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Individuals with acquired brain injury (ABI) may experience persistent and distressing challenging behaviours (CB), and therefore, effective delivery of behaviour interventions is crucial. This study aimed to investigate community ABI therapists’ experiences of using, training in and implementing behaviour interventions with a focus on Positive Behaviour Support (PBS).
A sample of Australian community ABI therapists (n = 136) completed an online survey about their experiences with behaviour interventions, including PBS. Data from open-ended questions were analysed using content analysis. Frequency and descriptive statistics were computed, and a multiple regression was performed to determine factors predicting readiness to learn and implement new behaviour interventions. Rank-based non-parametric tests were conducted to investigate the influence of clinical role on experiences with behaviour interventions and training preferences.
Consistent with PBS, participants indicated that the following were important in addressing CB: teamwork and collaboration, person-centred practice, working with antecedents, environmental modification, improving quality of life and skill-building. Despite a high level of desire and readiness, 80% of participants reported facing barriers to learning and implementing new behaviour interventions (e.g., lack of time). Participants’ confidence in using behaviour interventions (β = 0.31; p = 0.002) and the number of barriers faced (β = −0.30; p = 0.002) predicted their readiness to learn and implement new behaviour interventions. Confidence, duration of past training in behaviour interventions and preferred duration of future training did not differ based on clinical role.
Implications for the development of training in behaviour interventions such as PBS and implementation into community practice are discussed.
Introduction: There is currently no protocol for the initiation of extra corporeal cardiopulmonary resuscitation (ECPR) in out of hospital cardiac arrest (OHCA) in Atlantic Canada. Advanced care paramedics (ACPs) perform advanced cardiac life support in the prehospital setting often completing the entire resuscitation on-scene. Implementation of ECPR will present a novel intervention that is only available at the receiving hospital, altering how ACPs manage selected patients. Our objective is to determine if an educational program can improve paramedic identification of ECPR candidates. Methods: An educational program was delivered to paramedics including a short seminar and pocket card coupled with simulations of OHCA cases. A before and after study design using a case-based survey was employed. Paramedics were scored on their ability to correctly identify OHCA patients who met the inclusion criteria for our ECPR protocol. Scores before and after the education delivery were compared using a two tailed t-test. A 6-month follow-up is planned to assess knowledge retention. Qualitative data was also collected from paramedics during simulation to help identify potential barriers to implementation of our protocol in the prehospital setting. Results: Nine advanced care paramedics participated in our educational program. Mean score pre-education was 9.7/16 (61.1%) compared to 14/16 (87.5%) after education delivery. The mean difference between groups was 4.22 (CI = 2.65-5.80, p = 0.0003). There was a significant improvement in the paramedics’ ability to correctly identify ECPR candidates after completing our educational program. Conclusion: Paramedic training through a didactic session coupled with a pocket card and simulation appears to be a feasible method of knowledge translation. 6-month retention data will help ensure knowledge retention is achieved. If successful, this pilot will be expanded to train all paramedics in our prehospital system as we seek to implement an ECPR protocol at our centre.
Preventing suicide and self-harm is a global health priority. Although there is a growing evidence base for the effectiveness of psychoanalytic and psychodynamic psychotherapies for a range of disorders, to date there has been no systematic review of its effectiveness in reducing suicidal and self-harming behaviours.
To systematically review randomised controlled trials of psychoanalytic and psychodynamic psychotherapies for suicidal attempts and self-harm.
We searched PubMed, PsycINFO, Psycharticles, CINAHL, EMBASE and the Cochrane Central Register of Controlled Trials for randomise controlled trials of psychoanalytic and psychodynamic psychotherapies for reducing suicide attempts and self-harm.
Twelve trials (17 articles) were included in the meta-analyses. Psychoanalytic and psychodynamic therapies were effective in reducing the number of patients attempting suicide (pooled odds ratio, 0.469; 95% CI 0.274–0.804). We found some evidence for significantly reduced repetition of self-harm at 6-month but not 12-month follow-up. Significant treatment effects were also found for improvements in psychosocial functioning and reduction in number of hospital admissions.
Psychoanalytic and psychodynamic psychotherapies are indicated to be effective in reducing suicidal behaviour and to have short-term effectiveness in reducing self-harm. They can also be beneficial in improving psychosocial well-being. However, the small number of trials and moderate quality of the evidence means further high-quality trials are needed to confirm our findings and to identity which specific components of the psychotherapies are effective.
