To send content items to your account,
please confirm that you agree to abide by our usage policies.
If this is the first time you use this feature, you will be asked to authorise Cambridge Core to connect with your account.
Find out more about sending content to .
To send content items to your Kindle, first ensure email@example.com
is added to your Approved Personal Document E-mail List under your Personal Document Settings
on the Manage Your Content and Devices page of your Amazon account. Then enter the ‘name’ part
of your Kindle email address below.
Find out more about sending to your Kindle.
Note you can select to send to either the @free.kindle.com or @kindle.com variations.
‘@free.kindle.com’ emails are free but can only be sent to your device when it is connected to wi-fi.
‘@kindle.com’ emails can be delivered even when you are not connected to wi-fi, but note that service fees apply.
Evaluation of a mandatory immunization program to increase and sustain high immunization coverage for healthcare personnel (HCP).
Descriptive study with before-and-after analysis.
Tertiary-care academic medical center.
Medical center HCP.
A comprehensive mandatory immunization initiative was implemented in 2 phases, starting in July 2014. Key facets of the initiative included a formalized exemption review process, incorporation into institutional quality goals, data feedback, and accountability to support compliance.
Both immunization and overall compliance rates with targeted immunizations increased significantly in the years after the implementation period. The influenza immunization rate increased from 80% the year prior to the initiative to >97% for the 3 subsequent influenza seasons (P < .0001). Mumps, measles and varicella vaccination compliance increased from 94% in January 2014 to >99% by January 2017, rubella vaccination compliance increased from 93% to 99.5%, and hepatitis B vaccination compliance from 95% to 99% (P < .0001 for all comparisons). An associated positive effect on TB testing compliance, which was not included in the mandatory program, was also noted; it increased from 76% to 92% over the same period (P < .0001).
Thoughtful, step-wise implementation of a mandatory immunization program linked to professional accountability can be successful in increasing immunization rates as well as overall compliance with policy requirements to cover all recommended HCP immunizations.
Gravitational waves from coalescing neutron stars encode information about nuclear matter at extreme densities, inaccessible by laboratory experiments. The late inspiral is influenced by the presence of tides, which depend on the neutron star equation of state. Neutron star mergers are expected to often produce rapidly rotating remnant neutron stars that emit gravitational waves. These will provide clues to the extremely hot post-merger environment. This signature of nuclear matter in gravitational waves contains most information in the 2–4 kHz frequency band, which is outside of the most sensitive band of current detectors. We present the design concept and science case for a Neutron Star Extreme Matter Observatory (NEMO): a gravitational-wave interferometer optimised to study nuclear physics with merging neutron stars. The concept uses high-circulating laser power, quantum squeezing, and a detector topology specifically designed to achieve the high-frequency sensitivity necessary to probe nuclear matter using gravitational waves. Above 1 kHz, the proposed strain sensitivity is comparable to full third-generation detectors at a fraction of the cost. Such sensitivity changes expected event rates for detection of post-merger remnants from approximately one per few decades with two A+ detectors to a few per year and potentially allow for the first gravitational-wave observations of supernovae, isolated neutron stars, and other exotica.
Introduction: Emergency department (ED) staff carry a high risk for the burnout syndrome of increased emotional exhaustion, depersonalization and decreased personal accomplishment. Previous research has shown that task-oriented coping skills were associated with reduced levels of burnout compared to emotion-oriented coping. ED staff at one hospital participated in an intervention to teach task-oriented coping skills. We hypothesized that the intervention would alter staff coping behaviors and ultimately reduce burnout. Methods: ED physicians, nurses and support staff at two regional hospitals were surveyed using the Maslach Burnout Inventory (MBI) and the Coping Inventory for Stressful Situations (CISS). Surveys were performed before and after the implementation of communication and conflict resolution skills training at the intervention facility (I) consisting of a one-day course and a small group refresher 6 to 15 months later. Descriptive statistics and multivariate analysis assessed differences in staff burnout and coping styles compared to the control facility (C) and over time. Results: 85/143 (I) and 42/110 (C) ED staff responded to the initial survey. Post intervention 46 (I) and 23(C) responded. During the two year study period there was no statistically significant difference in CISS or MBI scores between hospitals (CISS: (Pillai's trace = .02, F(3,63) = .47, p = .71, partial η2 = .02); MBI: (Pillai's trace = .01, F(3,63) = .11, p = .95, partial η2 = .01)) or between pre- and post-intervention groups (CISS: (Pillai's trace = .01, F(3,63) = .22, p = .88, partial η2 = .01); MBI: (Pillai's trace = .09, F(3,63) = 2.15, p = .10, partial η2 = .01)). Conclusion: We were not able to measure improvement in staff coping or burnout in ED staff receiving communication skills intervention over a two year period. Burnout is a multifactorial problem and environmental rather than individual factors may be more important to address. Alternatively, to demonstrate a measurable effect on burnout may require more robust or inclusive interventions.
