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Urinary tract infections (UTIs) are common among college-aged women and often recur. Some antibiotics recommended to treat UTIs trigger dysbiosis of intestinal and vaginal microbiomes – where uropathogens originate, though few studies have investigated associations between these therapies with recurrent infections. We retrospectively analysed the electronic medical records of 6651 college-aged women diagnosed with a UTI at a US university student health centre between 2006 and 2014. Women were followed for 6 months for incidence of a recurrent infection. In a secondary analysis, associations in women whose experienced UTI recurrence within 2 weeks were also considered for potential infection relapse. Logistic regression was used to assess associations between infection recurrence or relapse and antibiotics prescribed, in addition to baseline patient characteristics including age, race/ethnicity, region of origin, year of encounter, presence of symptomology, pyelonephritis, vaginal coinfection and birth control consultation. There were 1051 instances of infection recurrence among the 6620 patients, indicating a prevalence of 16%. In the analysis of patient characteristics, Asian women were statistically more likely to experience infection recurrence whereas African American were less likely. No significant associations were identified between the antibiotic administered at the initial infection and the risk of infection recurrence after multivariable adjustment. Treatment with trimethoprim-sulphamethoxazole and being born outside of the USA were significantly associated with increased odds of infection relapse in the multivariate analysis. The results of the analyses suggest that treatment with trimethoprim-sulphamethoxazole may lead to an increased risk of UTI relapse, warranting further study.
The role that vitamin D plays in pulmonary function remains uncertain. Epidemiological studies reported mixed findings for serum 25-hydroxyvitamin D (25(OH)D)–pulmonary function association. We conducted the largest cross-sectional meta-analysis of the 25(OH)D–pulmonary function association to date, based on nine European ancestry (EA) cohorts (n 22 838) and five African ancestry (AA) cohorts (n 4290) in the Cohorts for Heart and Aging Research in Genomic Epidemiology Consortium. Data were analysed using linear models by cohort and ancestry. Effect modification by smoking status (current/former/never) was tested. Results were combined using fixed-effects meta-analysis. Mean serum 25(OH)D was 68 (sd 29) nmol/l for EA and 49 (sd 21) nmol/l for AA. For each 1 nmol/l higher 25(OH)D, forced expiratory volume in the 1st second (FEV1) was higher by 1·1 ml in EA (95 % CI 0·9, 1·3; P<0·0001) and 1·8 ml (95 % CI 1·1, 2·5; P<0·0001) in AA (Prace difference=0·06), and forced vital capacity (FVC) was higher by 1·3 ml in EA (95 % CI 1·0, 1·6; P<0·0001) and 1·5 ml (95 % CI 0·8, 2·3; P=0·0001) in AA (Prace difference=0·56). Among EA, the 25(OH)D–FVC association was stronger in smokers: per 1 nmol/l higher 25(OH)D, FVC was higher by 1·7 ml (95 % CI 1·1, 2·3) for current smokers and 1·7 ml (95 % CI 1·2, 2·1) for former smokers, compared with 0·8 ml (95 % CI 0·4, 1·2) for never smokers. In summary, the 25(OH)D associations with FEV1 and FVC were positive in both ancestries. In EA, a stronger association was observed for smokers compared with never smokers, which supports the importance of vitamin D in vulnerable populations.
Ischemic stroke treatment is time-sensitive, and barriers to providing prehospital care encountered by Emergency Medical Services (EMS) providers have been under-studied.
This study described barriers to providing prehospital care, identified predictors of these barriers, and assessed the impact of these barriers on EMS on-scene time and administration of tissue plasminogen activator (tPA) in the emergency department (ED).
A retrospective cohort study was performed using the Get With The Guidelines-Stroke (GWTG-S; American Heart Association [AHA]; Dallas, Texas USA) registry at two hospitals to identify ischemic stroke patients arriving by EMS. Variables were abstracted from prehospital and hospital medical records and merged with registry data. Barriers to care were grouped into themes. Logistic regression was used to identify predictors of barriers to care, and bi-variate tests were used to assess differences in EMS on-scene time and the proportion of patients receiving tPA between patients with and without barriers.
Barriers to providing prehospital care were documented for 15.5% of patients: 29.6% related to access, 26.7% communication, 23.0% extrication and transportation, 20.0% refusal, and 14.1% assessment/management. Non-white and non-black race (OR: 3.69; 95% CI, 1.63-8.36) and living alone (OR: 1.53; 95% CI, 1.05-2.23) were associated with greater odds of barriers to providing care. The EMS on-scene time was ≥15 minutes for 70.4% of patients who had a barrier to care, compared with 49.0% of patients who did not (P<.001). There was no significant difference in the proportion of patients who were administered tPA between those with and without barriers to care (14.1% vs 19.2%; P=.159).
