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Adult patients who triggered an electronic sepsis alert in the emergency department (ED), received ≥2 doses of vancomycin or an antipseudomonal beta-lactam, and were discharged with an ICD-10 sepsis code.
We assessed the prevalence of delays in second doses of antibiotics by ≥25% of the recommended dose interval and conducted multivariate regression analyses to assess for risk factors for delays and in-hospital mortality.
The cohort included 449 patients, of whom 123 (27.4%) had delays in second doses. In-hospital death occurred in 31 patients (25.2%) in the delayed group and 71 (21.8%) in the non-delayed group (p = 0.44). On multivariate analysis, only location in a non-ED unit at the time second doses were due was associated with delays (OR 2.75, 95% CI 1.20–6.32). In the mortality model, significant risk factors included malignant tumor, respiratory infection, and elevated Sequential Organ Failure Assessment (SOFA) score but not delayed second antibiotic doses (OR 1.19, 95% CI 0.69–2.05). In a subgroup analysis, delayed second doses were associated with higher mortality in patients admitted to non-intensive care units (ICUs) (OR 4.10, 95% CI 1.32–12.79).
Over a quarter of patients with sepsis experienced delays in second doses of antibiotics. Delays in second antibiotic doses were not associated with higher mortality overall, but an association was observed among patients admitted to non-ICUs.
Interventions in environmental conservation are intended to make things better, not worse. Yet unintended and unanticipated consequences plague environmental conservation; key is how uncertainty plays out. Insights from the intellectual humility literature offer constructive strategies for coming to terms with uncertainty. Strategies such as self-distancing and self-assessment of causal complexity can be incorporated into conservation decision-making processes. Including reflection on what we know and do not know in the decision-making process potentially reduces unintended and unanticipated consequences of environmental conservation and management decisions. An important caution is not to have intellectual humility legitimate failing to act in the face of uncertainty.
Invasive species can have disastrous effects on the ecosystems they invade, requiring costly, labour-intensive mitigation. Public awareness campaigns are often used as a tool to reduce these species’ impacts. While heralded as useful and cost-effective, little evidence suggests that these campaigns contribute to meaningful biological outcomes. Furthermore, awareness campaigns are relatively understudied despite their usage as a common approach to mitigating invasive species. We conducted a literature review to assess publications that evaluated the efficacy of public awareness campaigns for managing invasive species. Out of 4382 papers initially extracted for analysis, we determined that 24 of them included studies conducted on awareness campaigns for invasive species. Four public awareness campaigns were deemed a ‘success’, and the other campaigns’ success was indeterminable due to study design. Our study revealed that inconsistencies in defined end points, unclear procedures and variability of campaigns contribute to there being insufficient evidence to determine the efficacy of public awareness campaigns. To evaluate the true efficacy of public awareness campaigns, we recommend that organizations conducting such campaigns implement rigorous and standardized assessments (e.g., Before–After Control–Impact designs or Bayesian analyses) that include measures of not just changes in the knowledge and behaviour of target audiences, but also relevant biological outcomes.
In conventional microfluidic devices, fluids are often confined behind solid plastic walls that restrict access and trap gas bubbles; in open microfluidics some solid walls are replaced by fluid ones (i.e. interfaces with immiscible fluids). In both cases, flows are usually driven by external pumps or gravity. An innovative open technology has been developed in which two-dimensional patterns of cell-culture medium in standard Petri dishes are confined by fluid walls made of an immiscible and bio-inert fluorocarbon (FC40). To provide refreshing media flows to cells in such circuits, an established pumping system that exploits differences in Laplace pressure across open interfaces has been applied to drive flow without using external pumps: a source drop autonomously empties through a straight conduit into the rest of the dish (the sink). Whereas conduits with solid walls have unchanging boundaries and flows within them are well understood, the challenge is to predict flows in circuits where fluid walls morph as pressures change. Numerical and semi-analytical equations enabling the prediction of changing flows are developed, and predictions validated experimentally.
