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We used a survey to characterize contemporary infection prevention and antibiotic stewardship program practices across 64 healthcare facilities, and we compared these findings to those of a similar 2013 survey. Notable findings include decreased frequency of active surveillance for methicillin-resistant Staphylococcus aureus, frequent active surveillance for carbapenem-resistant Enterobacteriaceae, and increased support for antibiotic stewardship programs.
Background: Young-onset dementia (YOD) patients and their caregivers face unique challenges in diagnosis and management. We aimed to compare the characteristics of rural YOD and late-onset dementia (LOD) patients. Methods: A total of 333 consecutive patients (YOD=61, LOD=272) at a rural and remote memory clinic between March 2004 and July 2016 were included in this study. Each patient had neuropsychological assessment. Health, mood, function, behaviour, and social factors were also measured. Both groups were compared using χ2 tests and independent sample tests. Results: YOD patients were more likely to be married, employed, current smokers, and highly educated. They reported fewer cognitive symptoms, but had more depressive symptoms. YOD patients were less likely to live alone and use homecare services. YOD caregivers were also more likely to be a spouse and had higher levels of distress than LOD caregivers. Conclusions: Our findings indicate YOD and LOD patients have distinct characteristics and services must be modified to better meet YOD patient needs. In particular, the use of homecare services and caregiver support may alleviate the higher levels of distress found in YOD patients and their caregivers. Additional research should be directed to addressing YOD patient depression, caregiver distress, and barriers to services.
Background: To determine whether there is a difference in the average annual rate of decline in Mini Mental Status Examination (MMSE) scores between those with Alzheimer’s disease, vascular dementia, frontotemporal dementia and dementia with Lewy bodies. Methods: We conducted a retrospective chart review of 225 consecutive patients with dementia who attended the Rural and Remote Memory Clinic in Saskatoon, Saskatchewan. The data collected included MMSE scores and demographic information. Statistical analysis with ANOVA compared the average the annual rate of decline in MMSE score between patients with different types of dementia. Results: There was no statistically significant difference in the rate of MMSE score decline between these groups. Patients with frontotemporal dementia and vascular dementia were referred to the clinic at younger ages than those with Alzheimer’s disease and dementia with Lewy bodies. Conclusions: The rate of decline in MMSE did not differ between these four types of dementia. Patients with frontotemporal dementia and vascular dementia often experience cognitive decline earlier in life than those with Alzheimer’s disease and dementia with Lewy bodies.
Essential tremor (ET) is associated with psychological difficulties, including anxiety and depression. Demoralization (feelings of helplessness, hopelessness, inability to cope), another manifestation of psychological distress, has yet to be investigated in ET. Our objectives are to (1) estimate the prevalence of demoralization in ET, (2) assess its clinical correlates, and (3) determine whether demoralization correlates with tremor severity.
We administered the Kissane Demoralization Scale (KDS-II) and several psychosocial evaluations (ie, scales assessing subjective incompetence, resilience, and depression [eg, Geriatric Depression Scale]) to 60 ET subjects. Tremor was assessed with a disability score and total tremor score. KDS-II >8 indicated demoralization.
Among 60 ET subjects (mean age = 70.2 ± 6.8 years), the prevalence of demoralization was 13.3%, 95% confidence interval = 6.9–24.2%. Although there was overlap between demoralization and depression (10% of the sample meeting criteria for both), 54% of depressed subjects were not demoralized, and 25% of demoralized subjects were not depressed. Demoralization correlated with psychological factors, but demoralized subjects did not have significantly higher total tremor scores, tremor disability scores, or years with tremor.
Demoralization has a prevalence of 13.3% in ET, similar to that in other chronic or terminal illnesses (eg, cancer 13–18%, Parkinson’s disease 18.1%, coronary heart disease 20%). Demoralization was not a function of increased tremor severity, suggesting that it is a separable construct, which could dictate how a patient copes with his/her disease. These data further our understanding of the psychological and psychosocial correlates of ET.
To ascertain opinions regarding etiology and preventability of hospital-onset bacteremia and fungemia (HOB) and perspectives on HOB as a potential outcome measure reflecting quality of infection prevention and hospital care.
Hospital epidemiologists and infection preventionist members of the Society for Healthcare Epidemiology of America (SHEA) Research Network.
A web-based, multiple-choice survey was administered via the SHEA Research Network to 133 hospitals.
