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Pilot briefings, in their traditional form, drown pilots in a sea of information. Rather than unfocused swathes of air traffic management (ATM) information, pilots require only the information for their specific flight, preferably with an emphasis on the most important information. In this paper, we introduce the notion of ATM information cubes – in analogy to the well-established concept of Online analytical processing (OLAP) cubes in data warehousing. We propose a framework with merge and abstraction operations for the combination and summarization of the information in ATM information cubes to obtain management summaries of relevant information. To this end, we adopt the concept of semantic data container – a package of data items with a semantic description of the contents. The semantic descriptions then serve to hierarchically organise semantic containers along the dimensions of an ATM information cube. Leveraging this hierarchical organisation, a merge operation combines ATM information from individual semantic containers and collects the data items into composite containers. An abstraction operation summarises the data items within a semantic container, replacing individual data items with more abstract data items with summary information.
In the nineteenth century Roman Catholic orthodoxy (right belief) was defined by Scripture (the Bible), Catholic tradition, and, since 1870, the magisterium of the papal office. Eastern Orthodox Christianity was also characterised by the authority of Scripture and tradition, but it was only gradually affected by the conflicts that are the subject matter of this chapter. In Protestantism, for which Scripture was the ultimate authority, orthodoxy was defined by early Christian creeds (shared with Catholic tradition) and by confessions of the Reformation period.
In a crossover trial, a gown designed to increase skin coverage at the hands and wrists significantly reduced contamination of personnel during personal protective equipment (PPE) removal, and education on donning and doffing technique further reduced contamination. Simple modifications of PPE and education can reduce contamination during PPE removal.
Evidence has been accumulating regarding alterations in components of the endocannabinoid system in patients with psychosis. Of all the putative risk factors associated with psychosis, being at clinical high-risk for psychosis (CHR) has the strongest association with the onset of psychosis, and exposure to childhood trauma has been linked to an increased risk of development of psychotic disorder. We aimed to investigate whether being at-risk for psychosis and exposure to childhood trauma were associated with altered endocannabinoid levels.
We compared 33 CHR participants with 58 healthy controls (HC) and collected information about previous exposure to childhood trauma as well as plasma samples to analyse endocannabinoid levels.
Individuals with both CHR and experience of childhood trauma had higher N-palmitoylethanolamine (p < 0.001) and anandamide (p < 0.001) levels in peripheral blood compared to HC and those with no childhood trauma. There was also a significant correlation between N-palmitoylethanolamine levels and symptoms as well as childhood trauma.
Our results suggest an association between CHR and/or childhood maltreatment and elevated endocannabinoid levels in peripheral blood, with a greater alteration in those with both CHR status and history of childhood maltreatment compared to those with either of those risks alone. Furthermore, endocannabinoid levels increased linearly with the number of risk factors and elevated endocannabinoid levels correlated with the severity of CHR symptoms and extent of childhood maltreatment. Further studies in larger cohorts, employing longitudinal designs are needed to confirm these findings and delineate the precise role of endocannabinoid alterations in the pathophysiology of psychosis.
People with cerebral palsy (CP) are less physically active than the general population and, consequently, are at increased risk of preventable disease. Evidence indicates that low-moderate doses of physical activity can reduce disease risk and improve fitness and function in people with CP. Para athletes with CP typically engage in ‘performance-focused’ sports training, which is undertaken for the sole purpose of enhancing sports performance. Anecdotally, many Para athletes report that participation in performance-focused sports training confers meaningful clinical benefits which exceed those reported in the literature; however, supporting scientific evidence is lacking. The aim of this paper is to describe the protocol for an 18-month study evaluating the clinical effects of a performance-focused swimming training programme for people with CP who have high support needs.
This study will use a concurrent multiple-baseline, single-case experimental design across three participants with CP who have high support needs. Each participant will complete a five-phase trial comprising: baseline (A1); training phase 1 (B1); maintenance phase 1 (A2); training phase 2 (B2); and maintenance phase 2 (A3). For each participant, measurement of swim velocity, health-related quality of life and gross motor functioning will be carried out a minimum of five times in each of the five phases.
