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In the absence of pyuria, positive urine cultures are unlikely to represent infection. Conditional urine reflex culture policies have the potential to limit unnecessary urine culturing. We evaluated the impact of this diagnostic stewardship intervention.
We conducted a retrospective, quasi-experimental (nonrandomized) study, with interrupted time series, from August 2013 to January 2018 to examine rates of urine cultures before versus after the policy intervention. We compared 3 intervention sites to 3 control sites in an aggregated series using segmented negative binomial regression.
The study included 6 acute-care hospitals within the Veterans’ Health Administration across the United States.
Adult patients with at least 1 urinalysis ordered during acute-care admission, excluding pregnant patients or those undergoing urological procedures, were included.
At the intervention sites, urine cultures were performed if a preceding urinalysis met prespecified criteria. No such restrictions occurred at the control sites. The primary outcome was the rate of urine cultures performed per 1,000 patient days. The safety outcome was the rate of gram-negative bloodstream infection per 1,000 patient days.
The study included 224,573 urine cultures from 50,901 admissions in 24,759 unique patients. Among the intervention sites, the overall average number of urine cultures performed did not significantly decrease relative to the preintervention period (5.9% decrease; P = 0.8) but did decrease by 21% relative to control sites (P < .01). We detected no significant difference in the rates of gram-negative bloodstream infection among intervention or control sites (P = .49).
Conditional urine reflex culture policies were associated with a decrease in urine culturing without a change in the incidence of gram-negative bloodstream infection.
Neuropsychological deficits following brain injury include cognitive impairment, difficulties with emotion, changes in self-identity, impairment in insight, behavioural challenges and personality change. The reviews rehabilitation for neuropsychological problems and includes specific reference to mild traumatic brain injury and traumatic brain injury in children.
Rehabilitation has been defined in many ways, but in the broadest sense is concerned with maximising quality of life after injury or illness.1 More specifically, rehabilitation is about maximising the ability and opportunity of the person with brain injury to participate in those activities of daily living, work, education, leisure and relationships that are valued by that person. Wade discusses the importance of models of illness (and health) and highlights the value of the World Health Organization International Classification of Functioning, Disability and Health (ICF) as a framework for understanding the process of rehabilitation.
Propagating inhomogeneous electromagnetic waves called surface plasmon polaritons (SPPs) can be excited by free-space beams on corrugated conducting surfaces at resonance angles determined by corrugation period, permittivity, and optical frequency. SPPs are coupled to and co-propagate with surface charge displacements. Complete electrical isolation of individual conducting corrugations prevents the charge displacement necessary to sustain an SPP, such that excitation resonances of traveling SPPs are absent. However, SPPs can be excited via electric induction if a smooth conducting surface exists below and nearby the isolated conducting corrugations. The dependence of SPP excitation resonances on that separation is experimentally investigated here at long-wave infrared wavelengths. We find that excitation resonances for traveling SPPs broaden and disappear as the dielectric’s physical thickness is increased beyond ~1% of the free-space wavelength. The resonance line width increases with refractive index and optical thickness of the dielectric.
Cognitive impairment is strongly linked with persistent disability in people with mood disorders, but the factors that explain cognitive impairment in this population are unclear.
To estimate the total effect of (a) bipolar disorder and (b) major depression on cognitive function, and the magnitude of the effect that is explained by potentially modifiable intermediate factors.
Cross-sectional study using baseline data from the UK Biobank cohort. Participants were categorised as having bipolar disorder (n = 2709), major depression (n = 50 975) or no mood disorder (n = 102 931 and n = 105 284). The outcomes were computerised tests of reasoning, reaction time and memory. The potential mediators were cardiometabolic disease and psychotropic medication. Analyses were informed by graphical methods and controlled for confounding using regression, propensity score-based methods and G-computation.
