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This article explores the gender gap in attitudes toward the use of military force in the United States. Given that the United States has been continuously engaged in war for the last 17 years, we revisit the topic and explore whether a gender gap in attitudes persists by utilizing Cooperative Congressional Election Study data for 2006–16. In addition, given the primacy of partisanship to issue attitudes, we go beyond examining the gender gap to explore the impact of partisanship on these attitudes. We find that women are less likely than men to support the use of force in most circumstances. We also find gender gaps in the Democratic and Republican parties and acknowledge the diversity among women and among men in these attitudes because of partisan identity. Finally, we identify points of cross-pressure on individuals whose gender and partisan identities pull them in different directions, namely, Republican women and Democratic men.
Infection prevention and control (IPC) workflows are often retrospective and manual. New tools, however, have entered the field to facilitate rapid prospective monitoring of infections in hospitals. Although artificial intelligence (AI)–enabled platforms facilitate timely, on-demand integration of clinical data feeds with pathogen whole-genome sequencing (WGS), a standardized workflow to fully harness the power of such tools is lacking. We report a novel, evidence-based workflow that promotes quicker infection surveillance via AI-assisted clinical and WGS data analysis. The algorithm suggests clusters based on a combination of similar minimum inhibitory concentration (MIC) data, timing of sample collection, and shared location stays between patients. It helps to proactively guide IPC professionals during investigation of infectious outbreaks and surveillance of multidrug-resistant organisms and healthcare-acquired infections. Methods: Our team established a 1-year workgroup comprised of IPC practitioners, clinical experts, and scientists in the field. We held weekly roundtables to study lessons learned in an ongoing surveillance effort at a tertiary care hospital—utilizing Philips IntelliSpace Epidemiology (ISEpi), an AI-powered system—to understand how such a tool can enhance practice. Based on real-time case discussions and evidence from the literature, a workflow guidance tool and checklist were codified. Results: In our workflow, data-informed clusters posed by ISEpi underwent triage and expert follow-up analysis to assess: (1) likelihood of transmission(s); (2) potential vector(s) identity; (3) need to request WGS; and (4) intervention(s) to be pursued, if warranted. In a representative sample (spanning October 17, 2019, to November 7, 2019) of 67 total isolates suggested for inclusion in 19 unique cluster investigations, we determined that 9 investigations merited follow-up. Collectively, these 9 investigations involved 21 patients and required 115 minutes to review in ISEpi and an additional 70 minutes of review outside of ISEpi. After review, 6 investigations were deemed unlikely to represent a transmission; the other 3 had potential to represent transmission for which interventions would be performed. Conclusions: This study offers an important framework for adaptation of existing infection control workflow strategies to leverage the utility of rapidly integrated clinical and WGS data. This workflow can also facilitate time-sensitive decisions regarding sequencing of specific pathogens given the preponderance of available clinical data supporting investigations. In this regard, our work sets a new standard of practice: precision infection prevention (PIP). Ongoing effort is aimed at development of AI-powered capabilities for enterprise-level quality and safety improvement initiatives.
Funding: Philips Healthcare provided support for this study.
Disclosures: Alan Doty and Juan Jose Carmona report salary from Philips Healthcare.
