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We examined the quality of care provided to older persons with frailty in five Canadian provinces, using administrative health data. In each province, we identified two cohorts of older persons with frailty: decedents and living persons. Using decision rules, we considered individuals to be frail if they were long-term care residents, terminally ill, or met at least two of seven domains, which were based on frailty scales, geriatrician discussions, and health service utilization indicators. We assessed quality of care using selected quality indicators: decrease in length of hospital stay, decrease in the number of in-patient readmissions, decrease in the number of emergency department visits, increase in the level of family physician continuity of care, decrease in the use of mechanical ventilation, and decrease in the number of admissions to intensive care. Using regression analyses, we also found male sex and older age were associated with poorer quality of care in both cohorts. This study provides baseline data for evaluating future efforts to improve the quality of care provided to older persons with frailty.
To be effective, an army must contain the extent of desertion among its ranks. This phenomenon rose to particular prominence in Europe during the 18th and 19th centuries, with the appearance of the figure of the “citizen-soldier” on the battlefield. This paper offers the first theoretical treatment of the issue of desertion from an economic perspective. Building on the work of Yoram Barzel on the “economic analysis of property rights,” we develop a “desertion as theft” framework. We then test the empirical implications of the framework against qualitative and quantitative evidence from Napoleonic France.
Describe the epidemiological and molecular characteristics of an outbreak of Klebsiella pneumoniae carbapenemase (KPC)–producing organisms and the novel use of a cohorting unit for its control.
A 566-room academic teaching facility in Milwaukee, Wisconsin.
Solid-organ transplant recipients.
Infection control bundles were used throughout the time of observation. All KPC cases were intermittently housed in a cohorting unit with dedicated nurses and nursing aids. The rooms used in the cohorting unit had anterooms where clean supplies and linens were placed. Spread of KPC-producing organisms was determined using rectal surveillance cultures on admission and weekly thereafter among all consecutive patients admitted to the involved units. KPC-positive strains underwent pulsed-field gel electrophoresis and whole-genome sequencing.
A total of 8 KPC cases (5 identified by surveillance) were identified from April 2016 to April 2017. After the index patient, 3 patients acquired KPC-producing organisms despite implementation of an infection control bundle. This prompted the use of a cohorting unit, which immediately halted transmission, and the single remaining KPC case was transferred out of the cohorting unit. However, additional KPC cases were identified within 2 months. Once the cohorting unit was reopened, no additional KPC cases occurred. The KPC-positive species identified during this outbreak included Klebsiella pneumoniae, Enterobacter cloacae complex, and Escherichia coli. blaKPC was identified on at least 2 plasmid backbones.
A complex KPC outbreak involving both clonal and plasmid-mediated dissemination was controlled using weekly surveillances and a cohorting unit.
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.
Objectives: Youth and young adults with pediatric-onset multiple sclerosis (MS) are vulnerable to executive dysfunction; however, some patients do not demonstrate functional deficits despite showing abnormalities on structural magnetic resonance imaging (MRI). Cognitively intact adults with MS have shown enhanced activation patterns relative to healthy controls on working memory tasks. We aim to evaluate whether cognitively preserved pediatric-onset MS patients engage compensatory recruitment strategies to facilitate age-normative performance on a task of working memory. Methods: Twenty cognitively preserved patients (mean age=18.7±2.7 years; 15 female) and 20 age- and sex-matched controls (mean age=18.5±2.9 years; 15 female) underwent neuropsychological testing and 3.0 Tesla MRI, including structural and functional acquisitions. Patterns of activation during the Alphaspan task, a working memory paradigm with two levels of executive control demand, were examined via whole-brain and region of interest (ROI) analyses. Results: Across all participants, lower accuracy and greater activation of regions implicated in working memory were observed during the high demand condition. MS patients demonstrated 0.21 s longer response time than controls. ROI analyses revealed enhanced activation for pediatric-onset MS patients relative to controls in the right middle frontal, left paracingulate, right supramarginal, and left superior parietal gyri during the low executive demand condition, over and above differences in response time. MS patients also demonstrated heightened activation in the right supramarginal gyrus in the high executive demand condition. Conclusions: Our findings suggest that pediatric-onset MS patients may engage compensatory recruitment strategies during working memory processing. (JINS, 2019, 25, 432–442)
Excavations at the Pre-Pottery Neolithic B ritual site of Naḥal Roded 110 in the Southern Negev, Israel, have revealed evidence—unique to this region—for on-site flint knapping and abundant raptor remains.
Whitehouse adapts insights from evolutionary anthropology to interpret extreme self-sacrifice through the concept of identity fusion. The model neglects the role of normative systems in shaping behaviors, especially in relation to violent extremism. In peaceful groups, increasing fusion will actually decrease extremism. Groups collectively appraise threats and opportunities, actively debate action options, and rarely choose violence toward self or others.
