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To evaluate whether incorporating mandatory prior authorization for Clostridioides difficile testing into antimicrobial stewardship pharmacist workflow could reduce testing in patients with alternative etiologies for diarrhea.
Single center, quasi-experimental before-and-after study.
Tertiary-care, academic medical center in Ann Arbor, Michigan.
Adult and pediatric patients admitted between September 11, 2019 and December 10, 2019 were included if they had an order placed for 1 of the following: (1) C. difficile enzyme immunoassay (EIA) in patients hospitalized >72 hours and received laxatives, oral contrast, or initiated tube feeds within the prior 48 hours, (2) repeat molecular multiplex gastrointestinal pathogen panel (GIPAN) testing, or (3) GIPAN testing in patients hospitalized >72 hours.
A best-practice alert prompting prior authorization by the antimicrobial stewardship program (ASP) for EIA or GIPAN testing was implemented. Approval required the provider to page the ASP pharmacist and discuss rationale for testing. The provider could not proceed with the order if ASP approval was not obtained.
An average of 2.5 requests per day were received over the 3-month intervention period. The weekly rate of EIA and GIPAN orders per 1,000 patient days decreased significantly from 6.05 ± 0.94 to 4.87 ± 0.78 (IRR, 0.72; 95% CI, 0.56–0.93; P = .010) and from 1.72 ± 0.37 to 0.89 ± 0.29 (IRR, 0.53; 95% CI, 0.37–0.77; P = .001), respectively.
We identified an efficient, effective C. difficile and GIPAN diagnostic stewardship approval model.
Background: Biallelic variants in POLR1C are associated with POLR3-related leukodystrophy (POLR3-HLD), or 4H leukodystrophy (Hypomyelination, Hypodontia, Hypogonadotropic Hypogonadism), and Treacher Collins syndrome (TCS). The clinical spectrum of POLR3-HLD caused by variants in this gene has not been described. Methods: A cross-sectional observational study involving 25 centers worldwide was conducted between 2016 and 2018. The clinical, radiologic and molecular features of 23 unreported and previously reported cases of POLR3-HLD caused by POLR1C variants were reviewed. Results: Most participants presented between birth and age 6 years with motor difficulties. Neurological deterioration was seen during childhood, suggesting a more severe phenotype than previously described. The dental, ocular and endocrine features often seen in POLR3-HLD were not invariably present. Five patients (22%) had a combination of hypomyelinating leukodystrophy and abnormal craniofacial development, including one individual with clear TCS features. Several cases did not exhibit all the typical radiologic characteristics of POLR3-HLD. A total of 29 different pathogenic variants in POLR1C were identified, including 13 new disease-causing variants. Conclusions: Based on the largest cohort of patients to date, these results suggest novel characteristics of POLR1C-related disorder, with a spectrum of clinical involvement characterized by hypomyelinating leukodystrophy with or without abnormal craniofacial development reminiscent of TCS.
Central nervous system infections (CNSI) are a leading cause of death and long-term disability in children. Using ICD-10 data from 2005 to 2015 from three central hospitals in Ho Chi Minh City (HCMC), Vietnam, we exploited generalized additive mixed models (GAMM) to examine the spatial-temporal distribution and spatial and climatic risk factors of paediatric CNSI, excluding tuberculous meningitis, in this setting. From 2005 to 2015, there were 9469 cases of paediatric CNSI; 33% were ⩽1 year old at admission and were mainly diagnosed with presumed bacterial CNSI (BI) (79%), the remainder were >1 year old and mainly diagnosed with presumed non-bacterial CNSI (non-BI) (59%). The urban districts of HCMC in proximity to the hospitals as well as some outer districts had the highest incidences of BI and non-BI; BI incidence was higher in the dry season. Monthly BI incidence exhibited a significant decreasing trend over the study. Both BI and non-BI were significantly associated with lags in monthly average temperature, rainfall, and river water level. Our findings add new insights into this important group of infections in Vietnam, and highlight where resources for the prevention and control of paediatric CNSI should be allocated.