Background: Infection prevention surveillance for cross transmission is often performed by manual review of microbiologic culture results to identify geotemporally related clusters. However, the sensitivity and specificity of this approach remains uncertain. Whole-genome sequencing (WGS) analysis can help provide a gold-standard for identifying cross-transmission events. Objective: We employed a published WGS program, the Philips IntelliSpace Epidemiology platform, to compare accuracy of two surveillance methods: (i.) a virtual infection practitioner (VIP) with perfect recall and automated analysis of antibiotic susceptibility testing (AST), sample collection timing, and patient location data and (ii) a novel clinical matching (CM) algorithm that provides cluster suggestions based on a nuanced weighted analysis of AST data, timing of sample collection, and shared location stays between patients. Methods: WGS was performed routinely on inpatient and emergency department isolates of Enterobacter cloacae, Enterococcus faecium, Klebsiella pneumoniae, and Pseudomonas aeruginosa at an academic medical center. Single-nucleotide variants (SNVs) were compared within core genome regions on a per-species basis to determine cross-transmission clusters. Moreover, one unique strain per patient was included within each analysis, and duplicates were excluded from the final results. Results: Between May 2018 and April 2019, clinical data from 121 patients were paired with WGS data from 28 E. cloacae, 21 E. faecium, 61 K. pneumoniae, and 46 P. aeruginosa isolates. Previously published SNV relatedness thresholds were applied to define genomically related isolates. Mapping of genomic relatedness defined clusters as follows: 4 patients in 2 E. faecium clusters and 2 patients in 1 P. aeruginosa cluster. The VIP method identified 12 potential clusters involving 28 patients, all of which were “pseudoclusters.” Importantly, the CM method identified 7 clusters consisting of 27 patients, which included 1 true E. faecium cluster of 2 patients with genomically related isolates. Conclusions: In light of the WGS data, all of the potential clusters identified by the VIP were pseudoclusters, lacking sufficient genomic relatedness. In contrast, the CM method showed increased sensitivity and specificity: it decreased the percentage of pseudoclusters by 14% and it identified a related genomic cluster of E. faecium. These findings suggest that integrating clinical data analytics and WGS is likely to benefit institutions in limiting expenditure of resources on pseudoclusters. Therefore, WGS combined with more sophisticated surveillance approaches, over standard methods as modeled by the VIP, are needed to better identify and address true cross-transmission events.
Funding: This study was supported by Philips Healthcare.
Prototyping is an essential activity in product development, but novice designers lack awareness and purpose when they prototype. To foster prototyping mindsets in novice designers, we introduce a prototyping support tool that structures prototyping activities. This paper outlines the Prototyping Planner's development, evolution, and evaluation by 125 novice designers. The majority of novice designers’ experienced that the Prototyping Planner helped them create purposeful prototypes and evaluate results from prototyping.
Although cattle can synthesize vitamin C (VC) endogenously, stress may increase VC requirements above the biosynthetic threshold and warrant supplementation. This study investigated the effects of a VC injection delivered before or after a long-distance transit event on blood parameters and feedlot performance of beef steers. Fifty-two days prior to trial initiation, 90 newly weaned, Angus-based steers from a single source were transported to Ames, IA, USA. On day 0, 72 steers (356 ± 17 kg) were blocked by BW and randomly assigned to intramuscular injection treatments (24 steers/treatment): saline injection pre- and post-transit (CON), VC (Vet One, Boise, ID, USA; 5 g sodium ascorbate/steer) injection pre-transit and saline injection post-transit (PRE) or saline injection pre-transit and VC injection post-transit (POST). Following pre-transit treatment injections, steers were transported on a commercial livestock trailer for approximately 18 h (1675 km). Post-transit (day 1), steers were sorted into pens with one GrowSafe bunk/pen (4 pens/treatment; 6 steers/pen). Steers were weighed on day 0, 1, 7, 30, 31, 56 and 57. Blood was collected from 3 steers/pen on day 0, 1, 2 and 7; liver biopsies were performed on the same 3 steers/pen on day 2. Data were analyzed as a randomized complete block design (experimental unit = steer; fixed effects = treatment and block) and blood parameters were analyzed as repeated measures. A pre-transit VC injection improved steer average daily gain from day 7 to 31 (P = 0.05) and overall (day 1 to 57; P = 0.02), resulting in greater BW for PRE-steers on day 30/31 (P = 0.03) and a tendency for greater final BW (day 56/57; P = 0.07). Steers that received VC pre- or post-transit had greater DM intake from day 31 to 57 (P = 0.01) and overall (P = 0.02) v. CON-steers. Plasma ascorbate concentrations were greatest for PRE-steers on day 1 and POST-steers on day 2 (treatment × day; P < 0.01). No interaction or treatment effects were observed for other blood parameters (P ≥ 0.21). Plasma ferric-reducing antioxidant potential and malondialdehyde concentrations decreased post-transit (day; P < 0.01), while serum non-esterified fatty acids and haptoglobin concentrations increased post-transit (day; P < 0.01). In general, blood parameters returned to pre-transit values by day 7. Pre-transit administration of injectable VC to beef steers mitigated the decline in plasma ascorbate concentrations and resulted in superior feedlot performance compared to post-transit administration.
