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A nationwide survey indicated that screening for asymptomatic carriers of C. difficile is an uncommon practice in US healthcare settings. Better understanding of the role of asymptomatic carriage in C. difficile transmission, and of the measures available to reduce that risk, are needed to inform best practices regarding the management of carriers.
A variety of paediatric tracheostomy tubes are available. This article reviews the tubes in current use at Great Ormond Street Hospital for Children and Evelina London Children's Hospital.
This paper outlines our current preferences, and the particular indications for different tracheostomy tubes, speaking valves and other attachments.
Our preferred types of tubes have undergone significant design changes. This paper also reports further experience with certain tubes that may be useful in particular circumstances. An updated sizing chart is included for reference purposes.
The choice of a paediatric tracheostomy tube remains largely determined by individual clinical requirements. Although we still favour a small range of tubes for use in the majority of our patients, there are circumstances in which other varieties are indicated.
To date, there is a lack of consensus regarding the use of both computed tomography and magnetic resonance imaging in the pre-operative assessment of cochlear implant candidates.
Twenty-five patients underwent high-resolution computed tomography and magnetic resonance imaging. ‘Control scores’ describing the expected visualisation of specific features by computed tomography and magnetic resonance imaging were established. An independent radiological review of all computed tomography and magnetic resonance imaging scan features was then compared to the control scores and the findings recorded.
Agreement with control scores occurred in 83 per cent (20 out of 24) of computed tomography scans and 91 per cent (21 out of 23) of magnetic resonance imaging scans. Radiological abnormalities were demonstrated in 16 per cent of brain scans and 18 per cent of temporal bone investigations.
Assessment in the paediatric setting constitutes a special situation given the likelihood of congenital temporal bone abnormalities and associated co-morbidities that may be relevant to surgery and prognosis following cochlear implantation. Both computed tomography and magnetic resonance imaging contribute valuable information and remain necessary in paediatric cochlear implant pre-operative assessment.
Targets within the solar system generally fall into one of two types: a) major planets (except Pluto) and our Moon; b) minor planets, comets, Pluto and planetary satellites. The first group is noteworthy for being reasonably bright. Most are also spatially extended. The inner planets never achieve large solar elongation. The second group comprises bodies which are generally faint. Comets are spatially extended. The minor planets and comets may be in orbits which are highly inclined or viewed at small solar elongations. Comets may even be in retrograde orbits. Planetary satellites may be bright or faint but suffer from being in the glare of the parent planet.
A new astronomical system is nearing completion at U.N.S.W. in which a charge coupled device (CCD) array detector is matched to a Schmidt telescope, with the observations completely analyzed on-line. We have modified a Baker-Nunn satellite tracking camera, with its excellent 0.5m, f/1 super-Schmidt optics, converting it into a computer-controlled equatorially-mounted astronomical telescope. The telescope is expected to be located at Siding Spring Observatory in north-western New South Wales.
To develop common indicators, relevant to both EU member states and the United States, that characterize and allow for meaningful comparison of antimicrobial stewardship programs among different countries and healthcare systems.
Modified Delphi process.
A multinational panel of 20 experts in antimicrobial stewardship.
Potential indicators were rated on the perceived feasibility to implement and measure each indicator and clinical importance for optimizing appropriate antimicrobial prescribing.
The outcome was a set of 33 indicators developed to characterize the infrastructure and activities of hospital antimicrobial stewardship programs. Among them 17 indicators were considered essential to characterize an antimicrobial stewardship program and therefore were included in a core set of indicators. The remaining 16 indicators were considered optional indicators and included in a supplemental set.
The integration of these indicators in public health surveillance and special studies will lead to a better understanding of best practices in antimicrobial stewardship. Additionally, future studies can explore the association of hospital antimicrobial stewardship programs to antimicrobial use and resistance.
Gilliland et al. (2000) have reported HST photometric observations of 34000 stars in the globular cluster 47 Tuc, showing an absence of close-in giant planets in that cluster relative to their frequency in the solar neighborhood. Here we describe the methods of time-series analysis that were used to search the 47 Tuc data for transits by giant extrasolar planets, and the means by which these methods were validated.
To investigate the association between food insecurity and intimate partner violence in a population-based sample of heterosexual women.
Logistic regression was used to evaluate the association between three levels of food insecurity and intimate partner violence.
Data from 6 years of the California Women’s Health Survey.
Randomly selected women (n 16 562) aged 18 years and older from the State of California, USA.
