We use cookies to distinguish you from other users and to provide you with a better experience on our websites. Close this message to accept cookies or find out how to manage your cookie settings.
To send content items to your account,
please confirm that you agree to abide by our usage policies.
If this is the first time you use this feature, you will be asked to authorise Cambridge Core to connect with your account.
Find out more about sending content to .
To send content items to your Kindle, first ensure no-reply@cambridge.org
is added to your Approved Personal Document E-mail List under your Personal Document Settings
on the Manage Your Content and Devices page of your Amazon account. Then enter the ‘name’ part
of your Kindle email address below.
Find out more about sending to your Kindle.
Note you can select to send to either the @free.kindle.com or @kindle.com variations.
‘@free.kindle.com’ emails are free but can only be sent to your device when it is connected to wi-fi.
‘@kindle.com’ emails can be delivered even when you are not connected to wi-fi, but note that service fees apply.
Clostridioides difficile infection (CDI) causes significant morbidity and mortality; however, the diagnosis of CDI remains controversial. The primary aim of our study was to evaluate the association of polymerase chain reaction (PCR) cycle threshold (Ct) values with CDI disease severity, recurrence, and mortality among adult patients with CDI.
Design:
Retrospective cohort study.
Setting:
Single tertiary-care hospital.
Patients:
Adult patients diagnosed with hospital-onset, healthcare facility–associated CDI from June 2014 to September 2015.
Methods:
We performed a retrospective chart review of included patients. Univariate and multivariable logistic regression methods were used to evaluate the association between Ct values and CDI severity, 8-week recurrence, and 30-day mortality.
Results:
Among 318 included patients, 51% were male and the mean age was 62 years; ~32% of the patients developed severe CDI and 11% developed severe–complicated CDI. The 30-day all-cause mortality rate was 11% and the 8-week recurrence rate was 9.5%. The overall mean Ct value was 32.9 (range, 23–40). Multivariable analyses showed that lower values of PCR Ct were associated with increased odds of 30-day morality (odds ratio [OR] 0.83; 95% confidence interval [CI], 0.72–0.96) but were not independently associated with CDI severity (OR, 0.99; 95% CI, 0.90–1.09) or recurrence (OR, 0.88; 95% CI, 0.77–1.00).
Conclusions:
Our findings suggest that PCR Ct values at the time of diagnosis may have a limited predictive value and utility in clinical decision making for inpatients with CDI. Larger, prospective studies across different patient populations are needed to confirm our findings.
The Galactic TeV
${\gamma}$
-ray source
${\mathrm{HESS\,J}1804{-}216}$
is currently an unidentified source. In an attempt to unveil its origin, we present here the most detailed study of interstellar gas using data from the Mopra Southern Galactic Plane CO Survey, 7- and 12-mm wavelength Mopra surveys and Southern Galactic Plane Survey of HI. Several components of atomic and molecular gas are found to overlap
${\mathrm{HESS\,J}1804{-}216}$
at various velocities along the line of sight. The CS(1-0) emission clumps confirm the presence of dense gas. Both correlation and anti-correlation between the gas and TeV
${\gamma}$
-ray emission have been identified in various gas tracers, enabling several origin scenarios for the TeV
${\gamma}$
-ray emission from
${\mathrm{HESS\,J}1804{-}216}$
. For a hadronic scenario,
${\mathrm{SNR\,G}8.7{-}0.1}$
and the progenitor supernova remnant (SNR) of
${\mathrm{PSR\,J}1803{-}2137}$
require cosmic ray (CR) enhancement factors of
${\mathord{\sim} 50}$
times the solar neighbour CR flux value to produce the TeV
${\gamma}$
-ray emission. Assuming an isotropic diffusion model, CRs from both these SNRs require a slow diffusion coefficient, as found for other TeV SNRs associated with adjacent ISM gas. The morphology of gas located at 3.8 kpc (the dispersion measure distance to
${\mathrm{PSR\,J}1803{-}2137}$
) tends to anti-correlate with features of the TeV emission from
${\mathrm{HESS\,J}1804{-}216}$
, making the leptonic scenario possible. Both pure hadronic and pure leptonic scenarios thus remain plausible.
