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To reduce inappropriate antimicrobial prescribing across ambulatory care, understanding the patient-, provider-, and practice-level characteristics associated with antibiotic prescribing is essential. In this study, we aimed to elucidate factors associated with inappropriate antimicrobial prescribing across urgent care, family medicine, and pediatric and internal medicine ambulatory practices.
DESIGN, SETTING, AND PARTICIPANTS
Data for this retrospective cohort study were collected from outpatient visits for common upper respiratory conditions that should not require antibiotics. The cohort included 448,990 visits between January 2014 and May 2016. Carolinas HealthCare System urgent care, family medicine, internal medicine and pediatric practices were included across 898 providers and 246 practices.
Prescribing rates were reported per 1,000 visits. Indications were defined using the International Classification of Disease, Ninth and Tenth Revisions, Clinical Modification (ICD-9/10-CM) criteria. In multivariable models, the risk of receiving an antibiotic prescription was reported with adjustment for practice, provider, and patient characteristics.
The overall prescribing rate in the study cohort was 407 per 1,000 visits (95% confidence interval [CI], 405–408). After adjustment, adult patients seen by an advanced practice practitioner were 15% more likely to receive an antimicrobial than those seen by a physician provider (incident risk ratio [IRR], 1.15; 95% CI, 1.03–1.29). In the pediatric sample, older providers were 4 times more likely to prescribe an antimicrobial than providers aged ≤30 years (IRR, 4.21; 95% CI, 2.96–5.97).
Our results suggest that patient, practice, and provider characteristics are associated with inappropriate antimicrobial prescribing. Future research should target antibiotic stewardship programs to specific patient and provider populations to reduce inappropriate prescribing compared to a “one size fits all” approach.
We describe the investigation of two temporally coincident illness clusters involving salmonella and Staphylococcus aureus in two states. Cases were defined as gastrointestinal illness following two meal events. Investigators interviewed ill persons. Stool, food and environmental samples underwent pathogen testing. Alabama: Eighty cases were identified. Median time from meal to illness was 5·8 h. Salmonella Heidelberg was identified from 27 of 28 stool specimens tested, and coagulase-positive S. aureus was isolated from three of 16 ill persons. Environmental investigation indicated that food handling deficiencies occurred. Colorado: Seven cases were identified. Median time from meal to illness was 4·5 h. Five persons were hospitalised, four of whom were admitted to the intensive care unit. Salmonella Heidelberg was identified in six of seven stool specimens and coagulase-positive S. aureus in three of six tested. No single food item was implicated in either outbreak. These two outbreaks were linked to infection with Salmonella Heidelberg, but additional factors, such as dual aetiology that included S. aureus or the dose of salmonella ingested may have contributed to the short incubation periods and high illness severity. The outbreaks underscore the importance of measures to prevent foodborne illness through appropriate washing, handling, preparation and storage of food.
Introduction: Some non-urgent/low-acuity Emergency Department (ED) presentations are considered convenience visits and potentially avoidable with improved access to primary care services. This study surveyed patients who presented to the ED and explored their self-reported reasons and barriers for not being connected to a primary care provider (PCP). Methods: Patients aged 17 years and older were randomly selected from electronic registration records at three urban EDs in Edmonton, Alberta (AB), Canada. Following initial triage, stabilization, and verbal informed consent, patients completed a 47-item questionnaire. Data from the survey were cross-referenced to a minimal patient dataset consisting of ED and demographic information. The questionnaire collected information on patient characteristics, their connection to a PCP, and patients' reasons for not having a PCP. Results: Of the 2144 eligible patients, 1408 (65.7%) surveys were returned and 1402 (65.4%) were completed. The majority of patients (74.4%) presenting to the ED reported having a family physician; however, the ‘closeness’ of the connection to their family physician varied greatly among ED patients with the most recent family physician visit ranging from 1 hour before ED presentation to 45 years prior. Approximately 25% of low acuity ED patients reported no connection with a family physician. Reasons for a lack of PCP connection included: prior physician retired, left, or died (19.8%), they had never tried to find one (19.2%), they had recently moved to Alberta (18.0%), and they were unable to find one (16.5%). Conclusion: A surprisingly high proportion of ED patients (25.6%) have no identified PCP. Patients had a variety of reasons for not having a family physician. These need to be understood and addressed in order for primary care access to successfully contribute to diverting non-urgent, low acuity presentations from the ED.