Many novel therapeutic options for depression exist that are either not mentioned in clinical guidelines or recommended only for use in highly specialist services. The challenge faced by clinicians is when it might be appropriate to consider such ‘non-standard’ interventions. This analysis proposes a framework to aid this decision.
Declaration of interest
In the past 3 years R.H.M.W. has received support for research, expenses to attend conferences and fees for lecturing and consultancy work (including attending advisory boards) from various pharmaceutical companies including Astra Zeneca, Cyberonics, Eli Lilly, Janssen, LivaNova, Lundbeck, MyTomorrows, Otsuka, Pfizer, Roche, Servier, SPIMACO and Sunovion. D.M.B.C. has received fees from LivaNova for attending an advisory board. In the past 3 years A.J.C. has received fees for lecturing from Astra Zeneca and Lundbeck; fees for consulting from LivaNova, Janssen and Allergan; and research grant support from Lundbeck.
In the past 3 years A.C. has received fees for lecturing from pharmaceutical companies namely Lundbeck and Sunovion. In the past 3 years A.L.M. has received support for attending seminars and fees for consultancy work (including advisory board) from Medtronic Inc and LivaNova. R.M. holds joint research grants with a number of digital companies that investigate devices for depression including Alpha-stim, Big White Wall, P1vital, Intel, Johnson and Johnson and Lundbeck through his mindTech and CLAHRC EM roles. M.S. is an associate at Blueriver Consulting providing intelligence to NHS organisations, pharmaceutical and devices companies. He has received honoraria for presentations and advisory boards with Lundbeck, Eli Lilly, URGO, AstraZeneca, Phillips and Sanofi and holds shares in Johnson and Johnson. In the past 3 years P.R.A.S. has received support for research, expenses to attend conferences and fees for lecturing and consultancy work (including attending an advisory board) from life sciences companies including Corcept Therapeutics, Indivior and LivaNova. In the past 3 years P.S.T. has received consultancy fees as an advisory board member from the following companies: Galen Limited, Sunovion Pharmaceuticals Europe Ltd, myTomorrows and LivaNova. A.H.Y. has undertaken paid lectures and advisory boards for all major pharmaceutical companies with drugs used in affective and related disorders and LivaNova. He has received funding for investigator initiated studies from AstraZeneca, Eli Lilly, Lundbeck and Wyeth.
Adélie penguins (Pygoscelis adeliae) are responding to ocean–climate variability throughout the marine ecosystem of the western Antarctic Peninsula (WAP) where some breeding colonies have declined by 80%. Nuclear and mitochondrial DNA (mtDNA) markers were used to understand historical population genetic structure and gene flow given relatively recent and continuing reductions in sea ice habitats and changes in numbers of breeding adults at colonies throughout the WAP. Genetic diversity, spatial genetic structure, genetic signatures of fluctuations in population demography and gene flow were assessed in four regional Adélie penguin colonies. The analyses indicated little genetic structure overall based on bi-parentally inherited microsatellite markers (FST =-0.006–0.004). No significant variance was observed in overall haplotype frequency (mtDNA ΦST =0.017; P=0.112). Some comparisons with Charcot Island were significant, suggestive of female-biased philopatry. Estimates of gene flow based on a two-population coalescent model were asymmetrical from the species’ regional core to its northern range. Breeding Adélie penguins of the WAP are a panmictic population and hold adequate genetic diversity and dispersal capacity to be resilient to environmental change.
