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Innovation Concept: The fairness of the Canadian Residency Matching Service (CaRMS) selection process has been called into question by rising rates of unmatched medical students and reports of bias and subjectivity. We outline how the University of Saskatchewan Royal College emergency medicine program evaluates CaRMS applications in a standardized, rigorous, equitable and defensible manner. Methods: Our CaRMS applicant evaluation methods were first utilized in the 2017 CaRMS cycle, based on published Best Practices, and have been refined yearly to ensure validity, standardization, defensibility, rigour, and to improve the speed and flow of data processing. To determine the reliability of the total application scores for each rater, single measures intraclass correlation coefficients (ICCs) were calculated using a random effects model in 2017 and 2018. Curriculum, Tool or Material: A secure, online spreadsheet was created that includes applicant names, reviewer assignments, data entry boxes, and formulas. Each file reviewer entered data in a dedicated sheet within the document. Each application was reviewed by two staff physicians and two to four residents. File reviewers used a standardized, criterion-based scoring rubric for each application component. The file score for each reviewer-applicant pair was converted into a z-score based on each reviewer's distribution of scores. Z-scores of all reviewers for a single applicant were then combined by weighted average, with the group of staff and group of residents each being weighted to represent half of the final file score. The ICC for the total raw scores improved from 0.38 (poor) in 2017 to 0.52 (moderate) in 2018. The data from each reviewer was amalgamated into a master sheet where applicants were sorted by final file score and heat-mapped to offer a visual aid regarding differences in ratings. Conclusion: Our innovation uses heat-mapped and formula-populated spreadsheets, scoring rubrics, and z-scores to normalize variation in scoring trends between reviewers. We believe this approach provides a rigorous, defensible, and reproducible process by which Canadian residency programs can appraise applicants and create a rank order list.
All Fire and Emergency Services (FES) personnel must balance FES work with their other responsibilities. Given that women tend to take on a greater responsibility for management of household/domestic activities than men, the on-call component of their FES work may be associated with very different challenges. Despite this, women have rarely been the focus of on-call research.
To explore women’s on-call experiences in the FES by examining coping styles and strategies, with the goal of helping to innovate the way women are supported in FES roles.
Relevant findings from two studies are included. The first study involved FES personnel from two agencies in Australia (n=24) who participated in a semi-structured interview. The second study was an anonymous online survey to determine work characteristics, sleep, stress, and coping in on-call workers more broadly, with workers from all industries across Australia (n=228) invited to participate.
Interview data identified two major themes in terms of coping with on-call work. Support (from family, social, and work), planning, and preparation were identified as important in helping women cope in the context of on-call unpredictability. Results from the survey (43% women) showed that on-call workers were an engaged group in terms of their coping, with 67% classified as having a positive coping style and 58% of women indicating that they agreed/strongly agreed with the statement, “I cope well with on-call work.”
Taken together, these data highlight engagement with positive coping by women who do on-call work, including in the FES. Importantly, positive coping strategies, such as talking about emotions, problem-solving, and seeking support have been linked to increased shift work tolerance in other populations. Coping style and strategies represent modifiable variables which could be specifically applied to assist women to manage the unique challenges associated with on-call work in the FES.
Innovation Concept: Competence by Design (CBD) was implemented nationally for Emergency Medicine (EM) residents beginning training in 2018. One challenge is the need to introduce residents to Entrustable Professional Activities (EPAs) that are assessed across numerous clinical rotations. The Royal College's resources detail these requirements, but do not map them to specific rotations or present them in a succinct format. This is problematic as trainees are less likely to succeed when expectations are unclear. We identified a need to create practical resources that residents can use at the bedside. Methods: We followed an intervention mapping framework to design two practical, user-friendly, low-cost, aesthetically pleasing resources that could be used by residents and observers at the bedside to facilitate competency-based assessment. Curriculum, Tool or Material: First, we designed a set of rotation- and stage-specific EPA reference cards for the use of residents and observers at the bedside. These cards list EPAs and clinical presentations likely to be encountered during various stages of training and on certain rotations. Second, we developed a curriculum board to organize the EPA reference cards by stage based upon our program's curriculum map. The curriculum board allows residents to view the program's curriculum map and the EPAs associated with each clinical rotation at a glance. It also contains hooks to hang and store extra cards in an organized manner. Conclusion: We believe that these practical and inexpensive tools facilitated our residency program's transition to competency-based EPA assessments. Anecdotally, the residents are using the cards and completing the suggested rotation-specific EPAs. We hope that the reference cards and curriculum board will be successfully incorporated into other residency programs to facilitate the introduction of their EPA-based CBD assessment system.