The study described will produce Level II evidence regarding the effects of performance-focused swimming training on clinical outcomes in people with CP who have high support needs. Findings are expected to provide an indication of the potential for sport to augment outcomes in neurological rehabilitation.
Starting in 2016, we initiated a pilot tele-antibiotic stewardship program at 2 rural Veterans Affairs medical centers (VAMCs). Antibiotic days of therapy decreased significantly (P < .05) in the acute and long-term care units at both intervention sites, suggesting that tele-stewardship can effectively support antibiotic stewardship practices in rural VAMCs.
This article problematises the widespread assumption that the God of early Christianity is an invisible God. This assumption is found in both popular and academic discourse and often appeals to biblical critiques of divine images to make its case. Yet while Hebrew Bible scholars have recently questioned this axiomatic belief, New Testament scholars have yet to do the same. To address this oversight, this article first looks at divine images and idol polemic in the ancient world and then turns to Luke's depiction of divine images in the book of Acts as a test case. Here I demonstrate how Acts depicts God as a visible – and even embodied – being, while at the same time critiquing visual representations of the divine. With Acts, we find that not all Christians ‘imaged’ God as invisible.
Introduction: Acute aortic syndrome (AAS) is a time sensitive aortic catastrophe that is often misdiagnosed. There are currently no Canadian guidelines to aid in diagnosis. Our goal was to adapt the existing American Heart Association (AHA) and European Society of Cardiology (ESC) diagnostic algorithms for AAS into a Canadian evidence based best practices algorithm targeted for emergency medicine physicians. Methods: We chose to adapt existing high-quality clinical practice guidelines (CPG) previously developed by the AHA/ESC using the GRADE ADOLOPMENT approach. We created a National Advisory Committee consisting of 21 members from across Canada including academic, community and remote/rural emergency physicians/nurses, cardiothoracic and cardiovascular surgeons, cardiac anesthesiologists, critical care physicians, cardiologist, radiologists and patient representatives. The Advisory Committee communicated through multiple teleconference meetings, emails and a one-day in person meeting. The panel prioritized questions and outcomes, using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach to assess evidence and make recommendations. The algorithm was prepared and revised through feedback and discussions and through an iterative process until consensus was achieved. Results: The diagnostic algorithm is comprised of an updated pre test probability assessment tool with further testing recommendations based on risk level. The updated tool incorporates likelihood of an alternative diagnosis and point of care ultrasound. The final best practice diagnostic algorithm defined risk levels as Low (0.5% no further testing), Moderate (0.6-5% further testing required) and High ( >5% computed tomography, magnetic resonance imaging, trans esophageal echocardiography). During the consensus and feedback processes, we addressed a number of issues and concerns. D-dimer can be used to reduce probability of AAS in an intermediate risk group, but should not be used in a low or high-risk group. Ultrasound was incorporated as a bedside clinical examination option in pre test probability assessment for aortic insufficiency, abdominal/thoracic aortic aneurysms. Conclusion: We have created the first Canadian best practice diagnostic algorithm for AAS. We hope this diagnostic algorithm will standardize and improve diagnosis of AAS in all emergency departments across Canada.
Declining mortality following invasive pneumococcal disease (IPD) has been observed concurrent with a reduced incidence due to effective pneumococcal conjugate vaccines. However, with IPD now increasing due to serotype replacement, we undertook a statistical analysis to estimate the trend in all-cause 30-day case fatality rate (CFR) in the North East of England (NEE) following IPD. Clinical, microbiological and demographic data were obtained for all laboratory-confirmed IPD cases (April 2006–March 2016) and the adjusted association between CFR and epidemiological year estimated using logistic regression. Of the 2510 episodes of IPD included in the analysis, 486 died within 30 days of IPD (CFR 19%). Increasing age, male sex, a diagnosis of septicaemia, being in ⩾1 clinical risk groups, alcohol abuse and individual serotypes were independently associated with increased CFR. A significant decline in CFR over time was observed following adjustment for these significant predictors (adjusted odds ratio 0.93, 95% confidence interval 0.89–0.98; P = 0.003). A small but significant decline in 30-day all-cause CFR following IPD has been observed in the NEE. Nonetheless, certain population groups remain at increased risk of dying following IPD. Despite the introduction of effective vaccines, further strategies to reduce the ongoing burden of mortality from IPD are needed.
