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To assess the impact of a newly developed Central-Line Insertion Site Assessment (CLISA) score on the incidence of local inflammation or infection for CLABSI prevention.
A pre- and postintervention, quasi-experimental quality improvement study.
Setting and participants:
Adult inpatients with central venous catheters (CVCs) hospitalized in an intensive care unit or oncology ward at a large academic medical center.
We evaluated CLISA score impact on insertion site inflammation and infection (CLISA score of 2 or 3) incidence in the baseline period (June 2014–January 2015) and the intervention period (April 2015–October 2017) using interrupted times series and generalized linear mixed-effects multivariable analyses. These were run separately for days-to-line removal from identification of a CLISA score of 2 or 3. CLISA score interrater reliability and photo quiz results were evaluated.
Among 6,957 CVCs assessed 40,846 times, percentage of lines with CLISA score of 2 or 3 in the baseline and intervention periods decreased by 78.2% (from 22.0% to 4.7%), with a significant immediate decrease in the time-series analysis (P < .001). According to the multivariable regression, the intervention was associated with lower percentage of lines with a CLISA score of 2 or 3, after adjusting for age, gender, CVC body location, and hospital unit (odds ratio, 0.15; 95% confidence interval, 0.06–0.34; P < .001). According to the multivariate regression, days to removal of lines with CLISA score of 2 or 3 was 3.19 days faster after the intervention (P < .001). Also, line dwell time decreased 37.1% from a mean of 14 days (standard deviation [SD], 10.6) to 8.8 days (SD, 9.0) (P < .001). Device utilization ratios decreased 9% from 0.64 (SD, 0.08) to 0.58 (SD, 0.06) (P = .039).
The CLISA score creates a common language for assessing line infection risk and successfully promotes high compliance with best practices in timely line removal.
Declining species richness is a global concern; however, the coarse-scale metrics used at regional or landscape levels might not accurately represent the important habitat characteristics needed to estimate species richness. Currently, there exists a lack of knowledge with regard to the spatial extent necessary to correlate remotely sensed habitat metrics to species richness and animal surveys. We provide a protocol for determining the best scale to use when merging remotely sensed habitat and animal survey data as a step towards improving estimates of vertebrate species richness on broad scales. We test the relative importance of fine-resolution habitat heterogeneity and productivity metrics at multiple spatial scales as predictors of species richness for birds, frogs and mammals using a Bayesian approach and a combination of passive monitoring technologies. Model performance was different for each taxonomic group and dependent on the scale at which habitat heterogeneity and productivity were measured. Optimal scales included a 20-m radius for bats and frogs, an 80-m radius for birds and a 180-m radius for terrestrial mammals. Our results indicate that optimal scales do exist when merging remotely sensed habitat measures with ground-based surveys, but they differ between vertebrate groups. Additionally, the selection of a measurement scale is highly influential to our understanding of the relationships between species richness and habitat characteristics.
Myocardial strain measurements are increasingly used to detect complications following heart transplantation. However, the temporal association of these changes with allograft rejection is not well defined. The aim of this study was to describe the evolution of strain measurements prior to the diagnosis of rejection in paediatric heart transplant recipients.
All paediatric heart transplant recipients (2004–2015) with at least one episode of acute rejection were identified. Longitudinal and circumferential strain measurements were assessed at the time of rejection and retrospectively on all echocardiograms until the most recent negative biopsy. Smoothing technique (LOESS) was used to visualise the changes of each variable over time and estimate the time preceding rejection at which alterations are first detectable.
A total of 58 rejection episodes were included from 37 unique patients. In the presence of rejection, there were decrements from baseline in global longitudinal strain (−18.2 versus −14.1), global circumferential strain (−24.1 versus −19.6), longitudinal strain rate (−1 versus −0.8), circumferential strain rate (−1.3 versus −1.1), peak longitudinal early diastolic strain rate (1.3 versus 1), and peak circumferential early diastolic strain rate (1.5 versus 1.3) (p<0.01 for all). The earliest detectable changes occurred 45 days prior to rejection with simultaneous alterations in myocardial strain and ejection fraction.
Changes in graft function can be detected non-invasively prior to the diagnosis of rejection. However, changes in strain occur concurrently with a decline in ejection fraction. Strain measurements aid in the non-invasive detection of rejection, but may not facilitate earlier diagnosis compared to more traditional measures of ventricular function.
