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To update current estimates of non–device-associated pneumonia (ND pneumonia) rates and their frequency relative to ventilator associated pneumonia (VAP), and identify risk factors for ND pneumonia.
Academic teaching hospital.
All adult hospitalizations between 2013 and 2017 were included. Pneumonia (device associated and non–device associated) were captured through comprehensive, hospital-wide active surveillance using CDC definitions and methodology.
From 2013 to 2017, there were 163,386 hospitalizations (97,485 unique patients) and 771 pneumonia cases (520 ND pneumonia and 191 VAP). The rate of ND pneumonia remained stable, with 4.15 and 4.54 ND pneumonia cases per 10,000 hospitalization days in 2013 and 2017 respectively (P = .65). In 2017, 74% of pneumonia cases were ND pneumonia. Male sex and increasing age we both associated with increased risk of ND pneumonia. Additionally, patients with chronic bronchitis or emphysema (hazard ratio [HR], 2.07; 95% confidence interval [CI], 1.40–3.06), congestive heart failure (HR, 1.48; 95% CI, 1.07–2.05), or paralysis (HR, 1.72; 95% CI, 1.09–2.73) were also at increased risk, as were those who were immunosuppressed (HR, 1.54; 95% CI, 1.18–2.00) or in the ICU (HR, 1.49; 95% CI, 1.06–2.09). We did not detect a change in ND pneumonia risk with use of chlorhexidine mouthwash, total parenteral nutrition, all medications of interest, and prior ventilation.
The incidence rate of ND pneumonia did not change from 2013 to 2017, and 3 of 4 nosocomial pneumonia cases were non–device associated. Hospital infection prevention programs should consider expanding the scope of surveillance to include non-ventilated patients. Future research should continue to look for modifiable risk factors and should assess potential prevention strategies.
Viral pneumonia is an important cause of death and morbidity among infants worldwide. Transmission of non-influenza respiratory viruses in households can inform preventative interventions and has not been well-characterised in South Asia. From April 2011 to April 2012, household members of pregnant women enrolled in a randomised trial of influenza vaccine in rural Nepal were surveyed weekly for respiratory illness until 180 days after birth. Nasal swabs were tested by polymerase chain reaction for respiratory viruses in symptomatic individuals. A transmission event was defined as a secondary case of the same virus within 14 days of initial infection within a household. From 555 households, 825 initial viral illness episodes occurred, resulting in 79 transmission events. The overall incidence of transmission was 1.14 events per 100 person-weeks. Risk of transmission incidence was associated with an index case age 1–4 years (incidence rate ratio (IRR) 2.35; 95% confidence interval (CI) 1.40–3.96), coinfection as initial infection (IRR 1.94; 95% CI 1.05–3.61) and no electricity in household (IRR 2.70; 95% CI 1.41–5.00). Preventive interventions targeting preschool-age children in households in resource-limited settings may decrease the risk of transmission to vulnerable household members, such as young infants.
Dietary Zn has significant impacts on the growth and development of breeding rams. The objectives of this study were to evaluate the effects of dietary Zn source and concentration on serum Zn concentration, growth performance, wool traits and reproductive performance in rams. Forty-four Targhee rams (14 months; 68 ± 18 kg BW) were used in an 84-day completely randomized design and were fed one of three pelleted dietary treatments: (1) a control without fortified Zn (CON; n = 15; ~1 × NRC); (2) a diet fortified with a Zn amino acid complex (ZnAA; n = 14; ~2 × NRC) and (3) a diet fortified with ZnSO4 (ZnSO4; n = 15; ~2 × NRC). Growth and wool characteristics measured throughout the course of the study were BW, average daily gain (ADG), dry matter intake (DMI), feed efficiency (G : F), longissimus dorsi muscle depth (LMD), back fat (BF), wool staple length (SL) and average fibre diameter (AFD). Blood was collected from each ram at four time periods to quantify serum Zn and testosterone concentrations. Semen was collected 1 to 2 days after the trial was completed. There were no differences in BW (P = 0.45), DMI (P = 0.18), LMD (P = 0.48), BF (P = 0.47) and AFD (P = 0.9) among treatment groups. ZnSO4 had greater (P ≤ 0.03) serum Zn concentrations compared with ZnAA and CON treatments. Rams consuming ZnAA had greater (P ≤ 0.03) ADG than ZnSO4 and CON. There tended to be differences among groups for G : F (P = 0.06), with ZnAA being numerically greater than ZnSO4 and CON. Wool staple length regrowth was greater (P < 0.001) in ZnSO4 and tended to be longer (P = 0.06) in ZnAA treatment group compared with CON. No differences were observed among treatments in scrotal circumference, testosterone, spermatozoa concentration within ram semen, % motility, % live sperm and % sperm abnormalities (P ≥ 0.23). Results indicated beneficial effects of feeding increased Zn concentrations to developing Targhee rams, although Zn source elicited differential responses in performance characteristics measured.