Barriers to providing prehospital care were documented for a sizable proportion of ischemic stroke patients, with the majority related to patient access and communication, and occurred more frequently among non-white and non-black patients and those living alone. Although EMS on-scene time was longer for patients with barriers to care, the proportion of patients receiving tPA in the ED did not differ.
LiT, CushmanJT, ShahMN, KellyAG, RichDQ, JonesCMC. Barriers to Providing Prehospital Care to Ischemic Stroke Patients: Predictors and Impact on Care. Prehosp Disaster Med.2018;33(5):501–507.
Introduction: The specialist Emergency Medicine (EM) postgraduate training program at Queens University implemented a new Competency-Based Medical Education (CBME) model on July 1 2017. This occurred one year ahead of the national EM cohort, in the model of Competence By Design (CBD) as outlined by the Royal College of Physicians and Surgeons of Canada (RCPSC). This presents an opportunity to identify critical steps, successes, and challenges in the implementation process to inform ongoing national CBME implementation efforts. Methods: A case-study methodology with Rapid Cycle Evaluation was used to explore the lived experience of implementing CBME in EM at Queens, and capture evidence of behavioural change. Data was collected at 3- and 6- months post-implementation via multiple sources and methods, including: field observations, document analysis, and interviews with key stakeholders: residents, faculty, program director, CBME lead, academic advisors, and competence committee members. Qualitative findings have been triangulated with available quantitative electronic assessment data. Results: The critical processes of implementation have been outlined in 3 domain categories: administrative transition, resident transition, and faculty transition. Multiple themes emerged from stakeholder interviews including: need for holistic assessment beyond Entrustable Professional Activity (EPA) assessments, concerns about the utility of milestones in workplace based assessment by front-line faculty, trepidation that CBME is adding to, rather than replacing, old processes, and a need for effective data visualisation and filtering for assessment decisions by competency committees. We identified a need for administrative direction and faculty development related to: new roles and responsibilities, shared mental models of EPAs and entrustment scoring. Quantitative data indicates that the targeted number of assessments per EPA and stage of training may be too high. Conclusion: Exploring the lived experience of implementing CBME from the perspectives of all stakeholders has provided early insights regarding the successes and challenges of operationalizing CBME on the ground. Our findings will inform ongoing local implementation and higher-level national planning by the Canadian EM Specialty Committee and other programs who will be implementing CBME in the near future.
Introduction: Non-variceal upper gastrointestinal bleeding (NVUGIB) is a common presentation to the emergency department (ED) accounting for significant morbidity, mortality and health care resource usage. In Alberta, a provincial care pathway was recently developed to provide an evidence informed approach to managing patients with an UGIBs in the ED. Pantoprazole infusions are a commonly used treatment despite evidence that suggests they are generally not indicated prior to endoscopy in the ED. The goal of this project was to optimize management of patients with a NVUGIB, in particular reduce pre-endoscopy pantoprazole infusions. Methods: In July 2016, we implemented a multi-faceted intervention to optimize management of ED patients with NVUGIB including 1. de-emphasizing IV pantoprazole infusions in the ED, 2. clinical decision support (CDS) embedded (for endoscopy, disposition and transfusions) within the order set and 3. educating clinicians about the care pathway. We used a pre/post-order set design, analyzing 391 days pre and 189 days post-order set changes. Data was extracted from our fully integrated electronic health records system. The primary outcome was the % of patients receiving IV pantoprazole infusion ordered by an emergency physician (EP) among all patients with NVUGIB. Secondary outcomes included % transfused with hgb >70g/L and whether using the GIB order set impacted management of NVUGIB patients. Results: In the 391 days pre-order set changes, there were 2165 patients included and in the 189 days post-order set changes, there were 901 patients. For baseline characteristics, patients in the post-order set change group were significantly older (64.4 yrs vs 60.9 yrs p-value=0.0016) and had a lower hgb (115 vs 118, p-value=0.049) but otherwise for gender, measures of severity of illness (systolic blood pressure, heart rate, CTAS, % admitted) there were no significantly differences. For the primary outcome, in the pre-order set phase, 47.1% received a pantoprazole infusion ordered by an EP, compared to 31.5% in the post-order phase, for an absolute reduction of 15.6% (p-value= <0.001). For the secondary outcomes, transfusion rates were similar pre/post (22.08% vs 22.75%). Significant inter-site variability exists with respect to the reduction in pantoprazole infusion rates across the four sites (-23.3% to +6.12%). Conclusion: Our interventions resulted in a significant overall reduction in pantoprazole infusions in ED patients with NVUGIB. Reductions in pantoprazole infusions varied significantly across the different sites, future work in our department will explore and address this variability. Keys to the success of this project included engaging clinicians as well as leveraging the SCM order sets as well as the provincial care pathway. Although there were no changes in transfusion rates, it in unclear if this a function of the CDS not being effective or whether these transfusions were clinically indicated.
