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To evaluate whether incorporating mandatory prior authorization for Clostridioides difficile testing into antimicrobial stewardship pharmacist workflow could reduce testing in patients with alternative etiologies for diarrhea.
Single center, quasi-experimental before-and-after study.
Tertiary-care, academic medical center in Ann Arbor, Michigan.
Adult and pediatric patients admitted between September 11, 2019 and December 10, 2019 were included if they had an order placed for 1 of the following: (1) C. difficile enzyme immunoassay (EIA) in patients hospitalized >72 hours and received laxatives, oral contrast, or initiated tube feeds within the prior 48 hours, (2) repeat molecular multiplex gastrointestinal pathogen panel (GIPAN) testing, or (3) GIPAN testing in patients hospitalized >72 hours.
A best-practice alert prompting prior authorization by the antimicrobial stewardship program (ASP) for EIA or GIPAN testing was implemented. Approval required the provider to page the ASP pharmacist and discuss rationale for testing. The provider could not proceed with the order if ASP approval was not obtained.
An average of 2.5 requests per day were received over the 3-month intervention period. The weekly rate of EIA and GIPAN orders per 1,000 patient days decreased significantly from 6.05 ± 0.94 to 4.87 ± 0.78 (IRR, 0.72; 95% CI, 0.56–0.93; P = .010) and from 1.72 ± 0.37 to 0.89 ± 0.29 (IRR, 0.53; 95% CI, 0.37–0.77; P = .001), respectively.
We identified an efficient, effective C. difficile and GIPAN diagnostic stewardship approval model.
To inform the efficient allocation of testing resources, we evaluated the characteristics of those tested for COVID-19 to determine predictors of a positive test. Recent travel and exposure to a confirmed case were both highly predictive of positive testing. Symptom-based screening strategies alone may be inadequate to control the ongoing pandemic.
Twenty-six percent of children experience a traumatic event by the age of 4. Negative events during childhood have deleterious correlates later in life, including antisocial behavior. However, the mechanisms that play into this relation are unclear. We explored deficits in neurocognitive functioning, specifically problems in passive avoidance, a construct with elements of inhibitory control and learning as a potential acquired mediator for the pathway between cumulative early childhood adversity from birth to age 7 and later antisocial behavior through age 18, using prospective longitudinal data from 585 participants. Path analyses showed that cumulative early childhood adversity predicted impaired passive avoidance during adolescence and increased antisocial behavior during late adolescence. Furthermore, poor neurocognition, namely, passive avoidance, predicted later antisocial behavior and significantly mediated the relation between cumulative early childhood adversity and later antisocial behavior. This research has implications for understanding the development of later antisocial behavior and points to a potential target for neurocognitive intervention within the pathway from cumulative early childhood adversity to later antisocial behavior.
The measurement of thin film mechanical properties free from substrate influence remains one of the outstanding challenges in nanomechanics. Here, a technique based on indentation of a supported film with a flat punch whose diameter is many times the initial film thickness is introduced. This geometry generates a state of confined uniaxial strain for material beneath the punch, allowing direct access to intrinsic stress versus strain response. For simple elastic–plastic materials, this enables material parameters such as elastic modulus, bulk modulus, Poisson's ratio, and yield stress to be simultaneously determined from a single loading curve. The phenomenon of confined plastic yield has not been previously observed in thin films or homogeneous materials, which we demonstrate here for 170 -470 nm thick polystyrene (PS), polymethyl-methacrylate (PMMA) and amorphous Selenium films on silicon. As well as performing full elastic -plastic parameter extraction for these materials at room temperature, we used the technique to study the variation of yield stress in PS to temperatures above the nominal glass transition of 100 °C.
