To save content items to your account,
please confirm that you agree to abide by our usage policies.
If this is the first time you use this feature, you will be asked to authorise Cambridge Core to connect with your account.
Find out more about saving content to .
To save content items to your Kindle, first ensure firstname.lastname@example.org
is added to your Approved Personal Document E-mail List under your Personal Document Settings
on the Manage Your Content and Devices page of your Amazon account. Then enter the ‘name’ part
of your Kindle email address below.
Find out more about saving to your Kindle.
Note you can select to save to either the @free.kindle.com or @kindle.com variations.
‘@free.kindle.com’ emails are free but can only be saved to your device when it is connected to wi-fi.
‘@kindle.com’ emails can be delivered even when you are not connected to wi-fi, but note that service fees apply.
The application and provision of prehospital care in disasters and mass-casualty incident response in Europe is currently being explored for opportunities to improve practice. The objective of this translational science study was to align common principles of approach and action and to identify how technology can assist and enhance response. To achieve this objective, the application of a modified Delphi methodology study based on statements derived from key findings of a scoping review was undertaken. This resulted in 18 triage, eight life support and damage control interventions, and 23 process consensus statements. These findings will be utilized in the development of evidence-based prehospital mass-casualty incident response tools and guidelines.
Aberrant reward functioning is implicated in depression. While attention precedes behavior and guides higher-order cognitive processes, reward learning from an attentional perspective – the effects of prior reward-learning on subsequent attention allocation – has been mainly overlooked.
The present study explored the effects of reward-based attentional learning in depression using two separate, yet complimentary, studies. In study 1, participants with high (HD) and low (LD) levels of depression symptoms were trained to divert their gaze toward one type of stimuli over another using a novel gaze-contingent music reward paradigm – music played when fixating the desired stimulus type and stopped when gazing the alternate one. Attention allocation was assessed before, during, and following training. In study 2, using negative reinforcement, the same attention allocation pattern was trained while substituting the appetitive music reward for gazing the desired stimulus type with the removal of an aversive sound (i.e. white noise).
In study 1 both groups showed the intended shift in attention allocation during training (online reward learning), while generalization of learning at post-training was only evident among LD participants. Conversely, in study 2 both groups showed post-training generalization. Results were maintained when introducing anxiety as a covariate, and when using a more powerful sensitivity analysis. Finally, HD participants showed higher learning speed than LD participants during initial online learning, but only when using negative, not positive, reinforcement.
Deficient generalization of learning characterizes the attentional system of HD individuals, but only when using reward-based positive reinforcement, not negative reinforcement.
Misdiagnosis of bacterial pneumonia increases risk of exposure to inappropriate antibiotics and adverse events. We developed a diagnosis calculator (https://calculator.testingwisely.com) to inform clinical diagnosis of community-acquired bacterial pneumonia using objective indicators, including incidence of disease, risk factors, and sensitivity and specificity of diagnostic tests, that were identified through literature review.
Determination of whether vascular catheter disinfecting antiseptic-containing caps alone are effective at decreasing microbial colonization of connectors compared to antiseptic-containing caps plus a 5-second alcohol manual disinfection.
The study was conducted in a 718-bed, tertiary-care, academic hospital.
A convenience sample of adult patients across intensive care units and acute care wards with peripheral and central venous catheters covered with antiseptic-containing caps.
Quality improvement study completed over 5 days. The standard-of-care group consisted of catheter connectors with antiseptic-containing caps cleaned with a 5-second alcohol wipe scrub prior to culture. The comparison group consisted of catheter connectors with antiseptic-containing caps without a 5-second alcohol wipe scrub prior to culture. The connectors were pressed directly onto blood agar plates and incubated. Plates were assessed for growth after 48-72 hours.
In total, 356 catheter connectors were cultured: 165 in the standard-of-care group, 165 in the comparison group, and 26 catheters connectors without an antiseptic-containing cap, which were designated as controls. Overall, 18 catheter connectors (5.06%) yielded microbial growth. Of the 18 connectors with microbial growth, 2 (1.21%) were from the comparison group, 1 (0.61%) was from the standard-of-care group, and 15 were controls without an antiseptic-containing cap.
