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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.
The short-term impact of prolonged grief disorder (PGD) following bereavement is well documented. The longer term sequelae of PGD however are poorly understood, possibly unrecognized, and may be incorrectly attributed to other mental health disorders and hence undertreated.
The aims of this study were to prospectively evaluate the prevalence of PGD three years post bereavement and to examine the predictors of long-term PGD in a population-based cohort of bereaved cancer caregivers.
A cohort of primary family caregivers of patients admitted to one of three palliative care services in Melbourne, Australia, participated in the study (n = 301). Sociodemographic, mental health, and bereavement-related data were collected from the caregiver upon the patient's admission to palliative care (T1). Further data addressing circumstances around the death and psychological health were collected at six (T2, n = 167), 13 (T3, n = 143), and 37 months (T4, n = 85) after bereavement.
At T4, 5% and 14% of bereaved caregivers met criteria for PGD and subthreshold PGD, respectively. Applying the total PGD score at T4, linear regression analysis found preloss anticipatory grief measured at T1 and self-reported coping measured at T2 were highly statistically significant predictors (both p < 0.0001) of PGD in the longer term.
For almost 20% of caregivers, the symptoms of PGD appear to persist at least three years post bereavement. These findings support the importance of screening caregivers upon the patient's admission to palliative care and at six months after bereavement to ascertain their current mental health. Ideally, caregivers at risk of developing PGD can be identified and treated before PGD becomes entrenched.
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.
A 3-yr watermelon experiment was established in fall 2013 to evaluate cover crop, polyethylene mulch, tillage, and herbicide application components for weed control, yield, and profitability. Conservation tillage, either with a cereal rye cover crop alone or integrated with polyethylene mulch, was compared to the standard industry practice of conventional tillage with bedded polyethylene mulch. The study also used a non-bedded conventional tillage system without polyethylene to determine polyethylene and cover crop residue effects. Within each of the four systems, herbicide treatments comprised halosulfuron applied (1) at 26.3 g ai ha–1 PRE, (2) at 26.3 g ai ha–1 POST, or (3) sequentially at 26.3 g ai ha–1 PRE and POST. Each system also had a nontreated control. In addition, clethodim was applied in all plots twice POST at 140 g ai ha–1, except for nontreated in each system. In 2014, polyethylene or cereal rye cover crop effectively controlled tall morningglory, coffee senna, and carpetweed early season in nontreated plots, whereas the integration of the two was effective at controlling common purslane. Tall morningglory and purslane control was insufficient late season regardless of production system and herbicide application. In 2015, polyethylene effectively controlled cutleaf eveningprimrose, sicklepod, and arrowleaf sida early season in nontreated plots. Yellow nutsedge control was insufficient late season regardless of production system and herbicide application. Utilizing sequential halosulfuron applications did not increase weed control over PRE or POST alone in all years. Polyethylene use resulted in yields higher than systems without in all years. Across all 3 yr, net returns were highest for polyethylene mulch systems. The results of this experiment underscore the need for more progress in developing integrated conservation systems for watermelon production. Effective herbicides, low-disturbance cultivation, and/or hand weeding are most likely the key to success in conservation specialty crop systems.
The work of Aboriginal Education Workers (AEWs) in Australian schools is complex and multifaceted, and yet it is often misunderstood, or worse, devalued. Added to this, the conditions of employment for many AEWs is often insecure, with minimal pay, few opportunities for career progression or meaningful professional development. Despite this there continues to be, as there have been for decades, research findings, policies and reports attesting to the invaluable role of AEWs in schools and communities. The theoretical standpoint of Nakata's (2007) ‘cultural interface’ is used in this paper to critically (re) examine the role of AEWs in Australian schools. Drawing from relevant past and contemporary literature, this paper draws attention to past and contemporary theorising and policy concerning the roles of AEWs. It asserts that if the work of AEWs is to be better understood and valued then it must be reconsidered in a more transformative way that benefits both the students and schools which they support.
