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No standardized surveillance criteria exist for surgical site infection after breast tissue expander (BTE) access. This report provides a framework for defining postaccess BTE infections and identifies contributing factors to infection during the expansion period. Implementing infection prevention guidelines for BTE access may reduce postaccess BTE infections.
We used a survey to characterize contemporary infection prevention and antibiotic stewardship program practices across 64 healthcare facilities, and we compared these findings to those of a similar 2013 survey. Notable findings include decreased frequency of active surveillance for methicillin-resistant Staphylococcus aureus, frequent active surveillance for carbapenem-resistant Enterobacteriaceae, and increased support for antibiotic stewardship programs.
We compared the fluorescent gel removal rate using fewer high-touch surfaces (HTSs) and rooms and determined the optimum number of HTSs and rooms needed to ensure accuracy using 2,942 HTSs in 228 rooms on 13 units. Randomly selecting 3 HTS in 2 rooms predicted the optimal removal rate.
To ascertain opinions regarding etiology and preventability of hospital-onset bacteremia and fungemia (HOB) and perspectives on HOB as a potential outcome measure reflecting quality of infection prevention and hospital care.
Hospital epidemiologists and infection preventionist members of the Society for Healthcare Epidemiology of America (SHEA) Research Network.
A web-based, multiple-choice survey was administered via the SHEA Research Network to 133 hospitals.
A total of 89 surveys were completed (67% response rate). Overall, 60% of respondents defined HOB as a positive blood culture on or after hospital day 3. Central line-associated bloodstream infections and intra-abdominal infections were perceived as the most frequent etiologies. Moreover, 61% thought that most HOB events are preventable, and 54% viewed HOB as a measure reflecting a hospital’s quality of care. Also, 29% of respondents’ hospitals already collect HOB data for internal purposes. Given a choice to publicly report central-line–associated bloodstream infections (CLABSIs) and/or HOB, 57% favored reporting either HOB alone (22%) or in addition to CLABSI (35%) and 34% favored CLABSI alone.
Among the majority of SHEA Research Network respondents, HOB is perceived as preventable, reflective of quality of care, and potentially acceptable as a publicly reported quality metric. Further studies on HOB are needed, including validation as a quality measure, assessment of risk adjustment, and formation of evidence-based bundles and toolkits to facilitate measurement and improvement of HOB rates.
Targeted screening for carbapenem-resistant organisms (CROs), including carbapenem-resistant Enterobacteriaceae (CRE) and carbapenemase-producing organisms (CPOs), remains limited; recent data suggest that existing policies miss many carriers.
Our objective was to measure the prevalence of CRO and CPO perirectal colonization at hospital unit admission and to use machine learning methods to predict probability of CRO and/or CPO carriage.
We performed an observational cohort study of all patients admitted to the medical intensive care unit (MICU) or solid organ transplant (SOT) unit at The Johns Hopkins Hospital between July 1, 2016 and July 1, 2017. Admission perirectal swabs were screened for CROs and CPOs. More than 125 variables capturing preadmission clinical and demographic characteristics were collected from the electronic medical record (EMR) system. We developed models to predict colonization probabilities using decision tree learning.
Evaluating 2,878 admission swabs from 2,165 patients, we found that 7.5% and 1.3% of swabs were CRO and CPO positive, respectively. Organism and carbapenemase diversity among CPO isolates was high. Despite including many characteristics commonly associated with CRO/CPO carriage or infection, overall, decision tree models poorly predicted CRO and CPO colonization (C statistics, 0.57 and 0.58, respectively). In subgroup analyses, however, models did accurately identify patients with recent CRO-positive cultures who use proton-pump inhibitors as having a high likelihood of CRO colonization.
In this inpatient population, CRO carriage was infrequent but was higher than previously published estimates. Despite including many variables associated with CRO/CPO carriage, models poorly predicted colonization status, likely due to significant host and organism heterogeneity.
In this systematic evaluation of fluorescent gel markers (FGM) applied to high-touch surfaces with a metered applicator (MA) made for the purpose versus a generic cotton swab (CS), removal rates were 60.5% (476 of 787) for the MA and 64.3% (506 of 787) for the CS. MA-FGM removal interpretation was more consistent, 83% versus 50% not removed, possibly due to less varied application and more adhesive gel.
Using samples collected for VRE surveillance, we evaluated unit admission prevalence of carbapenem-resistant Enterobacteriaceae (CRE) perirectal colonization and whether CRE carriers (unknown to staff) were on contact precautions for other indications. CRE colonization at unit admission was infrequent (3.9%). Most CRE carriers were not on contact precautions, representing a reservoir for healthcare-associated CRE transmission.