Group differences of small magnitude were found on a visuospatial memory test. Z-score differences for the bipolar disorder group were in the range −0.23 to −0.17 (95% CI −0.39 to −0.03) across different estimation methods, and for the major depression group they were approximately −0.07 (95% CI −0.10 to −0.03). One-quarter of the effect was mediated via psychotropic medication in the bipolar disorder group (−0.05; 95% CI −0.09 to −0.01). No evidence was found for mediation via cardiometabolic disease.
In a large community-based sample in middle to early old age, bipolar disorder and depression were associated with lower visuospatial memory performance, in part potentially due to psychotropic medication use. Mood disorders and their treatments will have increasing importance for population cognitive health as the proportion of older adults continues to grow.
Declaration of interest
I.J.D. is a UK Biobank participant. J.P.P. is a member of the UK Biobank Steering Committee.
Objective: Post-stroke cognitive impairment is common, but mechanisms and risk factors are poorly understood. Frailty may be an important risk factor for cognitive impairment after stroke. We investigated the association between pre-stroke frailty and acute post-stoke cognition. Methods: We studied consecutively admitted acute stroke patients in a single urban teaching hospital during three recruitment waves between May 2016 and December 2017. Cognition was assessed using the Mini-Montreal Cognitive Assessment (min=0; max=12). A Frailty Index was used to generate frailty scores for each patient (min=0; max=100). Clinical and demographic information were collected, including pre-stroke cognition, delirium, and stroke-severity. We conducted univariate and multiple-linear regression analyses with covariates forced in (covariates included were: age, sex, stroke severity, stroke-type, pre-stroke cognitive impairment, delirium, previous stroke/transient ischemic attack) to investigate the association between pre-stroke frailty and post-stroke cognition. Results: Complete data were available for 154 stroke patients. Mean age was 68 years (SD=11; range=32–97); 93 (60%) were male. Median mini-Montreal Cognitive Assessment score was 8 (IQR=4–12). Mean Frailty Index score was 18 (SD=11). Pre-stroke cognitive impairment was apparent in 13/154 (8%) patients. Pre-stroke frailty was significantly associated with lower post-stroke cognition (Standardized-Beta=−0.40; p<0.001) and this association was independent of covariates (Unstandardized-Beta=−0.05; p=0.005). Additional significant variables in the multiple regression model were age (Unstandardized-Beta=−0.05; p=0.002), delirium (Unstandardized-Beta=−2.81; p<0.001), pre-stroke cognitive impairment (Unstandardized-Beta=−2.28; p=0.001), and stroke-severity (Unstandardized-Beta=−0.20; p<0.001). Conclusions: Pre-stroke frailty may be a moderator of post-stroke cognition, independent of other well-established post-stroke cognitive impairment risk factors. (JINS, 2019, 25, 501–506)
Crisis resolution teams (CRTs) offer brief, intensive home treatment for people experiencing mental health crisis. CRT implementation is highly variable; positive trial outcomes have not been reproduced in scaled-up CRT care.
To evaluate a 1-year programme to improve CRTs’ model fidelity in a non-masked, cluster-randomised trial (part of the Crisis team Optimisation and RElapse prevention (CORE) research programme, trial registration number: ISRCTN47185233).
Fifteen CRTs in England received an intervention, informed by the US Implementing Evidence-Based Practice project, involving support from a CRT facilitator, online implementation resources and regular team fidelity reviews. Ten control CRTs received no additional support. The primary outcome was patient satisfaction, measured by the Client Satisfaction Questionnaire (CSQ-8), completed by 15 patients per team at CRT discharge (n = 375). Secondary outcomes: CRT model fidelity, continuity of care, staff well-being, in-patient admissions and bed use and CRT readmissions were also evaluated.
All CRTs were retained in the trial. Median follow-up CSQ-8 score was 28 in each group: the adjusted average in the intervention group was higher than in the control group by 0.97 (95% CI −1.02 to 2.97) but this was not significant (P = 0.34). There were fewer in-patient admissions, lower in-patient bed use and better staff psychological health in intervention teams. Model fidelity rose in most intervention teams and was significantly higher than in control teams at follow-up. There were no significant effects for other outcomes.
