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Starting in 2016, we initiated a pilot tele-antibiotic stewardship program at 2 rural Veterans Affairs medical centers (VAMCs). Antibiotic days of therapy decreased significantly (P < .05) in the acute and long-term care units at both intervention sites, suggesting that tele-stewardship can effectively support antibiotic stewardship practices in rural VAMCs.
Laboratory identification of carbapenem-resistant Enterobacteriaceae (CRE) is a key step in controlling its spread. Our survey showed that most Veterans Affairs laboratories follow VA guidelines for initial CRE identification, whereas 55.0% use PCR to confirm carbapenemase production. Most respondents were knowledgeable about CRE guidelines. Barriers included staffing, training, and financial resources.
Shunt-related adverse events are frequent in infants after modified Blalock–Taussig despite use of acetylsalicylic acid prophylaxis. A higher incidence of acetylsalicylic acid-resistance and sub-therapeutic acetylsalicylic acid levels has been reported in infants. We evaluated whether using high-dose acetylsalicylic acid can decrease shunt-related adverse events in infants after modified Blalock–Taussig.
In this single-centre retrospective cohort study, we included infants ⩽1-year-old who underwent modified Blalock–Taussig placement and received acetylsalicylic acid in the ICU. We defined acetylsalicylic acid treatment groups as standard dose (⩽7 mg/kg/day) and high dose (⩾8 mg/kg/day) based on the initiating dose.
There were 34 infants in each group. Both groups were similar in age, gender, cardiac defect type, ICU length of stay, and time interval to second stage or definitive repair. Shunt interventions (18 versus 32%, p=0.16), shunt thrombosis (14 versus 17%, p=0.74), and mortality (9 versus 12%, p=0.65) were not significantly different between groups. On multiple logistic regression analysis, single-ventricle morphology (odds ratio 5.2, 95% confidence interval of 1.2–23, p=0.03) and post-operative red blood cells transfusion ⩾24 hours [odds ratio 15, confidence interval of (3–71), p<0.01] were associated with shunt-related adverse events. High-dose acetylsalicylic acid treatment [odds ratio 2.6, confidence interval of (0.7–10), p=0.16] was not associated with decrease in these events.
High-dose acetylsalicylic acid may not be sufficient in reducing shunt-related adverse events in infants after modified Blalock–Taussig. Post-operative red blood cells transfusion may be a modifiable risk factor for these events. A randomised trial is needed to determine appropriate acetylsalicylic acid dosing in infants with modified Blalock–Taussig.
Acute reactivity of the stress hormone cortisol is reflective of early adversity and stress exposure, with some studies finding that the impact of adversity on the stress response differs by race. The objectives of the current study were to characterize cortisol reactivity to two dyadically based stress paradigms across the first year of life, to examine cortisol reactivity within Black and White infants, and to assess the impact of correlates of racial inequity including socioeconomic status, experiences of discrimination, and urban life stressors, as well as the buffering by racial socialization on cortisol patterns. Salivary cortisol reactivity was assessed at 4 months of age during the Still Face paradigm (N = 207) and at 12 months of age across the Strange Situation procedure (N = 129). Infants demonstrated the steepest recovery after the Still Face paradigm and steepest reactivity to the Strange Situation procedure. Race differences in cortisol were not present at 4 months but emerged at 12 months of age, with Black infants having higher cortisol. Experiences of discrimination contributed to cortisol differences within Black infants, suggesting that racial discrimination is already “under the skin” by 1 year of age. These findings suggest that race-related differences in hypothalamic–pituitary–adrenal reactivity are present in infancy, and that the first year of life is a crucial time period during which interventions and prevention efforts for maternal–infant dyads are most likely able to shape hypothalamic–pituitary–adrenal reactivity thereby mitigating health disparities early across the life course.
The application of digital monitoring biomarkers in health, wellness and disease management is reviewed. Harnessing the near limitless capacity of these approaches in the managed healthcare continuum will benefit from a systems-based architecture which presents data quality, quantity, and ease of capture within a decision-making dashboard.
A framework was developed which stratifies key components and advances the concept of contextualized biomarkers. The framework codifies how direct, indirect, composite, and contextualized composite data can drive innovation for the application of digital biomarkers in healthcare.
The de novo framework implies consideration of physiological, behavioral, and environmental factors in the context of biomarker capture and analysis. Application in disease and wellness is highlighted, and incorporation in clinical feedback loops and closed-loop systems is illustrated.
The study of contextualized biomarkers has the potential to offer rich and insightful data for clinical decision making. Moreover, advancement of the field will benefit from innovation at the intersection of medicine, engineering, and science. Technological developments in this dynamic field will thus fuel its logical evolution guided by inputs from patients, physicians, healthcare providers, end-payors, actuarists, medical device manufacturers, and drug companies.