The GALLEX collaboration aims at the detection of solar neutrinos in a radiochemical experiment employing 30 tons of Gallium in form of concentrated aqueous Gallium-chloride solution. The detector is primarily sensitive to the otherwise inaccessible pp-neutrinos. Details of the experiment have been repeatedly described before [1-7]. Here we report the present status of implementation in the Laboratori Nazionali del Gran Sasso (Italy). So far, 12.2 tons of Gallium are at hand. The present status of development allows to start the first full scale run at the time when 30 tons of Gallium become available. This date is expected to be January, 1990.
Deep-sea submersible observations made in the Bahamas revealed interactions between the stalked crinoid Endoxocrinus parrae and the cidaroid sea urchin Calocidaris micans. The in situ observations include occurrence of cidaroids within “meadows” of sea lilies, close proximity of cidaroids to several upended isocrinids, a cidaroid perched over the distal end of the stalk of an upended isocrinid, and disarticulated crinoid cirri and columnals directly underneath a specimen of C. micans. Guts of two C. micans collected from the crinoid meadow contain up to 70% crinoid material. Two of three large museum specimens of another cidaroid species, Histocidaris nuttingi, contain 14–99% crinoid material.
A comparison of cidaroid gut contents with local sediment revealed significant differences: sediment-derived material consists of single crinoid ossicles often abraded and lacking soft tissue, whereas crinoid columnals, cirrals, brachials, and pinnulars found in the cidaroids are often articulated, linked by soft tissue, and unabraded. Furthermore, articulated, multi-element fragments often show a mode of fracture characteristic of fresh crinoid material. Taken together, these data suggest that cidaroids prey on live isocrinids.
We argue that isocrinid stalk-shedding, whose purpose has remained a puzzle, and the recently documented rapid crawling of isocrinids are used in escaping benthic predators: isocrinids sacrifice and shed the distal stalk portion when attacked by cidaroids and crawl away, reducing the chance of a subsequent encounter. If such predation occurred throughout the Mesozoic and Cenozoic (possibly since the mid-Paleozoic), several evolutionary trends among crinoids might represent strategies to escape predation by slow-moving benthic predators.
Children with Specific Language Impairment (SLI) have language difficulties of unknown origin. Syntactic profiles are atypical, with poor performance on non-canonical structures, e.g. object relatives, suggesting a localized deficit. However, existing analyses using ANOVAs are problematic because they do not systematically address unequal variance, or fully model random effects. Consequently, a Generalised Linear Model (GLM) was used to analyze data from a Sentence Repetition (SR) task involving relative clauses. seventeen children with SLI (mean age 6;7), twenty-one Language Matched (LM) children (mean age 4;8), and seventeen Age Matched (AM) children (mean age 6;5) repeated 100 canonical and non-canonical sentences. ANOVAs found a significant Group by Canonicity interaction for the SLI versus AM contrast only. However, the GLM found no significant interaction. Consequently, arguments for a localized deficit may depend on statistical methods which are prone to exaggerate profile differences. Nonetheless, a subgroup of SLI exhibited particularly severe structural language difficulties.
We present an analytical model that quantitatively describes the physics behind shunting in thin-film photovoltaics and predicts size-dependent effects in the I/V characteristics of solar cells. The model consists of an array of micro-diodes and shunt in parallel between the two electrodes, one of which mimics the TCO and has a finite resistance. We introduce the concept of the screening length L, over which the shunt affects the electrical potential of the system. The nature of this screening is that the system generates currents in response to the point perturbation caused by the shunt. L is expressed explicitly in terms of the system parameters. We find the spatial distribution of the electrical potential in the system and its I/V characteristics. The measured I/V characteristics depend on the relationship between the cell size l and L, being markedly different for the cases of small (l<<L) and large (l>>L) cells. This model is verified experimentally; good agreement is obtained.
