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To update current estimates of non–device-associated pneumonia (ND pneumonia) rates and their frequency relative to ventilator associated pneumonia (VAP), and identify risk factors for ND pneumonia.
Academic teaching hospital.
All adult hospitalizations between 2013 and 2017 were included. Pneumonia (device associated and non–device associated) were captured through comprehensive, hospital-wide active surveillance using CDC definitions and methodology.
From 2013 to 2017, there were 163,386 hospitalizations (97,485 unique patients) and 771 pneumonia cases (520 ND pneumonia and 191 VAP). The rate of ND pneumonia remained stable, with 4.15 and 4.54 ND pneumonia cases per 10,000 hospitalization days in 2013 and 2017 respectively (P = .65). In 2017, 74% of pneumonia cases were ND pneumonia. Male sex and increasing age we both associated with increased risk of ND pneumonia. Additionally, patients with chronic bronchitis or emphysema (hazard ratio [HR], 2.07; 95% confidence interval [CI], 1.40–3.06), congestive heart failure (HR, 1.48; 95% CI, 1.07–2.05), or paralysis (HR, 1.72; 95% CI, 1.09–2.73) were also at increased risk, as were those who were immunosuppressed (HR, 1.54; 95% CI, 1.18–2.00) or in the ICU (HR, 1.49; 95% CI, 1.06–2.09). We did not detect a change in ND pneumonia risk with use of chlorhexidine mouthwash, total parenteral nutrition, all medications of interest, and prior ventilation.
The incidence rate of ND pneumonia did not change from 2013 to 2017, and 3 of 4 nosocomial pneumonia cases were non–device associated. Hospital infection prevention programs should consider expanding the scope of surveillance to include non-ventilated patients. Future research should continue to look for modifiable risk factors and should assess potential prevention strategies.
Viral pneumonia is an important cause of death and morbidity among infants worldwide. Transmission of non-influenza respiratory viruses in households can inform preventative interventions and has not been well-characterised in South Asia. From April 2011 to April 2012, household members of pregnant women enrolled in a randomised trial of influenza vaccine in rural Nepal were surveyed weekly for respiratory illness until 180 days after birth. Nasal swabs were tested by polymerase chain reaction for respiratory viruses in symptomatic individuals. A transmission event was defined as a secondary case of the same virus within 14 days of initial infection within a household. From 555 households, 825 initial viral illness episodes occurred, resulting in 79 transmission events. The overall incidence of transmission was 1.14 events per 100 person-weeks. Risk of transmission incidence was associated with an index case age 1–4 years (incidence rate ratio (IRR) 2.35; 95% confidence interval (CI) 1.40–3.96), coinfection as initial infection (IRR 1.94; 95% CI 1.05–3.61) and no electricity in household (IRR 2.70; 95% CI 1.41–5.00). Preventive interventions targeting preschool-age children in households in resource-limited settings may decrease the risk of transmission to vulnerable household members, such as young infants.
Dietary Zn has significant impacts on the growth and development of breeding rams. The objectives of this study were to evaluate the effects of dietary Zn source and concentration on serum Zn concentration, growth performance, wool traits and reproductive performance in rams. Forty-four Targhee rams (14 months; 68 ± 18 kg BW) were used in an 84-day completely randomized design and were fed one of three pelleted dietary treatments: (1) a control without fortified Zn (CON; n = 15; ~1 × NRC); (2) a diet fortified with a Zn amino acid complex (ZnAA; n = 14; ~2 × NRC) and (3) a diet fortified with ZnSO4 (ZnSO4; n = 15; ~2 × NRC). Growth and wool characteristics measured throughout the course of the study were BW, average daily gain (ADG), dry matter intake (DMI), feed efficiency (G : F), longissimus dorsi muscle depth (LMD), back fat (BF), wool staple length (SL) and average fibre diameter (AFD). Blood was collected from each ram at four time periods to quantify serum Zn and testosterone concentrations. Semen was collected 1 to 2 days after the trial was completed. There were no differences in BW (P = 0.45), DMI (P = 0.18), LMD (P = 0.48), BF (P = 0.47) and AFD (P = 0.9) among treatment groups. ZnSO4 had greater (P ≤ 0.03) serum Zn concentrations compared with ZnAA and CON treatments. Rams consuming ZnAA had greater (P ≤ 0.03) ADG than ZnSO4 and CON. There tended to be differences among groups for G : F (P = 0.06), with ZnAA being numerically greater than ZnSO4 and CON. Wool staple length regrowth was greater (P < 0.001) in ZnSO4 and tended to be longer (P = 0.06) in ZnAA treatment group compared with CON. No differences were observed among treatments in scrotal circumference, testosterone, spermatozoa concentration within ram semen, % motility, % live sperm and % sperm abnormalities (P ≥ 0.23). Results indicated beneficial effects of feeding increased Zn concentrations to developing Targhee rams, although Zn source elicited differential responses in performance characteristics measured.