In 2018, the Clostridium difficile LabID event methodology changed so that hospitals doing 2-step tests, nucleic acid amplification test (NAAT) plus enzyme immunofluorescence assay (EIA), had their adjustment modified to EIA-based tests, and only positive final tests (eg, EIA) were counted in the numerator. We report the immediate impact of this methodological change at 3 Milwaukee hospitals.
The origins of agriculture in South-west Asia is a topic of continued archaeological debate. Of particular interest is how agricultural populations and practices spread inter-regionally. Was the Arabian Neolithic, for example, spread through the movement of pastoral groups, or did ideas perhaps develop independently? Here, the authors report on recent excavations at Alshabah, one of the first Neolithic sites discovered in Northern Arabia. The site’s material culture, environmental context and chronology provide evidence suggesting that well-adapted, seasonally mobile, pastoralist groups played a key role in the Neolithisation of the Arabian Peninsula.
Oldowan sites in primary geological context are rare in the archaeological record. Here we describe the depositional environment of Oldowan occurrences at Kanjera South, Kenya, based on field descriptions and granulometric analysis. Excavations have recovered a large Oldowan artefact sample as well as the oldest substantial sample of archaeological fauna. The deposits at Kanjera South consist of 30 m of fluvial, colluvial and lacustrine sediments. Magneto- and biostratigraphy indicate the Kanjera South Member of the Kanjera Formation was deposited during 2.3–1.92 Ma, with 2.0 Ma being a likely age for the archaeological occurrences. Oldowan artefacts and associated fauna were deposited in the colluvial and alluvial silts and sands of beds KS1–3, in the margins of a lake basin. Field descriptions and granulometric analysis of the sediment fine fraction indicate that sediments from within the main archaeological horizon were emplaced as a combination of tractional and hyperconcentrated flows with limited evidence of debris-flow deposition. This style of deposition is unlikely to significantly erode or disturb the underlying surface, and therefore promotes preservation of surface archaeological accumulations. Hominins were repeatedly attracted to the site locale, and rapid sedimentation, minimal bone weathering and an absence of bone or artefact rounding further indicate that fossils and artefacts were quickly buried.
Introduction: Emergency Departments (EDs) are frequently the first point of entry to access health services for First Nation (FN) members. In Alberta, FN members visit EDs at almost double the rate of non-FN persons. Furthermore, preliminary evidence demonstrates differences in ED experience for FN members as compared to the general population. The Alberta First Nations Information Governance Centre, Maskwacis Health Services, Yellowhead Tribal Council, Treaty 8 First Nations of Alberta, and Alberta Health Services are working together to research FN members ED experiences and concerns. Methods: This is participatory research guided by a two-eyed seeing approach that acknowledges the equal value of both Western and Indigenous worldviews. FN and non-FN leaders researchers are full partners in the development of the research project. Six sharing circles will be held in February 2018 across Alberta, with Elders, FN patients, FN and non-FN clinicians and FN and non-FN administrators. Sharing circles are similar to focus groups, but emphasize everyone having a turn to speak and demonstrating respect among participants in accordance with FN protocols. Elders will select the questions for discussion based on topics that arose in initial team meetings. Sharing circle discussions will be audio recorded and transcribed. Analysts will include both Western and Indigenous worldview researchers, who will collaboratively interpret findings. Elders will review, discuss, contextualize and expand upon study findings. The research is also guided by FN principles of Ownership, Control, Access, and Possession of FN information. It is through these principles that First Nation research projects can truly be classified as FN lead and driven. Results: Based on initial team meeting discussions, results of sharing circles are expected to provide insights on issues such as: healing, patient-provider communication (verbal and non-verbal), shared decision making, respect for patient preferences, experiences leading to trust or distrust, understandings of wait times and triage, times when multiple (repeat) ED presentations occur, distances travelled for care, choosing specific EDs when seeking care, impacts of stereotypes about FN patients, and racism and reconciliation. Conclusion: Understanding FN ED experience and bringing FN perspectives to Western conceptions of the goals and provision of ED care are important steps toward reconciliation.
Public Health England has set a definition for free sugars in the UK in order to estimate intakes of free sugars in the National Diet and Nutrition Survey. This follows the recommendation from the Scientific Advisory Committee on Nutrition in its 2015 report on Carbohydrates and Health that a definition of free sugars should be adopted. The definition of free sugars includes: all added sugars in any form; all sugars naturally present in fruit and vegetable juices, purées and pastes and similar products in which the structure has been broken down; all sugars in drinks (except for dairy-based drinks); and lactose and galactose added as ingredients. The sugars naturally present in milk and dairy products, fresh and most types of processed fruit and vegetables and in cereal grains, nuts and seeds are excluded from the definition.
