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To determine the effect of an electronic medical record (EMR) nudge at reducing total and inappropriate orders testing for hospital-onset Clostridioides difficile infection (HO-CDI).
An interrupted time series analysis of HO-CDI orders 2 years before and 2 years after the implementation of an EMR intervention designed to reduce inappropriate HO-CDI testing. Orders for C. difficile testing were considered inappropriate if the patient had received a laxative or stool softener in the previous 24 hours.
Four hospitals in an academic healthcare network.
All patients with a C. difficile order after hospital day 3.
Orders for C. difficile testing in patients administered a laxative or stool softener in <24 hours triggered an EMR alert defaulting to cancellation of the order (“nudge”).
Of the 17,694 HO-CDI orders, 7% were inappropriate (8% prentervention vs 6% postintervention; P < .001). Monthly HO-CDI orders decreased by 21% postintervention (level-change rate ratio [RR], 0.79; 95% confidence interval [CI], 0.73–0.86), and the rate continued to decrease (postintervention trend change RR, 0.99; 95% CI, 0.98–1.00). The intervention was not associated with a level change in inappropriate HO-CDI orders (RR, 0.80; 95% CI, 0.61–1.05), but the postintervention inappropriate order rate decreased over time (RR, 0.95; 95% CI, 0.93–0.97).
An EMR nudge to minimize inappropriate ordering for C. difficile was effective at reducing HO-CDI orders, and likely contributed to decreasing the inappropriate HO-CDI order rate after the intervention.
A national need is to prepare for and respond to accidental or intentional disasters categorized as chemical, biological, radiological, nuclear, or explosive (CBRNE). These incidents require specific subject-matter expertise, yet have commonalities. We identify 7 core elements comprising CBRNE science that require integration for effective preparedness planning and public health and medical response and recovery. These core elements are (1) basic and clinical sciences, (2) modeling and systems management, (3) planning, (4) response and incident management, (5) recovery and resilience, (6) lessons learned, and (7) continuous improvement. A key feature is the ability of relevant subject matter experts to integrate information into response operations. We propose the CBRNE medical operations science support expert as a professional who (1) understands that CBRNE incidents require an integrated systems approach, (2) understands the key functions and contributions of CBRNE science practitioners, (3) helps direct strategic and tactical CBRNE planning and responses through first-hand experience, and (4) provides advice to senior decision-makers managing response activities. Recognition of both CBRNE science as a distinct competency and the establishment of the CBRNE medical operations science support expert informs the public of the enormous progress made, broadcasts opportunities for new talent, and enhances the sophistication and analytic expertise of senior managers planning for and responding to CBRNE incidents.
South-East Asia’s bird trade is of global conservation concern as it has massively depleted wild populations of many species. Parrots (Order Psittaciformes) are especially vulnerable because they are the most heavily traded group of birds globally under the Convention on International Trade in Endangered Species (CITES) appendices. Singapore’s involvement in the global pet bird trade as a transhipment hub is well documented, particularly for parrots. Yet, much less is known about the links between its domestic and international trade. We attempt to quantify this relationship by comparing bird trade data on the CITES database with past market surveys of pet shops, complemented with semi-structured interviews with 30 parrot owners in Singapore. We report a decline in total imports and exports of CITES-listed birds in Singapore from 2005 to 2016, consistent with global trends after the European Union trade ban on wild bird imports. However, parrots continue to make up the majority of total imports; and there was a yearly increase in the percentage of parrot imports out of total imports. In addition, we report a difference in imports and exports of 54,207 CITES I, II and III listed birds into Singapore i.e. birds imported but not re-exported. A substantial proportion of these birds were possibly channelled into the domestic pet trade or used as breeding stock. Interviews with parrot owners confirmed the growing demand and popularity of parrots and particularly of larger species. We conclude that the domestic demand for parrots may have been previously underestimated, and make recommendations to manage Singapore’s international and domestic pet bird trade such as implementing a licensing and records system to track the movement of birds.
