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To describe the use of next-generation sequencing (NGS) and to determine whether NGS leads to changes in antimicrobial management.
Design and setting:
This retrospective cohort study included patients aged ≥18 years admitted to a single tertiary-care center in Houston, Texas, with an NGS test performed between January 1, 2017, and December 31, 2018.
In total, 167 NGS tests were performed. Most patients were of non-Hispanic ethnicity (n = 129), white (n = 106), and male (n = 116), with a mean age of 52 years (SD, 16). Moreover, 61 patients were immunocompromised: solid-organ transplant (n = 30), patients with human immunodeficiency virus (n = 14), and rheumatology patients on immunosuppressive therapy (n = 12).
Of the 167 NGS tests performed, 118 (71%) were positive. Test results associated with a change in antimicrobial management were found in 120 (72%) of 167 cases, with an average of 0.32 (SD, 1.57) fewer antimicrobials after the test. The largest change in antimicrobial management was in glycopeptide use (36 discontinuations) followed by antimycobacterial drug use (27 additions among 8 patients). Also, 49 patients had negative NGS results, but only 36 patients had their antibiotics discontinued.
Plasma NGS testing is associated with a change in antimicrobial management in most cases. We observed a decrease in glycopeptide use after NGS results, which highlights physicians’ comfort in withdrawing methicillin-resistant Staphylococcus aureus (MRSA) coverage. In addition, antimycobacterial coverage increased, corresponding with early mycobacterial detection by NGS. Further studies are needed to determine effective ways to use NGS testing as an antimicrobial stewardship tool.
The Red Sea is a largely homogeneous water column beyond the top 300 m, unique in exhibiting warm bottom water (~21.5 °C) at depths down to ~2900 m. The unusual conditions coupled with barriers to colonization by primary deep-sea species has resulted in an impoverished but distinct deep fauna. This study presents a rare investigation of the deep Red Sea. The bigeye hound shark Iago omanensis is a known deep-sea shark in the Red Sea. However, its full depth distribution has never been conclusively studied. Here, we confirm with videographic evidence the presence of I. omanensis at depths to 2522 m in the Red Sea, along with observations of other deep-sea species. Iago omanensis was the only species of scavenging fish observed and only in moderate numbers. The additional six species were mostly crustacea in low abundance. The lack of scavenging species present in the deep Red Sea is likely explained by the low productivity of the overlying surface waters and unusually warm water temperature resulting in low energetic input but high metabolic demands in deep communities.
Two experiments examined the benefits of unconscious thought on complex decisions (Dijksterhuis, 2004). Experiment 1 attempted to replicate and extend past research by examining the effect of providing reasons prior to rating the options. Results indicated no significant differences between the conditions. Experiment 2 attempted to replicate the findings of Dijksterhuis, Bos, Nordgren, and van Baaren (2006) and determine if a memory aid could overcome the limitations of conscious thought on complex tasks. Results revealed that a memory aid improved decisions compared to the conscious thought condition. Participants in the unconscious thought condition did not perform significantly better than did participants in the conscious thought condition.
We examined how the goal of a decision task influences the perceived positive, negative valence of the alternatives and thereby the likelihood and direction of framing effects. In Study 1 we manipulated the goal to increase, decrease or maintain the commodity in question and found that when the goal of the task was to increase the commodity, a framing effect consistent with those typically observed in the literature was found. When the goal was to decrease, a framing effect opposite to the typical findings was observed whereas when the goal was to maintain, no framing effect was found. When we examined the decisions of the entire population, we did not observe a framing effect. In Study 2, we provided participants with a similar decision task except in this situation the goal was ambiguous, allowing us to observe participants' self-imposed goals and how they influenced choice preferences. The findings from Study 2 demonstrated individual variability in imposed goal and provided a conceptual replication of Study 1.
