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Dietary fiber modulates gastrointestinal (GI) health and function, providing laxation, shifting microbiota, and altering bile acid (BA) metabolism. Fruit juice production removes the polyphenol- and fiber-rich pomace fraction. The effects of orange and apple pomaces on GI outcomes were investigated in healthy, free-living adults. Healthy adults were enrolled in two double-blinded, crossover trials, being randomized by baseline bowel movement (BM) frequency. In the first trial, subjects (n=91) received orange juice (OJ, 0g fiber/d) or OJ + orange pomace (OJ+P, 10g fiber/d) for 4 wk, separated by a 3-wk washout. Similarly, in the second trial, subjects (n=90) received apple juice (AJ, 0g fiber/d) or AJ + apple pomace (AJ+P, 10g fiber/d). Bowel habit diaries, GI tolerance surveys, and 3-d diet records were collected throughout. Fresh fecal samples were collected from a participant subset for microbiota and BA analyses in each study. Neither pomace interventions influenced BM frequency. At wk 4, OJ+P tended to increase (p=0.066) GI symptom occurrence compared to OJ, while AJ+P tended (p=0.089) to increase flatulence compared to AJ. Faecalibacterium (p=0.038) and Negativibacillus (p=0.043) were differentially abundant between pre- and post-interventions in the apple trial, but were no longer significant after FDR correction. Baseline fiber intake was independently associated with several microbial genera in both trials. Orange or apple pomace supplementation was insufficient to elicit changes in bowel habits, microbiota diversity, or BA of free-living adults with healthy baseline BM. Future studies should consider baseline BM frequency and habitual fiber intake.
Bloodstream infections (BSIs) are a frequent cause of morbidity in patients with acute myeloid leukemia (AML), due in part to the presence of central venous access devices (CVADs) required to deliver therapy.
To determine the differential risk of bacterial BSI during neutropenia by CVAD type in pediatric patients with AML.
We performed a secondary analysis in a cohort of 560 pediatric patients (1,828 chemotherapy courses) receiving frontline AML chemotherapy at 17 US centers. The exposure was CVAD type at course start: tunneled externalized catheter (TEC), peripherally inserted central catheter (PICC), or totally implanted catheter (TIC). The primary outcome was course-specific incident bacterial BSI; secondary outcomes included mucosal barrier injury (MBI)-BSI and non-MBI BSI. Poisson regression was used to compute adjusted rate ratios comparing BSI occurrence during neutropenia by line type, controlling for demographic, clinical, and hospital-level characteristics.
The rate of BSI did not differ by CVAD type: 11 BSIs per 1,000 neutropenic days for TECs, 13.7 for PICCs, and 10.7 for TICs. After adjustment, there was no statistically significant association between CVAD type and BSI: PICC incident rate ratio [IRR] = 1.00 (95% confidence interval [CI], 0.75–1.32) and TIC IRR = 0.83 (95% CI, 0.49–1.41) compared to TEC. When MBI and non-MBI were examined separately, results were similar.
In this large, multicenter cohort of pediatric AML patients, we found no difference in the rate of BSI during neutropenia by CVAD type. This may be due to a risk-profile for BSI that is unique to AML patients.
Background: Automated testing instruments (ATIs) are commonly used by clinical microbiology laboratories to perform antimicrobial susceptibility testing (AST), whereas public health laboratories may use established reference methods such as broth microdilution (BMD). We investigated discrepancies in carbapenem minimum inhibitory concentrations (MICs) among Enterobacteriaceae tested by clinical laboratory ATIs and by reference BMD at the CDC. Methods: During 2016–2018, we conducted laboratory- and population-based surveillance for carbapenem-resistant Enterobacteriaceae (CRE) through the CDC Emerging Infections Program (EIP) sites (10 sites by 2018). We defined an incident case as the first isolation of Enterobacter spp (E. cloacae complex or E. aerogenes), Escherichia coli, Klebsiella pneumoniae, K. oxytoca, or K. variicola resistant to doripenem, ertapenem, imipenem, or meropenem from normally sterile sites or urine identified from a resident of the EIP catchment area in a 30-day period. Cases had isolates that were determined to be carbapenem-resistant by clinical laboratory ATI MICs (MicroScan, BD Phoenix, or VITEK 2) or by other methods, using current Clinical and Laboratory Standards Institute (CLSI) criteria. A convenience sample of these isolates was tested by reference BMD at the CDC according to CLSI guidelines. Results: Overall, 1,787 isolates from 112 clinical laboratories were tested by BMD at the CDC. Of these, clinical laboratory ATI MIC results were available for 1,638 (91.7%); 855 (52.2%) from 71 clinical laboratories did not confirm as CRE at the CDC. Nonconfirming isolates were tested on either a MicroScan (235 of 462; 50.9%), BD Phoenix (249 of 411; 60.6%), or VITEK 2 (371 of 765; 48.5%). Lack of confirmation was most common among E. coli (62.2% of E. coli isolates tested) and Enterobacter spp (61.4% of Enterobacter isolates tested) (Fig. 1A), and among isolates testing resistant to ertapenem by the clinical laboratory ATI (52.1%, Fig. 1B). Of the 1,388 isolates resistant to ertapenem in the clinical laboratory, 1,006 (72.5%) were resistant only to ertapenem. Of the 855 nonconfirming isolates, 638 (74.6%) were resistant only to ertapenem based on clinical laboratory ATI MICs. Conclusions: Nonconfirming isolates were widespread across laboratories and ATIs. Lack of confirmation was most common among E. coli and Enterobacter spp. Among nonconfirming isolates, most were resistant only to ertapenem. These findings may suggest that ATIs overcall resistance to ertapenem or that isolate transport and storage conditions affect ertapenem resistance. Further investigation into this lack of confirmation is needed, and CRE case identification in public health surveillance may need to account for this phenomenon.