Continued reliance on chemical methods for controlling annual bluegrass has resulted in many populations evolving resistance to PRE and POST herbicides, particularly in warm-season turfgrass species such as zoysiagrass. Soil seedbank management is critically important when managing herbicide-resistant weeds. Fraise mowing (also spelled fraze, frase, and fraize) is a new turfgrass cultivation practice designed to remove aboveground biomass while allowing turf to regrow vegetatively. We hypothesized that this process would remove annual bluegrass seed and therefore be a mechanical means of controlling annual bluegrass in turfgrass. Zoysiagrass field plots were fraise-mowed in June 2015 only, June 2016 only, June 2015 and June 2016, or left untreated. The fraise mower was configured to remove the uppermost 25 mm of plot surface (i.e., 15-mm verdure and 10-mm soil). Annual bluegrass infestation was quantified in April following fraise mowing via grid count. Soil cores (10.8 cm diameter) were extracted from each plot after grid count data were collected to assess effects of fraise mowing on the soil seedbank. Moreover, replicated subsamples (7.6 L) of debris generated during fraise mowing were collected to better understand weed seed content removed during the fraise mowing process. Fraise mowing in June offered a slight reduction (24%) in annual bluegrass cover the following April. Whereas 28% of the seed in fraise-mowing debris consisted of annual bluegrass, there was no difference in the quantity of annual bluegrass seed remaining in the soil seedbank among fraise-mowed and non–fraise-mowed plots. Although fraise mowing may help to temporarily reduce existing annual bluegrass infestations via mechanical removal, the frequency and depth we studied did not effectively reduce the seedbank. Fraise mowing is a useful tool for providing mechanical suppression of annual bluegrass but it is not a replacement for properly timed herbicide applications.
Nanoindentation and microcrystal deformation are two methods that allow probing size effects in crystal plasticity. In many cases of microcrystal deformation, scale-free and potentially universal intermittency of event sizes during plastic flow has been revealed, whereas nanoindentation has been mainly used to assess the stress statistics of the first pop-in. Here, we show that both methods of deformation exhibit fundamentally different event-size statistics obtained from plastic instabilities. Nanoindentation results in scale-dependent intermittent microplasticity best described by Weibull statistics (stress and magnitude of the first pop-in) and lognormal statistics (magnitude of higher-order pop-ins). In contrast, finite-volume microcrystal deformation of the same material exhibits microplastic event-size intermittency of truncated power-law type even when the same plastic volume as in nanoindentation is probed. Furthermore, we successfully test a previously proposed extreme-value statistics model that relates the average first critical stress to the shape and scale parameter of the underlying Weibull distribution.
The diagnosis of anti-N-methyl-d-aspartate receptor (NMDAR) encephalitis relies on the detection of NMDAR IgG autoantibodies in the serum or cerebrospinal fluid (CSF) of symptomatic patients. Commercial kits are available that allow NMDAR IgG autoantibodies to be measured in local laboratories. However, the performance of these tests outside of reference laboratories is unknown.
To report an unexpectedly low rate of NMDAR autoantibody detection in serum from patients with anti-NMDAR encephalitis tested using a commercially available diagnostic kit in an exemplar clinical laboratory.
Paired CSF and serum samples from seven patients with definite anti-NMDAR encephalitis were tested for NMDAR IgG autoantibodies using commercially available cell-based assays run according to manufacturer’s recommendations. Rates of autoantibody detection in serum tested at our center were compared with those derived from systematic review and meta-analyses incorporating studies published during or before March 2019.
NMDAR IgG autoantibodies were detected in the CSF of all patients tested at our clinical laboratory but not in paired serum samples. Rates of the detection were lower than those previously reported. A similar association was recognized through meta-analyses, with lower odds of NMDAR IgG autoantibody detection associated with serum testing performed in nonreference laboratories.
Commercial kits may yield lower-than-expected rates of NMDAR IgG autoantibody detection in serum when run in exemplar clinical (nonreference) laboratories. Additional studies are needed to decipher the factors that contribute to lower-than-expected rates of serum positivity. CSF testing is recommended in patients with suspected anti-NMDAR encephalitis.