In its most basic sense, “Reformed catholicity” involves approaching Reformed theology, in its historic and contemporary forms, as one who belongs to the larger Christian tradition, the “holy, catholic church” confessed by the Apostles’ Creed. While this approach operates from within the Reformed theological tradition, it does so with an attentive ear to the catholic Christian voices from all eras; for those who embrace Reformed catholicity do not approach the Reformed tradition as an end in itself but rather as a way to fruitfully inhabit the larger catholic tradition. In its recent instantiation as a contemporary “sensibility,” “Reformed catholicity” generally means combining a theocentric focus upon theology as knowledge of the Triune God and creation in relation to God. It also involves a commitment to recovering the core catholic trinitarian and christological convictions that provide a framework for a theological journey of faith seeking understanding. Within this context, the task of biblical exegesis is embraced as fundamental to the renewal of a modern theological imagination. These catholic and Reformed convictions can help frame a way for the reception of the Word by the Spirit that moves God’s people away from self-serving and truncated ends and toward the fullness of maturity in Christ in life, worship, and witness.
Moral distress is a well-described phenomenon in medical providers. It has been linked to mental health deterioration, decreased job satisfaction, and early retirement. No study has been done on the level of moral distress associated with treating patients in simultaneous disasters.
1. To learn what is known about the experience of moral distress in frontline health care providers during the COVID-19 pandemic and the concurrent conflict in Armenia during 2020.
2. To determine how WHO EMTs can support their frontline staff experiencing moral distress.
A survey was designed to test the moral distress felt by Armenian EMS providers who had cared for both COVID-19 and war casualty patients. This was adapted from the Moral Distress Scale Revised (MDS-R).
Of the questions asked, respondents most often responded that they were disturbed by: “Continuing to participate in care for a hopelessly ill or injured person who is being sustained on a ventilator when no one will make a decision to withdraw support” (Mean 2.68/Median 3/Mode 4); and “Initiated extensive life-saving actions when I think they only prolong death” (2.47/3/3), which caused the next most distress to subjects.
It is expected that some health care workers in Armenia are likely facing on-going consequences of the moral distress they faced during this unprecedented period of global pandemic and war. Clinics and teams who are more likely to encounter potentially morally distressing events, such as disaster medicine workers, need to address their moral distress mitigation plan by identifying strategies across the continuum of disaster management.
A growing body of evidence attests that legislators are sometimes responsive to the policy preferences of citizens in single-party regimes, yet debate surrounds the mechanisms driving this relationship. We experimentally test two potential responsiveness mechanisms—elections versus mandates from party leaders—by provisioning delegates to the Vietnamese National Assembly with information on the policy preferences of their constituents and reminding them of either (1) the competitiveness of the upcoming 2021 elections or (2) a central decree that legislative activities should reflect constituents’ preferences. Consistent with existing work, delegates informed of citizens’ preferences are more likely to speak on the parliamentary floor and in closed-session caucuses. Importantly, we find that such responsiveness is entirely driven by election reminders; upward incentive reminders have virtually no effect on behavior.
In the United States, cardiovascular disease is the leading cause of death and the rate of maternal mortality remains among the highest of any industrialized nation. Maternal cardiometabolic health throughout gestation and postpartum is representative of placental health and physiology. Both proper placental functionality and placental microRNA expression are essential to successful pregnancy outcomes, and both are highly sensitive to genetic and environmental sources of variation. Placental pathologies, such as preeclampsia, are associated with maternal cardiovascular health but may also contribute to the developmental programming of chronic disease in offspring. However, the role of more subtle alterations to placental function and microRNA expression in this developmental programming remains poorly understood. We performed small RNA sequencing to investigate microRNA in placentae from the Rhode Island Child Health Study (n = 230). MicroRNA counts were modeled on maternal family history of cardiovascular disease using negative binomial generalized linear models. MicroRNAs were considered to be differentially expressed at a false discovery rate (FDR) less than 0.10. Parallel mRNA sequencing data and bioinformatic target prediction software were then used to identify potential mRNA targets of differentially expressed microRNAs. Nine differentially expressed microRNAs were identified (FDR < 0.1). Bioinformatic target prediction revealed 66 potential mRNA targets of these microRNAs, many of which are implicated in TGFβ signaling pathway but also in pathways involving cellular metabolism and immunomodulation. A robust association exists between familial cardiovascular disease and placental microRNA expression which may be implicated in both placental insufficiencies and the developmental programming of chronic disease.