X-ray reference powder patterns and structures have been determined for a series of cobalt- and tungsten-containing cubic alkaline-earth perovskites, (BaxSr1–x)2CoWO6 (x = 0.1, 0.2, 0.3, 0.5, 0.7, and 0.9). The structure of the end members of the series, Sr2CoWO6 and Ba2CoWO6, were tetragonal and cubic, respectively, agreeing with the literature data. From Rietveld refinements, it was found that when x = 0.1 and 0.2, the structure was tetragonal I4/m (a = 5.60481(6) and 5.62305(11) Å and c = 7.97989(12) and 7.9847(2) Å, respectively; Z = 2). When x > 0.2, the structure was cubic (Fm$\bar{3}$m, No. 225; Z = 4) (from x = 0.3 to 0.9, a increases from 7.98399(13) to 8.08871(10) Å). This tetragonal series of compounds exhibit the characteristics of a distorted double-perovskite structure. The bond valence sum values for the alkaline-earth (Ba, Sr) sites in all (BaxSr1−x)2CoWO6 members are greater than the ideal value of 2.0, indicating over-bonding situation, whereas for the W sites, as x increases, a change from under-bonding to slightly over-bonding situation was observed. Density functional theory calculations revealed that while Sr2CoWO6 is a semiconductor, Ba2CoWO6 and SrBaCoWO6 are half-metals. Powder X-ray diffraction patterns of this series of compounds (BaxSr1−x)2CoWO6, with x = 0.1, 0.2, 0.3, 0.5, 0.7, and 0.9, have been submitted to be included in the Powder Diffraction File.
Introduction: Providing comfort care support at home without transport to hospital has not traditionally been part of paramedic practice. The innovative Paramedics Providing Palliative Care at Home Program includes a new clinical practice guideline, medications, a database to share goals of care, and palliative care training. This study aimed to determine essential elements for scale and spread of this model of care through the application of an implementation science model, the Consolidated Framework for Implementation Research (CFIR). Methods: Deliberative dialogue sessions were held with paramedic, palliative care, primary care, and administrative experts in a province that had the Program (Nova Scotia, March 2018) and one that had not (British Columbia, July 2018). Sessions were audio recorded and transcribed. The CFIR was used as the foundation for a framework analysis, which was conducted by four team members independently. Themes were derived by consensus with the broader research team. Results: Inter-sectoral communication between paramedics and other health care providers was key, and challenging due to privacy concerns. Relationships with health care providers are critical to promoting the new model of care to patients, managing expectations, and providing follow up/ongoing care. Training was an essential characteristic of the intervention that can be adapted to suit local needs, although cost is a factor. There were challenges due to the culture and implementation climate as a shift in the mindset of paramedics away from traditional roles is required to implement the model. Paramedic champions can play an important role in shifting the mindset of paramedics towards a new way of practice Conclusion: The CFIR construct of cosmopolitanism, emphasizing the importance of breaking down silos and engaging diverse stakeholders, emerged as one of the most important. This will be helpful for successful scale and spread of the program.
