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To determine the effect of an electronic medical record (EMR) nudge at reducing total and inappropriate orders testing for hospital-onset Clostridioides difficile infection (HO-CDI).
An interrupted time series analysis of HO-CDI orders 2 years before and 2 years after the implementation of an EMR intervention designed to reduce inappropriate HO-CDI testing. Orders for C. difficile testing were considered inappropriate if the patient had received a laxative or stool softener in the previous 24 hours.
Four hospitals in an academic healthcare network.
All patients with a C. difficile order after hospital day 3.
Orders for C. difficile testing in patients administered a laxative or stool softener in <24 hours triggered an EMR alert defaulting to cancellation of the order (“nudge”).
Of the 17,694 HO-CDI orders, 7% were inappropriate (8% prentervention vs 6% postintervention; P < .001). Monthly HO-CDI orders decreased by 21% postintervention (level-change rate ratio [RR], 0.79; 95% confidence interval [CI], 0.73–0.86), and the rate continued to decrease (postintervention trend change RR, 0.99; 95% CI, 0.98–1.00). The intervention was not associated with a level change in inappropriate HO-CDI orders (RR, 0.80; 95% CI, 0.61–1.05), but the postintervention inappropriate order rate decreased over time (RR, 0.95; 95% CI, 0.93–0.97).
An EMR nudge to minimize inappropriate ordering for C. difficile was effective at reducing HO-CDI orders, and likely contributed to decreasing the inappropriate HO-CDI order rate after the intervention.
Salmonella enterica serovar Wangata (S. Wangata) is an important cause of endemic salmonellosis in Australia, with human infections occurring from undefined sources. This investigation sought to examine possible environmental and zoonotic sources for human infections with S. Wangata in north-eastern New South Wales (NSW), Australia. The investigation adopted a One Health approach and was comprised of three complimentary components: a case–control study examining human risk factors; environmental and animal sampling; and genomic analysis of human, animal and environmental isolates. Forty-eight human S. Wangata cases were interviewed during a 6-month period from November 2016 to April 2017, together with 55 Salmonella Typhimurium (S. Typhimurium) controls and 130 neighbourhood controls. Indirect contact with bats/flying foxes (S. Typhimurium controls (adjusted odds ratio (aOR) 2.63, 95% confidence interval (CI) 1.06–6.48)) (neighbourhood controls (aOR 8.33, 95% CI 2.58–26.83)), wild frogs (aOR 3.65, 95% CI 1.32–10.07) and wild birds (aOR 6.93, 95% CI 2.29–21.00) were statistically associated with illness in multivariable analyses. S. Wangata was detected in dog faeces, wildlife scats and a compost specimen collected from the outdoor environments of cases’ residences. In addition, S. Wangata was detected in the faeces of wild birds and sea turtles in the investigation area. Genomic analysis revealed that S. Wangata isolates were relatively clonal. Our findings suggest that S. Wangata is present in the environment and may have a reservoir in wildlife populations in north-eastern NSW. Further investigation is required to better understand the occurrence of Salmonella in wildlife groups and to identify possible transmission pathways for human infections.
During May 2015, an increase in Salmonella Agona cases was reported from western Sydney, Australia. We examine the public health actions used to investigate and control this increase. A descriptive case-series investigation was conducted. Six outbreak cases were identified; all had consumed cooked tuna sushi rolls purchased within a western Sydney shopping complex. Onset of illness for outbreak cases occurred between 7 April and 24 May 2015. Salmonella was isolated from food samples collected from the implicated premise and a prohibition order issued. No further cases were identified following this action. Whole genome sequence (WGS) analysis was performed on isolates recovered during this investigation, with additional S. Agona isolates from sporadic-clinical cases and routine food sampling in New South Wales, January to July 2015. Clinical isolates of outbreak cases were indistinguishable from food isolates collected from the implicated sushi outlet. Five additional clinical isolates not originally considered to be linked to the outbreak were genomically similar to outbreak isolates, indicating the point-source contamination may have started before routine surveillance identified an increase. This investigation demonstrated the value of genomics-guided public health action, where near real-time WGS enhanced the resolution of the epidemiological investigation.
Solutions are presented for both laminar developing flow in a curved pipe with a parabolic inlet velocity and laminar transitional flow downstream of a curved pipe into a straight outlet. Scalings and linearized analyses about appropriate base states are used to show that both cases obey the same governing equations and boundary conditions. In particular, the governing equations in the two cases are linearized about fully developed Poiseuille flow in cylindrical coordinates and about Dean’s velocity profile for curved pipe flow in toroidal coordinates respectively. Subsequently, we identify appropriate scalings of the axial coordinate and disturbance velocities that eliminate dependence on the Reynolds number
and dimensionless pipe curvature
from the governing equations and boundary conditions in the limit of small
. Direct numerical simulations confirm the scaling arguments and theoretical solutions for a range of
. Maximum values of the axial velocity, secondary velocity and pressure perturbations are determined along the curved pipe section. Results collapse when the scalings are applied, and the theoretical solutions are shown to be valid up to Dean numbers of
. The developing flows are shown numerically and analytically to contain spatial oscillations. The numerically determined decay of the velocity perturbations is also used to determine entrance/development lengths for both flows, which are shown to scale linearly with the Reynolds number, but with a prefactor
larger than the textbook case of developing flow in a straight pipe.