Objectives: Studies of neurocognitively elite older adults, termed SuperAgers, have identified clinical predictors and neurobiological indicators of resilience against age-related neurocognitive decline. Despite rising rates of older persons living with HIV (PLWH), SuperAging (SA) in PLWH remains undefined. We aimed to establish neuropsychological criteria for SA in PLWH and examined clinically relevant correlates of SA. Methods: 734 PLWH and 123 HIV-uninfected participants between 50 and 64 years of age underwent neuropsychological and neuromedical evaluations. SA was defined as demographically corrected (i.e., sex, race/ethnicity, education) global neurocognitive performance within normal range for 25-year-olds. Remaining participants were labeled cognitively normal (CN) or impaired (CI) based on actual age. Chi-square and analysis of variance tests examined HIV group differences on neurocognitive status and demographics. Within PLWH, neurocognitive status differences were tested on HIV disease characteristics, medical comorbidities, and everyday functioning. Multinomial logistic regression explored independent predictors of neurocognitive status. Results: Neurocognitive status rates and demographic characteristics differed between PLWH (SA=17%; CN=38%; CI=45%) and HIV-uninfected participants (SA=35%; CN=55%; CI=11%). In PLWH, neurocognitive groups were comparable on demographic and HIV disease characteristics. Younger age, higher verbal IQ, absence of diabetes, fewer depressive symptoms, and lifetime cannabis use disorder increased likelihood of SA. SA reported increased independence in everyday functioning, employment, and health-related quality of life than non-SA. Conclusions: Despite combined neurological risk of aging and HIV, youthful neurocognitive performance is possible for older PLWH. SA relates to improved real-world functioning and may be better explained by cognitive reserve and maintenance of cardiometabolic and mental health than HIV disease severity. Future research investigating biomarker and lifestyle (e.g., physical activity) correlates of SA may help identify modifiable neuroprotective factors against HIV-related neurobiological aging. (JINS, 2019, 25, 507–519)
The north-west European population of Bewick’s Swan Cygnus columbianus bewickii declined by 38% between 1995 and 2010 and is listed as ‘Endangered’ on the European Red List of birds. Here, we combined information on food resources within the landscape with long-term data on swan numbers, habitat use, behaviour and two complementary measures of body condition, to examine whether changes in food type and availability have influenced the Bewick’s Swan’s use of their main wintering site in the UK, the Ouse Washes and surrounding fens. Maximum number of Bewick’s Swans rose from 620 in winter 1958/59 to a high of 7,491 in winter 2004/05, before falling to 1,073 birds in winter 2013/14. Between winters 1958/59 and 2014/15 the Ouse Washes supported between 0.5 and 37.9 % of the total population wintering in north-west Europe (mean ± 95 % CI = 18.1 ± 2.4 %). Swans fed on agricultural crops, shifting from post-harvest remains of root crops (e.g. sugar beet and potatoes) in November and December to winter-sown cereals (e.g. wheat) in January and February. Inter-annual variation in the area cultivated for these crops did not result in changes in the peak numbers of swans occurring on the Ouse Washes. Behavioural and body condition data indicated that food supplies on the Ouse Washes and surrounding fens remain adequate to allow the birds to gain and maintain good body condition throughout winter with no increase in foraging effort. Our findings suggest that the recent decline in numbers of Bewick’s Swans at this internationally important site was not linked to inadequate food resources.
Multituberculates were among the most taxonomically diverse mammals of the early Paleocene, having survived the catastrophic Cretaceous-Paleogene mass extinction and radiating soon thereafter. Although their evolution during the early Paleocene saw the advent of increasingly specialized dentitions, multituberculates generally remained small, rarely exceeding body sizes greater than those of extant rabbits. A conspicuous exception is the Taeniolabidoidea, a primarily North American clade whose members include the largest multituberculates yet discovered. Taeniolabidoidea includes several genera, with one of these, Catopsalis, being speciose and geographically wide ranging. Until recently, the chronological succession of Catopsalis appeared to document a trend of increasing body size. We report here on a new species of Catopsalis from the early Paleocene of Alberta that violates this trend and suggests that the evolutionary history of Catopsalis is considerably more complex. Catopsalis kakwa new species is not only the smallest species of Catopsalis, but is the smallest taeniolabidoid so far discovered, with an estimated body mass between 400 g and 660 g. In contrast to previous studies, we used recently proposed regressions based on lower cheek tooth row length to estimate body masses for North American taeniolabidoids. Our results propose more modest body mass estimates, particularly for the largest taeniolabidoids. The occurrence of C. kakwa n. sp. in the late early Paleocene implies either a significant ghost lineage, or reversal of several characters, including body size, during the latter part of the early Paleocene; the more likely of these scenarios must await a better understanding of the phylogenetic position of C. kakwa n. sp.
Surgical site infections (SSIs) following colorectal surgery (CRS) are among the most common healthcare-associated infections (HAIs). Reduction in colorectal SSI rates is an important goal for surgical quality improvement.
