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There is compelling evidence for gradient effects of household income on school readiness. Potential mechanisms are described, yet the growth curve trajectory of maternal mental health in a child's early life has not been thoroughly investigated. We aimed to examine the relationships between household incomes, maternal mental health trajectories from antenatal to the postnatal period, and school readiness.
Prospective data from 505 mother–child dyads in a birth cohort in Singapore were used, including household income, repeated measures of maternal mental health from pregnancy to 2-years postpartum, and a range of child behavioural, socio-emotional and cognitive outcomes from 2 to 6 years of age. Antenatal mental health and its trajectory were tested as mediators in the latent growth curve models.
Household income was a robust predictor of antenatal maternal mental health and all child outcomes. Between children from the bottom and top household income quartiles, four dimensions of school readiness skills differed by a range of 0.52 (95% Cl: 0.23, 0.67) to 1.21 s.d. (95% CI: 1.02, 1.40). Thirty-eight percent of pregnant mothers in this cohort were found to have perinatal depressive and anxiety symptoms in the subclinical and clinical ranges. Poorer school readiness skills were found in children of these mothers when compared to those of mothers with little or no symptoms. After adjustment of unmeasured confounding on the indirect effect, antenatal maternal mental health provided a robust mediating path between household income and multiple school readiness outcomes (χ2 126.05, df 63, p < 0.001; RMSEA = 0.031, CFI = 0.980, SRMR = 0.034).
Pregnant mothers with mental health symptoms, particularly those from economically-challenged households, are potential targets for intervention to level the playing field of their children.
Introduction: Patients who are not identified upon presentation to the emergency department (ED), commonly referred to as John or Jane Does (JDs), are a vulnerable population due to the sequelae associated with this lack of patient information. To date, there has been minimal research describing JDs. We aimed to characterize the JD population and determine if it differs significantly from the general ED population. Methods: We conducted a retrospective chart review of 114 JDs admitted to Saskatoon EDs from May 2018 to April 2019. Patients met inclusion criteria if they were provided a unique JD identification number at ED admission because their identities were unknown or unverifiable. Data regarding demographics, clinical presentation, ED course, mode of identification, and major clinical outcomes (i.e. admission rates, mortality rates) were gathered from electronic records. A second reviewer abstracted a random 21.0% sample of charts to ensure validity of the data. The JD population was then compared to the general population of ED patients that presented during the same time period. Results: Male JDs most commonly presented as trauma activations (85.7%) in contrast to female JDs who most commonly presented with issues related to substance abuse (51.4%). Compared to the general ED population, a greater percentage of JDs were categorized as CTAS 1 or 2 (85.8% vs 18.9%, p < 0.0001), more likely to be 44 years of age or younger (82.4% vs 58.5%, p < 0.0001), and more likely to be male (64.9% vs 49.1%, p < 0.0001). Descriptive statistics on the JD population demonstrated that most JDs received consults to inpatient services (58.8%). Of JDs who presented to the ED, 34.2% were admitted to hospital. The mortality of the JD population was 13.2% at 3 months. The ED average (SD) length of stay for JDs was 8.7 (9.0) hours. How JDs were ultimately identified was recorded only 70.2% of the time. Most frequently, JDs identified themselves (26.3%), other identification methods included police services (14.9%), family members (7.9%), registered nurses (6.1%), government-issued identification (5.3%), social work (4.4%) or other measures (5.4%). Conclusion: JD's represent a unique population in the ED. Both their presentations and clinical outcomes differ significantly from the generalized ED population. More research is needed to better identify strategies to improve the management and identification methods of these unique patients.