To update current estimates of non–device-associated urinary tract infection (ND-UTI) rates and their frequency relative to catheter-associated UTIs (CA-UTIs) and to identify risk factors for ND-UTIs.
Academic teaching hospital.
All adult hospitalizations between 2013 and 2017 were included. UTIs (device and non-device associated) were captured through comprehensive, hospital-wide active surveillance using Centers for Disease Control and Prevention case definitions and methodology.
From 2013 to 2017 there were 163,386 hospitalizations (97,485 unique patients) and 1,273 UTIs (715 ND-UTIs and 558 CA-UTIs). The rate of ND-UTIs remained stable, decreasing slightly from 6.14 to 5.57 ND-UTIs per 10,000 hospitalization days during the study period (P = .15). However, the proportion of UTIs that were non–device related increased from 52% to 72% (P < .0001). Female sex (hazard ratio [HR], 1.94; 95% confidence interval [CI], 1.50–2.50) and increasing age were associated with increased ND-UTI risk. Additionally, the following conditions were associated with increased risk: peptic ulcer disease (HR, 2.25; 95% CI, 1.04–4.86), immunosuppression (HR, 1.48; 95% CI, 1.15–1.91), trauma admissions (HR, 1.36; 95% CI, 1.02–1.81), total parenteral nutrition (HR, 1.99; 95% CI, 1.35–2.94) and opioid use (HR, 1.62; 95% CI, 1.10–2.32). Urinary retention (HR, 1.41; 95% CI, 0.96–2.07), suprapubic catheterization (HR, 2.28; 95% CI, 0.88–5.91), and nephrostomy tubes (HR, 2.02; 95% CI, 0.83–4.93) may also increase risk, but estimates were imprecise.
Greater than 70% of UTIs are now non–device associated. Current targeted surveillance practices should be reconsidered in light of this changing landscape. We identified several modifiable risk factors for ND-UTIs, and future research should explore the impact of prevention strategies that target these factors.
Introduction: Emergency Department (ED) health care professionals are responsible for providing team-based care to critically ill patients. Given this complex responsibility, simulation training is paramount. In situ simulation (ISS) has many cited benefits as a training strategy that targets on-duty staff and occurs in the actual patient environment. Several evidence-based frameworks identify staff buy-in as essential for successful ISS implementation, however, the attitudes of interdisciplinary front-line ED staff in this regard are unknown. The purpose of this study is to identify contextual trends in interdisciplinary opinions on routine ISS in the ED. Methods: Qualitative and quantitative review, exploring the self-reported attitudes of interdisciplinary ED staff: before, during and after the implementation of a routine ISS pilot program (5 sessions in 5 months) at the Charles V Keating Emergency and Trauma Center in Halifax from Feb-Nov, 2018. Results: 149 surveys were received. Baseline support for ISS was high; 83% of respondents believed that the advantages of ISS outweigh the challenges and 47% favoured simulation in the ED, relative the sim bay (26%) and 28% were indifferent. The attitudes of direct participants in ISS were very positive, with 88% believing that the benefits outweighed the challenges after participation and 91% believing that they personally benefited from participating. A department wide post-ISS pilot survey suggested a slight decrease in support. Support for ISS dropped from 83% to 67%, a statistically insignificant reduction (p = 0.098) but a sizeable change that warrants further investigation. Most notably respondents reported increased support for simulation training in a simulation bay relative to ISS in the ED. Respondents still regarded simulation highly overall. Interestingly, when the results were stratified by position, staff physicians were the least positive. Conclusion: Pre-pilot or baseline opinions of ISS were very positive, and participants all responded positively to the simulations. This study generates valuable insight into the perceptions of interdisciplinary ED staff regarding the implementation and perceived impact of routine ISS. This evidence can be used to inform future programming, though further investigation is warranted into why opinions post-intervention may have changed at the department level.
