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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.
Despite aspirations to be a world-class national curriculum, the Australian Curriculum (AC) has been criticised as ‘manifestly deficient’ (Australian Government Department of Education and Training, 2014 p. 5) as an inclusive curriculum, failing to meet the needs of all students with disabilities (SWD) and their teachers. There is a need for research into the daily attempts of educators to navigate the tension between a ‘top-down’ system-wide curriculum and a ‘bottom-up’ regard for individual student needs, with a view to informing both policy and practice. This article is the first of two research papers in which we report the findings from a national online Research in Special Education (RISE) Australian Curriculum Survey of special educators in special schools, classes, and units regarding their experience using the AC to plan for and teach SWD. Survey results indicated (a) inconsistent use of the AC as the primary basis for developing learning objectives and designing learning experiences, (b) infrequent use of the achievement standards to support assessment and reporting, and (c) considerable supplementation of the AC from other resources when educating SWD. Overall, participants expressed a lack of confidence in translating the AC framework into a meaningful curriculum for SWD. Implications for policy, practice, and future research are discussed.
The Richtmyer–Meshkov instability (RMI) is experimentally investigated in a vertical shock tube using a broadband initial condition imposed on an interface between a helium–acetone mixture and argon (Atwood number
). In the present work, a shear layer is introduced at the interface to serve as a statistically repeatable, broadband initial condition to the RMI, and the density interface is accelerated by either an
planar shock wave. The development of the ensuing mixing layer is investigated using simultaneous planar laser-induced fluorescence (PLIF) and particle image velocimetry (PIV). PLIF images are processed to reveal the light-gas mole fraction, while PIV particle image pairs yield corresponding two-component planar velocity results. Field structure and distribution are explored through probability density functions (PDFs), and a decomposition is performed on concentration and velocity results to obtain a mean flow field and define fluctuations. Simultaneous concentration and velocity field measurements allow – for the first time in this regime – experimentally determined turbulence quantities such as Reynolds stresses, turbulent mass-flux velocities and turbulent kinetic energy to be obtained. We show that by the latest times the mixing layer has passed the turbulent threshold, and there is evidence of turbulent mixing occurring sooner for the higher Mach number case. Interface measurements show nonlinear growth with a power-law fit to the thickness data, and that integral measurements of mixing layer thickness are proportional to threshold measurements. Spectral analysis demonstrates the emergence of an inertial range with a slope
when considering both density and velocity effects in planar turbulent kinetic energy (TKE) measurements.
Little is known about terrestrial climate dynamics in the Levant during the penultimate interglacial-glacial period. To decipher the palaeoclimatic history of the Marine Oxygen Isotope Stage (MIS) 6 glacial period, a well-dated stalagmite (~194 to ~154 ka) from Kanaan Cave on the Mediterranean coast in Lebanon was analyzed for its petrography, growth history, and stable isotope geochemistry. A resolved climate record has been recovered from this precisely U–Th dated speleothem, spanning the late MIS 7 and early MIS 6 at low resolution and the mid–MIS 6 at higher resolution. The stalagmite grew discontinuously from ~194 to ~163 ka. More consistent growth and higher growth rates between ~163 and ~154 ka are most probably linked to increased water recharge and thus more humid conditions. More distinct layering in the upper part of the speleothem suggests strong seasonality from ~163 ka to ~154 ka. Short-term oxygen and carbon isotope excursions were found between ~155 and ~163 ka. The inferred Kanaan Cave humid intervals during the mid–MIS 6 follow variations of pollen records in the Mediterranean basins and correlate well with the synthetic Greenland record and East Asian summer monsoon interstadial periods, indicating short warm/wet periods similar to the Dansgaard-Oeschger events during MIS 4–3 in the eastern Mediterranean region.
