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To conduct a pilot study implementing combined genomic and epidemiologic surveillance for hospital-acquired multidrug-resistant organisms (MDROs) to predict transmission between patients and to estimate the local burden of MDRO transmission.
Pilot prospective multicenter surveillance study.
The study was conducted in 8 university hospitals (2,800 beds total) in Melbourne, Australia (population 4.8 million), including 4 acute-care, 1 specialist cancer care, and 3 subacute-care hospitals.
All clinical and screening isolates from hospital inpatients (April 24 to June 18, 2017) were collected for 6 MDROs: vanA VRE, MRSA, ESBL Escherichia coli (ESBL-Ec) and Klebsiella pneumoniae (ESBL-Kp), and carbapenem-resistant Pseudomonas aeruginosa (CRPa) and Acinetobacter baumannii (CRAb). Isolates were analyzed and reported as routine by hospital laboratories, underwent whole-genome sequencing at the central laboratory, and were analyzed using open-source bioinformatic tools. MDRO burden and transmission were assessed using combined genomic and epidemiologic data.
In total, 408 isolates were collected from 358 patients; 47.5% were screening isolates. ESBL-Ec was most common (52.5%), then MRSA (21.6%), vanA VRE (15.7%), and ESBL-Kp (7.6%). Most MDROs (88.3%) were isolated from patients with recent healthcare exposure.
Combining genomics and epidemiology identified that at least 27.1% of MDROs were likely acquired in a hospital; most of these transmission events would not have been detected without genomics. The highest proportion of transmission occurred with vanA VRE (88.4% of patients).
Genomic and epidemiologic data from multiple institutions can feasibly be combined prospectively, providing substantial insights into the burden and distribution of MDROs, including in-hospital transmission. This analysis enables infection control teams to target interventions more effectively.
COVID-19 has caused a major global pandemic and necessitated unprecedented public health restrictions in almost every country. Understanding risk factors for severe disease in hospitalised patients is critical as the pandemic progresses. This observational cohort study aimed to characterise the independent associations between the clinical outcomes of hospitalised patients and their demographics, comorbidities, blood tests and bedside observations. All patients admitted to Northwick Park Hospital, London, UK between 12 March and 15 April 2020 with COVID-19 were retrospectively identified. The primary outcome was death. Associations were explored using Cox proportional hazards modelling. The study included 981 patients. The mortality rate was 36.0%. Age (adjusted hazard ratio (aHR) 1.53), respiratory disease (aHR 1.37), immunosuppression (aHR 2.23), respiratory rate (aHR 1.28), hypoxia (aHR 1.36), Glasgow Coma Scale <15 (aHR 1.92), urea (aHR 2.67), alkaline phosphatase (aHR 2.53), C-reactive protein (aHR 1.15), lactate (aHR 2.67), platelet count (aHR 0.77) and infiltrates on chest radiograph (aHR 1.89) were all associated with mortality. These important data will aid clinical risk stratification and provide direction for further research.
This chapter will provide an overview of the various ways in which addictive disorders can be studied using human participants in laboratory settings. Human laboratory research provides an important piece of the translational research chain by enabling researchers to examine addictive behaviors in controlled settings using validated experimental methodologies. This chapter will cover three common laboratory techniques: cue exposure protocols, stress induction protocols, and addictive object self-administration protocols. The primary goal is to provide a methodological guide to conducting research using these approaches, but not extensively review previous research. Therefore, for each technique, we discuss the background and rationale, ethical considerations, strengths and limitations, and representative examples and promising future directions in the use of the technique to study substance and behavioral addictions.
Because of their structural versatility, fast redox reactivity, high storage capacity, sustainability, and environmental friendliness, soluble organic redox molecules have emerged as materials that have potential for use in energy-storage systems. Considering these advantages, this paper reviews recent progress in implementing such materials in aqueous soluble organic redox flow batteries and organic alkali metal/air batteries. We identify and discuss major challenges associated with molecular structures, cell configurations, and electrochemical parameters. Hopefully, we provide a general guidance for the future development of soluble organic redox materials for emerging energy-storage devices used in the electricity grid.
Hearing loss affects over 1.3 billion individuals worldwide, with the greatest burden among adults. Little is known regarding the association between adult-onset hearing loss and employment.
Seven databases (PubMed, Embase, Cochrane Library, ABI/Inform Collection, Business Source Ultimate, Web of Science and Scopus) were searched through to October 2018. The key word terms used related to hearing loss and employment, excluding paediatric or congenital hearing loss and deaf or culturally deaf populations.