The ideal sampling method and benefit of qualitative versus quantitative culture for carbapenem-resistant Enterobacteriaceae (CRE) recovery in hospitalized patient rooms and bathrooms is unknown. Although the use of nylon-flocked swabs improved overall gram-negative organism recovery compared with cellulose sponges, they were similar for CRE recovery. Quantitative culture was inferior and unrevealing beyond the qualitative results.
The objective of this study was to assess whether pet ownership contributes to social participation and life satisfaction for older adults. We used baseline data from the Canadian Longitudinal Study on Aging (CLSA) for this purpose, and logistic regression models to estimate associations between social participation and life satisfaction for pet owners and non-owners. One third of all older adults (≥ 65 years, n = 7,474) in our sample reported pet ownership. Pet owners were less likely than non-pet owners to report life satisfaction and to participate frequently in social, recreational, or cultural activities, but pet owners were no less satisfied than were non-owners with their current levels of social participation. For pet owners experiencing barriers to social participation, pets appeared protective of life satisfaction in some circumstances. Both individual characteristics and structural factors linked to the World Health Organization’s age-friendly communities framework were relevant to understanding these findings.
Antibiotic resistance is a major threat to public health. Resistance is largely driven by antibiotic usage, which in many cases is unnecessary and can be improved. The impact of decreasing overall antibiotic usage on resistance is unknown and difficult to assess using standard study designs. The objective of this study was to explore the potential impact of reducing antibiotic usage on the transmission of multidrug-resistant organisms (MDROs).
We used agent-based modeling to simulate interactions between patients and healthcare workers (HCWs) using model inputs informed by the literature. We modeled the effect of antibiotic usage as (1) a microbiome effect, for which antibiotic usage decreases competing bacteria and increases the MDRO transmission probability between patients and HCWs and (2) a mutation effect that designates a proportion of patients who receive antibiotics to subsequently develop a MDRO via genetic mutation.
Intensive care unit
Absolute reduction in overall antibiotic usage by experimental values of 10% and 25%
Reducing antibiotic usage absolutely by 10% (from 75% to 65%) and 25% (from 75% to 50%) reduced acquisition rates of high-prevalence MDROs by 11.2% (P<.001) and 28.3% (P<.001), respectively. We observed similar effect sizes for low-prevalence MDROs.
In a critical care setting, where up to 50% of antibiotic courses may be inappropriate, even a moderate reduction in antibiotic usage can reduce MDRO transmission.
Deep inspiration breath hold (DIBH) is a method of motion management used in stereotactic ablative body radiotherapy (SABR) for lung tumours. An external gating block marker can be used as a tumour motion surrogate, however, inter-fraction gross target volume (GTV) displacement within DIBH occurs. This study measured this displacement during a reproducible breath hold regime. In addition, factors such as position of the gating block marker were analysed.
Methods and materials
A total of 121 cone beam computed tomography scans (CBCTs) from 22 patients who received DIBH SABR were retrospectively evaluated and the magnitude of inter-fraction GTV displacement was calculated for each fraction. This data was analysed to assess if any correlation existed between tumour displacement and variation in the gating block marker position on the patient, the amplitude of breath hold (BH) at computed tomography (CT), the amplitude of BH at treatment and the tumour location.
The measured tumour displacement was applied to the original planning CT to evaluate the dosimetric effect on surrounding organs at risk (OARs) using cumulative dose volume histograms (DVHs).
BH amplitude was reproducible within 0·13±0·1 cm (mean±standard deviation). The magnitude of tumour displacement within BH ranged from 0 to 1·52 cm (0·41±0·28 cm). Displacement in the superior-inferior, anterior-posterior and left-right planes were 0·31±0·26 cm, 0·16±0·18 cm and 0·07±0·12 cm, respectively. No statistically significant correlation was detected between tumour displacement within DIBH and the factors investigated. The range of variation in OAR dose was −7·0 to +3·6 Gy with one statistically significant increase in OAR dose observed (oesophagus mean dose increasing by 0·16 Gy).
Reproducible BH was achievable across a range of patients. Inter-fraction GTV displacement measured 0·41±0·28 cm. Due to this low level of motion, the correction of soft tissue moves did not adversely affect OAR dose.
This review aimed to address the question of whether cognitive impairment should be considered a core feature of depression that may be a valuable target for treatment.
We conducted a systematic review and meta-analysis of cognitive function, assessed with a single neuropsychological test battery, the Cambridge Neuropsychological Test Automated Battery (CANTAB), in patients with depression during symptomatic and remitted states. Inclusion of studies comparing patients remitted from depression and controls enabled us to investigate whether cognitive impairment persists beyond episodes of low mood in depression.