Introduction: Some low acuity Emergency Department (ED) presentations are considered non-urgent or convenience visits and potentially avoidable with improved access to primary care. This study explored self-reported reasons why non-urgent patients presented to the ED. Methods: Patients, 17 years and older, were randomly selected from electronic registration records at three urban EDs in Edmonton, Alberta (AB), Canada during weekdays (0700 to 1900). A 47-item questionnaire was completed by each consenting patient, which included items on whether the patient believed the ED was their best care option and the rationale supporting their response. A thematic content analysis was performed on the responses, using previous experience and review of the literature to identify themes. Results: Of the 2144 eligible patients, 1408 (65.7%) questionnaires were returned, and 1402 (65.4%) were analyzed. For patients who felt the ED was their best option (n = 1234, 89.3%), rationales included: safety concerns (n = 309), effectiveness of ED care (n = 284), patient-centeredness of ED (n = 277), and access to health care professionals in the ED (n = 204). For patients who felt the ED was not their best care option (n = 148, 10.7%), rationales included a perception that: access to health professionals outside the ED was preferable (n = 39), patient-centeredness (particularly timeliness) was lacking in the ED (n = 26), and their health concern was not important enough to require ED care (n = 18). Conclusion: Even during times when alternative care options are available, the majority of non-urgent patients perceived the ED to be the most appropriate location for care. These results highlight that simple triage scores do not accurately reflect the appropriateness of care and that understanding the diverse and multi-faceted reasons for ED presentation are necessary to implement strategies to support non-urgent, low acuity care needs.
To report new prescriptions of psychotropic medications among adolescents presenting with new onset psychotic symptoms during a 5-year period.
The Northern Ireland Early Onset Psychosis Study is a naturalistic longitudinal observational study of patients with an early onset first psychotic episode. All patients aged <18 years presenting to specialist mental health services across Northern Ireland with new onset psychotic symptoms between 2001 and 2006 were recruited (n=113). Clinical case notes were analysed retrospectively for details of subsequent treatment with psychotropic medications.
A total of 100 patients (88.5%) were prescribed some form of psychotropic medication. Over three-quarters of patients received an antipsychotic as their first medication. Risperidone (45.8%), olanzapine (24.0%) and chlorpromazine (12.5%) were the most commonly prescribed first-line antipsychotic medications. Of a total of 160 antipsychotic prescriptions, 81 (50.6%) were off-label. Prescriptions were most likely to have been deemed off-label owing to medications not being licensed in under-18s (71.6% of off-label prescriptions) but other reasons were medications being used outside licensed age ranges (23.5%) and outside licensed indications (4.9%).
This is the first study examining psychotropic prescribing patterns in a complete sample of all children and adolescents presenting with early onset psychotic episodes in a single geographical area. The observation of risperidone as the most commonly prescribed antipsychotic was in keeping with previous studies in child and adolescent populations. Rates of off-label prescribing were lower than previously observed although our study was the first to investigate off-label prescribing solely in children and adolescents presenting with psychotic symptoms.
Religious stratification was a prominent part of colonial America. Anglicans, Congregationalists, and Presbyterians were so dominant socially, economically, and politically that they became known as “the Protestant Establishment.” Below them was a second stratum consisting of Unitarians and the Religious Society of Friends (a.k.a. Quakers). All other Protestants, such as Baptists and Methodists, occupied a third stratum. Catholics, Jews, and people with no religious affiliation were at the bottom (Davidson and Pyle 2011; Pyle 1996; Pyle and Davidson 2003).