A total of 89 surveys were completed (67% response rate). Overall, 60% of respondents defined HOB as a positive blood culture on or after hospital day 3. Central line-associated bloodstream infections and intra-abdominal infections were perceived as the most frequent etiologies. Moreover, 61% thought that most HOB events are preventable, and 54% viewed HOB as a measure reflecting a hospital’s quality of care. Also, 29% of respondents’ hospitals already collect HOB data for internal purposes. Given a choice to publicly report central-line–associated bloodstream infections (CLABSIs) and/or HOB, 57% favored reporting either HOB alone (22%) or in addition to CLABSI (35%) and 34% favored CLABSI alone.
Among the majority of SHEA Research Network respondents, HOB is perceived as preventable, reflective of quality of care, and potentially acceptable as a publicly reported quality metric. Further studies on HOB are needed, including validation as a quality measure, assessment of risk adjustment, and formation of evidence-based bundles and toolkits to facilitate measurement and improvement of HOB rates.
Solvency II came into force on 1 January 2016 and included a transitional measure on technical provisions (“TMTP”) designed to help smooth in the capital impact of Solvency II over a 16-year period. The working party’s view is that the main intention of the TMTP is to mitigate the impact of the introduction of the risk margin, which significantly increases the technical provisions of firms, relative to their Solvency I Pillar 2 liabilities.
The majority of firms who hold a TMTP have now had at least one recalculation approved by the Prudential Regulation Authority (PRA); or are in the process of applying for a recalculation. Despite this large number of approved recalculations, there remains significant uncertainty in the industry around the approach and triggers for recalculation.
This paper considers aspects of TMTP recalculation for regulated UK life firms, for example practicalities of the calculation, asset and liability considerations, and communications/announcements.
In this paper, we outline the need for pragmatism when considering the approach to recalculation of a measure originally intended to serve as the bridge between two regimes. We call for an allowance for doing what is sensible in a principles-based regime balancing what might be more theoretically correct with what is practical and possible to support effective management of the business.
We examined the epidemiology of invasive meningococcal disease (IMD) in the Republic of Ireland (ROI) between epidemiological year (EY) 1996/1997 and EY2015/2016. Over the 20 EYs, 3707 cases were reported with annual incidence rates per 100 000 peaking at 11.6 in EY1999/2000, decreasing significantly to 1.5 in EY2015/2016. The highest disease burden was in infants and children <5, whereas adults aged ⩾65 years experienced the highest case fatality ratio (CFR) of 15.7% but over the study period the median annual CFR remained low (4.4%). Meningococcal serogroup B (menB) dominated (78%), followed by menC (17%), menW (1%) and menY (1%). The incidence of menC IMD declined significantly in all age groups after menC vaccine introduction in 2000. MenB incidence also declined over the 20 EYs with decreasing trends in all age groups under 65, including an almost 50% decrease in infants over the final four EYs. IMD incidence in the ROI has declined, partly attributable to menC vaccination success, coupled with a spontaneous decline in menB. However, recent gradual increases in non-menB IMD and the introduction of vaccines targeting menB demand continued detailed surveillance to accurately monitor trends and to assess vaccine impact.
There has recently been growing interest in various atomic and nuclear techniques for the measurement of elements in the body. This has arisen through the realisation that (a) clinically-important amounts of toxic elements can be absorbed as a result of low-level environmental exposure, and (b) important information about the nutritional status of a patient can be obtained from measurements of major body elements. Where such information can be obtained by taking samples, a very wide range of analytical techniques is available, some capable of a sensitivity measured in parts-per-billion. Sampling is not possible, however, when the whole-body content (e.g. of nitrogen) is required, and is clinically undesirable when the element in question is concentrated in particular organs, for example as lead accumulates in the bones, and cadmium and many other toxic elements accumulate in the kidneys. It is in such cases that the various in vivo techniques are particularly important.
