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Angiostrongylus cantonensis has been found in Florida, USA, from the panhandle in the north to Miami and surrounding areas in the southern parts of the state, in both definitive and intermediate hosts in a limited studies completed in 2015. Additional studies have identified this parasite in a variety of intermediate hosts, both native and non-native gastropod species, with new host species recorded. Many areas in Florida with higher A. cantonensis prevalence were those with a high human population density, which suggests it is a matter of time before human infections occur in Florida. Case reports in the state currently involve non-human primates and include a gibbon and orangutan in Miami. Here, we report the current status of A. cantonensis in the state, as well as the infection in a capuchin monkey and presumptive infection in a red ruffed lemur in Gainesville, Florida.
Introduction: Emergency department (ED) patients with cellulitis that are treated with intravenous (IV) antibiotics may be eligible for outpatient parenteral antibiotic therapy (OPAT). The primary objective of this study was to determine whether the implementation of an OPAT clinic results in decreased hospitalization and return ED visits for patients treated with IV antibiotics. Methods: We conducted a before-after implementation study involving adults (age >=18 years) that presented to two tertiary care EDs with cellulitis and were treated with IV antibiotics. The intervention was referral to an infectious disease physician within one week of the index ED visit at the newly created OPAT clinic. The primary outcomes were hospital admission and return ED visits within 14 days. Secondary outcomes were treatment failure (admission after 48 hours of OPAT) and adverse events (e.g. vomiting, diarrhea). We conducted an interrupted time series analysis from January to December both pre-intervention (2013) and post-intervention (2015), with 24 monthly data points. The year of clinic implementation (2014) was considered a transition period. A segmented non-linear regression autoregressive error model was used to aggregate the monthly data to evaluate the effectiveness of the intervention. Results: A total of 1,666 patients met inclusion criteria: 858 pre-intervention (mean age 59 years, 53.1% male) and 808 post-intervention (mean age 62 years, 54.5% male). Hospitalization rates were not significantly higher one year after clinic implementation (p = 0.53) although there was a non-statistically significant gradual increase of 0.8% per month (95%CI -0.3% to 1.9%). One year after introduction of the OPAT clinic, return ED visits were significantly lower (change in intercept -24.4%, 95%CI -34.2% to -14.6%; p < 0.001), followed by an additional drop of 1.4% per month (95%CI -2.1% to -0.6%; p = 0.002). By the end of the study, return visits were 40.7% lower (95%CI 25.6% to 55.9%) than if the intervention had not been introduced. Treatment failure rates were <2% and adverse events were <5% in both groups. Conclusion: Implementation of an OPAT clinic significantly reduced return ED visits for cellulitis, which is critically important given the current ED overcrowding crisis. There was no significant change in hospital admission rates. There were low rates of treatment failures and adverse events. An OPAT clinic should be considered to reduce ED crowding while maintaining safe patient care.
Antidepressants have limited efficacy in older adults with depression and cognitive impairment, and psychosocial interventions for this population have been inadequately investigated. Problem Adaptation Therapy (PATH) is a psychosocial intervention for older adults with major depression, cognitive impairment, and disability.
Design:
This study tests the efficacy of PATH versus Supportive Therapy for Cognitively Impaired Older Adults (ST-CI) in reducing depression (Montgamery Asberg Depression Rating Scale [MADRS]) and disability (World Health Organization Disability Assessments Schedule-II [WHODAS-II]) and improving cognitive outcomes (Mini Mental State Examination [MMSE]) over 24 weeks (12 weeks of treatment and 12-week post-treatment follow-up).
Setting:
Participants were recruited through collaborating community agencies of Weill Cornell Institute of Geriatric Psychiatry. Both interventions and all research assessments were conducted at home.
Participants:
Thirty-five older adults (age ≥ 65 years) with major depression and cognitive impairment no dementia (CIND).
Interventions:
PATH aims to increase emotion regulation by incorporating a problem-solving approach, teaching compensatory strategies, and inviting caregiver participation. Supportive Therapy aims to facilitate the expression of affect, as well as promote empathy.