Over the past 2 decades, several categorizations have been proposed for the abnormalities of the aortic root. These schemes have mostly been devoid of input from specialists of congenital cardiac disease. The aim of this review is to provide a classification, from the perspective of these specialists, based on an understanding of normal and abnormal morphogenesis and anatomy, with emphasis placed on the features of clinical and surgical relevance. We contend that the description of the congenitally malformed aortic root is simplified when approached in a fashion that recognizes the normal root to be made up of 3 leaflets, supported by their own sinuses, with the sinuses themselves separated by the interleaflet triangles. The malformed root, usually found in the setting of 3 sinuses, can also be found with 2 sinuses, and very rarely with 4 sinuses. This permits description of trisinuate, bisinuate, and quadrisinuate variants, respectively. This feature then provides the basis for classification of the anatomical and functional number of leaflets present. By offering standardized terms and definitions, we submit that our classification will be suitable for those working in all cardiac specialties, whether pediatric or adult. It is of equal value in the settings of acquired or congenital cardiac disease. Our recommendations will serve to amend and/or add to the existing International Paediatric and Congenital Cardiac Code, along with the Eleventh iteration of the International Classification of Diseases provided by the World Health Organization.
Background: Our aim was to develop a National Quality Indicators Set for the Care of Adults Hospitalized for Neurological Problems, to serve as a foundation to build regional or national quality initiatives in Canadian neurology centres. Methods: We used a national eDelphi process to develop a suite of quality indicators and a parallel process of surveys and patient focus groups to identify patient priorities. Canadian content and methodology experts were invited to participate. To be included, >70% of participants had to rate items as critical and <15% had to rate it as not important. Two rounds of surveys and consensus meetings were used identify and rank indicators, followed by national consultation with members of the Canadian Neurological Society. Results: 38 neurologists and methodologists and 56 patients/caregivers participated in this project. An initial list of 91 possible quality indicators was narrowed to 40 indicators across multiple categories of neurological conditions. 21 patient priorities were identified. Conclusions: This quality indicators suite can be used regionally or nationally to drive improvement initiatives for inpatient neurology care. In addition, we identified multiple opportunities for further research where evidence was lacking or patient and provider priorities did not align.
We investigated cardiovascular disease (CVD) risk associated with latent tuberculosis infection (LTBI) (Aim-1) and LTBI therapy (Aim-2) in British Columbia, a low-tuberculosis-incidence setting. 49,197 participants had valid LTBI test results. Cox proportional hazards model was fitted, adjusting for potential confounders. Compared with the participants who tested LTBI negative, LTBI positive was associated with an 8% higher CVD risk in complete case data (adjusted hazard ratio (HR): 1.08, 95% CI: 0.99-1.18), a statistically significant 11% higher risk when missing confounder values were imputed using multiple imputation (HR: 1.11, 95% CI: 1.02-1.20), and 10% higher risk when additional proxy variables supplementing known unmeasured confounders were incorporated in the highdimensional disease risk score technique to reduce residual confounding (HR: 1.10, 95% CI: 1.01-1.20). Also, compared with participants who tested negative, CVD risk was 27% higher among people who were LTBI positive but incomplete LTBI therapy (HR: 1.27, 95% CI: 1.04-1.55), whereas the risk was similar in people who completed LTBI therapy (HR: 1.04, 95% CI: 0.87-1.24). Findings were consistent in different sensitivity analyses. We concluded that LTBI is associated with an increased CVD risk in low-tuberculosis-incidence settings, with a higher risk associated with incomplete LTBI therapy and attenuated risk when therapy is completed.
This article uses three fictitious case vignettes to raise questions and educate on how clinicians can appropriately approach patients experiencing spiritually significant hallucinations. Religious hallucinations are common but are not pathognomonic of mental illness. They are often intimate experiences for the patient that raise complex questions about psychopathology for clinicians. When assessing a patient with religious hallucinations it is important that clinicians hold at the centre that person's personal experience and create a safe space in which they are listened to and epistemic injustices are avoided. Involvement of chaplaincy services is important not just to support the patient but also to ensure that as clinicians we seek support in understanding the religious nature of these experiences.
Since 2000, literature on West (EU15) and East-Central European (EU8) welfare states has focused on a set of ‘new social risks’ including insecure employment and income, population ageing, unsustainable social security systems, and large-scale international immigration. Our State-of-the-Art (SOTA) article brings Russia into the dialogue on ‘new social risks’. We show that broadly similar structural changes in industrial economies, labour markets and demographic patterns ended the post-World-War-Two (WWII) ‘Golden Age’ of welfare expansion in both the EU15 and communist states. Shared new social risks rose to the top of policy agendas. Governments responded mainly, though not exclusively, with liberalising, privatising and exclusionary policies. The SOTA compares their policy responses, specifically pension system reforms, demographic (pro-natalist and family) policies, and integration of immigrants. We find both convergence and divergence based on states’ differing welfare legacies. The conclusion considers path-departing ‘emergency Keynesian’ responses to the COVID-19 crisis, and renewed attention to Beveridge welfare models.