Introduction: Distributing take-home naloxone (THN) kits from Emergency Departments (EDs) is an important strategy for preventing opioid overdose deaths. However, there is a lack of clear operational guidance for implementing ED-based THN programs. This scoping review had two objectives: 1) identify key strategies for THN distribution in EDs, and 2) develop a theory-informed implementation model that can be used to optimize the effectiveness of ED-based THN programs. Methods: We systematically searched health science databases through April 18, 2019. The search strategy combined terms representing the ED, naloxone, and take-home kits/bystander administration. Two reviewers independently screened the search results. We included all peer-reviewed articles that described THN distribution within EDs. A standardized form was used for data extraction. Included studies were coded by two reviewers and mapped to domains of the Consolidated Framework for Implementation Research (CFIR). A third reviewer with content expertise adjudicated disagreements in record screening and data coding. Results: Database searching retrieved 717 records after duplicates were removed. 87 full-text studies were assessed for eligibility. Two studies were added through other sources, resulting in a total of 21 studies included in the final review. Of note, 14 studies evaluated existing ED-based THN programs. We synthesized themes that emerged within each CFIR domain and identified four key implementation strategies: 1) develop ED policies on opioid harm reduction; 2) collaborate with community and government partners to ensure programs meet patient needs; 3) address provider attitudes and knowledge gaps through dedicated training; and 4) establish guidelines to identify patients who are at risk of opioid overdose, and engage at-risk patients to maximize THN acceptance. Conclusion: ED-based THN programs must be tailored to local community needs and available hospital resources. Innovative implementation strategies are needed to promote ED provider engagement, and reduce barriers to patient acceptance of THN in the ED. This scoping review highlights key considerations for ED-THN implementation that can guide EDs to establish new programs, or refine existing programs to maximize their effectiveness.
Over the last two decades, levels of childhood overweight and obesity have increased considerably in Malaysia, such that the country now has the highest prevalence of obesity in Asia. The preschool years are a key time for establishing healthy behaviours; hence, there is a need for effective interventions aimed at early childhood. The ToyBox Study is an intervention to prevent obesity in preschoolers that has previously been conducted successfully in six different countries but to date not outside Europe. Therefore, we conducted a feasibility study to determine whether the ToyBox Study methodology could be successfully adapted and applied in Malaysia.
The ToyBox Study Malaysia was conducted in 15 kindergartens in Kuala Lumpur and suburbs in Selangor and 7 kindergartens in Sarawak (Borneo), Malaysia. All participating kindergartens were funded by Jabatan Kemajuan Masyarakat (KEMAS), the Community Development Department, Ministry of Rural and Regional Development.The existing ToyBox resources and questionnaires were translated into Bahasa Malaysia and the materials were adapted to suit local culture. Theory of change workshops and focus groups were conducted with parents, caregivers, teachers, cooks and government officers in order to help develop the implementation model. Train-the-trainer and teacher training sessions were organised before the study commenced.
The study was a randomised controlled trial that compared the ToyBox Study with kindergarten usual practice, over a period of one year. The ToyBox Study specifically targeted four energy balance related behaviours, namely; eating healthy snacks and meals, making water the preferred drink, increasing physical activity and reducing sedentary behaviour. Food frequency questionnaires were used to assess food intake. Accelerometry was used to measure physical activity. Weight, height and waist circumference were also measured. All measurements were made at baseline and post-intervention. Equipment such as soft mats and drinking water stations were supplied where needed. Parents, caregivers and teachers were provided with relevant materials, newsletters and tip cards and encouraged to participate and act as role models. They also completed project evaluation surveys.
If successful, it is envisaged that the ToyBox Study Malaysia will be adopted by other kindergartens in Malaysia, with the intention of helping Malaysian children and their families to achieve healthy energy balance related behaviours that will benefit their health and reduce obesity risk in the long-term.
We assessed the impact of personal protective equipment (PPE) doffing errors on healthcare worker (HCW) contamination with multidrug-resistant organisms (MDROs).
Prospective, observational study.
The study was conducted at 4 adult ICUs at 1 tertiary-care teaching hospital.
HCWs who cared for patients on contact precautions for methicillin-resistant Staphylococcus aureus (MRSA), vancomycin-resistant Enterococci, or multidrug-resistant gram-negative bacilli were enrolled. Samples were collected from standardized areas of patient body, garb sites, and high-touch environmental surfaces in patient rooms. HCW hands, gloves, PPE, and equipment were sampled before and after patient interaction. Research personnel observed PPE doffing and coded errors based on CDC guidelines.
We enrolled 125 HCWs; most were nurses (66.4%) or physicians (19.2%). During the study, 95 patients were on contact precautions for MRSA. Among 5,093 cultured sites (HCW, patient, environment), 652 (14.7%) yielded the target MDRO. Moreover, 45 HCWs (36%) were contaminated with the target MDRO after patient interactions, including 4 (3.2%) on hands and 38 (30.4%) on PPE. Overall, 49 HCWs (39.2%) made multiple doffing errors and were more likely to have contaminated clothes following a patient interaction (risk ratio [RR], 4.69; P = .04). All 4 HCWs with hand contamination made doffing errors. The risk of hand contamination was higher when gloves were removed before gowns during PPE doffing (RR, 11.76; P = .025).