We have used sputtered ZnTe:N and ZnO:Al as transparent electrodes for CdTe based solar cells. ZnTe:N is reactively sputtered with 3% N2 in the sputter gas. The ZnTe:N films typically have transmission near 85% above 750 nm and resistivity as low as 10 ohm-cm with fine grains of approximately 30 nm diameter. ZnO:Al is sputtered from a ZnO:Al2O3 (2%) target. The ZnO:Al films have resistivity as low as 4 × 10-4 ohm-cm with 80-95% transmission over the visible spectrum. To test the stability of the films, ZnTe:N films were annealed in argon, dry air and nitrogen at a range of temperatures from 200°C to 500°C. Annealing decreased the resistivity for temperatures up to 350°C and increased for temperatures greater than 350°C. ZnO:Al films were annealed in dry air at temperatures from 300°C to 550°C. Though the resistivity increased at higher annealing temperatures, there was no change in the transmission. Important to the function of a tandem solar cell is a transparent contact, like ZnTe:N/ZnO:Al, to replace the traditional metal contact to the CdS/CdTe solar cell. We investigate the ZnTe:N/ ZnO:Al bilayer as a possible recombination junction. The rf sputtered ZnTe:N and ZnO:Al films were characterized by AFM, STM, XRD, transmission, 4-point probe, and Hall measurements.
In this paper, various approaches to extend scalability of Hafnium-based dielectrics are reported. Among the three crystal phases of HfO2 (monoclinic, cubic and tetragonal), the tetragonal phase has been reported to have the highest dielectric constant. Tetragonal phase stabilization by crystallizing the thin HfO2 using a metal capping layer and by adding zirconium is demonstrated. The microstructure, morphology, optical properties and impurities of HfxZr1-xO2 dielectrics (for 0<x<1) are discussed. Subtle but important modification to high-k / Si interface characteristics resulting from addition of Zr into HfO2 is reported. To further boost the dielectric constant of hafnium-based dielectrics, incorporation of TiO2, which has been reported to have high dielectric constant, is explored. HfxZr1-xO2/TiO2 bilayer films were fabricated. 30 Å TiO2 films were deposited on a 5, 8, 12 or 15 Å HfxZr1-xO2 underlayer to determine the minimum thickness needed to maintain good thermal stability with Si substrate. CV and IV results indicated that 12-15 Å is the optimal thickness range for the HfxZr1-xO2 underlayer. A dielectric constant as high as 150 for TiO2 layer is extracted from TiO2 thickness series deposited on12 Å HfxZr1-xO2 underlayer. In addition to increasing the k-value of Hafnium-based dielectrics, it is important that the threshold voltage of these high-k devices is low. Here we report the use of thin Al2O3 capping layers to modulate PMOS threshold voltages. About 100 mV reduction in threshold voltage is achieved by capping HfO2 with a 5Å Al2O3 film. Finally, dielectric scaling by modifying the Si/high-k interfacial layer is attempted. Nitrogen incorporation into HfxZr1-xO2 is shown to be a simple and effective method to lower the capacitance equivalent thickness (CET) of Hafnium-based dielectrics.
We present a preliminary reconstruction of the star formation history of the Sagittarius dwarf irregular galaxy (SagDIG), a dIrr galaxy at the border of the Local Group. SagDIG is a lively star-forming dwarf galaxy with very low metallicity and an abundant gas reservoir, for which deep HST ACS observations have been obtained (Momany et al. 2005). We have built synthetic color-magnitude diagrams in the intrinsic ACS bands F606W and F814W and compared them with our HST/ACS observations to derive the global star formation history of the galaxy. We find a broad episode of star formation between 3 and 8 Gyr ago, with a low-intensity tail of star formation at older ages, and a SF enhancement in the last Gyr. An upper limit to the old populations is set by modeling the old HB. Our modeling of the color-magnitude diagram also provides some constraints on the chemical enrichment history of SagDIG.
We present UV data of a small sample of shell galaxies. For the majority of them (namely, NGC 2865 and NGC 7135), the NUV matches the optical emission, while the FUV is present in the innermost regions alone.
When determining elastic modulus and hardness of viscoelastic-plastic materials by depth-sensing indentation, one must respect their specific response. In the monotonic load-unload testing mode, the unloading should be preceded by a dwell mitigating the influence of the delayed deforming. The continuous stiffness measurement (CSM) mode, with a small harmonic signal added to the basic monotonic load, enables continuous measurement of harmonic contact stiffness and mechanical properties as a function of depth. However, the contact depth and area in this mode actually depend on the slow (monotonic) component of the loading and should be determined not from the harmonic contact stiffness but from the unloading stiffness; otherwise, the calculated elastic modulus and mean contact pressure will be incorrect. This paper provides the formulae for these calculations, defines special characteristics—such as apparent dynamic hardness and the index of sensitivity to harmonic loading—and shows how to improve results by smoothing the harmonic stiffness curve. The proposed methods are illustrated through nanoindentation tests of polymethyl methacrylate.