To examine rates of SSI in patients with and without cancer and to identify potential predictors of SSI risk following CRS
American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) data files for 2011–2013 from a sample of 12 National Comprehensive Cancer Network (NCCN) member institutions were combined. Pooled SSI rates for colorectal procedures were calculated and risk was evaluated. The independent importance of potential risk factors was assessed using logistic regression.
Of 22 invited NCCN centers, 11 participated (50%). Colorectal procedures were selected by principal procedure current procedural technology (CPT) code. Cancer was defined by International Classification of Disease, Ninth Revision, Clinical Modification (ICD-9-CM) codes.
The primary outcome of interest was 30-day SSI rate.
A total of 652 SSIs (11.06%) were reported among 5,893 CRSs. Risk of SSI was similar for patients with and without cancer. Among CRS patients with underlying cancer, disseminated cancer (SSI rate, 17.5%; odds ratio [OR], 1.66; 95% confidence interval [CI], 1.23–2.26; P=.001), ASA score ≥3 (OR, 1.41; 95% CI, 1.09–1.83; P=.001), chronic obstructive pulmonary disease (COPD; OR, 1.6; 95% CI, 1.06–2.53; P=.02), and longer duration of procedure were associated with development of SSI.
Patients with disseminated cancer are at a higher risk for developing SSI. ASA score >3, COPD, and longer duration of surgery predict SSI risk. Disseminated cancer should be further evaluated by the Centers for Disease Control and Prevention (CDC) in generating risk-adjusted outcomes.
It is known that tungsten oxide may be reacted with selenium sources to form WSe2 but literature reports include processing steps that involve high temperatures, reducing atmospheres, and/or oxidative pre-treatments of tungsten oxide. In this work, we report a non-vacuum process for the fabrication of compositionally high quality WSe2 thin films via the selenization of tungsten oxide under milder conditions. Tungsten source materials were various hydrated WO3 and WO2.9 compounds that were prepared using chemical solution techniques. Resulting films were selenized using a two-stage heating profile (250 °C for 15 minutes and 550 °C for 30 minutes) under a static argon atmosphere. Effects of the starting tungsten oxide phase on WSe2 formation after single and double selenization cycles were investigated using Raman spectroscopy and X-ray diffraction (XRD). After two selenization cycles, hydrated WO3 was converted to (002)-oriented WSe2 that exhibits well-resolved peaks for E12g and A1g phonon modes. Only a single selenization cycle was required to convert amorphous WO2.9 to WSe2. All selenizations in this work were achieved in non-reducing atmospheres and at lower temperatures and shorter times than any non-laser-assisted processes reported for WO3-to-WSe2 conversions.
Recent excavation at Ucheliungs Cave in Palau has provided new evidence in the debate concerning the colonisation of the Palauan archipelago. An abundance of faunal material and the presence of transported artefacts contradict a previous interpretation that the site represents an early burial cave containing purported small-bodied humans. New radiocarbon dates suggest long-term use of the cave for both mortuary activity and small-scale marine foraging that may slightly precede the accepted date for the earliest human occupation of Palau. The results of this research here discount earlier claims for insular dwarfism among the earliest inhabitants of these islands.
OBJECTIVES/SPECIFIC AIMS: To develop an algorithm that identifies post-concussion syndrome (PCS) cases and controls from among patients with mild traumatic brain injury (mTBI) in a large academic biobank. METHODS/STUDY POPULATION: The Vanderbilt University Medical Center’s (VUMC) electronic medical record (EMR) research database includes longitudinal medical record data on 2.5 million people. DNA and genotype data were also available for >225,000 of these individuals. Our algorithm used a combination of billing codes and natural language processing to apply inclusion and exclusion criteria. We defined PCS cases as those with a PCS billing code (ICD-9 310.2 or ICD-10 F07.81) and/or symptoms of PCS within 1–6 months of a qualifying mTBI. We will compare the positive predictive value of our algorithm to that of 2 simpler case selection schemes: (1) 1 instance of the PCS billing code anywhere in the medical record; and (2) 2 or more instances of the PCS billing code anywhere in the medical record. RESULTS/ANTICIPATED RESULTS: An mTBI was diagnosed in 28,720 patients regularly attending VUMC, and 528 of these patients were classified as PCS cases by our algorithm. The characteristics of our EMR sample reflected known risk factors for PCS. Our cases were more likely than controls to be female (49.4% vs. 38.4%), to have sustained a previous TBI (31.0% vs. 12.0%) and to have comorbid mood disorders. Our PCS cases were also more likely than controls to be <18 years of age (42.4% vs. 33.6%) and to have a sports-related keyword associated with the mTBI (44.1% vs. 25.2%), emphasizing the relevance of PCS to young athletes. Nonetheless, the number of PCS cases identified by our algorithm was small, and within the VUMC EMR, there were 5039 patients with 1 PCS billing code, and 2457 patients with 2 or more PCS billing codes anywhere in their EMR. Our next step is to calculate the positive predictive values of each selection scheme by manually reviewing the EMR of a selection of cases. Ultimately, we will implement the selection scheme that maximizes both positive predictive value and sample size, and in future work, we will genotype the selected patients to better understand the genetic architecture of PCS. DISCUSSION/SIGNIFICANCE OF IMPACT: EMR and biobanks are the future of human health research, and we asked whether complex algorithms or simple billing codes were best for studying the genetics of recovery after mTBI within the VUMC EMR. Our results are relevant to other studies of brain injury phenotypes within biobanks, including recovery from moderate or severe TBI, recovery from stroke, or the occurrence of delirium after routine surgery, and will help transform biobanks into fruitful research tools.