We describe the parameters of a low-frequency all-sky survey of compact radio sources using Interplanetary Scintillation, undertaken with the Murchison Widefield Array. While this survey gives important complementary information to low-resolution survey, providing information on the sub-arsecond structure of every source, a survey of this kind has not been attempted in the era of low-frequency imaging arrays such as the Murchison Widefield Array and LOw Frequency Array. Here we set out the capabilities of such a survey, describing the limitations imposed by the heliocentric observing geometry and by the instrument itself. We demonstrate the potential for Interplanetary Scintillation measurements at any point on the celestial sphere and we show that at 160 MHz, reasonable results can be obtained within 30° of the ecliptic (2π str: half the sky). We also suggest some observational strategies and describe the first such survey, the Murchison Widefield Array Phase I Interplanetary Scintillation survey. Finally we analyse the potential of the recently upgraded Murchison Widefield Array and discuss the potential of the Square Kilometre Array-low to use Interplanetary Scintillation to probe sub-mJy flux density levels at sub-arcsecond angular resolution.
The work of the Kutak Commission in developing the Model Rules of Professional Conduct is probably the most important work in legal ethics since the Alabama State Bar Association first codified its Canons of Ethics in 1887. In general, the Commission's product is excellent. It is progressive without being radical and conservative without being timid. However, as can be expected in any discussion draft, there are issues not wholly thought through and concepts not clearly expressed. In the spirit of improving the next draft, these mostly critical comments are offered.
Objectives: Essential tremor (ET) confers an increased risk for developing both amnestic and non-amnestic mild cognitive impairment (MCI). Yet, the optimal measures for detecting mild cognitive changes in individuals with this movement disorder have not been established. We sought to identify the cognitive domains and specific motor-free neuropsychological tests that are most sensitive to mild deficits in cognition as defined by a Clinical Dementia Rating (CDR) of 0.5, which is generally associated with a clinical diagnosis of MCI. Methods: A total of 196 ET subjects enrolled in a prospective, longitudinal, clinical-pathological study underwent an extensive motor-free neuropsychological test battery and were assigned a CDR score. Logistic regression analyses were performed to identify the neuropsychological tests which best identified individuals with CDR of 0.5 (mild deficits in cognition) versus 0 (normal cognition). Results: In regression models, we identified five tests in the domains of Memory and Executive Function which best discriminated subjects with CDR of 0.5 versus 0 (86.9% model classification accuracy). These tests were the California Verbal Learning Test II Total Recall, Logical Memory II, Verbal-Paired Associates I, Category Switching Fluency, and Color-Word Inhibition. Conclusions: Mild cognitive difficulty among ET subjects is best predicted by combined performance on five measures of memory and executive function. These results inform the nature of cognitive dysfunction in ET and the creation of a brief cognitive battery to assess patients with ET for cognitively driven dysfunction in life that could indicate the presence of MCI. (JINS, 2018, 24, 1084–1098)
Twenty-seven species and two subspecies of Ficus are reported from one study site in central Africa. Characters for identification are explained. An identification key, illustrations, descriptions and habitats are provided. The species-level diversity of Ficus in tropical forests is discussed.
Background: A will, power of attorney and advanced healthcare directive are critical to guide decision-making in people with cognitive decline. We identified characteristics that are associated with the existence of these documents in patients who presented to a rural and remote memory clinic (RRMC). Methods: 95 consecutive patients were included in this study. Patients and caregivers completed questionnaires on initial presentation to the RRMC and patients were asked if they have legal documents. Patients also completed neuropsychological testing. Statistical analysis (t-test and χ2 test) was performed to identify significant variables. Results: 70 patients had a will, 62 had a power of attorney and 21 had an advanced healthcare directive. Having a will was associated with good quality of life (p=0.001), living alone (p=0.034), poor verbal fluency (p=0.055) and European ethnicity (p=0.028). Factors associated with having a power of attorney included good quality of life (p=0.031), living alone (p=0.053) and poor verbal fluency (p=0.015). Old age (p=0.015), poor verbal fluency (p=0.023) and severity of cognitive and functional impairment (p=0.023) were associated with having an advanced healthcare directive. Conclusions: Our results indicate that poor quality of life, good verbal fluency, non-European ethnicity and living with others are associated with a lower likelihood of creating legal documents in patients with cognitive decline
To directly observe healthcare workers in a nursing home setting to measure frequency and duration of resident contact and infection prevention behavior as a factor of isolation practice
SETTING AND PARTICIPANTS
Healthcare workers in 8 VA nursing homes in Florida, Maryland, Massachusetts, Michigan, Washington, and Texas
Over a 15-month period, trained research staff without clinical responsibilities on the units observed nursing home resident room activity for 15–30-minute intervals. Observers recorded time of entry and exit, isolation status, visitor type (staff, visitor, etc), hand hygiene, use of gloves and gowns, and activities performed in the room when visible.
