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Background: Hospital-acquired Clostridioides difficile infection (HA-CDI) rates are highly variable over time, posing problems for research assessing interventions that might improve rates. By understanding seasonality in HA-CDI rates and the impacts that other factors such as influenza admissions might have on these rates, we can account for them when establishing the relationship between interventions and infection rates. We assessed whether there were seasonal trends in HA-CDI and whether they could be accounted for by influenza rates. Methods: We assessed HA-CDI rates per 10,000 patient days, and the rate of hospitalized patients with influenza per 1,000 admissions in 4 acute-care facilities (n = 2,490 beds) in Calgary, Alberta, from January 2016 to December 2018. We used 4 statistical approaches in R (version 3.5.1 software): (1) autoregressive integrated moving average (ARIMA) to assess dependencies and trends in each of the monthly HA-CDI and influenza series; (2) cross correlation to assess dependencies between the HA-CDI and influenza series lagged over time; (3) Poisson harmonic regression models (with sine and cosine components) to assess the seasonality of the rates; and (4) Poisson regression to determine whether influenza rates accounted for seasonality in the HA-CDI rates. Results: Conventional ARIMA approaches did not detect seasonality in the HA-CDI rates, but we found strong seasonality in the influenza rates. A cross-correlation analysis revealed evidence of correlation between the series at a lag of zero (R = 0.41; 95% CI, 0.10–0.65) and provided an indication of a seasonal relationship between the series (Fig. 1). Poisson regression suggested that influenza rates predicted CDI rates (P < .01). Using harmonic regression, there was evidence of seasonality in HA-CDI rates (2 [2 df] = 6.62; P < .05) and influenza rates (2 [2 df] = 1,796.6; P < .001). In a Poisson model of HA-CDI rates with both the harmonic components and influenza admission rates, the harmonic components were no longer predictive of HA-CDI rates. Conclusions: Harmonic regression provided a sensitive means of identifying seasonality in HA-CDI rates, but the seasonality effect was accounted for by influenza admission rates. The relationship between HA-CDI and influenza rates is likely mediated by antibiotic prescriptions, which needs to be assessed. To improve precision and reduce bias, research on interventions to reduce HA-CDI rates should assess historic seasonality in HA-CDI rates and should account for influenza admissions.
Background:Clostridioides difficile infection (CDI) is the most common cause of infectious diarrhea in hospitalized patients. Probiotics have been studied as a measure to prevent CDI. Timely probiotic administration to at-risk patients receiving systemic antimicrobials presents significant challenges. We sought to determine optimal implementation methods to administer probiotics to all adult inpatients aged 55 years receiving a course of systemic antimicrobials across an entire health region. Methods: Using a randomized stepped-wedge design across 4 acute-care hospitals (n = 2,490 beds), the probiotic Bio-K+ was prescribed daily to patients receiving systemic antimicrobials and was continued for 5 days after antimicrobial discontinuation. Focus groups and interviews were conducted to identify barriers, and the implementation strategy was adapted to address the key identified barriers. The implementation strategy included clinical decision support involving a linked flag on antibiotic ordering and a 1-click order entry within the electronic medical record (EMR), provider and patient education (written/videos/in-person), and local site champions. Protocol adherence was measured by tracking the number of patients on therapeutic antimicrobials that received BioK+ based on the bedside nursing EMR medication administration records. Adherence rates were sorted by hospital and unit in 48- and 72-hour intervals with recording of percentile distribution of time (days) to receipt of the first antimicrobial. Results: In total, 340 education sessions with >1,800 key stakeholders occurred before and during implementation across the 4 involved hospitals. The overall adherence of probiotic ordering for wards with antimicrobial orders was 78% and 80% at 48 and 72 hours, respectively over 72 patient months. Individual hospital adherence rates varied between 77% and 80% at 48 hours and between 79% and 83% at 72 hours. Of 246,144 scheduled probiotic orders, 94% were administered at the bedside within a median of 0.61 days (75th percentile, 0.88), 0.47 days (75th percentile, 0.86), 0.71 days (75th percentile, 0.92) and 0.67 days (75th percentile, 0.93), respectively, at the 4 sites after receipt of first antimicrobial. The key themes from the focus groups emphasized the usefulness of the linked flag alert for probiotics on antibiotic ordering, the ease of the EMR 1-click order entry, and the importance of the education sessions. Conclusions: Electronic clinical decision support, education, and local champion support achieved a high implementation rate consistent across all sites. Use of a 1-click order entry in the EMR was considered a key component of the success of the implementation and should be considered for any implementation strategy for a stewardship initiative. Achieving high prescribing adherence allows more precision in evaluating the effectiveness of the probiotic strategy.