High-resolution Chirp sub-bottom data were obtained offshore from the Northern Channel Islands (NCI), California, to image submerged paleoshorelines and assess local uplift rates. Although modern bathymetry is often used for modeling paleoshorelines, Chirp data image paleoshorelines buried beneath sediment that obscures their seafloor expression. The NCI were a unified landmass during the last glacial maximum (LGM; ~20 ka), when eustatic sea level was ~120 m lower than present. We identified seven paleoshorelines, ranging from ~28 to 104 m in depth, across this now-submerged LGM platform. Paleoshoreline depths were compared to local sea-level curves to estimate ages, which suggest that some were reoccupied over multiple sea-level cycles. Additionally, previous studies determined conflicting uplift rates for the NCI, ranging from 0.16 to 1.5 m/ka. Our results suggest that a rate on the lower end of this range better fits the observed submerged paleoshorelines. Using the uplift rate of ~0.16 m/ka, we estimate that paleoshorelines formed during Marine Oxygen Isotope Stage 3, the LGM, and the Younger Dryas stade are preserved on the NCI platform. These results help clarify uplift rates for the NCI and illustrate the importance of sub-bottom data for mapping submerged paleoshorelines.
Introduction: In Ottawa, STEMI patients are transported directly to percutaneous coronary intervention (PCI) by advanced care paramedics (ACPs), primary care paramedics (PCPs), or transferred from PCP to ACP crew (ACP-intercept). PCPs have a limited skill set to address complications during transport.The objective of this study was to determine what clinically important events (CIEs) occurred in STEMI patients transported for primary PCI via a PCP crew, and what proportion of such events could only be treated by ACP protocols. Methods: We conducted a health record review of STEMI patients transported for primary PCI from Jan 1, 2011-Dec 21, 2015. Ottawa has a single PCI center and its EMS system employs both PCP and ACP paramedics. We identified consecutive STEMI bypass patients transported by PCP-only and ACP-intercept using the dispatch database. A data extraction form was piloted and used to extract patient demographics, transport times, and primary outcomes: CIEs and interventions performed during transport, and secondary outcomes: hospital diagnosis, and mortality. CIEs were reviewed by two investigators to determine if they would be treated differently by ACP protocols. We present descriptive statistics. Results: We identified 967 STEMI bypass cases among which 214 (118 PCP-only and 96 ACP-intercept) met all inclusion criteria. Characteristics were: mean age 61.4 years, 78% male, 31.8% anterior and 44.4% inferior infarcts, mean response time 6 min, total paramedic contact time 29 min, and in cases of ACP-intercept 7 min of PCP-only contact time.A CIE occurred in 127 (59%) of cases: SBP<90 mmHg 26.2%, HR<60 30.4%, HR>100 20.6%, malignant arrhythmias 7.5%, altered mental status 6.5%, airway intervention 2.3%, 2 patients (0.9%) arrested, both survived. Of the CIE identified, 54 (42.5%) could be addressed differently by ACP vs PCP protocols (25.2% of total cases). The majority related to fluid boluses for hypotension (44 cases; 35% of CIE). ACP intervention for CIEs within the ACP intercept group was 51.6%. There were 6 in-hospital deaths (2.8%) with no difference in transport crew type. Conclusion: CIEs are common in STEMI bypass patients however a smaller proportion of such CIE would be addressed differently by ACP protocols compared to PCP protocols. The vast majority of CIE appeared to be transient and of limited clinical significance.
