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We evaluated the relationship between local MRSA prevalence rates and antibiotic use across 122 VHA hospitals in 2016. Higher hospital-level MRSA prevalence was associated with significantly higher rates of antibiotic use, even after adjusting for case mix and stewardship strategies. Benchmarking anti-MRSA antibiotic use may need to adjust for MRSA prevalence.
Item 9 of the Patient Health Questionnaire-9 (PHQ-9) queries about thoughts of death and self-harm, but not suicidality. Although it is sometimes used to assess suicide risk, most positive responses are not associated with suicidality. The PHQ-8, which omits Item 9, is thus increasingly used in research. We assessed equivalency of total score correlations and the diagnostic accuracy to detect major depression of the PHQ-8 and PHQ-9.
We conducted an individual patient data meta-analysis. We fit bivariate random-effects models to assess diagnostic accuracy.
16 742 participants (2097 major depression cases) from 54 studies were included. The correlation between PHQ-8 and PHQ-9 scores was 0.996 (95% confidence interval 0.996 to 0.996). The standard cutoff score of 10 for the PHQ-9 maximized sensitivity + specificity for the PHQ-8 among studies that used a semi-structured diagnostic interview reference standard (N = 27). At cutoff 10, the PHQ-8 was less sensitive by 0.02 (−0.06 to 0.00) and more specific by 0.01 (0.00 to 0.01) among those studies (N = 27), with similar results for studies that used other types of interviews (N = 27). For all 54 primary studies combined, across all cutoffs, the PHQ-8 was less sensitive than the PHQ-9 by 0.00 to 0.05 (0.03 at cutoff 10), and specificity was within 0.01 for all cutoffs (0.00 to 0.01).
PHQ-8 and PHQ-9 total scores were similar. Sensitivity may be minimally reduced with the PHQ-8, but specificity is similar.
In this cohort of Escherichia coli and Klebsiella spp hospital-onset bacteremia, isolated fluoroquinolone resistance had a larger relative impact on mortality than other phenotypic resistance patterns. This finding may support stewardship efforts targeting unnecessary fluoroquinolone use and increased attention from infection prevention and control departments.
In this single-center study, the standardized antimicrobial administration ratio (SAAR) for total antimicrobial use decreased in response to a stewardship intervention. Antimicrobial prescribing and clinical outcomes were stable or improved during the period of lower SAARs. Our findings suggest that SAAR values of ~0.8 can be safely achieved.
The large-scale magnetic field in the accretion disks of young stars is investigated. Main features of our magnetohydrodynamical (MHD) model of the accretion disks and typical simulation results are presented. We discuss the role of MHD effects, ionization structure, magnetic field geometry and strength of the accretion disks.
We report long-term observations of H2O and OH maser emission sources at wavelengths of 1.35 and 18 cm associated with star-forming regions. Strong quasi-periodic flares of maser emission have been observed. Several sources (in particular, G25.65+1.05, IRAS 16293−2422, Cep A) have displayed strong flares in the H2O line, when their peak flux density raised by a few orders of magnitude above the quiet state. Possible causes of this are discussed.
We investigate dynamics of slender magnetic flux tubes (MFT) in the accretion disks of young stars. Simulations show that MFT rise from the disk and can accelerate to 20-30 km/s causing periodic outflows. Magnetic field of the disk counteracts the buoyancy, and the MFT oscillate near the disk’s surface with periods of 10-100 days. We demonstrate that rising and oscillating MFT can cause the IR-variability of the accretion disks of young stars.
In this study (Taubner et al.2018), three different methanogenic archaea (Methanothermococcus okinawensis, Methanothermobacter marburgensis, and Methanococcus villosus) were tested for metabolic activities and growth under putative Enceladus-like conditions, including high pressure experiments and tests on the tolerance towards potential gaseous and liquid inhibitors detected in Enceladus’ plume. In particular, M. okinawensis, an isolate from a deep marine trench (Takai et al.2002), showed tolerance towards all of the added inhibitors and maintained methanogenesis even in the range of 10 to 50 bar. Further, we were able to show that H2 production based on serpentinization may be sufficient to fuel such methanogenic life on Enceladus. The experiments revealed that methanogenesis could, in principle, be feasible under Enceladus-like conditions.