Two-month head-to-head clinical trials of escitalopram and venlafaxine demonstrated similar efficacy and better tolerability for escitalopram. However, as routine practice may differ from controlled trial, it is necessary to investigate the translation of clinical trial findings into real life. This work aims at comparing treatment early discontinuation (ED) at 1 and 2 months and its economic consequences at 6 months, under venlafaxine and escitalopram.
Using US denominator-based claims database PharMetrics (includes data from 86 managed care health plans covering 45 million patients), we included adult patients diagnosed with depression who started venlafaxine or escitalopram between January 1st and December 31st 2004. ED was compared at 1 and 2 months using Cox proportional hazard models and healthcare costs at 6 months, using log-linear regression. Propensity scoring was used to account for baseline differences.
13,227 patients started escitalopram; 5,922 patients started venlafaxine. ED at 2 months was 47% for venlafaxine, 45% for escitalopram. At 1 month, venlafaxine patients had 50% more risk of ED than escitalopram patients (Hazard Ratio=0.493 [95%CI 0.432-0.564]); while this difference decreased at 2 months, (Hazard Ratio=0.955 [95%CI 0.912-0.999]). Continuing treatment at 2 months doubled the chance of still being on treatment at 6 months. Moreover 1) ED at 2 months incurred more costs over 6 months (+US$173); 2) 6-month healthcare costs were higher with venlafaxine (+US$626, p<0.001).
Early discontinuation rate was higher with venlafaxine than escitalopram, possibly due to intolerance to venlafaxine. ED was shown to affect later continuation and incurred costs.
In patients with chronic idiopathic pain disorders we have analysed the construct validity of the Melancholia Scale as compared to the results with the scale in primary depression. The patients (n= 253) were treated in a placebo controlled trial with either clomipramine or mianserin independently of the Melancholia score. The construct validity of the Melancholia Scale was further analysed by the testing of the intensity model of depression versus anxiety using the Beck Depression Inventory, the Hamilton Anxiety Scale, the Spielberger State-Trait Anxiety Scale, and the Melancholia Scale. The construct validity in terms of scale homogeneity was analysed by Loevinger coefficients which can be considered as a latent structure evaluation. The Melancholia Scale showed acceptable homogeneity, while the Hamilton Anxiety Scale lacked sufficient homogeneity. In total, 33% of the patients had a score of 10 or more on the Melancholia Scale (corresponding to 13 or more on the Hamilton Depression Scale). The predictive validity of the Melancholia Scale was evaluated using active treatment versus placebo response after 6 weeks of therapy. It was shown that in patients with a Melancholia Scale score of 10 or more (corresponding to “less than major depression”) 72% had full recovery when treated with clomipramine, while 36% of the placebo treated patients obtained a full recovery (P≤0.05). The patients treated with mianserin obtained a full recovery in 52%. The group of patients with a Melancholia Scale score of 10 or more scored higher also on the anxiety scales indicating that the relation between depression and anxiety is a matter of severity. The depressed patients had significantly lower imipramine binding sites than the non-depressed patients.
Extended-release formulations of antidepressants have been marketed as a strategy to increase patient adherence. Changes in the formulation of drugs, however, could be related to changes in efficacy and tolerability. Among second-generation antidepressants, bupropion, fluoxetine, mirtazapine, paroxetine, and venlafaxine are available in immediate- and extended-release formulations.
To compare the efficacy, tolerability, and adherence of immediate- versus extended-release formulations of second-generation antidepressants for the treatment of major depressive disorder (MDD) in adults.
To provide an evidence base for clinicians when choosing immediate- or extended-release formulations of antidepressants for the treatment of MDD.
We conducted a comparative effectiveness review for the U.S. Agency for Healthcare Research and Quality searching PubMed, EMBASE, The Cochrane Library, and the International Pharmaceutical Abstracts up to May 2010. Two people independently reviewed the literature, abstracted data, and rated the risk of bias.
