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For patients with possible Staphylococcus aureus infection, providers must decide whether to treat empirically for methicillin-resistant S. aureus (MRSA). Nares MRSA colonization screening tests could inform decisions regarding empiric MRSA-active antibiotic use.1,2
Among 469 US military veterans with an Escherichia coli clinical isolate (2012–2013), we explored healthcare and non-healthcare risk factors for having E. coli sequence type 131 and its H30 subclone (ST131-H30). Overall, 66 (14%) isolates were ST131; 51 (77%) of these were ST131-H30. After adjustment for healthcare-associated factors, ST131 remained positively associated with medical lines and nursing home residence. After adjustment for environmental factors, ST131 remained associated with wild animal contact (positive), meat consumption (negative) and pet cat exposure (negative). Thus, ST131 was associated predominantly with healthcare-associated exposures, while non-ST131 E. coli were associated with some environmental exposures.
We developed a decision analytic model to evaluate the impact of a preoperative Staphylococcus aureus decolonization bundle on surgical site infections (SSIs), health-care–associated costs (HCACs), and deaths due to SSI.
Our model population comprised US adults undergoing elective surgery. We evaluated 3 self-administered preoperative strategies: (1) the standard of care (SOC) consisting of 2 disinfectant soap showers; (2) the “test-and-treat” strategy consisting of the decolonization bundle including chlorhexidine gluconate (CHG) soap, CHG mouth rinse, and mupirocin nasal ointment for 5 days) if S. aureus was found at any of 4 screened sites (nasal, throat, axillary, perianal area), otherwise the SOC; and (3) the “treat-all” strategy consisting of the decolonization bundle for all patients, without S. aureus screening. Model parameters were derived primarily from a randomized controlled trial that measured the efficacy of the decolonization bundle for eradicating S. aureus.
Under base-case assumptions, the treat-all strategy yielded the fewest SSIs and the lowest HCACs, followed by the test-and-treat strategy. In contrast, the SOC yielded the most SSIs and the highest HCACs. Consequently, relative to the SOC, the average savings per operation was $217 for the treat-all strategy and $123 for the test-and-treat strategy, and the average savings per per SSI prevented was $21,929 for the treat-all strategy and $15,166 for the test-and-treat strategy. All strategies were sensitive to the probability of acquiring an SSI and the increased risk if SSI if the patient was colonized with SA.
We predict that the treat-all strategy would be the most effective and cost-saving strategy for preventing SSIs. However, because this strategy might select more extensively for mupirocin-resistant S. aureus and cause more medication adverse effects than the test-and-treat approach or the SOC, additional studies are needed to define its comparative benefits and harms.
To determine the efficacy in eradicating Staphylococcus aureus (SA) carriage of a 5-day preoperative decolonization bundle compared to 2 disinfectant soap showers, with both regimens self-administered at home.
Open label, single-center, randomized clinical trial.
Ambulatory orthopedic, urologic, neurologic, colorectal, cardiovascular, and general surgery clinics at a tertiary-care referral center in the United States.
Patients at the University of Minnesota Medical Center planning to have elective surgery and not on antibiotics.
Consenting participants were screened for SA colonization using nasal, throat, axillary, and perianal swab cultures. Carriers of SA were randomized, stratified by methicillin resistance status, to a decolonization bundle group (5 days of nasal mupirocin, chlorhexidine gluconate [CHG] bathing, and CHG mouthwash) or control group (2 preoperative showers with antiseptic soap). Colonization status was reassessed preoperatively. The primary endpoint was absence of SA at all 4 screened body sites.
Of 427 participants screened between August 31, 2011, and August 9, 2016, 127 participants (29.7%) were SA carriers. Of these, 121 were randomized and 110 were eligible for efficacy analysis (57 decolonization bundle group, 53 control group). Overall, 90% of evaluable participants had methicillin-susceptible SA strains. Eradication of SA at all body sites was achieved for 41 of 57 participants (71.9%) in the decolonization bundle group and for 13 of 53 participants (24.5%) in the control group, a difference of 47.4% (95% confidence interval [CI], 29.1%–65.7%; P<.0001).
An outpatient preoperative antiseptic decolonization bundle aimed at 4 body sites was significantly more effective in eradicating SA than the usual disinfectant showers (ie, the control).
We surveyed resident physicians at 2 academic medical centers regarding urinary testing and treatment as they progressed through training. Demographics and self-reported confidence were compared to overall knowledge using clinical vignette-based questions. Overall knowledge was 40% in 2011 and increased to 48%, 55%, and 63% in subsequent years (P<.001).