Measurements:
Depression was measured using the MADRS, disability using the WHODAS-II, and cognition using the MMSE.
Results:
PATH participants showed significantly greater reduction in MADRS total score (7.04 points at 24 weeks, treatment group by time interaction: F[1,24.4] = 7.61, p = 0.0108), greater improvement in MMSE total score (2.30 points at 24 weeks, treatment group by time interaction: F[1,39.8] = 13.31, p = 0.0008), and greater improvement in WHODAS-II total score (2.95 points at 24 weeks, treatment group by time interaction: F[1,89] = 4.93, p = 0.0290) than ST-CI participants over the 24-week period.
Conclusions:
PATH participants had better depression, cognitive, and disability outcomes than ST-CI participants over 6 months. PATH may provide relief to depressed older adults with CIND who currently have limited treatment options.
We present a model for the scaling of mixing in weakly rotating stratified flows characterized by their Rossby, Froude and Reynolds numbers
$Ro,Fr$
,
$Re$
. This model is based on quasi-equipartition between kinetic and potential modes, sub-dominant vertical velocity,
$w$
, and lessening of the energy transfer to small scales as measured by a dissipation efficiency
$\unicode[STIX]{x1D6FD}=\unicode[STIX]{x1D716}_{V}/\unicode[STIX]{x1D716}_{D}$
, with
$\unicode[STIX]{x1D716}_{V}$
the kinetic energy dissipation and
$\unicode[STIX]{x1D716}_{D}=u_{rms}^{3}/L_{int}$
its dimensional expression, with
$w,u_{rms}$
the vertical and root mean square velocities, and
$L_{int}$
the integral scale. We determine the domains of validity of such laws for a large numerical study of the unforced Boussinesq equations mostly on grids of
$1024^{3}$
points, with
$Ro/Fr\geqslant 2.5$
, and with
$1600\leqslant Re\approx 5.4\times 10^{4}$
; the Prandtl number is one, initial conditions are either isotropic and at large scale for the velocity and zero for the temperature
$\unicode[STIX]{x1D703}$
, or in geostrophic balance. Three regimes in Froude number, as for stratified flows, are observed: dominant waves, eddy–wave interactions and strong turbulence. A wave–turbulence balance for the transfer time
$\unicode[STIX]{x1D70F}_{tr}=N\unicode[STIX]{x1D70F}_{NL}^{2}$
, with
$\unicode[STIX]{x1D70F}_{NL}=L_{int}/u_{rms}$
the turnover time and
$N$
the Brunt–Väisälä frequency, leads to
$\unicode[STIX]{x1D6FD}$
growing linearly with
$Fr$
in the intermediate regime, with a saturation at
$\unicode[STIX]{x1D6FD}\approx 0.3$
or more, depending on initial conditions for larger Froude numbers. The Ellison scale is also found to scale linearly with
$Fr$
. The flux Richardson number
$R_{f}=B_{f}/[B_{f}+\unicode[STIX]{x1D716}_{V}]$
, with
$B_{f}=N\langle w\unicode[STIX]{x1D703}\rangle$
the buoyancy flux, transitions for approximately the same parameter values as for
$\unicode[STIX]{x1D6FD}$
. These regimes for the present study are delimited by
${\mathcal{R}}_{B}=ReFr^{2}\approx 2$
and
$R_{B}\approx 200$
. With
$\unicode[STIX]{x1D6E4}_{f}=R_{f}/[1-R_{f}]$
the mixing efficiency, putting together the three relationships of the model allows for the prediction of the scaling
$\unicode[STIX]{x1D6E4}_{f}\sim Fr^{-2}\sim {\mathcal{R}}_{B}^{-1}$
in the low and intermediate regimes for high
$Re$
, whereas for higher Froude numbers,
$\unicode[STIX]{x1D6E4}_{f}\sim {\mathcal{R}}_{B}^{-1/2}$
, a scaling already found in observations: as turbulence strengthens,
$\unicode[STIX]{x1D6FD}\sim 1$
,
$w\approx u_{rms}$
, and smaller buoyancy fluxes together correspond to a decoupling of velocity and temperature fluctuations, the latter becoming passive.