We discuss the process of estimating the ecosystem service value (ESV) for provisioning of non-timber forest products (NTFPs) to market, with a focus on the United States. NTFPs are harvested throughout the U.S. for numerous purposes, and those sold in market contribute significantly to household and local economies. While estimates of ESV can aid decision-making related to conservation and management, NTFPs have been generally neglected. We discuss challenges and approaches for prioritizing valuation, quantifying production, measuring costs and benefits, and finding data sources. Many NTFP markets are informal, and market players may have an interest in withholding information. Data about geographic and temporal distribution, production cost, quantity harvested, and price may therefore be limited. In two case studies, we explore the nuances of estimating ESV of forests for medicinal products.
In patients with β-lactam allergies, administration of non–β-lactam surgical prophylaxis is associated with increased risk of infection. Although many patients self-report β-lactam allergies, most are unconfirmed or mislabeled. A quality improvement process, utilizing a structured β-lactam allergy tool, was implemented to improve the utilization of preferred β-lactam surgical prophylaxis.
Disaster Medicine (DM) education for Emergency Medicine (EM) residents is highly variable due to time constraints, competing priorities, and program expertise. The investigators’ aim was to define and prioritize DM core competencies for EM residency programs through consensus opinion of experts and EM professional organization representatives.
Investigators utilized a modified Delphi methodology to generate a recommended, prioritized core curriculum of 40 DM educational topics for EM residencies.
The DM topics recommended and outlined for inclusion in EM residency training included: patient triage in disasters, surge capacity, introduction to disaster nomenclature, blast injuries, hospital disaster mitigation, preparedness, planning and response, hospital response to chemical mass-casualty incident (MCI), decontamination indications and issues, trauma MCI, disaster exercises and training, biological agents, personal protective equipment, and hospital response to radiation MCI.
This expert-consensus-driven, prioritized ranking of DM topics may serve as the core curriculum for US EM residency programs.
Item 9 of the Patient Health Questionnaire-9 (PHQ-9) queries about thoughts of death and self-harm, but not suicidality. Although it is sometimes used to assess suicide risk, most positive responses are not associated with suicidality. The PHQ-8, which omits Item 9, is thus increasingly used in research. We assessed equivalency of total score correlations and the diagnostic accuracy to detect major depression of the PHQ-8 and PHQ-9.
We conducted an individual patient data meta-analysis. We fit bivariate random-effects models to assess diagnostic accuracy.
16 742 participants (2097 major depression cases) from 54 studies were included. The correlation between PHQ-8 and PHQ-9 scores was 0.996 (95% confidence interval 0.996 to 0.996). The standard cutoff score of 10 for the PHQ-9 maximized sensitivity + specificity for the PHQ-8 among studies that used a semi-structured diagnostic interview reference standard (N = 27). At cutoff 10, the PHQ-8 was less sensitive by 0.02 (−0.06 to 0.00) and more specific by 0.01 (0.00 to 0.01) among those studies (N = 27), with similar results for studies that used other types of interviews (N = 27). For all 54 primary studies combined, across all cutoffs, the PHQ-8 was less sensitive than the PHQ-9 by 0.00 to 0.05 (0.03 at cutoff 10), and specificity was within 0.01 for all cutoffs (0.00 to 0.01).
PHQ-8 and PHQ-9 total scores were similar. Sensitivity may be minimally reduced with the PHQ-8, but specificity is similar.
The Society of Academic Emergency Medicine Disaster Medicine Interest Group, the Office of the Assistant Secretary for Preparedness and Response – Technical Resources, Assistance Center, and Information Exchange (ASPR TRACIE) team, and the National Institutes of Health Library searched disaster medicine peer-reviewed and gray literature to identify, review, and disseminate the most important new research in this field for academics and practitioners.
MEDLINE/PubMed and Scopus databases were searched with key words. Additional gray literature and focused hand search were performed. A Level I review of titles and abstracts with inclusion criteria of disaster medicine, health care system, and disaster type concepts was performed. Eight reviewers performed Level II full-text review and formal scoring for overall quality, impact, clarity, and importance, with scoring ranging from 0 to 20. Reviewers summarized and critiqued articles scoring 16.5 and above.