The Infectious Disease Society of America (IDSA) publishes guidelines regularly for the management of skin and soft tissue infections; however, the extent to which practice patterns follow these guidelines and if this can affect treatment failure rates is unknown. We observed the treatment failure rates from a multicentre retrospective ambulatory cohort of adult emergency department patients treated for a non-purulent skin infection. We used multivariable logistic regression to examine the role of IDSA classification and whether adherence to IDSA guidelines reduced treatment failure. A total of 759 ambulatory patients were included in the cohort with 17.4% failing treatment. Among all patients, 56.0% had received treatments matched to the IDSA guidelines with 29.1% over-treated, and 14.9% under-treated based on the guidelines. After adjustment for age, gender, infection location and medical comorbidities, patients with a moderate infection type had three times increased risk of treatment failure (adjusted risk ratio (aRR) 2.98; 95% confidence interval (CI) 1.15–7.74) and two times increased risk with a severe infection type (aRR 2.27; 95% CI 1.25–4.13) compared with mild infection types. Patients who were under-treated based on IDSA guidelines were over two times more likely to fail treatment (aRR 2.65; 95% CI 1.16–6.05) while over-treatment was not associated with treatment failure. Patients ⩾70 years of age had a 56% increased risk of treatment failure (aRR 1.56; 95% CI 1.04–2.33) compared with those <70 years. Following the IDSA guidelines for non-purulent SSTIs may reduce the treatment failure rates; however, older adults still carry an increased risk of treatment failure.
To test the hypothesis that long-term care facility (LTCF) residents with Clostridium difficile infection (CDI) or asymptomatic carriage of toxigenic strains are an important source of transmission in the LTCF and in the hospital during acute-care admissions.
A 6-month cohort study with identification of transmission events was conducted based on tracking of patient movement combined with restriction endonuclease analysis (REA) and whole-genome sequencing (WGS).
Veterans Affairs hospital and affiliated LTCF.
The study included 29 LTCF residents identified as asymptomatic carriers of toxigenic C. difficile based on every other week perirectal screening and 37 healthcare facility-associated CDI cases (ie, diagnosis >3 days after admission or within 4 weeks of discharge to the community), including 26 hospital-associated and 11 LTCF-associated cases.
Of the 37 CDI cases, 7 (18·9%) were linked to LTCF residents with LTCF-associated CDI or asymptomatic carriage, including 3 of 26 hospital-associated CDI cases (11·5%) and 4 of 11 LTCF-associated cases (36·4%). Of the 7 transmissions linked to LTCF residents, 5 (71·4%) were linked to asymptomatic carriers versus 2 (28·6%) to CDI cases, and all involved transmission of epidemic BI/NAP1/027 strains. No incident hospital-associated CDI cases were linked to other hospital-associated CDI cases.
Our findings suggest that LTCF residents with asymptomatic carriage of C. difficile or CDI contribute to transmission both in the LTCF and in the affiliated hospital during acute-care admissions. Greater emphasis on infection control measures and antimicrobial stewardship in LTCFs is needed, and these efforts should focus on LTCF residents during hospital admissions.
Introduction: Ultrasonography (US), performed in the Emergency Department (ED) by Emergency Physicians, is well established. Educational studies have shown some promise in training paramedics in US use. We have developed and piloted a novel curriculum for paramedic US education. Methods: Based on an informal needs assessment, an US curriculum for paramedics was developed to include: Basic principles, Focused assessment with sonography for trauma (FAST), cardiac, and vascular access. Participants included ED-based and pre-hospital paramedics including all paramedics with critical care training who routinely perform vascular access and procedural sedation within our ED. Comparisons were made using paired non-parametric tests (GraphPad). Results: Participants (N=9) were provided pre- reading materials prior to completing a 6-hour course, consisting of a mix of didactic and practical sessions with live models and vascular access phantoms. Each module was introduced with a 30 minute didactic session, led by an Emergency Physician trained in US, followed immediately by a 1 hour hands-on session lead by either an Emergency Physician or an Emergency Medicine Resident at a learner to instructor ratio of 3:1. At the end of the course, participants were asked to complete a short 10 minute survey that included (1) an assessment of the course quality with regard to preparatory material and course content/delivery (4 point Likert scale; excellent, good, fair, poor); (2) self reported US knowledge pre and post course on a scale of 1-10 (10 high, 1 low); (3) general yes/no questions related to the future of ECCU paramedical and (4) a subjective written section for additional comments. All participants rated the content favourably: 97% scoring it as excellent, and 3% as good. The participants median self-reported US knowledge score increased from 2/10 (IQR 2-3) to 8/10 (IQR 7.25-8; p=0.009) post- course. All comments from the text field were positive in nature. Conclusion: We report a paramedic US course curriculum, which when piloted resulted in high learner satisfaction and a high rate of self reported improvement in US knowledge. Further study will include an assessment of knowledge acquisition and practical performance. Future modifications in our curriculum will be based on needs assessment and may include additional modules.