The majority of paediatric Clostridioides difficile infections (CDI) are community-associated (CA), but few data exist regarding associated risk factors. We conducted a case–control study to evaluate CA-CDI risk factors in young children. Participants were enrolled from eight US sites during October 2014–February 2016. Case-patients were defined as children aged 1–5 years with a positive C. difficile specimen collected as an outpatient or ⩽3 days of hospital admission, who had no healthcare facility admission in the prior 12 weeks and no history of CDI. Each case-patient was matched to one control. Caregivers were interviewed regarding relevant exposures. Multivariable conditional logistic regression was performed. Of 68 pairs, 44.1% were female. More case-patients than controls had a comorbidity (33.3% vs. 12.1%; P = 0.01); recent higher-risk outpatient exposures (34.9% vs. 17.7%; P = 0.03); recent antibiotic use (54.4% vs. 19.4%; P < 0.0001); or recent exposure to a household member with diarrhoea (41.3% vs. 21.5%; P = 0.04). In multivariable analysis, antibiotic exposure in the preceding 12 weeks was significantly associated with CA-CDI (adjusted matched odds ratio, 6.25; 95% CI 2.18–17.96). Improved antibiotic prescribing might reduce CA-CDI in this population. Further evaluation of the potential role of outpatient healthcare and household exposures in C. difficile transmission is needed.
Many patients with advanced serious illness or at the end of life experience delirium, a potentially reversible form of acute brain dysfunction, which may impair ability to participate in medical decision-making and to engage with their loved ones. Screening for delirium provides an opportunity to address modifiable causes. Unfortunately, delirium remains underrecognized. The main objective of this pilot was to validate the brief Confusion Assessment Method (bCAM), a two-minute delirium-screening tool, in a veteran palliative care sample.
This was a pilot prospective, observational study that included hospitalized patients evaluated by the palliative care service at a single Veterans’ Administration Medical Center. The bCAM was compared against the reference standard, the Diagnostic and Statistical Manual of Mental Disorders, fifth edition. Both assessments were blinded and conducted within 30 minutes of each other.
We enrolled 36 patients who were a median of 67 years (interquartile range 63–73). The primary reasons for admission to the hospital were sepsis or severe infection (33%), severe cardiac disease (including heart failure, cardiogenic shock, and myocardial infarction) (17%), or gastrointestinal/liver disease (17%). The bCAM performed well against the Diagnostic and Statistical Manual of Mental Disorders, fifth edition, for detecting delirium, with a sensitivity (95% confidence interval) of 0.80 (0.4, 0.96) and specificity of 0.87 (0.67, 0.96).
Significance of Results
Delirium was present in 27% of patients enrolled and never recognized by the palliative care service in routine clinical care. The bCAM provided good sensitivity and specificity in a pilot of palliative care patients, providing a method for nonpsychiatrically trained personnel to detect delirium.
Among powder diffractionists, there is a concern about establishing criteria for testing existing and new computer methods for searching the Powder Diffraction File (PDF) data base. A large number of papers on this subject have been presented at recent Denver Conferences and at other meetings, such as the American Crystallographic Association.
The PDF now exceeds 42,000 patterns, with an average of about thirty lines per pattern. Thus, it contains approximately 2.5 million numerical values. At its current rate of growth, the PDF will double in less than twenty years.
The photons resulting from the interaction of beta particles and matter have a certain complexity of origin; but the spectrum is made up, in large part, of two primary components, one of these being the white radiation continuum produced by the external bremsstrahlung mechanism of beta acceleration at the target atom. The second fraction consists of the characteristic K and L X-rays of the target atom. Published beta-excited X-ray spectra are centered about a small fraction of the available pure beta emitters and a restricted group of target materials. Furthermore, intercomparisons between references are difficult, due to an infinite variety of source and detector parameters influencing the data.
This laboratory has begun a comprehensive reference compilation of these spectra, done on a comparative basis and simplified and standardized for sensible cataloging and easy reproduction of the experimental design. The prime purpose is to make available coherent data for many beta-excited X-ray sources in which beta activities, target geometries, and other critical parameters are known, controlled, and constant. Spectral sets for given source-target combinations may, therefore, be intercompared, and application of the beta-excited X-ray may be made with the best possible source-target atom combination.