Carbonated calcium apatites doped with a monovalent cation (Li+, Na+, or K+) or a divalent cation (Mg2+ or Zn2+) were prepared in aqueous solution and analysed by powder X-ray diffraction, inductively coupled plasma atomic emission spectroscopy and infrared spectroscopy. The hypothesis that the location of carbonate in the apatite structure, either in place of hydroxide ions in the c-axis channels (A-type substitution) or in place of phosphate (B-type substitution), is affected by the solution energetics of the cation (specifically its enthalpy of hydration) was strengthened by the observation of larger amounts of Atype carbonate in apatites containing the monovalent cations in aqueous solution. It is shown that cations with low negative enthalpies of hydration favour A-type substitution, whereas cations with higher negative hydration enthalpies, such as divalent cations (Mg2+, Zn2+), favour B-type substitution.
Information about viral acute respiratory infections (ARIs) is essential for prevention, diagnosis and treatment, but it is limited in tropical developing countries. This study described the clinical and epidemiological characteristics of ARIs in children hospitalized in Vietnam. Nasopharyngeal samples were collected from children with ARIs at Ho Chi Minh City Children's Hospital 2 between April 2010 and May 2011 in order to detect respiratory viruses by polymerase chain reaction. Viruses were found in 64% of 1082 patients, with 12% being co-infections. The leading detected viruses were human rhinovirus (HRV; 30%), respiratory syncytial virus (RSV; 23·8%), and human bocavirus (HBoV; 7·2%). HRV was detected all year round, while RSV epidemics occurred mainly in the rainy season. Influenza A (FluA) was found in both seasons. The other viruses were predominant in the dry season. HRV was identified in children of all age groups. RSV, parainfluenza virus (PIV) 1, PIV3 and HBoV, and FluA were detected predominantly in children aged <6 months, 6–12 months, 12–24 months, and >24 months, respectively. Significant associations were found between PIV1 with croup (P < 0·005) and RSV with bronchiolitis (P < 0·005). HBoV and HRV were associated with hypoxia (P < 0·05) and RSV with retraction (P < 0·05). HRV, RSV, and HBoV were detected most frequently and they may increase the severity of ARIs in children.
Molecular epidemiology and clinical impact of human rhinovirus (HRV) are not well documented in tropical regions. This study compared the clinical characteristics of HRV to other common viral infections and investigated the molecular epidemiology of HRV in hospitalized children with acute respiratory infections (ARIs) in Vietnam. From April 2010 to May 2011, 1082 nasopharyngeal swabs were screened for respiratory viruses by PCR. VP4/VP2 sequences of HRV were further characterized. HRV was the most commonly detected virus (30%), in which 70% were diagnosed as either pneumonia or bronchiolitis. Children with single HRV infections presented with significantly higher rate of hypoxia than those infected with respiratory syncytial virus or parainfluenza virus (PIV)-3 (12·4% vs. 3·8% and 0%, respectively, P < 0·05), higher rate of chest retraction than PIV-1 (57·3% vs. 34·5%, P = 0·028), higher rate of wheezing than influenza A (63·2% vs. 42·3%, P = 0·038). HRV-C did not differ to HRV-A clinically. The genetic diversity and changes of types over time were observed and may explain the year-round circulation of HRV. One novel HRV-A type was discovered which circulated locally for several years. In conclusion, HRV showed high genetic diversity and was associated with significant morbidity and severe ARIs in hospitalized children.
Seasonal as well as weekly cycles in suicide have been described, replicated and poorly understood for a long time. In Western countries, suicides are typically least frequent on weekends and most frequent on Mondays and Tuesdays. To improve understanding of this phenomenon a strategy is required which focuses on anomalous findings beyond the regular patterns. Here, we focused on instances where the weekly suicide patterns disappear or are interrupted.
We used data from Swiss and Austrian mortality statistics for the periods 1969–2010 and 1970–2010, respectively. First, the data were cross-tabulated by days of the week and the available socio-demographic information (sex, age, religious affiliation and region). Second, time series of cumulated daily frequencies of suicide were analysed by seasonal Autoregressive Integrated Moving Average (ARIMA) models which included intervention effects accounting for Easter and Pentecost (Whit) holidays.
First, the cross tabulations showed that weekly cycles may be smoothed above all in young persons and smoothed in drowning, jumping and car gas exhaustion suicides. Second, the ARIMA analyses displayed occasional preventive effects for holidays Saturdays and Sundays, and more systematic effects for holiday Mondays. There were no after effects on Tuesdays following holiday Mondays.
In general, the weekend dip and the Monday backlog effect in suicide show striking similarities to the Advent season effect and are interpretable within the same template. The turning points between low and high frequencies possibly provide promising frames for the timing of prevention activities.