Introduction: The Canadian C-Spine Rule (CCR) was validated by emergency physicians and triage nurses to determine the need for radiography in alert and stable Emergency Department trauma patients. It was modified and validated for use by paramedics in 1,949 patients. The prehospital CCR calls for evaluation of active neck rotation if patients have none of 3 high-risk criteria and at least 1 of 4 low-risk criteria. This study evaluated the impact and safety of the implementation of the CCR by paramedics. Methods: This single-centre prospective cohort implementation study took place in Ottawa, Canada. Advanced and primary care paramedics received on-line and in-person training on the CCR, allowing them to use the CCR to evaluate eligible patients and selectively transport them without immobilization. We evaluated all consecutive eligible adult patients (GCS 15, stable vital signs) at risk for neck injury. Paramedics were required to complete a standardized study data form for each eligible patient evaluated. Study staff reviewed paramedic documentation and corresponding hospital records and diagnostic imaging reports. We followed all patients without initial radiologic evaluation for 30 days for referral to our spine service, or subsequent visit with radiologic evaluation. Analyses included sensitivity, specificity, kappa coefficient, t-test, and descriptive statistics with 95% CIs. Results: The 4,034 patients enrolled between Jan. 2011 and Aug. 2015 were: mean age 43 (range 16-99), female 53.3%, motor vehicle collision 51.9%, fall 23.8%, admitted to hospital 7.0%, acute c-spine injury 0.8%, and clinically important c-spine injury (0.3%). The CCR classified patients for 11 important injuries with sensitivity 91% (95% CI 58-100%), and specificity 67% (95% CI 65-68%). Kappa agreement for interpretation of the CCR between paramedics and study investigators was 0.94 (95% CI 0.92-0.95). Paramedics were comfortable or very comfortable using the CCR in 89.8% of cases. Mean scene time was 3 min (15.6%) shorter for those not immobilized (17 min vs. 20 min; p=0.0001). A total of 2,569 (63.7%) immobilizations were safely avoided using the CCR. Conclusion: Paramedics could safely and accurately apply the CCR to low-risk trauma patients. This had a significant impact on scene times and the number of prehospital immobilizations.
Introduction/Innovation Concept: In 2014, Eastern Ontario paramedic services, their medical director staff and area community colleges developed an EMS Boot Camp experience to orient Queen’s University and the University of Ottawa emergency medicine residents to the role of paramedics and the challenges they face in the field. Current EMS ride-alongs and didactic classroom sessions were deemed ineffective at adequately preparing residents to provide online medical control. From those early discussions came the creation of a real-world, real-time (RWRT) educational experience. Methods: Specific challenges unique to paramedicine are difficult to communicate to a medical control physician at the other end of a telephone. The goal of this one-day educational experience is for residents to gain insight into the complexity and time sensitive nature of delivering medical care in the field. Residents are immersed as responding paramedics in a day of intense RWRT simulation exercises reflecting the common paramedic logistical challenges to delivering patient care in an uncontrolled and dynamic environment. Curriculum, Tool, or Material: Scenarios, run by paramedic students, are overseen by working paramedics from participating paramedic services. Residents learn proper use of key equipment found on an Ontario ambulance while familiarize themselves with patient care standards and medical directives. Scenarios focus on prehospital-specific clinical care issues; performing dynamic CPR in a moving vehicle, extricating a bariatric patient with limited personnel, large scale multi-casualty triage as well as other time sensitive, high risk procedures requiring online medical control approval (i.e. chest needle thoracostomy). Conclusion: EMS Boot Camp dispels preconceived biases regarding “what it’s really like” to deliver high quality prehospital clinical care. When providing online medical control in the future, the residents will be primed to understand and expect certain challenges that may arise. The educational experience fosters collaboration between prehospital and hospital-based providers. The sessions provide a reproducible, standardized experience for all participants; something that cannot be guaranteed with traditional EMS ride-alongs. Future sessions will evaluate participant satisfaction and self-efficacy with the use of a standard evaluation form including pre/post self-evaluations.