Palladium germanide thin films were investigated for infrared plasmonic applications. Palladium thin films were deposited onto amorphous germanium thin films and subsequently annealed at a range of temperatures. X-ray diffraction was used to identify stoichiometry, and Scanning Electron Micrographs, along with Energy Dispersive Spectroscopy (EDS) was used to characterize composition and film quality. Resistivity was also measured for analysis. Complex permittivity spectra were measured from 0.3 to 15 µm using IR ellipsometry. From this, surface plasmon polariton (SPP) characteristics such as propagation length and mode confinement were calculated and used to determine appropriate spectral windows for plasmonic applications with respect to film characteristics. Films were evaluated for use with on-chip plasmonic components.
Skeletal remains from a burial in New South Wales exhibit evidence of fatal
trauma, of a kind normally indicative of sharp metal weapons, yet the burial
dates to the mid thirteenth century—600 years before European settlers
reached the area. Could sharp-edged wooden weapons from traditional
Aboriginal culture inflict injuries similar to those resulting from later,
metal blades? Analysis indicates that the wooden weapons known as
‘Lil-lils’ and the fighting boomerangs
(‘Wonna’) both have blades that could fit within the
dimensions of the major trauma and are capable of having caused the fatal
Though the US civilian trauma care system plays a critical role in disaster response, there is currently no systems-based strategy that enables hospital emergency management and local and regional emergency planners to quantify, and potentially prepare for, surges in trauma care demand that accompany mass-casualty disasters.
A proof-of-concept model that estimates the geographic distributions of patients, trauma center resource usage, and mortality rates for varying disaster sizes, in and around the 25 largest US cities, is presented. The model was designed to be scalable, and its inputs can be modified depending on the planning assumptions of different locales and for different types of mass-casualty events.
To demonstrate the model’s potential application to real-life planning scenarios, sample disaster responses for 25 major US cities were investigated using a hybrid of geographic information systems and dynamic simulation-optimization. In each city, a simulated, fast-onset disaster epicenter, such as might occur with a bombing, was located randomly within one mile of its population center. Patients then were assigned and transported, in simulation, via the new model to Level 1, 2, and 3 trauma centers, in and around each city, over a 48-hour period for disaster scenario sizes of 100, 500, 5000, and 10,000 casualties.
Across all 25 cities, total mean mortality rates ranged from 26.3% in the smallest disaster scenario to 41.9% in the largest. Out-of-hospital mortality rates increased (from 21.3% to 38.5%) while in-hospital mortality rates decreased (from 5.0% to 3.4%) as disaster scenario sizes increased. The mean number of trauma centers involved ranged from 3.0 in the smallest disaster scenario to 63.4 in the largest. Cities that were less geographically isolated with more concentrated trauma centers in their surrounding regions had lower total and out-of-hospital mortality rates. The nine US cities listed as being the most likely targets of terrorist attacks involved, on average, more trauma centers and had lower mortality rates compared with the remaining 16 cities.
The disaster response simulation model discussed here may offer insights to emergency planners and health systems in more realistically planning for mass-casualty events. Longer wait and transport times needed to distribute high numbers of patients to distant trauma centers in fast-onset disasters may create predictable increases in mortality and trauma center resource consumption. The results of the modeled scenarios indicate the need for a systems-based approach to trauma care management during disasters, since the local trauma center network was often too small to provide adequate care for the projected patient surge. Simulation of out-of-hospital resources that might be called upon during disasters, as well as guidance in the appropriate execution of mutual aid agreements and prevention of over-response, could be of value to preparedness planners and emergency response leaders. Study assumptions and limitations are discussed.
A Geographic Simulation Model for the Treatment of Trauma Patients in Disasters. Prehosp Disaster Med.2016;31(4):413–421.
Most often associated with modern artists such as Bob Dylan, Elton John, Don McLean, Neil Diamond, and Carole King, the singer-songwriter tradition in fact has a long and complex history dating back to the medieval troubadour and earlier. This Companion explains the historical contexts, musical analyses, and theoretical frameworks of the singer-songwriter tradition. Divided into five parts, the book explores the tradition in the context of issues including authenticity, gender, queer studies, musical analysis, and performance. The contributors reveal how the tradition has been expressed around the world and throughout its history to the present day. Essential reading for enthusiasts, practitioners, students, and scholars, this book features case studies of a wide range of both well and lesser-known singer-songwriters, from Thomas d'Urfey through to Carole King and Kanye West.