A cognitive–behavioural therapy (CBT) programme designed for
post-traumatic stress disorder (PTSD) in people with severe mental
illness, including breathing retraining, education and cognitive
restructuring, was shown to be more effective than usual services.
Aims
To evaluate the incremental benefit of adding cognitive restructuring to
the breathing retraining and education components of the CBT programme
(trial registration: clinicaltrials.gov identifier: NCT00494650).
Method
In all, 201 people with severe mental illness and PTSD were randomised to
12- to 16-session CBT or a 3-session brief treatment programme (breathing
retraining and education). The primary outcome was PTSD symptom severity.
Secondary outcomes were PTSD diagnosis, other symptoms, functioning and
quality of life.
Results
There was greater improvement in PTSD symptoms and functioning in the CBT
group than in the brief treatment group, with both groups improving on
other outcomes and effects maintained 1-year post-treatment.
Conclusions
Cognitive restructuring has a significant impact beyond breathing
retraining and education in the CBT programme, reducing PTSD symptoms and
improving functioning in people with severe mental illness.
Needle thoracostomy is the prehospital treatment for tension pneumothorax. Sufficient catheter length is necessary for procedural success. The authors of this study determined minimum catheter length needed for procedural success on a percentile basis.
Methods
A meta-analysis of existing studies was conducted. A Medline search was performed using the search terms: needle decompression, needle thoracentesis, chest decompression, pneumothorax decompression, needle thoracostomy, and tension pneumothorax. Studies were included if they published a sample size, mean chest wall thickness, and a standard deviation or confidence interval. A PubMed search was performed in a similar fashion. Sample size, mean chest wall thickness, and standard deviation were found or calculated for each study. Data were combined to create a pooled dataset. Normal distribution of data was assumed. Procedural success was defined as catheter length being equal to or greater than the chest wall thickness.
Results
The Medline and PubMed searches yielded 773 unique studies; all study abstracts were reviewed for possible inclusion. Eighteen papers were identified for full manuscript review. Thirteen studies met all inclusion criteria and were included in the analysis. Pooled sample statistics were: n=2,558; mean=4.19 cm; and SD=1.37 cm. Minimum catheter length needed for success at the 95th percentile for chest wall size was found to be 6.44 cm.
Discussion
A catheter of at least 6.44 cm in length would be required to ensure that 95% of the patients in this pooled sample would have penetration of the pleural space at the site of needle decompression, and therefore, a successful procedure. These findings represent Level III evidence.
ClemencyBM, TanskiCT, RosenbergM, MayPR, ConsiglioJD, LindstromHA. Sufficient Catheter Length for Pneumothorax Needle Decompression: A Meta-Analysis. Prehosp Disaster Med. 2015;30(3):15
The magnetized dusty plasma experiment (MDPX) is a newly commissioned plasma device that started operations in late spring, 2014. The research activities of this device are focused on the study of the physics, highly magnetized plasmas, and magnetized dusty plasmas. The design of the MDPX device is centered on two main components: an open bore, superconducting magnet that is designed to produce, in a steady state, both uniform magnetic fields up to 4 Tesla and non-uniform magnetic fields with gradients of 1–2 T m−1 and a flexible, removable, octagonal vacuum chamber that provides substantial probe and optical access to the plasma. This paper will provide a review of the design criteria for the MDPX device, a description of the research objectives, and brief discussion of the research opportunities offered by this multi-institution, multi-user project.
Antibiograms have effectively improved antibiotic prescribing in acute-care settings; however, their effectiveness in skilled nursing facilities (SNFs) is currently unknown.
Objective.
To develop SNF-specific antibiograms and identify opportunities to improve antibiotic prescribing.
Design and Setting.
Cross-sectional and pretest-posttest study among residents of 3 Maryland SNFs.
Methods.
