement between calculated and experimental values of the integral reflection coefficient is shown for, (a) LiF crystals of two degrees of perfection, (b) elastically bent quartz, and (c) 001, 005, 006, and 007 diffraction from KAP. Zachariasen's division of crystals into two types is extended. It is concluded that the integral reflection coefficients for 200 LiF cannot be raised to the ideally imperfect limiting values.
OBJECTIVES/SPECIFIC AIMS: The purpose of this case series is to show how helping parents instill a non-restrictive, structure-based (i.e., authoritative) approach to feeding is useful in addressing family food conflicts in a clinical child obesity treatment program. METHODS/STUDY POPULATION: Case reports are presented for 3 young children (two 8-year-old males and one 7-year-old female) with obesity (BMI ≥ 95th percentile for age and sex). Patients underwent family-based treatment at Brenner FIT® (Families In Training), an interdisciplinary tertiary weight management clinic. RESULTS/ANTICIPATED RESULTS: All patients experienced a period of rapid weight gain and/or severe onset obesity. Parents reported a combination of problematic eating behaviors (e.g., sneaking food, frequent complaints of hunger, vomiting from rapid consumption). Families implemented structure-based feeding with a meal-snack schedule and allowed children to eat until they were full from the food provided at meal-snack times. BMI z-score decreased from 2.19 to 2.07 in patient 1 and from 2.43 to 2.09 in patient 2 (follow-up weight was not available for patient 3). DISCUSSION/SIGNIFICANCE OF IMPACT: The improvements observed by our clinical program after families lifted restriction and instituted authoritative feeding is anecdotal evidence for the ecological validity of existing empirical work. Randomized controlled trials are needed to examine causality.
OBJECTIVES/SPECIFIC AIMS: Engaging patients and consumers in research is a complex process where innovative strategies are needed to effectively translate scientific discoveries into improvements in the public’s health (Wilkins et. al., 2013; Terry et. al., 2013). The Clinical Translational Science Awards (CTSA)—supported by the National Institute of Health (NIH) under the auspices of the National Center for Advancing Translational Sciences (NCATS)—aim to provide resources and support needed to strengthen our nation’s clinical and translational research (CTR) enterprise. In 2008, Stanford University was awarded a CTSA from the NIH, establishing Spectrum (Stanford Center for Clinical and Translational Research and Education) and its Community Engagement (CE) Program aimed at building long-standing community-academic research partnerships for translational research in the local area surrounding Stanford University. To date, the CE Pilot Program has funded 38 pilot projects from the 2009-2017 calendar year. The purpose of this study was to understand, through a unique pilot program, the barriers, challenges, and facilitators to community-engaged research targeting health disparities as well as community-academic partnerships. METHODS/STUDY POPULATION: Investigators conducted a qualitative study of the community engagement pilot program. Previous pilot awardees were recruited via email and phone to participate in a one-hour focus group to discuss their pilot project experience—describing any barriers, challenges, and facilitators to implementing their pilot project. RESULTS/ANTICIPATED RESULTS: The focus group revealed that community engage research through the pilot program was not only appreciated by faculty, but projects were successful, and partnerships developed were sustained after funding. Specifically, the pilot program has seen success in both traditional and capacity building metrics: the initial investment of $652,250.00 to fund 38 projects has led to over $11 million dollars in additional grant funding. In addition, pilot funding has led to peer-reviewed publications, data resources for theses and dissertations, local and national presentations/news articles, programmatic innovation, and community-level impact. Challenges and barriers were mainly related to timing, grant constraints, and university administrative processes. DISCUSSION/SIGNIFICANCE OF IMPACT: The Community Engagement Pilot Program demonstrates an innovative collaborative approach to support community-academic partnerships. This assessment highlights the value and importance of pilot program to increase community engaged research targeting health disparities. Challenges are mainly administrative in nature: pilot awardees mentioned difficulties working on university quarterly timelines, challenges of subcontracting or sharing money with community partners, onerous NIH prior approval process, and limitations to carryover funding. However, pilot grants administered through the program strengthen the capacity to develop larger scale community-based research initiatives.
Adverse pregnancy outcomes including prematurity and low birth weight (LBW) have been associated with life-long chronic disease risk for the infant. Stress during pregnancy increases the risk of adverse pregnancy outcomes. Many studies have reported the incidence of adverse pregnancy outcomes in Indigenous populations and a smaller number of studies have measured rates of stress and depression in these populations. This study sought to examine the potential association between stress during pregnancy and the rate of adverse pregnancy outcomes in Australian Indigenous women residing in rural and remote communities in New South Wales. This study found a higher rate of post-traumatic stress disorder, depression and anxiety symptoms during pregnancy than the general population. There was also a higher incidence of prematurity and LBW deliveries. Unfortunately, missing post-traumatic stress disorder and depressive symptomatology data impeded the examination of associations of interest. This was largely due to the highly sensitive nature of the issues under investigation, and the need to ensure adequate levels of trust between Indigenous women and research staff before disclosure and recording of sensitive research data. We were unable to demonstrate a significant association between the level of stress and the incidence of adverse pregnancy outcomes at this stage. We recommend this longitudinal study continue until complete data sets are available. Future research in this area should ensure prioritization of building trust in participants and overestimating sample size to ensure no undue pressure is placed upon an already stressed participant.