Introduction: Evidence is accumulating that a CT plus a CT angiogram (CTA) of the head and neck may be adequate to rule out subarachnoid haemorrhage (SAH) in patients with a thunderclap headache, thus potentially negating the need for lumbar puncture. One of the most widely cited objections to this strategy is the fear of detecting “incidental asymptomatic aneurysms,” lesions seen on angiography that are not in fact the cause of the patient's symptoms. Currently existing data on the background rate of aneurysms are based on cadaveric studies, invasive angiography, or MRI, and thus does not reflect the true rate of incidental aneurysms that would be detected using a CT plus CTA strategy. This study characterizes the rate of incidental aneurysms identified on CTA in an emergency department population. Methods: In this multicentre retrospective cohort study we analyzed the electronic medical records of all emergency department patients ≥ 18 years of age who underwent CTA of the head and neck over a two month period across four urban tertiary care emergency departments. Two independent reviewers evaluated the final radiology reports and extracted relevant data. The primary outcome of interest was the presence of incidental intracranial aneurysm, defined as a newly diagnosed aneurysm not associated with evidence of acute hemorrhage. Secondary outcomes included aneurysm location and size. Results: Of 739 charts meeting inclusion criteria, incidental intracranial aneurysms were detected in 21 cases or 2.85% (95% confidence interval, 1.77 - 4.32). An additional 20 aneurysms were identified but excluded from the analysis as they were previously known (n = 9) or were associated with evidence of acute hemorrhage (n = 11) and thus were not considered incidental. Of 21 patients with identified incidental aneurysms, 7 had multiple aneurysms. The most common aneurysm sites were internal carotid artery (n = 13), middle cerebral artery (n = 6) and anterior cerebral artery (n = 4). The average size of incidental aneurysm was 4.1 mm. Conclusion: The rate of incidental intracranial aneurysm among emergency department patients undergoing CTA of the head and neck is lower than many previously described estimates obtained through invasive angiography and MRI studies. To our knowledge, this is the first study on the prevalence of incidental intracranial aneurysms in an emergency department specific population and may therefore help guide clinicians when considering using a CT plus CTA rule out strategy for patients presenting with acute headache suspicious for SAH.
In an attempt to assess the universal applicability of the International Classification of Disease (ICD-10), two psychiatrists from different socio-cultural backgrounds and training independently performed a chart review of 238 Chinese patients. Inter-rater reliability figures were comparable to those found in the WHO-coordinated ICD-10 field trials. The results suggest that ICD-10 has good ‘universality’ in routine clinical practice.
Postgraduate medical trainees experience high rates of burnout, but evidence regarding psychiatric trainees is missing. We aim to determine burnout rates among psychiatric trainees, and identify individual, educational and work-related factors associated with severe burnout.
Methods
In an online survey psychiatric trainees from 22 countries were asked to complete the Maslach Burnout Inventory (MBI-GS) and provide information on individual, educational and work-related parameters. Linear mixed models were used to predict the MBI-GS scores, and a generalized linear mixed model to predict severe burnout.
Results
This is the largest study on burnout and training conditions among psychiatric trainees to date. Complete data were obtained from 1980 out of 7625 approached trainees (26%; range 17.8–65.6%). Participants were 31.9 (SD 5.3) years old with 2.8 (SD 1.9) years of training. Severe burnout was found in 726 (36.7%) trainees. The risk was higher for trainees who were younger (P < 0.001), without children (P = 0.010), and had not opted for psychiatry as a first career choice (P = 0.043). After adjustment for socio-demographic characteristics, years in training and country differences in burnout, severe burnout remained associated with long working hours (P < 0.001), lack of supervision (P < 0.001), and not having regular time to rest (P = 0.001). Main findings were replicated in a sensitivity analysis with countries with response rate above 50%.
Conclusions
Besides previously described risk factors such as working hours and younger age, this is the first evidence of negative influence of lack of supervision and not opting for psychiatry as a first career choice on trainees’ burnout.
Heart failure (HF) is a complex clinical syndrome that represents a major cause of morbidity and mortality in Western countries. Several nutraceuticals have shown interesting clinical results in HF prevention as well as in the treatment of the early stages of the disease, alone or in combination with pharmacological therapy. The aim of the present expert opinion position paper is to summarise the available clinical evidence on the role of phytochemicals in HF prevention and/or treatment that might be considered in those patients not treated optimally as well as in those with low therapy adherence. The level of evidence and the strength of recommendation of particular HF treatment options were weighed up and graded according to predefined scales. A systematic search strategy was developed to identify trials in PubMed (January 1970 to June 2019). The terms ‘nutraceuticals’, ‘dietary supplements’, ‘herbal drug’ and ‘heart failure’ or ‘left verntricular dysfunction’ were used in the literature search. The experts discussed and agreed on the recommendation levels. Available clinical trials reported that the intake of some nutraceuticals (hawthorn, coenzyme Q10, l-carnitine, d-ribose, carnosine, vitamin D, probiotics, n-3 PUFA and beet nitrates) might be associated with improvements in self-perceived quality of life and/or functional parameters such as left ventricular ejection fraction, stroke volume and cardiac output in HF patients, with minimal or no side effects. Those benefits tended to be greater in earlier HF stages. Available clinical evidence supports the usefulness of supplementation with some nutraceuticals to improve HF management in addition to evidence-based pharmacological therapy.