Public involvement in service change has been identified as a key facilitator of health care transformation (Foley et al., 2017) but little is known about how health policy influences whether and how organisations involve the public in change processes. This qualitative study compares policy and practice for involving the public in major service changes across the UK's four health systems (England, Northern Ireland, Wales and Scotland). We analysed policy documents, and conducted interviews with officials, stakeholders, NHS staff and public campaigners (total number of interviewees = 47). Involving the public in major service change was acknowledged as a policy challenge in all four systems. Despite ostensible similarities, there were some clear differences between the four health systems' processes for involving patients and the public in major changes to health services. The extent of central Government oversight, the prescriptiveness of Government guidance, the role for intermediary bodies and arrangements for independent scrutiny of contentious decisions all vary. We analyse how health policy in the four systems has used ‘sticks’ and ‘sermons’ to promote particular approaches, and conclude that both policy and the wider system context within which health care organisations try to effect change are significant, and understudied aspect of contemporary practice.
Paramedics Providing Palliative Care at Home was launched in two provinces, including a new clinical practice guideline, database, and paramedic training. The aim of this study was to evaluate patient/family satisfaction and paramedic comfort and confidence.
In Part A, we gathered perspectives of patients/families via surveys mailed at enrolment and telephone interviews after an encounter. Responses were reported descriptively and by thematic analysis. In Part B, we surveyed paramedics online pre- and 18 months post-launch. Comfort and confidence were scored on a 4-point Likert scale, and attitudes on a 7-point Likert scale, reported as the median (interquartile range [IQR]); analysis with Wilcoxon ranked sum/thematic analysis of free text.
In Part A, 67/255 (30%) enrolment surveys were returned. Three themes emerged: fulfilling wishes, peace of mind, and feeling prepared for emergencies. In 18 post-encounter interviews, four themes emerged: 24/7 availability, paramedic professionalism and compassion, symptom relief, and a plea for program continuation. Thematic saturation was reached with little divergence. In Part B, 235/1255 (18.9%) pre- and 267 (21.3%) post-surveys were completed. Comfort with providing palliative care without transport improved post launch (p = < 0.001) as did confidence in palliative care without transport (p = < 0.001). Respondents strongly agreed that all paramedics should be able to provide basic palliative care.
After implementation of the multifaceted Paramedics Providing Palliative Care at Home Program, paramedics describe palliative care as important and rewarding. The program resulted in high patient/family satisfaction; simply registering provides peace of mind. After an encounter, families particularly noted the compassion and professionalism of the paramedics.
To evaluate the long-term safety and tolerability of deutetrabenazine in patients with tardive dyskinesia (TD) at 2years.
In the 12-week ARM-TD and AIM-TD studies, deutetrabenazine showed clinically significant improvements in Abnormal Involuntary Movement Scale scores compared with placebo, and there were low rates of overall adverse events (AEs) and discontinuations associated with deutetrabenazine.
Patients who completed ARM-TD or AIM-TD were included in this open-label, single-arm extension study, in which all patients restarted/started deutetrabenazine 12mg/day, titrating up to a maximum total daily dose of 48mg/day based on dyskinesia control and tolerability. The study comprised a 6-week titration period and a long-term maintenance phase. Safety measures included incidence of AEs, serious AEs (SAEs), and AEs leading to withdrawal, dose reduction, or dose suspension. Exposure-adjusted incidence rates (EAIRs; incidence/patient-years) were used to compare AE frequencies for long-term treatment with those for short-term treatment (ARM-TD and AIM-TD). This analysis reports results up to 2 years (Week106).
343 patients were enrolled (111 patients received placebo in the parent study and 232 received deutetrabenazine). There were 331.4 patient-years of exposure in this analysis. Through Week 106, EAIRs of AEs were comparable to or lower than those observed with short-term deutetrabenazine and placebo, including AEs of interest (akathisia/restlessness [long-term EAIR: 0.02; short-term EAIR range: 0–0.25], anxiety [0.09; 0.13–0.21], depression [0.09; 0.04–0.13], diarrhea [0.06; 0.06–0.34], parkinsonism [0.01; 0–0.08], somnolence/sedation [0.09; 0.06–0.81], and suicidality [0.02; 0–0.13]). The frequency of SAEs (EAIR 0.15) was similar to those observed with short-term placebo (0.33) and deutetrabenazine (range 0.06–0.33) treatment. AEs leading to withdrawal (0.08), dose reduction (0.17), and dose suspension (0.06) were uncommon.