Funding: Partnerships for Research and Innovation in the Health System, Alberta Innovates/Health Solutions Funding: Award
Psychosocial interventions that mitigate psychosocial distress in cancer patients are important. The primary aim of this study was to examine the feasibility and acceptability of an adaptation of the Mindful Self-Compassion (MSC) program among adult cancer patients. A secondary aim was to examine pre–post-program changes in psychosocial wellbeing.
The research design was a feasibility and acceptability study, with an examination of pre- to post-intervention changes in psychosocial measures. A study information pack was posted to 173 adult cancer patients 6 months–5 years post-diagnosis, with an invitation to attend an eight-week group-based adaptation of the MSC program.
Thirty-two (19%) consented to the program, with 30 commencing. Twenty-seven completed the program (mean age: 62.93 years, SD 14.04; 17 [63%] female), attending a mean 6.93 (SD 1.11) group sessions. There were no significant differences in medico-demographic factors between program-completers and those who did not consent. However, there was a trend toward shorter time since diagnosis in the program-completers group. Program-completers rated the program highly regarding content, relevance to the concerns of cancer patients, and the likelihood of recommending the program to other cancer patients. Sixty-three percent perceived that their mental wellbeing had improved from pre- to post-program; none perceived a deterioration in mental wellbeing. Small-to-medium effects were observed for depressive symptoms, fear of cancer recurrence, stress, loneliness, body image satisfaction, mindfulness, and self-compassion.
Significance of results
The MSC program appears feasible and acceptable to adults diagnosed with non-advanced cancer. The preliminary estimates of effect sizes in this sample suggest that participation in the program was associated with improvements in psychosocial wellbeing. Collectively, these findings suggest that there may be value in conducting an adequately powered randomized controlled trial to determine the efficacy of the MSC program in enhancing the psychosocial wellbeing of cancer patients.
This study reports on non-durational acoustic correlates of typologically rare word-initial consonant gemination in Kelantan Malay (KM) by focusing on two acoustic parameters – amplitude and f0. Given the unusual characteristics of the word-initial consonant contrast and its potential maintenance in domain-initial environments, this study sets to examine the extent to which amplitude and f0 can potentially characterise such a contrast in KM in addition to the cross-linguistically established acoustic correlate of closure duration. The production data involved elicited materials from sixteen KM native speakers. RMS and f0 values were measured at the start of the vowel following stops and sonorants produced in isolation (i.e. utterance-initial position) and in a carrier sentence (i.e. utterance-medial position). Results indicate that the consonant contrast is reflected in systematic differences in (i) vowel onset amplitude and f0 following the target consonant and (ii) the ratios of amplitude and f0 across two syllables of disyllabic words. There are also effects of utterance position, manner of articulation and voicing type on the magnitude of contrast between singletons and geminates with utterance-initial voiceless stops generally showing the greatest magnitude difference. The conclusion is drawn that the KM word-initial singleton/geminate consonant contrast can be associated with a set of acoustic parameters alongside closure duration.
A plausible mechanism underlying flavonoid-associated cognitive effects is increased cerebral blood flow (CBF). However, behavioural and CBF effects following flavanone-rich juice consumption have not been explored. The aim of this study was to investigate whether consumption of flavanone-rich juice is associated with acute cognitive benefits and increased regional CBF in healthy, young adults. An acute, single-blind, randomised, cross-over design was applied with two 500-ml drink conditions – high-flavanone (HF; 70·5 mg) drink and an energy-, and vitamin C- matched, zero-flavanone control. A total of twenty-four healthy young adults aged 18–30 years underwent cognitive testing at baseline and 2-h after drink consumption. A further sixteen, healthy, young adults were recruited for functional MRI assessment, whereby CBF was measured with arterial spin labelling during conscious resting state at baseline as well as 2 and 5 h after drink consumption. The HF drink was associated with significantly increased regional perfusion in the inferior and middle right frontal gyrus at 2 h relative to baseline and the control drink. In addition, the HF drink was associated with significantly improved performance on the Digit Symbol Substitution Test at 2 h relative to baseline and the control drink, but no effects were observed on any other behavioural cognitive tests. These results demonstrate that consumption of flavanone-rich citrus juice in quantities commonly consumed can acutely enhance blood flow to the brain in healthy, young adults. However, further studies are required to establish a direct causal link between increased CBF and enhanced behavioural outcomes following citrus juice ingestion.
