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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
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.
It has long been recognized that astronomy was a catalyst of the Scientific Revolution, spurring on deeply consequential speculation about the nature of the cosmos and its physical principles. Yet the history of celestial physics is far richer than was thought a generation ago, and there is much to be learned about the origins of the field, particularly in the sixteenth century, when humanist activity brought forth a dazzling array of philosophical possibility—from reconsiderations of Aristotle and Islamicate commentary to the revival of Platonic, Epicurean, and Stoic worldviews. Celestial physics offered some of the most heated arguments for or against the Aristotelian cosmos, with controversial attempts to account for astronomical observation by integrating various causal innovations. This chapter will focus on a number of themes that mark celestial physics and cosmological speculation in the sixteenth and early seventeenth centuries: the order of the celestial bodies and their nature, the relationship between celestial and terrestrial things, the question of celestial animism or vitalism, and the status of the divine in celestial nature.
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.
Numerous areas of skull base neurosurgery and interventional neuroradiology overlap. Interventional neuroradiology techniques can often be employed in combination with open skull base surgery to provide solutions to complex cerebrovascular and oncological problems. This chapter describes the indications for, and technical nuances of, combined microsurgical and endovascular treatment of cerebrovascular and skull base disease. In particular, three major disease states are discussed: intracranial aneurysms, arteriovenous malformations of the brain and dura, and skull base tumors.
One of the main capabilities of atom probe tomography (APT) is the ability to not only identify but also characterize early stages of precipitation at length scales that are not achievable by other techniques. One of the most popular methods to identify nanoscale clustering in APT data, based on the density-based spatial clustering of applications with noise (DBSCAN), is used extensively in many branches of research. However, it is common that not all of the steps leading to the selection of certain parameters used in the analysis are reported. Without knowing the rationale behind parameter selection, it may be difficult to compare cluster parameters obtained by different researchers. In this work, a simple open-source tool, PosgenPy, is used to justify cluster search parameter selection via providing a systematic sweep through parameter values with multiple randomizations to minimize a false-positive cluster ratio. The tool is applied to several different microstructures: a simulated material system and two experimental datasets from a low-alloy steel . The analyses show how values for the various parameters can be selected to ensure that the calculated cluster number density and cluster composition are accurate.
The objective of this study was to investigate changes in serum biomarkers of acute brain injury, including white matter and astrocyte injury during chronic foetal hypoxaemia. We have previously shown histopathological changes in myelination and neuronal density in fetuses with chronic foetal hypoxaemia at a level consistent with CHD.
Mid-gestation foetal sheep (110 ± 3 days gestation) were cannulated and attached to a pumpless, low-resistance oxygenator circuit, and incubated in a sterile fluid environment mimicking the intrauterine environment. Fetuses were maintained with an oxygen delivery of 20–25 ml/kg/min (normoxemia) or 14–16 ml/kg/min (hypoxaemia). Myelin Basic Protein and Glial Fibrillary Acidic Protein serum levels in the two groups were assessed by ELISA at baseline and at 7, 14, and 21 days of support.
Based on overlapping 95% confidence intervals, there were no statistically significant differences in either Myelin Basic Protein or Glial Fibrillary Acidic Protein serum levels between the normoxemic and hypoxemic groups, at any time point. No statistically significant correlations were observed between oxygen delivery and levels of Myelin Basic Protein and Glial Fibrillary Acidic Protein.
Chronic foetal hypoxaemia during mid-gestation is not associated with elevated serum levels of acute white matter (Myelin Basic Protein) or astrocyte injury (Glial Fibrillary Acidic Protein), in this model. In conjunction with our previously reported findings, our data support the hypothesis that the brain dysmaturity with impaired myelination found in fetuses with chronic hypoxaemia is caused by disruption of normal developmental pathways rather than by direct cellular injury.
The 1960s-era, Nashville nonviolent civil rights movement—with its iconic lunch counter sit-ins—was not only an exemplary local movement that dismantled Jim Crow in downtown public accommodations. It was by design the chief vehicle for the intergenerational mentoring and training of activists that led to a dialogical diffusion of nonviolence praxis throughout the Southern civil rights movement of this period. In this article, we empirically derive from oral-history interviews with activists and archival sources a new “intergenerational model of movement mobilization” and assess its contextual and bridge-leading sustaining factors. After reviewing the literatures on dialogical diffusion and bridge building in social movements, we describe the model and its sustaining conditions—historical, demographic, and spatial conditions—and conclude by presenting a research agenda on the sustainability and generalizability of the Nashville model.
To investigate the relationship between the systemic inflammatory response syndrome (SIRS), early antibiotic use, and bacteremia in solid-tumor patients.