To update current estimates of non–device-associated urinary tract infection (ND-UTI) rates and their frequency relative to catheter-associated UTIs (CA-UTIs) and to identify risk factors for ND-UTIs.
Academic teaching hospital.
All adult hospitalizations between 2013 and 2017 were included. UTIs (device and non-device associated) were captured through comprehensive, hospital-wide active surveillance using Centers for Disease Control and Prevention case definitions and methodology.
From 2013 to 2017 there were 163,386 hospitalizations (97,485 unique patients) and 1,273 UTIs (715 ND-UTIs and 558 CA-UTIs). The rate of ND-UTIs remained stable, decreasing slightly from 6.14 to 5.57 ND-UTIs per 10,000 hospitalization days during the study period (P = .15). However, the proportion of UTIs that were non–device related increased from 52% to 72% (P < .0001). Female sex (hazard ratio [HR], 1.94; 95% confidence interval [CI], 1.50–2.50) and increasing age were associated with increased ND-UTI risk. Additionally, the following conditions were associated with increased risk: peptic ulcer disease (HR, 2.25; 95% CI, 1.04–4.86), immunosuppression (HR, 1.48; 95% CI, 1.15–1.91), trauma admissions (HR, 1.36; 95% CI, 1.02–1.81), total parenteral nutrition (HR, 1.99; 95% CI, 1.35–2.94) and opioid use (HR, 1.62; 95% CI, 1.10–2.32). Urinary retention (HR, 1.41; 95% CI, 0.96–2.07), suprapubic catheterization (HR, 2.28; 95% CI, 0.88–5.91), and nephrostomy tubes (HR, 2.02; 95% CI, 0.83–4.93) may also increase risk, but estimates were imprecise.
Greater than 70% of UTIs are now non–device associated. Current targeted surveillance practices should be reconsidered in light of this changing landscape. We identified several modifiable risk factors for ND-UTIs, and future research should explore the impact of prevention strategies that target these factors.
Paramedics Providing Palliative Care at Home was launched in two provinces, including a new clinical practice guideline, database, and paramedic training. The aim of this study was to evaluate patient/family satisfaction and paramedic comfort and confidence.
In Part A, we gathered perspectives of patients/families via surveys mailed at enrolment and telephone interviews after an encounter. Responses were reported descriptively and by thematic analysis. In Part B, we surveyed paramedics online pre- and 18 months post-launch. Comfort and confidence were scored on a 4-point Likert scale, and attitudes on a 7-point Likert scale, reported as the median (interquartile range [IQR]); analysis with Wilcoxon ranked sum/thematic analysis of free text.
In Part A, 67/255 (30%) enrolment surveys were returned. Three themes emerged: fulfilling wishes, peace of mind, and feeling prepared for emergencies. In 18 post-encounter interviews, four themes emerged: 24/7 availability, paramedic professionalism and compassion, symptom relief, and a plea for program continuation. Thematic saturation was reached with little divergence. In Part B, 235/1255 (18.9%) pre- and 267 (21.3%) post-surveys were completed. Comfort with providing palliative care without transport improved post launch (p = < 0.001) as did confidence in palliative care without transport (p = < 0.001). Respondents strongly agreed that all paramedics should be able to provide basic palliative care.
After implementation of the multifaceted Paramedics Providing Palliative Care at Home Program, paramedics describe palliative care as important and rewarding. The program resulted in high patient/family satisfaction; simply registering provides peace of mind. After an encounter, families particularly noted the compassion and professionalism of the paramedics.