Recent droughts in Puerto Rico and throughout the Caribbean have emphasized the region's agricultural vulnerability to this hazard and the increasing need for adaptation mechanisms to support sustainable production. In this study, we assessed the geographic extent of agricultural conservation practices incentivized by US Department of Agriculture Natural Resources Conservation Service (NRCS) and evaluated their large-scale contribution to drought adaptability. We identified concentrations of drought-related practices (e.g. cover crops, ponds) applied between 2000 and 2016. Using information from spatial databases and interviews with experts, we assessed the spatial correlation between these practices and areas exposed to drought as identified by the US Drought Monitor. Between 2000 and 2016, Puerto Rico experienced seven drought episodes concentrated around the south, east and southeastern regions. The most profound drought occurred between 2014 and 2016 when the island experienced 80 consecutive weeks of moderate drought, 48 of severe drought and 33 of extreme drought conditions. A total of 44 drought-related conservation practices were applied at 6984 locations throughout 860 km2 of farmlands between 2000 and 2016 through the NRCS-Environmental Quality Incentives Program (EQIP). Practices related to water availability were statistically clustered along the coasts, whereas soil and plant health practices were clustered in the mountainous region. While these concentrations strongly correlated with areas exposed to moderate drought conditions, >80% did not coincide with areas that experienced severe or extreme drought conditions, suggesting that areas highly exposed to drought conditions generally lacked drought preparedness assisted by EQIP. Climate projections indicate an increase in the frequency and intensity of drought events, particularly in the eastern region of Puerto Rico. Our analysis highlighted the need to implement more conservation practices in these areas subject to drought intensification and exposure. Government programs intended to address vulnerabilities and enhance capacity and resilience may not be reaching areas of highest exposure. Recommendations include raising producer awareness of past and future exposure and making programs more accessible to a broader audience.
The four main findings about the age and abundance structure of the Milky Way bulge based on microlensed dwarf and subgiant stars are: (1) a wide metallicity distribution with distinct peaks at [Fe/H] = -1.09, -0.63, -0.20, +0.12, +0.41; (2) a high fraction of intermediate-age to young stars where at [Fe/H] > 0 more than 35 % are younger than 8 Gyr, (3) several episodes of significant star formation in the bulge 3, 6, 8, and 11 Gyr ago; (4) the ‘knee’ in the α-element abundance trends of the sub-solar metallicity bulge appears to be located at a slightly higher [Fe/H] (about 0.05 to 0.1 dex) than in the local thick disk.
To investigate an outbreak of Pseudomonas aeruginosa infections and colonization in a neonatal intensive care unit.
Infection control assessment, environmental evaluation, and case-control study.
Newly built community-based hospital, 28-bed neonatal intensive care unit.
Neonatal intensive care unit patients receiving care between June 1, 2013, and September 30, 2014.
Case finding was performed through microbiology record review. Infection control observations, interviews, and environmental assessment were performed. A matched case-control study was conducted to identify risk factors for P. aeruginosa infection. Patient and environmental isolates were collected for pulsed-field gel electrophoresis to determine strain relatedness.
In total, 31 cases were identified. Case clusters were temporally associated with absence of point-of-use filters on faucets in patient rooms. After adjusting for gestational age, case patients were more likely to have been in a room without a point-of-use filter (odds ratio [OR], 37.55; 95% confidence interval [CI], 7.16–∞). Case patients had higher odds of exposure to peripherally inserted central catheters (OR, 7.20; 95% CI, 1.75–37.30) and invasive ventilation (OR, 5.79; 95% CI, 1.39–30.62). Of 42 environmental samples, 28 (67%) grew P. aeruginosa. Isolates from the 2 most recent case patients were indistinguishable by pulsed-field gel electrophoresis from water-related samples obtained from these case-patient rooms.
This outbreak was attributed to contaminated water. Interruption of the outbreak with point-of-use filters provided a short-term solution; however, eradication of P. aeruginosa in water and fixtures was necessary to protect patients. This outbreak highlights the importance of understanding the risks of stagnant water in healthcare facilities.