Just war, international law, and world order are all historically conditioned realities that interrelate with one another in complex ways. This paper explores their historical development and current status while critically examining their interrelationship. It begins with exploring just war as a basic frame for analysis and interconnection with the other two realities. Just war is not an abstract body of moral thought but instead a practically informed morality of war rooted in Christian thought and law, Roman law, and the practice of statecraft. The essay notes the importance of the ideas of jus gentium and jus naturale in just war's fundamental formation, as well as the parallel between its three basic features—sovereign authority, just cause, and the end of peace—and the three goods or ends of politics as classically defined, namely, order, justice, and peace. The essay then moves out to explore the historical and thematic relations between just war tradition and international law, especially the law of war, arguing that these together define a moral and legal structure that is normative for world order. The final section of the paper considers the functioning of the institutions of world order in the context of challenges from rival cultural understandings of war, law, and world order and from the rise of nonstate actors in the international sphere, arguing for dialogical efforts aimed at strengthening both the moral and legal basis for world order against contemporary threats to that order.
Accurate modeling of ice sheets requires proper information on boundary conditions, including the geothermal heat flow (or heat-flow density (HFD)). Traditionally, one uniform HFD value is adopted for the entire modeled domain. We have calculated a distributed, high-resolution HFD dataset for an approximate core area (Sweden and Finland) of the Scandinavian ice sheet, and imbedded this within lower-resolution data published for surrounding regions. Within the Last Glacial Maximum ice margin, HFD varies with a factor of as much as 2.8 (HFD values ranging between 30 and 83 mWm–2), with an average of 49 mWm–2. This average value is 17% higher than 42 mWm–2, a common uniform value used in ice-sheet modeling studies of Fennoscandia. Using this new distributed dataset on HFD, instead of a traditional uniform value of 42 mWm–2, yields a 1.4 times larger total basal meltwater production for the last glacial cycle. Furthermore, using the new dataset in high-resolution modeling results in increased spatial thermal gradients at the bed. This enhances and introduces new local and regional effects on basal ice temperatures and melt rates. We observed significant strengthening of local ‘ice streaming’, which in one case correlates to an ice-flow event previously interpreted from geomorphology. Regional to local variations in geothermal heat flow need to be considered for proper identification and treatment of thermal and hydraulic bed conditions, most likely also when studying Laurentide, Greenland and Antarctic ice sheets.
In the latter half of the twentieth century, lasting memories of two world wars and astonishment over the power of nuclear weapons left both policymakers and scholars of war largely preoccupied with the possibility of a catastrophic World War III. Instead, however, the face of war since 1945 has been that of regionally limited small wars and insurgencies fought with conventional weapons. Many of these conflicts began as armed rebellions against colonial regimes, but often later evolved into armed conflicts between and among various subgroups seeking control of state government. Such conflicts have usually been asymmetrical, with the party holding the reins of state power using aircraft, artillery, and armored vehicles, while those fighting against the regime have been limited to weapons that individuals can carry, such as automatic rifles, mortars, rocket-propelled grenade launchers, and improvised weapons of various sorts. The asymmetries have also typically gone deeper, with the fighters on the former side wearing uniforms and those on the latter often not; those on the former side making use of fortified bases and those on the latter side protecting themselves by blending in with the civilian population. Further, there have frequently been asymmetries in how each side has fought, with the militarily weaker side relying on stealth tactics, deception, and attacks against nonmilitary targets of more general public value, including direct attacks on people protected as noncombatants under the laws of war. The particular range of tactics classified as terrorism begins at this point, with the specific, direct, and intentional targeting of noncombatants. Such attacks not only have been the means of choice for transnational nonstate actors, including al-Qaeda and the self-styled Islamic State, but have also been used to considerable effect in local civil wars.
We present color-magnitude diagrams (CMDs) based on HST F555W (“V”) and F814W (“I”) observations of three old LMC clusters: NGC 2210, NGC 1786, and Reticulum. The fiducial derived from the CMD of NGC 2257, another LMC cluster, provided a good fit to the data for the new clusters. Because NGC 2257 has a similar metallicity ([Fe/H]∼ −1.8) to NGC 2210, NGC 1786, and Reticulum, the agreement between the CMDs of all four clusters indicates that they have the same age. This preliminary analysis suggests that any age differences are smaller than 2 Gyr. These new results mean that there are now 11 old LMC clusters with similar ages. An initial epoch of star cluster formation therefore happened in a short period over a large volume of space, a volume much larger than is now covered by the present-day optical LMC.
Local food systems are frequently touted as economic development strategies for rural communities. In this study, we estimated the local economic impacts of local compared with conventionally produced and marketed food in two regions of Missouri and one region in Nebraska. We found that local food systems generated substantial increases in value added for their local economies.