Design, setting, and participants:
We conducted a retrospective observational study of adults with solid tumors admitted to a tertiary-care hospital through the emergency department over a 2-year period. Patients with neutropenic fever, organ transplant, trauma, or cardiopulmonary arrest were excluded.
Rates of SIRS, bacteremia, and early antibiotics (initiation within 8 hours of presentation) were compared using the χ2 and Student t tests. Binomial regression and receiver operator curves were analyzed to assess predictors of bacteremia and early antibiotics.
Early antibiotics were administered in 507 (37%) of 1,344 SIRS-positive cases and 492 (22%) of 2,236 SIRS-negative cases (P < .0001). Of SIRS-positive cases, 70% had blood cultures drawn within 48 hours and 19% were positive; among SIRS negative cases, 35% had cultures and 13% were positive (19% vs 13%; P = .003). Bacteremic cases were more often SIRS positive than nonbacteremic cases (60% vs 50%; P =.003), but they received early antibiotics at similar rates (50% vs 49%, P = .72). Three SIRS components predicted early antibiotics: temperature (OR, 1.7; 95% CI, 1.31–2.29; P = .0001), tachycardia (OR, 1.4; 95% CI, 1.10–1.69; P < .0001), and white blood-cell count (OR, 1.8; 95% CI, 1.56–2.14; P < .0001). Only temperature (OR, 1.6; 95% CI, 1.09–2.41; P = .01) and tachycardia (OR, 1.5; 95% CI, 1.09–2.06; P = .01) predicted bacteremia. SIRS criteria as a composite were poorly predictive of bacteremia (AUC, 0.57).
SIRS criteria are frequently used to determine the need for early antibiotics, but they are poor predictors of bacteremia in solid-tumor patients. More reliable models are needed to guide judicious use of antibiotics in this population.
The vehicle exterior design conveys a variety of visual information. Among these are the brand identity, assumed characteristics, and the vehicle's age or newness. While previous research focusses mainly on the first two attributes, we broaden the perspective by examining the age perception for vehicle model portfolios across brands.
Information of age is embedded not only in branding but also in the entirety of a vehicle's exterior design features. Therefore, this paper examines how participants of a self-reported study perceive individual models inside successive product portfolios without typical branding. The stimulus patterns were derived from 12 different series of BMW, Mercedes-Benz and Audi and edited accordingly. A total of 67 models from the years 1968 to 2019 were presented and evaluated in terms of perceived age, model and brand recognition.
The results show that most vehicles are perceived as newer than their actual age, successive model generations are clearly distinguishable and participants were able to sort all models in their correct chronological order. Finally, design-related age perception and knowledge-based age perception are introduced as possible underlying concepts of the visual perception of product age.
During March 27–July 14, 2020, the Centers for Disease Control and Prevention’s National Healthcare Safety Network extended its surveillance to hospital capacities responding to COVID-19 pandemic. The data showed wide variations across hospitals in case burden, bed occupancies, ventilator usage, and healthcare personnel and supply status. These data were used to inform emergency responses.
Posttraumatic stress disorder (PTSD) and major depressive disorder (MDD) are commonly reported co-occurring mental health consequences of psychological trauma exposure. The disorders have high genetic overlap. Trauma is a complex phenotype but research suggests that trauma sensitivity has a heritable basis. We investigated whether sensitivity to trauma in those with MDD reflects a similar genetic component in those with PTSD.
Genetic correlations between PTSD and MDD in individuals reporting trauma and MDD in individuals not reporting trauma were estimated, as well as with recurrent MDD and single-episode MDD, using genome-wide association study (GWAS) summary statistics. Genetic correlations were replicated using PTSD data from the Psychiatric Genomics Consortium and the Million Veteran Program. Polygenic risk scores were generated in UK Biobank participants who met the criteria for lifetime MDD (N = 29 471). We investigated whether genetic loading for PTSD was associated with reporting trauma in these individuals.
Genetic loading for PTSD was significantly associated with reporting trauma in individuals with MDD [OR 1.04 (95% CI 1.01–1.07), Empirical-p = 0.02]. PTSD was significantly more genetically correlated with recurrent MDD than with MDD in individuals not reporting trauma (rg differences = ~0.2, p < 0.008). Participants who had experienced recurrent MDD reported significantly higher rates of trauma than participants who had experienced single-episode MDD (χ2 > 166, p < 0.001)
Our findings point towards the existence of genetic variants associated with trauma sensitivity that might be shared between PTSD and MDD, although replication with better powered GWAS is needed. Our findings corroborate previous research highlighting trauma exposure as a key risk factor for recurrent MDD.