Epidemiology formed the basis of ‘the Barker hypothesis’, the concept of ‘developmental programming’ and today’s discipline of the Developmental Origins of Health and Disease (DOHaD). Animal experimentation provided proof of the underlying concepts, and continues to generate knowledge of underlying mechanisms. Interventions in humans, based on DOHaD principles, will be informed by experiments in animals. As knowledge in this discipline has accumulated, from studies of humans and other animals, the complexity of interactions between genome, environment and epigenetics, has been revealed. The vast nature of programming stimuli and breadth of effects is becoming known. As a result of our accumulating knowledge we now appreciate the impact of many variables that contribute to programmed outcomes. To guide further animal research in this field, the Australia and New Zealand DOHaD society (ANZ DOHaD) Animals Models of DOHaD Research Working Group convened at the 2nd Annual ANZ DOHaD Congress in Melbourne, Australia in April 2015. This review summarizes the contributions of animal research to the understanding of DOHaD, and makes recommendations for the design and conduct of animal experiments to maximize relevance, reproducibility and translation of knowledge into improving health and well-being.
Introduction: Recent years have brought an epidemic of opioid abuse to Canada. At present, in Ontario, Naloxone may not be administered by any paramedic without the direct online medical approval of a Base Hospital Physician (BHP). The objective of this study was to review the use of Naloxone by Emergency Medical Service (EMS) personnel, under the existing Advanced Life Support Patient Care Standards (ALS-PCS) medical directive for opioid toxicity, for safety and potential complications that may occur with removal of the mandatory patch point. Methods: This study was a retrospective ambulance call report review of consecutive Naloxone requests placed to a BHP of the Regional Paramedic Program of Eastern Ontario (RPPEO) between Oct 1st, 2013 and Oct 31st, 2015. The RPPEO consists of 10 prehospital services, both urban and rural jurisdictions, and has a mix of advance care and primary care paramedics. All ambulance call reports are electronically stored at the secured RPPEO data warehouse. Data was extracted using a standardized data collection tool. All ambulance call reports were reviewed by 2 independent authors (VC, NC). Compliance with the existing medical directive for opioid toxicity was determined. We calculated the frequency of denied Naloxone requests and the rationale for each patch refusal was recorded. We also categorized all adverse events associated with Naloxone administration. Results: From 244 patches, 215 patients were administered Naloxone. Only 7.8% (19/215) of requests for Naloxone were refused; 78.9% (15/19) did not meet existing inclusion criteria for Naloxone administration in the ALS-PCS medical directive for opioid toxicity because the patient’s respiration rate was above 12/min. Of the 215 patients who were administered Naloxone, adverse events were extremely uncommon: 5 (2.3%) became violent or verbally abusive, 1 (0.5%) was transiently hypertensive and 4 (1.9%) vomited. Conclusion: Requests for Naloxone to a BHP are common and yet are seldom declined. The use of prehospital Naloxone is associated with few adverse events. These results demonstrate that it would be safe to remove online medical direction for Naloxone from the ALS-PCS medical directive for opioid toxicity if combined with updated paramedic education.
Acinetobacter is a well-recognized nosocomial pathogen. Previous reports of community-associated Acinetobacter infections have lacked clear case definitions and assessment of healthcare-associated (HCA) risk factors. We identified Acinetobacter bacteraemia cases from blood cultures obtained <3 days after hospitalization in rural Thailand and performed medical record reviews to assess HCA risk factors in the previous year and compare clinical and microbiological characteristics between cases with and without HCA risk factors. Of 72 Acinetobacter cases, 32 (44%) had no HCA risk factors. Compared to HCA infections, non-HCA infections were more often caused by Acinetobacter species other than calcoaceticus–baumannii complex species and by antibiotic-susceptible organisms. Despite similar symptoms, the case-fatality proportion was lower in non-HCA than HCA cases (9% vs. 45%, P < 0·01). Clinicians should be aware of Acinetobacter as a potential cause of community-associated infections in Thailand; prospective studies are needed to improve understanding of associated risk factors and disease burden.
There has been much debate in recent decades as to what fraction of ionising photons from star-forming regions in the Galactic disk escape into the halo. The recent detection of the Magellanic Stream in optical line emission at the CTIO 4 m and the AAT 3·9 m telescopes may now provide the strongest evidence that at least some of the radiation escapes the disk completely. We present a simple model to demonstrate that, while the distance to the Magellanic Stream is uncertain, the observed emission measures (εm ≈ 0·5 – 1 cm−6 pc) are most plausibly explained by photoionisation due to hot, young stars. This model requires that the mean Lyman-limit opacity perpendicular to the disk is τLL ≈ 3, and the covering fraction of the resolved clouds is close to unity. Alternative sources (e.g. shock, halo, LMC or metagalactic radiation) contribute negligible ionising flux.