Objectives: To examine academic performance in dystrophinopathy as a function of dystrophin gene mutation position as well as intellectual function, executive skills, socioeconomic status (SES), behavior, and physical ability. Methods: In a cross-sectional study, boys with dystrophinopathy (ages 5–17; n=50) completed tests of academics (Woodcock-Johnson-III: spelling, reading, calculation and total scores), executive functioning (selective attention/inhibitory control, set shifting, working memory, and processing speed), single word comprehension and nonverbal reasoning. Motor skills were assessed and parents provided demographic information and child behavioral assessments. Dystrophin gene mutation positions were dichotomized into groups (upstream versus downstream of exon 43, location of isoforms previously linked to intellectual impairment). Genetic mutation groups were compared on measures of academic achievement, and multiple regression analyses examined unique and joint contributions of executive skills, intelligence quotient (IQ), SES, motor abilities, behavior, and mutation positions to academic outcomes. Results: Academic performance was slightly, yet significantly, lower than IQ and varied as a function of dystrophin gene position, wherein boys possessing the downstream mutation exhibited greater impairment than boys with the upstream mutation. Digit span forward (indexing verbal span), but no other measure of executive function, contributed significant variance to total academic achievement, spelling and calculation. Conclusions: Weak academic performance is associated with dystrophinopathy and is more common in downstream mutations. A specific deficit in verbal span may underlie inefficiencies observed in children with dystrophinopathy and may drive deficits impacting academic abilities. (JINS, 2018, 24, 928–938)
Aeroacoustic measurements and analysis have been made for an unshrouded rotor partially immersed in a planar equilibrium turbulent boundary layer at low Mach number. This configuration provides an idealized model of inflow distortion effects seen when a rotor is mounted adjacent to the hull or fuselage of a vehicle. At low and moderate thrust conditions, the rotor produces broadband noise organized into haystacks produced by large eddies of the ingested turbulence being cut multiple times by successive rotor blades. At high thrust, however, the acoustic signature changes and becomes louder and more tonal. This change is accompanied by separation of the boundary layer from the wall in the vicinity of the rotor blade disk. The separation region is highly unsteady and populated by intense vortex structures. Acoustic analysis suggests that blade–vortex interactions with these structures are the source of the additional tonal noise at high thrust.
Many studies have identified changes in the brain associated with obsessive–compulsive disorder (OCD), but few have examined the relationship between genetic determinants of OCD and brain variation.
We present the first genome-wide investigation of overlapping genetic risk for OCD and genetic influences on subcortical brain structures.
Using single nucleotide polymorphism effect concordance analysis, we measured genetic overlap between the first genome-wide association study (GWAS) of OCD (1465 participants with OCD, 5557 controls) and recent GWASs of eight subcortical brain volumes (13 171 participants).
We found evidence of significant positive concordance between OCD risk variants and variants associated with greater nucleus accumbens and putamen volumes. When conditioning OCD risk variants on brain volume, variants influencing putamen, amygdala and thalamus volumes were associated with risk for OCD.
These results are consistent with current OCD neurocircuitry models. Further evidence will clarify the relationship between putamen volume and OCD risk, and the roles of the detected variants in this disorder.
Declaration of interest
The authors have declared that no competing interests exist.
Gliricidia sepium (Jacq.) Steud. is widely used as a high-protein supplementary food for ruminants in many parts of the tropics. Native to Central America and Mexico, it has become widely naturalized elsewhere but the introduced populations are mostly of unknown origin and uncertain quality. Studies of the genetic resources from the native range, under a research programme at OFI, have shown great variation between populations in yield (Dunsdon and Simons, 1996). The objective of the research described here was to investigate whether there is also important genetic variation in fodder quality, to inform decisions on future distribution of ‘superior’ germplasm of G. sepium under the OFI programme.
With the proposed ban on antibiotic growth promoters it is becoming increasingly important to provide diets to young pigs which enhance the long term health. Alternative strategies to promote health include organic acids, herbal products and natural antioxidants. These products have various proposed modes of action including improved liver function, removal of reactive oxygen species and the enhancement of the immune function. The objective of this experiment was to measure the effect of a commercial herbal mixture and Lycopene on the performance and immune function of weaned pigs.
The study purpose was to provide evidence of validity for the Primary Health Care Engagement (PHCE) Scale, based on exploratory factor analysis and reliability findings from a large national survey of regulated nurses residing and working in rural and remote Canadian communities.
There are currently no published provider-level instruments to adequately assess delivery of community-based primary health care, relevant to ongoing primary health care (PHC) reform strategies across Canada and elsewhere. The PHCE Scale reflects a contemporary approach that emphasizes community-oriented and community-based elements of PHC delivery.