Antibiograms were created using clinical culture data from a 6-month period in each SNF. We also used admission clinical culture data from the acute care facility primarily associated with each SNF for transferred residents. We manually collected all data from medical charts, and antibiograms were created using WHONET software. We then used a pretest-posttest study to evaluate the effectiveness of an antibiogram on changing antibiotic prescribing practices in a single SNF. Appropriate empirical antibiotic therapy was defined as an empirical antibiotic choice that sufficiently covered the infecting organism, considering antibiotic susceptibilities.
Results.
We reviewed 839 patient charts from SNF and acute care facilities. During the initial assessment period, 85% of initial antibiotic use in the SNFs was empirical, and thus only 15% of initial antibiotics were based on culture results. Fluoroquinolones were the most frequently used empirical antibiotics, accounting for 54.5% of initial prescribing instances. Among patients with available culture data, only 35% of empirical antibiotic prescribing was determined to be appropriate. In the single SNF in which we evaluated antibiogram effectiveness, prevalence of appropriate antibiotic prescribing increased from 32% to 45% after antibiogram implementation; however, this was not statistically significant (P = .32).
Conclusions.
Implementation of antibiograms may be effective in improving empirical antibiotic prescribing in SNFs.
The Magnetized Dusty Plasma Experiment (MDPX) device is a newly constructed research instrument for the study of dusty (complex) plasmas. The MDPX device is envisioned as an experimental platform in which the dynamical behavior of all three charged plasma components, the electrons, ions, and charged microparticles (i.e., the ‘dust’) will be significantly influenced by the magnetic force. This brief paper will provide a short overview of the design, magnetic performance, and initial plasma measurements in the MDPX device.
This chapter is an atlas of digital mammography intended to introduce the reader to the appearance of various benign and malignant entities as they may appear on digital imaging. Cases 1–17 were contributed by Robert D. Rosenberg, and cases 18–34 are from Michael N. Linver.
Dr. Rosenberg’s practice switched from film-screen mammography to computed radiographic technique using Fuji equipment with 50 mm pixel size, and approximately two years later switched again to Hologic direct digital radiographic technique with a 70 mm pixel size. Therefore, his digital images are a combination of these two image types. When it makes a difference which type of image is being shown, the Fuji computed radiographic images are designated as CR images, and the Hologic direct digital radiographic images as DR images.
Dr. Linver’s practice moved from film-screen mammography directly to Hologic direct digital mammography with a 70 mm pixel size, so all of his digital mammography images are obtained with that equipment.
To determine risk factors for consumption of soda and other sugar-sweetened beverages (SSB) among 2-year-old children.
Design
The analysis was performed using three linked data sets: the 2004–2005 Oregon Pregnancy Risk Assessment Monitoring Survey (PRAMS); its longitudinal follow-up, 2006–2007 Oregon PRAMS-2; and 2004–2005 Oregon birth certificates.
Setting
PRAMS is a surveillance programme supported by the federal Centers for Disease Control and Prevention and implemented by participating state health departments. Using mixed methods, PRAMS surveys women 2–6 months after a live birth. Oregon PRAMS-2 re-interviews respondents shortly after the index child's second birthday. Oregon PRAMS oversamples minority women.
Subjects
Using monthly cohorts, we randomly selected 5851 women from the 2004–2005 birth certificates. In total 1911 women completed both PRAMS and PRAMS-2. The weighted response rate of PRAMS-2 was 43·5 %.
Results
Almost half of mothers (49·9 %) reported that their child drank SSB on at least 1 d/week. Mothers whose children drank SSB at least once weekly were more likely to have low income (adjusted OR = 2·83, 95 % CI 2·09, 3·83) and to eat out on ≥2 d/week (OR = 2·11 %, 95 % CI 1·66, 2·70). Hispanic and non-Hispanic black women were most likely to report that their child drank SSB at least once weekly.
Conclusions
Half of mothers reported that their 2-year-old children drank SSB at least once weekly. Public health interventions and policies should address childhood SSB consumption including educating health-care providers and parents.