Articles totaling 1176 were identified, and 347 were screened in a Level II review. Of these, 193 (56%) were Original Research, 117 (34%) Case Report or other, and 37 (11%) were Review/Meta-Analysis. The average final score after a Level II review was 11.34. Eighteen articles scored 16.5 or higher. Of the 18 articles, 9 (50%) were Case Report or other, 7 (39%) were Original Research, and 2 (11%) were Review/Meta-Analysis.
This first review highlighted the breadth of disaster medicine, including emerging infectious disease outbreaks, terror attacks, and natural disasters. We hope this review becomes an annual source of actionable, pertinent literature for the emerging field of disaster medicine.
Blockchain is a distributed ledger technology for storing and transmitting information (value) that is secure, verifiable, and auditable. Two specific use-case opportunities exist, identity management and payment systems.
A secure and auditable solution for disaster refugee support.
Gap analysis, literature search, and synthesis using existing technologies.
Strategy foundation: A blockchain identity management system that utilizes the Hyperledger Fabric framework; identification on a large scale, in a distributed model that provides immutable record capabilities to prevent fraud, with the ability to incorporate biometrics and DNA; deploy applications that will provide supply-chain capabilities; cryptocurrency for recipients and other relief functions for refugees/disaster victims; components such as consensus, membership services, and Smart Contracts; cloud-based, with redundancies in multiple vendors and additional complex government cloud requirements/certifications, leveraging NIST 800–53 by utilizing a hybrid public permissions architecture.
There are an estimated 68 million refugees worldwide at any time. Valid identification is needed by most refugees to qualify for government or international donor relief. That identification is crucial in getting refugees and victims access to the aid supply chain. Blockchain stores data on a large number of computer nodes connected over the Internet. Each node contains an identical copy that is time-stamped and protected by a cryptographic technique called hashing, and control is decentralized. This blockchain strategy will revolutionize the way the government manages the $30 billion in foreign aid to refugees. It will build upon the identities established to deploy applications that will provide supply-chain capabilities, cryptocurrency for recipients, and other relief functions for refugees/disaster victims. Stakeholders beyond government will also benefit tremendously. The distributed nature of our application will provide visibility to NGOs, nonprofits, host nation stakeholders, and other relief organizations. A single system that provides information to everyone involved will almost instantaneously change the face of relief.
N95 respirator masks are recommended for protection against respiratory viruses. Despite passing fit-testing 10% of N95 respirator users encountered breakthroughs with exposure to influenza virus compared to full protection provided by a powered air purifying respirator. The current recommendation of N95 respirators should be evaluated for endemic and emerging scenarios.
Common reed [Phragmites australis (Cav.) Trin. ex Steud.], an aggressive invader in North American wetlands, is likely to undergo a range expansion as the climate changes. Increased atmospheric [CO2] and temperature have been shown to cause morphological and physiological changes in many species, sometimes altering the way they respond to herbicides. To understand how climate-related environmental parameters may impact P. australis management, we grew two P. australis haplotypes (the Gulf Coast type and the Eurasian type) under ambient (400 ppm CO2, 32/21 C) or elevated (650 ppm CO2, 35/24 C) climate conditions. After 6 wk, the Gulf Coast type had reduced leaf area, increased stomatal conductance, and increased transpiration under the elevated conditions. The Eurasian type had lower Vcmax (the maximum carboxylation rate of Rubisco) and lower Jmax (the maximum electron transport rate of RuBP regeneration) under elevated climate conditions. Results likely reflected a greater impact of higher temperatures rather than increased [CO2]. After the 6-wk period, plants were either treated with glyphosate (0.57 kg ae ha−1) or remained an untreated control. Data were collected 30 d after treatment (DAT) and 60 DAT to evaluate herbicide efficacy. Overall, the Gulf Coast type was less responsive to glyphosate applications under the elevated climate conditions than under current climate conditions. The lower leaf area of the Gulf Coast type in these climate conditions may have resulted in less herbicide interception and uptake. Glyphosate efficacy was less impacted by climate treatment for the Eurasian type than for the Gulf Coast type.