Whole apples have not been previously implicated in outbreaks of foodborne bacterial illness. We investigated a nationwide listeriosis outbreak associated with caramel apples. We defined an outbreak-associated case as an infection with one or both of two outbreak strains of Listeria monocytogenes highly related by whole-genome multilocus sequence typing (wgMLST) from 1 October 2014 to 1 February 2015. Single-interviewer open-ended interviews identified the source. Outbreak-associated cases were compared with non-outbreak-associated cases and traceback and environmental investigations were performed. We identified 35 outbreak-associated cases in 12 states; 34 (97%) were hospitalized and seven (20%) died. Outbreak-associated ill persons were more likely to have eaten commercially produced, prepackaged caramel apples (odds ratio 326·7, 95% confidence interval 32·2–3314). Environmental samples from the grower's packing facility and distribution-chain whole apples yielded isolates highly related to outbreak isolates by wgMLST. This outbreak highlights the importance of minimizing produce contamination with L. monocytogenes. Investigators should perform single-interviewer open-ended interviews when a food is not readily identified.
Although most non-typhoidal Salmonella illnesses are self-limiting, antimicrobial treatment is critical for invasive infections. To describe resistance in Salmonella that caused foodborne outbreaks in the United States, we linked outbreaks submitted to the Foodborne Disease Outbreak Surveillance System to isolate susceptibility data in the National Antimicrobial Resistance Monitoring System. Resistant outbreaks were defined as those linked to one or more isolates with resistance to at least one antimicrobial drug. Multidrug resistant (MDR) outbreaks had at least one isolate resistant to three or more antimicrobial classes. Twenty-one per cent (37/176) of linked outbreaks were resistant. In outbreaks attributed to a single food group, 73% (16/22) of resistant outbreaks and 46% (31/68) of non-resistant outbreaks were attributed to foods from land animals (P < 0·05). MDR Salmonella with clinically important resistance caused 29% (14/48) of outbreaks from land animals and 8% (3/40) of outbreaks from plant products (P < 0·01). In our study, resistant Salmonella infections were more common in outbreaks attributed to foods from land animals than outbreaks from foods from plants or aquatic animals. Antimicrobial susceptibility data on isolates from foodborne Salmonella outbreaks can help determine which foods are associated with resistant infections.
Although contamination of food can occur at any point from farm to table, restaurant food workers are a common source of foodborne illness. We describe the characteristics of restaurant-associated foodborne disease outbreaks and explore the role of food workers by analysing outbreaks associated with restaurants from 1998 to 2013 reported to the Centers for Disease Control and Prevention's Foodborne Disease Outbreak Surveillance System. We identified 9788 restaurant-associated outbreaks. The median annual number of outbreaks was 620 (interquartile range 618–629). In 3072 outbreaks with a single confirmed aetiology reported, norovirus caused the largest number of outbreaks (1425, 46%). Of outbreaks with a single food reported and a confirmed aetiology, fish (254 outbreaks, 34%) was most commonly implicated, and these outbreaks were commonly caused by scombroid toxin (219 outbreaks, 86% of fish outbreaks). Most outbreaks (79%) occurred at sit-down establishments. The most commonly reported contributing factors were those related to food handling and preparation practices in the restaurant (2955 outbreaks, 61%). Food workers contributed to 2415 (25%) outbreaks. Knowledge of the foods, aetiologies, and contributing factors that result in foodborne disease restaurant outbreaks can help guide efforts to prevent foodborne illness.
Toxigenic strains of Vibrio cholerae serogroups O1 and O139 have caused cholera epidemics, but other serogroups – such as O75 or O141 – can also produce cholera toxin and cause severe watery diarrhoea similar to cholera. We describe 31 years of surveillance for toxigenic non-O1, non-O139 infections in the United States and map these infections to the state where the exposure probably originated. While serogroups O75 and O141 are closely related pathogens, they differ in how and where they infect people. Oysters were the main vehicle for O75 infection. The vehicles for O141 infection include oysters, clams, and freshwater in lakes and rivers. The patients infected with serogroup O75 who had food traceback information available ate raw oysters from Florida. Patients infected with O141 ate oysters from Florida and clams from New Jersey, and those who only reported being exposed to freshwater were exposed in Arizona, Michigan, Missouri, and Texas. Improving the safety of oysters, specifically, should help prevent future illnesses from these toxigenic strains and similar pathogenic Vibrio species. Post-harvest processing of raw oysters, such as individual quick freezing, heat-cool pasteurization, and high hydrostatic pressurization, should be considered.
Psychiatric disorders commonly emerge during the first year following traumatic brain injury (TBI). However, it is not clear whether these disorders soon remit or persist for long periods post-injury. This study aimed to examine, prospectively: (1) the frequency, (2) patterns of co-morbidity, (3) trajectory, and (4) risk factors for psychiatric disorders during the first 5 years following TBI.
