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To quantify the frequency and outcomes of receiving an antibiotic prescription upon discharge from the hospital to long-term care facilities (LTCFs).
Retrospective cohort study.
A 576-bed, academic hospital in Portland, Oregon.
Adult inpatients (≥18 years of age) discharged to an LTCF between January 1, 2012, and June 30, 2016.
Our primary outcome was receiving a systemic antibiotic prescription upon discharge to an LTCF. We also quantified the association between receiving an antibiotic prescription and 30-day hospital readmission, 30-day emergency department (ED) visit, and Clostridium difficile infection (CDI) on a readmission or ED visit at the index facility within 60 days of discharge.
Among 6,701 discharges to an LTCF, 22.9% were prescribed antibiotics upon discharge. The most prevalent antibiotic classes prescribed were cephalosporins (20.4%), fluoroquinolones (19.1%), and penicillins (16.7%). The medical records of ~82% of patients included a diagnosis code for a bacterial infection on the index admission. Among patients prescribed an antibiotic upon discharge, the incidence of 30-day hospital readmission to the index facility was 15.9%, the incidence of 30-day ED visit at the index facility was 11.0%, and the incidence of CDI on a readmission or ED visit within 60 days of discharge was 1.6%. Receiving an antibiotic prescription upon discharge was significantly associated with 30-day ED visits (adjusted odds ratio [aOR], 1.2; 95% confidence interval [CI], 1.02–1.5) and with CDI within 60 days (aOR, 1.7; 95% CI, 1.02–2.8) but not with 30-day readmissions (aOR, 1.01; 95% CI, 0.9–1.2).
Antibiotics were frequently prescribed upon discharge to LTCFs, which may be associated with increased risk of poor outcomes post discharge.
Postoperative cognitive impairment is among the most common medical complications associated with surgical interventions – particularly in elderly patients. In our aging society, it is an urgent medical need to determine preoperative individual risk prediction to allow more accurate cost–benefit decisions prior to elective surgeries. So far, risk prediction is mainly based on clinical parameters. However, these parameters only give a rough estimate of the individual risk. At present, there are no molecular or neuroimaging biomarkers available to improve risk prediction and little is known about the etiology and pathophysiology of this clinical condition. In this short review, we summarize the current state of knowledge and briefly present the recently started BioCog project (Biomarker Development for Postoperative Cognitive Impairment in the Elderly), which is funded by the European Union. It is the goal of this research and development (R&D) project, which involves academic and industry partners throughout Europe, to deliver a multivariate algorithm based on clinical assessments as well as molecular and neuroimaging biomarkers to overcome the currently unsatisfying situation.
Background: Hyponatremia has been found to be associated with increased complications in a variety of surgical populations. No study looked specifically at patients undergoing spine surgery. We also specifically address whether it has an effect on the typical low-risk patient admitted for degenerative spine disease, a population that forms the major bulk of clinical practice. Methods: Data was obtained from the American college of surgeons National Surgical Quality Improvement Program (ACS-NSQIP). All patients who underwent elective spinal surgery for degenerative disease from 2011 to 2013 were included. The two arms (normonatremic and hyponatremic) were then compared. Results: A total of 58049 patients were included, 3037 were hyponatremic. Hyponatremic patients were older and had more comorbidities. They also developed more minor and major complications. When all comorbidities were controlled for, hyponatremia was only associated with increased minor but not major complications. These patients were more likely to require a blood transfusion (OR=1.23, CI 1.10-1.43) and a prolonged hospital stay (OR=1.52, CI 1.33-1.75). Conclusions: This study finds an association between hyponatremia and postoperative adverse events in a low risk population that forms the major bulk of clinical practice. This addresses a potential target for quality improvement strategies with significant cost saving implications.
Historically, alloy development with better radiation performance has been focused on traditional alloys with one or two principal element(s) and minor alloying elements, where enhanced radiation resistance depends on microstructural or nanoscale features to mitigate displacement damage. In sharp contrast to traditional alloys, recent advances of single-phase concentrated solid solution alloys (SP-CSAs) have opened up new frontiers in materials research. In these alloys, a random arrangement of multiple elemental species on a crystalline lattice results in disordered local chemical environments and unique site-to-site lattice distortions. Based on closely integrated computational and experimental studies using a novel set of SP-CSAs in a face-centered cubic structure, we have explicitly demonstrated that increasing chemical disorder can lead to a substantial reduction in electron mean free paths, as well as electrical and thermal conductivity, which results in slower heat dissipation in SP-CSAs. The chemical disorder also has a significant impact on defect evolution under ion irradiation. Considerable improvement in radiation resistance is observed with increasing chemical disorder at electronic and atomic levels. The insights into defect dynamics may provide a basis for understanding elemental effects on evolution of radiation damage in irradiated materials and may inspire new design principles of radiation-tolerant structural alloys for advanced energy systems.