Sodium bismuth titanate (NBT) and its solid solutions with other ABO3 perovskites are of great interest for lead-free ferroelectric and piezoelectric applications. In this article, we provide an introduction to the complex structure of NBT, including atomic displacements and nanoscale defects. We also review poling effects and properties as well as NBT-ABO3 phase equilibria. The interesting relaxor properties, frequency dispersion in dielectric permittivity, and field-induced structural phase transitions of these systems are discussed. Finally, we describe other functional, mechanical, and electrical properties of NBT.
No discipline has been impacted more by war and armed conflict than health care has. Health systems and health care providers are often the first victims, suffering increasingly heinous acts that cripple the essential health delivery and public health infrastructure necessary for the protection of civilian and military victims of the state at war. This commentary argues that current instructional opportunities to prepare health care providers fall short in both content and preparation, especially in those operational skill sets necessary to manage multiple challenges, threats, and violations under international humanitarian law and to perform triage management in a resource-poor medical setting. Utilizing a historical framework, the commentary addresses the transformation of the education and training of humanitarian health professionals from the Cold War to today followed by recommendations for the future. (Disaster Med Public Health Preparedness. 2019;13:383-396)
Since 1945, the reason for humanitarian crises and the way in which the world responds to them has dramatically changed every 10 to 15 years or less. Planning, response, and recovery for these tragic events have often been ad hoc, inconsistent, and insufficient, largely because of the complexity of global humanitarian demands and their corresponding response system capabilities. This historical perspective chronicles the transformation of war and armed conflicts from the Cold War to today, emphasizing the impact these events have had on humanitarian professionals and their struggle to adapt to increasing humanitarian, operational, and political challenges. An unprecedented independent United Nations–World Health Organization decision in the Battle for Mosul in Iraq to deploy to combat zones emergency medical teams unprepared in the skills of decades-tested war and armed conflict preparation and response afforded to health care providers and dictated by International Humanitarian Law and Geneva Convention protections has abruptly challenged future decision-making and deployments. (Disaster Med Public Health Preparedness. 2019;13:109–115)
To compare the epidemiology, clinical characteristics, and mortality of patients with bloodstream infections (BSI) caused by extended-spectrum β-lactamase (ESBL)-producing Escherichia coli (ESBL-EC) versus ESBL-producing Klebsiella pneumoniae (ESBL-KP) and to examine the differences in clinical characteristics and outcome between BSIs caused by isolates with CTX-M versus other ESBL genotypes
As part of the INCREMENT project, 33 tertiary hospitals in 12 countries retrospectively collected data on adult patients diagnosed with ESBL-EC BSI or ESBL-KP BSI between 2004 and 2013. Risk factors for ESBL-EC versus ESBL-KP BSI and for 30-day mortality were examined by bivariate analysis followed by multivariable logistic regression.
The study included 909 patients: 687 with ESBL-EC BSI and 222 with ESBL-KP BSI. ESBL genotype by polymerase chain reaction amplification of 286 isolates was available. ESBL-KP BSI was associated with intensive care unit admission, cardiovascular and neurological comorbidities, length of stay to bacteremia >14 days from admission, and a nonurinary source. Overall, 30-day mortality was significantly higher in patients with ESBL-KP BSI than ESBL-EC BSI (33.7% vs 17.4%; odds ratio, 1.64; P=.016). CTX-M was the most prevalent ESBL subtype identified (218 of 286 polymerase chain reaction-tested isolates, 76%). No differences in clinical characteristics or in mortality between CTX-M and non–CTX-M ESBLs were detected.
Clinical characteristics and risk of mortality differ significantly between ESBL-EC and ESBL-KP BSI. Therefore, all ESBL-producing Enterobacteriaceae should not be considered a homogeneous group. No differences in outcomes between genotypes were detected.