Triticale possesses favourable agronomic attributes originating from both its wheat and rye progenitors, including high grain and biomass yields. Triticale, primarily used as animal feed in North America, is an excellent candidate for production of industrial bio-products. Little is known about the coordination of gene expression of rye and wheat genomes in this intergeneric hybrid, but significant DNA losses from the parental genomes have been reported. To clarify the regulation of gene expression in triticale, we carried out 454 sequencing of cDNAs obtained from root, leaf, stem and floral tissues in different lines of triticale and rye exhibiting different phenotypes and assembled reads into contigs. Related to the data assembly were the absence of reference genomes and the paucity of rye sequences in GenBank or other public databases. Consequently, we have sequenced cDNA libraries from roots, seedlings, leaves, floral tissues and immature seeds to facilitate the identification of triticale sequences originating from rye. To further characterize the wheat-derived cDNAs, we also developed a database close to 25,000 non-redundant full-length wheat coding sequence genes, based on existing databases and contigs that were verified against protein sequences from the grass genomes of Brachypodium distachyon, rice, sorghum and maize.
EuroRotaNet, a laboratory network, was established in order to determine the diversity of co-circulating rotavirus strains in Europe over three or more rotavirus seasons from 2006/2007 and currently includes 16 countries. This report highlights the tremendous diversity of rotavirus strains co-circulating in the European population during three years of surveillance since 2006/2007 and points to the possible origins of these strains including genetic reassortment and interspecies transmission. Furthermore, the ability of the network to identify strains circulating with an incidence of ⩾1% allowed the identification of possible emerging strains such as G8 and G12 since the beginning of the study; analysis of recent data indicates their increased incidence. The introduction of universal rotavirus vaccination in at least two of the participating countries, and partial vaccine coverage in some others may provide data on diversity driven by vaccine introduction and possible strain replacement in Europe.
Aspergillus flavus and A. parasiticus are closely related species belonging to the Aspergillus section Flavi. Both species can produce
aflatoxins, but not all isolates of either species do so. We examined the genetic relationship between toxigenic and non-toxigenic
isolates using RAPD and Neighbour Joining analysis. Twenty-four RAPD amplifications using a combination of 17 primers
discriminated between 20 isolates of A. flavus and 15 isolates of A. parasiticus. A. flavus isolates divided into two distinct groups
with both toxigenic and non-toxigenic isolates occurring in each group. No association was seen between RAPD genotype and the
ability to produce toxin. Five non-toxigenic isolates of A. parasiticus separated into two groups, in which the isolates were similar
but not identical. These groups of non-toxigenic isolates occurred on branches in which toxigenic isolates also occurred. This study
suggests that either multiple losses of toxigenicity in A. flavus and A. parasiticus have occurred, or that recombination has reassorted
this phenotype into a variety of different genetic backgrounds.
Amacrine cells that respond transiently to maintained
illumination are thought to mediate transient inhibitory
input to ganglion cells. The excitation of these transient
amacrine cells is thought to be limited by inhibitory feedback
to bipolar cells. We investigated the possibility that
desensitizing AMPA and/or kainate (KA) receptors on amacrine
cells might also limit the duration of amacrine cell excitation.
To determine how these receptors might affect amacrine
cell input and output, we made whole-cell recordings from
amacrine and ganglion cells in the salamander retinal slice.
The specific AMPA receptor antagonist GYKI-53655 blocked
non-NMDA receptor-mediated amacrine cell excitatory postsynaptic
currents (EPSCs) and kainate puff-elicited currents, indicating
that AMPA, and not KA, receptors mediated the responses.
Cyclothiazide, an agent that reduces AMPA receptor desensitization,
increased the amplitude and duration of amacrine cell EPSCs.
To measure the output of transient amacrine cells, we recorded
glycinergic inhibitory postsynaptic currents (IPSCs) from
ganglion cells, and found that these were also enhanced
by cyclothiazide. Thus, prolongation of amacrine cell AMPA
receptor activation enhanced amacrine cell output. Current
responses elicited by puffing glycine onto ganglion cell
dendrites were not affected by cyclothiazide, indicating
that the enhancement of glycinergic IPSCs was not due to
a direct effect on glycine receptors. These data suggest
that rapid AMPA receptor desensitization and/or deactivation
limits glycinergic amacrine cell excitation and the resulting
inhibitory synaptic output.