These results confirm the safety outcomes seen in the ARM-TD and AIM-TD parent studies, demonstrating that deutetrabenazine is well tolerated for long-term use in TD patients.
Presented at: American Academy of Neurology Annual Meeting; April 21–27, 2018, Los Angeles, California,USA
Funding Acknowledgements: Funding: This study was supported by Teva Pharmaceuticals, Petach Tikva, Israel
To evaluate long-term efficacy of deutetrabenazine in patients with tardive dyskinesia (TD) by examining response rates from baseline in Abnormal Involuntary Movement Scale (AIMS) scores. Preliminary results of the responder analysis are reported in this analysis.
In the 12-week ARM-TD and AIM-TD studies, the odds of response to deutetrabenazine treatment were higher than the odds of response to placebo at all response levels, and there were low rates of overall adverse events and discontinuations associated with deutetrabenazine.
Patients with TD who completed ARM-TD or AIM-TD were included in this open-label, single-arm extension study, in which all patients restarted/started deutetrabenazine 12mg/day, titrating up to a maximum total daily dose of 48mg/day based on dyskinesia control and tolerability. The study comprised a 6-week titration and a long-term maintenance phase. The cumulative proportion of AIMS responders from baseline was assessed. Response was defined as a percent improvement from baseline for each patient from 10% to 90% in 10% increments. AlMS score was assessed by local site ratings for this analysis.
343 patients enrolled in the extension study (111 patients received placebo in the parent study and 232 patients received deutetrabenazine). At Week 54 (n=145; total daily dose [mean±standard error]: 38.1±0.9mg), 63% of patients receiving deutetrabenazine achieved ≥30% response, 48% of patients achieved ≥50% response, and 26% achieved ≥70% response. At Week 80 (n=66; total daily dose: 38.6±1.1mg), 76% of patients achieved ≥30% response, 59% of patients achieved ≥50% response, and 36% achieved ≥70% response. Treatment was generally well tolerated.
Patients who received long-term treatment with deutetrabenazine achieved response rates higher than those observed in positive short-term studies, indicating clinically meaningful long-term treatment benefit.
Presented at: American Academy of Neurology Annual Meeting; April 21–27, 2018, Los Angeles, California, USA.
Funding Acknowledgements: This study was supported by Teva Pharmaceuticals, Petach Tikva, Israel.
The choice of animal-based traits to identify and deal with production diseases is often a challenge for pig farmers, researchers and other related professionals. This systematic review focused on production diseases, that is, the diseases that arise from management practices, affecting the digestive, locomotory and respiratory system of pigs. The aim was to classify all traits that have been measured and conduct a meta-analysis to quantify the impact of diseases on these traits so that these can be used as indicators for intervention. Data were extracted from 67 peer-reviewed publications selected from 2339 records. Traits were classified as productive (performance and carcass composition), behavioural, biochemical and molecular traits. A meta-analysis based on mixed models was performed on traits assessed more than five times across studies, using the package metafor of the R software. A total of 524 unique traits were recorded 1 to 31 times in a variety of sample material including blood, muscle, articular cartilage, bone or at the level of whole animal. No behavioural traits were recorded from the included experiments. Only 14 traits were measured on more than five occasions across studies. Traits within the biochemical, molecular and productive trait groups were reported most frequently in the published literature and were most affected by production diseases; among these were some cytokines (interleukin (IL) 1-β, IL6, IL8 and tumour necrosis factor-α), acute phase proteins (haptoglobin) and daily weight gain. Quantification of the influence of factors relating to animal characteristics or husbandry practices was not possible, due to the low frequency of reporting throughout the literature. To conclude, this study has permitted a holistic assessment of traits measured in the published literature to study production diseases occurring in various stages of the production cycle of pigs. It shows the lack of consensus and common measurements of traits to characterise production diseases within the scientific literature. Specific traits, most of them relating to performance characteristics or immunological response of pigs, are proposed for further study as potential tools for the prognosis and study of production diseases.