The initial search resulted in 13 144 articles. A total of 7494 articles underwent title and abstract screening, and 243 underwent full-text review. Twenty-five articles met the inclusion criteria. Studies were set in 10 predominantly high-income countries. Seven of the 25 studies analysed regionally or nationally representative datasets and controlled for key variables. Six of these seven studies reported associations between hearing loss and employment.
The highest quality studies currently available indicate that adult-onset hearing loss is associated with unemployment. However, considerable heterogeneity exists, and more rigorous studies that include low- and middle-income countries are needed.
To explore factors associated with work impairment at 2 years following an acute episode.
European Mania in Bipolar disorder Longitudinal Evaluation of Medication (EMBLEM) is a prospective, observational study on the outcomes of patients with a manic/mixed episode. Work impairment was measured using a Longitudinal Interval Follow-up Evaluation (slice of LIFE) item and patients were categorised with either low or high work impairment at each observation. Baseline factors associated with work impairment at 2 years were assessed using multivariate modelling.
At baseline (n = 2289), 69% of patients had high work impairment. At 2 years (n = 1393), high impairment reduced to 41%. Modelling identified rapid cycling as the strongest disease-related factor associated with high work impairment at 2 years, although high work impairment at baseline had the strongest association overall. Lower levels of education, recent admissions, CGI-BP overall severity in the 12 months prior to baseline and CGI-BP mania at baseline all predicted higher work impairment. Living together in a relationship and independent housing were both significantly associated with having low work impairment at 2 years.
Work impairment in bipolar disorder is maintained over long periods, and is strongly associated with relationship status, living conditions and various disease-related factors.
Research suggests that cannabis use negatively impacts on onset and outcome of schizophrenia. Possible effects in mood disorders have received little investigation. The first study analysing the influence of cannabis exposure on clinical and social treatment outcomes within a bipolar disorder (BP) population during 1 year of treatment is presented.
3684 patients were enrolled in an observational study when psychotropic treatment for mania was initiated/changed. The influence of cannabis exposure on baseline-corrected clinical and social treatment outcome measures was examined. Mediating effects of six variables on associations between cannabis and outcome measures were investigated further.
Over 12 months of treatment, cannabis users exhibited higher levels of BP overall illness severity, mania and psychosis, and less severe depression symptoms compared to non-users. These associations were most frequently mediated by abuse of alcohol and other substances. Users more frequently abused alcohol and other substances; these associations were not mediated by other variables. Cannabis users engaged in more social activities but had a higher probability of not having a relationship and fewer dependents to care for. Associations with activities and dependents to care for were mediated by various variables, whereas no variables mediated the association with not having a relationship.
Cannabis use impacts on clinical outcomes in patients with BP, with a modest impact on social outcomes. More research is required to further elucidate the mechanism by which cannabis exerts its influence. Understanding the associations between cannabis use and outcome measures may offer valuable insights into treatment strategies.
The objective is to describe the prevalence and nature of painful symptoms among depressive outpatients and how are they related with depressive symptoms and somatic non painful symptoms at baseline.
The FINDER study, conducted in 12 European countries in depressed outpatients in routine primary and specialist care settings provides a unique opportunity to answer these questions.
Painful symptoms were evaluated among 3468 patients enrolled by 437 investigators, using the 28-item Somatic Symptom Inventory (SSI-28) and 6 Visual Analogue Scales (1 item on overall pain and 5 items on pain characteristics: headaches, back pain, shoulder pain, interferences with daily activities and pain while awake). There was a strong correlation between the VAS overall pain score and the pain sub score of the SSI-28. The threshold score of 30 mm on the overall pain severity in combination with selected comorbidities was used to divide patients in three pain cohorts: (1) those with no/mild pain; (2) those with moderate/severe œmedically explained pain and (3) those with moderate/severe medically unexplained pain.
Results showed that 1447 (43.7%) patients had no/mild pain, 550 (16,6%) had moderate/severe medically explained pain, and 1311 (39,6%) had moderate/severe medically unexplained pain. Of the different locations of pain symptoms (from the SSI-28), headaches were the most common, followed by muscle soreness and lower back pain. The mean depression score (HADS-D) was higher in patients with pain-related symptoms.
We studied the correlations between the measures of pain and depression. These results and their implications will be discussed.