Bacterial colonization rates were similar between the catheter connectors cultured with antiseptic-containing caps alone and catheter connectors with antiseptic-containing caps cultured after a 5-second scrub with alcohol. This finding suggests that the use of antiseptic-containing caps precludes the need for additional disinfection.
Repetitive transcranial magnetic stimulation (rTMS) is used for treatment of late-life depression. In the FOUR-D study, sequential bilateral theta-burst stimulation (TBS) had comparable remission rates to standard bilateral rTMS. Data were analysed from the FOUR-D trial to compare remission rates between two types of rTMS based on the number and class of prior medication trials. The remission rate was higher in participants with ≤1 previous trial (43.9%) than in participants with 2 previous trials (26.5%) or ≥3 previous trials (24.6%; χ² = 6.36, d.f. = 2, P = 0.04). Utilising rTMS earlier in late-life depression may lead to better outcomes.
In a survey of infection prevention programs, leaders reported frequent clinical and infection prevention practice modifications to avoid coronavirus disease 2019 (COVID-19) exposure that exceeded national guidance. Future pandemic responses should emphasize balanced approaches to precautions, prioritize educational campaigns to manage safety concerns, and generate an evidence-base that can guide appropriate infection prevention practices.
Multiplex polymerase chain reaction (PCR) respiratory panels are rapid, highly sensitive tests for viral and bacterial pathogens that cause respiratory infections. In this study, we (1) described best practices in the implementation of respiratory panels based on expert perspectives and (2) identified tools for diagnostic stewardship to enhance the usefulness of testing.
We conducted a survey of the Society for Healthcare Epidemiology of America Research Network to explore current and future approaches to diagnostic stewardship of multiplex PCR respiratory panels.
In total, 41 sites completed the survey (response rate, 50%). Multiplex PCR respiratory panels were perceived as supporting accurate diagnoses at 35 sites (85%), supporting more efficient patient care at 33 sites (80%), and improving patient outcomes at 23 sites (56%). Thirteen sites (32%) reported that testing may support diagnosis or patient care without improving patient outcomes. Furthermore, 24 sites (58%) had implemented diagnostic stewardship, with a median of 3 interventions (interquartile range, 1–4) per site. The interventions most frequently reported as effective were structured order sets to guide test ordering (4 sites), restrictions on test ordering based on clinician or patient characteristics (3 sites), and structured communication of results (2 sites). Education was reported as “helpful” but with limitations (3 sites).
Many hospital epidemiologists and experts in infectious diseases perceive multiplex PCR respiratory panels as useful tests that can improve diagnosis, patient care, and patient outcomes. However, institutions frequently employ diagnostic stewardship to enhance the usefulness of testing, including most commonly clinical decision support to guide test ordering.
The Horus and other research teams have found that atherosclerosis is not uncommon in ancient people through the study of their mummified remains (Murphy et al., 2003; Allam et al., 2009, 2011; Thompson et al., 2013, 2014). However, some have postulated that traditional hunter-gatherers are in some ways healthier than modern people and that they had very little atherosclerotic disease (O’Keefe et al., 2010).
We assess emerging relationships between production decisions and market channel selection among a small sample of hemp growers (22) in Colorado and Kentucky using qualitative interviews. We found producers differences by market channel, product and state. For instance, producers who relied on intermediated marketing strategies cultivated more acres on average and used fewer distinct market channels and strategies than those relying on direct markets. Product differences were found regarding processing, storage and perishability. Respondents identified four factors critical to their choice of market channels for their hemp products: research, profitability, trust and knowledge. The findings can help inform public and private decision-making regarding best hemp marketing practices and future needs of the hemp industry.