A total of 999 hours of observation were conducted across 8 VA nursing homes during which 4,325 visits were observed. Residents in isolation received an average of 4.73 visits per hour of observation compared with 4.21 for nonisolation residents (P<.01), a 12.4% increase in visits for residents in isolation. Residents in isolation received an average of 3.53 resident care activities per hour of observation, compared with 2.46 for residents not in isolation (P<.01). For residents in isolation, compliance was 34% for gowns and 58% for gloves. Healthcare worker hand hygiene compliance was 45% versus 44% (P=.79) on entry and 66% versus 55% (P<.01) on exit for isolation and nonisolation rooms, respectively.
Healthcare workers visited residents in isolation more frequently, likely because they required greater assistance. Compliance with gowns and gloves for isolation was limited in the nursing home setting. Adherence to hand hygiene also was less than optimal, regardless of isolation status of residents.
This paper discusses the composition and nutritional values of a limited number of materials of tropical or sub-tropical origin encountered in advisory work. These products have emerged in recent years chiefly as minor components of compounds and to a lesser extent as ‘straights’. These by-products are olive pulp, grape pulp pellets, grape seed meal, dried coffee residues, citrus pulp pellets, cocoa shell meal, extracted cocoa meal, shea-nut pellets and shea expeller meal, guar meal, illipe meal and cassava meal. Other foods such as cereal by-products and sugar cane molasses are discussed elsewhere, whilst materials that may originally have been by-products of oil extraction such as soya, ground nut and palm kernel, etc., are now such significant parts of the modern sophisticated feed compounding industry that it may be unfair to classify them as by-products in the usually accepted sense. In any case information on them is well documented and readily available and hence they will not be discussed here.
The by-products listed above form only a small proportion of the imported feeding stuffs bill but nevertheless can be of economic and nutritional significance in isolated circumstances. Some idea of their overall monetary significance is as follows. The total quantity of imported feeding stuffs other than cereals in 1977 was 1 495 973 tonnes. Of the above list of by-products, only olive pulp and grape residues are listed separately on official lists and each account for less than 1% of the total. Olive pulp imports were 33 457 tonnes and grape residues 11 276 tonnes. Undefined residues from oil extraction, which presumably includes some of the above listed products, amounted to 58 791 tonnes, whilst ‘Other products of vegetable origin’ would account for some other imported products totalling 45 013 tonnes.
The structural integrity of nuclear fission and fusion power plant components is the focus of this research. The state of the art is using micro scale specimens milled with a focussed ion beam (FIB). Because of their very low volume such specimens can be lab tested, even when irradiated to low or medium level of activity. This offers a possibility of testing multiple specimens to investigate stochastic effects, e.g. effects of irradiation on the shift of the ductile to brittle transition. However, FIB milled specimens suffer from Ga contamination, to the degree that the validity of fracture data obtained on such specimens is questionable. We propose to use nano-additive manufacturing as an alternative to FIB for making micro scale fracture specimens. A combination of two-photon polymerization and electrodeposition and sputtering was used to manufacture micro-scale Brazilian disk fracture specimens (CBD), which are free from Ga and thus better suited for the study of irradiation effects on structural integrity. In this study Ni CBD specimens were made with 30 µm diameter and up to 13 µm thickness. The slot width varied between 1 µm to 2.9 µm width the corresponding slot length of between 7.5 µm and 8 µm. Consecutive FIB characterization shows that the specimens have polycrystalline microstructure with sub-µm grains. The work is ongoing making W CBD specimens and on reducing the slot width and using chemical vapor deposition fabrication.
The merits of solar coronal at metric-wavelength (MW) radio have long been recognised (e.g. Pick and Vilmer, 2008). High-fidelity solar radio imaging at these frequencies has however remained challenging. On the one hand, dealing with the small spectral and temporal scales of variation in solar radio emission requires a data product capable of tracking the emission simultaneously across time, frequency and morphology. The Fourier imaging nature of interferometry, on the other hand, severely limits the instrumental ability to gather sufficient information to do this with the required fidelity and resolution. Benefiting from the enormous advances in technology the new generation of instruments, like the Murchison Widefield Array (MWA; Tingay et al. (2013), Bowman et al. (2013)), represent a quantum leap in our ability to gather data suitable for radio solar physics.