Six RCTs and one observational study provided evidence about the comparative efficacy, tolerability, and adherence of bupropion SR (sustained release) versus bupropion XL (extended release), fluoxetine daily vs. fluoxetine weekly, paroxetine IR (immediate release) versus paroxetine CR (continuous release), and venlafaxine IR versus venlafaxine XR (extended release). Overall, no substantial differences in efficacy and safety could be detected. Open-label and observational evidence indicated better adherence for bupropion XL and fluoxetine weekly than for immediate-release medications. No differences in adherence could be detected between paroxetine IR and paroxetine CR.
Our findings indicate similar efficacy and tolerability between immediate- and extended-release formulations. Whether extended-release formulations lead to better adherence remains unclear.
Cognitive Adaptation Training Cognitive Adaptation Training (CAT) is a treatment that circumvents cognitive impairments by rearranging the environment to support, prompt and sequence appropriate behaviours. CAT has shown promising results, including improved social functioning. As yet, no reports have appeared on the use of CAT in combination with Assertive Community Treatment (ACT).
To evaluate the effect of CAT in comparison with ACT, focusing on social functions (primary outcome), symptoms, readmission, and quality of life of outpatients with schizophrenia.
To conduct a randomised clinical trial to test the effect of CAT compared to ACT on primary and secondary outcome.
From January 2009 to September 2010, 62 patients from three early intervention centres (where ACT was a principal part of the treatment) were enrolled in a randomised clinical trial. The effect of CAT was assessed at six and nine months.
The results indicated no significant difference between intervention group and control group at six and nine months for any outcome. The results indicated no significant difference on primary outcome GAF-F at six months (p= 0.32) or nine months (p= 0.34).
The results from this trial differ from previous CAT trials; this is the first trial without significant results in comparison with treatment as usual. However, the low number of patients in the trial may have resulted in accepting a false null hypothesis, giving a type II error. Further studies are needed to determine if some elements from CAT can make ACT more economically effective.
Can Cognitive Adaptation Training (CAT) improve daily living due to impaired cognition and social cognition?
Compared to a background population, most patients with schizophrenia have impaired cognition as well as impaired social cognition, giving problems in managing daily living and social contacts. Antipsychotic treatment can decrease cognitive impairment, even though it cannot eliminate the problem and cognitive remediation has only been shown to have a moderate effect on cognitive impairments. CAT is a treatment that circumvents cognitive impairments by rearranging the environment to support, prompt and sequence appropriate behaviours. CAT has shown promising results, including improved social functioning. As yet, no reports have appeared on the positive effect of CAT in combination with Assertive Community Treatment (ACT). The ACT treatment includes several supportive elements. Patients in ACT teams meet a specifically mental health worker in their own home, who has the opportunity to support and advise the patients. The low caseload allows for regular visits and the 14-hour crisis support gives a sense of security. Furthermore, the ACT mental health worker can assist patients in achieving sufficient material aid and services
A trial comparing CAT+ACT versus ACT alone in regard to social functioning did not document differences. However the treatment as usual in this trial was more intensive than that in previous studies in regard to time spent with patients, in instructions in correct medication management, and adjusting the medication. Thus it is uncertain if some elements from CAT can make ACT more economically effective.
Despite concerns about rising treatment of psychiatric patients with psychotropic medications and declining treatment with psychotherapy, actual treatment profiles of psychiatric patients is largely unknown.
To describe patterns in the treatment of patients in a large psychiatric university hospital department.
A descriptive mapping of treatment of in- and outpatients in a psychiatric department at Aarhus University Hospital Risskov, Denmark. Information was collected by health care staff using a 25-item survey form. The P-value was calculated with a Chi2 test and P < 0.05 was considered significant. The study was preceded by a pilot study on 41 patients.
Over a 1 month period we assessed a total of 343 consecutive patients and hereof included 200 in the age range 18–90 years (mean 53.76); 86 men and 114 women. One hundred and eighty-eight patients (94%) used psychotropic medication, 37 (19%) as monotherapy and 148 (74%) in combination with non-pharmacological therapy. Ninety-seven (49%) had psychotherapy and 104 (52%) social support. Among inpatients, 21 (64%) had physical therapy, and 10 (30%) electroconvulsive therapy. In total, 163 (82%) had non-pharmacological therapy. Fifty-two (26%) patients had monotherapy and 148 (74%) polytherapy. Mean number of treatment modalities used pr. patient was 2.07 for all patients and 3.23 for inpatients.