We found: (i) that African-American women had a higher prevalence of food insecurity and were more likely to report severe intimate partner violence; (ii) a strong positive association between food insecurity and intimate partner violence; (iii) evidence of effect modification of the association between food insecurity and intimate partner violence by marital status; and (iv) higher odds of intimate partner violence among those reporting more severe food insecurity.
Food insecurity is an important risk indicator for intimate partner violence among women. Understanding the factors that put women, especially minority women, at greatest risk facilitates intervention development.
Aspects of eudaimonic well-being, such as personal growth (PG) and purpose in life (PL), have been highlighted as important to older adults’ health. We investigated the relationship of PG and PL with patterns of survival to the age of 85 years and older.
The sample included 8,880 women from the Women's Health Initiative cohort who reached 85 years of age by December 1, 2013, and for whom data on the PG and PL constructs were available. Women were classified into mutually exclusive outcomes: Healthy, Prevalent, Incident, Disabled, and Deceased. PG and PL were each assessed using a modified seven-item measure derived from the Psychological Well-Being scale.
Women were most commonly classified as Healthy (38.2%, n = 3,395), followed by Incident (24.4%, n = 2,163), Disabled (19.0%, n = 1,685), Prevalent (14.3%, 1,273), and Deceased (4.1%, n = 364). Women with low PL and PG levels were more likely to have prevalent mobility disability and disease or incident death before the age of 85 years. Specifically, those who reported low levels of PG and PL had a 2.1- and 3.6-fold higher risk, respectively, of death.
These findings indicate that even among the oldest old, experience of purposeful life engagement and continuing PG may contribute to better health outcomes.
Temperature is a significant factor influencing seed germination and for many species temperature-mediated germination cues are vital for plant persistence. Rising temperatures forecast as a result of anthropogenic climate change may have a substantial influence on the population and range dynamics of plant species. Here, we report on the thermal constraints on seed germination in natural populations of four congeneric Banksia species collected from a longitudinal climate gradient in Western Australia. We investigated whether germination niche: (1) varied between species; (2) varied among populations of each species; and (3) varied in a consistent manner reflecting the climatic gradients of seed origin. We hypothesized that species would differ and that populations from warmer sites would have a broader temperature window for germination than populations from cooler sites. Species differed in the breadth of their germination niche, but temperatures that stimulated the most rapid and complete germination were similar across all species. A sharp reduction in germination percentage occurred above the optimum temperature, which coincided with significant delays in germination relative to the optimum. The temperatures causing these declines varied among populations. Across the species, there was a significant correlation between optimum germination temperature and mean annual temperature at seed source; however, there was no relationship at the population level for individual species. These data provide insight into the vulnerability of Banksia species to climate change, with those populations that require lower temperatures for germination, or have narrower optimal ranges for germination, likely to be most vulnerable to a warming climate.
Childhood cardiovascular risk factors affect vascular function long before overt cardiovascular disease. Twin studies provide a unique opportunity to examine the influence of shared genetic and environmental influences on childhood cardiovascular function. We examined the relationship between birth parameters, markers of adiposity, insulin resistance, lipid profile and blood pressure and carotid–femoral pulse wave velocity (PWV), a validated non-invasive measure of arterial stiffness in a healthy cohort of school-aged twin children.
PWV was performed on a population-based birth cohort of 147 twin pairs aged 7–11 years. Fasting blood samples, blood pressure and adiposity measures were collected concurrently. Mixed linear regression models were used to account for twin clustering, within- and between-twin pair associations.
There were positive associations between both markers of higher adiposity, insulin resistance, elevated triglycerides and PWV, which remained significant after accounting for twin birth-set clustering. There was a positive association between both diastolic and mean arterial blood pressure and PWV in within-pair analysis in dizygotic, but not monozygotic twins, indicating genetic differences evident in dizygotic not monozygotic twins may affect these associations.
Increased blood pressure, triglycerides and other metabolic markers are associated with increased PWV in school-aged twins. These results support both the genetic and environmental contribution to higher PWV, as a marker of arterial stiffness, and reiterate the importance of preventing metabolic syndrome from childhood.
The purpose of this study was to describe the longitudinal trajectories and bidirectional relationships of the physical-social and emotional functioning (EF) dimensions of positive aging and to identify their baseline characteristics.
Women age 65 and older who enrolled in one or more Women's Health Initiative clinical trials (WHI CTs) and who had positive aging indicators measured at baseline and years 1, 3, 6, and 9 were included in these analyses (N = 2281). Analytic strategies included latent class growth modeling to identify longitudinal trajectories and multinomial logistic regression to examine the effects of baseline predictors on these trajectories.