This study explored the combined impact of depression and inflammation on memory functioning among Mexican-American adults and elders.
Data were analyzed from 381 participants of the Health and Aging Brain study among Latino Elders (HABLE). Fasting serum samples were collected and assayed in duplicate using electrochemiluminesce on the SECTOR Imager 2400A from Meso Scale Discovery. Positive DepE (depression endophenotype) was codified as any score >1 on a five-point scale based on the GDS-30. Inflammation was determined by TNFα levels and categorized by tertiles (1st, 2nd, 3rd). WMS-III LMI and LMII as well as CERAD were utilized as measures of memory. ANOVAs examined group differences between positive DepE and inflammation tertiles with neuropsychological scale scores as outcome variables. Logistic regressions were used to examine level of inflammation and DepE positive status on the risk for MCI.
Positive DepE as well as higher inflammation were both independently found to be associated with lower memory scores. Among DepE positive, those who were high in inflammation (3rd tertile) were found to perform significantly worse on WMS-III LM I (F = 4.75, p = 0.003), WMS-III LM II (F = 8.18, p < 0.001), and CERAD List Learning (F = 17.37, p < 0.001) when compared to those low on inflammation (1st tertile). The combination of DepE positive and highest tertile of inflammation was associated with increased risk for MCI diagnosis (OR = 6.06; 95% CI = 3.9–11.2, p < 0.001).
Presence of elevated inflammation and positive DepE scores increased risk for worse memory among Mexican-American older adults. Additionally, the combination of DepE and high inflammation was associated with increased risk for MCI diagnosis. This work suggests that depression and inflammation are independently associated with worse memory among Mexican-American adults and elders; however, the combination of both increases risk for poorer memory beyond either alone.
The American Heart Association (AHA; Dallas, Texas USA) and European Resuscitation Council (Niel, Belgium) cardiac arrest (CA) guidelines recommend the intraosseous (IO) route when intravenous (IV) access cannot be obtained. Vasopressin has been used as an alternative to epinephrine to treat ventricular fibrillation (VF).
Limited data exist on the pharmacokinetics and resuscitative effects of vasopressin administered by the humeral IO (HIO) route for treatment of VF. The purpose of this study was to evaluate the effects of HIO and IV vasopressin, on the occurrence, odds, and time of return of spontaneous circulation (ROSC) and pharmacokinetic measures in a swine model of VF.
Twenty-seven Yorkshire-cross swine (60 to 80 kg) were assigned randomly to three groups: HIO (n=9), IV (n=9), and a control group (n=9). Ventricular fibrillation was induced and untreated for two minutes. Chest compressions began at two minutes post-arrest and vasopressin (40 U) administered at four minutes post-arrest. Serial blood specimens were collected for four minutes, then the swine were resuscitated until ROSC or 29 post-arrest minutes elapsed.
Fisher’s Exact test determined ROSC was significantly higher in the HIO 5/7 (71.5%) and IV 8/11 (72.7%) groups compared to the control 0/9 (0.0%; P=.001). Odds ratios of ROSC indicated no significant difference between the treatment groups (P=.68) but significant differences between the HIO and control, and the IV and control groups (P=.03 and .01, respectively). Analysis of Variance (ANOVA) indicated the mean time to ROSC for HIO and IV was 621.20 seconds (SD=204.21 seconds) and 554.50 seconds (SD=213.96 seconds), respectively, with no significant difference between the groups (U=11; P=.22). Multivariate Analysis of Variance (MANOVA) revealed the maximum plasma concentration (Cmax) and time to maximum concentration (Tmax) of vasopressin in the HIO and IV groups was 71753.9 pg/mL (SD=26744.58 pg/mL) and 61853.7 pg/mL (SD=22745.04 pg/mL); 111.42 seconds (SD=51.3 seconds) and 114.55 seconds (SD=55.02 seconds), respectively. Repeated measures ANOVA indicated no significant difference in plasma vasopressin concentrations between the treatment groups over four minutes (P=.48).
The HIO route delivered vasopressin effectively in a swine model of VF. Occurrence, time, and odds of ROSC, as well as pharmacokinetic measurements of HIO vasopressin, were comparable to IV.
BurgertJM, JohnsonAD, Garcia-BlancoJ, FultonLV, LoughrenMJ. The Resuscitative and Pharmacokinetic Effects of Humeral Intraosseous Vasopressin in a Swine Model of Ventricular Fibrillation. Prehosp Disaster Med. 2017;32(3):305–310.