Federal agencies are made responsible for managing the historic properties under their jurisdiction by the National Historic Preservation Act of 1966, as amended. A component of this responsibility is to mitigate the effect of a federal undertaking on historic properties through mitigation often through documentation. Providing public access to this documentation has always been a challenge. To address the issue of public access to mitigation information, personnel from Argonne National Laboratory created the Box Digital Display Platform, a system for communicating information about historic properties to the public. The platform, developed for the US Army Dugway Proving Ground, uses short introductory videos to present a topic but can also incorporate photos, drawings, GIS information, and documents. The system operates from a small, self-contained computer that can be attached to any digital monitor via an HDMI cable. The system relies on web-based software that allows the information to be republished as a touch-screen device application or as a website. The system does not connect to the Internet, and this increases security and eliminates the software maintenance fees associated with websites. The platform is designed to incorporate the products of past documentation to make this information more accessible to the public; specifically those documentations developed using the Historic American Building Survey/ Historic American Engineering Record (HABS/HAER) standards. Argonne National Laboratory’s Box Digital Display Platform can assist federal agencies in complying with the requirements of the National Historic Preservation Act.
To describe the prevalence, characteristics, and appropriateness of systemic antibiotic use in assisted living (AL) and to conduct a preliminary quality improvement intervention trial to reduce inappropriate prescribing.
Pre-post study, with a 13-month intervention period.
Four AL communities.
All prescribers, all AL staff who communicate with prescribers, and all patients who had an infection during the baseline and intervention periods.
A standardized form for AL staff, an online education course and 5 practice briefs for prescribers, and monthly quality improvement meetings with AL staff.
Monthly inventory of all systemic antibiotic prescriptions; interviews with the prescriber, AL staff member, closest family member, and patient (when capable) regarding 85 antibiotic prescribing episodes (30 baseline, 55 intervention), with data review by an expert panel to determine prescribing appropriateness.
The mean number of systemic antibiotic prescriptions was 3.44 per 1,000 resident-days at baseline and 3.37 during the intervention, a nonsignificant change (P = .30). Few prescribers participated in online training. AL staff use of the standardized form gradually increased during the program. The proportion of prescriptions rated as probably inappropriate was 26% at baseline and 15% during the intervention, a nonsignificant trend (P = .25). Drug selection was largely appropriate during both time periods.
AL antibiotic prescribing rates appear to be approximately one-half those seen in nursing homes, with up to a quarter being potentially inappropriate. Interventions to improve prescribing must reach all physicians and staff and most likely will require long time periods to have the optimal effect.
The 2013 Infection Prevention and Control (IP&C) Guideline for Cystic Fibrosis (CF) was commissioned by the CF Foundation as an update of the 2003 Infection Control Guideline for CF. During the past decade, new knowledge and new challenges provided the following rationale to develop updated IP&C strategies for this unique population:
1. The need to integrate relevant recommendations from evidence-based guidelines published since 2003 into IP&C practices for CF. These included guidelines from the Centers for Disease Control and Prevention (CDC)/Healthcare Infection Control Practices Advisory Committee (HICPAC), the World Health Organization (WHO), and key professional societies, including the Infectious Diseases Society of America (IDSA) and the Society for Healthcare Epidemiology of America (SHEA). During the past decade, new evidence has led to a renewed emphasis on source containment of potential pathogens and the role played by the contaminated healthcare environment in the transmission of infectious agents. Furthermore, an increased understanding of the importance of the application of implementation science, monitoring adherence, and feedback principles has been shown to increase the effectiveness of IP&C guideline recommendations.
2. Experience with emerging pathogens in the non-CF population has expanded our understanding of droplet transmission of respiratory pathogens and can inform IP&C strategies for CF. These pathogens include severe acute respiratory syndrome coronavirus and the 2009 influenza A H1N1. Lessons learned about preventing transmission of methicillin-resistant Staphylococcus aureus (MRSA) and multidrug-resistant gram-negative pathogens in non-CF patient populations also can inform IP&C strategies for CF.
Studies investigating structural brain abnormalities in depression have typically employed a categorical rather than dimensional approach to depression [i.e. comparing subjects with Diagnostic and Statistical Manual of Mental Disorders (DSM)-defined major depressive disorder (MDD) v. healthy controls]. The National Institute of Mental Health, through their Research Domain Criteria initiative, has encouraged a dimensional approach to the study of psychopathology as opposed to an over-reliance on categorical (e.g. DSM-based) diagnostic approaches. Moreover, subthreshold levels of depressive symptoms (i.e. severity levels below DSM criteria) have been found to be associated with a range of negative outcomes, yet have been relatively neglected in neuroimaging research.
To examine the extent to which depressive symptoms – even at subclinical levels – are linearly related to gray matter volume reductions in theoretically important brain regions, we employed whole-brain voxel-based morphometry in a sample of 54 participants.
The severity of mild depressive symptoms, even in a subclinical population, was associated with reduced gray matter volume in the orbitofrontal cortex, anterior cingulate, thalamus, superior temporal gyrus/temporal pole and superior frontal gyrus. A conjunction analysis revealed concordance across two separate measures of depression.