The origin of the Brγ-line emission in Herbig Ae/Be stars is still an open question and might be related e.g., to a disc wind or the stellar magnetosphere. The study of the continuum and Brγ-emitting region of Herbig Ae/Be stars with high-spectral and high-spatial resolution gives great insights into the sub-au scale hydrogen gas distribution.
We observed the Herbig Be star MWC 120 with the VLTI/AMBER instrument in different spectral channels across the Brγ line with a spectral resolution of R~1500. Using radiative transfer modeling we found a radius of the line emitting region of ~0.4 au that is only two times smaller than the K-band continuum region. This is consistent with a disc wind scenario rather than an origin of magnetospheric emission.
We present near-infrared AMBER (R~12000) observations of the Herbig B[e] star MWC297 in the Brγ-line. We found that the near-infrared continuum emission is ~3.6 times more compact than the expected dust-sublimation radius, possibly indicating the presence of highly refractory dust grains or optically thick gas emission in the inner disk. Our velocity-resolved channel maps marking the first time that kinematic effects in the sub-AU inner regions of a protoplanetary disk could be directly imaged.
Different diagnostic interviews are used as reference standards for major depression classification in research. Semi-structured interviews involve clinical judgement, whereas fully structured interviews are completely scripted. The Mini International Neuropsychiatric Interview (MINI), a brief fully structured interview, is also sometimes used. It is not known whether interview method is associated with probability of major depression classification.
To evaluate the association between interview method and odds of major depression classification, controlling for depressive symptom scores and participant characteristics.
Data collected for an individual participant data meta-analysis of Patient Health Questionnaire-9 (PHQ-9) diagnostic accuracy were analysed and binomial generalised linear mixed models were fit.
A total of 17 158 participants (2287 with major depression) from 57 primary studies were analysed. Among fully structured interviews, odds of major depression were higher for the MINI compared with the Composite International Diagnostic Interview (CIDI) (odds ratio (OR) = 2.10; 95% CI = 1.15–3.87). Compared with semi-structured interviews, fully structured interviews (MINI excluded) were non-significantly more likely to classify participants with low-level depressive symptoms (PHQ-9 scores ≤6) as having major depression (OR = 3.13; 95% CI = 0.98–10.00), similarly likely for moderate-level symptoms (PHQ-9 scores 7–15) (OR = 0.96; 95% CI = 0.56–1.66) and significantly less likely for high-level symptoms (PHQ-9 scores ≥16) (OR = 0.50; 95% CI = 0.26–0.97).
The MINI may identify more people as depressed than the CIDI, and semi-structured and fully structured interviews may not be interchangeable methods, but these results should be replicated.
Declaration of interest
Drs Jetté and Patten declare that they received a grant, outside the submitted work, from the Hotchkiss Brain Institute, which was jointly funded by the Institute and Pfizer. Pfizer was the original sponsor of the development of the PHQ-9, which is now in the public domain. Dr Chan is a steering committee member or consultant of Astra Zeneca, Bayer, Lilly, MSD and Pfizer. She has received sponsorships and honorarium for giving lectures and providing consultancy and her affiliated institution has received research grants from these companies. Dr Hegerl declares that within the past 3 years, he was an advisory board member for Lundbeck, Servier and Otsuka Pharma; a consultant for Bayer Pharma; and a speaker for Medice Arzneimittel, Novartis, and Roche Pharma, all outside the submitted work. Dr Inagaki declares that he has received grants from Novartis Pharma, lecture fees from Pfizer, Mochida, Shionogi, Sumitomo Dainippon Pharma, Daiichi-Sankyo, Meiji Seika and Takeda, and royalties from Nippon Hyoron Sha, Nanzando, Seiwa Shoten, Igaku-shoin and Technomics, all outside of the submitted work. Dr Yamada reports personal fees from Meiji Seika Pharma Co., Ltd., MSD K.K., Asahi Kasei Pharma Corporation, Seishin Shobo, Seiwa Shoten Co., Ltd., Igaku-shoin Ltd., Chugai Igakusha and Sentan Igakusha, all outside the submitted work. All other authors declare no competing interests. No funder had any role in the design and conduct of the study; collection, management, analysis and interpretation of the data; preparation, review or approval of the manuscript; and decision to submit the manuscript for publication.
The optimal approach to auditing outpatient antimicrobial prescribing has not been established. We assessed how different types of electronic data—including prescriptions, patient-visits, and International Classification of Disease, Tenth Revision (ICD-10) codes—could inform automated antimicrobial audits.