When caring for patients on CP for MDROs, HCWs appear to have differential risk for hand contamination based on their method of doffing PPE. An intervention as simple as reinforcing the preferred order of doffing may reduce HCW contamination with MDROs.
Bathing intensive care unit (ICU) patients with 2% chlorhexidine gluconate (CHG)–impregnated cloths decreases the risk of healthcare-associated bacteremia and multidrug-resistant organism transmission. Hospitals employ different methods of CHG bathing, and few studies have evaluated whether those methods yield comparable results.
To determine whether 3 different CHG skin cleansing methods yield similar residual CHG concentrations and bacterial densities on skin.
Prospective, randomized 2-center study with blinded assessment.
PARTICIPANTS AND SETTING
Healthcare personnel in surgical ICUs at 2 tertiary-care teaching hospitals in Chicago, Illinois, and Boston, Massachusetts, from July 2015 to January 2016.
Cleansing skin of one forearm with no-rinse 2% CHG-impregnated polyester cloth (method A) versus 4% CHG liquid cleansing with rinsing on the contralateral arm, applied with either non–antiseptic-impregnated cellulose/polyester cloth (method B) or cotton washcloth dampened with sterile water (method C).
In total, 63 participants (126 forearms) received method A on 1 forearm (n=63). On the contralateral forearm, 33 participants received method B and 30 participants received method C. Immediately and 6 hours after cleansing, method A yielded the highest residual CHG concentrations (2500 µg/mL and 1250 µg/mL, respectively) and lowest bacterial densities compared to methods B or C (P<.001).
In healthy volunteers, cleansing with 2% CHG-impregnated cloths yielded higher residual CHG concentrations and lower bacterial densities than cleansing with 4% CHG liquid applied with either of 2 different cloth types and followed by rinsing. The relevance of these differences to clinical outcomes remains to be determined.
The quality of prenatal maternal mental health, from psychological stress and depressive symptoms to anxiety and other nonpsychotic mental disorders, profoundly affects fetal neurodevelopment. Despite the evidence for the influence of positive mental well-being on health, there is, to our knowledge, no research examining the possible effects of positive antenatal mental health on the development of the offspring. Using exploratory bifactor analysis, this prospective study (n = 1,066) demonstrated the feasibility of using common psychiatric screening tools to examine the effect of positive maternal mental health. Antenatal mental health was assessed during 26th week of pregnancy. The effects on offspring were assessed when the child was 12, 18, and 24 months old. Results showed that positive antenatal mental health was uniquely associated with the offspring's cognitive, language and parentally rated competences. This study shows that the effects of positive maternal mental health are likely to be specific and distinct from the sheer absence of symptoms of depression or anxiety.
To identify modifiable risk factors for acquisition of Klebsiella pneumoniae carbapenemase-producing Enterobacteriaceae (KPC) colonization among long-term acute-care hospital (LTACH) patients.
Multicenter, matched case-control study.
Four LTACHs in Chicago, Illinois.
Each case patient included in this study had a KPC-negative rectal surveillance culture on admission followed by a KPC-positive surveillance culture later in the hospital stay. Each matched control patient had a KPC-negative rectal surveillance culture on admission and no KPC isolated during the hospital stay.
From June 2012 to June 2013, 2,575 patients were admitted to 4 LTACHs; 217 of 2,144 KPC-negative patients (10.1%) acquired KPC. In total, 100 of these patients were selected at random and matched to 100 controls by LTACH facility, admission date, and censored length of stay. Acquisitions occurred a median of 16.5 days after admission. On multivariate analysis, we found that exposure to higher colonization pressure (OR, 1.02; 95% CI, 1.01–1.04; P=.002), exposure to a carbapenem (OR, 2.25; 95% CI, 1.06–4.77; P=.04), and higher Charlson comorbidity index (OR, 1.14; 95% CI, 1.01–1.29; P=.04) were independent risk factors for KPC acquisition; the odds of KPC acquisition increased by 2% for each 1% increase in colonization pressure.
Higher colonization pressure, exposure to carbapenems, and a higher Charlson comorbidity index independently increased the odds of KPC acquisition among LTACH patients. Reducing colonization pressure (through separation of KPC-positive patients from KPC-negative patients using strict cohorts or private rooms) and reducing carbapenem exposure may prevent KPC cross transmission in this high-risk patient population.