The endeavour to take jurisprudence seriously is addressed by Baghai, a sociologist, to those within her own discipline who fail to engage with the internal understandings of law, most particularly those exhibited within the discourse that accompanies appeal court decisions, namely the discourse that helps to establish and develop legal doctrine. In effect, the book is an appeal for sociologists to assign greater attention to legal doctrine as an object of study. But such an appeal can also be interpreted as a request for theorists who study legal doctrine to take sociology seriously – namely an invitation to legal theorists to bring sociology, or at least one version of it, to bear on their study of the evolution of doctrine. This proposal faces considerable resistance from those on both sides of this divide. Whilst Hart notoriously described The Concept of Law as an essay in both analytical jurisprudence and descriptive sociology, the analytic tradition that he sponsored has sought to augment its academic credentials by moving ever closer to philosophy rather than sociology. With the important exception of Brian Leiter's arguments for ‘naturalising jurisprudence’, the general drift of analytical jurisprudence has been towards a prioritising of philosophical methods over empirical insights. And the resistance to some rapprochement has not been limited to the philosophical side of the divide. The sociology of law has a long tradition of approaching the study of law in a manner that distances itself from the self-understandings of participants in the legal system (lawyers and especially judges). This transfers in turn into hostility towards the manner in which legal philosophy has engaged with those self-understandings, with its willingness to consider, at high levels of abstraction, whether law consists of rules, norms or principles. Rather than organising insiders' views into conceptual schemes, and then examining them for their coherence and consistency, legal sociology has generated its own facts and truths about laws and lawyers, principally using empirical methods (but also other methods) and contrasting these ‘truths’ with lawyer's self-understandings, treating the latter as an inferior form of knowledge either disconnected from reality or ideological rather than descriptive. It has also noticeably failed to engage with much of the central concern of legal philosophy – the attempt to identify law as a separate entity within society. Rather than considering the existence of law as a unity, it focuses instead on parts of law as examples of more general sociological categories, such as studying the legal profession within the sociology of professions or courts, legislatures and administrative agencies within the sociology of institutions or organisations.
The International Federation for Emergency Medicine (IFEM) Ultrasound Special Interest Group (USIG) was tasked with development of a hierarchical consensus approach to the use of point of care ultrasound (PoCUS) in patients with hypotension and cardiac arrest.
The IFEM USIG invited 24 recognized international leaders in PoCUS from emergency medicine and critical care to form an expert panel to develop the sonography in hypotension and cardiac arrest (SHoC) protocol. The panel was provided with reported disease incidence, along with a list of recommended PoCUS views from previously published protocols and guidelines. Using a modified Delphi methodology the panel was tasked with integrating the disease incidence, their clinical experience and their knowledge of the medical literature to evaluate what role each view should play in the proposed SHoC protocol.
Consensus on the SHoC protocols for hypotension and cardiac arrest was reached after three rounds of the modified Delphi process. The final SHoC protocol and operator checklist received over 80% consensus approval. The IFEM-approved final protocol, recommend Core, Supplementary, and Additional PoCUS views. SHoC-hypotension core views consist of cardiac, lung, and inferior vena vaca (IVC) views, with supplementary cardiac views, and additional views when clinically indicated. Subxiphoid or parasternal cardiac views, minimizing pauses in chest compressions, are recommended as core views for SHoC-cardiac arrest; supplementary views are lung and IVC, with additional views when clinically indicated. Both protocols recommend use of the “4 F” approach: fluid, form, function, filling.
An international consensus on sonography in hypotension and cardiac arrest is presented. Future prospective validation is required.
This paper uses the example of civil disobedience to explore Luhmann's description of the constitution as structural coupling between law and politics. Civil disobedience highlights the paradox of constituent and constituted power. The claims made for constituent power provide a basis for challenging the current configuration and expression of constituted power. This paradox is first avoided in the legal system through that system's inability to recognise a legal right to disobey law. In turn, a political system that has, under conditions of modernity, increasingly second coded power as legality, has an ever decreasing capacity to include communications that acknowledge a right to disobey law. Civil disobedience is only able to operate within the political system in the form of protest, and is accommodated through the exercise of discretionary powers. However, juridification of those powers has the capacity to threaten this accommodation.