We present Herschel-SPIRE imaging spectroscopy (194-671 μm) of the bright starburst galaxy M82. We use RADEX and a Bayesian Likelihood Analysis to simultaneously model the temperature, density, column density, and filling factor of both the cool and warm components of molecular gas traced by the entire CO ladder up to J=13-12. The high-J lines observed by SPIRE trace much warmer gas (~500 K) than those observable from the ground. The addition of 13CO (and [C I]) is new and indicates that [C I] may be tracing different gas than 12CO. At such a high temperature, cooling is dominated by molecular hydrogen; we conclude with a discussion on the possible excitation processes in this warm component. Photon-dominated region (PDR) models require significantly higher densities than those indicated by our Bayesian likelihood analysis in order to explain the high-J CO line ratios, though cosmic-ray enhanced PDR models can do a better job reproducing the emission at lower densities. Shocks and turbulent heating are likely required to explain the bright high-J emission.
Patients with major depressive disorder (MDD) show deficits in processing of facial emotions that persist beyond recovery and cessation of treatment. Abnormalities in neural areas supporting attentional control and emotion processing in remitted depressed (rMDD) patients suggests that there may be enduring, trait-like abnormalities in key neural circuits at the interface of cognition and emotion, but this issue has not been studied systematically.
Nineteen euthymic, medication-free rMDD patients (mean age 33.6 years; mean duration of illness 34 months) and 20 age- and gender-matched healthy controls (HC; mean age 35.8 years) performed the Emotional Face N-Back (EFNBACK) task, a working memory task with emotional distracter stimuli. We used blood oxygen level-dependent (BOLD) functional magnetic resonance imaging (fMRI) to measure neural activity in the dorsolateral (DLPFC) and ventrolateral prefrontal cortex (VLPFC), orbitofrontal cortex (OFC), ventral striatum and amygdala, using a region of interest (ROI) approach in SPM2.
rMDD patients exhibited significantly greater activity relative to HC in the left DLPFC [Brodmann area (BA) 9/46] in response to negative emotional distracters during high working memory load. By contrast, rMDD patients exhibited significantly lower activity in the right DLPFC and left VLPFC compared to HC in response to positive emotional distracters during high working memory load. These effects occurred during accurate task performance.
Remitted depressed patients may continue to exhibit attentional biases toward negative emotional information, reflected by greater recruitment of prefrontal regions implicated in attentional control in the context of negative emotional information.
In the Magellanic Clouds, the [CII]/CO and the [CII]/FIR ratios are much higher than seen in Milky Way star-forming regions. The enhanced relative strength of the [CII] line reflects the physical environment characterised by the low metallicities, dust abundances, and PAH abundances of the LMC, and especially the SMC.
Although pneumonia is a leading cause of death from infectious disease worldwide, comprehensive information about its causes and incidence in low- and middle-income countries is lacking. Active surveillance of hospitalized patients with pneumonia is ongoing in Thailand. Consenting patients are tested for seven bacterial and 14 viral respiratory pathogens by PCR and viral culture on nasopharyngeal swab specimens, serology on acute/convalescent sera, sputum smears and antigen detection tests on urine. Between September 2003 and December 2005, there were 1730 episodes of radiographically confirmed pneumonia (34·6% in children aged <5 years); 66 patients (3·8%) died. A recognized pathogen was identified in 42·5% of episodes. Respiratory syncytial virus (RSV) infection was associated with 16·7% of all pneumonias, 41·2% in children. The viral pathogen with the highest incidence in children aged <5 years was RSV (417·1/100 000 per year) and in persons aged ⩾50 years, influenza virus A (38·8/100 000 per year). These data can help guide health policy towards effective prevention strategies.
Translocation outcomes for mobile species can be affected by post-release movement of individuals, yet few population reintroduction and supplementation projects consider propensity to move as a selection criterion when selecting individuals to release or sites for release. We investigate the influence of release age (juvenile or subadult), the size of the release group and the size of the wild population at the release site on movements of Critically Endangered kaki (black stilt) Himantopus novaezelandiae. Over 460 subadult and juvenile kaki have been released during 12 years at nine sites in the Waitaki Basin, New Zealand, with the aim of supplementing specific sub-populations. Among the survivors that reached breeding age, 32% of released kaki ended up away from their release sites, i.e. away from the subpopulations they were intended to augment and 15% of these birds were in unmanageable areas where monitoring cannot take place. Kaki released as juveniles (2–3 months) made more long moves and moved further from the release site during 2 months post-release. The presence of conspecifics affected behaviour after release: released birds were more likely to remain closer to the release site when the size of the wild population at the release site was large, and kaki released in larger groups were more likely to make more longer moves. Despite initial differences in mobility, long-term monitoring revealed equal proportions of 2-year old survivors that had been released as juveniles and subadults returning and being observed consistently at release sites, emphasizing the value of long-term monitoring in informing release strategies for population restorations.