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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.
Given the evidence of multi-parameter risk factors in shaping cognitive outcomes in aging, including sleep, inflammation, cardiometabolism, and mood disorders, multidimensional investigations of their impact on cognition are warranted. We sought to determine the extent to which self-reported sleep disturbances, metabolic syndrome (MetS) factors, cellular inflammation, depressive symptomatology, and diminished physical mobility were associated with cognitive impairment and poorer cognitive performance.
This is a cross-sectional study.
Participants with elevated, well-controlled blood pressure were recruited from the local community for a Tai Chi and healthy-aging intervention study.
One hundred forty-five older adults (72.7 ± 7.9 years old; 66% female), 54 (37%) with evidence of cognitive impairment (CI) based on Montreal Cognitive Assessment (MoCA) score ≤24, underwent medical, psychological, and mood assessments.
CI and cognitive domain performance were assessed using the MoCA. Univariate correlations were computed to determine relationships between risk factors and cognitive outcomes. Bootstrapped logistic regression was used to determine significant predictors of CI risk and linear regression to explore cognitive domains affected by risk factors.
The CI group were slower on the mobility task, satisfied more MetS criteria, and reported poorer sleep than normocognitive individuals (all p < 0.05). Multivariate logistic regression indicated that sleep disturbances, but no other risk factors, predicted increased risk of evidence of CI (OR = 2.00, 95% CI: 1.26–4.87, 99% CI: 1.08–7.48). Further examination of MoCA cognitive subdomains revealed that sleep disturbances predicted poorer executive function (β = –0.26, 95% CI: –0.51 to –0.06, 99% CI: –0.61 to –0.02), with lesser effects on visuospatial performance (β = –0.20, 95% CI: –0.35 to –0.02, 99% CI: –0.39 to 0.03), and memory (β = –0.29, 95% CI: –0.66 to –0.01, 99% CI: –0.76 to 0.08).
Our results indicate that the deleterious impact of self-reported sleep disturbances on cognitive performance was prominent over other risk factors and illustrate the importance of clinician evaluation of sleep in patients with or at risk of diminished cognitive performance. Future, longitudinal studies implementing a comprehensive neuropsychological battery and objective sleep measurement are warranted to further explore these associations.
Though theory suggests that individual differences in neuroticism (a tendency to experience negative emotions) would be associated with altered functioning of the amygdala (which has been linked with emotionality and emotion dysregulation in childhood, adolescence, and adulthood), results of functional neuroimaging studies have been contradictory and inconclusive. We aimed to clarify the relationship between neuroticism and three hypothesized neural markers derived from functional magnetic resonance imaging during negative emotion face processing: amygdala activation, amygdala habituation, and amygdala-prefrontal connectivity, each of which plays an important role in the experience and regulation of emotions. We used general linear models to examine the relationship between trait neuroticism and the hypothesized neural markers in a large sample of over 500 young adults. Although neuroticism was not significantly associated with magnitude of amygdala activation or amygdala habituation, it was associated with amygdala–ventromedial prefrontal cortex connectivity, which has been implicated in emotion regulation. Results suggest that trait neuroticism may represent a failure in top-down control and regulation of emotional reactions, rather than overactive emotion generation processes, per se. These findings suggest that neuroticism, which has been associated with increased rates of transdiagnostic psychopathology, may represent a failure in the inhibitory neurocircuitry associated with emotion regulation.
Although there is extensive evidence that problematic alcohol use is associated with smaller hippocampal volume, the typical cross-sectional study design cannot determine whether hippocampal deviations reflect pre-existing liability toward problematic alcohol use or instead reflect an alcohol exposure-related effect. We used the co-twin control study design, which capitalizes upon differences within a twin pair in levels of drinking, to differentiate pre-existing liability from an effect of alcohol exposure.
The sample included 100 female twins, prospectively assessed from ages 11 to 24. Problematic alcohol use was assessed dimensionally and included indicators of quantity, frequency, and density of alcohol use and intoxication. Hippocampal volume was assessed using magnetic resonance imaging.
Problematic alcohol use (proximal and cumulative) was associated with significantly smaller left and right hippocampal volume. Follow-up co-twin control analyses that partitioned individual-level alcohol effects into pre-existing, familial liability and non-shared alcohol exposure-related effects indicated that this association reflected alcohol exposure. Greater alcohol using twins had smaller hippocampal volume relative to lesser alcohol using co-twins, beyond effects of their shared genetic and environmental liability toward problematic alcohol use. Results held accounting for recent alcohol use, other substance use, externalizing and internalizing psychopathology, personality traits, trauma exposure, and menstrual phase.
The association between problematic alcohol use and smaller hippocampal volume likely reflects an alcohol exposure-related effect. Differentiating pre-existing brain deviations that confer risk for problematic alcohol use from those that reflect effects of alcohol on the brain will inform etiological models of addiction and further prevention and intervention efforts.