To describe 12 month outcomes of French patients enrolled in EMBLEM (European Mania in Bipolar Longitudinal Evaluation of Medication).
EMBLEM is a prospective, observational study on outcomes of manic/mixed episode. Adult patients were enrolled within the standard course of care if they initiated/changed oral medication for treatment of acute mania. All treatment decisions were at the discretion of the treating psychiatrist. 530 psychiatrists (126 French) enrolled 3459 eligible patients (771 French). 12 months results of the French cohort will be presented.
At baseline, mean age was 45.5 years (sd 13.6) and 59% were female. 68% were outpatients and 34% had a mixed episode. 76% of French patients were eligible for follow-up at 12 months. 80% improved (CGI-BP overall decrease >2) during follow-up whereas 47% patients never achieved recovery (two consecutive CGI-BP overall <2). 37% of patients presented with no medication at baseline. 41.6% were started on monotherapy and 58.4% on combination therapy; of those 54% and 28% respectively remained on their initial medication throughout the 12 months. 25% were treated with antidepressants in addition to their new oral medication, which increased to 35% at 12 months.
In this naturalistic study, less than half of French patients achieved recovery during 12 months follow-up. Antidepressant was frequent at baseline and use increased during follow-up. Twice as many patients remained on the same monotherapy as those on the same combination therapy
To contrast the outcomes of olanzapine- and valproate-treated patients in an observational study of acute mania with the results of a RCT assessing the same treatments (Tohen et al., 2002).
EMBLEM (European Mania in Bipolar Evaluation of Medication) was a 2-year, prospective, observational study of health outcomes associated with treatment of mania. Severity of mania and depression was assessed at baseline and 6 weeks using the YMRS and 5-item version of the HAMD, respectively. The RCT was a 3-week, randomised, double-blind comparison of olanzapine (n=125) and divalproate-treated (n=123) patients hospitalised for acute manic or mixed episodes. The YMRS and HAMD were used to quantify manic and depressive symptoms, respectively.
621 EMBLEM patients were analysed (n=107 valproate, n=514 olanzapine). Both observed groups improved from baseline to 6 weeks in mean YMRS and HAMD-5 total scores, with significantly greater mean improvements in the olanzapine compared with the valproate group using linear regression to adjust for baseline differences. The RCT reported significantly greater mean YMRS improvement (but not HAMD) in the olanzapine-treated group. EMBLEM patients treated with olanzapine experienced significantly greater weight gain than patients treated with valproate, similar to RCT results. There was a significantly greater incidence of treatment-emergent gastrointestinal adverse events in EMBLEM patients treated with valproate.
The EMBLEM results support those of the RCT, which suggest that olanzapine monotherapy may be more effective than valproate monotherapy in the treatment of acute mania. Contrasting observational and RCT results present methodological challenges but can provide important complementary information.
The PAtient SAtisfaction with Psychotropic (PASAP) scale is a self-completed questionnaire measuring satisfaction with psychotropic medication. The aim of the study was to describe its development in French and its psychometric properties.
Materials and methods:
Scale construction was based on an extensive search of the literature. The item reduction process required semi-structured interviews of psychiatric outpatients (n = 30). The final version of the PASAP is a 9-item, 5-point Likert-type scale, covering the scope of effectiveness and adherence. To assess the psychometric properties of the scale, French patients with an acute manic episode (n = 314) from a large European observational cohort completed the PASAP scale 3 months after psychotropic treatment initiation/change. Internal validity and reliability were assessed using principal component analysis (PCA). Concurrent validity was assessed using comparisons to physician-rated satisfaction with life, illness severity, mood relapse, compliance and side effects.
Participation rate was 68.4%. PCA was in favour of uni-dimensionality. Cronbach's α coefficient was 0.85 (95%CI 0.83–0.88). All five concurrent measures were significantly associated with the PASAP score.
The PASAP scale showed good psychometric properties in a large bipolar population and thus seems adequate for evaluating treatment satisfaction. Its short length and good acceptability makes it suitable for clinical research.
One of the WHO's innovations for improving the ICD-11 chapter Mental and Behavioral Disorders was the creation of the Global Clinical Practice Network (GCPN), an international network of more than 12,000 mental health and primary care professionals from 144 countries.
Aims and objectives
In order to evaluate perceived clinical utility of the ICD-11 guidelines, the case-controlled field studies that involved the application of the proposed diagnostic guidelines to standardized case material were implemented via the Internet in different languages.