Objectives: One of the most prominent features of schizophrenia is relatively lower general cognitive ability (GCA). An emerging approach to understanding the roots of variation in GCA relies on network properties of the brain. In this multi-center study, we determined global characteristics of brain networks using graph theory and related these to GCA in healthy controls and individuals with schizophrenia. Methods: Participants (N=116 controls, 80 patients with schizophrenia) were recruited from four sites. GCA was represented by the first principal component of a large battery of neurocognitive tests. Graph metrics were derived from diffusion-weighted imaging. Results: The global metrics of longer characteristic path length and reduced overall connectivity predicted lower GCA across groups, and group differences were noted for both variables. Measures of clustering, efficiency, and modularity did not differ across groups or predict GCA. Follow-up analyses investigated three topological types of connectivity—connections among high degree “rich club” nodes, “feeder” connections to these rich club nodes, and “local” connections not involving the rich club. Rich club and local connectivity predicted performance across groups. In a subsample (N=101 controls, 56 patients), a genetic measure reflecting mutation load, based on rare copy number deletions, was associated with longer characteristic path length. Conclusions: Results highlight the importance of characteristic path lengths and rich club connectivity for GCA and provide no evidence for group differences in the relationships between graph metrics and GCA. (JINS, 2016, 22, 240–249)
It is unclear to what extent the traditional distinction between
neurological and psychiatric disorders reflects biological
To examine neuroimaging evidence for the distinction between neurological
and psychiatric disorders.
We performed an activation likelihood estimation meta-analysis on
voxel-based morphometry studies reporting decreased grey matter in 14
neurological and 10 psychiatric disorders, and compared the regional and
network-level alterations for these two classes of disease. In addition,
we estimated neuroanatomical heterogeneity within and between the two
Basal ganglia, insula, sensorimotor and temporal cortex showed greater
impairment in neurological disorders; whereas cingulate, medial frontal,
superior frontal and occipital cortex showed greater impairment in
psychiatric disorders. The two classes of disorders affected distinct
functional networks. Similarity within classes was higher than between
classes; furthermore, similarity within class was higher for neurological
than psychiatric disorders.
From a neuroimaging perspective, neurological and psychiatric disorders
represent two distinct classes of disorders.
Lifelong learning is believed to have physical, social and emotional benefits for older adults. In recognition of this, numerous programmes encouraging learning in later life exist worldwide. One example is the University of the Third Age (U3A) – a lifelong learning co-operative rooted in peer-support and knowledge sharing. This article is based on a collaborative study conducted by university researchers and members of a U3A in North-East England (United Kingdom) investigating the social inclusivity of the group in light of low attendance levels among those from social housing and non-professional backgrounds. A qualitative approach comprising semi-structured interviews and focus groups was adopted to explore knowledge and experience of lifelong learning and the U3A. Sixty individuals aged 50+ were interviewed. The demographic profile of participants largely reflected the socio-economic make-up of the area, with the majority living in areas of high socio-economic deprivation. Several barriers to lifelong learning were revealed, including: poor health, insufficient transport and caring responsibilities. Regarding U3A participation, three exclusionary factors were outlined: lack of knowledge, organisational name and location. Poor comprehension of the purpose and remit of the U3A can result in the development of ‘middle-class' myths regarding membership, perpetuating poor participation rates among lower socio-economic groups. Such perceptions must be dispelled to allow the U3A to fulfil its potential as a highly inclusive organisation.