In our department, polytherapy including non-pharmacological modalities is applied widely across all settings and patient categories. However, psychotropic medication clearly dominates as the most frequently applied treatment.
Disclosure of interest
The authors have not supplied their declaration of competing interest.
Recent data suggest that organic broilers often score worse on footpad lesions than conventional broilers but also that the current scoring of organic broiler feet may be misleading. In order to characterise footpad lesions in organic broilers, this study assessed and compared footpad lesions in a sample of 2987 conventional and 3578 organic broiler feet obtained from a large Danish abattoir during summer and winter. The feet were scored according to two scoring systems: the modified Danish surveillance scoring system and a histopathology-based new scoring system specifically developed to target the ability to differentiate between broiler feet with hyperkeratosis and ulcers. For both systems, all broiler feet with visible lesions were cross-sectionally incised. Significant differences between the two production systems were found for both scoring systems (χ2 = 710; P < 0.001 and χ2 = 247; P < 0.001 for the new and the surveillance systems, respectively), showing that a larger proportion of the organic feet compared to conventional feet – summer and winter – exhibited signs of hyperkeratosis. In addition, a smaller fraction of the organic feet than of the conventional feet were given the outermost scores, that is, normal or ulcerated; 13.4% v. 25.3% broiler feet were given score 0 for organic v. conventional production systems, respectively (χ2 = 152; P < 0.001), and 18.4% v. 23.8% feet were given score 4 for organic v. conventional production systems, respectively (χ2 = 308; P < 0.001). Thus, the results suggest that surveillance scoring systems such as the one used in Denmark are useful for the examination of footpad lesions in broilers from both types of production systems. However, the results have also raised attention to a typical characteristic of the feet of organic broilers, that is, profound hyperkeratosis, which may underlie potential misclassifications in surveillance scoring systems like the one used in Denmark. Among the possible solutions to this challenge to the correctness and fairness of the scoring system are improved procedures (such as mandatory incision), training of technicians and calibration of results (especially for the organic footpads).
In the past few years, there has been an unprecedented increase in the number of forcibly displaced migrants worldwide, of which a substantial proportion is refugees and asylum seekers. Refugees and asylum seekers may experience high levels of psychological distress, and show high rates of mental health conditions. It is therefore timely and particularly relevant to assess whether current evidence supports the provision of psychosocial interventions for this population. We conducted a systematic review and meta-analysis of randomised controlled trials (RCTs) assessing the efficacy and acceptability of psychosocial interventions compared with control conditions (treatment as usual/no treatment, waiting list, psychological placebo) aimed at reducing mental health problems in distressed refugees and asylum seekers.
We used Cochrane procedures for conducting a systematic review and meta-analysis of RCTs. We searched for published and unpublished RCTs assessing the efficacy and acceptability of psychosocial interventions in adults and children asylum seekers and refugees with psychological distress. Post-traumatic stress disorder (PTSD), depressive and anxiety symptoms at post-intervention were the primary outcomes. Secondary outcomes include: PTSD, depressive and anxiety symptoms at follow-up, functioning, quality of life and dropouts due to any reason.
We included 26 studies with 1959 participants. Meta-analysis of RCTs revealed that psychosocial interventions have a clinically significant beneficial effect on PTSD (standardised mean difference [SMD] = −0.71; 95% confidence interval [CI] −1.01 to −0.41; I2 = 83%; 95% CI 78–88; 20 studies, 1370 participants; moderate quality evidence), depression (SMD = −1.02; 95% CI −1.52 to −0.51; I2 = 89%; 95% CI 82–93; 12 studies, 844 participants; moderate quality evidence) and anxiety outcomes (SMD = −1.05; 95% CI −1.55 to −0.56; I2 = 87%; 95% CI 79–92; 11 studies, 815 participants; moderate quality evidence). This beneficial effect was maintained at 1 month or longer follow-up, which is extremely important for populations exposed to ongoing post-migration stressors. For the other secondary outcomes, we identified a non-significant trend in favour of psychosocial interventions. Most evidence supported interventions based on cognitive behavioural therapies with a trauma-focused component. Limitations of this review include the limited number of studies collected, with a relatively low total number of participants, and the limited available data for positive outcomes like functioning and quality of life.
