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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.
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.
During March 2003, Autosub, an autonomous underwater vehicle (AUV) operated by the UK National Oceanography Centre, Southampton, was deployed under Sea ice north of Thurston Island, Amundsen Sea, Antarctica (at ∽71˚ S, 100˚ W). The vehicle was fitted with an upward-looking 300 kHz acoustic Doppler current profiler (ADCP) to provide current velocity above the AUV. The ADCP also recorded ranges to the ocean–ice interface. Such data can be used to derive Sea-ice draft by using a number of novel processing Steps Such as correcting for the coordinate Systems of the ADCP unit and the vehicle as well as corrections for changes in Sound Speed. This paper outlines the processing Stages required to obtain a probability density function (PDF) of Sea-ice draft and presents PDFs for the region north of Thurston Island. The distribution of ice draft was found to be unimodal, with modes between 2.2 and 2.4 m. Given the uncertainty in Sound Speed, the limit of accuracy was estimated as ∽6 cm.
Limitations of access have long restricted exploration and investigation of the cavities beneath ice shelves to a small number of drillholes. Studies of sea-ice underwater morphology are limited largely to scientific utilization of submarines. Remotely operated vehicles, tethered to a mother ship by umbilical cable, have been deployed to investigate tidewater-glacier and ice-shelf margins, but their range is often restricted. The development of free-flying autonomous underwater vehicles (AUVs) with ranges of tens to hundreds of kilometres enables extensive missions to take place beneath sea ice and floating ice shelves. Autosub2 is a 3600 kg, 6.7 m long AUV, with a 1600 m operating depth and range of 400 km, based on the earlier Autosub1 which had a 500 m depth limit. A single direct-drive d.c. motor and five-bladed propeller produce speeds of 1–2 m s−1. Rear-mounted rudder and stern-plane control yaw, pitch and depth. The vehicle has three sections. The front and rear sections are free-flooding, built around aluminium extrusion space-frames covered with glass-fibre reinforced plastic panels. The central section has a set of carbon-fibre reinforced plastic pressure vessels. Four tubes contain batteries powering the vehicle. The other three house vehicle-control systems and sensors. The rear section houses subsystems for navigation, control actuation and propulsion and scientific sensors (e.g. digital camera, upward-looking 300 kHz acoustic Doppler current profiler, 200 kHz multibeam receiver). The front section contains forward-looking collision sensor, emergency abort, the homing systems, Argos satellite data and location transmitters and flashing lights for relocation as well as science sensors (e.g. twin conductivity–temperature–depth instruments, multibeam transmitter, sub-bottom profiler, AquaLab water sampler). Payload restrictions mean that a subset of scientific instruments is actually in place on any given dive. The scientific instruments carried on Autosub are described and examples of observational data collected from each sensor in Arctic or Antarctic waters are given (e.g. of roughness at the underside of floating ice shelves and sea ice).
Objectives: Cognitive impairment is an important aspect of Parkinson’s disease (PD), but there is considerable heterogeneity in its presentation. This investigation aims to identify and characterize latent cognitive phenotypes in early PD. Methods: Latent class analysis, a data-driven, person-centered, cluster analysis was performed on cognitive data from the Parkinson’s Progressive Markers Initiative baseline visit. This analytic method facilitates identification of naturally occurring endophenotypes. Resulting classes were compared across biomarker, symptom, and demographic data. Results: Six cognitive phenotypes were identified. Three demonstrated consistent performance across indicators, representing poor (“Weak-Overall”), average (“Typical-Overall”), and strong (“Strong-Overall”) cognition. The remaining classes demonstrated unique patterns of cognition, characterized by “Strong-Memory,” “Weak-Visuospatial,” and “Amnestic” profiles. The Amnestic class evidenced greater tremor severity and anosmia, but was unassociated with biomarkers linked with Alzheimer’s disease. The Weak-Overall class was older and reported more non-motor features associated with cognitive decline, including anxiety, depression, autonomic dysfunction, anosmia, and REM sleep behaviors. The Strong-Overall class was younger, more female, and reported less dysautonomia and anosmia. Classes were unrelated to disease duration, functional independence, or available biomarkers. Conclusions: Latent cognitive phenotypes with focal patterns of impairment were observed in recently diagnosed individuals with PD. Cognitive profiles were found to be independent of traditional biomarkers and motoric indices of disease progression. Only globally impaired class was associated with previously reported indicators of cognitive decline, suggesting this group may drive the effects reported in studies using variable-based analysis. Longitudinal and neuroanatomical characterization of classes will yield further insight into the evolution of cognitive change in the disease. (JINS, 2017, 23, 551–563)
A. N. Lewis’s scheme of Tasmania’s Pleistocene glacial history in terms of three full glaciations —Malanna (ice cap), Yolande (valley glacier) and Margaret (cirque glacier)—is criticized on a number of specific and general grounds. The area reliably known to be glaciated is thought to be much smaller than Lewis claimed. Future work on Tasmanian glaciations should not be grafted on to Lewis’s scheme and should aim especially to provide more reliable evidence for distinguishing and evaluating the glacial phases.