We present numerical evidence of how three-dimensionalization occurs at small scale in rotating turbulence with Beltrami () forcing, creating helical flow. The Zeman scale at which the inertial and eddy turn-over times are equal is more than one order of magnitude larger than the dissipation scale, with the relevant domains (large-scale inverse cascade of energy, dual regime in the direct cascade of energy and helicity , and dissipation) each moderately resolved. These results stem from the analysis of a large direct numerical simulation on a grid of points, with Rossby and Reynolds numbers, respectively, equal to and . At scales smaller than the forcing, a helical wave-modulated inertial law for the energy and helicity spectra is followed beyond by Kolmogorov spectra for and . Looking at the two-dimensional slow manifold, we also show that the helicity spectrum breaks down at , a clear sign of recovery of three-dimensionality in the small scales.
Agents of opportunity (AO) in academic medical centers (AMC) are defined as unregulated or lightly regulated substances used for medical research or patient care that can be used as “dual purpose” substances by terrorists to inflict damage upon populations. Most of these agents are used routinely throughout AMC either during research or for general clinical practice. To date, the lack of careful regulations for AOs creates uncertain security conditions and increased malicious potential. Using a consensus-based approach, we collected information and opinions from staff working in an AMC and 4 AMC-affiliated hospitals concerning identification of AO, AO attributes, and AMC risk and preparedness, focusing on AO security and dissemination mechanisms and likely hospital response. The goal was to develop a risk profile and framework for AO in the institution. Agents of opportunity in 4 classes were identified and an AO profile was developed, comprising 16 attributes denoting information critical to preparedness for AO misuse. Agents of opportunity found in AMC present a unique and vital gap in public health preparedness. Findings of this project may provide a foundation for a discussion and consensus efforts to determine a nationally accepted risk profile framework for AO. This foundation may further lead to the implementation of appropriate regulatory policies to improve public health preparedness. Agents of opportunity modeling of dissemination properties should be developed to better predict AO risk.
(Disaster Med Public Health Preparedness. 2010;4:318-325)
Background: Agents of opportunity (AO) are potentially harmful biological, chemical, radiological, and pharmaceutical substances commonly used for health care delivery and research. AOs are present in all academic medical centers (AMC), creating vulnerability in the health care sector; AO attributes and dissemination methods likely predict risk; and AMCs are inadequately secured against a purposeful AO dissemination, with limited budgets and competing priorities. We explored health care workers' perceptions of AMC security and the impact of those perceptions on AO risk.
Methods: Qualitative methods (survey, interviews, and workshops) were used to collect opinions from staff working in a medical school and 4 AMC-affiliated hospitals concerning AOs and the risk to hospital infrastructure associated with their uncontrolled presence. Secondary to this goal, staff perception concerning security, or opinions about security behaviors of others, were extracted, analyzed, and grouped into themes.
Results: We provide a framework for depicting the interaction of staff behavior and access control engineering, including the tendency of staff to “defeat” inconvenient access controls. In addition, 8 security themes emerged: staff security behavior is a significant source of AO risk; the wide range of opinions about “open” front-door policies among AMC staff illustrates a disparity of perceptions about the need for security; interviewees expressed profound skepticism concerning the effectiveness of front-door access controls; an AO risk assessment requires reconsideration of the security levels historically assigned to areas such as the loading dock and central distribution sites, where many AOs are delivered and may remain unattended for substantial periods of time; researchers' view of AMC security is influenced by the ongoing debate within the scientific community about the wisdom of engaging in bioterrorism research; there was no agreement about which areas of the AMC should be subject to stronger access controls; security personnel play dual roles of security and customer service, creating the negative perception that neither role is done well; and budget was described as an important factor in explaining the state of security controls.
Conclusions: We determined that AMCs seeking to reduce AO risk should assess their institutionally unique AO risks, understand staff security perceptions, and install access controls that are responsive to the staff's tendency to defeat them. The development of AO attribute fact sheets is desirable for AO risk assessment; new funding and administrative or legislative tools to improve AMC security are required; and security practices and methods that are convenient and effective should be engineered.
(Disaster Med Public Health Preparedness. 2010;4:291-299)