Rehabilitation of memory after stroke remains an unmet need. Telehealth delivery may overcome barriers to accessing rehabilitation services.
Method:
We conducted a non-randomized intervention trial to investigate feasibility and effectiveness of individual telehealth (internet videoconferencing) and face-to-face delivery methods for a six-week compensatory memory rehabilitation program. Supplementary analyses investigated non-inferiority to an existing group-based intervention, and the role of booster sessions in maintaining functional gains. The primary outcome measure was functional attainment of participants’ goals. Secondary measures included subjective reports of lapses in everyday memory and prospective memory, reported use of internal and external memory strategies, and objective measures of memory functioning.
Results:
Forty-six stroke survivors were allocated to telehealth and face-to-face intervention delivery conditions. Feasibility of delivery methods was supported, and participants in both conditions demonstrated treatment-related improvements in goal attainment, and key subjective outcomes of everyday memory, and prospective memory. Gains on these measures were maintained at six-week follow-up. Short-term gains in use of internal strategies were also seen. Non-inferiority to group-based delivery was established only on the primary measure for the telehealth delivery condition. Booster sessions were associated with greater maintenance of gains on subjective measures of everyday memory and prospective memory.
Conclusions:
This exploratory study supports the feasibility and potential effectiveness of telehealth options for remote delivery of compensatory memory skills training after a stroke. These results are also encouraging of a role for booster sessions in prolonging functional gains over time.
The Murchison Widefield Array (MWA) is an open access telescope dedicated to studying the low-frequency (80–300 MHz) southern sky. Since beginning operations in mid-2013, the MWA has opened a new observational window in the southern hemisphere enabling many science areas. The driving science objectives of the original design were to observe 21 cm radiation from the Epoch of Reionisation (EoR), explore the radio time domain, perform Galactic and extragalactic surveys, and monitor solar, heliospheric, and ionospheric phenomena. All together
$60+$
programs recorded 20 000 h producing 146 papers to date. In 2016, the telescope underwent a major upgrade resulting in alternating compact and extended configurations. Other upgrades, including digital back-ends and a rapid-response triggering system, have been developed since the original array was commissioned. In this paper, we review the major results from the prior operation of the MWA and then discuss the new science paths enabled by the improved capabilities. We group these science opportunities by the four original science themes but also include ideas for directions outside these categories.
At some time during one’s practice in anaesthesiology, one cannot help but notice certain obsessive–compulsive tendencies in our colleagues. Such traits are quickly revealed when you put them under pressure by asking them to do an unplanned emergency case and disrupt the cocoon that is their elective list. In contrast to having known and prepared for all of the patient’s problems, they are now compelled to deal with a relatively unknown and often sub-optimal situation. More likely than not, they will have to induce anaesthesia with rapid sequence induction (RSI). Whereas some may be thrilled, others are less impressed with the disorder introduced into their world. What is it about emergency cases that should be such a bother? In particular, can TIVA enthusiasts thrive in this environment? At the time of writing, the use of TIVA in emergency is indeed somewhat uncharted territory as very few studies have examined this area.
In keeping with the spirit of producing a practical book, we took editorial privileges and removed some of the more detailed text from various chapters and yet felt it would be a waste if some of it weren’t shared with our readers. At the same time, there are aspects of TIVA that are not necessarily recommended for novices but may entice those who have had a bit of experience and want to extend their TIVA repertoire. Therefore we thought we would create a final chapter that would incorporate some such material, hopefully in a semi-logical fashion.