The effect of transport on core and peripheral body temperatures and heart rate was assessed in ten 18-month-old Coopworth ewes (Ovis aries) Manual recordings of core (rectal) temperatures were obtained, and automated logging of peripheral (external auditory canal and pinna) temperatures and heart rate was carried out on the day prior to (day 1) and during (day 2) a standardised transport procedure. Transport produced a significant increase in the rectal temperature, which declined following unloading. Peripheral measures of body temperature also exhibited changes with transport. However, both ear-canal and pinna temperatures declined during actual transport, reflecting to some extent the decline in ambient temperatures recorded externally by sensors on the ear tags of the animals. Peripheral measurement of temperature, particularly at the readily accessible ear canal, may offer potential as a technique for the long-term monitoring of thermal responses to stress. However, further research is required into the potentially confounding effects of ambient temperature and wind chill factors.
Two experiments were conducted to determine whether maximum eye temperature, measured using infrared thermography (IRT), could be a non-invasive technique for detecting responses of cattle to handling procedures. Experiment one used six crossbred heifers randomly assigned to two groups in a crossover design and subjected to i) being hit with a plastic tube on the rump and ii) being startled by the sudden waving of a plastic bag. Experiment two used 32 crossbred bulls randomly assigned to three treatments: i) control, restraint only; ii) electric prod, two brief applications of an electric prod or, iii) startled, as in experiment one, accompanied by shouting. Exit speed (m s−1) was recorded on release from the restraint. Maximum eye temperature was recorded continuously pre- and post-treatment. In experiment one, eye temperature dropped rapidly between 20 and 40 s following both treatments and returned to baseline between 60 and 80 s following hitting and between 100 and 120 s following startling. In experiment two, eye temperature dropped between 0 and 20 s, following both treatments, and returned to baseline by 180 s, following startling plus shouting, but did not return to baseline for five minutes following electric prod. Exit speed tended to be faster following the electric prod. In conclusion, IRT detected responses that were due possibly to fear and/or pain associated with the procedures and may therefore be a useful, non-invasive method for assessing aversiveness of handling practices to cattle.
We assessed patterns of enteric infections caused by 14 pathogens, in a longitudinal cohort study of sequelae in British Columbia (BC) Canada, 2005–2014. Our population cohort of 5.8 million individuals was followed for an average of 7.5 years/person; during this time, 40 523 individuals experienced 42 308 incident laboratory-confirmed, provincially reported enteric infections (96.4 incident infections per 100 000 person-years). Most individuals (38 882/40 523; 96%) had only one, but 4% had multiple concurrent infections or more than one infection across the study. Among individuals with more than one infection, the pathogens and combinations occurring most frequently per individual matched the pathogens occurring most frequently in the BC population. An additional 298 557 new fee-for-service physician visits and hospitalisations for enteric infections, that did not coincide with a reported enteric infection, also occurred, and some may be potentially unreported enteric infections. Our findings demonstrate that sequelae risk analyses should explore the possible impacts of multiple infections, and that estimating risk for individuals who may have had a potentially unreported enteric infection is warranted.
During the early 2000s governments in Russia, Poland and Hungary declared demographic crises and adopted pro-natalist programmes to increase fertility, as well as policies to support families with children. Our article compares their ‘flagship’ pro-natalist programmes: Russia’s Maternity Capital, Poland’s Family 500+, and Hungary’s enhanced earned income tax credit, all framed by governments’ neo-familialist discourses. We confirm these policies had limited impacts on fertility, finding that their most significant and disparate effects were instead on childhood poverty. Provision of preschool public childcare and parental leaves with levels of mothers’ employment across the cases were compared. We find no relationship between coverage of childcare institutions and employment rates of mothers with young children. Data show a weak relationship between length and compensation for parental leaves and maternal employment. We conclude that post-communist governments’ flagship pro-natalist incentives, family policies and traditionalist rhetoric have had limited effects in reversing demographic decline or in re-traditionalising contemporary women’s lives.