The CRT service improvement programme did not achieve its primary aim of improving patient satisfaction. It showed some promise in improving CRT model fidelity and reducing acute in-patient admissions.
Metal–insulator–metal (MIM) resonant absorbers comprise a conducting ground plane, a dielectric of thickness t, and thin separated metal top-surface structures of dimension l. The fundamental resonance wavelength is predicted by an analytic standing-wave model based on t, l, and the dielectric refractive index spectrum. For the dielectrics SiO2, AlN, and TiO2, values for l of a few microns give fundamental resonances in the 8-12 μm long-wave infrared (LWIR) wavelength region. Agreement with theory is better for t/l exceeding 0.1. Harmonics at shorter wavelengths were already known, but we show that there are additional resonances in the far-infrared 20 - 50 μm wavelength range in MIM structures designed to have LWIR fundamental resonances. These new resonances are consistent with the model if far-IR dispersion features in the index spectrum are considered. LWIR fundamental absorptions are experimentally shown to be optimized for a ratio t/l of 0.1 to 0.3 for SiO2- and AlN-based MIM absorbers, respectively, with TiO2-based MIM optimized at an intermediate ratio.
Monitoring the effectiveness of knee and hip arthroplasties could be useful at the clinical, economic, and patient levels. In Catalonia, there is currently no systematic monitoring of the different prostheses available. The aims of this study were to propose an approach for the systematic identification of knee and hip prostheses with the highest revision rates, and to identify those with the poorest outcomes.
Data recorded from January 2005 to December 2016 were considered from 53 out of the 61 public hospitals in Catalonia included in the Catalonian Arthroplasty Register (RACat). Specific prostheses were classified by joint, type, fixation, and, in total hip prostheses, the bearing surface. Prostheses with the worst outcomes were identified using a three-step approach, based on previous literature: (i) screening using Poisson models; (ii) comparison of prostheses using adjusted Cox models; and (iii) consensus-based review by a panel of orthopedic surgeons to detect possible sources of bias. After this process, selected prostheses were provisionally labeled as having the poorest outcomes. This process will be repeated periodically within the RACat to definitively classify the prostheses.
After first two steps, ten knee prostheses and eight hip prostheses were identified. After the panel discussion (third step), one knee and one hip prosthesis were excluded from the final list. The knee prosthesis was excluded because it was a unicompartmental implant, while the hip prosthesis was excluded because it was a monoblock implant. Finally, nine knee prostheses and seven hip prostheses were provisionally identified as having the worst results relative to other available prostheses. These results await confirmation in subsequent analyses.
This study contributed to the current need to identify hip and knee prostheses whose outcomes might be worse than expected. This identification could have an impact at the patient, surgeon, industry, and stakeholder levels.
Depression is a common post-stroke complication. Pre-stroke depression may be an important contributor, however the epidemiology of pre-stroke depression is poorly understood. Using systematic review and meta-analysis, we described the prevalence of pre-stroke depression and its association with post-stroke depression.
We searched multiple cross-disciplinary databases from inception to July 2017 and extracted data on the prevalence of pre-stroke depression and its association with post-stroke depression. We assessed the risk of bias (RoB) using validated tools. We described summary estimates of prevalence and summary odds ratio (OR) for association with post-stroke depression, using random-effects models. We performed subgroup analysis describing the effect of depression assessment method. We used a funnel plot to describe potential publication bias. The strength of evidence presented in this review was summarised via ‘GRADE’.