The molecular, neurobiological, and physical health impacts of child maltreatment are well established, yet mechanistic pathways remain inadequately defined. Telomere length (TL) decline is an emerging molecular indicator of stress exposure with definitive links to negative health outcomes in maltreated individuals. The multiple confounders endemic to human maltreatment research impede the identification of causal pathways. This study leverages a unique randomized, cross-foster, study design in a naturalistic translational nonhuman primate model of infant maltreatment. At birth, newborn macaques were randomly assigned to either a maltreating or a competent control mother, balancing for sex, biological mother parenting history, and social rank. Offspring TL was measured longitudinally across the first 6 months of life (infancy) from peripheral blood. Hair cortisol accumulation was also determined at 6, 12, and 18 months of age. TL decline was greater in animals randomized to maltreatment, but also interacted with biological mother group. Shorter TL at 6 months was associated with higher mean cortisol levels through 18 months (juvenile period) when controlling for relevant covariates. These results suggest that even under the equivalent social, nutritional, and environmental conditions feasible in naturalistic translational nonhuman primate models, early adverse caregiving results in lasting molecular scars that foreshadow elevated health risk and physiologic dysregulation.
Chemical constituents trapped within glacial ice provide a unique record of climate, as well as repositories for biological material such as pollen grains, fungal spores, viruses, bacteria and dissolved organic carbon. Past research suggests that the veins of polycrystalline ice may provide a liquid microenvironment for active microbial metabolism fueled by concentrated impurities in the veins. Despite these claims, no direct measurements of impurity concentration in ice veins have been made. Using micro-Raman spectroscopy, we show that sulfate and nitrate concentrations in the veins of glacial ice from Greenland (Greenland Ice Sheet Project 2) and Antarctic (Newall Glacier and a Dominion Range glacier) core samples were 104 and 105 times greater than the concentrations measured in melted (bulk) core water. Methanesulfonate was not found in the veins, consistent with its presence as particulate matter within the ice. The measured vein concentration of molecular anions implies a highly acidic (pH < 3) vein environment with high ionic strength (mM-M). We estimate that the vein volume provides 16.7 and 576 km3 of habitable space within the Greenland and Antarctic ice sheets, respectively, which could support the metabolism of organisms that are capable of growing in cold, high ionic strength solutions with low pH.
We argue that political sciexntists can provide additional evidence for the predictive validity of observational and quasi-experimental research designs by minimizing the expected prediction error or generalization error of their empirical models. For observational and quasi-experimental data not generated by a stochastic mechanism under the researcher’s control, the reproduction of statistical analyses is possible but replication of the data-generating procedures is not. Estimating the generalization error of a model for this type of data and then adjusting the model to minimize this estimate—regularization—provides evidence for the predictive validity of the study by decreasing the risk of overfitting. Estimating generalization error also allows for model comparisons that highlight underfitting: when a model generalizes poorly due to missing systematic features of the data-generating process. Thus, minimizing generalization error provides a principled method for modeling relationships between variables that are measured but whose relationships with the outcome(s) are left unspecified by a deductively valid theory. Overall, the minimization of generalization error is important because it quantifies the expected reliability of predictions in a way that is similar to external validity, consequently increasing the validity of the study’s conclusions.
To identify training needs of the next generation of psychiatrists and barriers in prescribing first-generation antipsychotics (FGAs). We have surveyed psychiatry trainees in East Anglia with regard to their training experience, knowledge and attitudes to the use of oral FGAs as regular medication.
Two-thirds of trainees were aware that first- and second-generation antipsychotics (SGAs) have similar efficacy, and a similar proportion perceived the older drugs to have more or ‘stronger’ side-effects. Lack of training experience was noted as the second leading concern for prescribing FGAs. A quarter of trainees received no training exposure to the older drugs and two-thirds had never initiated these drugs themselves. Although nearly 90% of trainees felt confident about initiating an oral SGA as a regular medication, only about 40% felt confident with FGAs (P<0.001).
The survey highlights worrying gaps in training. FGAs can be used effectively, minimising side-effects, by careful dose titration, avoiding antipsychotic polypharmacy, high-dose, and high-potency drugs, thus ensuring they are not lost to future generations of psychiatrists.
How does living in a battleground state during a presidential election affect an individual’s political engagement? We utilize a unique collection of 113 million Facebook status updates to compare users’ political discussion during the 2008 election. “Battleground” state users are significantly more likely to discuss politics in the campaign season than are users in uncompetitive “blackout” states. Posting a political status update—a form of day-to-day engagement with politics—mediates ∼20 percent of the relationship between exposure to political competition and self-reported voter turnout. This paper is among the first to use a massive quantity of social media data to explain the microfoundations of how people think, feel, and act on a daily basis in response to their political environment.