Scholars have different views of what has happened to religious stratification since the colonial period. Some emphasize the changes that have taken place, such as the decline in both hegemony and size of the Protestant Establishment and the upward mobility of Catholics and Jews (Baltzell 1958, 1964, 1976; Christopher 1989; Hammond 1992a, 1992b; Hutchison 1989; Roof and McKinney 1987; Schrag 1970; Schneiderman 1994). Others stress the continuities, pointing out that Episcopalians, UCC/Congregationalists, and Presbyterians are still at or near the top of society and that other groups, such as the Baptists, which were at or near the bottom of the status hierarchy in colonial times, still occupy that position (Davidson 2008; Feagin 1984; Greeley 1977; Knebel 1968; Pyle 1996; Rossides 1990; Sturdivant and Adler 1976).
Applications that produce a large amount of heat, such as combustion engines, can benefit from high temperature thermoelectrics to reduce the amount of energy lost. Superlattice (SL) structures have shown reduced thermal conductivity at room temperature and below, suggesting applicability at high temperatures may be possible. This reduction could greatly increase the thermoelectric figure of merit. The Si/SiGe material system is studied here for high temperature application. Two growth temperatures of 300 C and 500 C are examined. Two superlattice periods were studied (8 nm and 20 nm) to determine the effects of lattice spacing on thermal conductivity. Laser Flash Analysis is applied to determine the thermal diffusivity, hence thermal conductivity, from 100 C to 500 C. Thermal diffusivity was found to be an order of magnitude lower than the constituent alloy at 100 C. Superlattice spacing and growth temperature showed little effect on the diffusivity within the error of this measurement.
Mid-infrared (mid-IR) spectra from ~5 to 14 μm of five, nearby (< 70 Mpc) elliptical galaxies are presented that were observed with the Infrared Spectrograph on the Spitzer Space Telescope. The sample galaxies have a main stellar component that is typical for normal, passively evolving ellipticals; however, they are rich in cold gas and dust and have morphological-merger signatures from which a time order of the galaxies since the merger or accretion events can be estimated. The presented results are significant because (1) emission due to Polycyclic Aromatic Hydrocarbons (PAHs) and associated species is detected for the first time in these galaxies and (2) the detected mid-IR spectra are independently exploited as a probe of current or recent star-formation that, in this case, is assumed to be triggered by the merger. As shown in exemplary spectra of the early-age merger NGC 3656, the strength of the PAH emission is more centrally peaked in the earlier-age mergers, suggesting that the PAH data are indeed probing star-formation that is correlated with the time since the mergers and systematically depletes the centrally located gas, becoming weaker and more flatly distributed as the merger evolves.
Many of the most pervasive disease challenges to livestock are transmitted via oral contact with faeces (or by faecal–aerosol) and the current paper focuses on how disease risk may depend on: spatial heterogeneity, animal searching behaviour, different grazing systems and faecal deposition patterns including those representative of livestock and a range of wildlife. A spatially explicit agent-based model was developed to describe the impact of empirically observed foraging and avoidance behaviours on the risk of disease presented by investigative and grazing contact with both livestock and wildlife faeces. To highlight the role of spatial heterogeneity on disease risks an analogous deterministic model, which ignores spatial heterogeneity and searching behaviour, was compared with the spatially explicit agent-based model. The models were applied to assess disease risks in temperate grazing systems. The results suggest that spatial heterogeneity is crucial in defining the disease risks to which individuals are exposed even at relatively small scales. Interestingly, however, although sensitive to other aspects of behaviour such as faecal avoidance, it was observed that disease risk is insensitive to search distance for typical domestic livestock restricted to small field plots. In contrast disease risk is highly sensitive to distributions of faecal contamination, in that contacts with highly clumped distributions of wildlife contamination are rare in comparison to those with more dispersed contamination. Finally it is argued that the model is a suitable framework to study the relative inter- and intra-specific disease risks posed to livestock under different realistic management regimes.
