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Recent infection testing algorithms (RITA) for HIV combine serological assays with epidemiological data to determine likely recent infections, indicators of ongoing transmission. In 2016, we integrated RITA into national HIV surveillance in Ireland to better inform HIV prevention interventions. We determined the avidity index (AI) of new HIV diagnoses and linked the results with data captured in the national infectious disease reporting system. RITA classified a diagnosis as recent based on an AI < 1.5, unless epidemiological criteria (CD4 count <200 cells/mm3; viral load <400 copies/ml; the presence of AIDS-defining illness; prior antiretroviral therapy use) indicated a potential false-recent result. Of 508 diagnoses in 2016, we linked 448 (88.1%) to an avidity test result. RITA classified 12.5% of diagnoses as recent, with the highest proportion (26.3%) amongst people who inject drugs. On multivariable logistic regression recent infection was more likely with a concurrent sexually transmitted infection (aOR 2.59; 95% CI 1.04–6.45). Data were incomplete for at least one RITA criterion in 48% of cases. The study demonstrated the feasibility of integrating RITA into routine surveillance and showed some ongoing HIV transmission. To improve the interpretation of RITA, further efforts are required to improve completeness of the required epidemiological data.
Patients with Parkinson’s disease psychosis (PDP) are often treated with an atypical antipsychotic, especially quetiapine or clozapine, but side effects, lack of sufficient efficacy, or both may motivate a switch to pimavanserin, the first medication approved for management of PDP. How best to implement a switch to pimavanserin has not been clear, as there are no controlled trials or case series in the literature to provide guidance. An abrupt switch may interrupt partially effective treatment or potentially trigger rebound effects from antipsychotic withdrawal, whereas cross-taper involves potential drug interactions. A panel of experts drew from published data, their experience treating PDP, lessons from switching antipsychotic drugs in other populations, and the pharmacology of the relevant drugs, to establish consensus recommendations. The panel concluded that patients with PDP can be safely and effectively switched from atypical antipsychotics used off label in PDP to the recently approved pimavanserin by considering each agent’s pharmacokinetics and pharmacodynamics, receptor interactions, and the clinical reason for switching (efficacy or adverse events). Final recommendations are that such a switch should aim to maintain adequate 5-HT2A antagonism during the switch, thus providing a stable transition so that efficacy is maintained. Specifically, the consensus recommendation is to add pimavanserin at the full recommended daily dose (34 mg) for 2–6 weeks in most patients before beginning to taper and discontinue quetiapine or clozapine over several days to weeks. Further details are provided for this recommendation, as well as for special clinical circumstances where switching may need to proceed more rapidly.
Caring for patients with personality disorder is one of the biggest challenges in psychiatric work. We investigated whether mentalisation-based treatment skills (MBT-S) teaching improves clinicians' understanding of mentalising and attitudes towards personality disorder. Self-report questionnaires (Knowledge and Application of MBT (KAMQ) and Attitudes to Personality Disorder (APDQ)) were completed at baseline and after a 2-day MBT-S workshop.
Ninety-two healthcare professionals completed questionnaires before and after training. The mean within-participant increase in scores from baseline to end-of-programme was 11.6 points (95% CI 10.0–13.3) for the KAMQ and 4.0 points (1.8–6.2) for the APDQ.
MBT-S is a short intervention that is effective in improving clinicians' knowledge of personality disorder and mentalisation. That attitudes to personality disorder improved overall is encouraging in relation to the possibility of deeper learning in staff and, ultimately, improved care for patients with personality disorder.
To summarize and discuss logistic and administrative challenges we encountered during the Benefits of Enhanced Terminal Room (BETR) Disinfection Study and lessons learned that are pertinent to future utilization of ultraviolet (UV) disinfection devices in other hospitals
Multicenter cluster randomized trial
SETTING AND PARTICIPANTS
Nine hospitals in the southeastern United States
All participating hospitals developed systems to implement 4 different strategies for terminal room disinfection. We measured compliance with disinfection strategy, barriers to implementation, and perceptions from nurse managers and environmental services (EVS) supervisors throughout the 28-month trial.
Implementation of enhanced terminal disinfection with UV disinfection devices provides unique challenges, including time pressures from bed control personnel, efficient room identification, negative perceptions from nurse managers, and discharge volume. In the course of the BETR Disinfection Study, we utilized several strategies to overcome these barriers: (1) establishing safety as the priority; (2) improving communication between EVS, bed control, and hospital administration; (3) ensuring availability of necessary resources; and (4) tracking and providing feedback on compliance. Using these strategies, we deployed ultraviolet (UV) disinfection devices in 16,220 (88%) of 18,411 eligible rooms during our trial (median per hospital, 89%; IQR, 86%–92%).