Considering the epidemiological relevance of psychological distress and mental health conditions in refugees and asylum seekers, and in view of the existing data on the effectiveness of psychosocial interventions, these interventions should be routinely made available as part of the health care of distressed refugees and asylum seekers. Evidence-based guidelines and implementation packages should be developed accordingly.
This study examined the effectiveness of a formal postdoctoral education program designed to teach skills in clinical and translational science, using scholar publication rates as a measure of research productivity.
Participants included 70 clinical fellows who were admitted to a master’s or certificate training program in clinical and translational science from 1999 to 2015 and 70 matched control peers. The primary outcomes were the number of publications 5 years post-fellowship matriculation and time to publishing 15 peer-reviewed manuscripts post-matriculation.
Clinical and translational science program graduates published significantly more peer-reviewed manuscripts at 5 years post-matriculation (median 8 vs 5, p=0.041) and had a faster time to publication of 15 peer-reviewed manuscripts (matched hazard ratio = 2.91, p=0.002). Additionally, program graduates’ publications yielded a significantly higher average H-index (11 vs. 7, p=0.013).
These findings support the effectiveness of formal training programs in clinical and translational science by increasing academic productivity.
The heavy reliance on imported soybean meal (SBM) as a protein source makes it necessary for the European pig industry to search for alternatives and to develop pigs that perform efficiently when fed such ingredients. Digestion and metabolism are major physiological processes contributing to variation in feed efficiency. Therefore, an experiment was conducted to assess the effects of replacing SBM with increasing levels of rapeseed meal (RSM) in diets for young pigs on apparent total tract digestibility (ATTD) of energy and nutrients, nitrogen (N) balance, energy metabolism and carbohydrate, protein and fat oxidation. Four diets were fed to 32 pigs (22.7±4.1 kg initial BW) for three weeks. The diets consisted of a control cereal grain-SBM basal diet and three test diets where SBM and wheat were partially replaced with 10%, 20%, and 30% of expeller RSM. Increasing level of RSM in the diets linearly reduced ATTD of organic matter, CP, total carbohydrates, dietary fiber and energy. Utilization of digested nitrogen (DN) for N retention and total N excretion were not affected by RSM inclusion, however, RSM inclusion induced a shift in N excretion from urine to feces. Despite a linear increase in liver to metabolic BW ratio, heat production and utilization of metabolizable energy (ME) for retention were not affected by increasing RSM inclusion. In conclusion, replacing SBM with up to 30% of expeller RSM in nutritionally balanced diets for young pigs reduced the ATTD of most nutrients and energy, but did not affect N and energy retention in the body or efficiency of utilization of DN or ME for retention.
Coinfection with human immunodeficiency virus (HIV) and viral hepatitis is associated with high morbidity and mortality in the absence of clinical management, making identification of these cases crucial. We examined characteristics of HIV and viral hepatitis coinfections by using surveillance data from 15 US states and two cities. Each jurisdiction used an automated deterministic matching method to link surveillance data for persons with reported acute and chronic hepatitis B virus (HBV) or hepatitis C virus (HCV) infections, to persons reported with HIV infection. Of the 504 398 persons living with diagnosed HIV infection at the end of 2014, 2.0% were coinfected with HBV and 6.7% were coinfected with HCV. Of the 269 884 persons ever reported with HBV, 5.2% were reported with HIV. Of the 1 093 050 persons ever reported with HCV, 4.3% were reported with HIV. A greater proportion of persons coinfected with HIV and HBV were males and blacks/African Americans, compared with those with HIV monoinfection. Persons who inject drugs represented a greater proportion of those coinfected with HIV and HCV, compared with those with HIV monoinfection. Matching HIV and viral hepatitis surveillance data highlights epidemiological characteristics of persons coinfected and can be used to routinely monitor health status and guide state and national public health interventions.