Salmonella is a leading cause of bacterial foodborne illness. We report the collaborative investigative efforts of US and Canadian public health officials during the 2013–2014 international outbreak of multiple Salmonella serotype infections linked to sprouted chia seed powder. The investigation included open-ended interviews of ill persons, traceback, product testing, facility inspections, and trace forward. Ninety-four persons infected with outbreak strains from 16 states and four provinces were identified; 21% were hospitalized and none died. Fifty-four (96%) of 56 persons who consumed chia seed powder, reported 13 different brands that traced back to a single Canadian firm, distributed by four US and eight Canadian companies. Laboratory testing yielded outbreak strains from leftover and intact product. Contaminated product was recalled. Although chia seed powder is a novel outbreak vehicle, sprouted seeds are recognized as an important cause of foodborne illness; firms should follow available guidance to reduce the risk of bacterial contamination during sprouting.
This study investigated the extent to which proximity to cattle and weather events in Alberta predispose human populations to E. coli O157 disease. Cases of human E. coli O157 infection in Alberta between 2004 and 2011 were obtained from the province's Communicable Disease Reporting System and Discharge Abstract Database. Regression models based on spatial area incorporated human infection data with livestock and weather covariates. A variety of regression models were applied (i.e. least squares, spatial lag/error, Poisson, negative binomial) to test the most appropriate approach. Ratios for the total number of calves, bulls and beef cows to human population were highlighted as significant cattle density variables in all final best-fitting models. Weather variables were not significant in final regression models averaged over the full study period. Our results provide evidence of a significant association between measures of cattle density and human E. coli O157 disease in Alberta.
To evaluate the impact of an institutional hand hygiene accountability program on healthcare personnel hand hygiene adherence.
Time-series design with correlation analysis.
Tertiary care academic medical center, including outpatient clinics and procedural areas.
Medical center healthcare personnel.
A comprehensive hand hygiene initiative was implemented in 2 major phases starting in July 2009. Key facets of the initiative included extensive project planning, leadership buy-in and goal setting, financial incentives linked to performance, and use of a system-wide shared accountability model. Adherence was measured by designated hand hygiene observers. Adherence rates were compared between baseline and implementation phases, and monthly hand hygiene adherence rates were correlated with monthly rates of device-associated infection.
A total of 109,988 observations were completed during the study period, with a sustained increase in hand hygiene adherence throughout each implementation phase (P<.0001) as well as from one phase to the next (P < .0001), such that adherence greater than 85% has been achieved since January 2011. Medical center departments were able to reclaim some rebate dollars allocated through a self-insurance trust, but during the study period, departments did not achieve full reimbursement. Hand hygiene adherence rates were inversely correlated with device-associated standardized infection ratios (R2 = 0.70).
Implementation of this multifaceted, observational hand hygiene program was associated with sustained improvement in hand hygiene adherence. The principles of this program could be applied to other medical centers pursuing improved hand hygiene adherence among healthcare personnel.
The success of central line-associated bloodstream infection (CLABSI) prevention programs in intensive care units (ICUs) has led to the expansion of surveillance at many hospitals. We sought to compare non-ICU CLABSI (nCLABSI) rates with national reports and describe methods of surveillance at several participating US institutions.
Design and Setting.
An electronic survey of several medical centers about infection surveillance practices and rate data for non-ICU Patients.
Ten tertiary care hospitals.
In March 2011, a survey was sent to 10 medical centers. The survey consisted of 12 questions regarding demographics and CLABSI surveillance methodology for non-ICU patients at each center. Participants were also asked to provide available rate and device utilization data.
Hospitals ranged in size from 238 to 1,400 total beds (median, 815). All hospitals reported using Centers for Disease Control and Prevention (CDC) definitions. Denominators were collected by different means: counting patients with central lines every day (5 hospitals), indirectly estimating on the basis of electronic orders (n = 4), or another automated method (n = 1). Rates of nCLABSI ranged from 0.2 to 4.2 infections per 1,000 catheter-days (median, 2.5). The national rate reported by the CDC using 2009 data from the National Healthcare Surveillance Network was 1.14 infections per 1,000 catheter-days.