Two hundred and seventy-eight Russian mental health care professionals, the GCPN members, have participated in case controlled Internet study for the chapter “Schizophrenia and Other Primary Psychotic Disorders”. Russian participants were represented by psychiatrists mostly (89%) and much less by psychologists (8%) which corresponds with the general situation in the Russian mental health care system.
Russian clinicians have used the proposed ICD-11 diagnostic guidelines successfully to assess delusional disorder as well as schizophrenia. But there were certain categories (schizoaffective disorder, subthreshold delusions) with which the participants seemed to struggle. The critical comments were focused on opposing so called syndrome-based assessment and nosological diagnostics. Most concerns were about elimination of Schizophrenia subtypes.
Russian mental health care professionals proved to be interested in ICD revision process and demonstrated their special diagnostics opinion based on rich clinical traditions and psychopathological approach. In order to use ICD-11 guidelines in clinical practice more efficiently supplementary appropriate training would be needed.
Disclosure of interest
The authors have not supplied their declaration of competing interest.
A survey of hospital antimicrobial stewardship programs was performed to validate core element achievement data from the National Healthcare Safety Network’s (NHSN) Patient Safety Component Annual Survey. In total, 89% of hospitals met all 7 core elements, compared to only 68% according to the NHSN survey.
When Hurricane Harvey landed along the Texas coast on August 25, 2017, it caused massive flooding and damage and displaced tens of thousands of residents of Harris County, Texas. Between August 29 and September 23, Harris County, along with community partners, operated a megashelter at NRG Center, which housed 3365 residents at its peak. Harris County Public Health conducted comprehensive public health surveillance and response at NRG, which comprised disease identification through daily medical record reviews, nightly “cot-to-cot” resident health surveys, and epidemiological consultations; messaging and communications; and implementation of control measures including stringent isolation and hygiene practices, vaccinations, and treatment. Despite the lengthy operation at the densely populated shelter, an early seasonal influenza A (H3) outbreak of 20 cases was quickly identified and confined. Influenza outbreaks in large evacuation shelters after a disaster pose a significant threat to populations already experiencing severe stressors. A holistic surveillance and response model, which consists of coordinated partnerships with onsite agencies, in-time epidemiological consultations, predesigned survey tools, trained staff, enhanced isolation and hygiene practices, and sufficient vaccines, is essential for effective disease identification and control. The lessons learned and successes achieved from this outbreak may serve for future disaster response settings. (Disaster Med Public Health Preparedness. 2019;13:97-101)
Secondary plant compounds have shown bioactivity against multi-drug resistant Haemonchus contortus in small ruminants. This study screened 51 strains of birdsfoot trefoil (BFT, Lotus corniculatus) crude aqueous extracts (BFT-AqE) for anti-parasitic activity in vitro against egg hatching, and of those 51 strains, 13 were selected for further testing of motility of first (L1) and third stage (L3) larvae, and exsheathment of L3. Proanthocyanidin content ranged between 1.4 and 63.8 mg PAC g−1 powder across the 51 BFT strains. When tested against egg hatching, 21 of the 51 aqueous extracts had an EC50 of 1–2 mg powder mL−1, 70% of the strains were >90% efficacious at 6 mg powder mL−1 and 11 of the strains were 100% efficacious at 3 mg powder mL−1 BFT-AqE. Across the 13 strains tested against L3, efficacy ranged from 0 to 75% exsheathment inhibition, and 17 to 92% L3 motility inhibition at a concentration of 25 mg powder mL−1 BFT-AqE. There was no correlation between the PAC content of BFT powders and the anti-parasitic activity of aqueous extracts, therefore other secondary compounds may have contributed to the observed anti-parasitic effects. Further testing of BFT using bioactivity-driven fractionation and screening of BFT populations for the identified anti-parasitic compounds is needed.