Invertebrates are of particular interest on heather moorlands because of their rapid response to small scale habitat changes. Spiders constitute a variable proportion of the diet of heather moorland bird, mammal and reptile species. Furthermore, spiders may be an important indicator of habitat change resulting from management practices, especially those that exert a large- scale spatial impact, e.g. grazing. The component families and species of spider assemblages indicate, through their differing preference for web attachments and web structure, the vegetation density, height and structure (Marc et al., 1999). This effect may be especially pronounced where continued grazing at a particular stocking rate results in characteristic patterns in the vegetation structure. Species and family specific hunting strategies determine prey type and so the presence of some spider species may indicate the presence of a preferred prey species. This study aims to investigate the effect of grazing with sheep alone or in combination with cattle grazing on an upland heather moorland in the north of England.
The type identity of strains of Pseudomonas aeruginosa from primary and recurrent blood stream infection (BSI) has not been widely studied. Twenty-eight patients were identified retrospectively from 2008 to 2013 from five different laboratories; available epidemiological, clinical and microbiological data were obtained for each patient. Isolates were genotyped by iPLEX MassARRAY MALDI-TOF MS and rep-PCR. This showed that recurrent P. aeruginosa BSI was more commonly due to the same genotypically related strain as that from the primary episode. Relapse due to a genotypically related strain occurred earlier in time than a relapsing infection from an unrelated strain (median time: 26 vs. 91 days, respectively). Line related infections were the most common source of suspected BSI and almost half of all BSI episodes were associated with neutropenia, possibly indicating translocation of the organism from the patient's gut in this setting. Development of meropenem resistance occurred in two relapse isolates, which may suggest that prior antibiotic therapy for the primary BSI was a driver for the subsequent development of resistance in the recurrent isolate.
To achieve their conservation goals individuals, communities and organizations need to acquire a diversity of skills, knowledge and information (i.e. capacity). Despite current efforts to build and maintain appropriate levels of conservation capacity, it has been recognized that there will need to be a significant scaling-up of these activities in sub-Saharan Africa. This is because of the rapid increase in the number and extent of environmental problems in the region. We present a range of socio-economic contexts relevant to four key areas of African conservation capacity building: protected area management, community engagement, effective leadership, and professional e-learning. Under these core themes, 39 specific recommendations are presented. These were derived from multi-stakeholder workshop discussions at an international conference held in Nairobi, Kenya, in 2015. At the meeting 185 delegates (practitioners, scientists, community groups and government agencies) represented 105 organizations from 24 African nations and eight non-African nations. The 39 recommendations constituted six broad types of suggested action: (1) the development of new methods, (2) the provision of capacity building resources (e.g. information or data), (3) the communication of ideas or examples of successful initiatives, (4) the implementation of new research or gap analyses, (5) the establishment of new structures within and between organizations, and (6) the development of new partnerships. A number of cross-cutting issues also emerged from the discussions: the need for a greater sense of urgency in developing capacity building activities; the need to develop novel capacity building methodologies; and the need to move away from one-size-fits-all approaches.
Palm oil (PO) is a very important commodity used as food, in pharmaceuticals, for cooking and as biodiesel: PO is a major contributor to the economies of many countries, especially Indonesia and Malaysia. Novel tropical regions are being explored increasingly to grow oil palm as current land decreases, whilst recent published modelling studies by the current authors for Malaysia and Indonesia indicate that the climate will become less suitable. Countries that grow the crop commercially include those in Latin America, Africa and Asia. How will climate change (CC) affect the ability to grow oil palm in these countries? Worldwide projections for apt climate were made using Climex software in the present paper and the global area with unsuitable climate was assessed to increase by 6%, whilst highly suitable climate (HSC) decreased by 22% by 2050. The suitability decreases are dramatic by 2100 suggesting regions totally unsuitable for growing OP, which are currently appropriate: the global area with unsuitable climate increased from 154 to 169 million km2 and HSC decreased from 17 to 4 million km2. This second assessment of Indonesia and Malaysia confirmed the original findings by the current authors of large decreases in suitability. Many parts of Latin America and Africa were dramatically decreased: reductions in HSC for Brazil, Columbia and Nigeria are projected to be 119 000, 35 and 1 from 5 000 000, 219 and 69 km2, respectively. However, increases in aptness were observed in 2050 for Paraguay and Madagascar (HSC increases were 90 and 41%, respectively), which were maintained until 2100 (95 and 45%, respectively). Lesser or transient increases were seen for a few other countries. Hot, dry and cold climate stresses upon oil palm for all regions are also provided. These results have negative implications for growing oil palm in countries as: (a) alternatives to Malaysia and Indonesia or (b) economic resources per se. The inability to grow oil palm may assist in amelioration of CC, although the situation is complex. Data suggest a moderate movement of apposite climate towards the poles as previously predicted.
