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An observational study was conducted to characterize high-touch surfaces in emergency departments and hemodialysis facilities. Certain surfaces were touched with much greater frequency than others. A small number of surfaces accounted for the majority of touch episodes. Prioritizing disinfection of these surfaces may reduce pathogen transmission within healthcare environments.
Background: The healthcare environment can serve as a reservoir for many microorganisms and, in the absence of appropriate cleaning and disinfection, can contribute to pathogen transmission. Identification of high-touch surfaces (HTS) in hospital patient rooms has allowed the recognition of surfaces that represent the greatest transmission risk and prioritization of cleaning and disinfection resources for infection prevention. HTS in other healthcare settings, including high-volume and high-risk settings such as emergency departments (EDs) and hemodialysis facilities (HDFs), have not been well studied or defined. Methods: Observations were conducted in 2 EDs and 3 HDFs using structured observation tools. All touch episodes, defined as hand-to-surface contact regardless of hand hygiene and/or glove use, were recorded. Touches by healthcare personnel, patients, and visitors were included. Surfaces were classified as being allocated to individual patients or shared among multiple patients. The number of touch episodes per hour was calculated for each surface to rank surfaces by frequency of touch. Results: In total, 28 hours of observation (14 hours each in EDs and HDFs) were conducted. 1,976 touch episodes were observed among 62 surfaces. On average, more touch episodes were observed per hour in HDFs than in EDs (89 vs 52, respectively). The most frequently touched surfaces in EDs included stretcher rails, privacy curtains, visitor chair arm rests and seats, and patient bedside tables, which together accounted for 68.8% of all touch episodes in EDs (Fig. 1). Frequently touched surfaces in HDFs included both shared and single-patient surfaces: 27.8% and 72.2% of HDF touch episodes, respectively. The most frequently touched surfaces in HDFs were supply cart drawers, dialysis machine control panels and keyboards, handwashing faucet handles, bedside work tables, and bed rail or dialysis chair armrests, which accounted for 68.4% of all touch-episodes recorded. Conclusions: To our knowledge, this is the first quantitative study to identify HTSs in EDs and HDFs. Our observations reveal that certain surfaces within these environments are subject to a substantially greater frequency of hand contact than others and that a relatively small number of surfaces account for most touch episodes. Notably, whereas HTSs in EDs were primarily single-patient surfaces, HTSs in HDFs included surfaces shared in the care of multiple patients, which may represent an even greater risk of patient-to-patient pathogen transmission than single-patient surfaces. The identification of HTSs in EDs and HDFs contributes to a better understanding of the risk of environment-related pathogen transmission in these settings and may allow prioritization and optimization of cleaning and disinfection resources within facilities.
Background:Pseudomonas aeruginosa is an important nosocomial pathogen associated with intrinsic and acquired resistance mechanisms to major classes of antibiotics. To better understand clinical risk factors for drug-resistant P. aeruginosa infection, decision-tree models for the prediction of fluoroquinolone and carbapenem-resistant P. aeruginosa were constructed and compared to multivariable logistic regression models using performance characteristics. Methods: In total, 5,636 patients admitted to 4 hospitals within a New York City healthcare system from 2010 to 2016 with blood, respiratory, wound, or urine cultures growing PA were included in the analysis. Presence or absence of drug-resistance was defined using the first culture of any source positive for P. aeruginosa during each hospitalization. To train and validate the prediction models, cases were randomly split (60 of 40) into training and validation datasets. Clinical decision-tree models for both fluoroquinolone and carbapenem resistance were built from the training dataset using 21 clinical variables of interest, and multivariable logistic regression models were built using the 16 clinical variables associated with resistance in bivariate analyses. Decision-tree models were optimized using K-fold cross validation, and performance characteristics between the 4 models were compared. Results: From 2010 through 2016, prevalence of fluoroquinolone and carbapenem resistance was 32% and 18%, respectively. For fluoroquinolone resistance, the logistic regression algorithm attained a positive predictive value (PPV) of 0.57 and a negative predictive value (NPV) of 0.73 (sensitivity, 0.27; specificity, 0.90) and the decision-tree algorithm attained a PPV of 0.65 and an NPV of 0.72 (sensitivity 0.21, specificity 0.95). For carbapenem resistance, the logistic regression algorithm attained a PPV of 0.53 and a NPV of 0.85 (sensitivity 0.20, specificity 0.96) and the decision-tree algorithm attained a PPV of 0.59 and an NPV of 0.84 (sensitivity 0.22, specificity 0.96). The decision-tree partitioning algorithm identified prior fluoroquinolone resistance, SNF stay, sex, and length-of-stay as variables of greatest importance for fluoroquinolone resistance compared to prior carbapenem resistance, age, and length-of-stay for carbapenem resistance. The highest-performing decision tree for fluoroquinolone resistance is illustrated in Fig. 1. Conclusions: Supervised machine-learning techniques may facilitate prediction of P. aeruginosa resistance and risk factors driving resistance patterns in hospitalized patients. Such techniques may be applied to readily available clinical information from hospital electronic health records to aid with clinical decision making.