Considered as a less hazardous piezoelectric material, potassium sodium niobate (KNN) has been in the fore of the search for replacement of lead (Pb) zirconate titanate for piezoelectrics applications. Here, we challenge the environmental credentials of KNN due to the presence of ~60 wt% Nb2O5, a substance much less toxic to humans than Pb oxide, but whose mining and extraction cause significant environmental damage.
Clarification of memory characteristics of tiny cell is important for practical use of resistive random access memory (ReRAM). However, limitation of semiconductor micro-fabrication technology hinders to obtain memory characteristics in tiny cell with an area comparable to the size of filaments. In this paper, we established a method to prepare a very small memory cell by fabricating ReRAM structure on the tip of a cantilever of atomic force microscope (AFM). We also established a method to avoid the overshoot of set current. As a result, reset current was successfully reduced enough to suppress serious damage to the cantilever. The effective cell size was estimated to be less than 10 nm in diameter due to electric field concentration at the tip of the cantilever, which was confirmed by an electric field simulator based on finite element method. We performed a unique experiment to verify the presence of oxygen pool in an anode, by utilizing removable bottom electrode structure. The result was not consistent with resistive switching models that require the anode to play a role as an oxygen reservoir.
A total of 245 patients with confirmed 2009 H1N1 influenza were admitted to the intensive-care units of 28 hospitals (South Korea). Their mean age was 55·3 years with 68·6% aged >50 years, and 54·7% male. Nine were obese and three were pregnant. One or more comorbidities were present in 83·7%, and nosocomial acquisition occurred in 14·3%. In total, 107 (43·7%) patients received corticosteroids and 66·1% required mechanical ventilation. Eighty (32·7%) patients died within 30 days after onset of symptoms and 99 (40·4%) within 90 days. Multivariate logistic regression analysis showed that the clinician's decision to prescribe corticosteroids, older age, Sequential Organ Failure Assessment score and nosocomial bacterial pneumonia were independent risk factors for 90-day mortality. In contrast with Western countries, critical illness in Korea in relation to 2009 H1N1 was most common in older patients with chronic comorbidities; nosocomial acquisition occurred occasionally but disease in obese or pregnant patients was uncommon.
CVD polycrystalline diamond surfaces were etched using reactive ion etching system with either a conventional stainless steel electrode or MgO sintered ceramic containing electrode. The micro-needle array of high aspect on diamond substrate surfaces obtained with MgO electrode was fabricated by using back-sputtering from MgO electrode. The RMS roughness of diamond substrate surfaces obtained with MgO electrode is higher than those obtained with stainless steel electrode.
Gas hydrates are typically formed when water and gas (e.g., light hydrocarbons) come into contact at high pressure and low temperature. Current estimates of the amount of energy trapped in naturally occurring gas hydrate deposits, which are found in ocean sediments along the continental margins and in sediments under the permafrost, range from twice to orders of magnitude larger than conventional gas reserves. This has led to gas hydrates being considered as a potential future unconventional energy source.
Gas hydrates (or clathrate hydrates) are icelike crystalline solids imprisoning gas molecules (e.g., methane, carbon dioxide, hydrogen) within icy cages. These fascinating solids present an attractive medium for storing energy: naturally in the deep oceans and permafrost regions, which hold vast quantities of energy waiting to be unlocked and used as an alternative energy supply; and artificially by manipulating synthetic clathrate materials to store clean fuel (natural gas or hydrogen). Conversely, the formation of these solids in oil and gas flowlines (the pipes through which oil and gas are transported, for example, from a well to a processing facility) can lead to blockage of the flowlines and disastrous consequences if not carefully controlled. This chapter on gas hydrates begins with an overview of the discovery and evolving scientific interest in gas hydrates, followed by a basic description of the structural and physical properties of gas hydrates and the different energy applications of gas hydrates. The main focus of this chapter is on surveying the potential prospect of producing energy in the form of clean gas from naturally occurring gas hydrates, which present a potential alternative energy resource and could be a significant component of the alternative energy portfolio. The paradigm shift from exploration to production of energy from gas hydrates is clearly illustrated by the production tests that have either been performed or are planned in the Mackenzie Delta in Canada, on the North Slope of Alaska, and off the coast of Japan.