Reduced gray matter volume in theoretically important brain regions can be observed even in a sample that does not meet DSM criteria for MDD, but who nevertheless report relatively elevated levels of depressive symptoms. Overall, these findings highlight the need for additional research using dimensional conceptual and analytic approaches, as well as further investigation of subclinical populations.
Tuberculosis (TB) due to infection with Mycobacterium bovis is transmitted between cattle and badgers (Meles meles) in the UK and Ireland but it is unclear where or when transmission occurs. We investigated direct and indirect interactions between badgers and cattle using automated proximity loggers on animals and at badger latrines located on pasture, in an area of south-west England with a high-density badger population. Direct contacts (interactions within 1·4 m) between badgers and cattle at pasture were very rare (four out of >500 000 recorded animal-to-animal contacts) despite ample opportunity for interactions to occur. Indirect interactions (visits to badger latrines by badgers and cattle) were two orders of magnitude more frequent than direct contacts: 400 visits by badgers and 1700 visits by cattle were recorded. This suggests that indirect contacts might be more important than direct contacts in terms of disease transmission at pasture. The TB infection status of individual badgers (ascribed with 93% accuracy using three diagnostic tests) did not affect the frequency or duration of their visits to latrines located on pasture grazed by cattle. Nevertheless, there was wide variation in contact behaviour between individuals, which highlights the importance of understanding heterogeneity in contact patterns when developing strategies to control disease spread in wildlife and livestock.
Thin films of nanocrystalline ceria on a Si substrate have been irradiated with 3 MeV Au+ ions to fluences of up to 1x1016 ions cm-2, at temperatures ranging between 160 to 400 K. During the irradiation, a band of contrast is observed to form at the thin film/substrate interface. Analysis by scanning transmission electron microscopy in conjunction with energy dispersive and electron energy loss spectroscopy techniques revealed that this band of contrast was a cerium silicate amorphous phase, with an approximate Ce:Si:O ratio of 1:1:3.
To present the auditory implant manipulator, a navigation-controlled mechanical and electronic system which enables minimally invasive (‘keyhole’) transmastoid access to the tympanic cavity.
Materials and methods:
The auditory implant manipulator is a miniaturised robotic system with five axes of movement and an integrated drill. It can be mounted on the operating table. We evaluated the surgical work field provided by the system, and the work sequence involved, using an anatomical whole head specimen.
The work field provided by the auditory implant manipulator is considerably greater than required for conventional mastoidectomy. The work sequence for a keyhole procedure included pre-operative planning, arrangement of equipment, the procedure itself and post-operative analysis.
Although system improvements are necessary, our preliminary results indicate that the auditory implant manipulator has the potential to perform keyhole insertion of implantable hearing devices.
To determine risk factors for cholera in an epidemic-disease area in South America, a case–control investigation was performed in Guayaquil, Ecuador, in July 1991. Residents > 5 years old who were hospitalized for treatment of acute, watery diarrhoea and two matched controls for each were interviewed regarding sources of water and food, and eating, drinking, and hygienic habits. Interviewers inspected homes of case-patients and controls to document water treatment, food-handling, and hygienic practices. Faecal specimens and shellfish were cultured for Vibrio cholerae O 1. Isolates were tested for susceptibility to a variety of antimicrobial agents. Drinking unboiled water (odds ratio [OR] = 4.0, confidence interval [CI] = 1.8–7.5), drinking a beverage from a street vendor (OR = 2.8, CI = 1.3–5.9), eating raw seafood (OR = 3.4, CI = 1.4–11.5), and eating cooked crab (OR = 5.1, CI = 1.4–19.2) were associated with illness. Always boiling drinking water at home (OR = 0.5, CI = 0.2–0.9) was protective against illness. The presence of soap in either the kitchen (OR = 0.3, CI = 0.2–0.8) or bathroom (OR = 0.4, CI = 0.2–0.9) at home was also protective. V. cholerae O 1 was recovered from a pooled sample of a bivalve mollusc and from 68% of stool samples from case-patients. Thirty-six percent of the isolates from stool specimens were resistant to multiple antimicrobial agents. Specific prevention measures may prevent transmission through these vehicles in the future. The appearance of antimicrobial resistance suggests the need for changes in current methods of prevention and treatment.
Use of well persons as the comparison group for laboratory-confirmed cases of sporadic salmonellosis may introduce ascertainment bias into case-control studies. Data from the 1996–1997 FoodNet case-control study of laboratory-confirmed Salmonella serogroups B and D infection were used to estimate the effect of specific behaviours and foods on infection with Salmonella serotype Enteritidis (SE). Persons with laboratory-confirmed Salmonella of other serotypes acted as the comparison group. The analysis included 173 SE cases and 268 non-SE controls. SE was associated with international travel, consumption of chicken prepared outside the home, and consumption of undercooked eggs prepared outside the home in the 5 days prior to diarrhoea onset. SE phage type 4 was associated with international travel and consumption of undercooked eggs prepared outside the home. The use of ill controls can be a useful tool in identifying risk factors for sporadic cases of Salmonella.