Participants were 161 individuals (78.3% male) with moderate (31.2%) or severe (68.8%) TBI. Psychiatric disorders were diagnosed using the Structured Clinical Interview for DSM-IV, administered soon after injury and 3, 6 and 12 months, and 2, 3, 4 and 5 years post-injury. Disorder frequencies and generalized estimating equations were used to identify temporal relationships and risk factors.
In the first 5 years post-injury, 75.2% received a psychiatric diagnosis, commonly emerging within the first year (77.7%). Anxiety, mood and substance-use disorders were the most common diagnostic classes, often presenting co-morbidly. Many (56.5%) experienced a novel diagnostic class not present prior to injury. Disorder frequency ranged between 61.8 and 35.6% over time, decreasing by 27% [odds ratio (OR) 0.73, 95% confidence interval (CI) 0.65–0.83] with each year post-injury. Anxiety disorders declined significantly over time (OR 0.73, 95% CI 0.63–0.84), whilst mood and substance-use disorder rates remained stable. The strongest predictors of post-injury disorder were pre-injury disorder (OR 2.44, 95% CI 1.41–4.25) and accident-related limb injury (OR 1.78, 95% CI 1.03–3.07).
Findings suggest the first year post-injury is a critical period for the emergence of psychiatric disorders. Disorder frequency declines thereafter, with anxiety disorders showing greater resolution than mood and substance-use disorders.
We assessed the impact of a reflex urine culture protocol, an intervention aimed to reduce unnecessary urine culturing, in intensive care units at a tertiary care hospital. Significant decreases in urine culturing rates and reported rates of catheter-associated urinary tract infection followed implementation of the protocol.
We present a catalogue containing the redshifts of 3 660 X-ray selected targets in the XXL southern field. The redshifts were obtained with the AAOmega spectrograph and 2dF fibre positioner on the Anglo-Australian Telescope. The catalogue contains 1 515 broad line AGN, 528 stars, and redshifts for 41 out of the 49 brightest X-ray selected clusters in the XXL southern field.
Giardia intestinalis is the leading parasitic aetiology of human enteric infections in the United States, with an estimated 1·2 million cases occurring annually. To better understand transmission, we analysed data on all giardiasis outbreaks reported to the Centers for Disease Control and Prevention for 1971–2011. The 242 outbreaks, affecting ~41 000 persons, resulted from waterborne (74·8%), foodborne (15·7%), person-to-person (2·5%), and animal contact (1·2%) transmission. Most (74·6%) waterborne outbreaks were associated with drinking water, followed by recreational water (18·2%). Problems with water treatment, untreated groundwater, and distribution systems were identified most often during drinking water-associated outbreak investigations; problems with water treatment declined after the 1980s. Most recreational water-associated outbreaks were linked to treated swimming venues, with pools and wading pools implicated most often. Produce was implicated most often in foodborne outbreaks. Additionally, foods were most commonly prepared in a restaurant and contaminated by a food handler. Lessons learned from examining patterns in outbreaks over time can help prevent future disease. Groundwater and distribution system vulnerabilities, inadequate pool disinfection, fruit and vegetable contamination, and poor food handler hygiene are promising targets for giardiasis prevention measures.
To investigate natural enemies of emerald ash borer (EAB), Agrilus planipennis Fairmaire (Coleoptera: Buprestidae), in northeastern China, we conducted field surveys of ash (Fraxinus Linnaeus (Oleaceae)) trees in semi-natural forests and plantations at variable EAB densities from 2008 to 2013. Our surveys revealed a complex of natural enemies including eight hymenopteran parasitoids and two apparently parasitic Coleoptera, woodpeckers, and several undetermined mortality factors. Parasitoid complex abundance and its contribution to EAB mortality varied with the time of year, type of ash stands, and geographic regions. The egg parasitoid Oobius agrili Zhang and Huang (Hymenoptera: Encyrtidae) and the larval parasitoid Tetrastichus planipennisi Yang (Hymenoptera: Eulophidae) were frequently observed in Jilin, Liaoning, and Heilongjiang provinces and in Beijing, but not in Tianjin. Spathius agrili Yang (Hymenoptera: Braconidae), however, was more prevalent near Beijing and further south in Tianjin. Larvae of two species of apparently parasitic beetle, Tenerus Laporte (Coleoptera: Cleridae) species and Xenoglena quadrisignata Mannerheim (Coleoptera: Trogossitidae), were also recovered attacking overwintering EAB in Liaoning Province, with Tenerus species being a dominant mortality agent (~13%). Our findings support the need to consider the geographic origin of insect natural enemies for EAB biocontrol, as well as an expanded foreign exploration for EAB natural enemies throughout its native range in Asia.