A five-trajectory model was chosen to best represent the data. For Physical-Social Functioning (PSF), trajectory groups included Low Maintainer (8.3%), Mid-Low Improver (10.4%), Medium Decliner (10.7%), Mid-High Maintainer (31.2%), and High Maintainer (39.4%); for EF, trajectories included Low Maintainer (3%), Mid-Low Improver (9%), Medium Decliner (7.7%), Mid-High Maintainer (22.8%), and High Maintainer (57.5%). Cross-classification of the groups of trajectories demonstrated that the impact of a high and stable EF on PSF might be greater than the reverse. Low depression symptoms, low pain, and high social support were the most consistent predictors of high EF trajectories.
Aging women are heterogeneous in terms of positive aging indicators for up to 9 years of follow-up. Interventions aimed at promoting sustainable EF might have diffused effects on other domains of healthy aging.
To identify differences in organizational culture and better understand motivators to implementation of abundle intervention to control Klebsiella pneumoniae carbapenemase–producing Enterobacteriaceae (KPC).
Four long-term acute care hospitals (LTACHs) in Chicago.
LTACH staff across 3 strata of employees (administration, midlevel management, and frontline clinical workers).
Qualitative interviews or focus groups and completion of a quantitative questionnaire.
Eighty employees (frontline, 72.5%; midlevel, 17.5%; administration, 10%) completed surveys and participated in qualitative discussions in August 2012. Although 82.3% of respondents felt that quality improvement was a priority at their LTACH, there were statistically significant differences in organizational culture between staff strata, with administrative-level having higher organizational culture scores (ie, more favorable responses) than midlevel or frontline staff. When asked to rank the success of the KPC control program, mean response was 8.0 (95% confidence interval, 7.6–8.5), indicating a high level of agreement with the perception that the program was a success. Patient safety and personal safety were reported most often as personal motivators for intervention adherence. The most convergent theme related to prevention across groups was that proper hand hygiene is vital to prevention of KPC transmission.
Despite differences in organizational culture across 3 strata of LTACH employees, the high degree of convergence in motivation, understanding, and beliefs related to implementation of a KPC control bundle suggests that all levels of staff may be able to align perspectives when faced with a key infection control problem and quality improvement initiative.
Semiconductor materials have shown promise as ionizing radiation detection devices; however, to be used as a neutron detector, these materials require the addition of a nucleus with a large neutron absorption cross section (such as 10B or 6Li) to capture thermal neutrons and convert them into directly detectable particles. A semiconducting material that contains the neutron absorber within its regular stoichiometry has the potential to be more efficient than a layered or heterogeneous device at transferring the kinetic energy of the charged particle into the semiconducting material. One class of materials that has shown promise is Li-containing AIBIIIXVI2 compounds such as LiGaTe2, LiGaSe2, and LiInSe2. These materials have band gaps (2-3.5 eV) appropriate for room-temperature detection of thermal neutrons and would be the first detection material that is simultaneously, exquisitely sensitive to thermal neutrons; is insensitive to gammas; and acts as a direct conversion device. A vacuum distillation process provided high-purity lithium metal for AIBIIIXVI2 synthesis. Single crystals of sufficient bulk resistivity (grown for LiGaSe2 and LiInSe2LiInSe2) showed a distinct photo response as well as a clear response to alpha particles. Additional radiation measurements indicated that a 6 mm x 7 mm x 1.33 mm crystal of LiInSe2 detected gamma rays, and despite being composed of natural abundance lithium, responded to thermal neutrons as well.
The conditions for an almost perfect growth of smooth Cr (001) films on an iron whisker substrate have been investigated by means of reflection high energy electron diffraction (RHEED). The exchange interaction between 20 Monolayer thick Fe (001) films separated from a bulk whisker Fe (001) substrate by a variable number of Cr (001) Monolayers (ML) has been investigated by means of Brillouin light scattering experiments (BLS). These experiments show unambiguously that the exchange coupling strength between the iron film and the iron whisker can be described by a short wavelength oscillatory term superposed on a slowly varying antiferromagnetic background. The BLS data enabled one to separate the bilinear and the biquadratic contributions to the antiferromagnetic exchange coupling terms. Both the bilinear and the biquadratic coupling strengths exhibited a short period oscillatory dependence on the Cr interlayer thickness (∼2 Monolayers). Maxima in the bilinear antiferromagnetic coupling strength occur for an odd number of Cr Monolayers. This observation is not in agreement with first principles calculations. The first phase inversion has been found to occur between 4 and 5 ML of Cr.