This article reviews the major paradigm shifts that have occurred in the area of the application of clinical and experimental neuropsychology to epilepsy and epilepsy surgery since the founding of the International Neuropsychological Society. The five paradigm shifts discussed include: 1) The neurobiology of cognitive disorders in epilepsy – expanding the landscape of syndrome-specific neuropsychological impairment; 2) pathways to comorbidities: bidirectional relationships and their clinical implications; 3) discovering quality of life: The concept, its quantification and applicability; 4) outcomes of epilepsy surgery: challenging conventional wisdom; and 5) Iatrogenic effects of treatment: cognitive and behavioral effects of antiepilepsy drugs. For each area we characterize the status of knowledge, the key developments that have occurred, and how they have altered our understanding of the epilepsies and their management. We conclude with a brief overview of where we believe the field will be headed in the next decade which includes changes in assessment paradigms, moving from characterization of comorbidities to interventions; increasing development of new measures, terminology and classification; increasing interest in neurodegenerative proteins; transitioning from clinical seizure features to modifiable risk factors; and neurobehavioral phenotypes. Overall, enormous progress has been made over the lifespan of the INS with promise of ongoing improvements in understanding of the cognitive and behavioral complications of the epilepsies and their treatment. (JINS, 2017, 23, 791–805)
Elizabeth A. R. Brown provides below a list of Anne's children, based on Patrick Van Kerrebrouck, Les Valois (pp. 157–9, 166–7).
With Charles VIII (30 June 1470–7 April 1498)
Charles-Orland, dauphin of Viennois (10 Oct. 1492–16 Dec. 1495), buried at Saint-Martin of Tours.
Unnamed (Aug. 1493), buried at Notre-Dame of Cléry.
Unnamed (March 1495).
Charles, dauphin of Viennois (8 Sept. 1496–2 Oct. 1496), buried at Saint-Martin of Tours.
François, dauphin of Viennois (1497), buried at Saint-Martin of Tours.
Anne (20 March 1498), buried at Saint-Martin of Tours.
With Louis XII (27 June 1462–1 Jan. 1515)
Claude, duchess of Brittany, countess of Blois (13 Oct. 1499–20 July 1524), married 18 May 1514 to François, duke of Valois and Milan, count of Angoulême, the future François Ier (12 Sept. 1494–31 March 1547), crowned queen of France 10 May 1517, buried at Saint-Denis.
Unnamed (21 Jan. 1503), perhaps buried at Blois.
Renée, duchess of Chartres, countess of Gisors (25 Oct. 1510–12 June 1575), married 10 Feb. 1528 to Hercule of Este, duke of Ferrara (4 April 1508–3 Oct. 1560); buried at Montargis.
The profile of Claude de France has long been at a discouraging low amongst French queens. Although pictured an uncommon number of times as a child or youth, her adult face is particularly hard to grasp: Henri Pigaillem's 2006 monograph sports on its cover, tellingly, a portrait of someone other than the queen. Historians have had trouble tracing the contours of Claude's queenly persona, too. Even in Nantes, where the cult of Anne de Bretagne overflows into the streets and squares, the 2007 exhibition dedicated to the history and myth of the queen-duchess cast a rather somber light on the daughters who survived Queen Anne and King Louis XII. In the eyes of Odette Turias, both Claude and Renée were content to bow to the will of King François Ier; and Claude's virtues – modesty, discretion, prudence – fostered a self-abnegation unworthy of a princess of royal descent. The tone of Guillaume Michel de Tours's Elegies threnes et complainctes sur la mort de tresilustre dame Madame Claude …, printed two years after the queen's death, could hardly be more at odds. Michel exhorts Jean de Paris (Jean Perréal) to design a sepulchre for this ‘lady of distinction’ and position her heart of gold on its dexter right; and he proposes adding Claude to Boccaccio's list of illustrious women, deeming her a ‘femme forte’ no fewer than four times. Closer readings of historical fact, texts, and images should help ascertain whether Michel was a base flatterer or if, rather, the oft belittled Claude was a worthy scion of Anne de Bretagne and Louis XII.
Before the Wheel of Fortune Turned
Louise de Savoie, generally cast as Claude's greatest badgerer, had no trouble whatsoever getting her dates straight: her journal informs us that Claude de France was born in Louise's castle of Romorantin on 13 October 1499, at 8:54 p.m. This astrologically precise data is but one of many signs that Princess Claude benefited from a truly exceptional start in life. For seven days bonfires were lit in her honor throughout the realm; hence she entered the collective psyche of French subjects just after birth. Months later, her grateful mother undertook a pilgrimage to thank St Claude for his assistance in procreation; and her daughter would gaze upon her namesake bishop at the beginning and the end of her primer as she was learning to read.