Gaps in the implementation of effective interventions impact nearly all cancer prevention and control strategies in the US including Massachusetts. To close these implementation gaps, evidence-based interventions must be rapidly and equitably implemented in settings serving racially, ethnically, socioeconomically, and geographically diverse populations. This paper provides a brief overview of The Implementation Science Center for Cancer Control Equity (ISCCCE) and describes how we have operationalized our commitment to a robust community-engaged center that aims to close these gaps. We describe how ISCCCE is organized and how the principles of community-engaged research are embedded across the center. Principles of community engagement have been operationalized across all components of ISCCCE. We have intentionally integrated these principles throughout all structures and processes and have developed evaluation strategies to assess whether the quality of our partnerships reflects the principles. ISCCCE is a comprehensive community-engaged infrastructure for studying efficient, pragmatic, and equity-focused implementation and adaptation strategies for cancer prevention in historically and currently disadvantaged communities with built-in methods to evaluate the quality of community engagement. This engaged research center is designed to maximize the impact and relevance of implementation research on cancer control in community health centers.
Do all PhD students aspire to an academic career? Do PhD programs appropriately prepare students for the realities of the job market? There is a well-established gap between political science PhD graduates and tenure-track academic postings. The mismatch between PhD graduates and academic positions may point to alternative models of doctoral education as a possible solution. However, the survey of Canadian and Australian PhD students described in this article suggests that issues and challenges are common regardless of the model of doctoral education. Canadian PhDs report more mentoring activity, but they also are more fixated on securing academic positions. However, we find important gender differences across countries: men are more interested in an academic career and only a (disproportionately male) minority is confident that they will succeed in securing a faculty career. This raises questions about diversity in the future of the profession. This research suggests that although students have different experiences under different doctoral models, issues of academic jobs and a mismatch are common in both systems.
Satellite remote sensing is transforming coastal science from a “data-poor” field into a “data-rich” field. Sandy beaches are dynamic landscapes that change in response to long-term pressures, short-term pulses, and anthropogenic interventions. Until recently, the rate and breadth of beach change have outpaced our ability to monitor those changes, due to the spatiotemporal limitations of our observational capacity. Over the past several decades, only a handful of beaches worldwide have been regularly monitored with accurate yet expensive in situ surveys. The long-term coastal-change data of these few well-monitored beaches have led to in-depth understanding of many site-specific coastal processes. However, because the best-monitored beaches are not representative of all beaches, much remains unknown about the processes and fate of the other >99% of unmonitored beaches worldwide. The fleet of Earth-observing satellites has enabled multiscale monitoring of beaches, for the very first time, by providing imagery with global coverage and up to daily frequency. The long-standing and ever-expanding archive of satellite imagery will enable coastal scientists to investigate coastal change at sites vulnerable to future sea-level rise, that is, (almost) everywhere. In the past decade, our capability to observe coastal change from space has grown substantially with computing and algorithmic power. Yet, further advances are needed in automating monitoring using machine learning, deep learning, and computer vision to fully leverage this massive treasure trove of data. Extensive monitoring and investigation of the causes and effects of coastal change at the requisite spatiotemporal scales will provide coastal managers with additional, valuable information to evaluate problems and solutions, addressing the potential for widespread beach loss due to accelerated sea-level rise, development, and reduced sediment supply. Monitoring from Earth-observing satellites is currently the only means of providing seamless data with high spatiotemporal resolution at the global scale of the impending impacts of climate change on coastal systems.
The balance between neurotoxic and neuroprotective effects of kynurenine pathway (KP) components has been recently proposed as a key element in the pathophysiology of bipolar disorder (BD) and related mood episodes. This comprehensive overview explored the link of KP with symptom severity and other clinical features of BD.
We searched Medline, Embase, and PsycInfo electronic databases for studies assessing the association of peripheral and/or central concentrations of KP metabolites with putative clinical features, including symptom severity and other clinical domains in BD.