Throughout his life, Hegel showed great interest in physics and mathematics. His most sustained, surviving treatment of Euclidean geometry is his early work ‘Geometrische Studien’, which he completed while he was a private tutor [Hoffmeister] in Frankfurt, shortly before leaving for Jena to join Schelling. GS is not easy reading, but despite that, it seems to me that Hegel presents in it a remarkably erudite as well as interesting and insightful critique of geometry. He investigates some of the themes from the foundations of geometry, in particular from the first book of the Elements of Euclid. Like the mathematical philosophies of Kant and Frege, Hegel's understanding of geometry is conceptually based, but unlike them, it is also grounded in the classical Greek philosophy of mathematics, which achieved its definitive expression in Proclus's great commentary on Euclid 1. Much of this classical philosophy of geometry is forgotten nowadays, under the influence of the great modern mathematical philosophers (in particular, Cantor, Frege and Gödel). In my view, it well deserves reconsideration, especially since, as illustrated by Gödel's incompleteness theorems, modern mathematical philosophy has failed in its attempt to ground mathematics within the framework of formal systems.
Much of GS has not survived, and what remains is condensed and fragmentary. It seems that originally, Hegel covered all of the propositions of Euclid 1 rather than just the 14 propositions (1-12, 26, 29) that are covered in what remains of the original GS. I have given detailed treatment of GS together with related material in Hegel's Jena dissertation elsewhere (Paterson 2004/2005). The objective of the present paper is to introduce the translation of GS.
Clostridium difficile infection (CDI) has been extensively described in healthcare settings; however, risk factors associated with community-acquired (CA) CDI remain uncertain. This study aimed to synthesize the current evidence for an association between commonly prescribed medications and comorbidities with CA-CDI.
A systematic search was conducted in 5 electronic databases for epidemiologic studies that examined the association between the presence of comorbidities and exposure to medications with the risk of CA-CDI. Pooled odds ratios were estimated using 3 meta-analytic methods. Subgroup analyses by location of studies and by life stages were conducted.
Twelve publications (n=56,776 patients) met inclusion criteria. Antimicrobial (odds ratio, 6.18; 95% CI, 3.80–10.04) and corticosteroid (1.81; 1.15–2.84) exposure were associated with increased risk of CA-CDI. Among the comorbidities, inflammatory bowel disease (odds ratio, 3.72; 95% CI, 1.52–9.12), renal failure (2.64; 1.23–5.68), hematologic cancer (1.75; 1.02–5.68), and diabetes mellitus (1.15; 1.05–1.27) were associated with CA-CDI. By location, antimicrobial exposure was associated with a higher risk of CA-CDI in the United States, whereas proton-pump inhibitor exposure was associated with a higher risk in Europe. By life stages, the risk of CA-CDI associated with antimicrobial exposure greatly increased in adults older than 65 years.
Antimicrobial exposure was the strongest risk factor associated with CA-CDI. Further studies are required to investigate the risk of CA-CDI associated with medications commonly prescribed in the community. Patients with diarrhea who have inflammatory bowel disease, renal failure, hematologic cancer, or diabetes are appropriate populations for interventional studies of screening.