Pollen-mediated gene flow (PMGF) refers to the transfer of genetic information (alleles) from one plant to another compatible plant. With the evolution of herbicide-resistant (HR) weeds, PMGF plays an important role in the transfer of resistance alleles from HR to susceptible weeds; however, little attention is given to this topic. The objective of this work was to review reproductive biology, PMGF studies, and interspecific hybridization, as well as potential for herbicide resistance alleles to transfer in the economically important broadleaf weeds including common lambsquarters, giant ragweed, horseweed, kochia, Palmer amaranth, and waterhemp. The PMGF studies involving these species reveal that transfer of herbicide resistance alleles routinely occurs under field conditions and is influenced by several factors, such as reproductive biology, environment, and production practices. Interspecific hybridization studies within Amaranthus and Ambrosia spp. show that herbicide resistance allele transfer is possible between species of the same genus but at relatively low levels. The widespread occurrence of HR weed populations and high genetic diversity is at least partly due to PMGF, particularly in dioecious species such as Palmer amaranth and waterhemp compared with monoecious species such as common lambsquarters and horseweed. Prolific pollen production in giant ragweed contributes to PMGF. Kochia, a wind-pollinated species can efficiently disseminate herbicide resistance alleles via both PMGF and tumbleweed seed dispersal, resulting in widespread occurrence of multiple HR kochia populations. The findings from this review verify that intra- and interspecific gene flow can occur and, even at a low rate, could contribute to the rapid spread of herbicide resistance alleles. More research is needed to determine the role of PMGF in transferring multiple herbicide resistance alleles at the landscape level.
Porous metals represent a class of materials where the interplay of ligament length, width, node structure, and local geometry/curvature offers a rich parameter space for the study of critical length scales on mechanical behavior. Colloidal crystal templating of three-dimensionally ordered macroporous (3DOM, i.e., inverse opal) tungsten provides a unique structure to investigate the mechanical behavior at small length scales across the brittle–ductile transition. Micropillar compression tests show failure at 50 MPa contact pressure at 30 °C, implying a ligament yield strength of approximately 6.1 GPa for a structure with 5% relative density. In situ SEM frustum indentation tests with in-plane strain maps perpendicular to loading indicate local compressive strains of approximately 2% at failure at 30 °C. Increased sustained contact pressure is observed at 225 °C, although large (20%) nonlocal strains appear at 125 °C. The elevated-temperature mechanical performance is limited by cracks that initiate on planes of greatest shear under the indenter.
OBJECTIVES/GOALS: We examined how individual characteristics and characteristics of the socioeconomic and built environment were associated with care coordination’s effect on cardiovascular disease (CVD) risks to identify geographic areas that may benefit from supplementary clinic-community linkages. METHODS/STUDY POPULATION: We analyzed data with geocoded residential addresses and data from electronic health records for 9946 adults from a Centers for Medicare & Medicaid Services funded innovation project from 7/1/2013 to 3/30/2015. Variables included patient-level demographics, Elixhauser comorbidity index, total time with a nurse care manager, and neighborhood factors such as poverty indicators, walkability, and social capital index. Outcomes were change in CVD risk factors, hemoglobin A1C, blood pressure (BP), and low-density lipoprotein (LDL). Generalized linear models were used to assess the effect of nurse care management program on outcomes after controlling for confounding factors. RESULTS/ANTICIPATED RESULTS: We report preliminary models that include patient demographics (age, sex, race), health care utilization, nurse care manager contact time, Elixhauser comorbidity index, neighborhood education status, percent of population below 200% federal poverty level, median home value, walkability score of the residential address, and social capital index. After adjusting for all mentioned variables, in adults with HbA1C more than 7.5% at baseline, females had worsening HbA1C by 0.53% over the study period. Additionally, LDL values in females worsened over the study period by 4.8 mg/dL after adjusting for all variables. No clinically significant changes were noted for BP. DISCUSSION/SIGNIFICANCE OF IMPACT: Women’s HbA1C and LDL worsened despite nurse care management and may benefit from additional community-based interventions or interventionists. In future analyses, we anticipate that CVD risk will worsen for patients with higher fast food proximity and with greater geographic distance from their PCP.
We completely classify the possible extensions between semistable vector bundles on the Fargues–Fontaine curve (over an algebraically closed perfectoid field), in terms of a simple condition on Harder–Narasimhan (HN) polygons. Our arguments rely on a careful study of various moduli spaces of bundle maps, which we define and analyze using Scholze’s language of diamonds. This analysis reduces our main results to a somewhat involved combinatorial problem, which we then solve via a reinterpretation in terms of the Euclidean geometry of HN polygons.