Of 11 884 studies identified, 29 were included (total participants n = 164 993). Pre-stroke depression pooled prevalence was 11.6% [95% confidence interval (CI) 9.2–14.7]; range: 0.4–24% (I2 95.8). Prevalence of pre-stroke depression varied by assessment method (p = 0.02) with clinical interview suggesting greater pre-stroke depression prevalence (~17%) than case-note review (9%) or self-report (11%). Pre-stroke depression was associated with increased odds of post-stroke depression; summary OR 3.0 (95% CI 2.3–4.0). All studies were judged to be at RoB: 59% of included studies had an uncertain RoB in stroke assessment; 83% had high or uncertain RoB for pre-stroke depression assessment. Funnel plot indicated no risk of publication bias. The strength of evidence based on GRADE was ‘very low’.
One in six stroke patients have had pre-stroke depression. Reported rates may be routinely underestimated due to limitations around assessment. Pre-stroke depression significantly increases odds of post-stroke depression.
Metal–insulator–metal (MIM) resonant absorbers comprise a conducting ground plane, a thin dielectric, and thin separated metal top-surface structures. The dielectric SiO2 strongly absorbs near 9 µm wavelength and has correspondingly strong long-wave-infrared (LWIR) dispersion for the refractive index. This dispersion results in multiple absorption resonances spanning the LWIR, which can enhance broad-band sensitivity for LWIR bolometers. Similar considerations apply to silicon nitride Si3N4. TiO2 and AlN have comparatively low dispersion and give simple single LWIR resonances. These dispersion-dependent features for infrared MIM devices are demonstrated by experiment, electrodynamic simulation, and an analytic model based on standing waves.
Background: People with relapsing remitting multiple sclerosis (PwRRMS) suffer disproportionate decrements in gait under dual-task conditions, when walking and a cognitive task are combined. There has been much less investigation of the impact of cognitive demands on balance. Objectives: This study investigated whether: (1) PwRRMS show disproportionate decrements in postural stability under dual-task conditions compared to healthy controls, and (2) dual-task decrements are associated with everyday dual-tasking difficulties. The impact of mood, fatigue, and disease severity on dual-tasking was also examined. Methods: A total of 34 PwRRMS and 34 matched controls completed cognitive (digit span) and balance (movement of center of pressure on Biosway on stable and unstable surfaces) tasks under single- and dual-task conditions. Everyday dual-tasking was measured using the Dual-Tasking Questionnaire. Mood was measured by the Hospital Anxiety & Depression Scale. Fatigue was measured via the Modified Fatigue Index Scale. Results: No differences in age, gender, years of education, estimated pre-morbid IQ, or baseline digit span between groups. Compared with controls, PwRRMS showed significantly greater decrement in postural stability under dual-task conditions on an unstable surface (p=.007), but not a stable surface (p=.679). Balance decrement scores were not correlated with everyday dual-tasking difficulties or fatigue. Stable surface balance decrement scores were significantly associated with levels of anxiety (rho=0.527; p=.001) and depression (rho=0.451; p=.007). Conclusions: RRMS causes dual-tasking difficulties, impacting balance under challenging conditions, which may contribute to increased risk of gait difficulties and falls. The relationship between anxiety/depression and dual-task decrement suggests that emotional factors may be contributing to dual-task difficulties. (JINS, 2018, 24, 247–258)
Although violence over Northern Ireland's constitutional position has largely subsided, the problem of sectarian animosity between sections of the Protestant Unionist British and Catholic Irish Nationalist population remains. One such area of communal contestation is attitudes to Protestant parades, organized mainly by the Orange Order. For many Protestants, Orange Order marches are legitimate cultural, religious, and political expressions of Protestant culture, loyalty to the British Crown and a pro-United Kingdom position. For many Catholics, the Orange Order is seen as a sectarian and anti-Catholic organization, which prohibits its members marrying Catholics or attending Catholic Church services. The Parades Commission was established two decades ago to adjudicate on Orange Order parading routes. Its decisions have sometimes involved re-routing marches away from Catholic areas and the inability to satisfy both sides has been followed by riots on several occasions at the annual height of the Protestant “marching season.” This article examines levels of support or antipathy toward Orange Order marching rights among Protestants and Catholics. Drawing upon evidence from the most extensive recent study of public opinion in Northern Ireland, the 2015 Economic and Social Research Council general election study, the piece tests the importance of demographic, religious, political, and geographical variables in conditioning attitudes towards Orange parades.