This retrospective, descriptive case-series reviews the clinical presentations and significant laboratory findings of patients diagnosed with and treated for injectional anthrax (IA) since December 2009 at Monklands Hospital in Central Scotland and represents the largest series of IA cases to be described from a single location. Twenty-one patients who fulfilled National Anthrax Control Team standardized case definitions of confirmed, probable or possible IA are reported. All cases survived and none required limb amputation in contrast to an overall mortality of 28% being experienced for this condition in Scotland. We document the spectrum of presentations of soft tissue infection ranging from mild cases which were managed predominantly with oral antibiotics to severe cases with significant oedema, organ failure and coagulopathy. We describe the surgical management, intensive care management and antibiotic management including the first description of daptomycin being used to treat human anthrax. It is noted that some people who had injected heroin infected with Bacillus anthracis did not develop evidence of IA. Also highlighted are biochemical and haematological parameters which proved useful in identifying deteriorating patients who required greater levels of support and surgical debridement.
Antibiotic resistance is a major risk to human health, and to provide valuable insights into mechanisms of resistance, innovative methods are needed to examine the cellular responses to antibiotic treatment. Focused ion beam tomography is proposed to image and assess the detailed three-dimensional (3D) ultrastructure of single bacterial cells. By iteratively removing slices of thickness in the order of 10 nm, high magnification 2D images can be acquired by scanning electron microscopy at single-digit nanometer resolution. In this study, Klebsiella pneumoniae was treated with polymyxin B, and 3D models of both cell envelope and cytoplasm regions containing the nucleoid and ribosomes were reconstructed. The 3D volume containing the nucleoid and ribosomes was significantly smaller, and the cell length along the longitudinal axis was extended by 40% in the treated cells, implying stress responses to the drug treatment. More than a 200% increase in protrusions per unit surface area on the cell envelope was observed in the curvature analysis after treatment. Experiments by conventional transmission electron microscopy and atomic force microscopy were also performed, followed by comparison and discussions. In conclusion, the proposed 3D imaging method and associated analysis provide a unique tool for the assessment of antibiotic effects on multidrug-resistant bacteria at nanometer resolution.
Highly crystalline core-shell FeCo-CoFe2O4 nanowires were obtained from a three step process. Initially, CoFe2O4 nanowires were grown using electrospinning and annealing at higher temperatures. Through a thermal reduction under controlled conditions, CoFe2O4 nanostructures were converted to FeCo alloy nanowires. Then by natural oxidation, a highly crystalline shell of CoFe2O4 formed over the FeCo core structure. Structural and magnetic characterizations revealed the presence of highly crystalline FeCo-Co2FeO4 core-shell structure. Magnetically, the soft FeCo phase switches at a lower magnetic field compared to the hard CoFe2O4 phase, yielding an irregular hysteresis loop with a squeezed loop in the middle. The FeCo/CoFe2O4 core-shell is stable and it retains its structure for a prolonged duration.
Objective: To assess the association of mode of conception and sex concordance with neonatal outcomes in very preterm twins. Study design: Twin pairs born at gestational age ≤32 weeks and admitted to a Level 3 neonatal intensive care unit (NICU) in 2010–2011 were retrospectively identified from the Canadian Neonatal Network™ database. A composite outcome representing neonatal mortality or any severe morbidity (intraventricular hemorrhage grades ≥3 or periventricular leukomalacia, retinopathy of prematurity stages ≥3, bronchopulmonary dysplasia, or necrotizing enterocolitis stages ≥2) was compared between twins conceived using assisted reproduction technologies (ARTs) or spontaneously (SP), and tested for association with sex concordance in individual-level and pair-wise multivariable logistic regression analyses. Results: Study subjects included 1,508 twins from 216 ART (53 [25%] male–male, 104 [48%] male–female, and 59 [27%] female–female) and 538 SP (192 [36%] male–male, 123 [23%] male–female, and 223 [41%] female–female) pairs. No statistically significant association was detected between mode of conception and the composite outcome of mortality/morbidities. The composite outcome was significantly higher in same-sex than in opposite-sex twins (OR = 1.68; 95% CI = [1.09, 2.59]). This relationship was most pronounced in ART pairs (OR = 2.25; 95% CI = [1.02, 4.98]), with increased rates in one or both twins from male–male versus opposite-sex ART pairs (OR = 3.0; 95% CI = [1.07, 8.36]). Conclusion: Same-sex pairing was associated with higher mortality/morbidities in very preterm twins admitted to the NICU, and can be used in clinical practice to identify twins at higher risk of adverse neonatal outcomes.