The Numeniini is a tribe of 13 wader species (Scolopacidae, Charadriiformes) of which seven are Near Threatened or globally threatened, including two Critically Endangered. To help inform conservation management and policy responses, we present the results of an expert assessment of the threats that members of this taxonomic group face across migratory flyways. Most threats are increasing in intensity, particularly in non-breeding areas, where habitat loss resulting from residential and commercial development, aquaculture, mining, transport, disturbance, problematic invasive species, pollution and climate change were regarded as having the greatest detrimental impact. Fewer threats (mining, disturbance, problematic native species and climate change) were identified as widely affecting breeding areas. Numeniini populations face the greatest number of non-breeding threats in the East Asian-Australasian Flyway, especially those associated with coastal reclamation; related threats were also identified across the Central and Atlantic Americas, and East Atlantic flyways. Threats on the breeding grounds were greatest in Central and Atlantic Americas, East Atlantic and West Asian flyways. Three priority actions were associated with monitoring and research: to monitor breeding population trends (which for species breeding in remote areas may best be achieved through surveys at key non-breeding sites), to deploy tracking technologies to identify migratory connectivity, and to monitor land-cover change across breeding and non-breeding areas. Two priority actions were focused on conservation and policy responses: to identify and effectively protect key non-breeding sites across all flyways (particularly in the East Asian- Australasian Flyway), and to implement successful conservation interventions at a sufficient scale across human-dominated landscapes for species’ recovery to be achieved. If implemented urgently, these measures in combination have the potential to alter the current population declines of many Numeniini species and provide a template for the conservation of other groups of threatened species.
Inequalities in college access are a major concern for policymakers in both developed and developing countries. Policymakers in China have largely tried to address these inequalities by helping disadvantaged students successfully transition from high school to college. However, they have paid less attention to the possibility that inequalities in college access may also arise earlier in the pathway to college. The purpose of this paper is to understand where inequalities emerge along the pathway to college in China, focusing on three major milestones after junior high. By analysing administrative data on over 300,000 students from one region of China, we find that the largest inequalities in college access emerge at the first post-compulsory milestone along the pathway to college: when students transition from junior high to high school. In particular, only 60 per cent of students from poor counties take the high school entrance exam (compared to nearly 100 per cent of students from non-poor counties). Furthermore, students from poor counties are about one and a half times less likely to attend academic high school and elite academic high school than students from non-poor counties.
The steady profile of a finite-amplitude kinematic wave on a glacier is calculated with the assumption that the wave velocity varies linearly with h1, the departure of the ice thickness from the datum state. If the flow of ice is due mainly to sliding of the glacier on its bed, the width of the calculated steady profile is several hundred times the datum state ice thickness. The width of an observed kinematic wave front on Nisqually Glacier, Mt. Rainier, Washington is at least an order of magnitude smaller than the calculated steady profile. This indicates that the observed steepening of the wave may be due to effects other than variation of wave velocity with ice thickness.
The effects on very low-frequency surface-impedence measurements of lateral variations commonly found in ice environments have been measured and modelled numerically using die quasi-static two-dimensional boundary-element method. Results indicate that surface-impedance measurements made in the vicinity of crevasses oriented perpendicular to the plane Of incidence, and those made in the vicinity of moraines and melt streams, can all show significant changes to the measured apparent resistivity. It is, therefore, misleading to use such measurements in the interpretation of ice depth.
We construct the complete network of 26,681 majority opinions written by the U.S. Supreme Court and the cases that cite them from 1791 to 2005. We describe a method for using the patterns in citations within and across cases to create importance scores that identify the most legally relevant precedents in the network of Supreme Court law at any given point in time. Our measures are superior to existing network-based alternatives and, for example, offer information regarding case importance not evident in simple citation counts. We also demonstrate the validity of our measures by showing that they are strongly correlated with the future citation behavior of state courts, the U.S. Courts of Appeals, and the U.S. Supreme Court. In so doing, we show that network analysis is a viable way of measuring how central a case is to law at the Court and suggest that it can be used to measure other legal concepts.
Operation Canine Lifeline was a tabletop exercise developed by students and faculty of Boston University School of Medicine’s Healthcare Emergency Management master’s program. The tabletop exercise led to discussion on current protocols for canines working in the field, what occurs if a canine encounters a toxin in the field, and what to do in situations of national security that require working with civilian agencies. This discussion led to the creation of a set of recommendations around providing prehospital veterinary care to government working dogs. The recommendations include a government-run veterinary toxicology hotline for the sole use of the government, issuing handlers deployment kits and preprogrammed smartphones that contain information on the care practices for dogs, and an increased effort for civilian integration, through local emergency medical services, in the emergency care of government canines. (Disaster Med Public Health Preparedness. 2017;11:15–20)