OBJECTIVES/SPECIFIC AIMS: Identify objective neurological substrates of cognitive fatigue in Parkinson’s disease and in aging. METHODS/STUDY POPULATION: Structural and diffusion MRI. Behavioral assessments for aged adults and Parkinson’s disease. RESULTS/ANTICIPATED RESULTS: Gray and white matter deficits that correlate with deficits in the basal ganglia for fatigued Parkinson’s disease patients Versus anterior cingulate cortex in healthy aged adults with fatigue. DISCUSSION/SIGNIFICANCE OF IMPACT: Over 50% of patients with Parkison’s disease and 38% of healthy older adults suffer from cognitive fatigue. However, diagnostics are limited to subjective surveys and there are no treatments for either population. Therefore, objective measures are greatly needed for better diagnosis and development of treatment targets.
Acute kidney injury after cardiac surgery is a frequent and serious complication among children with congenital heart disease (CHD) and adults with acquired heart disease; however, the significance of kidney injury in adults after congenital heart surgery is unknown. The primary objective of this study was to determine the incidence of acute kidney injury after surgery for adult CHD. Secondary objectives included determination of risk factors and associations with clinical outcomes.
This single-centre, retrospective cohort study was performed in a quaternary cardiovascular ICU in a paediatric hospital including all consecutive patients ⩾18 years between 2010 and 2013.
Data from 118 patients with a median age of 29 years undergoing cardiac surgery were analysed. Using Kidney Disease: Improving Global Outcome creatinine criteria, 36% of patients developed kidney injury, with 5% being moderate to severe (stage 2/3). Among higher-complexity surgeries, incidence was 59%. Age ⩾35 years, preoperative left ventricular dysfunction, preoperative arrhythmia, longer bypass time, higher Risk Adjustment for Congenital Heart Surgery-1 category, and perioperative vancomycin use were significant risk factors for kidney injury development. In multivariable analysis, age ⩾35 years and vancomycin use were significant predictors. Those with kidney injury were more likely to have prolonged duration of mechanical ventilation and cardiovascular ICU stay in the univariable regression analysis.
We demonstrated that acute kidney injury is a frequent complication in adults after surgery for CHD and is associated with poor outcomes. Risk factors for development were identified but largely not modifiable. Further investigation within this cohort is necessary to better understand the problem of kidney injury.
This paper presents an overview of the results of two brief excavation seasons (2008 and 2010) at Foxhole Cave, Gower, south Wales, placing them into the wider context of mid-Holocene Britain. No prehistoric pottery was found and the few pieces of worked flint recovered are diagnostic of the Mesolithic period. Typically for the Carboniferous limestone caves of Gower, bone was well preserved, however, and though much of the material in the heavily disturbed upper metre or so of the deposits was modern sheep and rabbit, scattered fragments representing the remains of at least six humans were also recovered, of which two have been directly radiocarbon-dated using accelerator mass spectrometry (AMS 14C) to the Late Mesolithic and two to the earlier Neolithic (the remaining two providing Romano-British and medieval dates). Their associated stable carbon and nitrogen isotope values indicate a significant difference in diet between the two periods (contrary to the results from an earlier excavation in 1997), with marine foods contributing around half of the protein for the Mesolithic individuals and little or none for the Neolithic individuals. The new results are consistent with those from Caldey Island, Pembrokeshire, some 30km to the west. The floor of the cave has still not been reached at around 2m depth; limited investigation of the lowermost levels has yielded a Pleistocene fauna (including reindeer, aurochs or bison and collared lemming) with dates back to approx 33,500 cal bc, though with no definite evidence for human activity so far. A small, dark-stained fragment of human cranium was recovered from what may be pre-Holocene levels, but this failed to produce sufficient collagen for dating. In addition to a marked dietary shift, the combined stable isotope and dating programme provides further support for an equally striking temporal gap of some two millennia between the Mesolithic and Neolithic use of caves for burial.