Data from the pan-Canadian Nursing Practice in Rural and Remote Canada II (RRNII) survey were used to conduct an exploratory factor analysis and evaluate the internal consistency reliability of the final PHCE Scale.
The RRNII survey sample included 1587 registered nurses, nurse practitioners, licensed practical nurses, and registered psychiatric nurses residing and working in rural and remote Canada. Exploratory factor analysis identified an eight-factor structure across 28 items overall, and good internal consistency reliability was indicated by an α estimate of 0.89 for the final scale. The final 28-item PHCE Scale includes three of four elements in a contemporary approach to PHC (accessibility/availability, community participation, and intersectoral team) and most community-oriented/based elements of PHC (interdisciplinary collaboration, person-centred, continuity, population orientation, and quality improvement). We recommend additional psychometric testing in a range of health care providers and settings, as the PHCE Scale shows promise as a tool for health care planners and researchers to test interventions and track progress in primary health care reform.
Introduction: Understanding factors that influence laboratory test ordering in emergency departments (EDs) can help to improve current laboratory test ordering practices. The aim of this study is to compare patterns and influences in laboratory test ordering between emergency physicians and nurses at two ED sites, Halifax Infirmary (HI) and Dartmouth General (DG). Methods: A mixed-methods approach involving administrative data and telephone interviews was employed. Data from 211,279 patients at HI and DG EDs were analyzed. Chi-square analysis and binary logistic regression were used to determine significant factors influencing whether a test was ordered, as well as significant factors predicting likelihood of a nurse or a physician ordering a test. All significant associations had a p-value of <0.0001. Interviews were conducted (n=25) with doctors and nurses in order to explore areas of potential influence in a clinician’s decision-making process, and discuss what makes decision making difficult or inconsistent in the ED. These interviews were analyzed according to the Theoretical Domains Framework. The interviews were coded by two individuals using a consensus methodology in order to ensure accuracy of coding. Results: Overall, laboratory tests were more likely to be ordered at DG than at HI (OR=1.52, 95% CI: [1.48, 1.55]). Laboratory tests were more likely to be ordered by nurses at DG than at HI (OR=1.58, 95% CI: [1.54, 1.62]). Laboratory tests were more likely to be ordered if the ED was not busy, if the patient was over 65, had a high acuity, had a long stay in the ED, required consults, or was admitted to hospital. Doctors were more likely to order a laboratory test in patients over 65, requiring consults or hospital admission, whereas nurses were more likely to order laboratory tests in patients with high acuity or long stays in the ED. Data from the interviews suggested differing influences on decision making between nurses and doctors, especially in the areas of social influence and knowledge. Conclusion: Currently, there is limited research that investigates behaviour of both emergency physicians and nurses. By determining barriers that are most amenable to behaviour change in emergency physicians and nurses, findings from this work may be used to update practice guidelines, ensuring more consistency and efficiency in laboratory test ordering in the ED.
Vitamin D is obtained by cattle from the diet and from skin production via UVB exposure from sunlight. The vitamin D status of the cow impacts the vitamin D content of the milk produced, much like human breast milk, with seasonal variation in the vitamin D content of milk well documented. Factors such as changes in husbandry practices therefore have the potential to impact the vitamin D content of milk. For example, a shift to year-round housing from traditional practices of cattle being out to graze during the summer months and housed during the winter only, minimises exposure to the sun and has been shown to negatively influence the vitamin D content of the milk produced. Other practices such as changing dietary sources of vitamin D may also influence the vitamin D content of milk, and evidence exists to suggest genetic factors such as breed can cause variation in the concentrations of vitamin D in the milk produced. The present review aims to provide an overview of the current understanding of how genetic and environmental factors influence the vitamin D content of the milk produced by dairy cattle. A number of environmental and genetic factors have previously been identified as having influence on the nutritional content of the milk produced. The present review highlights a need for further research to fully elucidate how farmers could manipulate the factors identified to their advantage with respect to increasing the vitamin D content of milk and standardising it across the year.
Within acute psychiatric inpatient services, patients exhibiting severely disturbed behaviour can be transferred to a psychiatric intensive care unit (PICU) and/or secluded in order to manage the risks posed to the patient and others. However, whether specific patient groups are more likely to be subjected to these coercive measures is unclear. Using robust methodological and statistical techniques, we aimed to determine the demographic, clinical and behavioural predictors of both PICU and seclusion.