Voting is a fundamental part of any democratic society. But survey-based measures of voting are problematic because a substantial proportion of nonvoters report that they voted. This over-reporting has consequences for our understanding of voting as well as the behaviors and attitudes associated with voting. Relying on the “bogus pipeline” approach, we investigate whether altering the wording of the turnout question can cause respondents to provide more accurate responses. We attempt to reduce over-reporting simply by changing the wording of the vote question by highlighting to the respondent that: (1) we can in fact find out, via public records, whether or not they voted; and (2) we (survey administrators) know some people who say they voted did not. We examine these questions through a survey on US voting-age citizens after the 2010 midterm elections, in which we ask them about voting in those elections. Our evidence shows that the question noting we would check the records improved the accuracy of the reports by reducing the over-reporting of turnout.
Long-term care facilities (LTCFs) and their residents are especially susceptible to disruptions associated with natural disasters and often have limited experience and resources for disaster planning and response. Previous reports have offered disaster planning and response recommendations. We could not find a comprehensive review of studied interventions or facility attributes that affect disaster outcomes in LTCFs and their residents. We reviewed articles published from 1974 through September 30, 2015, that studied disaster characteristics, facility characteristics, patient characteristics, or an intervention that affected outcomes for LTCFs experiencing or preparing for a disaster. Twenty-one articles were included in the review. All of the articles fell into 1 of the following categories: facility or disaster characteristics that predicted preparedness or response, interventions to improve preparedness, and health effects of disaster response, most often related to facility evacuation. All of the articles described observational studies that were heterogeneous in design and metrics. We believe that the evidence-based literature supports 6 specific recommendations for facilities, governmental agencies, health care communities and academia. These include integrated and coordinated disaster planning, staff training, careful consideration before governments order mandatory evacuations, anticipation of the increased medical needs of LTCF residents following a disaster, and the need for more outcomes research. (Disaster Med Public Health Preparedness. 2017;11:140–149)
Twenty-eight 14C analyses are reported for carbonized roots and other plant material collected from beneath 15 prehistoric lava flows erupted from the northeast rift zone (NERZ) of Mauna Loa Volcano (ML) utilizing the recovery techniques of Lockwood and Lipman (1980). Most samples were collected from the Hilo 7 1/2’ quadrangle during field work for a geologic map of that quadrangle (Buchanan-Banks, unpub data); a few sample sites are located in adjacent quadrangles: Piihonua to the west and Mountain View to the south. Altitudes are given in English units as well as metric to facilitate locating sites on USGS topographic maps.
In 1952, the African National Congress (ANC) initiated its Defiance Campaign, opposing apartheid laws through organized civil disobedience and African nationalism. On Sunday 9 November, the city of East London became a site of political mobilization when 1,500 Xhosa-speaking ANC sympathizers peacefully protested in Bantu Square, the hub of a township named Duncan Village. Police arrived and fired on the crowd, igniting ‘spontaneous riots’. An Afrikaner salesman and an Irish nun were killed in the ensuing unrest. Rumours circulated that a mob ate the white woman; troop reinforcements then fanned into the township to wage a retaliatory war, shooting and bayoneting their victims. Upwards of 200 Africans may have died but only nine fatalities were recorded. If the revised toll is credible, the bloodshed exceeds that of Sharpeville, the worst one-day massacre in apartheid South Africa. Oral sources explain why the slaughter in Duncan Village is not widely known. Township residents secretly carted the dead to rural graves, fearing to report their losses as people mourned the tragic slaying of the nun named Sister Aidan. Today, ANC rulers of East London seem content to silence the memory of a mass killing reputedly spawned by chaos and cannibalism. At the centre of this incident is Sr Aidan's mutilation for the purpose of making muthi, a shocking incident that dominates the story of violence on Black Sunday. Using archival documents and oral histories, and incorporating the methodologies of Jennifer Cole, Donald Donham and Veena Das, this article reconstructs a narrative of ‘critical events’ surrounding the nun's muthi murder. The scrutinized witness testimonies relay how township residents framed their fierce encounters with a symbolic (white person) and ubiquitous (militarized police) enemy. Oral sources reject the notion that an aimless ‘riot’ occurred on 9 November. Instead, they reflect on cultural enactments of purposeful violence through scripted assaults and muthi ritual. Ultimately, they view the fatal attack on Sr Aidan as an evolving customary act of defensive retribution and symbolic warning, submerging truths in apartheid and hindering reconciliations in democracy.