Objectives: To examine academic performance in dystrophinopathy as a function of dystrophin gene mutation position as well as intellectual function, executive skills, socioeconomic status (SES), behavior, and physical ability. Methods: In a cross-sectional study, boys with dystrophinopathy (ages 5–17; n=50) completed tests of academics (Woodcock-Johnson-III: spelling, reading, calculation and total scores), executive functioning (selective attention/inhibitory control, set shifting, working memory, and processing speed), single word comprehension and nonverbal reasoning. Motor skills were assessed and parents provided demographic information and child behavioral assessments. Dystrophin gene mutation positions were dichotomized into groups (upstream versus downstream of exon 43, location of isoforms previously linked to intellectual impairment). Genetic mutation groups were compared on measures of academic achievement, and multiple regression analyses examined unique and joint contributions of executive skills, intelligence quotient (IQ), SES, motor abilities, behavior, and mutation positions to academic outcomes. Results: Academic performance was slightly, yet significantly, lower than IQ and varied as a function of dystrophin gene position, wherein boys possessing the downstream mutation exhibited greater impairment than boys with the upstream mutation. Digit span forward (indexing verbal span), but no other measure of executive function, contributed significant variance to total academic achievement, spelling and calculation. Conclusions: Weak academic performance is associated with dystrophinopathy and is more common in downstream mutations. A specific deficit in verbal span may underlie inefficiencies observed in children with dystrophinopathy and may drive deficits impacting academic abilities. (JINS, 2018, 24, 928–938)
Aeroacoustic measurements and analysis have been made for an unshrouded rotor partially immersed in a planar equilibrium turbulent boundary layer at low Mach number. This configuration provides an idealized model of inflow distortion effects seen when a rotor is mounted adjacent to the hull or fuselage of a vehicle. At low and moderate thrust conditions, the rotor produces broadband noise organized into haystacks produced by large eddies of the ingested turbulence being cut multiple times by successive rotor blades. At high thrust, however, the acoustic signature changes and becomes louder and more tonal. This change is accompanied by separation of the boundary layer from the wall in the vicinity of the rotor blade disk. The separation region is highly unsteady and populated by intense vortex structures. Acoustic analysis suggests that blade–vortex interactions with these structures are the source of the additional tonal noise at high thrust.
Many studies have identified changes in the brain associated with obsessive–compulsive disorder (OCD), but few have examined the relationship between genetic determinants of OCD and brain variation.
We present the first genome-wide investigation of overlapping genetic risk for OCD and genetic influences on subcortical brain structures.
Using single nucleotide polymorphism effect concordance analysis, we measured genetic overlap between the first genome-wide association study (GWAS) of OCD (1465 participants with OCD, 5557 controls) and recent GWASs of eight subcortical brain volumes (13 171 participants).
We found evidence of significant positive concordance between OCD risk variants and variants associated with greater nucleus accumbens and putamen volumes. When conditioning OCD risk variants on brain volume, variants influencing putamen, amygdala and thalamus volumes were associated with risk for OCD.
These results are consistent with current OCD neurocircuitry models. Further evidence will clarify the relationship between putamen volume and OCD risk, and the roles of the detected variants in this disorder.
Declaration of interest
The authors have declared that no competing interests exist.
OBJECTIVES/SPECIFIC AIMS: “Cure Quest” is an adventure quest game for mobile tablets that aims to teach the player about the complexities of discovery and development of new medicines. The game instills a sense of wonderment into the learning process, taking the player to a world of magic where a mysterious condition has affected the land and they must follow the steps of the discovery and development process to find a treatment. METHODS/STUDY POPULATION: The game is being developed through a collaboration between faculty and students at ISMMS and the Games and Simulation Arts and Science Program at Rensselaer Polytechnic Institute. The first target audience is 2nd–3rd year medical students, with the future goal of adapting the game to a broader population. RESULTS/ANTICIPATED RESULTS: The game is currently in development, but the project has yielded insight into the design process for serious games in medicine. We found that for a game of this type it is essential not just to have both designers and subject matter experts, but to enable cross-pollination of modes of thinking. Through multiple design iterations and focus groups, we found that a game design approach rooted in narrative and allegorical abstraction would have a better ability to engage the target audience than one focused only on realistic simulation. When complete, we anticipate that the game will improve understanding of the core concepts in drug discovery. DISCUSSION/SIGNIFICANCE OF IMPACT: If successful, the game-based learning approach can help fill key gaps in current formal medical and scientific training, as well as gaps in understanding among the general public. The design process serves as an informative model of evolving collaborative team science.
The ‘Landscapes of Production and Punishment’ project aims to examine how convict labour from 1830–1877 affected the built and natural landscapes of the Tasman Peninsula, as well as the lives of the convicts themselves.