We investigated a cluster of cases of bloodstream infection (BSI) due to the mold Phialemonium at a hemodialysis center in Illinois and conducted a cohort study to identify risk factors.
Environmental assessment and cohort study.
A hemodialysis center in a tertiary care hospital.
A case patient was defined as a person who underwent dialysis at the center and had a blood sample that tested positive for Phialemonium curvatum on culture. We reviewed microbiology and medical records and tested water, surface, and dialysate samples by culture. Molds isolated from environmental and clinical specimens were identified by their morphological features and confirmed by sequencing DNA.
We identified 2 case patients with BSI due to P. curvatum. Both became febrile and hypotensive while undergoing dialysis on the same machine at the same treatment station, although on different days. Dialysis machines were equipped with waste handling option ports that are used to discard dialyzer priming fluid. We isolated P. curvatum from the product water (ie, water used for dialysis purposes) at 2 of 19 treatment stations, one of which was the implicated station.
The source of P. curvatum was likely the water distribution system. To our knowledge, this is the first report of patients acquiring a mold BSI from contaminated product water. The route of exposure in these cases of BSI due to P. curvatum may be related to the malfunction and improper maintenance of the waste handling option ports. Waste handling option ports have been previously implicated as the source of bacterial BSI due to the backflow of waste fluid into a patient's blood line. No additional cases of infection were noted after remediation of the water distribution system and after discontinuing use of waste handling option ports at the facility.
1. ‘Resistant’ and ‘susceptible’ species of animals appear to be more or less equally susceptible to lung infection with equal doses of tubercle bacilli. Therefore it is pertinent to ask whether recognized natural differences in species resistant are in fact significant. For example, in terms of death rates (i.e. of overall resistance) the C57 mouse is at least as susceptible to tuberculosis as the guinea-pig and much more so than man.
2. Resistant, moderately susceptible and susceptible strains of mice as determined by death rates when exposed to large infecting doses, were equally susceptible to intranasal infection with small numbers of tubercle bacilli.
3. A state of tolerance of the parasite by the host lasting for about 3 weeks was observed in all mouse strains, regardless of ultimate strain resistance.
4. Pre-allergic deaths commenced in all groups when the tuberculous processes left insufficient normal lung to support life, but the deaths stopped first in the resistant strain and last in the susceptible strain, coinciding approximately in each strain with the onset of allergy.
5. Acquired immunity, once established, appeared not to vary in quality from one mouse strain to another, at least during 3 months' observation.
6. Racial or strain variations in the resistance of mice to tuberculosis are therefore natural, only in the sense that speed of onset of acquired immunity is probably genetically determined for each strain.
7. It is suggested that both species and racial variations in natural resistance to pulmonary infection are insignificant. Differences in the subsequent course of the disease appear to be explainable by the rapidity, efficiency and duration of the acquired immune response.
1. This paper confirms and extends several observations during the past 20 years that, despite many reports to the contrary, the rat is not unduly resistant to initial infection with tubercle bacilli provided they lodge in the lungs.
2. The pattern of pathogenesis in the rat is probably closest to the now classical picture in the mouse, i.e. the response of a species with a low hypersensitivity potential. The pathology of the lesions agreed closely with the descriptions of Wessels (1941) and Kumashiro (1958b) resembling the mouse in most respects but, unlike the mouse, including the production of giant cells.
3. When tested by footpad inoculation with 1/3·5 Old Tuberculin a positive reaction was demonstrated, commencing between 2 and 5 weeks after infection and persisting for several weeks. A fatal systemic reaction could often be induced with large doses of tuberculin given intraperitoneally.
4. In a few cases loss of allergy was shown to be associated with a terminal anergic flare of the type observed previously in mice and guinea-pigs.