This article, prepared for the symposium on ‘The Future of Restrictivist Scholarship on the Use of Force’, examines the current trajectory of restrictivist scholarship in the United States. In contrast to their counterparts in continental Europe, American restrictivists tend to devote less energy to defending narrow constructions of the UN Charter. Instead, they generally focus on legal constraints outside the Charter's text, including customary norms and general principles of law such as necessity, proportionality, deliberative rationality, and robust evidentiary burdens. The article considers how these features of the American restrictivist tradition reflect distinctive characteristics of American legal culture, and it explores the tradition's influence on debates over anticipatory self-defense and the use of force against non-state actors abroad. The article concludes by examining how the American restrictivist tradition is beginning to shape the United States’ approach to the use of force in response to cyber attacks.
We analysed data from a prospective cohort of 255024 adults aged ⩾45 years recruited from 2006–2009 to identify characteristics associated with a zoster diagnosis. Diagnoses were identified by linkage to pharmaceutical treatment and hospitalization records specific for zoster and hazard ratios were estimated. Over 940583 person-years, 7771 participants had a zoster diagnosis; 253 (3·3%) were hospitalized. After adjusting for age and other factors, characteristics associated with zoster diagnoses included: having a recent immunosuppressive condition [adjusted hazard ratio (aHR) 1·58, 95% confidence interval (CI) 1·32–1·88], female sex (aHR 1·36, 95% CI 1·30–1·43), recent cancer diagnosis (aHR 1·35, 95% CI 1·24–1·46), and severe physical limitation vs. none (aHR 1·33, 95% CI 1·23–1·43). The relative risk of hospitalization for zoster was higher for those with an immunosuppressive condition (aHR 3·78, 95% CI 2·18–6·55), those with cancer (aHR 1·78, 95% CI 1·24–2·56) or with severe physical limitations (aHR 2·50, 95% CI 1·56–4·01). The novel finding of an increased risk of zoster diagnoses and hospitalizations in those with physical limitations should prompt evaluation of the use of zoster vaccine in this population.
The prevalence of anti-HEV isotype-specific antibodies and viraemia were investigated in serum samples collected from slaughter-age pigs (aged 22–24 weeks) from 23 farms in Scotland. Of 176 serum samples tested, 29·0% (n = 51) were anti-HEV IgG positive, 36·9% (n = 65) anti-HEV IgA positive and 29·0% (n = 51) anti-HEV IgM positive. Overall seroprevalence (anti-HEV IgG+ and/or IgA+ and/or IgM+) was 61·4% (n = 108). HEV RNA was detected in 72/162 serum samples (44·4%). Partial sequence of ORF2 (98 nt) was obtained from eight HEV RNA-positive samples and phylogenetic analysis confirmed that they were all of genotype 3. This is the first report on the prevalence of HEV in pigs in Scotland. Given the increasing incidence of locally acquired HEV infection in the UK, evidence that HEV is a foodborne zoonosis emphasizes the need for surveillance in pigs.
We evaluated the behaviors of anesthesiologists during induction and maintenance of anesthesia. Contacts with surfaces occurred a mean (±standard error) of 154.8 ± 7.7 and 60 ± 3.1 times per hour during induction and maintenance, respectively (P < .0001). Hand hygiene events were 1.8 ± 0.27 per hour during induction versus 1.19 ± 0.27 during maintenance (P = .018).
Infect Control Hosp Epidemiol 2014;35(8):1056–1059
Forty anesthesia providers were evaluated with and without hand sanitizer dispensers present on the anesthesia machine. Having a dispenser increased the frequency of hand hygiene only from 0.5 to 0.8 events per hour (P = .01). Other concomitant interventions are needed to further increase hand hygiene frequency among anesthesia providers.