The spectra are studied by three proportional counters (operating down to the 1 kV energy range) and two standard scintillation crystals, accumulated in a 256-channel analyzer, and are presented in sets (representing one beta source-target combination) consisting of a minimum of eight spectra, six of which represent the most critical transmission target geometry.
Examples of the cataloging of the spectral sets, for the mixture, apposition, and compound isotopic X-ray sources, are presented.
OBJECTIVES/SPECIFIC AIMS: The study investigated whether adults diagnosed with epilepsy or migraine (a neurological disorder with common features to epilepsy) are at increased risk for developing substance abuse disorders following diagnosis compared to (presumably healthy) adults with lower extremity fracture (LEF). METHODS/STUDY POPULATION: A retrospective cohort analysis was conducted using a subset of surveillance data of hospital admissions, emergency department visits and outpatient visits in South Carolina, USA from January 1, 2000 through December 31, 2011. Individuals aged 18 years or older were identified using the International Classification of Disease, 9th Revision Clinical modification (ICD-9) with a diagnosis of epilepsy (epilepsy-cohort 1; n = 78,547; 52.7% female, mean age [SD] 51.3 years [19.2]), migraine (migraine-cohort 2; n = 121,155; 81.5% female, mean age [SD] 40.0 years [14.5]), or LEF (control cohort; n = 73,911; 55.4% female, mean age [SD] 48.7 years [18.7]). Individuals with substance abuse or dependence diagnosis following epilepsy, migraine, or LEF were identified with ICD-9 codes. Cox proportional hazard regression analyses modelled the time to substance abuse diagnosis comparing epilepsy to LEF and comparing migraine to LEF. RESULTS/ANTICIPATED RESULTS: Adjusting for insurance payer, age and sex, adults with epilepsy are diagnosed with substance abuse disorders at 2.5 times the rate of those with LEF [HR 2.54 (2.43, 2.67)] and adults with migraine are diagnosed with substance abuse disorders at 1.10 times the rate of those with LEF [HR 1.10 (1.04, 1.16)]. An interaction between exposure and insurance payer was found with hazard ratios comparing epilepsy to LEF of 4.56, 3.60, and 1.94 within the commercial payer, uninsured and Medicaid strata, respectively. DISCUSSION/SIGNIFICANCE OF IMPACT: Compared to adults with LEF, adults with epilepsy had a substantially higher hazard of subsequent substance abuse, while adults with migraine showed a small, but still significant, increased hazard of subsequent substance abuse.
Thirteen bryozoan species are described from the Brewer Dock (Hickory Corners) Member of the Reynales Formation (lower Silurian, Aeronian) at the locality Hickory Corners in western New York, USA. Three species are new: trepostomes Homotrypa niagarensis n. sp. and Leioclema adsuetum n. sp. and the rhabdomesine cryptostome Moyerella parva n. sp. Only one species, Hennigopora apta Perry and Hattin, 1960, developed obligatory encrusting colonies whereas the others produced erect ramose colonies of various thicknesses and shapes: cylindrical, branched, and lenticular. Bryozoans display high abundance and richness within the rock. This fauna is characteristic of a moderately agitated environment with a stable substrate. The identified species reveal paleobiogeographic connections to other Silurian localities of New York as well as Ohio and Indiana (USA) and Anticosti (Canada).