Reproducible nanoscale surface lithography have been produced on La00.66Ba0.33MnO3 thin films using Atomic Force Microscopy. Using an anodic oxidation technique, structures were produced using both positive tip bias voltages as well as negative tip voltages. The electric field produced by applying a positive tip bias acts to reduce the region near the surface, whereas negative tip bias causes an oxidation reaction. Using a positive tip bias, stable structures were consistently achieved which demonstrated a linear dependence of height and width on tip voltage and writing speed. Heights ranged from 5 – 50 nm and widths from 400 – 2000 nm. Negative bias voltages produced a rapid oxidation of the surface, resulting in uncontrollable writing. After etching with a 50% HCL solution it was found that controlled writing was possible with negative bias voltages.
We are developing Colossal Magnetoresistive (CMR) manganite thin film bolometric sensors to be employed as total energy detectors for beam diagnostics of the Linear Coherent Light Source (LCLS) Free Electron Laser (FEL) (at the Stanford Linear Accelerator). LCLS is an ultra bright, ultra short coherent x-ray source whose peak brightness will exceed that of third generation x-ray sources by about ten orders of magnitude and average brightness by three orders of magnitudes. It is expected to produce 1012 x-rays per 200 fs pulse with a repeat frequency of 120 Hz through self-amplified stimulated emission. In characterizing the beam, it will be necessary to measure the total energy of the FEL pulse. The Advanced Detector Group at Lawrence Livermore Laboratory has developed a scheme for FEL total energy measurements based on bolometric detection and are collaborating with Towson University to implement such a detector using CMR manganite thin films. Here we discuss the basic scheme, results of simulations of the thermal response and the materials development efforts towards fabricating the thin film detectors.
Objective: To audit sore throat management in adults, introduce proforma-based guidelines and to reaudit clinical practice.
Setting: Adult emergency department of an inner city teaching hospital.
Methods: A literature search was carried out to identify relevant guidelines. In stage one, patients presenting to the emergency department with sore throat were identified retrospectively from the emergency department attendance register. Proformas were completed retrospectively. In stage two, new guidelines were introduced and staff educated about the guidelines. In stage three, patients presenting with sore throat were identified at triage and proformas were completed at time of consultation.
Outcome Measures: (1) appropriate clinical assessment of the likelihood of bacterial infection using the clinical scoring system, (2) appropriateness of antibiotic prescription, (3) recommendation of supportive treatments to patients.
Results: Introduction of a clinical scoring system reduced the inappropriate prescribing of antibiotics from 44 per cent to 11 per cent. Correct antibiotic prescription rose from 60 per cent to 100 per cent. Although the variety of advice given about supportive treatment increased, the actual number of patients receiving documented supportive advice fell from 67.8 per cent in stage one to 58 per cent in stage three.
Conclusion: The introduction of clinically based guidelines for the diagnosis and management of sore throat in adults can reduce inappropriate antibiotic prescribing.
Future planetary exploration missions will require safe and precision soft-landing to target scientifically interesting sites near hazardous terrain features, such as escarpments, craters, slopes, and rocks. Although the landing accuracy has steadily improved over time to approximately 35 km for the recent Mars Exploration Rovers due to better approach navigation, a drastically different guidance, navigation and control concept is required to meet future mission requirements. For example, future rovers will require better than 6 km landing accuracy for Mars and better than 1 km for the Moon plus 100 m maneuvering capability to avoid hazards. Laser Radar or Lidar technology can be the key to meeting these objectives since it can provide highresolution 3-D maps of the terrain, accurately measure ground proximity and velocity, and determine atmospheric pressure and wind velocity. These lidar capabilities can enable the landers of the future to identify the pre-selected landing zone and hazardous terrain features within it, determine the optimum flight path, having atmospheric pressure and winds data, and accurately navigate using precision ground proximity and velocity data. This paper examines the potential of lidar technology in future human and robotic missions to the Moon, Mars, and other planetary bodies. A guidance and navigation control architecture concept utilizing lidar sensors will be presented and its operation will be described. The performance and physical requirements of the lidar sensors will be also discussed.
Diffuse elastic scattering of electrons by single nanometer-sized defects in ion irradiated Au has been measured quantitatively. Results are given for two dislocation loops and compared with published calculations to establish the loop geometry and interstitial or vacancy nature. Defect images using only diffuse scatttering are achieved with high sensitivity and good resolution by a hollow-cone dark-field method.