Only 2 hospitals were below the pooled CLABSI rate for inpatient wards; all others exceeded this rate. Possible explanations include differences in average central line utilization or hospital size in the impact of certain clinical risk factors notably absent from the definition and in interpretation and reporting practices. Further investigation is necessary to determine whether the national benchmarks are low or whether the hospitals surveyed here represent a selection of outliers.
Vaccination of healthcare workers (HCWs) is an important strategy in the control and prevention of hospital outbreaks. The decision to vaccinate is often based on self-report of vaccination status. Self-report of previous receipt of tetanus-diphtheria or tetanus toxin vaccination was validated using an electronic medical record. Results showed that HCWs' self-report is reliable during a vaccination campaign.
To determine the impact of known observers on hand hygiene performance in inpatient care units with differing baseline levels of hand hygiene compliance.
Three inpatient care units, selected on the basis of past hand hygiene performance, in a hospital where hand hygiene observation and feedback are routine.
Three infection control practitioners (ICPs) and a student intern observed hospital staff.
Beginning in late 2005, the 3 ICPs, who were well known to the hospital staff, performed frequent, regular observations of hand hygiene in all 3 inpatient care units of the hospital, as part of routine surveillance. During the study period (January-May 2007), a student intern who was unknown to the hospital staff also performed observations of hand hygiene in the 3 inpatient care units. The rates of hand hygiene compliance observed by the 3 ICPs were compared with those observed by the student intern.
The 3 ICPs observed 332 opportunities for hand hygiene during 15 observation periods, and the student intern observed 355 opportunities during 19 observation periods. The overall rate of hand hygiene compliance observed by the ICPs was 65% (ie, in 215 of the 332 opportunities, the performance of proper hand hygiene by hospital staff was observed), and the overall rate of hand hygiene compliance observed by the student intern was 58% (ie, in 207 of the 355 opportunities, the performance of proper hand hygiene by hospital staff was observed) (P = .1). Both the ICPs and the student intern were able to distinguish between inpatient care units with a high rate of hand hygiene compliance (hereafter referred to as high-performing units) and those with a low rate (hereafter referred to as low-performing units). However, in the 2 high-performing units, the ICPs observed significantly higher compliance rates than did the student intern, whereas in the low-performing unit, both the ICPs and the student intern measured similarly low rates of hand hygiene compliance.
Recognized observers are associated with higher rates of hand hygiene compliance, even in a healthcare setting where such observations have become routine. This effect (ie, the Hawthorne effect) is more pronounced in high-performing units and insignificant in low-performing units. The use of unrecognized observers may be important for verifying high performance but is probably unnecessary for documenting poor performance. Moreover, the Hawthorne effect may be a useful tool for sustaining and improving hand hygiene compliance.
In light of consumers' and regulators' increasing focus on infection prevention, infection control practices and resources were surveyed at 134 hospitals owned by the Hospital Corporation of America. Infection control practices and resources varied substantially among hospitals, and many facilities reported difficulty acquiring the data they needed to report infection rates.