To understand the feasibility of implementing a standardized performance measure for collecting and reporting influenza vaccination rates among healthcare personnel, qualitative, semistructured interviews were conducted with key informants in 32 healthcare facilities. Despite practical and logistical challenges to implementing the measure, respondents perceived clear benefits to its use.
Little is known about how hospital organizational and cultural factors associated with implementation of quality initiatives such as the Institute for Healthcare Improvement's (IHI) 100,000 Lives Campaign differ among levels of healthcare staff.
Evaluation of a mixed qualitative and quantitative methodology (“trilogic evaluation model”).
Six hospitals that joined the campaign before June 2006.
Three strata of staff (executive leadership, midlevel, and frontline) at each hospital.
Surveys were completed in 2008 by 135 hospital personnel (midlevel, 43.7%; frontline, 38.5%; executive, 17.8%) who also participated in 20 focus groups. Overall, 93% of participants were aware of the IHI campaign in their hospital and perceived that 58% (standard deviation, 22.7%) of improvements in quality at their hospital were a direct result of the campaign. There were significant differences between staff levels on the organizational culture (OC) items, with executive-level staff having higher scores than midlevel and frontline staff. All 20 focus groups perceived that the campaign interventions were sustainable and that data feedback, buy-in, hardwiring (into daily activities), and leadership support were essential to sustainability.
The trilogic model demonstrated that the 3 levels of staff had markedly different perceptions regarding the IHI campaign and OC. A framework in which frontline, midlevel, and leadership staff are simultaneously assessed may be a useful tool for future evaluations of OC and quality initiatives such as the IHI campaign.
To assess healthcare personnel (HCP) perceptions regarding implementation of sensor-based electronic systems for automated hand hygiene adherence monitoring.
Using a mixed-methods approach, structured focus groups were designed to elicit quantitative and qualitative responses on familiarity, comfort level, and perceived impact of sensor-based hand hygiene adherence monitoring
A university hospital, a Veterans Affairs hospital, and a community hospital in the Midwest.
Focus groups were homogenous by HCP type, with separate groups held for leadership, midlevel management, and frontline personnel at each hospital.
Overall, 89 HCP participated in 10 focus groups. Levels of familiarity and comfort with electronic oversight technology varied by HCP type; when compared with frontline HCP, those in leadership positions were significantly more familiar with (P<.01) and more comfortable with (P<.01) the technology. The most common concerns cited by participants across groups included lack of accuracy in the data produced, such as the inability of the technology to assess the situational context of hand hygiene opportunities, and the potential punitive use of data produced. Across groups, HCP had decreased tolerance for electronic collection of spatial-temporal data, describing such oversight as Big Brother.
While substantial concerns were expressed by all types of HCP, participants' recommendations for effective implementation of electronic oversight technologies for hand hygiene monitoring included addressing accuracy issues before implementation and transparent communication with frontline HCP about the intended use of the data.
In August 2007, Illinois passed legislation mandating methicillin-resistant Staphylococcus aureus (MRSA) admission screening for intensive care unit patients. We assessed hospital staff perceptions of the implementation of this law.
Mixed-methods evaluation using structured focus groups and questionnaires.
Eight Chicago-area hospitals.
Three strata of staff (leadership, midlevel, and frontline) at each hospital.
All participants completed a questionnaire and participated in a focus group. Focus group transcripts were thematically coded and analyzed. The proportion of staff agreeing with statements about MRSA and the legislation was compared across staff types.
Overall, 126 hospital staff participated in 23 focus groups. Fifty-six percent of participants agreed that the legislation had a positive effect at their facility; frontline staff were more likely to agree than midlevel and leadership staff (P < .01). Perceived benefits of the legislation included increased awareness of MRSA among staff and better knowledge of the epidemiology of MRSA colonization. Perceived negative consequences included the psychosocial effect of screening and contact precautions on patients and increased use of resources. Most participants (59%) would choose to continue the activities associated with the legislation but advised facilities in states considering similar legislation to educate staff and patients about MRSA screening and to draft clear implementation plans.
Staff from Chicago-area hospitals perceived that mandatory MRSA screening legislation resulted in some benefits but highlighted implementation challenges. States considering similar initiatives might minimize these challenges by optimizing messaging to patients and healthcare staff, drafting implementation plans, and developing program evaluation strategies.