Data were extracted from an anonymised database comprising the electronic medical records of patients within a large South London mental health trust. Two cohorts were derived, (1) a PICU cohort comprising all patients transferred from general adult acute wards to a non-forensic PICU ward between April 2008 and April 2013 (N = 986) and a randomly selected group of patients admitted to general adult wards within this period who were not transferred to PICU (N = 994), and (2) a seclusion cohort comprising all seclusion episodes occurring in non-forensic PICU wards within the study period (N = 990) and a randomly selected group of patients treated in these wards who were not secluded (N = 1032). Demographic and clinical factors (age, sex, ethnicity, diagnosis, admission status and time since admission) and behavioural precursors (potentially relevant behaviours occurring in the 3 days preceding PICU transfer/seclusion or random sample date) were extracted from electronic medical records. Mixed effects, multivariable logistic regression analyses were performed with all variables included as predictors.
PICU cases were significantly more likely to be younger in age, have a diagnosis of bipolar disorder and to be held on a formal section compared with patients who were not transferred to PICU; female sex and longer time since admission were associated with lower odds of transfer. With regard to behavioural precursors, the strongest predictors of PICU transfer were incidents of physical aggression towards others or objects and absconding or attempts to abscond. Secluded patients were also more likely to be younger and legally detained relative to non-secluded patients; however, female sex increased the odds of seclusion. Likelihood of seclusion also decreased with time since admission. Seclusion was significantly associated with a range of behavioural precursors with the strongest associations observed for incidents involving restraint or shouting.
Whilst recent behaviour is an important determinant, patient age, sex, admission status and time since admission also contribute to risk of PICU transfer and seclusion. Alternative, less coercive strategies must meet the needs of patients with these characteristics.
Radiocarbon ages were measured on replicate samples of burnt grain and 5 mollusk species collected from a single sealed layer at an archaeological site (Hornish Point) on the west coast of South Uist, Scotland. The aim was to examine the impact of using different mollusk species on ΔR determinations that are calculated using the paired terrestrial/marine sample approach. The mollusk species examined inhabit a range of environments and utilize a variety of food sources within the intertidal zone. Several authors have suggested that these factors may be responsible for observed variations in the 14C activity of mollusk shells that were contemporaneous in a single location. This study found no significant variation in the 14C ages of the mollusk species, and consequently, no significant variation in calculated values of ΔR. The implication is that in an area where there are no carboniferous rocks or significant local inputs of freshwater to the surface ocean, any of a range of marine mollusk species can be used in combination with short-lived terrestrial material from the same secure archaeological context to accurately determine a ΔR value for a particular geographic location and period in time.
Previous neuroimaging studies indicate abnormalities in cortico-limbic circuitry in mood disorder. Here we employ prospective longitudinal voxel-based morphometry to examine the trajectory of these abnormalities during early stages of illness development.
Unaffected individuals (16–25 years) at high and low familial risk of mood disorder underwent structural brain imaging on two occasions 2 years apart. Further clinical assessment was conducted 2 years after the second scan (time 3). Clinical outcome data at time 3 was used to categorize individuals: (i) healthy controls (‘low risk’, n = 48); (ii) high-risk individuals who remained well (HR well, n = 53); and (iii) high-risk individuals who developed a major depressive disorder (HR MDD, n = 30). Groups were compared using longitudinal voxel-based morphometry. We also examined whether progress to illness was associated with changes in other potential risk markers (personality traits, symptoms scores and baseline measures of childhood trauma), and whether any changes in brain structure could be indexed using these measures.
Significant decreases in right amygdala grey matter were found in HR MDD v. controls (p = 0.001) and v. HR well (p = 0.005). This structural change was not related to measures of childhood trauma, symptom severity or measures of sub-diagnostic anxiety, neuroticism or extraversion, although cross-sectionally these measures significantly differentiated the groups at baseline.
These longitudinal findings implicate structural amygdala changes in the neurobiology of mood disorder. They also provide a potential biomarker for risk stratification capturing additional information beyond clinically ascertained measures.
Young supernova remnants are poorly understood and few are known. Further examples may be present, but unrecognised, within existing catalogues of radio sources. G274.68–2.84 was recently suggested as one such candidate but our new radio map from the Australia Telescope indicates that it is not a supernova remnant. Rather, it appears to be extragalactic with a strong, variable, flat-spectrum nucleus, and a bright X-ray counterpart.