In a rejoinder to Gill et alia (2021), Martin (2022) accuses us of perpetuating misconceptions about human nutrition and erroneously describing geophytes as a dietary staple. We provide authoritative definitions for the terms “essential” and “dietary staple” to show that it is Martin who mischaracterizes and misunderstands the foundational role of geophytes and other plant foods to human diets and subsistence economies in Native North America outside of the Arctic. Recent data demonstrate that carbohydrate-rich geophytes were abundant, regularly utilized, and essential resources on the Northern Channel Islands, a dietary staple that was a rich source of calories and complemented the protein-rich shellfish and finfish that were also staple foods for the Island Chumash.
Early in the COVID-19 pandemic, the World Health Organization stressed the importance of daily clinical assessments of infected patients, yet current approaches frequently consider cross-sectional timepoints, cumulative summary measures, or time-to-event analyses. Statistical methods are available that make use of the rich information content of longitudinal assessments. We demonstrate the use of a multistate transition model to assess the dynamic nature of COVID-19-associated critical illness using daily evaluations of COVID-19 patients from 9 academic hospitals. We describe the accessibility and utility of methods that consider the clinical trajectory of critically ill COVID-19 patients.
Many triage algorithms exist for use in mass-casualty incidents (MCIs) involving pediatric patients. Most of these algorithms have not been validated for reliability across users.
Investigators sought to compare inter-rater reliability (IRR) and agreement among five MCI algorithms used in the pediatric population.
A dataset of 253 pediatric (<14 years of age) trauma activations from a Level I trauma center was used to obtain prehospital information and demographics. Three raters were trained on five MCI triage algorithms: Simple Triage and Rapid Treatment (START) and JumpSTART, as appropriate for age (combined as J-START); Sort Assess Life-Saving Intervention Treatment (SALT); Pediatric Triage Tape (PTT); CareFlight (CF); and Sacco Triage Method (STM). Patient outcomes were collected but not available to raters. Each rater triaged the full set of patients into Green, Yellow, Red, or Black categories with each of the five MCI algorithms. The IRR was reported as weighted kappa scores with 95% confidence intervals (CI). Descriptive statistics were used to describe inter-rater and inter-MCI algorithm agreement.
Of the 253 patients, 247 had complete triage assignments among the five algorithms and were included in the study. The IRR was excellent for a majority of the algorithms; however, J-START and CF had the highest reliability with a kappa 0.94 or higher (0.9-1.0, 95% CI for overall weighted kappa). The greatest variability was in SALT among Green and Yellow patients. Overall, J-START and CF had the highest inter-rater and inter-MCI algorithm agreements.
The IRR was excellent for a majority of the algorithms. The SALT algorithm, which contains subjective components, had the lowest IRR when applied to this dataset of pediatric trauma patients. Both J-START and CF demonstrated the best overall reliability and agreement.
Given the relatively small industry scale of cow-calf operations in New York to other regions of the country, little is known about differences in determinant values for feeder cattle. Using auction prices and quality characteristics over 7 years, differences in market, lot, and quality parameters suggest opportunities for improved marketing performance. A delta profit model is constructed to inform timing of marketing decisions for producers. The results indicate a relatively high potential for producers to increase farm returns by delaying sales of lighter-weight feeder cattle from the fall to spring auction months, given sufficient rates of gain and reasonable overwintering costs.