Foraminifera are important components of tropical marine benthic ecosystems and their recovery pattern from the end-Permian mass extinction can yield insights into the Mesozoic history of this group. Here we report the calcareous and agglutinated foraminifera recovered from five measured stratigraphic sections on the Great Bank of Guizhou, an uppermost Permian to Upper Triassic isolated carbonate platform in the Nanpanjiang Basin, south China. The material contains >100 Triassic species, including three that are newly described (Arenovidalina weii n. sp., Meandrospira? enosi n. sp., and Spinoendotebanella lehrmanni n. gen., n. sp.), ranging from Griesbachian (Induan) to Cordevolian (Carnian) age. The species belong to the classes Miliolata, Textulariata, Fusulinata, Nodosariata, and to an unknown class housing all aragonitic forms of the orders Involutinida and Robertinida. Based on previously established conodont zones and carbon isotope chemostratigraphy, the Griesbachian (early Induan) through Illyrian (late Anisian) interval has been subdivided into 12 foraminiferal zones and two unnamed intervals devoid of foraminifera. Following the extinction at the Permian-Triassic boundary, habitable ecological niches of Griesbachian age were invaded by disaster taxa that subsequently became extinct during the Dienerian (late Induan) and left no younger descendants. The disaster taxa were replaced by Lazarus taxa with Permian origins, which were then decimated by the Smithian-Spathian (mid-Olenekian) boundary crisis. The tempo of recovery appears to have been modulated by environmental changes during the Griesbachian through Smithian that involved both climate change and expansion of anoxic ocean bottom waters. Uninterrupted and lasting recovery of benthic foraminifera did not begin until the Spathian.
The carrasco is a dense, shrubby vegetation type that covers the higher parts of table-top mountains in north-eastern Brazil. The vegetation of this phytophysiognomy is often considered to have biogeographical and ecological affinities with the cerrado of Central Brazil, but the biogeographical affinities of its avifauna remain unclear. In recent years, deforestation due to local economic activities has been particularly severe in some carrasco-dominated landscapes. In 2013, we initiated avian surveys at the Fazenda Pau D‘Arco, a privately owned property located on top of the Araripe Plateau, to evaluate the effects of a legal forest management program on the avifauna. Here, we present the results of four years of avian inventories to: i) characterize a well-preserved patch of carrasco vegetation; ii) assess avian biogeographical affinities of this vegetation type; iii) identify associations between managed/unmanaged areas and bird species; and iv) provide baseline data for future avian monitoring studies. Using different survey methods, we provide a list of 148 bird species, including several dry-forest specialists and caatinga endemics. Biogeographically, the avifauna of the carrasco represents a subsample of the Caatinga dry forest, lacking cerrado elements. Forest management significantly affected the distribution of several bird species in the study area. We found that 1/5 of the species (24) recorded during our standardized surveys were significantly associated with either unmanaged (14 species) or managed (10 species) areas. Species such as the Ceará Leaftosser Sclerurus cearensis, a globally vulnerable species, have only been detected in non-managed areas and therefore can be negatively affected by the management program. We also present data on 16 avian taxa with ecological and conservation concerns. By presenting a fairly complete and documented list of the avifauna, we characterize the carrasco avifauna and offer the tools to evaluate the effects of forest management on this poorly known vegetation type.
Data reported to the Centers for Disease Control and Prevention’s National Healthcare Safety Network (CDC NHSN) were analyzed to understand the potential impact of the COVID-19 pandemic on central-line–associated bloodstream infections (CLABSIs) in acute-care hospitals. Descriptive analysis of the standardized infection ratio (SIR) was conducted by location, location type, geographic area, and bed size.
Real-life decisions are often complex because they involve making sequential choices that constrain future options. We have previously shown that to render such multi-step decisions manageable, people ‘prune’ (i.e. selectively disregard) branches of decision trees that contain negative outcomes. We have theorized that sub-optimal pruning contributes to depression by promoting an oversampling of branches that result in unsavoury outcomes, which results in a negatively-biased valuation of the world. However, no study has tested this theory in depressed individuals.
Thirty unmedicated depressed and 31 healthy participants were administered a sequential reinforcement-based decision-making task to determine pruning behaviours, and completed measures of depression and anxiety. Computational, Bayesian and frequentist analyses examined group differences in task performance and relationships between pruning and depressive symptoms.
Consistent with prior findings, participants robustly pruned branches of decision trees that began with large losses, regardless of the potential utility of those branches. However, there was no group difference in pruning behaviours. Further, there was no relationship between pruning and levels of depression/anxiety.
We found no evidence that sub-optimal pruning is evident in depression. Future research could determine whether maladaptive pruning behaviours are observable in specific sub-groups of depressed patients (e.g. in treatment-resistant individuals), or whether misuse of other heuristics may contribute to depression.