Different diagnostic interviews are used as reference standards for major depression classification in research. Semi-structured interviews involve clinical judgement, whereas fully structured interviews are completely scripted. The Mini International Neuropsychiatric Interview (MINI), a brief fully structured interview, is also sometimes used. It is not known whether interview method is associated with probability of major depression classification.
To evaluate the association between interview method and odds of major depression classification, controlling for depressive symptom scores and participant characteristics.
Data collected for an individual participant data meta-analysis of Patient Health Questionnaire-9 (PHQ-9) diagnostic accuracy were analysed and binomial generalised linear mixed models were fit.
A total of 17 158 participants (2287 with major depression) from 57 primary studies were analysed. Among fully structured interviews, odds of major depression were higher for the MINI compared with the Composite International Diagnostic Interview (CIDI) (odds ratio (OR) = 2.10; 95% CI = 1.15–3.87). Compared with semi-structured interviews, fully structured interviews (MINI excluded) were non-significantly more likely to classify participants with low-level depressive symptoms (PHQ-9 scores ≤6) as having major depression (OR = 3.13; 95% CI = 0.98–10.00), similarly likely for moderate-level symptoms (PHQ-9 scores 7–15) (OR = 0.96; 95% CI = 0.56–1.66) and significantly less likely for high-level symptoms (PHQ-9 scores ≥16) (OR = 0.50; 95% CI = 0.26–0.97).
The MINI may identify more people as depressed than the CIDI, and semi-structured and fully structured interviews may not be interchangeable methods, but these results should be replicated.
Declaration of interest
Drs Jetté and Patten declare that they received a grant, outside the submitted work, from the Hotchkiss Brain Institute, which was jointly funded by the Institute and Pfizer. Pfizer was the original sponsor of the development of the PHQ-9, which is now in the public domain. Dr Chan is a steering committee member or consultant of Astra Zeneca, Bayer, Lilly, MSD and Pfizer. She has received sponsorships and honorarium for giving lectures and providing consultancy and her affiliated institution has received research grants from these companies. Dr Hegerl declares that within the past 3 years, he was an advisory board member for Lundbeck, Servier and Otsuka Pharma; a consultant for Bayer Pharma; and a speaker for Medice Arzneimittel, Novartis, and Roche Pharma, all outside the submitted work. Dr Inagaki declares that he has received grants from Novartis Pharma, lecture fees from Pfizer, Mochida, Shionogi, Sumitomo Dainippon Pharma, Daiichi-Sankyo, Meiji Seika and Takeda, and royalties from Nippon Hyoron Sha, Nanzando, Seiwa Shoten, Igaku-shoin and Technomics, all outside of the submitted work. Dr Yamada reports personal fees from Meiji Seika Pharma Co., Ltd., MSD K.K., Asahi Kasei Pharma Corporation, Seishin Shobo, Seiwa Shoten Co., Ltd., Igaku-shoin Ltd., Chugai Igakusha and Sentan Igakusha, all outside the submitted work. All other authors declare no competing interests. No funder had any role in the design and conduct of the study; collection, management, analysis and interpretation of the data; preparation, review or approval of the manuscript; and decision to submit the manuscript for publication.
Polarization-dependent absorption spectra of two functionalized derivatives of fluorinated anthradithiophene, diF TES-ADT and diF TDMS-ADT, were studied in the crystal phase using a Holstein-like Hamiltonian. For both molecules, the primary contribution to the lowest energy absorption was found to be the S0-S1 excitonic transition perturbed by an intermolecular coupling of 15 meV for both TES and TDMS. A secondary contribution, consistent with that from charge-transfer states, was also found. Additionally, absorption spectra were analysed when crystals were placed inside of optical microcavities formed by two metal mirrors. Cavities exhibited a primary absorption peak determined to be an enhanced absorption from the lowest-energy S0-S1 transition.