Implementation of enhanced terminal room disinfection strategies using UV devices requires recognition and mitigation of 2 key barriers: (1) timely and accurate identification of rooms that would benefit from enhanced terminal disinfection and (2) overcoming time constraints to allow EVS cleaning staff sufficient time to properly employ enhanced terminal disinfection methods.
Mindfulness-based cognitive therapy (MBCT) is a group-based intervention similar to mindfulness-based stress reduction, but which includes cognitive therapy techniques. This study investigates its usefulness in the treatment of depressive, anxiety and stress/distress symptoms in cancer patients referred to a psycho-oncology service. It also examines whether effect on depression is mediated by self-compassion.
In phase 1 of this study, 16 cancer patients with mild/moderate psychological distress were randomised to MBCT (n=8) or treatment as usual (TAU; n=8), and assessed pre- and post-treatment. Analysis of variance was performed to examine the effect of treatment on anxiety and depression. In phase 2, the TAU group received the intervention, and results of pre- and post-MBCT assessments were combined with those receiving MBCT in phase 1. Finally, both groups were followed up at 3 months.
In phase 1, the MBCT group had a significant improvement in mindfulness and a decrease in anxiety. Statistically significant improvements in both depression and anxiety were found at 3 month follow-up. Self-compassion appeared to mediate the effect on anxiety/depression.
This small pilot study suggests that MBCT may have a beneficial effect on psychological variables often adversely affected in cancer in a heterogeneous cancer population.
Depression is a common and important cause of morbidity and mortality worldwide. It is commonly treated with antidepressants and/or psychological therapy, but some people prefer alternative approaches such as exercise. There are a number of theoretical reasons why exercise may improve depression. This is an update of a review first published in 2009.
Tuberculosis and mental illness share common risk factors including homelessness, HIV positive serology, alcohol/ substance abuse and migrant status leading to frequent co-morbidity. We sought to generate a comprehensive literature review that examines the complex relationship between tuberculosis and mental illness.
A literature search was conducted in MedLine, Ovid and Psychinfo, with further examination of the references of these articles. 316 articles were identified. It was not possible to conduct a formal meta-analysis due to the absence of randomised controlled data.
Rates of mental illness of up to 70% have been identified in tuberculosis patients. Medications used in the treatment of common mental illnesses may have significant interactions with anti-tuberculosis agents, especially isoniazid and increasingly linezolid. Many medications used in the treatment of tuberculosis can have significant adverse psychiatric effects; others such as rifampicin may reduce the effective doses of anti-psychotics by their enzyme-inducing actions. Mental illness and substance abuse may also affect treatment concordance, with consequences for public health.
Due to the common co-morbidity of mental illness and tuberculosis, it is important that both psychiatrists and physicians are aware of the potential for interactions between the drugs used to treat tuberculosis and psychiatric conditions.
Wireless communications such as those in cell phones are utilizing increasing chip design complexity. For example analog mixed-signal chips can contain RF capability which requires integrated inductors [1,2]. High performance RF designs are enabled by the use of thick Copper (Cu) and Aluminum (Al) wires (>3um). In particular, the quality factor of the inductor, which is the ratio of magnetic stored energy over average dissipation, is dependent on the metal thickness. High quality factors, can be achieved by using thick Cu inductors. In some applications, the total thickness of Cu in the inductor can be as much as 12 um.
The fabrication of thick Cu layers is in many ways easier than that of thin Cu layers. For example, there are no limitations in terms of lithography or liner and seed layer thickness. However, there are still challenges with fabrication due to stress. Cracking of the dielectric can occur, due to the mismatch in coefficient of thermal expansion between Cu and SiO2, and due to the thick Cu layers in the inductor stack. Both the layout and the processing must be optimized to ensure that cracking does not occur.
This paper will discuss current applications, inductor design, and the reliability challenges and solutions associated with thick Cu interconnects.
Assess current monitoring standards of vital signs, agents in rapid tranquilization, and adverse events related to poor monitoring.