Comparisons were made between two groups of anorectic patients, ‘non-white’ and ‘white‘, on a variety of clinical and social characteristics.
The study is based on a 34-year long database (1960–93) associated with a national tertiary referral centre. Thirty-six non-white patients meeting DSM–III–R criteria for anorexia nervosa (AN) and five with ‘partial syndrome’ are compared with a white group comprising 944 patients with full syndrome.
The main finding is clinical similarity between the two groups, extending to social class and pathological patterns of family relationship. The non-whites are shorter in stature (P = 0.004) and report earlier menarche (P = 0.004); they are younger at presentation (P < 0.001), somewhat less emaciated, and practice veganism slightly more commonly; they less often acknowledge sensitivity to ‘fatness’ (P < 0.003). This sensitivity was exposed later whenever treatment involved substantial weight gain. The proportion of non-white cases accepted for assessment has not changed in respect of year of onset (around 6%) for the last 20 years, or year of presentation (around 6–7%) over the last 15 years. There was a tendency for non-white patients to be referred earlier in their illness.
The clinical and background profiles of non-white and white anorectics are generally similar. The numbers arising and presenting have not changed recently. Non-white patients apparently have as ready access as white patients to assessment and treatment by us.
Linoleic acid (LA) transport in rats with experimental short-term and long-term renal failure (RF) was compared with that of sham-operated normal animals on liberal food intake and pair-fed animals. The perfusions in vivo and incubations in vitro were conducted using a micellar solution containing a wide range of LA concentrations. Both absorption in vivo and uptake in vitro of LA were significantly reduced in animals with short-term RF. Lipid extraction and separation by thin-layer chromatography revealed a marked LA trapping as trilinolein (TL) in the perfused intestinal tissue in the short-term RF group. The esterification process, as defined by the rate of LA incorporation into TL, was moderately reduced in short-term RF animals. The thickness of the unstirred water layer showed no significant difference among the groups studied. In contrast, animals with long-term RF exhibited normal absorption of LA in vivo at all concentrations tested. In conclusion, LA absorption is reduced in short-term RF and restored in long-term RF. Several steps including LA transport into and TL transport out of the enterocyte and the esterification process were impaired in short-term RF. These changes are not due to alteration in the unstirred water layer, anorexia, weight loss or a rapid effect of uraemic chemical environment or circulatory factors.
Effect of low level doping of boron and phosphorus on the properties of amorphous silicon films (a-Si:H) was studied. Doping level of both boron and phosphorus was in the range of 1017 atoms/cm3. Apparent improvement in the stability of dark and photoconductivity of a-Si:H films upon low level doping does not result from the elimination of light-induced defects. The stability of the dark and photoconductivity upon doping is an indication of pinning of the Fermi level.
Carbon grading in the buffer layer at the p/i interface increases the open circuit voltage of both p-i-n and n-i-p amorphous silicon solar cells. We propose that carbon grading enlarges the electric field and reduces the electron tunneling at the p/i interface.
Amorphous hydrogenated silicon carbide alloy films (a-SiC:H) were produced by the decomposition of methane and silane in a glow discharge deposition system. A deposition rate of 13 Å/sec was achieved for good quality films. Amorphous SiC:H films of p+ type and n+ type of a band gap of 1.86 eV and 1.8 eV and the activation energy of 0.4 eV and 0.23 eV, respectively were obtained. Results show that p+ type and n+ type a-SiC:H films can be good window layers and good diffusion barriers for indium in polyimide/metal/n-i-p(p-i-n)/ITO amorphous silicon solar cells.
Hydrogenated amorphous silicon films were produced from silane/hydrogen and silane/helium gas mixtures by RF glow discharge. We examined the optical and electrical properties of films produced with these gas mixtures, at various RF power levels and silane fractions. Film quality was analyzed by measuring the dark and photoconductivity, optical band gap, and activation energy. Optical emission spectroscopy was also used as a diagnostic tool for studying the plasma during glow discharge depositions. Experimental results indicate that amorphous silicon films made from silane/helium mixtures exhibit improved optoelectronic properties, higher deposition rates, and higher emission intensity ratios (ISiH/IH) as compared to films produced from silane/hydrogen mixtures. In preparing films from silane/helium mixtures, the onset of dust/powder formation occurs at considerably higher RF powers as compared to silane/hydrogen, thus making this approach an attractive commercial option for depositing films at high rates.
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