Our meta-analysis revealed significant moderate cognitive deficits in executive function, memory and attention in patients with depression relative to controls (Cohen's d effect sizes ranging from −0.34 to −0.65). Significant moderate deficits in executive function and attention (Cohen's d ranging from −0.52 to −0.61) and non-significant small/moderate deficits in memory (Cohen's d ranging from −0.22 to −0.54) were found to persist in patients whose depressive symptoms had remitted, indicating that cognitive impairment occurs separately from episodes of low mood in depression.
Both low mood and cognitive impairment are associated with poor psychosocial functioning. Therefore, we argue that remediation of cognitive impairment and alleviation of depressive symptoms each play an important role in improving outcome for patients with depression. In conclusion, this systematic review and meta-analysis demonstrates that cognitive impairment represents a core feature of depression that cannot be considered an epiphenomenon that is entirely secondary to symptoms of low mood and that may be a valuable target for future interventions.
The purpose of this study was to examine global epidemiological trends in human norovirus (NoV) outbreaks by transmission route and setting, and describe relationships between these characteristics, viral attack rates, and the occurrence of genogroup I (GI) or genogroup II (GII) strains in outbreaks. We analysed data from 902 reverse transcriptase–polymerase chain reaction-confirmed, human NoV outbreaks abstracted from a systematic review of articles published from 1993 to 2011 and indexed under the terms ‘norovirus’ and ‘outbreak’. Multivariate regression analyses demonstrated that foodservice and winter outbreaks were significantly associated with higher attack rates. Foodborne and waterborne outbreaks were associated with multiple strains (GI+GII). Waterborne outbreaks were significantly associated with GI strains, while healthcare-related and winter outbreaks were associated with GII strains. These results identify important trends for epidemic NoV detection, prevention, and control.
We show that the X-ray emission observed towards the center of our Milky Way Galaxy is consistent with a strong (2.1 M⊙/yr) outflow powered by both cosmic-ray pressure and thermal-gas pressure. In addition, the inferred launch parameters of such an outflow seem consistent with conditions inferred in the central Milky Way and other galaxies (although it is not clear if a significant vertical magnetic field exists in the center of the Galaxy). We also show that in galaxies with cosmic-ray pressure, gas pressure, and a vertical magnetic field component, cosmic-ray pressure can yield outflows over a wider range of conditions.
The validity of self-reported dietary intake is critical to the design and interpretation of diet–disease investigations. For many nutrients, there are no ideal methods to establish validity, given correlated error between reference and assessment tools, and constraints on time and resources available to perform such studies. Therefore, we quantified associations between macronutrient intakes and plasma HDL-cholesterol and TAG, relying on known associations between these factors to test the criterion validity of the FFQ used in the Multi-Ethnic Study of Atherosclerosis (MESA). Baseline dietary macronutrient intakes (derived from 120-item FFQ), and fasting plasma HDL and TAG were measured in 4510 MESA participants, aged 45–84 years. After adjusting for non-dietary factors known to affect plasma lipid concentrations, greater carbohydrate intake was associated with lower HDL and higher TAG (β per 5-unit change in percentage energy intake from carbohydrate = − 5 (se 1) mg/l (P < 0·001) for HDL and 15 (se 6) mg/l (P = 0·008) for TAG), whereas higher energy intake from fat was associated with higher HDL and lower TAG (β per 5-unit change in percentage energy from fat = 3·7 (se 2) mg/l (P = 0·01) for HDL and β = 19 (se 7) mg/l (P = 0·004) for TAG). Associations of dietary carbohydrate and fat intakes with HDL and TAG concentrations were consistent with previous studies, demonstrating criterion validity of these dietary measures in the MESA.
To ensure rapid and efficient impulse conduction, myelinated axons establish and maintain specific protein domains. For instance, sodium (Na+) channels accumulate in the node of Ranvier; potassium (K+) channels aggregate in the juxtaparanode and neurexin/caspr/paranodin clusters in the paranode. Our understanding of the mechanisms that control the initial clustering of these proteins is limited and less is known about domain maintenance. Correlative data indicate that myelin formation and/or mature myelin-forming cells mediate formation of all three domains. Here, we test whether myelin is required for maintaining Na+ channel domains in the nodal gap by employing two demyelinating murine models: (1) cuprizone ingestion, which induces complete demyelination through oligodendrocyte toxicity; and (2) ceramide galactosyltransferase deficient mice, which undergo spontaneous adult-onset demyelination without oligodendrocyte death. Our data indicate that the myelin sheath is essential for long-term maintenance of sodium channel domains; however, oligodendrocytes, independent of myelin, provide a partial protective influence on the maintenance of nodal Na+ channel clusters. Thus, we propose that multiple mechanisms regulate the maintenance of nodal protein organization. Finally, we present evidence that following the loss of Na+ channel clusters the chronological progression of expression and reclustering of Na+ channel isoforms during the course of CNS remyelination recapitulates development.