There is limited evidence of the prevalence of enteric protozoon infections in developed settings. We estimated the prevalence of enteric protozoa and evaluated the outcome of testing algorithms used in hospital settings in Sydney, Australia. This retrospective study assessed microbiological data from four public clinical laboratories. Pooled data from the four hospitals revealed the most common enteric protozoon detected was Blastocystis spp. in an average of 5·4% of cases, followed by Giardia intestinalis (1·1%) and Dientamoeba fragilis (0·8%). Protozoon detection rates between hospitals were significantly different and could be based on multiple factors. The modified iron haematoxylin staining method, consistently detected higher rates of Blastocystis spp., and G. intestinalis in comparison with microscopy of wet preparations, as well as higher rates of G. intestinalis and Cryptosporidium when compared with enzyme immunoassay. The study concludes that there are multiple factors that contribute to the variability in protozoa detection rates in metropolitan hospitals, including widespread variability in the testing protocols for enteric protozoa, individual and population characteristics. A gold standard approach for diagnosis of enteric protozoa is recommended. Molecular diagnostic methods such as polymerase chain reaction would provide consistency across laboratories and yield more reliable estimates of the actual prevalence of enteric protozoa.
Advanced machine learning techniques like Gaussian process regression and multi-task learning are novel in the area of wine price prediction; previous research in this area being restricted to parametric linear regression models when predicting wine prices. Using historical price data of the 100 wines in the Liv-Ex 100 index, the main contributions of this paper to the field are, firstly, a clustering of the wines into two distinct clusters based on autocorrelation. Secondly, an implementation of Gaussian process regression on these wines with predictive accuracy surpassing both the trivial and simple ARMA and GARCH time series prediction benchmarks. Lastly, an implementation of an algorithm which performs multi-task feature learning with kernels on the wine returns as an extension to our optimal Gaussian process regression model. Using the optimal covariance kernel from Gaussian process regression, we achieve predictive results which are comparable to that of Gaussian process regression. Altogether, our research suggests that there is potential in using advanced machine learning techniques in wine price prediction. (JEL Classifications: C6, G12)
How did the kings of England and France govern their kingdoms? This volume, the product of a ten-year international project, brings together specialists in late medieval England and France to explore the multiple mechanisms by which monarchs exercised their power in the final centuries of the Middle Ages. Collaborative chapters, mostly co-written by experts on each kingdom, cover topics ranging from courts, military networks and public finance; office, justice and the men of the church; to political representation, petitioning, cultural conceptions of political society; and the role of those excluded from formal involvement in politics. The result is a richly detailed and innovative comparison of the nature of government and political life, seen from the point of view of how the king ruled his kingdom, but bringing to bear the methods of social, cultural and economic history to understand the underlying armature of royal power.
Smoking cessation interventions during routine clinical encounters by health professionals have the potential to reach smokers and facilitate cessation. Although psychologists might appear to be ideal providers of such interventions, international research suggests that their provision is limited. This paper reports the results of a survey conducted in NSW, Australia, of psychologists’ (n = 72) smoking intervention practices, attitudes, and barriers to providing such care. Less than half of the respondents reported assessing smoking status for ‘all or nearly all’ of their clients. Across a range of smoking cessation intervention types, the most frequent response given indicated provision to ‘none or almost none’ of clients who smoked. Only 13% of respondents indicated even ‘advising cessation’ to ‘all or nearly all’ of their smoking clients. Barriers included concern about negative influence on the therapeutic relationship, inadequacy of training and lack of confidence to intervene. Respondents were less likely to provide intervention for smoking than for cannabis, methamphetamine ‘ice’, and alcohol. The study suggests that the potential of Australian psychologists to assist smokers to quit is not being realised, and that there is a need to address the barriers to care provision.