Davis translated three books by Michel Leiris: Brisées: Broken Branches (1989), a collection of occasional essays, and two parts of his fourpart autobiography, Rules of the Game: Scratches (1997a) and Scraps (1997b). As mentioned in the Introduction, Davis wondered if Leiris was the ‘real pinnacle’ of a translator's career (Davis 1999: 87), given the complexity of his style and its close ties to the sound and sense of French. This chapter explores how Davis’ translations of Leiris produce a dialogue between the two authors, focusing, because of its centrality in Leiris’ oeuvre, on Davis’ relationship with La Règle du jeu. Leiris wrote in many genres, from surrealist poetry to ethnography, but for many critics his most important works are in the field of autobiography.
I begin with analyses of Davis’ translations of Leiris. Her approach to his work is uniquely radical, as Davis broke norms of translational procedure in responding to an unorthodox, poetic text. The recreative form of translation she practises here suggests a productive dialogue between the translation and Davis’ stories, which is also suggested by two texts by Davis with an intertextual link to Leiris, ‘Swimming in Egypt: Dreams While Awake and Asleep’ (Davis 2007b: 35–44) and ‘To Reiterate’ (Davis 1997a: 83). The second section of this chapter argues that these texts position Leiris as a precursor and influence, and the final section reads La Règle du jeu in relation to Davis’ writing, focusing on how Davis and Leiris have an affinity in their privileging of what Roman Jakobson (1960: 356–8) calls the ‘poetic function’ above narrative development in their texts. The poetic function is where language brings attention to itself, ‘focus[ing] on the message [i.e. the verbal text] for its own sake’ (ibid.: 356). This is not only relevant to poetry, but to any verbal text that is self-reflexive, folding the reader's attention back onto the text and the formal construction of that text.
Davis’ most enduring relationship as a translator is with Maurice Blanchot. She began publishing her translation of Death Sentence in 1975 in the magazine Living Hand, which Davis and her then husband Paul Auster edited. Over the next eighteen years, Davis translated six books of Blanchot's: L'Arrêt de mort (1977, first published 1948) as Death Sentence (1978), Au moment voulu (1951) as When the Time Comes (1985), Celui qui m'accompagnait pas (1953) as The One Who Was Standing Apart from Me (1993), Le dernier homme (1957) as The Last Man (1987), La folie du jour (2002, first published 1973) as ‘The Madness of the Day’ (1977) and The Gaze of Orpheus and other literary essays (1981). The first four of these are novella-length texts, called ‘récits’ by Blanchot. The fifth, ‘The Madness of the Day’, is a short text that was published separately as a book in 1981, despite only being nine full pages in length in its 1977 English magazine publication and the same when it was reprinted in The Station Hill Blanchot Reader (Blanchot 1999: 191–9). Davis’ other translation, The Gaze of Orpheus and other literary essays (Blanchot 1981b), was the first English collection of Blanchot's critical essays. It contains work from Blanchot's collections Faux pas (1943), La Part du feu (1949), L'Espace littéraire (1955), Le Livre à venir (1959) and L'Entretien infini (1969). It appeared just before two other translations of Blanchot's essays (Blanchot 1982a and 1982b).
Davis has stated how important translating Blanchot was for her as a translator. While translating him she ‘learned to stay extremely close to the text … practising an extreme fidelity’ (Davis 2007b: 7). She published early versions of her translations in magazines (Blanchot 1975, 1976, 1977) which, with the exception of Michel Leiris’ work, is something she has not done with her other translations, although it mirrors her practice with her own short stories. These early publications increased her visibility as a translator and helped to establish her reputation.