The places in which people live and spend time are steeped in history, memory, and meaning from the intersection of daily life, environmental interactions, cultural practices, and ritual. Geologic features, plants, animals, and ecosystems merge with these cultural histories, forming critical parts of the landscape and areas of “high cultural salience,” or “cultural keystone places” (CKPs). We identify Kumqaq’ (Point Conception) and the surrounding area in California as a Chumash CKP. Ethnohistoric accounts and contemporary Chumash community members have long demonstrated the importance of Point Conception in Chumash worldview and identity, whereas biologists, ecologists, and conservationists reference the area's rich biodiversity and significance as a biogeographical boundary. Recent archaeological survey of the coastline surrounding Kumqaq’ highlights these connections, identifying over 50 archaeological sites—including shell middens, villages, lithic scatters, and rock art—with at least 9,000 years of occupation. Ongoing collaborations among archaeologists, the Nature Conservancy, and Chumash community members help document and understand the long-term linkages between cultural and biological diversity and how integrating these perspectives can help ensure the resilience of this nexus of human and natural history in the Anthropocene future.
An enduring problem in North American archaeology concerns the nature of the transition between the Clovis and Folsom Paleoindian complexes in the West. Traditional models indicate a temporal hiatus between the two complexes implying that Folsom was a population replacement for Clovis. Alternatively, if Folsom was an innovation that occurred within Clovis populations and subsequently spread, we would expect to see a temporal overlap. Here, we test these hypotheses using high-quality radiocarbon dates and Bayesian statistics to infer the temporal boundaries of the complexes. We show that the Folsom complex initially appears between 12,900 and 12,740 cal BP, whereas Clovis disappears between 12,720 and12,490 cal BP. Therefore, Folsom may have appeared about 200 years before Clovis disappeared, and so the two complexes likely co-occurred in the West for nearly eight generations. This finding suggests that Folsom was a successful adaptive innovation that diffused through the western Clovis population, eventually going to fixation over multiple generations.
Glyphosate’s efficacy is influenced by the amount absorbed and translocated throughout the plant to inhibit 5-enolpyruvyl shikimate-3-phosphate synthase (EPSPS). Glyphosate resistance can be due to target-site (TS) or non–target site (NTS) resistance mechanisms. TS resistance includes an altered target site and gene overexpression, while NTS resistance includes reduced absorption, reduced translocation, enhanced metabolism, and exclusion/sequestration. The goal of this research was to elucidate the mechanism(s) of glyphosate resistance in common ragweed (Ambrosia artemisiifolia L.) from Ontario, Canada. The resistance factor for this glyphosate-resistant (GR) A. artemisiifolia biotype is 5.1. No amino acid substitutions were found at positions 102 or 106 of the EPSPS enzyme in this A. artemisiifolia biotype. Based on [14C]glyphosate studies, there was no difference in glyphosate absorption or translocation between glyphosate-susceptible (GS) and GR A. artemisiifolia biotypes. Radio-labeled glyphosate metabolites were similar for GS and GR A. artemisiifolia 96 h after application. Glyphosate resistance in this A. artemisiifolia biotype is not due to an altered target site due to amino acid substitutions at positions 102 and 106 in the EPSPS and is not due to the NTS mechanisms of reduced absorption, reduced translocation, or enhanced metabolism.
Obesity increases the risk of post-operative arrhythmias in adults undergoing cardiac surgery, but little is known regarding the impact of obesity on post-operative arrhythmias after CHD surgery.
Patients undergoing CHD surgery from 2007 to 2019 were prospectively enrolled in the parent study. Telemetry was assessed daily, with documentation of all arrhythmias. Patients aged 2–20 years were categorised by body mass index percentile for age and sex (underweight <5, normal 5–85, overweight 85–95, and obese >95). Patients aged >20 years were categorised using absolute body mass index. We investigated the impact of body mass index category on arrhythmias using univariate and multivariate analysis.
There were 1250 operative cases: 12% underweight, 65% normal weight, 12% overweight, and 11% obese. Post-operative arrhythmias were observed in 38%. Body mass index was significantly higher in those with arrhythmias (18.8 versus 17.8, p = 0.003). There was a linear relationship between body mass index category and incidence of arrhythmias: underweight 33%, normal 38%, overweight 42%, and obese 45% (p = 0.017 for trend). In multivariate analysis, body mass index category was independently associated with post-operative arrhythmias (p = 0.021), with odds ratio 1.64 in obese patients as compared to normal-weight patients (p = 0.036). In addition, aortic cross-clamp time (OR 1.007, p = 0.002) and maximal vasoactive–inotropic score in the first 48 hours (OR 1.03, p = 0.04) were associated with post-operative arrhythmias.