Outpatient visits during 2016 were retrospectively reviewed, including chart abstraction, if an antimicrobial was prescribed (cohort 1) or if the visit was associated with an infection-related ICD-10 code (cohort 2). Findings from cohorts 1 and 2 were compared.
Primary care clinics and the emergency department (ED) at the Iowa City Veterans Affairs Medical Center.
In cohort 1, we reviewed 2,353 antimicrobial prescriptions across 52 providers. ICD-10 codes had limited sensitivity and positive predictive value (PPV) for validated cases of cystitis and pneumonia (sensitivity, 65.8%, 56.3%, respectively; PPV, 74.4%, 52.5%, respectively). The volume-adjusted antimicrobial prescribing rate was 13.6 per 100 ED visits and 7.5 per 100 primary care visits. In cohort 2, antimicrobials were not indicated in 474 of 851 visits (55.7%). The antimicrobial overtreatment rate was 48.8% for the ED and 59.7% for primary care. At the level of the individual prescriber, there was a positive correlation between a provider’s volume-adjusted antimicrobial prescribing rate and the individualized rates of overtreatment in both the ED (r=0.72; P<.01) and the primary care setting (r=0.82; P=0.03).
In this single-center study, ICD-10 codes had limited sensitivity and PPV for 2 infections that typically require antimicrobials. Electronically extracted data on a provider’s rate of volume-adjusted antimicrobial prescribing correlated with the frequency at which unnecessary antimicrobials were prescribed, but this may have been driven by outlier prescribers.
The nucleation and growth of Al on 7 × 7 and
$\sqrt 3 \times \sqrt 3$
R30 Al reconstructed Si(111) that result in strain-free Al overgrown films grown with an atomically abrupt metamorphic interface are compared. The reconstructed surfaces and abrupt strain relaxations are verified using reflection high-energy electron diffraction. The topography of evolution is examined with atomic force microscopy. The growth of Al on both the surfaces exhibits 3D island growth, but the island evolution of growth is dramatically different. On the 7 × 7 surface, mounds formed are uniformly distributed across the substrate, and growth appears to proceed uniformly. Alternatively, on the
$\sqrt 3 \times \sqrt 3$
R30 surface, Al atoms exhibit a clear preference to form mounds near the step edges. During Al growth, mounds increase in size and number, expanding out from step edges until they cover the whole substrate. Consistent expression of a mounded nucleation and growth mode imparts a physical limitation to the achievable surface roughness that may impact the ultimate performance of layered devices such as Josephson junctions that are critical components of superconducting quantum circuits.
We investigated the frequency and determinants of guideline-discordant antibiotic prescribing in outpatients with respiratory infections or cystitis. Antibiotic prescribing was guideline discordant in 60% of patients. The most common reason for discordance was prescribing an antibiotic when not indicated. In a multivariate analysis, physicians in training had the highest likelihood of guideline-concordant antibiotic prescribing.
Objectives: The aim of this study was to determine the aspects of expert advice that decision makers find most useful in the development of evidence-based guidance and to identify the characteristics of experts providing the most useful advice.
Methods: First, semi-structured interviews were conducted with seventeen members of the Interventional Procedures Advisory Committee of the UK's National Institute of Health and Care Excellence. Interviews examined the usefulness of expert advice during guidance development. Transcripts were analyzed inductively to identify themes. Second, data were extracted from 211 experts’ questionnaires for forty-one consecutive procedures. Usefulness of advice was scored using an index developed through the qualitative work. Associations between usefulness score and characteristics of the expert advisor were investigated using univariate and multivariate analyses.
Results: Expert opinion was seen as a valued complement to empirical evidence, providing context and tacit knowledge unavailable in published literature, but helpful for interpreting it. Interviewees also valued advice on the training and experience required to perform a procedure, on patient selection criteria and the place of a procedure within a clinical management pathway. Limitations of bias in expert opinion were widely acknowledged and skepticism expressed regarding the anecdotal nature of advice on safety or efficacy outcomes. Quantitative analysis demonstrated that the most useful advice was given by clinical experts with direct personal experience of the procedure, particularly research experience.
Conclusions: Evidence-based guidance production is often characterized as a rational, pipeline process. This ignores the valuable role that expert opinion plays in guidance development, complementing and supporting the interpretation of empirical data.
To identify important risk factors for recurrent methicillin-resistant Staphylococcus aureus (MRSA) to assist clinicians in identifying high-risk patients for continued surveillance and follow-up.