Retrospective audit. 136 Physical restraints reviewed. 92 case notes examined. Gold standard: All physical restraints requiring rapid tranquilization had immediate and regular monitoring every 5 – 10 minutes for the first hour then every 30 minutes for next two hours. in repeat rapid tranquilization, same monitoring standards were examined. Adverse effects or clinical incidents were recorded along with agents used in rapid tranquilization.
Of 92 physical restraints, 62 required rapid tranquilization. of 62 rapid tranquilizations, 12 were repeat rapid tranquilizations. No rapid tranquilizations had adequate monitoring. Adverse events seen in 19% of cases, of these 40% were seen in repeat rapid tranquilization events. the most commonly used agents were a combination of benzodiazepine + antipsychotic (52%). Single agent use was associated with a higher risk of repeat physical restraint and rapid tranquilization (32%) versus combination of agents (18%).
Adequate monitoring of vital signs could have prevented many of the adverse events seen in this audit. Evidence suggests training of staff in both monitoring of patient and the use of de-escalation techniques can sometimes prevent the need for rapid tranquilisation or if required, ensure that it is done so in a safe manner. Recommendations included the proposal of a document for vital sign monitoring along with guidance on managing common adverse events. Training for all staff members,in use of de-escalation techniques, monitoring equipment, resuscitation skills and equipment training.
Inflammatory bowel disease (IBD) is a collective term for conditions characterised by chronic inflammation of the gastrointestinal tract involving an inappropriate immune response to commensal micro-organisms in a genetically susceptible host. Previously, aqueous and ethyl acetate extracts of gold kiwifruit (Actinidia chinensis) or green kiwifruit (A. deliciosa) have demonstrated anti-inflammatory activity using in vitro models of IBD. The present study examined whether these kiwifruit extracts (KFE) had immune-modulating effects in vivo against inflammatory processes that are known to be increased in patients with IBD. KFE were used as a dietary intervention in IL-10-gene-deficient (Il10− / −) mice (an in vivo model of IBD) and the C57BL/6J background strain in a 3 × 2 factorial design. While all Il10− / − mice developed significant colonic inflammation compared with C57BL/6J mice, this was not affected by the inclusion of KFE in the diet. These findings are in direct contrast to our previous study where KFE reduced inflammatory signalling in primary cells isolated from Il10− / − and C57BL/6J mice. Whole-genome gene and protein expression level profiling indicated that KFE influenced immune signalling pathways and metabolic processes within the colonic tissue; however, the effects were subtle. In particular, expression levels across gene sets related to adaptive immune pathways were significantly reduced using three of the four KFE in C57BL/6J mice. The present study highlights the importance of investigating food components identified by cell-based assays with appropriate in vivo models before making dietary recommendations, as a food that looks promising in vitro may not be effective in vivo.
Isolates of adenovirus types 1 and 2, obtained from 11 infants with prolonged faecal excretion (up to 515 days), were compared by DNA restriction analysis with seven standard endonucleases which recognize hexanucleotides and two additional endonucleases which recognize tetranucleotides. In all instances identical genome types were identified in isolates obtained early and late after infection. Our interpretation of these data is that a chronic persistent infection occurred in these children. and not a reinfection with the same serotype.
The exits which passengers select in evacuation situations and the exits which are available post-crash is of great interest to aviation safety regulators who make rulings defining exit separation and aircraft evacuation certification, aircraft designers who develop the interior layout of aircraft cabins and position exits within the fuselage, cabin safety specialists who develop procedures for managing aircraft evacuation and cabin crew who must control aircraft evacuations. In this paper we examine issues associated with passenger exit selection behaviour and exit configurations frequently experienced during survivable crashes. This work makes use of the latest version of the Aircraft Accident Statistics and Knowledge database AASK V4.0, which contains information from 105 survivable crashes and over 2,000 survivors.
abstract A mass balance model was developed to examine the transport, fate, and bioaccumulation of Polychlorinated Biphenyls (PCBs) in the Lower Hudson River. The model was applied to five (di- through hexa-) PCB homologues over a fifteen-year simulation period (1987–2002) and results compared well to observed PCB homologue concentrations in river sediments and fish. From model evaluations, we found that partitioning of PCBs to suspended solids appears to be largely controlled by phytoplankton. Phytoplankton production and subsequent decomposition of phytoplankton-derived material in sediments plays a particularly important role in scavenging PCBs from the water column and accumulating them in sediments. In addition, there is a continuous exchange of PCBs between the overlying water and surface sediments associated with settling of phytoplankton and other suspended organic matter, resuspension of sedimentary organic matter, and pore water diffusion of dissolved and dissolved organic carbon (DOC)-bound contaminant. These processes, along with the large capacity of sediments to store contaminants, work to sequester PCBs in sediments during periods of high contaminant loads and subsequently release them to the overlying water. This results in highly dampened responses of PCBs in water, sediments and fish in the mid estuary, and in “smearing” the effects of increased PCB loads from the Upper Hudson in the early 1990s. Model results clearly demonstrate that both the magnitude and distribution of PCBs in sediments and fish are strongly dependent on homologue-specific partitioning behavior (as expressed in terms of hydrophobicity and Kow values). Finally, the migration of striped bass also plays a critical role in limiting their exposure to PCBs in the mid estuary.