Body mass index is independently associated with incidence of post-operative arrhythmias in children after CHD surgery.
We present the first fully coupled 3D full-Stokes model of a tidewater glacier, incorporating ice flow, subglacial hydrology, plume-induced frontal melting and calving. We apply the model to Store Glacier (Sermeq Kujalleq) in west Greenland to simulate a year of high melt (2012) and one of low melt (2017). In terms of modelled hydrology, we find perennial channels extending 5 km inland from the terminus and up to 41 and 29 km inland in summer 2012 and 2017, respectively. We also report a hydrodynamic feedback that suppresses channel growth under thicker ice inland and allows water to be stored in the distributed system. At the terminus, we find hydrodynamic feedbacks exert a major control on calving through their impact on velocity. We show that 2012 marked a year in which Store Glacier developed a fully channelised drainage system, unlike 2017, where it remained only partially developed. This contrast in modelled behaviour indicates that tidewater glaciers can experience a strong hydrological, as well as oceanic, control, which is consistent with observations showing glaciers switching between types of behaviour. The fully coupled nature of the model allows us to demonstrate the likely lack of any hydrological or ice-dynamic memory at Store Glacier.
Mass-casualty incident (MCI) algorithms are used to sort large numbers of patients rapidly into four basic categories based on severity. To date, there is no consensus on the best method to test the accuracy of an MCI algorithm in the pediatric population, nor on the agreement between different tools designed for this purpose.
This study is to compare agreement between the Criteria Outcomes Tool (COT) to previously published outcomes tools in assessing the triage category applied to a simulated set of pediatric MCI patients.
An MCI triage category (black, red, yellow, and green) was applied to patients from a pre-collected retrospective cohort of pediatric patients under 14 years of age brought in as a trauma activation to a Level I trauma center from July 2010 through November 2013 using each of the following outcome measures: COT, modified Baxt score, modified Baxt combined with mortality and/or length-of-stay (LOS), ambulatory status, mortality alone, and Injury Severity Score (ISS). Descriptive statistics were applied to determine agreement between tools.
A total of 247 patients were included, ranging from 25 days to 13 years of age. The outcome of mortality had 100% agreement with the COT black. The “modified Baxt positive and alive” outcome had the highest agreement with COT red (65%). All yellow outcomes had 47%-53% agreement with COT yellow. “Modified Baxt negative and <24 hours LOS” had the highest agreement with the COT green at 89%.
Assessment of algorithms for triaging pediatric MCI patients is complicated by the lack of a gold standard outcome tool and variability between existing measures.
A laboratory intercomparison project was carried out on 20 annually resolved late-wood samples from the Danish oak record. The project included the following three laboratories: (1) the University of Arizona AMS Laboratory, University of Arizona, USA (AA); (2) HEKAL AMS Laboratory, MTA Atomki, Hungary (DeA); and (3) Aarhus AMS Centre (AARAMS), Aarhus University, Denmark (AAR). The large majority of individual data points (96%) lie within ±2σ of the weighted mean. Further assessment of the accuracy associated with the individual laboratories showed good agreement, indicating that consistent and reliable 14C measurements well in agreement with each other are produced at the three laboratories. However, the quoted analytical uncertainties appear to be underestimated when compared to the observed variance of differences from the geometric mean of the samples. This study provides a general quality check of the single-year tree-ring 14C measurements that are included in the new calibration curve.
The coronavirus disease 2019 (COVID-19) pandemic has caused the greatest global loss of life and economic impact due to a respiratory virus since the 1918 influenza pandemic. While health care systems around the world faced the enormous challenges of managing COVID-19 patients, health care workers in the Republic of Armenia were further tasked with caring for the surge of casualties from a concurrent, large-scale war. These compounding events put a much greater strain on the health care system, creating a complex humanitarian crisis that resulted in significant psychosocial consequences for health care workers in Armenia.