Fomesafen is a protoporphyrinogen oxidase–inhibitor herbicide with an alternative mode of action that provides PRE weed control in strawberry [Fragaria×ananassa (Weston) Duchesne ex Rozier (pro sp.) [chiloensis×virginiana]] produced in a plasticulture setting in Florida. Plasticulture mulch could decrease fomesafen dissipation and increase crop injury in rotational crops. Field experiments were conducted in Balm, FL, to investigate fomesafen persistence and movement in soil in Florida strawberry systems for the 2014/2015 and 2015/2016 production cycles. Treatments included fomesafen preplant at 0, 0.42, and 0.84 kg ai ha−1. Soil samples were taken under the plastic from plots treated with fomesafen at 0.42 kg ha−1 throughout the production cycle. Fomesafen did not injure strawberry or decrease yield. Fomesafen concentration data for the 0.0- to 0.1-m soil depth were described using a three-parameter logistic function. The fomesafen 50% dissipation times were 37 and 47 d for the 2014/2015 and 2015/2016 production cycles, respectively. At the end of the study, fomesafen was last detected in the 0.0- to 0.1-m depth soil at 167 and 194 d after treatment in the 2014/2015 and 2015/2016 production cycles, respectively. Fomesafen concentration was less than 25 ppb on any sampling date for 0.1- to 0.2-m and 0.2- to 0.3-m depths. Fomesafen concentration decreased significantly after strawberry was transplanted and likely leached during overhead and drip irrigation used during the crop establishment.
A study conducted as part of the development of the Eleventh International Classification of Mental Disorders for Primary Health Care (ICD-11 PHC) provided an opportunity to test the relationships among depressive, anxious and somatic symptoms in PHC.
Primary care physicians participating in the ICD-11 PHC field studies in five countries selected patients who presented with somatic symptoms not explained by known physical pathology by applying a 29-item screening on somatic complaints that were under study for bodily stress disorder. Patients were interviewed using the Clinical Interview Schedule-Revised and assessed using two five-item scales that measure depressive and anxious symptoms. Structural models of anxious-depressive symptoms and somatic complaints were tested using a bi-factor approach.
A total of 797 patients completed the study procedures. Two bi-factor models fit the data well: Model 1 had all symptoms loaded on a general factor, along with one of three specific depression, anxiety and somatic factors [x2 (627) = 741.016, p < 0.0011, RMSEA = 0.015, CFI = 0.911, TLI = 0.9]. Model 2 had a general factor and two specific anxious depression and somatic factors [x2 (627) = 663.065, p = 0.1543, RMSEA = 0.008, CFI = 0.954, TLI = 0.948].
These data along with those of previous studies suggest that depressive, anxious and somatic symptoms are largely different presentations of a common latent phenomenon. This study provides support for the ICD-11 PHC conceptualization of mood disturbance, especially anxious depression, as central among patients who present multiple somatic symptoms.
Use of ketamine in the prehospital setting may be advantageous due to its potent analgesic and sedative properties and favorable risk profile. Use in the military setting has demonstrated both efficacy and safety for pain relief. The purpose of this study was to assess ketamine training, use, and perceptions in the civilian setting among nationally certified paramedics (NRPs) in the United States.
A cross-sectional survey of NRPs was performed. The electronic questionnaire assessed paramedic training, authorization, use, and perceptions of ketamine. Included in the analysis were completed surveys of paramedics who held one or more state paramedic credentials, indicated “patient care provider” as their primary role, and worked in non-military settings. Descriptive statistics were calculated.
A total of 14,739 responses were obtained (response rate=23%), of which 10,737 (73%) met inclusion criteria and constituted the study cohort. Over one-half (53%) of paramedics reported learning about ketamine during their initial paramedic training. Meanwhile, 42% reported seeking ketamine-related education on their own. Of all respondents, only 33% (3,421/10,737) were authorized by protocol to use ketamine. Most commonly authorized uses included pain management (55%), rapid sequence intubation (RSI; 72%), and chemical restraint/sedation (72%). One-third of authorized providers (1,107/3,350) had never administered ketamine, with another 32% (1,070/3,350) having administered ketamine less than five times in their career. Ketamine was perceived to be safe and effective as the vast majority reported that they were comfortable with the use of ketamine (94%) and would, in similar situations (95%), use it again.
This was the first large, national survey to assess ketamine training, use, and perceptions among paramedics in the civilian prehospital setting. While training related to ketamine use was commonly reported among paramedics, few were authorized to administer the drug by their agency’s protocols. Of those authorized to use ketamine, most paramedics had limited experience administering the drug. Future research is needed to determine why the prevalence of ketamine use is low and to assess the safety and efficacy of ketamine use in the prehospital setting.
BucklandDM, CroweRP, CashRE, GondekS, MalusoP, SirajuddinS, SmithER, DangerfieldP, ShapiroG, WankaC, PanchalAR, SaraniB. Ketamine in the Prehospital Environment: A National Survey of Paramedics in the United States. Prehosp Disaster Med. 2018;33(1):23–28.