Fifteen confirmed cases and 15 possible cases of Shiga toxin-producing Escherichia coli (STEC) O157 phage type 21/28 were linked to direct contact with lambs at a ‘Lambing Live’ event in the North West of England between 29 March and 21 April 2014. Twenty-one (70%) of the cases were female, 23 (77%) were children aged <16 years, of whom 14 (46%) were in the 0–5 years age group. Five children developed haemolytic uraemic syndrome. Multilocus variable number tandem repeat analysis (MLVA) profiles on 14 human cases were indistinguishable, and 6/10 animal isolates had a MLVA profile identical to the outbreak profile. Whole-genome sequencing analysis revealed that all isolates, both human and animal, fell within a 5-single nucleotide polymorphism cluster indicating the isolates belonged to the same point source. On inspection of the premises, extensive and uncontrolled physical contact between visitors and animals was occuring within the animal pens and during bottle-feeding. Public areas were visibly contaminated with animal faeces. Information to visitors, and the infection control awareness demonstrated by staff, was inadequate. Managing the risk to visitors of STEC O157 infection at animal petting events and open farms requires implementation of stringent control measures by the operator, as outlined in the industry code of practice. Enforcement action is sometimes required to prevent high-risk activities taking place at both permanent and temporary attractions.
Direct numerical simulations were used to investigate the downstream decay of fully developed flow in a
curved pipe that exits into a straight outlet. The flow is studied for a range of Reynolds numbers and pipe-to-curvature radius ratios. Velocity, pressure and vorticity fields are calculated to visualize the downstream decay process. Transition ‘decay’ lengths are calculated using the norm of the velocity perturbation from the Hagen–Poiseuille velocity profile, the wall-averaged shear stress, the integral of the magnitude of the vorticity, and the maximum value of the
-criterion on a cross-section. Transition lengths to the fully developed Poiseuille distribution are found to have a linear dependence on the Reynolds number with no noticeable dependence on the pipe-to-curvature radius ratio, despite the flow’s dependence on both parameters. This linear dependence of Reynolds number on the transition length is explained by linearizing the Navier–Stokes equations about the Poiseuille flow, using the form of the fully developed Dean flow as an initial condition, and using appropriate scaling arguments. We extend our results by comparing this flow recovery downstream of a curved pipe to the flow recovery in the downstream outlets of a T-junction flow. Specifically, we compare the transition lengths between these flows and document how the transition lengths depend on the Reynolds number.
Praseodymium doped CaFe2As2 (122 structure) and CaFeAs2 (112 structure) are characterized by modulated Low Magnetic Field Microwave Absorption (LFMA) spectroscopy. In both (Pr,Ca)122 and (Pr,Ca)112 structures, a strong hysteretic LFMA is found, with a TcH of ∼30 K and ∼26 K, respectively. However, in (Pr,Ca)122, measurements also show an unusual Narrow Peak (NP) LFMA signal appearing at higher temperatures, above the lower TcH superconducting state until a TcNP of 49 K. We associate this NP LFMA with interfacial superconductivity, which has been found previously by highly anisotropic magnetization measurements. Furthermore, the absence of NP in (Pr,Ca)112 correlates with the absence of an interfacial phase. These results give useful information about the microwave signature of interfacial superconductivity present in the (Pr,Ca)122 system, and may form a roadmap towards a stabilized high temperature superconducting phase in pnictides.
We measure the mechanical response of optical multilayer dielectric (MLD) diffraction gratings, geometries which are constrained in only one transverse direction but free in the other, using nanoindentation. The results are explained using a stress-strain model, which reveals a uniaxial yield stress of 4.1- 4.6 GPa and predicts a similar dependence of yield stress on loads for both fully-elastic and fully-plastic solutions. Following R. Hill’s model of an expanding cavity under internal pressure, we show that the indentation response of the high-aspect ratio “pillar” geometry can be expressed in terms of uniaxial yield stress rather than material hardness.
We characterize “blisters”, defects observed in multilayer dielectric (MLD) coatings after exposure to acid cleaning procedures. Nanoindentation is used to make site-specific indentations across blisters to measure the mechanical response, especially their compliance under different conditions of loading. Two regions of statistically different mechanical response are identified within a blister defect and compared to the undisturbed regions of the MLD coating. The indentation response of blisters can vary across samples, and we suggest reasons for this variation.
Three handbooks have been developed, in conjunction with a wide range of stakeholders to
assist in the management of contaminated food production systems, inhabited areas and
drinking water following a radiological incident. The handbooks are aimed at national and
local authorities, central government departments and agencies, emergency services,
radiation protection experts, the agriculture and food production sectors, industry and
others who may be affected. The handbooks include management options for application in
the different phases of an incident. Sources of contamination considered in the handbooks
include nuclear accidents and radiological dispersion devices; the most relevant
radionuclides are included. The handbooks are divided into several sections which provide
supporting scientific and technical information; an analysis of the factors influencing
recovery; compendia of comprehensive, state-of-the-art datasheets for around 100
management options and guidance on planning in advance. A decision-aiding framework
comprising colour coded selection tables, look-up tables and decision trees and several
worked examples are also included. The handbooks can be used as a preparatory tool, under
non-crisis conditions, to engage stakeholders and to develop local and regional plans. The
handbooks can also be applied as part of the decision-aiding process to develop a recovery
strategy following an incident. In addition, the handbooks are useful for training
purposes and during emergency exercises. To realise their full potential, the handbooks
should be customised at national, regional and local levels.
An investigation was undertaken to determine the isolation rate and antibiotic resistance of Haemophilus influenzae from the nasopharynx of young children. The 996 subjects studied were up to 6 years of age. H. influenzae was isolated from 304 (30·5%) and strains of capsular type b from 11 (1·1%). Age, sibling status, season, respiratory infection and antibiotic therapy all influenced isolation rates. The overall prevalence of antibiotic resistance in the strains isolated was ampicillin 5·4% (all β-lactamase producers), cefaclor 0·3%, chloramphenicol 1·3%, erythromycin 38·2%, tetracycline 1·3%, trimethoprim 5·4% and sulphamethoxazole 0%. Ampicillin resistance was more common in type b than non-capsulated strains.