We included the findings of 13 observational studies investigating the possible variations of KP metabolites according to symptom severity, psychotic features, suicidal behaviors, and sleep disturbances in BD. Studies testing the relationship between KP metabolites and depression severity generated mixed and inconsistent findings. No statistically significant correlations with manic symptoms were found. Moreover, heterogeneous variations of the KP across different clinical domains were shown. Few available studies found (a) higher levels of cerebrospinal fluid kynurenic acid and lower of plasma quinolinic acid in BD with psychotic features, (b) lower central and peripheral picolinic acid levels in BD with suicide attempts, and (c) no significant correlations between KP metabolites and BD-related sleep disturbances.
An imbalance of KP metabolism toward the neurotoxic branches is likely to occur in people with BD, though evidence on variations according to specific clinical features of BD is less clear. Additional research is needed to clarify the role of KP in the etiopathogenesis of BD and related clinical features.
Shallow firn cores, in addition to a near-basal ice core, were recovered in 2018 from the Quelccaya ice cap (5470 m a.s.l) in the Cordillera Vilcanota, Peru, and in 2017 from the Nevado Illimani glacier (6350 m a.s.l) in the Cordillera Real, Bolivia. The two sites are ~450 km apart. Despite meltwater percolation resulting from warming, particle-based trace element records (e.g. Fe, Mg, K) in the Quelccaya and Illimani shallow cores retain well-preserved signals. The firn core chronologies, established independently by annual layer counting, show a convincing overlap indicating the two records contain comparable signals and therefore capture similar regional scale climatology. Trace element records at a ~1–4 cm resolution provide past records of anthropogenic emissions, dust sources, volcanic emissions, evaporite salts and marine-sourced air masses. Using novel ultra-high-resolution (120 μm) laser technology, we identify annual layer thicknesses ranging from 0.3 to 0.8 cm in a section of 2000-year-old radiocarbon-dated near-basal ice which compared to the previous annual layer estimates suggests that Quelccaya ice cores drilled to bedrock may be older than previously suggested by depth-age models. With the information collected from this study in combination with past studies, we emphasize the importance of collecting new surface-to-bedrock ice cores from at least the Quelccaya ice cap, in particular, due to its projected disappearance as soon as the 2050s.
The study objective was to determine the feasibility of training physicians in the principles of the National Incident Management System (NIMS) and Incident Command System (ICS) as applied to in-hospital rapid responses and to assess physicians’ attitudes regarding rapid responses.
This was an educational pilot study. Resident physicians completed a pre-survey, followed by online training in the principles of NIMS and ICS, a knowledge test, and a post-survey.
The number of residents who participated was 22. In the pre-survey, most (20/22) did not have a working understanding of NIMS/ICS. Participants (21/22) agreed that residents should have more training in resource organization. On the knowledge test, the median score was 9.5/10. In the post-survey, participants felt more comfortable clearing extra resources from the scene (P < 0.001) and that it would be easier to keep track of resources (P < 0.001). Most indicated that they had a working understanding of NIMS/ICS (P < 0.001) and felt more comfortable establishing command using NIMS/ICS (P < 0.001). All agreed that they would consider using an NIMS/ICS-based structure on their next rapid response.
Training physicians in the principles of NIMS/ICS as they pertain to rapid responses is feasible and appears to change residents’ attitudes about rapid responses.