Nutrigenomics is the study of how constituents of the diet interact with genes, and their products, to alter phenotype and, conversely, how genes and their products metabolise these constituents into nutrients, antinutrients, and bioactive compounds. Results from molecular and genetic epidemiological studies indicate that dietary unbalance can alter gene–nutrient interactions in ways that increase the risk of developing chronic disease. The interplay of human genetic variation and environmental factors will make identifying causative genes and nutrients a formidable, but not intractable, challenge. We provide specific recommendations for how to best meet this challenge and discuss the need for new methodologies and the use of comprehensive analyses of nutrient–genotype interactions involving large and diverse populations. The objective of the present paper is to stimulate discourse and collaboration among nutrigenomic researchers and stakeholders, a process that will lead to an increase in global health and wellness by reducing health disparities in developed and developing countries.
We investigate the pricing of 4,989 equity IPOs with offer dates between 1981 and 2000. Approximately three-fourths of these IPOs have integer offer prices. Average initial returns for IPOs with integer offer prices are significantly higher (24.5%) than those priced on the fraction of the dollar (8.1%). This result is robust through time and after conditioning for other effects known to influence initial returns. We hypothesize that integer vs. fractional dollar IPOs are the result of negotiations between the issuing firm and underwriter. Under this negotiation hypothesis, the frequency of integer pricing should be an increasing function of the offer price and the degree of uncertainty surrounding the value of the firm. Empirical evidence, supportive of the negotiation hypothesis, is presented.
Background and objective: Transurethral prostatectomy is routinely performed under spinal anaesthesia. This technique can cause hypotension, which is particularly undesirable in the elderly. The objective was to compare spinal anaesthesia for transurethral prostatectomy using hyperbaric bupivacaine 15 mg (control group) and hyperbaric bupivacaine 10 mg (limiting spread by maintaining the upright position for 15 min) and fentanyl 25 μg (fentanyl group) in terms of haemodynamic and pulmonary function.
Methods: Thirty ASA I–III patients were randomly selected and underwent spinal anaesthesia with either hyperbaric bupivacaine 15 mg (immediately positioned supine) or hyperbaric bupivacaine 10 mg (upright for 15 min) and fentanyl 25 μg.
Results: The greatest changes in mean arterial pressure (P = 0.9), ephedrine requirements (P = 0.8) and mean maximum change in forced vital capacity (P = 0.5) were similar in both groups.
Conclusions: The addition of fentanyl 25 μg to bupivacaine 10 mg and limiting the spread of the block does not improve either haemodynamic or pulmonary function compared with bupivacaine 15 mg in patients undergoing transurethral prostatectomy.
The Aircraft Accident Statistics and Knowledge (AASK) database is a repository of survivor accounts from aviation accidents. Its main purpose is to store observational and anecdotal data from the actual interviews of the occupants involved in aircraft accidents. The database has wide application to aviation safety analysis, being a source of factual data regarding the evacuation process. It is also key to the development of aircraft evacuation models such as airEXODUS, where insight into how people actually behave during evacuation from survivable aircraft crashes is required. This paper describes recent developments with the database leading to the development of AASK v3.0. These include significantly increasing the number of passenger accounts in the database, the introduction of cabin crew accounts, the introduction of fatality information, improved functionality through the seat plan viewer utility and improved ease of access to the database via the internet. In addition, the paper demonstrates the use of the database by investigating a number of important issues associated with aircraft evacuation. These include issues associated with social bonding and evacuation, the relationship between the number of crew and evacuation efficiency, frequency of exit/slide failures in accidents and exploring possible relationships between seating location and chances of survival. Finally, the passenger behavioural trends described in analysis undertaken with the earlier database are confirmed with the wider data set.