Neuroticism is associated with the onset and maintenance of a number of mental health conditions, as well as a number of deleterious outcomes (e.g. physical health problems, higher divorce rates, lost productivity, and increased treatment seeking); thus, the consideration of whether this trait can be addressed in treatment is warranted. To date, outcome research has yielded mixed results regarding neuroticism's responsiveness to treatment, perhaps due to the fact that study interventions are typically designed to target disorder symptoms rather than neuroticism itself. The purpose of the current study was to explore whether a course of treatment with the unified protocol (UP), a transdiagnostic intervention that was explicitly developed to target neuroticism, results in greater reductions in neuroticism compared to gold-standard, symptom focused cognitive behavioral therapy (CBT) protocols and a waitlist (WL) control condition.
Patients with principal anxiety disorders (N = 223) were included in this study. They completed a validated self-report measure of neuroticism, as well as clinician-rated measures of psychological symptoms.
At week 16, participants in the UP condition exhibited significantly lower levels of neuroticism than participants in the symptom-focused CBT (t(218) = −2.17, p = 0.03, d = −0.32) and WL conditions(t(207) = −2.33, p = 0.02, d = −0.43), and these group differences remained after controlling for simultaneous fluctuations in depression and anxiety symptoms.
Treatment effects on neuroticism may be most robust when this trait is explicitly targeted.
Landscapes are defined as ‘an area, as perceived by people, whose character is the result of the action and interaction of natural and/or human factors’ (Council of Europe, 2000). Cultural landscapes are defined by the UNESCO World Heritage Convention (1992) as distinct geographical areas or properties uniquely ‘represent[ing] the combined work of nature and of man’. It also describes cultural landscapes as a ‘diversity of manifestations of the interaction between humankind and its natural environment’, and that the protection of traditional cultural landscapes can contribute to maintaining biological diversity. Indeed, Pilgrim and Pretty (2010) propose that the resilience of ecocultural systems is at its strongest when biological and cultural diversity can be considered as an interdependent whole.
A focused laser can cause local optical breakdown of a gas, which leads to rapid deposition of energy into a high-temperature plasma kernel that expands and induces a complex flow. For some conditions, hot gas is rapidly ejected along the laser axis up to distances several times the kernel size, with a particularly curious feature: relatively small changes in, for example, initial pressure can cause the direction of this ejection to reverse. Detailed axisymmetric simulations of a model energy kernel in an inert gas provide a hydrodynamic description of this phenomenon, reproducing key observations in corresponding experiments, including the vortex-ring-like features that constitute the ejection. These simulations are analysed to show how changes in the early-time kernel can lead to ejection or its reversal via alteration in the relative strength and position of the vorticity produced. A corresponding semi-infinite geometry is used to isolate two mechanisms: vorticity production by the generated shock and by baroclinic torque at the kernel boundary. Dependence on the initial kernel asymmetry is quantified, as it ultimately determines whether the vorticity, upon its subsequent evolution, develops into the ring-like structure that ejects. Even simple elongation of the energy kernel alone can reverse the direction.
Nutritional therapy is a cornerstone of burns management. The optimal macronutrient intake for wound healing after burn injury has not been identified, although high-energy, high-protein diets are favoured. The present study aimed to identify the optimal macronutrient intake for burn wound healing. The geometric framework (GF) was used to analyse wound healing after a 10 % total body surface area contact burn in mice ad libitum fed one of the eleven high-energy diets, varying in macronutrient composition with protein (P5−60 %), carbohydrate (C20−75 %) and fat (F20−75 %). In the GF study, the optimal ratio for wound healing was identified as a moderate-protein, high-carbohydrate diet with a protein:carbohydrate:fat (P:C:F) ratio of 1:4:2. High carbohydrate intake was associated with lower mortality, improved body weight and a beneficial pattern of body fat reserves. Protein intake was essential to prevent weight loss and mortality, but a protein intake target of about 7 kJ/d (about 15 % of energy intake) was identified, above which no further benefit was gained. High protein intake was associated with delayed wound healing and increased liver and spleen weight. As the GF study demonstrated that an initial very high protein intake prevented mortality, a very high-protein, moderate-carbohydrate diet (P40:C42:F18) was specifically designed. The dynamic diet study was also designed to combine and validate the benefits of an initial very high protein intake for mortality, and subsequent moderate protein, high carbohydrate intake for optimal wound healing. The dynamic feeding experiment showed switching from an initial very high-protein diet to the optimal moderate-protein, high-carbohydrate diet accelerated wound healing whilst preventing mortality and liver enlargement.
Scholars and policy makers need systematic assessments of the validity of the measures produced by V-Dem. In Chapter 6, we present our approach to comparative data validation – the set of steps we take to evaluate the precision, accuracy, and reliability of our measures, both in isolation and compared to extant measures of the same concepts. Our approach assesses the degree to which measures align with shared concepts (content validation), shared rules of translation (data generation assessment), and shared realities (convergent validation). Within convergent validity, we execute two convergent validity tests. First, we examine convergent validity as it is typically conceived – examining convergence between V-Dem measures and extant measures. Second, we evaluate the level of convergence across coders, considering the individual coder and country traits that predict coder convergence. Throughout the chapter, we focus on three indices included in the V-Dem data set: polyarchy, corruption, and core civil society. These three concepts collectively provide a “hard test” for the validity of our data, representing a range of existing measurement approaches, challenges, and solutions.