The second defining principle of the tea Party is its unapologetic defense of U.S. sovereignty. Tea Partiers believe that the United States has a right and a duty to defend its geographic territory and legal independence from other nations and supranational entities such as the United Nations. The sovereignty principle is evident in several issues of importance to the Tea Party, including the war on terror, immigration, and the role of international law in applying and interpreting the U.S. Constitution. Before diving into these controversies, however, it's useful to discuss what sovereignty means, why the Tea Party thinks it's so important, and what could happen if it's lost.
In its most basic sense, sovereignty is power. Power over what? The power to make, interpret, and enforce law. This is why God is often referred to as a sovereign, because Christians and Jews believe he made, and judges compliance with, the Ten Commandments. In secular terms, sovereignty is concerned with man-made laws that are understood and acquiesced to within a specific geographic territory. In any given geographic area, the people residing there will recognize a person or group of persons with the power to make, interpret, and enforce law. This sovereignty may be parsed among multiple people or entities, each with limited and defined spheres of power. In the United States, for example, the Constitution divides sovereignty between a law-making branch (Congress), a law-executing branch (the president), and a law-interpreting branch (courts). Each of these branches has a share of sovereignty, but none possesses the whole of it. Dividing sovereignty horizontally, among various branches of government, is one way to check against tyranny.
Much of the Constitution is concerned with setting forth the form of our government, and the courts have traditionally invalidated measures deviating from that form. The result may appear “formalistic” in a given case to partisans of the measure at issue, because such measures are typically the product of the era's perceived necessity. But the Constitution protects us from our own best intentions: It divides power among sovereigns and among branches of government precisely so that we may resist the temptation to concentrate power in one location as an expedient solution to the crisis of the day.
– New York v. United States (1992)
The dominant theme of the tea party movement is its insistence on limited government. In the words of the movement's Contract from America, the movement seeks to “restore limited government consistent with the U.S. Constitution's meaning.” The most prominent examples of this principle are the Tea Party's opposition to bailouts and health-care reform, although it is also evident in the movement's support of things like a rule requiring congressional bills to cite their constitutional power source and proposed constitutional amendments to require a balanced budget, to restore federalism, and to permit states to veto federal laws.
In The Tea Party: Three Principles, constitutional law professor Elizabeth Price Foley takes on the mainstream media's characterization of the American Tea Party movement, asserting that it has been distorted in a way that prevents meaningful political dialogue and may even be dangerous for America's future. Foley sees the Tea Party as a movement of principles over politics. She identifies three 'core principles' of American constitutional law that bind the decentralized, wide-ranging movement: limited government, unapologetic US sovereignty and constitutional originalism. These three principles, Foley explains, both define the Tea Party movement and predict its effect on the American political landscape. Foley explains the three principles' significance to the American founding and constitutional structure. She then connects the principles to current issues such as health care reform, illegal immigration, the war on terror, and internationalism.
For many reasons, this has been the most challenging book project I’ve ever undertaken. Nonetheless, it's been a labor of love. Writing a book about the Tea Party presents a unique set of challenges. For one reason or another, mere mention of the phrase “Tea Party” seems to incite passionate feelings from across the ideological spectrum. In many ways, Americans have come to love ’em or hate ’em; rarely does one encounter indifference. Because of this, telling someone you're writing a book “about the Tea Party” is often an awkward moment, engendering a pregnant pause during which one waits for the deluge of either effusive or suspicious comments. In an attempt to get along, I have found it generally more pleasant not to reveal my own thoughts about the Tea Party in the context of such conversations. Instead, I’ve learned to listen, soaking up the information conveyed and discerning the basis of the speaker's perspective.
This isn't to say that I don't have my own thoughts about the Tea Party. As the dedication to the book reveals, I’ve developed admiration and respect for the movement. This isn't a politically motivated conclusion: I consider myself libertarian, not pledging any particular allegiance to either the Republican or Democrat party. I am quite conservative on some issues, quite liberal on others.