In this retrospective cohort study, we examined patients with MRSA bacteremia at 122 Veterans Affairs medical facilities from January 1, 2003, through December 31, 2010. Recurrent MRSA bacteremia was identified by a positive blood culture result from 2 to 180 days after index hospitalization discharge. Subset analyses were performed to evaluate risk factors for early-onset (2–60 days after discharge) and late-onset (61–180 days after discharge) recurrence. Risk factors were evaluated using Cox proportional hazards regression.
Of 18,425 patients, 1,159 (6.3%) had recurrent MRSA bacteremia. The median time to recurrence was 63 days. Longer duration of index bacteremia, increased severity of illness, receipt of only vancomycin, community-acquired infection, and several comorbidities were risk factors for recurrence. Congestive heart failure, hypertension, and rheumatoid arthritis/collagen disease were risk factors for early-onset but not late-onset recurrence. Geographic region and cardiac arrhythmias were risk factors for late-onset but not early-onset recurrence.
Risk factors for recurrent MRSA bacteremia included comorbidities, severity of illness, duration of bacteremia, and receipt of only vancomycin. Awareness of risk factors may be important at patient discharge for implementation of quality improvement initiatives including surveillance, follow-up, and education for high-risk patients.
Between 1270 and 1870 Britain slowly progressed from the periphery of the European economy to centre-stage of an integrated world economy. In the process it escaped from Malthusian constraints and by the eighteenth century had successfully reconciled rising population with rising living standards. This final chapter reflects upon this protracted but profound economic transformation from the perspective of the national income estimates assembled in Part I and analysed in Part II of this book. Because Britain’s economic rise did not unfold in isolation, account is taken of the broader comparative context provided by the national income reconstructions now available for several other Eurasian countries: Spain from 1282, Italy from 1310 and Holland from 1348, plus Japan from 725, China from 980 and India from 1600. All are output-based estimates but have been derived via a range of alternative approaches according to the nature of the available historical evidence. Several make ingenious use of real wage rates and urbanisation ratios (Malanima, 2011; Álvarez-Nogal and Prados de la Escosura, 2013), two economic indicators often used as surrogates for estimates of GDP per head. Only the GDP estimates for Holland, like these for Britain, have been made the hard way, by summing the weighted value-added outputs of the agricultural, industrial and service sectors and then dividing the results by estimates of total population obtained by reconciling time-series and cross-sectional demographic data. Methodologically, the British and Dutch national income estimates are therefore the most directly comparable. Each is free from overdependence upon any single or narrow range of data series and, instead, they encapsulate variations in the wide range of economic indicators, appropriately weighted in line with their importance in overall economic activity, from which they have been reconstructed.
Agriculture was for long the single largest component of the English and British economies, both in terms of its share of employment and the value of its output. The latter was a function of the amount of land under cultivation, the uses to which it was put, the productivities of crops and animals and their respective prices. The main purpose of this chapter is to describe the methods used to derive the areas under arable and grass and, in particular, the total sown acreage. The crops produced and animals stocked are the subjects of the following chapter. Along the way, it will be demonstrated that claims that the peak arable area in the medieval period may have exceeded 20 million acres (Clark, 2007a: 124) are unrealistic, since, on the best available evidence, the combined total under field crops and fallow could not have been more than 12.75 million acres. In the absence of significant food imports, this limited both the population that could be supported and the supply of kilocalories per head needed for survival. It also shaped the production choices made by agricultural producers.
Comprehensive national agricultural statistics were collected annually from 1866 and provide the starting point for calculating the acreages of arable and grass (Anon, 1968; Coppock, 1984). Together with the tithe files, which provide a precise but incomplete guide to the share of land in each county devoted to arable production during the 1830s (Kain, 1986; Overton, 1986), they are used to provide a nineteenth-century benchmark. The chapter proceeds as follows. After a discussion of the potential agricultural area of England in Section 2.2, Section 2.3 reviews the arable acreage by county from the tithe files of the 1830s and from the agricultural statistics of 1871. Section 2.4 then examines changes in land use between 1290 and 1871, while Section 2.5 presents county-level estimates of the arable acreage in 1290. Section 2.6 provides a further cross-check by examining changes in land use between 1086 and 1290. Finally, Section 2.7 provides estimates of land use for a number of benchmark years between 1270 and 1871.