Across the globe, the implementation of quality improvement science and collaborative learning has positively affected the care and outcomes for children born with CHD. These efforts have advanced the collective expertise and performance of inter-professional healthcare teams. In this review, we highlight selected quality improvement initiatives and strategies impacting the field of cardiovascular care and describe implications for future practice and research. The continued leveraging of technology, commitment to data transparency, focus on team-based practice, and recognition of cultural norms and preferences ensure the success of sustainable models of global collaboration.
The Siwalik sequence, particularly the interval from 18 to 7 Ma, provides one of the few terrestrial data sets that allows direct measurement of temporal durations of mammalian species. Its data are drawn from a single biogeographic subprovince and superposed collections likely represent successive samples of single lineages. Observed temporal ranges underestimate total species longevities if (1) species existed in other biogeographic provinces before or after the temporal ranges recorded in the Siwaliks, or (2) the fossil record inadequately samples species durations in the Siwalik subprovince. Some data, notably from Afghanistan, China, and Thailand, bear on the first variable. The second can be controlled by considering data quality, in this case the temporal distribution of good data sets, to assess the scale of accuracy available for defining range endpoints. In general, range endpoints can be estimated to the nearest 0.1 million years.
The diverse Rodentia give a mean species longevity of 2.2 million years for the Miocene Siwaliks. This includes single records, but of course ignores unretrieved rare or short-lived taxa. The diverse Artiodactyla yield 3.1 million years. The difference may reflect greater body size and longer generation time; large Perissodactyla and Proboscidea have longer temporal ranges. Carnivorous mammals also show about 3 million year durations. Given these data, the average longevity for Sivapithecus species (1.6 million years) is modest. The deposits of the Clarks Fork Basin, Wyoming, offer a Paleogene data set comparable to that of the Neogene Siwaliks. Paleocene-Eocene mammals of North America yield shorter longevities (most less than one million years).
Extinction is the dominant mode of species termination for Siwalik mammals. Most taxa originated by immigration (as at about 13.5 Ma) or abrupt speciation. There are some cases for insitu transformation of lineages, for example in the genera Punjabemys, Antemus, Percrocuta, Dorcatherium, Giraffokeryx, and Selenoportax. The rodent Kanisamys shows a rate of increase in tooth size of 0.5 darwins. This overall rate is moderate by Paleogene standards, but includes an interval of more rapid change between 9.0 and 8.5 Ma.
The fluvial Neogene Siwalik formations of northern Pakistan contain one of the longest and richest sequences of terrestrial vertebrate faunas known. The complete sequence extends from ca. 18 Ma to 1 Ma, with the interval between 18 and 7 Ma being best sampled. Throughout this best known interval vertebrate remains are frequently abundant in channel fills and less common in large channel sands, levees, and paleosols. Although the abundance and quality of fossil preservation varies, all stratigraphic levels have some fossils and the record of most subintervals is good to excellent. As a consequence the patterns of faunal turnover and changes in diversity can be documented and analyzed for 0.5 my long subintervals.
Thirteen orders of Siwalik mammals have been identified, with well sampled subintervals typically having 50 or more species. Despite the ordinal diversity, however, most Siwalik mammal species belong to just three orders: rodents, artiodactyls, and perissodactyls. Among the larger mammals, the bovids and equids are the most common and have the most species, while the murid and cricetid rodents dominate the small mammal assemblages. These Siwalik abundance and diversity patterns differ markedly from those of the Paleogene and are a result of Neogene radiations in these four families and extinction of Paleogene groups.
Between 18 and 7 Ma species diversity varies considerably. Among artiodactyls and rodents the number of species first increases between 15 and 13 Ma and then falls after 12 Ma. Significant changes in relative abundance are also known, including an increase in the abundance of bovids between 16.5 and 15 Ma and a very abrupt increase of murids at 12 Ma.
Data on stratigraphic ranges of rodents and artiodactyls show that faunal change in the Siwaliks was episodic, occurring as short intervals with high turnover, followed by longer periods with considerably less change. Maxima of first appearances occur at approximately 13.5 and 8.5 Ma, while maxima of last appearances come at 12.0, 9.5, and 8.0 Ma. It is thus apparent that in the Siwaliks increased extinction did not accompany or closely follow maxima of first appearances.
Correlations of these faunal events to global climatic trends are ambiguous. However, it is apparent that the middle Miocene diversification of Siwalik faunas occurred during a period of global cooling, while the late Miocene decline in diversity preceded a second episode of cooling and increasing aridity.