This study was performed to determine the prevalence, distribution of specimen sources, and antimicrobial susceptibility of the Acinetobacter calcoaceticus–Acinetobacter baumannii (Acb) species complex in Singapore. One hundred and ninety-three non-replicate Acb species complex clinical isolates were collected from six hospitals over a 1-month period in 2006. Of these, 152 (78·7%) were identified as A. baumannii, 18 (9·3%) as ‘Acinetobacter pittii’ [genomic species (gen. sp.) 3], and 23 (11·9%) as ‘Acinetobacter nosocomialis’ (gen. sp. 13TU). Carbapenem resistance was highest in A. baumannii (72·4%), followed by A. pittii (38·9%), and A. nosocomialis (34·8%). Most carbapenem-resistant A. baumannii and A. nosocomialis possessed the blaOXA-23-like gene whereas carbapenem-resistant A. pittii possessed the blaOXA-58-like gene. Two imipenem-resistant strains (A. baumannii and A. pittii) had the blaIMP-like gene. Representatives of carbapenem-resistant A. baumannii were related to European clones I and II.
As Hurricane Katrina bore down on New Orleans in August 2005, the city's mandatory evacuation prompted the exodus of an estimated 80% of its 485,000 residents. According to estimates from the US Centers for Disease Control and Prevention (CDC), at least 18 states subsequently hosted >200,000 evacuees.
In this case study, “Operation Helping Hands” (OHH), the Massachusetts health and medical response in assisting Hurricane Katrina evacuees is described. Operation Helping Hands represents the largest medical response to evacuees in recent Massachusetts history.
The data describing OHH were derived from a series of structured interviews conducted with two leading public health officials directing planning efforts, and a sample of first responders with oversight ofoperations at the evacuation site. Also, a literature review was conducted to identify similar experiences, common challenges, and lessons learned.
Activities and services were provided in the following areas: (1) administration and management;(2) medical and mental health; (3) public health; and (4) social support. This study adds to the knowledge base for future evacuation and shelter planning, and presents a conceptual framework that could be used by other researchers and practitioners to describe the process and out comes of similar operations.
This study provides a description of the planning and implementation efforts of the largest medical evacuee experience in recent Massachusetts history, an effort that involved multiple agencies and partners. The conceptual framework can inform future evacuation and shelter initiatives at the state and national levels, and promotes the overarching public health goal of the highest attainable standard of health for all.
Although widespread support favors prospective planning for altered standards of care during mass casualty events, the literature includes few, if any, accounts of groups that have formally addressed the overarching policy considerations at the state level. We describe the planning process undertaken by public health officials in the Commonwealth of Massachusetts, along with community and academic partners, to explore the issues surrounding altered standards of care in the event of pandemic influenza. Throughout 2006, the Massachusetts Department of Public Health and the Harvard School of Public Health Center for Public Health Preparedness jointly convened a working group comprising ethicists, lawyers, clinicians, and local and state public health officials to consider issues such as allocation of antiviral medications, prioritization of critical care, and state seizure of private assets. Community stakeholders were also engaged in the process through facilitated discussion of case scenarios focused on these and other issues. The objective of this initiative was to establish a framework and some fundamental principles that would subsequently guide the process of establishing specific altered standards of care protocols. The group collectively identified 4 goals and 7 principles to guide the equitable allocation of limited resources and establishment of altered standards of care protocols. Reviewing and analyzing this process to date may serve as a resource for other states. (Disaster Med Public Health Preparedness. 2009;3(Suppl 2):S132–S140)
The term adjuvant analgesic was originally coined to refer to a small number of drugs that were commercialized for reasons other than pain but could be used as analgesics in selected circumstances. When these nontraditional analgesics were prescribed to cancer patients to supplement the analgesia provided by opioids, they were considered to be adjuvant to the mainstay therapy – hence the term. In recent years, the number, diversity, and conventional use of these nontraditional analgesics have increased dramatically. Several are now indicated and promoted for specific types of noncancer pain and many are used as first-line therapies in varied populations. Accordingly, the term adjuvant analgesic is now a commonly applied misnomer and refers to a large and diverse group of drugs that have an expanding role in pain medicine.
In the management of cancer pain, the term adjuvant analgesic also must be distinguished from other labels, specifically adjuvant drug and co-analgesic. According to the three-step analgesic ladder model of cancer pain pharmacotherapy developed under the auspices of the World Health Organization in the mid-1980s, adjuvant drugs comprise both analgesics used to supplement opioid therapy (adjuvant analgesics) and drugs used to manage the side effects of the opioids. Given this dual labeling, the drugs intended to provide analgesia are best denoted by the more specific term adjuvant analgesics. The label co-analgesic has been used synonymously with adjuvant analgesic in the cancer treatment setting and also could be used whenever referring to a drug added for analgesic purposes to an existing opioid regimen.