Background: Under ideal circumstances, multiplex molecular respiratory panels can support early all discontinuation of unnecessary antibiotics by facilitating diagnosis of viral infection. Our goal was to identify clinic situations in which a positive respiratory panel was associated with antibiotic de-escalation. We focused on gram-negative antibiotics in recognition of the urgent threat posed by gram-negative resistance. Methods: The sample included hospitalized adults tested by respiratory panel while receiving gram-negative antibiotics at the University of Maryland Medical Center from 2015 to 2020. Only the first respiratory panel performed during hospitalization was included. The primary outcome was the combination of a positive result on respiratory panel indicating detection of a viral pathogen and de-escalation of gram-negative antibiotics. De-escalation was assessed based on antibiotics administered on day 3 after testing and was defined by discontinuation or switch to an agent with a narrower spectrum of activity. Least absolute shrinkage and selection operator (LASSO) regression was used to construct the multivariable logistic regression model. Classification and regression tree (CART) analysis was used to identify subgroups with a higher likelihood of the primary outcome. Results: Of 8,326 patients, 1,462 (17.6%) tested positive by respiratory panel. The most common pathogen was rhinovirus (7.9% of the sample). Gram-negative–targeted antibiotics were de-escalated in 4,456 cases (53.5% of the sample), including 887 patients with a positive result on respiratory panel indicating a viral pathogen (60.7% of patients with a positive viral result). LASSO regression was used to select 12 variables (Table 1). Admitting diagnosis of pneumonia (OR, 1.42), comorbid substance abuse (OR, 1.39), chronic pulmonary disease (OR, 1.39), and admission from home (OR, 1.34) were associated with antibiotic de-escalation in conjunction with a positive respiratory panel. Leukocytosis (OR, 0.59), hematologic malignancy (OR, 0.64), mechanical ventilation at time of testing (OR, 0.68), and hypotension (OR, 0.77) were associated with decreased likelihood of antibiotic de-escalation in conjunction with a positive respiratory panel. CART analysis identified patients tested within 40 hours of admission as having a higher likelihood of a positive result in conjunction with antibiotic de-escalation. Among patients tested within 40 hours of admission, the probability of a positive result followed by antibiotic de-escalation was 11.9% (95% CI, 11.1%–12.8%). For patients tested >40 hours after admission, the probability was 6.0% (95% CI, 4.8%–7.2%). Conclusions: Targeted use of respiratory panel testing may increase the likelihood of an informative result that can drive decision making related to antibiotic use. Our exploratory analysis suggests that respiratory panel testing in the first 2 days
Early in the COVID-19 pandemic, the World Health Organization stressed the importance of daily clinical assessments of infected patients, yet current approaches frequently consider cross-sectional timepoints, cumulative summary measures, or time-to-event analyses. Statistical methods are available that make use of the rich information content of longitudinal assessments. We demonstrate the use of a multistate transition model to assess the dynamic nature of COVID-19-associated critical illness using daily evaluations of COVID-19 patients from 9 academic hospitals. We describe the accessibility and utility of methods that consider the clinical trajectory of critically ill COVID-19 patients.
The incidence of infections from extended-spectrum β-lactamase (ESBL)–producing Enterobacterales (ESBL-E) is increasing in the United States. We describe the epidemiology of ESBL-E at 5 Emerging Infections Program (EIP) sites.
During October–December 2017, we piloted active laboratory- and population-based (New York, New Mexico, Tennessee) or sentinel (Colorado, Georgia) ESBL-E surveillance. An incident case was the first isolation from normally sterile body sites or urine of Escherichia coli or Klebsiella pneumoniae/oxytoca resistant to ≥1 extended-spectrum cephalosporin and nonresistant to all carbapenems tested at a clinical laboratory from a surveillance area resident in a 30-day period. Demographic and clinical data were obtained from medical records. The Centers for Disease Control and Prevention (CDC) performed reference antimicrobial susceptibility testing and whole-genome sequencing on a convenience sample of case isolates.
We identified 884 incident cases. The estimated annual incidence in sites conducting population-based surveillance was 199.7 per 100,000 population. Overall, 800 isolates (96%) were from urine, and 790 (89%) were E. coli. Also, 393 cases (47%) were community-associated. Among 136 isolates (15%) tested at the CDC, 122 (90%) met the surveillance definition phenotype; 114 (93%) of 122 were shown to be ESBL producers by clavulanate testing. In total, 111 (97%) of confirmed ESBL producers harbored a blaCTX-M gene. Among ESBL-producing E. coli isolates, 52 (54%) were ST131; 44% of these cases were community associated.
The burden of ESBL-E was high across surveillance sites, with nearly half of cases acquired in the community. EIP has implemented ongoing ESBL-E surveillance to inform prevention efforts, particularly in the community and to watch for the emergence of new ESBL-E strains.