Soldier operational performance is determined by their fitness, nutritional status, quality of rest/recovery, and remaining injury/illness free. Understanding large fluctuations in nutritional status during operations is critical to safeguarding health and well-being. There are limited data world-wide describing the effect of extreme climate change on nutrient profiles. This study investigated the effect of hot-dry deployments on vitamin D status (assessed from 25-hydroxyvitamin D (25(OH)D) concentration) of young, male, military volunteers. Two data sets are presented (pilot study, n 37; main study, n 98), examining serum 25(OH)D concentrations before and during 6-month summer operational deployments to Afghanistan (March to October/November). Body mass, percentage of body fat, dietary intake and serum 25(OH)D concentrations were measured. In addition, parathyroid hormone (PTH), adjusted Ca and albumin concentrations were measured in the main study to better understand 25(OH)D fluctuations. Body mass and fat mass (FM) losses were greater for early (pre- to mid-) deployment compared with late (mid- to post-) deployment (P<0·05). Dietary intake was well-maintained despite high rates of energy expenditure. A pronounced increase in 25(OH)D was observed between pre- (March) and mid-deployment (June) (pilot study: 51 (sd 20) v. 212 (sd 85) nmol/l, P<0·05; main study: 55 (sd 22) v. 167 (sd 71) nmol/l, P<0·05) and remained elevated post-deployment (October/November). In contrast, PTH was highest pre-deployment, decreasing thereafter (main study: 4·45 (sd 2·20) v. 3·79 (sd 1·50) pmol/l, P<0·05). The typical seasonal cycling of vitamin D appeared exaggerated in this active male population undertaking an arduous summer deployment. Further research is warranted, where such large seasonal vitamin D fluctuations may be detrimental to bone health in the longer-term.
Sugarcane growers in Florida have been reporting reduced control of fall panicum with asulam, the main herbicide used for POST grass control. Therefore, outside container experiments were conducted to determine the response of four fall panicum populations from Florida to asulam applied alone and to evaluate whether tank-mix combination with trifloxysulfuron enhances control. Asulam was applied at 230 to 7,400 g ai ha−1, corresponding to 1/16 to 2X the maximum labeled rate for a single application in sugarcane, with or without combination with trifloxysulfuron at 16 g ai ha−1. Three fall panicum populations were collected from fields in which reduced control had been reported, while one population was from a field not used for sugarcane production but adjacent to a sugarcane field. The potency of asulam based on ED50 values (the rate required to cause 50% dry weight reduction at 28 d after treatment) ranged from 2,249 to 5,412 g ha−1 for tolerant populations with reported reduced fall panicum control compared with 1,808 g ha−1 for the susceptible population from the field not used for sugarcane production, showing that the latter was most sensitive to asulam. Addition of trifloxysulfuron to asulam increased potency on fall panicum by 5- to 15-fold, indicating that the tank mix enhanced dry weight reduction for all populations. The probability of fall panicum survival (regrowth after aboveground biomass harvesting) at the labeled rate of asulam ranged from 2% to 47% compared with 0% to 6% when trifloxysulfuron was added to the tank mix. Our results show differential response of fall panicum populations in Florida to asulam, which can be overcome by tank mixing with trifloxysulfuron even for populations that are difficult to control in sugarcane, but no evolution of resistance to asulam.
To test the feasibility of using telehealth to support antimicrobial stewardship at Veterans Affairs medical centers (VAMCs) that have limited access to infectious disease-trained specialists.
A prospective quasi-experimental pilot study.
Two rural VAMCs with acute-care and long-term care units.
At each intervention site, medical providers, pharmacists, infection preventionists, staff nurses, and off-site infectious disease physicians formed a videoconference antimicrobial stewardship team (VAST) that met weekly to discuss cases and antimicrobial stewardship-related education.
Descriptive measures included fidelity of implementation, number of cases discussed, infectious syndromes, types of recommendations, and acceptance rate of recommendations made by the VAST. Qualitative results stemmed from semi-structured interviews with VAST participants at the intervention sites.
Each site adapted the VAST to suit their local needs. On average, sites A and B discussed 3.5 and 3.1 cases per session, respectively. At site A, 98 of 140 cases (70%) were from the acute-care units; at site B, 59 of 119 cases (50%) were from the acute-care units. The most common clinical syndrome discussed was pneumonia or respiratory syndrome (41% and 35% for sites A and B, respectively). Providers implemented most VAST recommendations, with an acceptance rate of 73% (186 of 256 recommendations) and 65% (99 of 153 recommendations) at sites A and B, respectively. Qualitative results based on 24 interviews revealed that participants valued the multidisciplinary aspects of the VAST sessions and felt that it improved their antimicrobial stewardship efforts and patient care.
This pilot study has successfully demonstrated the feasibility of using telehealth to support antimicrobial stewardship at rural VAMCs with limited access to local infectious disease expertise.