The identification of volatile pheromones attractive to and produced by many species within the family Cerambycidae (Coleoptera) has spurred development of synthetic pheromone lures that can be used to assess cerambycid populations and to monitor for invasive and rare species. We applied this method of trapping to examine cerambycid attraction to pheromone compounds and to initiate an analysis of the cerambycid communities within western Idaho, United States of America. A total of 8195 cerambycids, representing 67 species, 17 tribes, and 42 genera within six subfamilies of the Cerambycidae, were captured. Thirteen volatile pheromone lures were tested over three years, and a significant treatment effect was detected for nine cerambycid species. No significant differences were found among sites for species richness, diversity, or evenness. No significant differences were found among lures for species richness or diversity, but a significant difference was detected among lures for species evenness. We propose a method for designing a multicomponent lure, based on data from the target region, to maximise the number of species captured and to target specific cerambycid species within a targeted region.
Compare rates, clinical characteristics, and outcomes of paediatric palliative care consultation in children supported on extracorporeal membrane oxygenation admitted to a single-centre 16-bed cardiac or a 28-bed paediatric ICU.
Retrospective review of clinical characteristics and outcomes of children (aged 0–21 years) supported on extracorporeal membrane oxygenation between January, 2017 and December, 2019 compared by palliative care consultation.
Measurements and results:
One hundred children (N = 100) were supported with extracorporeal membrane oxygenation; 19% received a palliative care consult. Compared to non-consulted children, consulted children had higher disease severity measured by higher complex chronic conditions at the end of extracorporeal membrane oxygenation hospitalisation (5 versus. 3; p < 0.001), longer hospital length of stay (92 days versus 19 days; p < 0.001), and higher use of life-sustaining therapies after decannulation (79% versus 23%; p < 0.001). Consultations occurred mainly for longitudinal psychosocial-spiritual support after patient survived device deployment with a median of 27 days after cannulation. Most children died in the ICU after withdrawal of life-sustaining therapies regardless of consultation status. Over two-thirds of the 44 deaths (84%; n = 37) occurred during extracorporeal membrane oxygenation hospitalisation.
Palliative care consultation was rare showing that palliative care consultation was not viewed as an acute need and only considered when the clinical course became protracted. As a result, there are missed opportunities to involve palliative care earlier and more frequently in the care of extracorporeal membrane survivors and non-survivors and their families.
Forensic mental health services provide care to people in secure psychiatric hospitals and specialised community teams. Measuring outcomes is important to ensure such services perform optimally, however existing measures are not sufficiently comprehensive and are rarely patient reported.
To examine a novel instrument for measuring outcomes in forensic mental health services, the FORensic oUtsome Measure (FORUM), which consists of a complementary patient reported questionnaire (FORUM-P) and clinician reported questionnaire (FORUM-C).
Inpatients at a forensic psychiatric service based in a regional healthcare organization in the UK completed the FORUM-P, while members of their clinical teams completed the FORUM-C. Patients and clinicians also provided feedback on the questionnaires.
Sixty-two patients participated with a mean age of 41.0 years (standard deviation 11.3). For internal consistency, Cronbach’s alpha for the FORUM-P was 0.87 (95% confidence interval (CI) 0.80-0.93) and for the FORUM-C was 0.93 (95% CI 0.91-0.96). For test-retest reliability the weighted kappa for the FORUM-P was 0.44 (95% CI 0.24-0.63) and for the FORUM-C was 0.78 (95% CI 0.73-0.85). For interrater reliability of the FORUM-C the Spearman correlation coefficient was 0.47 (95% CI 0.18-0.69). The FORUM-P received an average rating of 4.0 out of 5 for comprehensiveness, 4.6 for ease of use and 3.9 for relevance, while the FORUM-C received 4.1 for comprehensiveness, 4.5 for ease of use and 4.3 for relevance.
Outcome measures in forensic mental health can be developed with good measures of reliability and validity, and can be introduced into services to monitor patient progress.
Tidewater glaciers are an important and difficult part of the cryosphere to study owing to their complex nature and often inaccessible and physically challenging environments. The interaction of glacier and fjord processes furthermore presents particular observational challenges. Modelling provides a possible solution to these issues, but, at the glacier scale, the processual complexities require a 3-D full-Stokes approach that is computationally expensive. Additionally, the lack of data for model validation or constraints imposes further obstacles. Despite this, progress on modelling such glaciers with explicit inclusion of all relevant processes is being made. The key remaining challenges are including more realistic representations of calving and coupling 3-D glacier modelling with 3-D fjord circulation modelling to allow inclusion of the effect of cross-fjord circulation. We are confident, however, that these issues can be resolved and will be resolved over the next decade.