The rapid spread of severe acute respiratory coronavirus virus 2 (SARS-CoV-2) throughout key regions of the United States in early 2020 placed a premium on timely, national surveillance of hospital patient censuses. To meet that need, the Centers for Disease Control and Prevention’s National Healthcare Safety Network (NHSN), the nation’s largest hospital surveillance system, launched a module for collecting hospital coronavirus disease 2019 (COVID-19) data. We present time-series estimates of the critical hospital capacity indicators from April 1 to July 14, 2020.
From March 27 to July 14, 2020, the NHSN collected daily data on hospital bed occupancy, number of hospitalized patients with COVID-19, and the availability and/or use of mechanical ventilators. Time series were constructed using multiple imputation and survey weighting to allow near–real-time daily national and state estimates to be computed.
During the pandemic’s April peak in the United States, among an estimated 431,000 total inpatients, 84,000 (19%) had COVID-19. Although the number of inpatients with COVID-19 decreased from April to July, the proportion of occupied inpatient beds increased steadily. COVID-19 hospitalizations increased from mid-June in the South and Southwest regions after stay-at-home restrictions were eased. The proportion of inpatients with COVID-19 on ventilators decreased from April to July.
The NHSN hospital capacity estimates served as important, near–real-time indicators of the pandemic’s magnitude, spread, and impact, providing quantitative guidance for the public health response. Use of the estimates detected the rise of hospitalizations in specific geographic regions in June after they declined from a peak in April. Patient outcomes appeared to improve from early April to mid-July.
In this article, we discuss the backgrounds and technical details about several smart manufacturing projects in a tier-one electronics manufacturing facility. We devise a process to manage logistic forecast and inventory preparation for electronic parts using historical data and a recurrent neural network to achieve significant improvement over current methods. We present a system for automatically qualifying laptop software for mass production through computer vision and automation technology. The result is a reliable system that can save hundreds of man-years in the qualification process. Finally, we create a deep learning-based algorithm for visual inspection of product appearances, which requires significantly less defect training data compared to traditional approaches. For production needs, we design an automatic optical inspection machine suitable for our algorithm and process. We also discuss the issues for data collection and enabling smart manufacturing projects in a factory setting, where the projects operate on a delicate balance between process innovations and cost-saving measures.
Functional benefits of the morphologies described by Bergmann's and Allen's rules in human males have recently been reported. However, the functional implications of ecogeographical patterning in females remain poorly understood. Here, we report the findings of preliminary work analysing the association between body shape and performance in female ultramarathon runners (n = 36) competing in hot and cold environments. The body shapes differed between finishers of hot and cold races, and also between hot race finishers and non-finishers. Variability in race performance across different settings supports the notion that human phenotype is adapted to different thermal environments as ecogeographical patterns have reported previously. This report provides support for the recent hypothesis that the heightened thermal strain associated with prolonged physical activity in hot/cold environments may have driven the emergence of thermally adaptive phenotypes in our evolutionary past. These results also tentatively suggest that the relationship between morphology and performance may be stronger in female vs. male athletes. This potential sex difference is discussed with reference to the evolved unique energetic context of human female reproduction. Further work, with a larger sample size, is required to investigate the observed potential sex differences in the strength of the relationship between phenotype and performance.
Sink drains in healthcare facilities may provide an environment for antimicrobial-resistant microorganisms, including carbapenemase-producing Klebsiella pneumoniae (CPKP).
We investigated the colonization of a biofilm consortia by CPKP in a model system simulating a sink-drain P-trap. Centers for Disease Control (CDC) biofilm reactors (CBRs) were inoculated with microbial consortia originally recovered from 2 P-traps collected from separate patient rooms (designated rooms A and B) in a hospital. Biofilms were grown on stainless steel (SS) or polyvinyl chloride (PVC) coupons in autoclaved municipal drinking water (ATW) for 7 or 28 days.
Microbial communities in model systems (designated CBR-A or CBR-B) were less diverse than communities in respective P-traps A and B, and they were primarily composed of β and γ Proteobacteria, as determined using 16S rRNA community analysis. Following biofilm development CBRs were inoculated with either K. pneumoniae ST45 (ie, strain CAV1016) or K. pneumoniae ST258 KPC+ (ie, strain 258), and samples were collected over 21 days. Under most conditions tested (CBR-A: SS, 7-day biofilm; CBR-A: PVC, 28-day biofilm; CBR-B: SS, 7-day and 28-day biofilm; CBR-B: PVC, 28-day biofilm) significantly higher numbers of CAV1016 were observed compared to 258. CAV1016 showed no significant difference in quantity or persistence based on biofilm age (7 days vs 28 days) or substratum type (SS vs PVC). However, counts of 258 were significantly higher on 28-day biofilms and on SS.
These results suggest that CPKP persistence in P-trap biofilms may be strain specific or may be related to the type of P-trap material or age of the biofilm.