Comparative and functional fungal genomics
R. A. Dean, Center for Integrated Fungal Research Department of Plant Pathology 1200 Partners Building II Box 7251 North Carolina State University Raleigh NC 27695 USA,
T. Mitchell, North Carolina State University Department of Plant Pathology Campus Box 7251 Raleigh NC 27695–7251 USA,
R. Kulkarni, RTI 3040 Cornwallis Road Research Triangle Park NC 27709 USA,
N. Donofrio, North Carolina State University Department of Plant Pathology Campus Box 7251 Raleigh NC 27695–7251 USA,
A. Powell, North Carolina State University Department of Plant Pathology Campus Box 7251 Raleigh NC 27695–7251 USA,
Y. Y. Oh, North Carolina State University Department of Plant Pathology Campus Box 7251 Raleigh NC 27695–7251 USA,
S. Diener, North Carolina State University Department of Plant Pathology Campus Box 7253 Raleigh NC 27695–7253 USA,
H. Pan, RTI 3040 Cornwallis Road Research Triangle Park NC 27709 USA,
D. Brown, North Carolina State University Department of Plant Pathology Campus Box 7251 Raleigh NC 27695–7251 USA,
J. Deng, North Carolina State University Department of Plant Pathology Campus Box 7251 Raleigh NC 27695–7251 USA,
I. Carbone, North Carolina State University Department of Plant Pathology Campus Box 7244 Raleigh NC 27695–7244 USA,
D. J. Ebbole, Department of Plant Pathology and Microbiology Peterson Building Rm 120 MS# 2132 Texas A&M University College Station TX 77843–2132 USA,
M. Thon, Department of Computer Science 320C Peterson Building MS# 2132 Texas A&M University College Station TX 77843–2132 USA,
M. L. Farman, Department of Plant Pathology University of Kentucky 1405 Veterans Drive Lexington KY 40546–0312 USA,
M. J. Orbach, Department of Plant Pathology University of Arizona Forbes Room 105 PO Box 210036 Tucson AZ 85721–0036 USA,
C. Soderlund, Director of Bioinformatics Department of Plant Science 303 Forbes Building Tucson AZ 85721 USA,
J-R. Xu, Department of Botany and Plant Pathology 915 West State Street Purdue University West Lafayette IN 47906 USA,
Y-H. Lee, Seoul National University School of Agricultural Biotechnology Suwon 441–744 Korea,
N. J. Talbot, Department of Biological Sciences University of Exeter Hatherly Laboratories Prince of Wales Road Exeter EX4 4PS UK,
S. Coughlan, Agilent Technologies Inc. Little Falls Site 2850 Centerville Road Wilmington DE 19808 USA,
J. E. Galagan, The Broad Institute Massachusetts Institute of Technology 77 Massachusetts Avenue Cambridge MA 02139–4307 USA,
B. W. Birren, The Broad Institute Massachusetts Institute of Technology 77 Massachusetts Avenue Cambridge MA 02139–4307 USA
Rice blast disease, caused by the filamentous fungus Magnaporthe grisea, is a serious and recurrent problem in all rice-growing regions of the world (Talbot, 2003; Valent & Chumley, 1991). It is estimated that each year enough rice is destroyed by rice blast disease to feed 60 million people. Control of this disease is difficult; new host-specific forms develop quickly to overcome host resistance and chemical control is typically not cost effective (Ou, 1987). Infections occur when fungal spores land and attach themselves to leaves using a special adhesive released from the tip of each spore (Hamer et al., 1988). The germinating spore develops an appressorium, a specialized infection cell, which generates enormous turgor pressure – up to 8 MPa – that ruptures the leaf cuticle allowing invasion of the underlying leaf tissue (de Jong et al., 1997; Dean, 1997). Subsequent colonization of the leaf produces disease lesions from which the fungus sporulates and spreads to new plants. When rice blast infects young rice seedlings, whole plants often die, while spread of the disease to the stems, nodes or panicle of older plants results in nearly total loss of the rice grain. Recent reports have further shown that the fungus has the capacity to infect plant roots (Sesma & Osbourn, 2004). Different host-limited forms of Magnaporthe also infect a broad range of grass species including wheat, barley and millet.
British success at the Battle of Plassey in 1757 marked a decisive upswing in the East India Company's fortunes, for less than a decade later in 1765 the Mughal emperor gave it the official right to collect Bengal's revenues. This was little more than a recognition of the Company's actual position as de facto ruler of Bengal; by this time the independent government of Bengal had been rendered toothless. A good deal of Bengal's resources was already entering the coffers of the EIC and its employees; now all of the state's revenues would officially belong to the Company, except for the annual tribute owed to the Mughal emperor in Delhi. The conferment of an official position on the East India Company was primarily a pragmatic means for the imperial court to ensure that it obtained some small share of Bengal's riches. Its symbolic significance was tremendous, however, since it meant that the English were now formally incorporated into the Mughal imperial system. Foreigners and merchants they might be, but now they were also sanctioned participants in the realm of Indian politics.
In practical terms, by 1765 the Mughal state was merely a small regional kingdom among a welter of others. Several Mughal successor states had made cash payments to the imperial dynasty in their first decades of existence, but by this time had ceased to express any loyalty other than in name.